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Crash of an Airbus A300-622R in Taipei: 203 killed

Date & Time: Feb 16, 1998 at 2006 LT
Type of aircraft:
Operator:
Registration:
B-1814
Survivors:
No
Site:
Schedule:
Denpasar - Taipei
MSN:
578
YOM:
1990
Flight number:
CI676
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
182
Pax fatalities:
Other fatalities:
Total fatalities:
203
Captain / Total flying hours:
7210
Copilot / Total flying hours:
3530
Aircraft flight hours:
20193
Aircraft flight cycles:
8800
Circumstances:
Following an uneventful flight from Denpasar-Ngurah Rai Airport, the aircraft was approaching Taipei-Taoyuan Airport by night and marginal weather conditions with a limited visibility of 2,400 feet, an RVR of 3,900 feet and 300 feet broken ceiling, 3,000 feet overcast. On final approach to runway 05L in light rain and fog, at the altitude of 1,515 feet, the aircraft was 1,000 feet too high on the glide so the captain decided to initiate a go-around procedure. The automatic pilot system was disconnected but for unknown reasons, the crew failed to correct the pitch up attitude. The aircraft passed the runway threshold at an altitude of 1,475 feet, pitched up go around thrust was applied. The aircraft rapidly pitched up, reaching +35° and climbed through 1,723 feet at an airspeed of 134 knots. The gear had just been raised and the flaps set to 20°. The aircraft continued to climb to 2,751 feet when the speed dropped to 43 knots. At this point, the aircraft stalled, entered an uncontrolled descent (pitched down to 44,65°). The crew was apparently able to regain control when the aircraft rolled to the right at an angle of 20° 2-3 seconds prior to final impact. The aircraft struck the ground 200 feet to the right of the runway 05L centerline and 3,7 km from its threshold and eventually crashed on 12 houses. The aircraft disintegrated on impact and all 196 occupants were killed, among them five US citizens, one Indonesian and one French. On the ground, seven people were killed.
Probable cause:
The following factors were identified:
- Wrong approach configuration as the aircraft was too high on the glide,
- Poor crew coordination,
- The crew failed to comply with published procedures,
- Poor crew training,
- The crew failed to correct the pitch up attitude during the go-around procedure,
- Lack of visibility due to night, rain and fog.

Crash of an Airbus A300-622R in Nagoya: 264 killed

Date & Time: Apr 26, 1994 at 2015 LT
Type of aircraft:
Operator:
Registration:
B-1816
Survivors:
Yes
Schedule:
Taipei - Nagoya
MSN:
580
YOM:
1990
Flight number:
CI140
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
256
Pax fatalities:
Other fatalities:
Total fatalities:
264
Captain / Total flying hours:
8340
Captain / Total hours on type:
1350.00
Copilot / Total flying hours:
1624
Copilot / Total hours on type:
1033
Aircraft flight hours:
8550
Aircraft flight cycles:
3910
Circumstances:
China Airlines' Flight 140 (from Taipei International Airport to Nagoya Airport), B-1816, took off from Taipei International Airport at 0853 UTC (1753 JST) on April 26, 1994 (hereinafter all times shown are Coordinated Universal Time, unless otherwise specified), canying a total of 271 persons consisting of 2 flight crew members, 13 cabin crew members and 256 passengers (including 2 infants). The flight plan of the aircraft, which had been filed to the Taiwanese civil aviation authorities, Zhongzheng International Airport Office, was as follows:
Flight rule: IFR, Aerodrome of departure: Taipei International Airport, Destination Aerodrome: Nagoya Airport, Cruising speed: 465 knots, Level: FL330, Route: A1 SUCJAKAL-KE-SIV-XMC, total estimated enroute time: 2 hours and 18 minutes, Alternate Aerodrome: Tokyo International Airport.
DFDR shows that the aircraft reached FL330 about 0914 and continued its course toward Nagoya Airport in accordance with its flight plan.
DFDR and CVR show that its flight history during approximately 30 minutes prior to the accident progressed as follows:
The aircraft which was controlled by the FIO, while cruising at FL330 was cleared at 1047:35 to descend to FL210 by the Tokyo Area Control Center and commenced descent. For about 25 minutes from a few minutes before the aircraft began its descent, the CAP briefed the F/O on approach and landing.
At 1058:18, communication was established with Nagoya Approach Control. The aircraft began to descend and decreased its speed gradually, in accordance with the clearances given by Approach Control.
At 1104:03, the aircraft was instructed by Nagoya Approach control to make a left turn to a heading of 010". Later, at 1107:14, the aircraft was cleared for ILS approach to Runway 34 and was instructed to contact Nagoya Tower. After the aircraft took off from Taipei International Airport, from 0854 when the aircraft had passed 1,000 feet pressure altitude, AP No.2 was engaged during climb, cruise and descent.
At 1107:22, when the aircraft was in the initial phase of approach to Nagoya airport, AP No. 1 was also engaged. Later, at 1111:36, both AP No. 1 and 2 were disengaged by the FIO. The aircraft passed the outer marker at 1112:19, and at 1113:39, received landing clearance from Nagoya Tower. At this time, the aircraft was reported of winds 290 degrees at 6 knots. Under manual control, the aircraft continued normal LS approach.
At 1114:05, however, while crossing approximately 1,070 feet pressure altitude, the F/O inadvertently triggered the GO lever. As a result the aircraft shifted into GO AROUND mode leading to an increase in thrust. The CAP cautioned the FIO that he had triggered the GO lever and instructed him, saying "disengage it". The aircraft leveled off for about 15 seconds at approximately 1,040 feet pressure altitude (at a point some 5.5 km from the Runway). The CAP instructed the F/O to correct the descent path which had become too high. The F/O acknowledged this. Following the instruction, the F/O applied nose down elevator input to adjust its descent path, and consequently the aircraft gradually regained its normal glide path. During this period, the CAP cautioned to the FIO twice that the aircraft was in GO AROUND Mode.
At 1114: 18, both AP No.2 and No. 1 were engaged almost simultaneously when the aircraft was flying at approximately 1,040 feet pressure altitude, a point 1.2 dots above the glide slope. Both APs were used for the next 30 seconds. There is no definite record in the CVR of either the crew expressing their intention or calling out to use the AP. For approximately 18 seconds after the AP was engaged, the THS gradually moved from -5.3" to -12.3", which is close to the maximum nose-up limit. The THS remained at -12.3" until 1115: 1 1. During this period, the elevator was continually moved in the nose-down direction. In this condition, the aircraft continued its approach, and at 1115:02, when it was passing about 510 feet pressure altitude (at a point approximately 1.8 km from the runway), the CAP, who had been informed by the FIO that the THR had been latched, told the FIO that he would take over the controls. Around this time, the THR levers had moved forward greatly, increasing EPR from about 1.0 to more than 1.5. Immediately afterwards, however, the THR levers were retarded, decreasing EPR to 1.3. In addition, the elevator was moved close to its nose-down limit when the CAP took the controls.
At 1115:11, immediately after the CAP called out "Go lever", the THR levers were moved forward greatly once again, increasing EPR to more than 1.6. The aircraft therefore began to climb steeply. The F/O reported to Nagoya Tower that the aircraft would go around, and Nagoya Tower acknowledged this. The aircraft started climbing steeply, AOA increased sharply and CAS decreased rapidly. During this period, the TI-IS decreased from -12.3" to -7.4", and SLATS/FLAPS were retracted from 30/40 to 15/15 after the F/O reported "Go Around to Nagoya Tower.
At 1115:17, the GPWS activated Mode 5 warning "Glide Slope" once, and at 1115:25, the stall warning sounded for approximately 2 seconds.
At 1115:31, after reaching about 1,730 feet pressure altitude (about 1,790 feet radio altitude), the aircraft lowered its nose and began to dive.
At 1115:37, the GPWS activated Mode 2 warning "Terrain, Terrain" once, and the stall warning sounded from 1115:40 to the time of crash.
At about 1115:45, the aircraft crashed into the landing zone close to the El taxiway. The accident occurred within the landing zone approximately 110 meters east-northeast of the center of the Runway 34 end at Nagoya Airport. It occurred at about 1115:45. Seven passengers were seriously injured and all 264 other occupants were killed.
Probable cause:
While the aircraft was making an ILS approach to Runway 34 of Nagoya Airport, under manual control by the F/O, the F/O inadvertently activated the GO lever, which changed the FD (Flight Director) to GO AROUND mode and caused a thrust increase. This made the aircraft deviate above its normal glide path. The APs were subsequently engaged, with GO AROUND mode still engaged. Under these conditions the FIO continued pushing the control wheel in accordance with the CAP'S instructions. As a result of this, the THS (Horizontal Stabilizer) moved to its full nose-up position and caused an abnormal out-of-trim situation. The crew continued approach, unaware of the abnormal situation. The AOA increased. The Alpha Floor function was activated and the pitch angle increased. It is considered that, at this time, the CAP (who had now taken the controls), judged that landing would be difficult and opted for go-around. The aircraft began to climb steeply with a high pitch angle attitude. The CAP and the FIO did not carry out an effective recovery operation, and the aircraft stalled and crashed.
The AAIC determined that the following factors, as a chain or a combination thereof, caused the accident:
1. The F/O inadvertently triggered the Go lever. It is considered that the design of the GO lever contributed to it: normal operation of the thrust lever allows the possibility of an inadvertent triggering of the GO lever.
2. The crew engaged the APs while GO AROUND mode was still engaged, and continued approach.
3. The F/O continued pushing the control wheel in accordance with the CAP'S instructions, despite its strong resistive force, in order to continue the approach.
4. The movement of the THS conflicted with that of the elevators, causing an abnormal out-of-trim situation.
5. There was no warning and recognition function to alert the crew directly and actively to the onset of the abnormal out-of-trim condition.
6. The CAP and FIO did not sufficiently understand the FD mode change and the AP override function. It is considered that unclear descriptions of the AFS (Automatic Flight System) in the FCOM (Flight Crew Operating Manual) prepared by the aircraft manufacturer contributed to this.
7. The CAP'S judgment of the flight situation while continuing approach was inadequate, control take-over was delayed, and appropriate actions were not taken.
8. The Alpha-Floor function was activated; this was incompatible with the abnormal out-of-trim situation, and generated a large pitch-up moment. This narrowed the range of selection for recovery operations and reduced the time allowance for such operations.
9. The CAP'S and F/O's awareness of the flight conditions, after the PIC took over the controls and during their recovery operation, was inadequate respectively.
10. Crew coordination between the CAP and the FiO was inadequate.
11. The modification prescribed in Service Bulletin SB A300-22-6021 had not been incorporated into the aircraft.
12. The aircraft manufacturer did not categorise the SB A300-22-602 1 as "Mandatory", which would have given it the highest priority. The airworthiness authority of the nation of design and manufacture did not issue promptly an airworthiness directive pertaining to implementation of the above SB.
Final Report:

Crash of a Boeing 747-409 in Hong Kong

Date & Time: Nov 4, 1993 at 1136 LT
Type of aircraft:
Operator:
Registration:
B-165
Survivors:
Yes
Schedule:
Taipei - Hong Kong
MSN:
24313
YOM:
1993
Flight number:
CI605
Country:
Region:
Crew on board:
22
Crew fatalities:
Pax on board:
274
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12469
Captain / Total hours on type:
3559.00
Copilot / Total flying hours:
5705
Copilot / Total hours on type:
908
Aircraft flight hours:
1969
Aircraft flight cycles:
359
Circumstances:
China Airlines' scheduled passenger flight CAL605 departed Taipei (TPE), Taiwan at 02:20 for the 75-minute flight to Hong Kong-Kai Tak (HKG). The departure and cruise phases were uneventful. During the cruise the commander briefed the co-pilot on the approach to Hong Kong using the airline's own approach briefing proforma as a checklist for the topics to cover. The briefing included the runway-in-use, navigation aids, decision height, crosswind limit and missed approach procedure. He paid particular attention to the crosswind and stated that, should they encounter any problem during the approach, they would go-around and execute the standard missed approach procedure. The commander did not discuss with the co-pilot the autobrake setting, the reverse thrust power setting or their actions in the event of a windshear warning from the Ground Proximity Warning System (GPWS). Weather reports indicated strong gusty wind conditions, rain and windshear. On establishing radio contact with Hong Kong Approach Control at 03:17, the crew were given radar control service to intercept the IGS approach to runway 13 which is offset from the extended runway centreline by 47°. After intercepting the IGS localiser beam, the pilots changed frequency to Hong Kong Tower and were informed by the AMC that the visibility had decreased to 5 kilometres in rain and the mean wind speed had increased to 22 kt. Two minutes before clearing CAL605 to land, the air traffic controller advised the crew that the wind was 070/25 kt and to expect windshear turning short final. During the approach the pilots completed the landing checklist for a flaps 30 landing with the autobrakes controller selected to position '2' and the spoilers armed. The reference airspeed (Vref) at the landing weight was 141 kt; to that speed the commander added half the reported surface wind to give a target airspeed for the final approach of 153 kt. Rain and significant turbulence were encountered on the IGS approach and both pilots activated their windscreen wipers. At 1,500 feet altitude the commander noted that the wind speed computed by the Flight Management Computer (FMC) was about 50 kt. At 1,100 feet he disconnected the autopilots and commenced manual control of the flightpath. A few seconds later at 1,000 feet he disconnected the autothrottle system because he was dissatisfied with its speed holding performance. From that time onwards he controlled the thrust levers with his right hand and the control wheel with his left hand. Shortly afterwards the commander had difficulty in reading the reference airspeed on his electronic Primary Flying Display (PFD) because of an obscure anomaly, but this was rectified by the co-pilot who re-entered the reference airspeed of 141 kt into the FMC. Shortly before the aircraft started the visual right turn onto short final, the commander saw an amber 'WINDSHEAR' warning on his PFD. A few seconds later, just after the start of the finals turn, the ground proximity warning system (GPWS) gave an aural warning of "GLIDESLOPE" which would normally indicate that the aircraft was significantly below the IGS glidepath. One second later the aural warning changed to "WINDSHEAR" and the word was repeated twice. At the same time both pilots saw the word 'WINDSHEAR' displayed in red letters on their PFDs. Abeam the Checkerboard the commander was aware of uncommanded yawing and pitch oscillations. He continued the finals turn without speaking whilst the co-pilot called deviations from the target airspeed in terms of plus and minus figures related to 153 kt. At the conclusion of the turn both pilots were aware that the aircraft had descended below the optimum flight path indicated by the optical Precision Approach Path Indicator (PAPI) system. The air traffic controller watched the final approach and landing of the aircraft. It appeared to be on or close to the normal glidepath as it passed abeam the tower and then touched down gently on the runway just beyond the fixed distance marks (which were 300 metres beyond the threshold) but within the normal touchdown zone. The controller was unable to see the aircraft in detail after touchdown because of water spray thrown up by it but he watched its progress on the Surface Movement Radar and noted that it was fast as it passed the penultimate exit at A11. At that time he also observed a marked increase in the spray of water from the aircraft and it began to decelerate more effectively. The commander stated that the touchdown was gentle and in a near wings level attitude. Neither pilot checked that the speed brake lever, which was 'ARMED' during the approach, had moved to the 'UP' position on touchdown. A few seconds after touchdown, when the nose wheel had been lowered onto the runway, the co-pilot took hold of the control column with both hands in order to apply roll control to oppose the crosswind from the left. The aircraft then began an undesired roll to the left. Immediately the commander instructed the co-pilot to reduce the amount of applied into-wind roll control. At the same time he physically assisted the co-pilot to correct the aircraft's roll attitude. Shortly after successful corrective action the aircraft again rolled to the left and the commander intervened once more by reducing the amount of left roll control wheel rotation. During the period of unwanted rolling, which lasted about seven seconds, the aircraft remained on the runway with at least the left body and wing landing gears in contact with the surface. After satisfactory aerodynamic control was regained, the co-pilot noticed a message on the Engine Indicating and Crew Alerting System (EICAS) display showing that the autobrake system had disarmed. He informed the commander that they had lost autobrakes and then reminded him that reverse thrust was not selected. At almost the same moment the commander selected reverse thrust on all engines and applied firm wheel braking using his foot pedals. As the aircraft passed abeam the high speed exit taxiway (A11), the commander saw the end of the runway approaching. At that point both he and the co-pilot perceived that the distance remaining in which to stop the aircraft might be insufficient. At about the same time the co-pilot also began to press hard on his foot pedals. As the aircraft approached the end of the paved surface the commander turned the aircraft to the left using both rudder pedal and nose wheel steering tiller inputs. The aircraft ran off the end of the runway to the left of the centreline. The nose and right wing dropped over the sea wall and the aircraft entered the sea creating a very large plume of water which was observed from the control tower, some 3.5 km to the northwest. The controller immediately activated the crash alarm and the Airport Fire Contingent, which had been on standby because of the strong winds, responded very rapidly in their fire vehicles and fire boats. Other vessels in the vicinity also provided prompt assistance. After the aircraft had settled in the water, the commander operated the engine fuel cut-off switches and the co-pilot operated all the fire handles. The commander attempted to speak to the cabin crew using the interphone system but it was not working. The senior cabin crew member arrived on the flight deck as the commander was leaving his seat to proceed aft. The instruction to initiate evacuation through the main deck doors was then issued by the commander and supervised by the senior cabin crew member from the main deck. Ten passengers were injured, one seriously.
Probable cause:
The accident was the consequence of the combination of the following factors:
- The commander deviated from the normal landing roll procedure in that he inadvertently advanced the thrust levers when he should have selected reverse thrust.
- The commander diminished the co-pilot's ability to monitor rollout progress and proper autobrake operation by instructing him to perform a non-standard duty and by keeping him ill-informed about his own intentions.
- The copilot lacked the necessary skill and experience to control the aircraft during the landing rollout in strong, gusty crosswind conditions.
- The absence of a clearly defined crosswind landing technique in China Airline's Operations Manual deprived the pilots of adequate guidance on operations in difficult weather conditions.
Final Report:

Crash of a Boeing 747-2R7F near Wanli: 5 killed

Date & Time: Dec 29, 1991 at 1505 LT
Type of aircraft:
Operator:
Registration:
B-198
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Taipei - Anchorage
MSN:
22390
YOM:
1980
Flight number:
CI358
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
45868
Aircraft flight cycles:
9094
Circumstances:
Four minutes after takeoff from Taipei-Chiang Kai Shek Airport, while climbing to an altitude of 5,000 feet, the crew contacted ATC and declared an emergency after the engine n°3 separated from the right wing. The crew was instructed first to maintain FL050 and to initiate a left turn but the captain replied this was not possible so he was eventually cleared to turn to the right. Two minutes later, the aircraft entered an uncontrolled descent and crashed on the slope of Mt Wuzu located near Wanli, about 20 km northeast of Taipei. The aircraft disintegrated on impact and all five crew members were killed. The accident occurred six minutes after takeoff.
Probable cause:
It was determined that the engine n°3 detached during initial climb following the rupture of its pylon due to the presence of fatigue cracks. After the engine n°3 detached, it struck the engine n°4 that separated as well. In such conditions, the crew was unable to maintain a safe control of the aircraft. Last A-check maintenance programme was completed last December 21. It was also reported that a misunderstanding occurred between pilots and ATC who misunderstood which engine was lost, thinking that the emergency situation was reporting to a loss of engine n°2.

Crash of a Boeing 737-209 in Hualien: 54 killed

Date & Time: Oct 26, 1989 at 1855 LT
Type of aircraft:
Operator:
Registration:
B-180
Flight Phase:
Survivors:
No
Site:
Schedule:
Hualien - Taipei
MSN:
23795
YOM:
1986
Flight number:
CI204
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
54
Circumstances:
Following a night takeoff from runway 03 at Hualien Airport, while climbing, the crew initiated a turn to the left when, at an altitude of 7,000 feet, the aircraft struck the slope of a mountain located in the Chiashan Mountain Range located about 10 km northwest of the airport. The aircraft disintegrated on impact and all 54 occupants were killed.
Probable cause:
It was determined that the collision with the ground was the consequence of a controlled flight into terrain after the crew failed to follow the proper departure route and published procedure.
The following contributing factors were reported:
- Poor flight preparation,
- The crew failed to follow the departure route from runway 03 and initiated a turn to the left, a procedure valid for runway 21 departure onl. After takeoff from runway 03, crew must turn to the right over the sea,
- Poor crew coordination,
- The crew failed to follow the pre-takeoff checklist,
- Poor visibility due to the night.

Crash of a Boeing 737-281 off Magong: 13 killed

Date & Time: Feb 16, 1986 at 1850 LT
Type of aircraft:
Operator:
Registration:
B-1870
Survivors:
No
Schedule:
Kaohsiung - Magong
MSN:
20226
YOM:
1969
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
On final approach to Magong Airport by night, the crew apparently encountered problems with the nose gear. The captain decided to initiate a go-around procedure. Few minutes later, while climbing, the airplane entered an uncontrolled descent and crashed in the sea. On March 10, the wreckage was found in a depth of 58 meters about 19 km north of the airport. All 13 occupants were killed.

Crash of a Boeing 707-309C in Manila: 2 killed

Date & Time: Feb 27, 1980 at 1345 LT
Type of aircraft:
Operator:
Registration:
B-1826
Survivors:
Yes
Schedule:
Taipei - Manila
MSN:
20262/830
YOM:
1969
Flight number:
CI811
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On final approach to Manila Intl Airport, the airplane was too low and struck the ground about 50 meters short of runway threshold. Upon impact, two engines were torn off and out of control, the aircraft crash landed and came to rest in flames. 82 occupants escaped uninjured while 51 others were injured. Two passengers were killed. The aircraft was partially destroyed by fire.
Probable cause:
Wrong approach configuration on part of the crew who failed to follow the approach checklist. A lack of crew coordination led the aircraft descending below the glide.

Crash of a Boeing 707-324C off Taipei: 6 killed

Date & Time: Sep 11, 1979
Type of aircraft:
Operator:
Registration:
B-1834
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Taipei - Taipei
MSN:
18887/431
YOM:
1965
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The crew departed Taipei-Chiang Kai-shek Airport for a local training mission. During initial climb, the four engine airplane went out of control and crashed into the sea few hundred meters offshore. The aircraft was destroyed and all six crew members were killed.

Crash of a Douglas C-47A-90-DL in Kompong Som

Date & Time: Mar 26, 1975
Operator:
Registration:
B-1553
Flight Phase:
MSN:
20434
YOM:
1944
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in Kompong Som after an in-flight collision with a Cessna L-19 Bird Dog, The occupant's fate and the exact circumstances of the mishap remains unknown.

Crash of a Douglas C-54A-5-DC Skymaster in Battambang

Date & Time: Jul 15, 1974
Type of aircraft:
Operator:
Registration:
B-1811
Survivors:
Yes
MSN:
10302
YOM:
1944
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Suffered an accident at Battambang Airport. There were no injuries while the aircraft was damaged beyond repair.