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both pilots as competent pilots with good airplane handling skills. It was concluded
that both pilots were properly trained, licensed and qualified to conduct the flight.
• The relationship between the PIC and the F/O was examined. There were no reports
of any conflict or difficulties between the pilots prior to the occurrence and before the
day of the crash. Based on the available recorded data of the CVR, there was no
evidence of any conflict or difficulties between the pilots during the approach and
landing into Jakarta, on the ground at Jakarta, and during the accident flight. The
infrequent non-flight related conversations between the pilots were also cordial. It was
concluded that the investigation did not find any evidence of difficulties in the
relationship between the two pilots either during or before the accident flight.
12 Amended based on suggestion in Appendix N.
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• During their career in SilkAir, the PIC and the F/O received training in recovery from
unusual flight attitudes. The PIC was a member of the RSAF “Black Knights”
aerobatic team in the 1970s. The F/O was reported to be sought after as co-pilot by
other SilkAir pilots who were undergoing command upgrade training. This training
typically includes scenarios which require handling of system failures or other
abnormal flight situations. Therefore both pilots were familiar with recovery from
unusual flight attitudes.
2.13 Human Factors Aspects of the CVR and ATC Recordings
2.13.1 CVR
(a) The conversations and sounds recorded by the CVR before it stopped were
examined. The CVR transcript (Appendix A) showed that at 09:04:57 the PIC
indicated his intention to go to the passenger cabin, "go back for a while …. finish
your plate….". At 09:05:02 the PIC offered water to the F/O, and at about the same
time, several metallic snapping sounds were recorded. Thirteen seconds later, at
09:05:15.6 the CVR ceased recording. Analysis of the recording indicated that the
metallic snapping sounds were made by a seatbelt buckle striking the floor. (See
Section 1.16.2)
(b) During the period recorded by the CVR, all door openings or closings were related to
pre-departure activities, in-flight meal service and normal pilot-cabin crew
interaction. In the four minutes following the last meal service, there were no sounds
associated with cockpit door opening or closing. After takeoff from Jakarta,
conversations within the flight deck were between pilot-to-pilot, pilot-to-flight
attendants, and normal pilot-to-ATC radio communications. During the flight, except
for cabin attendants serving meals and drinks to the pilots, there were no indications
of any other person(s) in the cockpit. It is concluded that after the last meal service
and until the stoppage of the CVR, the recording did not reveal any indications that
person(s) other than the flight crew and cabin attendants attending to their duties
were in the cockpit.
(c) Analysis of the CVR stoppage indicated that the failure of the CVR could not have
been caused by a short circuit or overload. This is because either occurrence would
have resulted in the CVR recording a “pop” sound which was heard on the test
recording but not on the accident recording.
The CVR in-flight tests could not identify the sound of the CVR circuit breaker being
manually pulled as the ambient noise obscured the sound made. The accident tape did
not contain any identifiable sound attributable to manual pulling of the CVR circuit
breaker. It was not possible to determine from the CVR tests if there was a pulling
out of the CVR circuit breaker.
2.13.2 ATC Recordings
The data transcribed from the ATC communications recording of the air-to-ground
conversation indicates that at 09:10:26, or 5 minutes and 10.4 seconds after the CVR
stoppage, the F/O acknowledged the “abeam Palembang” call from the ATC. The F/O
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was positively identified by voice analysis examination. This confirms that the F/O was in
the cockpit when the aircraft was abeam Palembang. However, it is not possible to
conclude whether the PIC was in the cockpit at the time. It was also not possible to
determine events or persons present in the cockpit from the time of the last transmission
to ATC.
The absence of a distress call could suggest that the pilots were preoccupied with the
handling of an urgent situation. However, it is not possible to conclude on the reason for
the absence of a distress call.
2.14 Specific Human Factors Issues
In this section, the specific, personal, financial backgrounds and recent behaviour of the
PIC and the F/O are examined.
2.14.1 Personal Relationships
　
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本文鏈接地址：NTSC Aircraft Accident Report SILKAIR FLIGHT MI 185 BOEING B(29)