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1.16.5 Flutter Studies 21
1.16.6 Flight Simulation Tests 21
1.17 Organizational and Management Information 22
1.18 Other Information 23
1.18.1 Air Traffic Control 23
1.18.2 Radar Surveillance 23
1.18.2.1 Radar Facilities. 23
1.18.2.2 Radar Data Output 24
1.18.2.3 Aircraft Flight Path Based on Radar 24
1.18.3 PIC’s Background and Training 24
1.18.3.1 Professional Background in RSAF 24
1.18.3.2 Professional Background with SilkAir. 25
1.18.3.3 Financial Background Information 25
1.18.3.4 Recent Behaviour 26
1.18.4 F/O’s Background and Training 26
1.18.4.1 Professional Background with SilkAir 26
1.18.4.2 Financial Background Information 27
1.18.4.3 Recent Behaviour 27
1.18.5 Relationship Between the PIC and the F/O 27
2 ANALYSIS 28
2.1 Introduction 28
2.2 Aircraft Structural and Systems Integrity 28
2.2.1 Horizontal Stabilizers and Elevators 29
2.2.2 Vertical Stabilizer and Rudder 29
2.3 Break Up of the Empennage 30
2.3.1 Results of Trajectory Studies 30
2.3.2 Results of Flutter Studies 30
2.3.3 Explanation to the Break Up of the Empennage 31
2.4 Power Control Units and Actuators 31
2.4.1 Main Rudder PCU 31
2.4.2 Standby Rudder PCU 32
2.4.3 Aileron PCU 32
2.4.4 Elevator PCU 32
2.4.5 Horizontal Stabilizer Jackscrew 32
2.4.6 Other Actuators 34
2.5 Powerplant 34
2.6 Stoppage of the CVR and FDR 35
2.6.1 CVR Stoppage 35
2.6.2 FDR Stoppage 36
2.7 Radio Transmission Voice Recognition 36
2.8 Maintenance Aspects 37
2.8.1 Aircraft Maintenance 37
2.8.2 Patch Repair 37
2.9 General Operational Issues 37
2.10 Simulated Descent Profile 38
2.11 High Speed Descent Issues 39
2.11.1 Mach Trim System and its Function 39
2.11.2 Emergency Descent due to Fire, Smoke or Depressurization 39
v
2.12 General Human Performance Issues 40
2.13 Human Factors Aspects of the CVR and ATC Recordings 41
2.13.1 CVR 41
2.13.2 ATC Recordings 41
2.14 Specific Human Factors Issues 42
2.14.1 Personal Relationships 42
2.14.2 First Officer (F/O) 42
2.14.3 Pilot-in-Command (PIC) 42
2.14.3.1 Recent Behaviour 43
2.14.3.2 Insurance 43
2.14.3.3 Overall Comments on Pilot-in-Command 44
3 CONCLUSIONS 45
3.1 Findings 45
Engineering and Systems 45
Flight Operations 45
Human Factors 46
3.2 Final Remarks 46
4 RECOMMENDATIONS 48
Recommendations to manufacturers 48
General recommendation 48
REFERENCES 49
FIGURES
Figure 1 Route from Jakarta to Singapore over Sumatra, Indonesia 50
Figure 2 Sequence of events 52
Figure 3 Boeing B737-300 – Three view drawing 53
Figure 4 Flight Data Recorder (FDR) 54
Figure 5 Cockpit Voice Recorder (CVR) 56
Figure 6 Debris recovery 57
Figure 7 Sketch of the wreckage pieces found on land 59
Figure 8 Picture of wreckage recovered from the river 60
Figure 9 Sketch of fuselage skin patch repair 64
Figure 10 Sketch of empennage parts found on land 65
Figure 11 Picture of the reconstructed empennage 75
Figure 12 Impact marks at the cam feel centering unit 76
Figure 13 Pictures of horizontal stabilizer jackscrew 77
Figure 14 Diagram of debris distribution analysis 80
Figure 15 Boeing B737-300 flutter flight envelope diagram 83
Figure 16 Corrected radar data 84
Figure 17 Wiring diagram 24-58-11 85
Figure 18 Flight control surfaces location 86
APPENDICES
Appendix A Transcript of the Last Portion of CVR Recording A-1
Appendix B Plots of the Last Portion of Several FDR Parameters B-1
Appendix C Transcript of ATC recording C-1
Appendix D Wreckage weight D-1
Appendix E Actuator matrix E-1
Appendix F Letters from AlliedSignal F-1
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Appendix G Results of flight simulation exercises G-1
Appendix H Site Acceptance Certificate of the Hughes GUARDIAN System H-1
Appendix I Professional events in the Flight Crew’s career during 1997 I-1
Appendix J History of FAA AD related to Boeing 737 rudder system J-1
Appendix K Boeing B737 non-normal procedures - emergency descent K-1
Appendix L Boeing B737 Alert Service Bulletin, Subject on Flight Controls –
Trailing Edge Flap and Horizontal Stabilizer Trim Systems L-1
Appendix M Singapore Accredited Representative’s Comments on
Draft Final Report M-1
Appendix N USA Accredited Representative’s Comments on
Draft Final Report N-1
vii
Abbreviation
AAIB Air Accidents Investigation Branch
AAIC Aircraft Accident Investigation Commission
AC Advisory Circular
AD Airworthiness Directive
AFM Airplane Flight Manual
AFS Auto-Flight System
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NTSC Aircraft Accident Report SILKAIR FLIGHT MI 185 BOEING B(2)
