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 in Tainan

Date & Time: Mar 22, 2003 at 2235 LT
Type of aircraft:
Operator:
Registration:
B-22603
Survivors:
Yes
Schedule:
Taipei-Tainan
MSN:
0602
YOM:
1996
Flight number:
TNA543
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, while decelerating, the aircraft struck construction vehicles on runway 36R right side. The aircraft sustained severe damage. Notam's were not sufficiently correct to inform pilots about the presence of these vehicles on runway and ATC can not monitor and control movements on ground.

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

Crash of a Boeing 747-200 in Taiwan: 225 killed

Date & Time: May 25, 2002 at 1528 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

Crash of a Boeing 747-400 in Taipeh: 83 killed

Date & Time: Oct 31, 2000 at 2318 LT
Type of aircraft:
Operator:
Registration:
9V-SPK
Flight Phase:
Survivors:
Yes
Schedule:
Singapore - Taipeh - 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

Crash of a McDonnell Douglas MD-90 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
Aircraft flight hours:
4929
Aircraft flight cycles:
7736

Crash of a Saab 340 in 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

Crash of an Airbus A300-600 in Taipei: 203 killed

Date & Time: Feb 16, 1998 at 2006 LT
Type of aircraft:
Operator:
Registration:
B-1814
Survivors:
No
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
Aircraft flight hours:
20193
Aircraft flight cycles:
8800