Region

Crash of an ATR72-600 in Taipei: 43 killed

Date & Time: Feb 4, 2015 at 1054 LT
Type of aircraft:
Operator:
Registration:
B-22816
Flight Phase:
Survivors:
Yes
Schedule:
Taipei - Kinmen
MSN:
1141
YOM:
2014
Flight number:
GE235
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
53
Pax fatalities:
Other fatalities:
Total fatalities:
43
Captain / Total flying hours:
4914
Captain / Total hours on type:
3151.00
Copilot / Total flying hours:
6922
Copilot / Total hours on type:
5687
Aircraft flight hours:
1627
Aircraft flight cycles:
2356
Circumstances:
The twin turboprop took off from runway 10 at 1052LT. While climbing to a height of 1,200 feet, the crew sent a mayday message, stating that an engine flamed out. Shortly later, the aircraft stalled and banked left up to an angle of 90° and hit the concrete barrier of a bridge crossing over the Keelung River. Out of control, the aircraft crashed into the river and was destroyed. It has been confirmed that 40 occupants were killed while 15 others were rescued. Three occupants remains missing. A taxi was hit on the bridge and its both occupants were also injured. According to the images available, it appears that the left engine was windmilling when the aircraft hit the bridge. First investigations reveals that the master warning activated during the initial climb when the left engine was throttled back. Shortly later, the right engine auto-feathered and the stall alarm sounded.
Probable cause:
The accident was the result of many contributing factors which culminated in a stall-induced loss of control. During the initial climb after takeoff, an intermittent discontinuity in engine number 2’s auto feather unit (AFU) may have caused the automatic take off power control system (ATPCS) sequence which resulted in the uncommanded autofeather of engine number 2 propellers. Following the uncommanded autofeather of engine number 2 propellers, the flight crew did not perform the documented abnormal and emergency procedures to identify the failure and implement the required corrective actions. This led the pilot flying (PF) to retard power of the operative engine number 1 and shut down it ultimately. The loss of thrust during the initial climb and inappropriate flight control inputs by the PF generated a series of stall warnings, including activation of the stick shaker and pusher. After the engine number 1 was shut down, the loss of power from both engines was not detected and corrected by the crew in time to restart engine number 1. The crew did not respond to the stall warnings in a timely and effective manner. The aircraft stalled and continued descent during the attempted engine restart. The remaining altitude and time to impact were not enough to successfully restart the engine and recover the aircraft.
The following findings related to probable causes were noted:
An intermittent signal discontinuity between the auto feather unit (AFU) number 2 and the torque sensor may have caused the automatic take off power control system (ATPCS):
- Not being armed steadily during takeoff roll,
- Being activated during initial climb which resulted in a complete ATPCS sequence including the engine number 2 autofeathering.
The available evidence indicated the intermittent discontinuity between torque sensor and auto feather unit (AFU) number 2 was probably caused by the compromised soldering joints inside the AFU number 2.
The flight crew did not reject the take off when the automatic take off power control system ARM pushbutton did not light during the initial stages of the take off roll.
TransAsia did not have a clear documented company policy with associated instructions, procedures, and notices to crew for ATR72-600 operations communicating the requirement to reject the take off if the automatic take off power control system did not arm.
Following the uncommanded autofeather of engine number 2, the flight crew failed to perform the documented failure identification procedure before executing any actions. That resulted in pilot flying’s confusion regarding the identification and nature of the actual propulsion system malfunction and he reduced power on the operative engine number 1.
The flight crew’s non-compliance with TransAsia Airways ATR72-600 standard operating procedures - Abnormal and Emergency Procedures for an engine flame out at take off resulted in the pilot flying reducing power on and then shutting down the wrong engine.
The loss of engine power during the initial climb and inappropriate flight control inputs by the pilot flying generated a series of stall warnings, including activation of the stick pusher. The crew did not respond to the stall warnings in a timely and effective manner.
The loss of power from both engines was not detected and corrected by the crew in time to restart an engine. The aircraft stalled during the attempted restart at an altitude from which the aircraft could not recover from loss of control.
Flight crew coordination, communication, and threat and error management (TEM) were less than effective, and compromised the safety of the flight. Both operating crew members failed to obtain relevant data from each other regarding the status of both engines at different points in the occurrence sequence. The pilot flying did not appropriately respond to or integrate input from the pilot monitoring.
The engine manufacturer attempted to control intermittent continuity failures of the auto feather unit (AFU) by introducing a recommended inspection service bulletin at 12,000 flight hours to address aging issues. The two AFU failures at 1,624 flight hours and 1,206 flight hours show that causes of intermittent continuity failures of the AFU were not only related to aging but also to other previously undiscovered issues and that the inspection service bulletin implemented by the engine manufacturer to address this issue before the occurrence was not sufficiently effective. The engine manufacturer has issued a modification addressing the specific finding of this investigation. This new modification is currently implemented in all new production engines, and another service bulletin is available for retrofit.
Pilot flying’s decision to disconnect the autopilot shortly after the first master warning increased the pilot flying’s subsequent workload and reduced his capacity to assess and cope with the emergency situation.
The omission of the required pre-take off briefing meant that the crew were not as mentally prepared as they could have been for the propulsion system malfunction they encountered after takeoff.
Final Report:

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
Schedule:
Kaohsiung – Makung
MSN:
642
YOM:
14
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 a Britten-Norman Islander near Jhuosi: 3 killed

Date & Time: Aug 30, 2012 at 0915 LT
Type of aircraft:
Registration:
B-68801
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Taipeh - Taitung
MSN:
2255
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Aircraft flight hours:
4909
Aircraft flight cycles:
2426
Circumstances:
On August 30, 2012, a RAC’s BN-2B-26 aircraft, registration number B-68801, contracted by Real World Engineering Consultants Inc. (Real World) to perform an aerial photogrammetry mission with a captain, a first officer and an aerial photographer on board. The flight plan was to take off from Songshan Airport, requested for instrument departure and visual flight rules to conduct aerial photogrammetry mission in Hualien and Taitung area, the aircraft planned to land at Taitung Airport after the mission accomplished. The aircraft took off at 0726, approximately 18 minutes after took off, the flight crew changed flight mode from instrument flight rules to visual flight rules. At 0827, the aircraft entered Hualien County Fenglin, Guangfu, Wanrong aerial photograph area, maintain 8,300 feet to 8,500 feet altitude and continued climbing to Jhuosi, Hualien County photo area at 0919. From 0837 to 0843, Taipei Approach informed the flight crew ‘Radar can’t cover you…..make sure maintain visual flight’. There were about 7 times communication blockage between the aircraft and Taipei Approach during 0755 to 0913 period. The Kaohsiung Approach Control contacted the aircraft at 0913:39 and lost contact with the aircraft at 0914:20 after the last communication. At 0920:55, the aircraft was at 260 degrees, 31.5 km mountain area from Yuli, Taitung and began to turn right heading 280 degrees. The last recorded Light Detection and Ranging (LIDAR) device data was 262 degrees, 35.9 km west of Yuli′s mountain area with coordinates of 23 ° 20 ′25.01 " latitude and 121 ° 01′ 50.03" longitude. At the time of the last recording, the aircraft was at 9,572 feet with about 69 knots ground speed, 250 degrees heading, the climb rate was 874 ft / min and the pitch was 23.5 degrees. At 0940, Taipei Mission Control Center (MCC) received ELT (Emergency Locator Transmitter) signals, about the same time, Japan Coast Guard informed Rescue Command Center, Executive Yuan (RCC) of the same ELT signals. After verification with Civil Aeronautics Administration, Ministry of Transportation and Communications (CAA), RCC confirmed that the aircraft had lost contact. At 0955 on September 1, 2012, the search and rescue aircraft discovered the aircraft crashed at altitude about 9,568 feet of the original forest, about 20 kilometers southwest of Jhuosi, Hualien County. Three crew members on board were killed, and the aircraft was destroyed.

Crash of an Airbus A321-131 in Tainan

Date & Time: Mar 22, 2003 at 2235 LT
Type of aircraft:
Operator:
Registration:
B-22603
Survivors:
Yes
Schedule:
Taipei - Tainan
MSN:
602
YOM:
1996
Flight number:
GE543
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
169
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
13516
Aircraft flight cycles:
18580
Circumstances:
After landing on runway 36R at Tainan Airport, while decelerating, the aircraft struck construction vehicles parked beside the runway. The crew was able to stop the aircraft on the main runway and all 175 occupants evacuated safely. Two workers on the ground were injured. The aircraft was damaged beyond repair.
Probable cause:
Inadequate planning and implementation in airport construction safety procedures by both the CAA and the military authority, inadequacy in landing approval when exceeding the curfew hour, insufficient cooperation and coordination between the CAA and the military base authorities prior to construction work, lack of awareness to a lit runway when entering an active runway without acknowledging the tower controllers.

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 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 a McDonnell Douglas MD-90-30 in Hualien

Date & Time: Aug 24, 1999 at 1236 LT
Type of aircraft:
Operator:
Registration:
B-17912
Survivors:
Yes
Schedule:
Taipei - Hualien
MSN:
53536
YOM:
1996
Flight number:
UNI873
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
90
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6532
Captain / Total hours on type:
1205.00
Copilot / Total flying hours:
5167
Copilot / Total hours on type:
96
Aircraft flight hours:
4929
Aircraft flight cycles:
7736
Circumstances:
As the MD-90 touched down following a 25-minute flight from Taipei, there was a loud noise from the front of the cabin and thick black smoke poured from one of the overhead luggage compartments on the right hand side of the plane. Insulation and charred luggage littered the runway. Passengers were swiftly evacuated, but it took firefighters more than half an hour to control the fire. Twenty-eight people were injured. Preliminary investigation reports in 1999 indicated that the blast was caused by two bottles of household bleach. However, the Hualien District Court judges decided the bottles contained gasoline. According to the judges, Ku Chin-shui had put the gasoline into two plastic bleach bottles and gave them to his nephew. The gasoline leaked during the flight and exploded when it caused a short-circuit in a motorbike battery in a nearby overhead luggage compartment. In July 2003 Ku appealed a seven-and-a-half-year prison term. Considering the prosecutor's case against Ku to be full of holes, the Supreme Court ordered a retrial.
Probable cause:
A flammable liquid (gasoline) inside bleach and softener bottles and sealed with silicone was carried on board the aircraft. A combustible vapor formed as the leaking gasoline filled the stowage bin, and the impact of the landing aircraft created a short in a battery. The short ignited the gasoline vapor and created the explosion. Contributing factors to the accident were:
- The Civil Aeronautical Administration Organic Regulations and its operational bylaws fail to designate any entity as responsible for hazardous materials;
- The Aviation Police fail to properly recruit and train personnel, to include preparing training materials and evaluating training performance. Some new recruits were found to have not received any formal security check training, but instead were following instructions from senior inspectors. Consequently, new inspectors cannot be relied upon to identify hazardous materials;
- The detectors and inspectors failed to detect the hazardous materials. The detectors used by the Aviation Police did not detect the banned motorcycle batteries, nor did security inspectors detect the liquid bleach, a banned corrosive substance.
Final Report:

Crash of a Saab 340 off Hsinchu: 13 killed

Date & Time: Mar 18, 1998 at 1932 LT
Type of aircraft:
Operator:
Registration:
B-12255
Flight Phase:
Survivors:
No
Schedule:
Hsinchu - Kaohsiung
MSN:
337
YOM:
1993
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
13
Aircraft flight hours:
8076
Circumstances:
When the crew boarded the aircraft in Hsinchu for the flight to Kaohsiung it had been a long and demanding day for the captain who was to fly the aircraft. He had been on duty more than 11 hours and performed nine flights. The accident flight, which was planned to be his last flight of the day, was to take place in darkness. The weather was above minima but IMC. During the pre-flight check the crew noted a failure in the RH Main Bus. This caused a number of systems to be unavailable, a.o.: the autopilot, the left hand EFIS, LH/RH Flight Director, LH RMI, EFIS Comparators, and the no. 2 engine anti-ice start bleed valve being open (as a result of this, the ITT on this engine was approximately 15°C higher than normal at selected power on this engine). Despite the fact that, according to the Minimum Equipment List (MEL), taking off for a flight with any of the Main Buses inoperative was not allowed, the captain decided to continue. During taxi to runway 05 the aircraft was cleared for a Chunan One (CN1) departure. The aircraft took off at 19:29:09. Because of the autopilot was not available, the captain now had to fly manually. In addition, the flying had to be performed without support from the yaw-damper that was also inoperative as a result of the RH Main Bus failure. This means that more active rudder control was required, while the DFDR-data shows that such input was not made. The more than 30°C ITT-split between the engines, of which approximately 15°C was caused by the RH Engine Anti-ice Start Bleed Valve being open, did have little effect on the behavior of the aircraft in the initial start-sequence. But when the crew, 30 seconds after lift off, disengaged CTOT and started to manually adjust the RH PLA downwards, possibly to get equal ITT in the engines, this ended up in a torque-split of more than 13% between the engines, with the RH engine being lower in torque. This asymmetry tended to yaw and roll the aircraft to the right and required higher aileron input than normal to the left in order to keep the aircraft at a constant bank angle. Normally the flaps are retracted at around 1,000 feet during initial climb. In this flight the flap retraction was not initiated until the first officer was reading the Climb Check List in which the flap position should be checked and verified. Flap retraction was done just prior to the aircraft reaching VFE15 (175 KIAS, which is the maximum allowed speed with flaps extended). When the climb power was set, a symmetric PLA change was made. However, due to the earlier RH Power Lever Angle (PLA) pull in combination with the normal backlash in the power lever cables between the PLA and the HMU, the RH engine torque was decreased while the LH engine torque remained unchanged. Hence, a torque split occurred. This resulted in an increased aerodynamic asymmetry giving a force tending to yaw and bank the aircraft to the right. Consequently, still more aileron input was required in order to maintain a correct bank angle. Because the behavior of the aircraft was very different from what the captain was used to, the need for continuous manual flying under IMC-conditions may have totally occupied his capacity. This could also explain why, during this phase of flight, he did not observe the aircraft starting a turn to the right 78 seconds after take off instead of continuing the left turn for a heading of 260. At about this same time, and for no obvious reasons, the positive rate of climb decreased and the aircraft leveled out at approximately 2,000 feet for a short time instead of continuing the climb to its assigned altitude of 3,000 feet. The captain's actions could be interpreted as signs that he might have been suffering from fatigue or spatial disorientation. It is difficult to determine if the F/O was aware of the captain's deviation from the cleared departure route. All indications point to the fact that he was not aware or that he out of respect for the captain did not report of the deviations. For example, the F/O transmitted back to Taipei Approach 114 seconds after takeoff, "Left 230, Bravo 12255," while at the same time the aircraft was in a right turn with a 21 degree right bank, passing through a heading of 312 degrees. In fact, his primary means for monitoring the flight were very limited due to dark, IMC-conditions since his EFIS instruments were black or flagged. This could also explain why the captain did not receive any support from the F/O about the flight becoming more and more uncontrolled. Not until 124 seconds after takeoff and 37 seconds prior to the last DFDR-recording did the captain state that he was having a problem with the heading and asked for help with the magnetic compass. At that time the aircraft was in a 24° right bank and 10° pitch up position and had a heading and roll rate by one degree per second. From that moment a continuous decrease in pitch angle was recorded down to -65,4° just prior to the impact. Just 19 seconds before the last DFDR-recording, with a heading of 022 and a bank angle of 36° to the right, the captain said "Ask for a radar vector." At this moment, he also initiates a short aileron input to the right, further increasing the bank angle. The other crewmembers did not answer or give any notable response to the captain's request for help with the magnetic compass. The reason might be that they also were very confused about the situation and unable to take any relevant action. When the captain, 14 seconds before the last DFDR-recording, said "Wah Sei!!! Everything is wrong." the aircraft was in a 8,4° pitch down and the right bank angle was 47,5°. Finally, only 10 seconds before the last data point was recorded, the first officer responds by asking "Sir, shall we look at this one? ". Pitch down was then 15,8° and the right roll angle 71,7°. In the last part of the flight the pitch and bank angles were at extreme values not to be experienced in normal operation. At this stage of the flight, the control inputs recorded are rapid aileron inputs to the right that further increased the adverse attitudes. The aircraft was then totally uncontrolled and the airspeed and sink rate increased dramatically. Four seconds before impact the Vmo warning started. The aircraft then crashed into the sea.
Probable cause:
The following factors were identified:
- The flight crew's failure to maintain the situational awareness resulting in the loss of aircraft control,
- The failure of R/H main electrical bus resulting in the malfunction of R/H navigation system and flight instruments,
- Flight crew did not comply with MEL,
- Night time and IMC resulted in no or limited visual reference for the flight crew,
- The captain conducted the flight in a fatigue and spatial disorientation condition,
- Flight crew did not comply with standard operation procedures.

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.