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the accident site and the lack of information from the flight recorders during the final
moments of the accident sequence.
• The NTSC accident investigation team members and participating organizations
have done the investigation in a thorough manner and to the best of their conscience,
knowledge and professional expertise, taking into consideration all available data
and information recovered and gathered during the investigation.
• Given the limited data and information from the wreckage and flight recorders, the
NTSC is unable to find the reasons for the departure of the aircraft from its cruising
level of FL350 and the reasons for the stoppage of the flight recorders.
• The NTSC has to conclude that the technical investigation has yielded no evidence to
explain the cause of the accident.
The technical investigation has, in fact, yielded sufficient information, which
was derived through the on-scene and postaccident investigation activities, to
definitively conclude that there were no mechanical anomalies with the aircraft,
there were no environmental anomalies, nor were there any other significant
technical factors that would have caused or contributed to the accident.
Additionally, the statement regarding the participating organizations in
bullet 2 is made with a level of certainty that may not truly reflect the opinions of
the “participating” organizations. Further, the remaining concluding statements do
not necessarily reflect an analysis of all of the facts, conditions, and circumstances
revealed during the course of this accident investigation.
NTSC’S COMMENTS:
With respect to the proposals relating to the conclusions of
the final report, please refer to comments made at the
relevant sections above.
N-57
4 RECOMMENDATIONS
TO MANUFACTURERS
1. It is recommended that a comprehensive review and analysis of flight data recorders
and cockpit voice recorders systems design philosophy be undertaken by aircraft and
equipment manufacturers. The purpose of the review and analysis would be to
identify and rectify latent factors associated with stoppage of the recorders in flight,
and if needed, to propose improvements to ensure recording until time of occurrence.
2. It is recommended that a review of the flight recorders design philosophy be
undertaken by aircraft and equipment manufacturers to include recording of actual
displays as observed by pilots in particular for CRT type of display panels.
3. It is recommended that a review of the flight crew training syllabi be undertaken by
aircraft manufacturers to include recovery from high speed flight upsets beyond the
normal flight envelope. The purpose of developing the additional training is to
enhance pilot awareness on the possibility of unexpected hazardous flight situations.
GENERAL RECOMMENDATION
4. It is recommended that regional investigation framework for co-operation in aircraft
accident investigations be established to enable fast mobilization of resources and
coordination of activities to support those states that do not have the resources and
facilities to do investigations on their own.
The factual evidence does not support recommendations 1 and 3 because the
postaccident tests and examination suggest that the CVR stopped recording as a
result of the unit’s circuit breaker being pulled. This scenario also likely explains
why the DFDR stopped recording.
The investigation did not reveal any evidence to suggest that a mechanical
malfunction or failure of a particular system caused an unexpected upset. If such a
scenario had occurred, the flight crew should have been able to take immediate
corrective action because they had received training at SilkAir in the recovery from
unusual attitudes. Based on the evidence, the departure from cruise flight was likely
an intentional maneuver; therefore, recommendation 3 is without merit.
NTSC’S COMMENTS:
There was no evidence to positively conclude that the
departure from cruise flight was an intentional maneuver.
Present line crew training does not include recovery from
high speed flight upset beyond the normal flight envelope
from whatever cause. If such crew training is developed, it
would enhance crew awareness on the possibility of
unexpected hazardous flight situations and provide them with
the necessary recovery techniques to handle any high speed
flight upsets.
Errata-1
Errata
No. Page, Section, Paragraph/Bullet, Line Originally It should be modified to
1 Page i, Abstract, Para 7, Line 2 Except parts of the empennage that ... Except for parts of the empennage …
2 Page i, Abstract, Para 8, Line 3 … to what have happened, … … to what had happened, …
　
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