Adam Air Flight 574
Boeing 737-4Q8 · Inertial navigation system malfunction leading to spatial disorientation, pilot error, loss of control, and in-flight breakup
From Soekarno-Hatta International Airport (CGK) to Sam Ratulangi International Airport (MDC)
Event
- NTSB case
- DCA07RA019
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Accident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Unknown · led by another country; figures from NTSB notifications
- Event fatalities
- 102 · all aircraft and ground
- Ground fatalities
- Unknown
- Occupants
- 102
- Survivors
- 0
- InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
- 0 serious · 0 minor (NTSB)
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- Airline
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Not recorded
Boeing 737-4Q8
- Flight
- KI574
- Aircraft type
- Boeing 737
- Category
- Airplane · from aircraft type
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- PK-KKW
- Operator
- Adam Air
- Onboard fatalities
- 102
- Route
- From Soekarno-Hatta International Airport (CGK)To Sam Ratulangi International Airport (MDC)
- Aircraft age
- Not recorded
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Non-U.S., Commercial
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- Not recorded
- Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- Not recorded
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Not recorded
Cause areas
- Personnel issues › Psychological
- Aircraft › Aircraft systems
- Personnel issues › Task performance
- Personnel issues › Miscellaneous
- Personnel issues › Experience/knowledge
- Organizational issues › Development
From the investigation findings the Wikipedia article reports, sorted into the NTSB's cause areas with AI assistance.
Approximate · Coordinates from the Wikipedia article; not checked against an investigation report.
From the Wikipedia article
Adam Air Flight 574 was a scheduled domestic passenger flight operated by an Adam Air Boeing 737-400 between the Indonesian cities of Jakarta, Surabaya, and Manado that crashed into the Makassar Strait near Polewali in Sulawesi on 1 January 2007. All 102 people on board were killed, making it the deadliest aviation accident involving a 737-400. After this, Adam Air faced intense scrutiny by the Indonesian government, which launched a national investigation into the disaster. The government's final report, released on 25 March 2008, concluded that the pilots lost control of the aircraft after they became preoccupied with troubleshooting the inertial navigation system and inadvertently disconnected the autopilot. Despite a series of safety incidents, which contributed to the shutdown of Adam Air in 2008, this was the only incident resulting in fatalities during the airline's 5-year existence.
Together with the subsequent crash of Adam Air Flight 172 and several other transportation accidents, the crash contributed to the United States' downgrading of its safety rating of Indonesian aviation. This eventually led to large-scale transportation safety reforms in Indonesia. All Indonesian airlines were banned from flying into the European Union for several years after the crash. After numerous warnings by the authorities for Adam Air to implement safety regulations went unheeded, the airline was banned from flying by the Indonesian government in March 2008, and declared bankruptcy in June of the same year.
Flight chronology
On 1 January 2007, at 12:59 local time (05:59 UTC), the plane departed from Juanda Airport, Surabaya, with 96 passengers (85 adults, seven children, and four infants), a 56% load factor, and 6 crew on board. The passenger list was composed mainly of Indonesian nationals with a majority of the passengers returning to Manado after New Year's Day; the foreigners were an American family of three and a German national. The two-hour flight, scheduled to arrive at Sam Ratulangi Airport, Manado, at 16:00 local time, was normal until the plane vanished from air traffic control radar screens at Makassar, South Sulawesi, with the final contact at around 15:00 local time. The last known beacon position was detected by a Singaporean satellite. The altitude of the plane was shown as 35000 ft on the radar screen.
Weather in the region was stormy; the Indonesian Bureau of Meteorology and Geophysics noted that the cloud tops were up to 30000 ft in altitude with an average wind speed of 30 kn in the area. Although the Juanda Airport operator, PT Angkasa Pura I, had given the pilot the weather conditions, the plane departed as scheduled. The plane ran into crosswinds of more than 70 kn over the Makassar Strait, west of Sulawesi, where it changed course eastward toward land before losing contact.
Problems started when the pilots noticed an anomaly in the inertial reference system (IRS). The first officer then attempted to troubleshoot, resetting his IRS unit by switching the knob on his side to Attitude (ATT) mode; this disengaged the autopilot with a 4-second autopilot disconnect tone, effectively requiring the captain to take control and fly the plane straight and level for 30 seconds as the realignment process was completed. Neither crew member noticed the autopilot was no longer engaged, and the captain did not take control. Previous maintenance issues involving the aircraft's ailerons caused the airplane to slowly roll to the right and the nose to drop. When the aircraft reached 35° right bank and increasing, a "bank angle" audible warning sounded in the cockpit.
This accident resulted from a combination of factors, including the failure of the pilots to adequately monitor the flight instruments, particularly during the final 2 minutes of the flight. Preoccupation with a malfunction of the IRS diverted both pilots' attention from the flight instruments and allowed the increasing bank angle and descent to go unnoticed. The pilots did not detect and appropriately arrest the descent soon enough to prevent loss of control.
Captain Widodo told the first officer to switch the IRS mode back to NAV, to hopefully reverse the situation. Now that the first officer's attitude indicator had returned to its normal state, First Officer Susanto could see that the aircraft was in a dangerous position, and attempted to notify the captain. When this failed, he then tried to recover the aircraft from its descent by turning the yoke to the left. Believing that the aircraft was flying straight and level, Captain Widodo then unknowingly reminded First Officer Susanto that the aircraft needed to fly straight and level to complete the IRS alignment process. The aircraft was now in a 100° right bank with a 60 nose-down attitude. First Officer Susanto successfully notified the captain of their situation. In response to the first officer telling him to pull up to stop the rapid descent towards the sea, Captain Widodo pulled back on his yoke, and the aircraft, travelling at Mach 0.926 (92.6% the speed of sound), experienced a force 3.5 times the force of gravity at a calibrated airspeed of 490 knots (well above its maximum speed) and began to break apart in-flight. All recordings stopped at 9,000 feet, presumably because the aircraft had fully broken apart.
No distress signals were sent by the aircraft.
Flight 172
On 21 February 2007, just 51 days after the loss of Flight 574, Flight 172, an Adam Air Boeing 737-300 aircraft (registration PK-KKV) flying from Jakarta to Surabaya had a hard landing at Juanda International Airport. The incident caused the fuselage of the plane to crack and bend in the middle, with the tail of the plane drooping towards the ground. No serious injuries from the incident were reported. As a result, six Adam Air 737s were grounded awaiting safety checks. Adam Air described this as "harsh punishment" for an accident it blamed on poor weather conditions, but Vice-president Kalla had said that all Boeing 737-300s should be checked.
Investigation and cause
Investigation
President Susilo Bambang Yudhoyono ordered a full investigation to discover the cause of the aircraft's disappearance, including the cause of the accident, before the main debris field had even been found. The investigation also looked at the airworthiness of the plane and standard procedure on aircraft operations. A team from the United States with representatives from the National Transportation Safety Board, the Federal Aviation Administration, Boeing, and General Electric was sent to Indonesia to assist the Indonesian National Committee for Transportation in the investigation. A wider investigation into Indonesia's transport system as a whole was planned. Eyewitnesses reported seeing a low-flying, unstable aircraft in the area from which the wreckage has been recovered, but lost sight of it after hearing a loud bang. The chief of the Indonesian Aircraft Technicians Association, Wahyu Supriantono, said that the plane was unlikely to have suffered an in-flight break up or explosion, as the debris field would have been larger, and as a result, wreckage would have been discovered earlier. The flight recorders were recovered in August 2007, without which discovery of the cause of the accident would not have been possible. The National Transportation Safety Committee (NTSC, or KNKT as per its Indonesian name) described the near eight-month wait for the recovery of the flight recorders as "unacceptable".
On 25 March 2008, the inquiry ruled that pilot error and a faulty navigation device were to blame. While cruising at 35000 ft, the pilots became preoccupied with troubleshooting the aircraft's two inertial reference systems (IRS), part of the navigation system. As they were correcting the problem, the autopilot was disengaged and they failed to correct for a slow right roll even after a "bank angle" alarm sounded. By the time the pilots noticed the situation, the bank angle had reached 100° with almost 60° nose-down attitude. Contrary to the correct recovery procedure, the pilots did not level the wings before trying to regain pitch control. The aircraft reached 490 kn at the end of the recording, in excess of the aircraft's maximum operating speed of (400 kn). The descent rate varied during the fatal dive, with a maximum recorded value of 53760 ft/min. The tailplane suffered a structural failure 20 seconds prior to the end of the recording, when the investigators concluded the aircraft was in a "critically unrecoverable state". Both flight recorders ceased to function when the 737 broke up in midair at 9,000 ft above sea level.
The NTSC determined:
Flight crew coordination was less than effective, as the pilot-in-command did not manage task sharing and crew resource management practices were not followed.
The crew focused their attention on troubleshooting the IRS failure and neither pilot was flying the aircraft.
After the autopilot disengaged and the aircraft exceeded 30° right bank, the pilots appeared to have become spatially disoriented.
The Adam Air syllabus of pilot training did not cover complete or partial IRS failure.
The pilots had not received training in aircraft upset recovery, including spatial disorientation.
Text from the Wikipedia article “Adam Air Flight 574” (revision 1374729867, retrieved 2026-09-18) by its authors, under CC BY-SA 4.0. Extracted as plain text: references, tables, images and some sections are left out. Read the article
Sources
Wikipedia article: Adam Air Flight 574
- Article
- Adam Air Flight 574
- Revision
- 1374729867 · 2026-09-13 · retrieved 2026-09-18
- Wikidata
- Q250439
- Licence
- Text CC BY-SA 4.0, by the article's authors; Wikidata CC0; town positions GeoNames (CC BY 4.0)
NTSB record DCA07RA019
- Event ID
- 20070108X00016
- Case number
- DCA07RA019
- Dataset
- historical-pre2008
- Source SHA-256
- 89e2df6d848e7ab3b42e7d7c7a03ff403303057a26ca04c95b3ea67201c3ce74
Where each value comes from
- Record
- Wikipedia article "Adam Air Flight 574" (page 8704921, revision 1374729867); merged with NTSB case DCA07RA019 (events / aircraft)
- Date
- Wikipedia infobox: date
- Place and country
- Wikipedia infobox: site
- Map position
- Wikipedia: Wikipedia article coordinates
- Aircraft, operator and route
- Wikipedia infobox: aircraft type, registration, operator, origin and destination; route airports from the linked airport articles' Wikidata codes (OurAirports); gaps and aircraft details from NTSB record DCA07RA019
- Operation
- airline flight number in the infobox
- Fatalities
- Wikipedia: Wikipedia infobox: aircraft fatalities
- Ground fatalities
- Wikipedia: not stated in the Wikipedia infobox
- Summary
- Wikipedia infobox: summary
Source notes (2)
- One occurrence in two sources, merged: the Wikipedia article "Adam Air Flight 574" and NTSB case DCA07RA019, matched by the same aircraft registration and date. For this event outside the United States Wikipedia's values are used where the two differ; each value names its source.
- No bulk values were replaced by the NTSB case API.