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A FAULTY component, a poor maintenance regime, bad weather, a critical mistake, a communication failure, 162 people dead.
The loss of AirAsia Flight 8501 on a stormy December morning a year ago, from an airline that previously had an excellent safety record, came as a shock, even in a country with one of the world's worst aviation records.
This was a relatively new plane, captained by a pilot with a decade of experience in the air force and more than 9,000 hours flying commercial jets. Yet interviews with pilots, air traffic controllers, flight trainers and regulators show that the combination of mistakes and failures that doomed those on board show why Indonesia still has more than three times the global average rate of fatal air crashes.
In the past few years, Indonesia has redoubled efforts to improve that record, but the challenges are enormous. The country has a shortage of skilled pilots, ground crew and air traffic controllers. Equipment and planes are often outdated or not working.
Many of its 296 airports are under par or have runways that are too short. And the terrain of 17,000 islands, dotted with volcanoes, makes for some of the most treacherous flying conditions in the world.
When a fatal crash does occur - and the country averages more than one a year - the blame often falls on the pilots, after investigators painstakingly try to recreate the last moments of the flight from debris and the flight recorders.
"The way the plane is being flown by the pilot and operational problems are the dominant cause of accidents," said Soerjanto Tjahjono, who took over in August as head of Indonesia's National Transportation Safety Committee. He cites inadequate training and issues of discipline and poor cockpit cooperation.
A failure of communication was one factor on the AirAsia Bhd flight, which took off from Surabaya, the nation's second- largest city, on Dec 28 last year. The Indonesian pilot and French co-pilot ended up counteracting each other at the controls after their attempts to fix a faulty rudder system caused the auto-pilot to disengage, according to the final crash investigators' report, published on Dec 1. The plane rose steeply, stalled and plummeted into the ocean.
For Ignasius Jonan, who had been appointed transport minister just two months before the crash, the disaster was an horrific reminder of the need to improve the nation's aviation record.
"When I was assigned to this job almost 13 months ago, one thing I learned is that the airline industry in Indonesia should improve safety a lot," Mr Jonan said in a speech on Nov 13 in Bali to the Association of Asia Pacific Airlines.
He said the government will allocate around US$1 billion next year to improve safety for land, sea and air transport, the largest sum since independence.
Still, that money has to cover a chain of islands that would stretch from London to New York, including 4,600km of rail lines, 300 ports and half a million kilometers of roads.
Much of the network, including the airports, has suffered from underinvestment and is operating at as much as three times over capacity.
Mr Jonan said the government plans to extend and improve existing runways and terminals and build another 15 airports by 2018 so that domestic airlines can upgrade some flights to jets, instead of the smaller turboprop planes that have a higher accident rate.
Even with the new runways, Indonesia is playing catch-up.
Economic growth at an average 5.8 per cent clip over the past decade has enabled millions of Indonesians to take to the skies and prompted airlines to add more flights to the beaches of Bali and booming cities like Bandung and Makassar. Annual passenger numbers have almost trebled in the past seven years, to 87 million in 2014.
Yet many of the country's runways have no instrument landing system, according to Wisnu Darjono, operations director at AirNav Indonesia, the state-affiliated air traffic control organisation. That makes it harder for pilots to land in bad weather.
Mr Jonan said the transport ministry is trying to modernise its system with help from UK and US companies and agencies, with the aim of having 100 airports with ILS by 2018.
More modern planes and better navigation equipment have helped cut global crash rates, including in Indonesia. In the nine-year period ending 1998, the nation's fatal accident rate was 7.81 per million flights, 5.5 times worse than the world average. It's dropped to 1.96 per million flights, still 3.4 times higher than the global mean.
Still, the number of flights in the country has increased, so the number of fatal crashes hasn't changed very much. Indonesia had 13 fatal plane crashes in the past 10 years, compared with 14 in the previous decade, according to data from Flightglobal.
"We are seeing some improvement in reducing the accident rate but the pace of that improvement has not matched what has been achieved elsewhere in the region," said Andrew Herdman, director general of the Association of Asia Pacific Airlines. "People underestimate the sheer size of the Indonesia aviation market and how rapidly it's grown." Watching over the nation's 10,000 daily flights are 1,400 air-traffic-control staff monitoring an airspace almost the size of Europe. There are 17,000 air traffic controllers in Europe, partly because of the number of countries.
One part of its airspace Indonesia doesn't control is the area used by planes as they typically line up for approach to Changi airport in neighbouring Singapore. Indonesia allocated control of that space to Singapore in 1946 because it didn't have the capability to manage the flights at the time.
Now it wants it back. President Joko Widodo has ordered that within four years, the country must control all its airspace.
"Our facilities are almost equal with Singapore, we are ready to control that area," said Mr Darjono at AirNav. "Safety is much, much better than before." Changi handles almost 1,000 takeoffs and landings a day, including the world's largest airliner, Airbus Group's A380.
Mr Darjono said Indonesia is spending 1.8 trillion rupiah (S$183 million) this year to upgrade facilities and is hiring 300 more air traffic controllers.
The heart of the nation's air traffic is Jakarta's Soekarno-Hatta airport, the ninth-busiest in the world, ahead of Changi and Amsterdam, and serving a metropolis of nearly 30 million people.
In the control tower, built in 1984, dozens of men and women monitor screens showing planes across the country as they guide aircraft in to land at the airport's two runways. Above them, a sign in English says: "Don't find your limits by an accident." Like many airports in the country, Soekarno-Hatta is struggling to cope with Asia's boom in air travel. Its designed annual capacity is 22 million passengers. Last year, it handled more than 60 million.
"The workload is increasing, the hazard is increasing," said Mr Darjono. "We need a third runway." Plans for that third runway have been in discussion for at least five years and construction is now slated to start in 2016.
Even with the improvement in control equipment and staff, problems in the maintenance of Indonesia's often aging aircraft have been a common source of trouble in accidents.
In the canteen of the flight health center in Jakarta, where pilots have six-monthly checkups, F Novara recalls a turboprop flight he piloted in 2011 with 74 passengers, where one of his engines caught fire after takeoff because of a leaking fuel nozzle.
"We had fuel, we had air and we had heat - boom!' he said, drinking milky sweet coffee and smoking after passing his medical. "All I could do was pray the passengers would be safe."
The plane landed safely, and an investigation by the engine manufacturer showed there was a kink in the fuel pipe, a fault Novara says the maintenance crew should have spotted.
Maintenance records for the doomed AirAsia flight showed 23 reported problems with the rudder system on the aircraft in the year leading up to the accident, increasing in frequency in the final three months. The fault, related to a crack in the solder on a circuit board, occurred four times during the fatal flight, according to the investigators' report.
The report said the maintenance regime "resulted in inadequate data to identify and analyse the defects" and was "a missed opportunity to identify and rectify" the problem.
In an effort to improve safety, the transport minister has been clamping down on pilots and airlines, revoking route approvals and handing out suspensions for violators.
Most recently, the ministry banned Batik Air from flying to Yogyakarta from Jakarta after one of its planes overshot Yogyakarta's runway on Nov 6. Batik Air didn't respond to e- mails requesting comment on the incident.
The clampdown has angered some pilots, who say the measures, which include threatening to punish them for hard landings or go-arounds, are likely to make safety worse, not better.
"There is no such thing anywhere else in the world," said Captain Bambang Adisurya, a pilot for national airline PT Garuda Indonesia, and a member of the Indonesia Pilots Association. "The fear is now that if something happens pilots won't report it. If the industry is not regulated well, then things will stay as they are. It seems like there is an accident every month." Other pilots say the enforcement of regulations is long overdue.
"You can't play around anymore, things are strict," said Ongky Soetadi, a helicopter pilot who used to fly planes in Indonesia.
He said previous practices by some pilots included getting a "jockey" to take medical exams for you, and flying longer hours than they should. "But we need time because we were left behind." No matter how well the regulations are enforced, the industry is struggling to keep up with demand for qualified and experienced staff. The aviation boom in Asia means that there are thousands of airports and carriers trying to find pilots, air traffic controllers and maintenance staff from the same limited global pool of talent.
A pilot in charge of training at one of the biggest carriers in the region said that out of every 100 new pilots from flight school, only about 10 would be good enough to meet the airline's standards. Schools falsify times for solo hours to speed up certification, so the new fliers don't have enough experience or confidence in handling different situations, he said, asking for him and his airline not to be named because of company confidentiality.
He said that the lack of confidence or experience reinforced cultural constraints that discourage junior officers from questioning or criticising decisions of the senior pilot, which jeopardised safety.
"At flight school the instructors are treated like Gods, and this continues afterwards," said Soetadi, the helicopter pilot. "When he or she is senior, they get the same treatment. It's the Eastern culture."
Poor cockpit resource management - pilots' communication, leadership, and decision making - was identified by government crash investigators as a factor in the 2013 crash of a Lion Air jet into the sea off Bali and the 2011 crash of a CASA 212-200 aircraft operated by Nusantara Buana Air on Sumatra.
It also contributed to the AirAsia disaster.
The pilots didn't discuss the risks of disengaging the auto-pilot and, once it was done, the senior officer gave a series of ambiguous commands, such as "pull down," resulting in both pilots trying to control the plane with their flight control columns, according to the investigation.
"The captain pulled while the co-pilot pushed, so the recovery wasn't effective," head investigator Nurcahyo Utomo said.
Neither pilot had received training on how to recover from a stall on the Airbus A320, since it's not required according to the Flight Crew Training Manual, and isn't mandated by Indonesia's civilian aviation regulator, the investigators said.
"It is true that the pilots failed to control the plane properly once the AP disengaged, but they should not have ever been in the situation where that was necessary," said Mike Exner, a pilot and satellite engineer based in Boulder, Colorado.
In an e-mail response to questions about the faulty circuit board, Airbus said it had noted the details in the final report. "The contributing factors need to be considered together to enable all parties concerned to take actions to ensure that such a tragedy does not reoccur," the company said.
AirAsia said it has improved training, especially for the circumstances the pilots faced before the crash, and implemented a real-time monitoring system that transmits data about aircraft performance during flights. It also hired former FAA regulators and global testing company Bureau Veritas Group to make recommendations on improving safety.
With thunderstorms ahead, the pilots radioed air traffic control, asking to alter the flight path and climb to 38,000 feet, according to an initial report from investigators in January. Four minutes later, a controller cleared them to climb to 34,000 feet. About two minutes after that, he lost contact with the plane. Satellite images showed the storm clouds reached as high as 44,000 feet.
The final crash report says weather wasn't a factor, but pilots who fly regularly in Indonesia say they frequently face tough conditions, especially for the smaller aircraft that serve remote airports.
LAND OF THUNDERSTORMS
The region has one of the highest incidences of thunderstorms and lightning strikes in the world. (The city of Bogor had a record 322 days of thunderstorms in one year in 1988.) Add to that, volcanic eruptions, which throw plumes of ash into the air that can get sucked into jet engines, causing them to fail. Airlines canceled hundreds of flights in and out of Bali after nearby Mount Rinjani erupted in October and November this year.
Then there are man-made hazards from the burning of thousands of acres of rainforest for agriculture, creating a cloud of smoke that covered large parts of Southeast Asia this year and delayed or canceled dozens of flights.
Mr Novara, who's been flying commercial planes for 23 years and sometimes delivers new planes to Indonesia from Boeing's factory, says the weather is one of the differences between flying in Europe and Indonesia. "There the equipment is great, clouds stop at 10,000 feet. Here they reach 36,000 feet."
Extreme weather occurrences in the country are becoming more common, according to local meteorologists. Earlier this year in the province of Papua, hailstones fell continuously for three days in tropical Lanny Jaya regency, as temperatures dropped to minus 2 deg C, killing 11 people, according to a report in the Jakarta Post.
Papua, more than anywhere, shows the challenges pilots face in Indonesia. The Indonesian half of the island of New Guinea is an intimidating mix of remote jungles and soaring mountains. The land rises from coastal mangrove swamps to a range with the highest island peak in the world, Puncak Jaya, and the site of one of the world's last tropical glaciers.
"There are dozens of airports in Papua with steep inclines," said Matt Dearden, a British commercial pilot who has been working in Indonesia for six years. Some can be as much as 30 degrees and conditions aren't suited to new pilots with little experience, he said.
"There are no go-around options on many of them - once you are committed on the approach, you must land," said Mr Dearden, whose 9-seater craft often ferries sick or injured passengers, tribesmen with bows and arrows or officials carrying cash.
"Some operators cut corners when it comes to training, which in a place as unforgiving as Papua compromises safety," he said. "Papua is not a place for pilots straight out of flight school as some of these accidents demonstrate."
When a PT Trigana Air Service twin-propeller plane disappeared in Papua in August, it took two days before rescuers found and reached the crash site in the jungle, to report that all 54 people on board had died. Trigana didn't respond to requests for comment on the incident.
While there's little the government and airlines can do about the weather, the industry will need billions of dollars of investment to keep up with demand from residents and tourists.
"Indonesia still has some way to go before it reaches a state where the culture of safety is paramount," said Shukor Yusof, founder of Singapore-based aviation research firm Endau Analytics. "There are issues that remain undealt with because money, effort and energy have not been fully utilised."