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FEATURED INDONESIA AIR INVESTIGATOR REPORT: Found Faulty System & Poor Pilot Monitoring Causes of 2021 Plane Crash

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#AceNewsDesk – A faulty automatic engine throttle system that was not properly monitored by pilots led to the deadly January 2021 crash of a Sriwijaya Air Boeing 737-500, according to Indonesia’s air accident investigator KNKT.

Three officials inspect aircraft debris that has been spread across a white tarp.
All 62 people on board died when the plane crashed into the Java Sea in January 2021. (AP: Dita Alangkara)none

The crash into the Java Sea after take-off from Jakarta, which killed all 62 people on board, was Indonesia’s third major commercial air disaster in just over six years and shone a spotlight on its poor air safety record.

Problems with the 26-year old plane’s auto-throttle system, which controls engine power, had been reported 65 times since 2013 and were still unresolved before the accident, the agency said in its 202-page report.

A working auto-throttle is not required for an aircraft to take-off because pilots can control the thrust levers manually.

Divers in dinghies move their vessels toward large red buoys on a calm sea under cloudy skies.
Indonesian navy divers searched through debris and seabed mud for the Sriwijaya Air jet’s black box recorders. (AP: Tatan Syuflana)none

However, KNKT said in this case the crew did not appear to have closely monitored an ‘asymmetrical thrust situation’, which involved the left engine throttle lever moving back to as low as 34 percent speed after take-off, while the right lever stayed in its original climb setting at about 92 percent.

“There were several indications available that the pilots could have checked to identify the aircraft anomalies, such as engine parameters, thrust levers position, and roll angle,” the agency said, adding that complacency and confirmation bias may have been a factor in the poor monitoring.

Sriwijaya Air did not respond immediately to a request for comment.

Manufacturer Boeing declined to comment.

‘Upset’ situation

At about 10,700 feet, the autopilot disengaged, the plane rolled to the left more than 45 degrees and started to dive into the sea.

The first officer said “upset, upset” and “captain, captain” before the recording stopped, but the captain’s channel was not working, making it more difficult for investigators to analyse events.

An upset situation involves an aircraft operating outside normal flying parameters like speed, angle or altitude.

KNKT chief investigator Nurcahyo Utomo told reporters there had been no regulations and guidelines on upset prevention training by Indonesian airlines that ensured a pilot’s ability to stop unwanted situations from occurring, with a key part of that being monitoring.

He said Sriwijaya Air has since carried out such training for its pilots.

KNKT had raised the lack of upset recovery training after the 2014 crash of an AirAsia Indonesia jet that killed all 162 people on board.

Upset recovery training was then mandated in Indonesia in 2017, according to the final report, but Utomo said the aviation regulator did not update the requirement after the UN aviation body ICAO said in 2018 the course should also include upset prevention.

Indonesia is putting in place updated upset prevention and recovery training, KNKT said in the report.


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