Indonesia AirAsia Flight 8501

Sequence of events

Flight 8501 was a scheduled flight from Surabaya, Java, Indonesia to Singapore on Sunday, 28 December 2014. It was scheduled to depart Juanda International Airport at 05:20 Western Indonesian Time (WIB, UTC+7) and arrive at Singapore Changi Airport at 08:30 Singapore Standard Time (SST, UTC+8). Flight 8501 took off at 05:35. Indonesia AirAsia did not have permission from the Indonesian Ministry of Transportation to operate the route on Sundays.

After departure, Flight 8501 was in contact with the Jakarta Area Control Centre (callsign: "Jakarta Centre"), which provides air traffic control (ATC) service over the western Java Sea, and flying along air route M635, when it approached a line of thunderstorms off the southwest coast of Borneo. At 06:12, Flight 8501 was flying at flight level 320—approximately 32,000 ft (9,750 m)—when the cockpit requested and received permission to deviate left from its original flight path to avoid these storms. The pilot then requested to climb to flight level 380, which was deferred by ATC because of other aircraft in the vicinity. AirNav Indonesia, which operates the Jakarta Area Control Centre, reported that Jakarta Centre then cleared Flight 8501 to flight level 340 at 06:14, but no response was received; other aircraft in the vicinity were asked to contact Flight 8501, but also did not receive a response.

Between 06:17:00 and 06:17:54, the aircraft climbed from 32,000 to 37,000 ft (9,800 to 11,300 m), exceeding a climb rate of 6,000 ft (1,800 m) per minute, about twice the maximum rate that a commercial aircraft should climb in still air. A photo of a secondary radar screen, without a timestamp, showed the aircraft at flight level 363—approximately 36,300 ft (11,100 m)—and climbing with a ground speed of 353 knots (654 km/h), which is too slow to maintain stable level flight in still air. The Indonesian Minister of Transport interpreted the apparent aircraft behaviour at peak altitude as an aerodynamic stall, when it began to descend at 06:17:54, descending 1,000 ft (300 m) within six seconds and 8,000 ft (2,400 m) within 31 seconds. The aircraft also began a turn to the left, forming at least one complete circle before disappearing from radar at 06:18:44. Its last recorded position was over the Java Sea, Karimata Strait between the islands of Belitung and Kalimantan (3.3708°S 109.6911°E / -3.3708; 109.6911 (AirAsia Flight 8501 last transponder signal)). The cockpit voice recorder captured multiple warnings, including a stall warning, sounding in the cockpit during the final minutes of the flight. No distress signal was sent from the aircraft. Search and rescue (SAR) operations were activated by the Indonesia National Search and Rescue Agency (Basarnas) from the Pangkal Pinang office.

Aircraft

The aircraft was an Airbus A320-216, with serial number 3648, registered as PK-AXC. It first flew on 25 September 2008, and was delivered to AirAsia on 15 October 2008. The aircraft had accumulated approximately 23,000 flight hours over 13,600 flights. It had undergone its most recent scheduled maintenance on 16 November 2014. The aircraft was powered by two CFM International CFM56-5B6 engines and was configured to carry 180 passengers.

Passengers and crew

AirAsia released details of the 155 passengers which included 137 adults, 17 children, and one infant. The crew consisted of two pilots and four flight attendants. A company engineer was also on board and was not counted as one of the passengers.

The pilots on board the flight were:

41 people who were on board the AirAsia flight were members of a single church congregation in Surabaya. Most were families with young children travelling to Singapore for a new year's holiday.

The bodies began to be returned to their families on 1 January 2015. At that time the East Java Department of Visual Identification commissioner stated that the victims were identified by the means of post-mortem results, thumb prints and their personal belongings.

Search and recovery

Shortly after the aircraft was confirmed to be missing, unconfirmed reports stated that wreckage had been found off the island of Belitung in Indonesia. Indonesia's National Search and Rescue Agency (Basarnas) deployed seven ships and two helicopters to search the shores of Belitung and Kalimantan. The Indonesian Navy and the provincial Indonesian National Police Air and Water Unit each sent out search and rescue teams. In addition, an Indonesian Air Force Boeing 737 reconnaissance aircraft was dispatched to the last known location of the airliner.

The Indonesian Navy dispatched four ships by the end of the first search day and the Air Force deployed aircraft including a CASA/IPTN CN-235. The Indonesian Army deployed ground troops to search the shores and mountains of adjacent islands. Local fishermen also participated in the search.

Ongoing search and rescue operations were under the guidance of the Civil Aviation Authority of Indonesia. The search was suspended at 7:45 pm local time on 28 December due to darkness and bad weather, to be resumed in daylight. An operations center to coordinate search efforts was set up in Pangkal Pinang. The search area was a 270-nautical-mile (500 km) radius near Belitung Island.

Search and rescue operations quickly became an international effort. By 30 December naval and air units from Singapore, Malaysia and Australia had joined Indonesian authorities in patrolling designated search areas. Singapore's Rescue Coordination Centre (RCC) deployed three C-130 Hercules aircraft to aid in the search and rescue operation. A Formidable-class frigate, a Victory-class corvette, a Landing Ship Tank, and a submarine support and rescue vessel subsequently took part in the search and rescue after Indonesia's National Search and Rescue Agency accepted the offer of help from the Republic of Singapore Navy. Singapore's Ministry of Transport provided specialist teams from the Air Accident and Investigation Bureau and underwater locator equipment. The Malaysian government set up a rescue coordination centre at Subang and deployed three military vessels and three aircraft, including a C-130, to assist in search and rescue operations. Australia deployed a P-3 Orion to assist in the search and rescue operation. Elements of the United States Navy joined the search effort; USS Sampson arrived on station late on 30 December, and USS Fort Worth on 3 January.

By 5 January, 31 bodies had been recovered with the aid of the Russian and the US search teams. Divers entered the main section of the fuselage underwater and discovered 6 bodies on 24 January.

More than ninety vessels and aircraft from Indonesia, Singapore, Malaysia, Australia, South Korea, Japan, China, the United States, and Russia participated in the search. This fleet included three ships with underwater detectors and two fuel tankers seconded to ensure efficient operation of the vessels in the search area. On 2 January the Indonesian Ministry of Transport reported that two other Indonesian tender vessels had been fitted with equipment which could detect acoustic signals from the flight recorder ("black box") beacons and airframe metal, as well as multibeam side scan sonar.

The official search for bodies ended on 17 March, after 106 bodies had been recovered. 56 bodies remained unaccounted for.

A live Reddit feed that was constantly updating the details of the search and recovery efforts, leaked details of the operation. An April press conference revealed details discovered by the BASARNAS rescue team divers. 115 remains (including body parts) were recovered. 111 of them are believed to be from 99 passengers.

Wreckage

On the day of the disappearance, a fisherman observed "a lot of debris, small and large, near Pulau Tujuh. [...] It looked like the Air Asia colours." Another fisherman reported that, while moored on Sunday at Pulau Senggora, south of the town of Pangkalan Bun in Central Kalimantan, "Around 7am, I heard a loud booming sound. Soon afterwards, there was haze that usually happened only during the dry season. [...] Before the exploding sound, my friends saw a plane from above Pulau Senggaro heading towards the sea. The plane was said to be flying relatively low but then disappeared."

The fishermen's reports, delivered after they had returned home the next day, were credited with guiding the search and rescue team to the vicinity of the crash. The first items of wreckage were spotted by search aircraft on 30 December in the Karimata Strait, 10 km (6.2 mi) from where the crew last contacted air traffic control, and three bodies were recovered by the warship KRI Bung Tomo.

On 31 December, Basarnas claimed that a sonar image obtained 30 December by an Indonesian naval ship appeared to show an aircraft upside down on the seabed in about 24–30 m (80–100 ft) of water, approximately 3.2–3.5 km (2.0–2.2 mi) from the debris found on 30 December. The head of the Search and Rescue Agency also denied the existence of any sonar images of the wreckage (as well as the reported recovery of a body wearing a life vest). He stressed that only official information from his Search and Rescue service can be considered to be reliable.

On 2 January 2015, Basarnas reported evidence of a fuel slick on the water surface in the search area, but detection of the fuselage remained unconfirmed.

At a press conference given on the morning of 3 January by Basarnas, the discovery of two large submerged objects was reported: 9.4 m × 4.8 m × 0.4 m (30.8 ft × 15.7 ft × 1.3 ft), and a thin object 7.2 m × 0.5 m (23.6 ft × 1.6 ft). Also, the previously reported fuel slick was confirmed. A later media report mentioned four large sections of wreckage, the largest being 18 m × 5.4 m × 2.2 m (59.1 ft × 17.7 ft × 7.2 ft) located at 3.9242°S 110.5252°E / -3.9242; 110.5252 (AirAsia Flight 8501 first wreckage). Later in the day, Basarnas announced no more bodies were found, leaving the total at 30.

On 7 January divers found parts of the aircraft including a section of the tail. Other sections of the tail are expected to lie nearby. On 10 January divers used an inflatable device to bring the aircraft's tail to the surface of the sea. They continued to search the sea floor within 500 m (1,600 ft) of where faint pings were heard.

The flight data recorder was recovered by Indonesian divers on 12 January at 3.6225°S 109.7117°E / -3.6225; 109.7117 (AirAsia Flight 8501 FDR salvage), within 4 km (2.5 mi) of part of the fuselage and tail. Later in the day the cockpit voice recorder was located and was recovered the following day.

On 14 January searchers located a large section of the fuselage with one wing attached. On 25 January ropes around the fuselage snapped during an initial failed effort to raise the wreckage. Four bodies were recovered, taking the total recovered to 69. More bodies were thought to be inside. Rear Admiral Widodo, who is in charge of recovery operations, said that the fuselage might be too fragile to be lifted.

On 27 February salvage workers recovered a large piece of fuselage, including the wings, of the A320. Lifting balloons were used to lift the fuselage, but the first attempt failed as the balloons deflated. By March 2015 all large pieces of fuselage from the jet had been lifted from the seafloor and moved for investigation purposes.

AirAsia

An emergency call center was established by the airline, for family of those who were on board the aircraft, and an emergency information center was set up at Juanda International Airport, providing hourly updates and lodging for relatives. Smaller posts were also opened at Soekarno–Hatta International Airport and Sultan Hasanuddin International Airport.

On 31 December 2014, Indonesia AirAsia retired the flight number QZ8501, changing the designation of its Surabaya-Singapore route to QZ678. The return flight number was also changed, from QZ8502 to QZ679.

Subsequent to the 1 December 2015 NTSC report as to the causes of the crash, the airline said it had already implemented improved pilot training.

Airbus

Immediately after the NTSC report on the crash was released on 1 December 2015, the manufacturer of the A320 aircraft was not ready to provide a comment, stating in an e-mail that “Airbus has just received the final accident report. We are now carefully studying its content.”

Indonesia

AirAsia did not have any official permission to fly the Surabaya–Singapore route on Sunday – the day of the crash – but was licensed on four other days of the week, and, according to an Indonesian Ministry of Transport statement, "The Indonesian authorities are suspending the company's flights on this route with immediate effect pending an investigation." In response on the same day, the Civil Aviation Authority of Singapore (CAAS) and the Changi Airport Group (CAG) made a clarification that AirAsia QZ8501 "has been given approval at Singapore's end to operate a daily flight for the Northern Winter Season from 26 October 2014 to 28 March 2015".

On 6 January 2015, Indonesian Ministry of Transport representative Djoko Murjatmojo stated that "officials at the airport operator in Surabaya and [the] air traffic control agency who had allowed the flight to take off had been moved to other duties", and an immediate air transport directive had been issued "making it mandatory for pilots to go through a face-to-face briefing by an airline flight operations officer on weather conditions and other operational issues prior to every flight".

The loss of Flight 8501 also brought attention to the lack of weather radar at Indonesian air traffic control centres. According to the Toronto Star, "Indonesia’s aviation industry has been plagued with problems ... pilot shortages, shoddy maintenance and poor oversight have all been blamed following a string of deadly accidents in recent years."

The West Kotawaringin administration in Pangkalan Bun, Central Kalimantan, planned to build a memorial for the Air Asia flight which also doubles as a monument for aviation safety. Central Kalimantan deputy governor Achmad Diran also stated that the monument is also going to be the symbol of gratitude and appreciation for the efforts of the National Search and Rescue Agency. The cornerstone ceremony took place on Wednesday, and was attended by local and state officials and representatives from Australia and Singapore. West Kotawaringin regent Ujang Iskandar stated that "With this monument, we hope that the families and the government will lay flowers every 28 December, and continue the dialogue on aviation safety in Indonesia." On 22 March, there was a gathering of people near the site of the crash and the crowd laid flowers around.

Family members of crew members and passengers

Air Asia has reportedly offered US$32,000 or Rp300 million to each of the grieving family members of the victims of the incident as 'initial compensation from an overall part of compensation, Wall Street Journal claimed from a letter on Air Asia stationary dated 2 January grieving family member David Thejakusuma received; who had 7 family members on the flight, the amount for each family member he lost.

On 16 March 2015, Monash University awarded in the form of posthumous title (award of posthumous degree) the Bachelor of Commerce to one of the late crash victims, Kevin Alexander Sujipto. Professor Colm Kearney, Dean of the Faculty of Business and Economics presented it to a member of his family. A memorial service was held alongside the presentation of the award, and was attended by the Consul General of Indonesia for Victoria and Tasmania, Dewi Savitri Wahab, 40 of the deceased's friends and representatives from the Indonesian Student Association in Australia (PPIA) Monash University branch.

On 28 December 2015, the first anniversary of the crash, a private prayer service was held in a private room in Mahameru Building, East Java Regional Police, Surabaya, and was attended by family members and relatives of the victims of the crash. The service was also attended by the Head Chief of the Search and Rescue Agency Henry Bambang Soelistyo. Representatives from the family members asked the National Transportation Safety Committee to ensure the safety of air travel in Indonesia. Indonesian Government was also asked by the family members to ratify the Montreal Convention.

Legal proceedings

France opened a criminal investigation to investigate possible manslaughter charges. The family of the first officer, a French national, have filed a lawsuit against AirAsia in connection to the lack of permission to fly on that day, claiming the airline was "endangering the life of others".

Surabaya Mayor Tri Rismaharini says her administration is ready to sue AirAsia should it ignore the rights of the families of passengers on flight QZ8501, following the suspension of the airline’s flight permit from the East Java city to Singapore. Risma said her administration had also consulted with legal experts from Airlangga University on the fears of most families regarding the difficulties in disbursing insurance funds, after the Transportation Ministry regarded the Surabaya-Singapore flight on Dec. 28 as illegitimate. She said her administration continued to collect data on the victims, including their valuable belongings. The data would later be used for insurance purposes and matters related to the beneficiary rights of the affected families.

A US-based aviation lawyer was planning to sue AirAsia claiming that they are "representing" 10 families over an aircraft malfunction following the crash of Flight QZ8501. Principal of Chicago-based Wisner Law Firm Floyd Wisner said that although preliminary investigations found that weather was a factor, the Airbus A320-200 suffered a malfunction of the fly-by-wire system. According to the statement, the lawsuit, which was filed in the US state of Illinois, states that “at the time the accident aircraft left the control of defendant Airbus, it was defectively and unreasonably dangerous,” and names Honeywell International, Motorola Inc and other suppliers along with Airbus as defendants.

The case is Aris Siswanto et al. v Airbus, SAS et al., 1:15-cv-05486. U.S. District Court, Northern District of Illinois (Chicago). As of 30 June 2015, the suit had still named only Airbus and its suppliers but AirAsia was to be added as a defendant, according to Floyd Wisner of the Wisner law firm.

Air transport industry

Following the recovery of the flight recorders, on 12 and 13 January, an anonymous International Civil Aviation Organization (ICAO) representative said, "The time has come that deployable recorders are going to get a serious look." Unlike military recorders, which jettison away from an aircraft and float on the water, signalling their location to search and rescue bodies, recorders on commercial aircraft sink. A second ICAO official said that public attention had "galvanized momentum in favour of ejectable recorders on commercial aircraft".

Indonesian tourism

Indonesia's tourism was badly affected by the incident. According to the head of Indonesia’s Central Statistics Agency (CSA) Suryamin in a press conference at his office on the 1st of April, the accident has caused the number of foreign visitors to decline. Figures from the Indonesian Ministry of Tourism has shown that the number of incoming foreign tourists at Surabaya’s Juanda Airport has declined by 5.33 percent, Jakarta’s Soekarno-Hatta International Airport by 15.01 percent, and Bandung’s Husein Sastranegara Airport by 10.66 percent.

Investigation

The events leading to the crash were investigated by Indonesia's National Transportation Safety Committee (KNKT or NTSC). Assistance was provided by Australia, France, Singapore, and Malaysia.

Data from the flight data recorder were downloaded. One-hundred and twenty-four minutes of cockpit dialogue was successfully extracted from the cockpit voice recorder. The sound of many alarms from the flight system can be heard in the final minutes, almost drowning out the voices of the pilots. The investigators ruled out a terrorist attack as the cause and then examined the possibility of human error or aircraft malfunction. The aircraft altitude recorded by ATC radar increased from 32,000 to 37,000 ft (9,750 to 11,300 m) between 06:17:00 and 06:17:54 WIB, at an initial rate of up to 6,000 ft/min (1,830 m/min). At 06:17:54, the aircraft descended from 37,000 to 36,000 ft (11,300 to 11,000 m) in six seconds, and to 29,000 ft (8,840 m) in 31 seconds.

Although the aircraft's route took it through areas of cloud that extended from 12,000 ft (3,700 m) up to 44,000 ft (13,000 m), FDR data showed that weather was not a factor in the accident.

Acting director of Air Transportation, Djoko Murjatmodjo, clearly stated that the investigation of the flight route and the investigation of the crash itself are separate. Murjatmodjo said that "AirAsia is clearly wrong because they didn’t fly at a time and schedule that was already determined." Both Singapore’s civil aviation authority and the Changi Airport Group stated that Air Asia was allowed daily flights between Surabaya and Singapore. Tatang Kurniadi, head of Indonesia’s national transportation safety committee, stated that sabotage was ruled out as a cause of the incident by the black boxes, and a preliminary report was supposedly submitted to the International Civil Aviation Organisation by early February.

Final NTSC report

After studying the wreckage of the Airbus A320-216 as well as the two black boxes and the cockpit recorder, Indonesia's National Transportation Safety Committee issued a report with their conclusions from the investigation on 1 December 2015. The report stated that the sequence of events that led to the crash started with a malfunction in two of the plane’s rudder travel limiter units. A tiny soldered electrical connection in the rudder-travel limiter unit was found to be cracked, causing it to send four amber master caution warnings to the electronic centralised aircraft monitor (ECAM) system. The ECAM system gave the warning "Auto Flight Rudder Travel Limiter System", and the pilot in command followed the instruction book for ECAM procedures, by toggling the flight augmentation computer(FAC) 1 and 2 buttons on the cockpit's overhead panel to off and then on. The crew repeated the procedure for the first three warnings.

Specifics in the report indicate that French First Officer Rémi Emmanuel Plesel was at the controls just before the stall warning sounded in the cockpit indicating that the jet had lost lift. The final step of the attempted fix consisted of one of the pilots pulling out and then pushing in the circuit breaker of the FAC, which disengaged the autopilot and the system did not start up again after the circuit breakers were reset. This circuit breaker is not on the list of circuit breakers that are allowed to be reset in flight, and disabling both FAC computers places the aircraft in alternate law mode, disengaging the autopilot and stopping the automatic stall protection. The FAC is the part of the fly-by-wire system in A320 aircraft responsible for controlling flight surfaces including the rudder. Without the FAC's computerized flight augmentation, pilots would have to "rely on manual flying skills that are often stretched during a sudden airborne emergency". When the crew was required to fly the Airbus A320 manually, there was an unexplained nine-second delay between the start of the roll and a pilot attempting to take control. After nine seconds, the aircraft was banking at a 54° angle.

The report did not specifically conclude that pilot error caused the crash while detailing the chain of events leading to the loss of Flight 8501. However, one of the investigators, the NTSC's Nurcahyo Utomo, referred to an apparent miscommunication between the pilots (based on the recordings on the cockpit voice recorder) and said that the malfunction should not have led to a total loss of control had they followed the recommended procedure.

The example of miscommunication between the pilots was when the plane was in a critical stalling condition, the co-pilot misunderstood the captain's command "pull down"; instead of pushing the airplane's nose down (pushing forward on the stick to regain speed and escape the stall), he pulled the stick back, which would have ordered the plane to climb more steeply. Because the captain was also pushing the stick forward and because Airbus has a dual-input system, the two stick inputs cancelled each other out, which led to the plane remaining in a stall condition until the end of the black box recording.

Specifically, the report stated, "Subsequent flight crew action resulted in inability to control the aircraft... causing the aircraft to depart from the normal flight envelope and enter a prolonged stall condition that was beyond the capability of the flight crew to recover". CNN's aviation correspondent Richard Quest summarized the chain of events as follows: "it's a series of technical failures, but it's the pilot response that leads to the plane crashing."

On 3 December 2015, Indonesia's air transportation director general, Suprasetyo, said that the National Safety Transportation Board (KNKT) had provided recommendations as to tightened controls on aircraft maintenance and flight crew competence. He added that the government had implemented "... a series of corrective actions as a preventive measure so that the same accident will not happen again in the future." Suprasetyo also confirmed that the suspension of Indonesia AirAsia's Surabaya–Singapore route would not be lifted until the carrier had completed the steps recommended by the KNKT.

The report stated that the crash resulted from the flight crew’s inability to control the aircraft in alternate law. The cracking of a solder joint resulted in the failure of the Rudder Travel Limiter Unit four times during the flight. The flight crew action to the first three faults was in accordance with the Electronic Centralized Aircraft Monitor messages. Following the fourth fault, the FAC’s circuit breakers were reset by the flight crew, resulting in electrical interruption to the computers causing the autopilot to disengage and the flight control logic to change to Alternate Law. The rudder deflected 2 degrees to the left, causing the aircraft to roll up to 54 degrees. Subsequent flight crew actions resulted in the aircraft entering a prolonged stall from which they were unable to recover.

Dramatization

The crash was dramatized in the 16th season of the TV Series Mayday, in an episode entitled "Deadly Solution", airing just over two years after the crash in early February 2017.