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policy was set by the insurance company to be 19 December 1997. This information was
not conveyed to the PIC. The cheque was cleared on 22 December 1997. From the data
available to the NTSC there was no evidence to indicate if this mortgage policy has any
relevance to the accident.
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2.14.3.3 Overall Comments on the Pilot-in-Command
NTSC concluded that the combination of financial situation and his work related events
could be stressors on the PIC. However, NTSC could not determine the magnitude of
these stressors and its impact on the PIC’s behaviour.
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3 CONCLUSIONS
3.1 Findings
Engineering and Systems
• There was no evidence found of in-flight fire or explosion.
• From flutter analysis and wreckage distribution study, the empennage break-up could
have occurred in the range between 5,000 and 12,000 feet altitude.
• Examination of engine wreckage indicated that the conditions of the engines at
impact were not inconsistent with high engine rotation speed. No indications were
found of in-flight high energy uncontained engine failures. Therefore, the engines
were considered to be not a factor contributing to the accident.
• Examination of the actuators of flight and ground spoilers, trailing and leading edge
flaps, as well as engine thrust reversers indicate retracted or stowed positions of the
respective systems.
• Examination of the main rudder power control unit (including the servo-valve), the
yaw damper modulating piston, the rudder trim actuator, the rudder trim and feel
centering unit, the standby rudder PCU, the aileron PCUs, the elevator PCUs, and the
horizontal stabilizer jack-screw components, revealed no indications or evidence of
pre-impact malfunctions.
• Examination of the 370 kg of recovered electrical wires, connectors and circuit
boards showed no indication or evidence of corrosion, shorting, burning or arcing in
these wires or parts.
• The CVR stopped recording at 09:05:15.6 and the FDR stopped recording at
09:11:33.7. The examination of the CVR and FDR showed no malfunction of the
units. The stoppages could be attributed to a loss of power supply to the units.
However, there were no indications or evidence found to conclude on the reason for
the stoppages due to the loss of power. The cause of the CVR and FDR stoppages
and the reason for the time difference between the stoppages could not be concluded.
• The inspection of the aircraft maintenance records did not reveal any defects or
anomalies that could have affected the airworthiness of the aircraft or that may have
been a factor contributing to the accident.
• The horizontal stabilizer trim was found to be in the 2.5 units position which matched
the forward limit of the manual electrical trim.
Flight Operations
• Weather and Air Traffic Control were not factors contributing to the accident.
• Audio spectral analyses on Air Traffic Control communications and the accident
CVR indicate that the last communication from the MI 185 at 09:10:26, occurring at
a position approximately abeam Palembang was performed by the F/O.
• The examination of the flight deck noise and sounds concludes that the metallic snap
recorded on the CVR was made by a seatbelt buckle hitting against a metal surface.
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• Based on flight simulations, it was observed that the simulated descent trajectory
resulting from any single failure of flight control or autopilot system would not
match the radar data.
• Based on the same flight simulations, it was also observed that the trajectory shown
by the radar data could have been, among other possibilities, the result of the
combination of lateral and longitudinal inputs together with the horizontal stabilizer
trim input to its forward manual electrical trim limit of 2.5 units.
Human Factors
• Both pilots were properly trained, licensed, and qualified to conduct the flight.
• There was no evidence found to indicate that the performance of either pilot was
adversely affected by any medical or physiological condition.
• Interviews with respective superiors, colleagues, friends and family revealed no
evidence that both the flight crew members had changed their normal behaviour prior
to the accident.
• There was no evidence found to indicate that there were any difficulties in the
relationship between the two pilots either during or before the accident flight; or had
been experiencing noteworthy difficulties in any personal relationships (family and
friends).
• Until the stoppage of the CVR, the pilots conducted the flight in a normal manner
and conformed to all requirements and standard operating procedures.
　
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本文鏈接地址：NTSC Aircraft Accident Report SILKAIR FLIGHT MI 185 BOEING B(31)