Crash of an ATR72-500 in Magong: 48 killed

Date & Time: Jul 23, 2014 at 1906 LT
Type of aircraft:
Operator:
Registration:
B-22810
Survivors:
Yes
Site:
Schedule:
Kaohsiung – Magong
MSN:
642
YOM:
2000
Flight number:
GE222
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
54
Pax fatalities:
Other fatalities:
Total fatalities:
48
Captain / Total flying hours:
22994
Captain / Total hours on type:
19069.00
Copilot / Total flying hours:
2392
Copilot / Total hours on type:
2083
Aircraft flight hours:
27039
Aircraft flight cycles:
40387
Circumstances:
The aircraft was being operated on an instrument flight rules (IFR) regular public transport service from Kaohsiung to Magong in the Penghu archipelago. At 1906 Taipei Local Time, the aircraft impacted terrain approximately 850 meters northeast of the threshold of runway 20 at Magong Airport and then collided with a residential area on the outskirts of Xixi village approximately 200 meters to the southeast of the initial impact zone. At the time of the occurrence, the crew was conducting a very high frequency omni-directional radio range (VOR) non-precision approach to runway 20. The aircraft was destroyed by impact forces and a post-impact fire. Ten passengers survived the occurrence and five residents on the ground sustained minor injuries. The occurrence was the result of controlled flight into terrain, that is, an airworthy aircraft under the control of the flight crew was flown unintentionally into terrain with limited awareness by the crew of the aircraft’s proximity to terrain. The crew continued the approach below the minimum descent altitude (MDA) when they were not visual with the runway environment contrary to standard operating procedures. The investigation report identified a range of contributing and other safety factors relating to the flight crew of the aircraft, TransAsia’s flight operations and safety management processes, the communication of weather information to the flight crew, coordination issues at civil/military joint-use airport, and the regulatory oversight of TransAsia by the Civil Aeronautics Administration (CAA).
Probable cause:
- The flight crew did not comply with the published runway 20 VOR non-precision instrument approach procedures at Magong Airport with respect to the minimum descent altitude (MDA). The captain, as the pilot flying, intentionally descended the aircraft below the published MDA of 330 feet in the instrument meteorological conditions (IMC) without obtaining the required visual references.
- The aircraft maintained an altitude between 168 and 192 feet before and just after overflying the missed approach point (MAPt). Both pilots spent about 13 seconds attempting to visually locate the runway environment, rather than commencing a missed approach at or prior to the MAPt as required by the published procedures.
- As the aircraft descended below the minimum descent altitude (MDA), it diverted to the left of the inbound instrument approach track and its rate of descent increased as a result of the flying pilot’s control inputs and meteorological conditions. The aircraft’s hazardous flight path was not detected and corrected by the crew in due time to avoid the collision with the terrain, suggesting that the crew lost situational awareness about the aircraft’s position during the latter stages of the approach.
- During the final approach, the heavy rain and associated thunderstorm activity intensified producing a maximum rainfall of 1.8 mm per minute. The runway visual range (RVR) subsequently reduced to approximately 500 meters. The degraded visibility significantly reduced the likelihood that the flight crew could have acquired the visual references to the runway environment during the approach.
- Flight crew coordination, communication, and threat and error management were less than effective. That compromised the safety of the flight. The first officer did not comment about or challenge the fact that the captain had intentionally descended the aircraft below the published minimum descent altitude (MDA). Rather, the first officer collaborated with the captain’s intentional descent below the MDA. In addition, the first officer did not detect the aircraft had deviated from the published inbound instrument approach track or identify that those factors increased the risk of a controlled flight into terrain (CFIT) event.
- None of the flight crew recognized the need for a missed approach until the aircraft reached the point (72 feet, 0.5 nautical mile beyond the missed approach point) where collision with the terrain became unavoidable.
- The aircraft was under the control of the flight crew when it collided with foliage 850 meters northeast of the runway 20 threshold, two seconds after the go around decision had been made. The aircraft sustained significant damage and subsequently collided with buildings in a residential area. Due to the high impact forces and post-impact fire, the crew and most passengers perished.
- According to the flight recorders data, non-compliance with standard operating procedures (SOP's) was a repeated practice during the occurrence flight. The crew’s recurring non-compliance with SOP's constituted an operating culture in which high risk practices were routine and considered normal.
- The non-compliance with standard operating procedures (SOP's) breached the obstacle clearances of the published procedure, bypassed the safety criteria and risk controls considered in the design of the published procedures, and increased the risk of a controlled flight into terrain (CFIT) event.
Final Report:

Crash of an ATR72-202 off Magong: 2 killed

Date & Time: Dec 21, 2002 at 0152 LT
Type of aircraft:
Operator:
Registration:
B-22708
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Taipei - Macau
MSN:
322
YOM:
1992
Flight number:
GE791
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
14247
Captain / Total hours on type:
10608.00
Copilot / Total flying hours:
4578
Copilot / Total hours on type:
4271
Aircraft flight hours:
19254
Aircraft flight cycles:
25529
Circumstances:
The aircraft departed Taipei-Chiang Kai Shek Airport at 0105LT on a cargo flight to Macau with two pilots on board and a load consisting of leather parts and electronic materials. While cruising at an altitude of 18,000 feet off the Penghu Islands, the crew contacted ATC and was cleared to descend to 16,000 feet due to icing conditions. At 01h52, at an altitude of 17,853 feet, the stall warning sounded and the stick shaker activated. The crew disconnected the autopilot system and elected to maintain control of the airplane. Sixteen seconds later, the aircraft entered an uncontrolled descent and reached the speed of 320 knots with a rate of descent of 603 feet per second (more than 36,000 feet per minute) before crashing in the sea 17 km southwest of the city of Magong. Few debris were found floating on water and both pilots were killed.
Probable cause:
The following findings were identified:
1. The accident flight encountered severe icing conditions. The liquid water content and maximum droplet size were beyond the icing certification envelope of FAR/JAR 25 appendix C.
2. TNA's training and rating of aircraft severe icing for this pilots has not been effective and the pilots have not developed a familiarity with the Note, CAUTION and WARNING set forth in Flight Crew Operating Manual and Airplane Flight Manual to adequately perform their duties.
3. After the flight crew detected icing condition and the airframe de-icing system was activated twice, the flight crew did not read the relative Handbook, thereby the procedure was not able to inform the flight crew and to remind them of "be alert to severe icing detection".
4. The "unexpected decrease in speed" indicated by the airspeed indicator is an indication of severe icing.
5. The flight crew did not respond to the severe Icing conditions with pertinent alertness and situation awareness that the aircraft might have encountered conditions which was "outside that for which the aircraft was certificated and might seriously degrade the performance and controllability of the aircraft".
6. The flight crew was too late in detecting the severe icing conditions. After detection, they did not change altitude immediately, nor take other steps required in the Severe Icing Emergency Procedures.
7. The aircraft was in an "unusual or uncontrolled rolling and pitching" state, and a stall occurred thereafter.
8. After the aircraft had developed a stall and an abnormal attitude, the recovery maneuvering did not comply with the operating procedures and techniques for Recovery of Unusual Attitudes. The performance and controllability of the aircraft may have been seriously degraded by then. It cannot be confirmed whether the unusual attitudes of the aircraft could have been recovered if the crew's operation had complied with the relevant procedures and techniques.
9. During the first 25 minutes, the extra drag increased about 100 counts, inducing a speed diminishing about 10 knots.
10. During the airframe de-icing system was intermittently switched off, it is highly probable that residual ice covered on the wings of the aircraft.
11. Four minutes prior to autopilot disengaged, the extra drag increased about 500 counts, and airspeed decayed to 158 knots, and lift-drag ratio loss about 64% rapidly.
12. During the 10s before the roll upset, the longitudinal and lateral stability has been modified by the severe ice accumulated on the wings producing the flow separation. Before autopilot disengaged, the aerodynamic of the aircraft (lift/drag) was degraded of about 40%.
Final Report:

Crash of a Boeing 747-209B off Magong: 225 killed

Date & Time: May 25, 2002 at 1529 LT
Type of aircraft:
Operator:
Registration:
B-18255
Flight Phase:
Survivors:
No
Schedule:
Taipei - Hong Kong
MSN:
21843
YOM:
1979
Flight number:
CI1611
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
206
Pax fatalities:
Other fatalities:
Total fatalities:
225
Captain / Total flying hours:
10148
Captain / Total hours on type:
4732.00
Copilot / Total flying hours:
10173
Copilot / Total hours on type:
5831
Aircraft flight hours:
64810
Aircraft flight cycles:
21398
Circumstances:
On May 25, 2002, China Airlines (CAL) CI611, a Boeing 747-200, Republic of China (ROC) registration B-18255, was a regularly scheduled flight from Chiang Kai Shek International Airport (CKS), Taoyuan, Taiwan, ROC to Chek Lap Kok International Airport, Hong Kong. Flight CI611 was operating in accordance with ROC Civil Aviation Administration (CAA) regulations. The captain (Crew Member-1, CM-1) reported for duty at 1305 , at the CAL CKS Airport Dispatch Office and was briefed by the duty dispatcher for about 20 minutes, including Notices to Airmen (NOTAM) regarding the TPE Flight Information Region (FIR). The first officer (Crew Member-2, CM-2) and flight engineer (Crew Member-3, CM-3) reported for duty at CAL Reporting Center, Taipei, and arrived at CKS Airport about 1330. The aircraft was prepared for departure with two pilots, one flight engineer, 16 cabin crew members, and 206 passengers aboard. The crew of CI611 requested taxi clearance at 1457:06. At 1507:10, the flight was cleared for takeoff on Runway 06 at CKS. The takeoff and initial climb were normal. The flight contacted Taipei Approach at 1508:53, and at 1510:34, Taipei Approach instructed CI611 to fly direct to CHALI. At 1512:12, CM-3 contacted China Airlines Operations with the time off-blocks, time airborne, and estimated time of arrival at Chek Lap Kok airport. At 1516:24, the Taipei Area Control Center controller instructed CI611 to continue its climb to flight level 350, and to maintain that altitude while flying from CHALI direct to KADLO4. The acknowledgment of this transmission, at 1516:31, was the last radio transmission received from the aircraft. Radar contact with CI611 was lost by Taipei Area Control at 1528:03. An immediate search and rescue operation was initiated. At 1800, floating wreckage was sighted on the sea in the area 23 nautical miles northeast of Makung, Penghu Islands. The aircraft was totally destroyed and all 225 occupants were killed.
Probable cause:
Findings related to probable causes:
1. Based on the recordings of CVR and FDR, radar data, the dado panel open-close positions, the wreckage distribution, and the wreckage examinations, the in-flight breakup of CI611, as it approached its cruising altitude, was highly likely due to the structural failure in the aft lower lobe section of the fuselage.
2. In February 7 1980, the accident aircraft suffered a tail strike occurrence in Hong Kong. The aircraft was ferried back to Taiwan on the same day un-pressurized and a temporary repair was conducted the day after. A permanent repair was conducted on May 23 through 26, 1980.
3. The permanent repair of the tail strike was not accomplished in accordance with the Boeing SRM, in that the area of damaged skin in Section 46 was not removed (trimmed) and the repair doubler did not extend sufficiently beyond the entire damaged area to restore the structural strength.
4. Evidence of fatigue damage was found in the lower aft fuselage centered about STA 2100, between stringers S-48L and S-49L, under the repair doubler near its edge and outside the outer row of securing rivets. Multiple Site Damage (MSD), including a 15.1-inch through thickness main fatigue crack and some small fatigue cracks were confirmed. The 15.1-inch crack and most of the MSD cracks initiated from the scratching damage associated with the 1980 tail strike incident.
5. Residual strength analysis indicated that the main fatigue crack in combination with the Multiple Site Damage (MSD) were of sufficient magnitude and distribution to facilitate the local linking of the fatigue cracks so as to produce a continuous crack within a two-bay region (40 inches). Analysis further indicated that during the application of normal operational loads the residual strength of the fuselage would be compromised with a continuous crack of 58 inches or longer length. Although the ASC could not determine the length of cracking prior to the accident flight, the ASC believes that the extent of hoop-wise fretting marks found on the doubler, and the regularly spaced marks and deformed cladding found on the fracture surface suggest that a continuous crack of at least 71 inches in length, a crack length considered long enough to cause structural separation of the fuselage, was present before the in-flight breakup of the aircraft.
6. Maintenance inspection of B-18255 did not detect the ineffective 1980 structural repair and the fatigue cracks that were developing under the repair doubler. However, the time that the fatigue cracks propagated through the skin thickness could not be determined.
Final Report:

Crash of an ATR72-202 near Taipei: 4 killed

Date & Time: Jan 30, 1995 at 1943 LT
Type of aircraft:
Operator:
Registration:
B-22717
Flight Type:
Survivors:
No
Site:
Schedule:
Magong - Taipei
MSN:
435
YOM:
1994
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew was completing a positioning flight from Magong to Taipei. While descending to Taipei-Songshan Airport, the crew encountered poor weather conditions with a limited visibility due to heavy rain falls. The minimum descent altitude was fixed at 2,500 feet but for unknown reasons, the crew descended to 1,000 feet when the aircraft struck the slope of a wooded hill located 20 km from the airport. The aircraft was destroyed upon impact and all four crew members were killed.
Probable cause:
The crew failed to adhere to the published approach procedures and continued the descent below MDA until the aircraft struck the ground. Brand new, the aircraft was delivered to TransAsia Airways last December 20 and was equipped with a category II GPWS. It is believed that the GPWS alarm did not sound in the cockpit and was not recorded on the CVR.

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.