A rudder control system problem that had occurred 23 times in the previous 12 months coupled with the pilots’ response led to last year’s crash of an AirAsia plane that killed all 162 people on board, Indonesian investigators said Tuesday.
In releasing their report, the National Transportation Safety Committee said an analysis of Flight 8501’s data recorder showed the rudder control system had sent repeated warnings to the pilots during the Dec. 28 flight from the Indonesian city of Surabaya to Singapore.
Aircraft maintenance records for the Airbus A320 showed that similar problems with the rudder system had occurred 23 times during the year prior to the crash, including nine instances in December. The investigators said the fault was caused by cracked soldering on an electronic card.
Investigator Nurcahyo Utomo said the problem by itself should not have been dangerous. But after the fourth time an alarm went off during the flight, a crew member apparently went outside of handbook recommendations and removed a circuit breaker to try to reset the system, he said.
The autopilot then became disengaged, and the aircraft began to roll, but no movement was detected on the plane’s manual control stick for nine seconds, he said. It then began climbing rapidly before stalling and plummeting into the Java Sea.
Utomo said the voice recorder showed the pilot said “pull down,” but in fact the plane was ascending.
“It seemed that there was a miscommunication between the pilot and co-pilot after the fourth fault,” he said.
The same warnings had occurred three days before the crash with the same pilot, who witnessed a technician on the ground addressing the problem by removing the circuit breaker and then replacing it, according to Utomo and the investigation report.
The last contact the pilots had with air traffic control indicated they were entering stormy weather. They asked to climb from 32,000 feet (9,753 meters) to 38,000 feet (11,582 meters) to avoid threatening clouds, but were denied permission because of heavy air traffic. Four minutes later, the plane dropped off the radar. No distress signal was issued, and investigators said weather conditions did not play a role in the crash.
Only 106 bodies were recovered from the sea due to rough conditions and poor underwater visibility that hampered divers’ efforts. Most of those on board were Indonesian headed to Singapore ahead of the New Year holiday.
“There is much to be learned here for AirAsia, the manufacturer and the aviation industry,” tweeted Tony Fernandes, chief executive of the Malaysia-based budget carrier. “We will not leave any stone unturned to make sure the industry learns from this tragic incident.”
AirAsia Indonesia said in a statement that more pilot training along with a new system that provides real-time monitoring of aircraft warning messages has been initiated as a result of the crash. The Associated Press was referred to the statement when asking why the faulty rudder system was not fixed, but the issue was not addressed there.
Indonesia’s aviation safety record has been plagued with problems stemming largely from the explosion of travelers and new airlines popping up in the archipelago of 250 million people. Pilot shortages, shoddy maintenance and poor oversight have all been blamed following a string of deadly incidents in recent years.
The AirAsia crash came at the end of a particularly tragic year for air travel in Southeast Asia, including the mysterious disappearance of Malaysia Airlines Flight 370 in March 2014 with 239 people aboard, and the downing of Malaysia Airlines Flight 17 four months later over Ukraine, which killed all 298 passengers and crew.
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