Ground fire of a Boeing 737-809 in Naha

Date & Time: Aug 20, 2007 at 1033 LT
Type of aircraft:
Operator:
Registration:
B-18616
Flight Phase:
Survivors:
Yes
Schedule:
Taipei - Naha
MSN:
30175/1182
YOM:
2002
Flight number:
CI120
Location:
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7941
Captain / Total hours on type:
3823.00
Copilot / Total flying hours:
890
Copilot / Total hours on type:
182
Aircraft flight hours:
13664
Circumstances:
The aircraft departed Taipei-Taoyuan Airport at 0814LT on a schedule service to Naha with 157 passengers and a crew of 8. Following an uneventful flight, the crew was cleared to land on runway 18 and vacated via taxiway E6 then A5. After being stopped at spot 41, engines were shot down when a fire broke out somewhere in an area aft of the right engine and spread to the right wing leading edge near the n°5 slat and the apron surface below the right engine. All 165 occupants evacuated safely while the aircraft was totally destroyed by fire.
Probable cause:
It is considered highly probable that this accident occurred through the following causal chain: When the Aircraft retracted the slats after landing at Naha Airport, the track can that housed the inboard main track of the No. 5 slat on the right wing was punctured, creating a hole. Fuel leaked out through the hole, reaching the outside of the wing. A fire started when the leaked fuel came into contact with high-temperature areas on the right engine after the Aircraft stopped in its assigned spot, and the Aircraft burned out after several explosions. With regard to the cause of the puncture in the track can, it is certain that the downstop assembly having detached from the aft end of the above-mentioned inboard main track fell off into the track can, and when the slat was retracted, the assembly was pressed by the track against the track can and punctured it. With regard to the cause of the detachment of the downstop assembly, it is considered highly probable that during the maintenance works for preventing the nut from loosening, which the Company carried out on the downstop assembly about one and a half months prior to the accident based on the Service Letter from the manufacturer of the Aircraft, the washer on the nut side of the assembly fell off, following which the downstop on the nut side of the assembly fell off and then the downstop assembly eventually fell off the track. It is considered highly probable that a factor contributing to the detachment of the downstop assembly was the design of the downstop assembly, which was unable to prevent the assembly from falling off if the washer is not installed. With regard to the detachment of the washer, it is considered probable that the following factors contributed to this: Despite the fact that the nut was in a location difficult to access during the maintenance works, neither the manufacturer of the Aircraft nor the Company had paid sufficient attention to this when preparing the Service Letter and Engineering Order job card, respectively. Also, neither the maintenance operator nor the job supervisor reported the difficulty of the job to the one who had ordered the job.
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 a Boeing 747-412 in Taipei: 83 killed

Date & Time: Oct 31, 2000 at 2318 LT
Type of aircraft:
Operator:
Registration:
9V-SPK
Flight Phase:
Survivors:
Yes
Schedule:
Singapore – Taipei – Los Angeles
MSN:
28023/1099
YOM:
1997
Flight number:
SQ006
Country:
Region:
Crew on board:
20
Crew fatalities:
Pax on board:
159
Pax fatalities:
Other fatalities:
Total fatalities:
83
Captain / Total flying hours:
11235
Captain / Total hours on type:
2017.00
Copilot / Total flying hours:
2442
Copilot / Total hours on type:
552
Aircraft flight hours:
18459
Aircraft flight cycles:
2274
Circumstances:
Singapore Airlines Flight 006 departed Singapore for a flight to Los Angeles via Taipei. Scheduled departure time at Taipei was 22:55. The flight left gate B-5 and taxied to taxiway NP, which ran parallel to runway 05L and 05R. The crew had been cleared for a runway 05L departure because runway 05R was closed because of construction work. CAA Taiwan had issued a NOTAM on Aug 31, 2000 indicating that part of runway 05R between Taxiway N4 and N5 was closed for construction between Sept. 13 to Nov. 22, 2000. Runway 05R was to have been converted and re-designated as Taxiway NC effective Nov. 1, 2000. After reaching the end of taxiway NP, SQ006 turned right into Taxiway N1 and immediately made a 180-degree turn to runway 05R. After approximately 6 second hold, SQ006 started its takeoff roll at 23:15:45. Weather conditions were very poor because of typhoon 'Xiang Sane' in the area. METAR at 23:20 included Wind 020 degrees at 36 knots gusting 56 knots, visibility - 600 meters, and heavy rainfall. On takeoff, 3.5 seconds after V1, the aircraft hit concrete barriers, excavators and other equipment on the runway. The plane crashed back onto the runway, breaking up and bursting into flames while sliding down the runway and crashing into other objects related to work being done on runway 05R. The aircraft wreckage was distributed along runway 05R beginning at about 4,080 feet from the runway threshold. The airplane broke into two main sections at about fuselage station 1560 and came to rest about 6,480 feet from the runway threshold.
Probable cause:
Findings related to probable causes:
- At the time of the accident, heavy rain and strong winds from typhoon "Xangsane" prevailed. At 2312:02 Taipei local time, the flight crewmembers of SQ006 received Runway Visual Range (RVR) 450 meters on Runway 05L from Automatic Terminal Information Service (ATIS) "Uniform". At 2315:22 Taipei local time, they received wind direction 020 degrees with a magnitude of 28 knots, gusting to 50 knots, together with the takeoff clearance issued by the local controller.
- On August 31, 2000, CAA of ROC issued a Notice to Airmen (NOTAM) A0606 indicating that a portion of the Runway 05R between Taxiway N4 and N5 was closed due to work in progress from September 13 to November 22, 2000. The flight crew of SQ006 was aware of the fact that a portion of Runway 05R was closed, and that Runway 05R was only available for taxi.
- The aircraft did not completely pass the Runway 05R threshold marking area and continue to taxi towards Runway 05L for the scheduled takeoff. Instead, it entered Runway 05R and CM-1 commenced the takeoff roll. CM-2 and CM-3 did not question CM-1's decision to take off.
- The flight crew did not review the taxi route in a manner sufficient to ensure they all understood that the route to Runway 05L included the need for the aircraft to pass Runway 05R, before taxiing onto Runway 05L.
- The flight crew had CKS Airport charts available when taxing from the parking bay to the departure runway; however, when the aircraft was turning from Taxiway NP to Taxiway NI and continued turning onto Runway 05R, none of the flight crewmembers verified the taxi route. As shown on the Jeppesen "20-9" CKS Airport chart, the taxi route to Runway 05L required that the aircraft make a 90-degree right turn from Taxiway NP and then taxi straight ahead on Taxiway NI, rather than making a continuous 180-degree turn onto Runway 05R. Further, none of the flight crewmembers confirmed orally which runway they had entered.
- CM-1's expectation that he was approaching the departure runway coupled with the saliency of the lights leading onto Runway 05R resulted in CM?1 allocating most of his attention to these centerline lights. He followed the green taxiway centerline lights and taxied onto Runway 05R.
- The moderate time pressure to take off before the inbound typhoon closed in around CKS Airport, and the condition of taking off in a strong crosswind, low visibility, and slippery runway subtly influenced the flight crew's decision?making ability and the ability to maintain situational awareness.
- On the night of the accident, the information available to the flight crew regarding the orientation of the aircraft on the airport was:
- CKS Airport navigation chart
- Aircraft heading references
- Runway and Taxiway signage and marking
- Taxiway NI centerline lights leading to Runway 05L
- Color of the centerline lights (green) on Runway 05R
- Runway 05R edge lights most likely not on
- Width difference between Runway 05L and Runway 05R
- Lighting configuration differences between Runway 05L and Runway 05R
- Para-Visual Display (PVD) showing aircraft not properly aligned with the Runway 05L localizer
- Primary Flight Display (PFD) information
The flight crew lost situational awareness and commenced takeoff from the wrong runway.
The Singapore Ministry of Transport (MOT) did not agree with the findings and released their own report. They conclude that the systems, procedures and facilities at the CKS Airport were seriously inadequate and that the accident could have been avoided if internationally-accepted precautionary measures had been in place at the Airport.
Final Report:

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 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.