Taiwan Crash Report Released
October, 2000 747: Wrong Runway
The pilots were the largest of the "probable causes," when 83 people died, that monsoon night at Taipei a year and a half ago. That's what the Taiwan-led investigation team figured out, in a report released Friday. [In their system, courts alone actually assign blame].
True, they admitted, the airport was a mess, in the middle of that pitch-black heavy rain -- taxiway lights were out; runway markers were missing -- but the ultimate responsibility for the safety of flight rests with the captain.
The investigative report said the crew could have, and should have used existing airport charts, and that they should have asked more questions of the tower (which couldn't see them). It also noted that a double-check of headings would have clued them in.
Singapore Airlines Flight SQ006, you may recall, ended when the 747-400, Singapore Air's first hull loss ever, smashed into parked heavy equipment, as it tried to take off from a closed runway.
Singapore, while admitting to some pilot involvement in the bad decisions that night, also spent more time detailing the failures and shortcomings of the facility and its people. Their report said the crash was a result of "a failure of the aviation system, rather than a failure of a person or people."
 
 

Comment

I have read the report and very thorough it is.
I note in the "interview with flight crew" section,the Captain says he thinks the 05R edge lights were illuminated (but couldn't be sure). Conversely, the F/O and relief pilot both think the edge lights were NOT illuminated. However, all 3 pilots testify to being confronted by the "correct picture" when they lined up...The inability to determine whether the runway edge lights were on or not might appear to undermine the report's ability to establish probable cause...although it never in fact tries to do this anyway.

If the runway edge lights were NOT illuminated (and hence they didnt have the "correct picture"), then it was a gross oversight on the part of the crew. If they were illuminated, what we are left with is still "pilot error" but with strong mitigating circumstances. Reminds me a little of the Erebus disaster...in that a web of unfortunate circumstances conspired against the crew. But however entangled that web is, it never relieves the pilot-in-command of his/her duty to fulfill that most basic of tenets...to know where the hell you are at all times.

If all 05R´s lights were ablaze and 05L was in absolute darkness,the fact remains that all it takes is one cursory glance at the taxi chart to see that 05L is the second right after turning off the end of NP and NOT the first. Talk about lights on 05R that shouldn't have been on relates to the setting of the trap that any of us might fall into, but it doesn't relate to probable cause.

I know that some will counter this with:
"How did the crew know that they hadn´t indeed
passed the first turn (ie 05R), and that the green
lights were leading them onto 05L?After all, they couldn't
see out of the side windows (no wipers),and they
couldn't be expected to make out the runway
designator/markers in those conditions,and they were
quite rightly expecting 05R to be unlit or red-barred?"

This argument does represent the crew´s best chance for an "escape clause" but the turn from NP onto 05R must really be considered an almost continuous 180, which cannot in all honesty be confused with proceeding to the end of N1 before making a 90 degree turn onto 05L. Additionally, the Captains decision to ignore the fact that the PVD was trying to tell him something was certainly most unfortunate.

There is no denying that the crew was aware of the NOTAMed closure of 05R. There is also no denying that they suffered a loss of SA(situational awareness) which eventually led to that wrong turn while still believing they were on 05L as cleared. No one - not even SIA or the Singapore government - denies this.

However, as has been pointed out by many before me, the events that have contributed to this loss of SA need to be identified and given their due weight in the matter. My personal take on this is that since the Taiwanese had intended to continue using 05R as a taxiway despite the runway closure, the NOTAM should more correctly have been worded something to the effect of "Runway 05R not operational but still available for taxiing. Runway edge and centreline lights remain illuminated." That would have at least alerted the crew to a potential catch-22 of an unservicable runway appearing still open. I don't know about others, but as for me, when I read that a runway is closed, that is what I expect : total closure, including de-activation of the lights. You may not agree with me on this, but if a NOTAM indicates a runway is closed without specifying further that things like the lights are gonna be left ON, then when you taxi out there, the very fact that you see some runway lights WILL ACTUALLY RE-INFORCE your belief that you are now on the correct runway and CONTRIBUTE TO LOSS OF SA - especially so in conditions of marginal/reduced viz. That 05R was a non-instrument runway while 05L WAS an instrument runway does certainly provide clues to the crew, but only if they can see the runway all the way down. The viz that night was 400-600 mtr in driving rain - unlikely to have revealed the 05L barrettes at all.

There is no doubt to me that the crew goofed big time, but as others have pointed out, there does seem to be many other links in this error chain that have gone un-noticed or swept under the carpet. It would be a shame if it takes another crash involving Taiwanese before it is recognised that attitudes all round really need to change.

My initial reaction on hearing about this tragic accident was to ask myself one simple question. I still believe this is the central question. (I understand that 05R was in partial use as a taxiway during the construction period, which is why it was not blocked off entirely - also explains the type of lighting used).

But if aircraft were not supposed to use runway 05R for departure, because it was covered in heavy plant & equipment, why were effective measures not taken to close the runway thresholds at each end to prevent aircraft entering and starting to roll?

All it needed was a line of illuminated barriers or a few parked vehicles down each threshold side with amber beacons on at each end and with a big sign saying "Runway 05R is Closed". Clearly a ground radar system monitored by ATC might also have made a big difference.

Any pilot attempting to turn onto the wrong runway would have seen the barriers or vehicles and realised he was in the wrong place. It is usually the simplest and most obvious precautions that are the most effective.

Taiwan Airport and all other airport authorities should examine their ground movements control, especially during runway/taxiway maintenance, and it is about time ground radar was installed and used at all international airports.

What is required is an ICAO Deputy Commissar with a roving commission to visit all international airports and physically ascertain that national deficiencies aren't creating accident potentials. His pronouncements should be a heads up to National Aviation Authorities that, if an accident happens, the fact that they were warned (but have yet failed to act) will be in his Safety Hazard Report - and will be made public.

IASA Safety

 
 

Aircraft Accident Investigation Reports: Flight SQ006, 31 October 2000


26 April 2002


Singapore Airlines (SIA) has received copies of two reports on the accident that happened in Taipei on 31 October 2000. One report is by Taiwan's Aviation Safety Council (ASC) and the other by a Singapore investigation team, headed by the Ministry of Transport (MOT).

When read together, these reports provide a comprehensive analysis of the accident. They conclude that it could have been the result of several contributing factors involving the flight crew, the air traffic controllers and the airport, as well as the weather conditions.

SIA accepts generally the findings of fact in these two reports; however, we disagree with some of the conclusions drawn in the ASC report.

It has always been clear that the aircraft took off from the wrong runway, but it appears that the ASC report does not give due weight to the deficiencies found at Chiang Kai Shek (CKS) Airport. We believe these deficiencies misled the pilots into taking off from the wrong runway.

We would like to highlight below some of the deficiencies at CKS Airport as mentioned in the two reports.


Runway 05R, which was being converted into a taxiway, had not been properly marked or closed. There were no barriers, markings or other visual warnings to prevent an aircraft from entering this runway. If barriers had been erected, or a white cross painted on the runway as required by the International Civil Aviation Organization (ICAO), the accident may not have happened.

Instead, Runway 05R was prominently lit and marked as if it were an operational runway. The lights leading from the taxiway onto Runway 05R were also prominently lit and spaced 7.5 metres apart. In contrast, the taxiway lights leading to Runway 05L were, contrary to ICAO standards, spaced several times further apart, and not all of them were working. Consequently, the crew could see only the taxiway lights leading on to 05R.

The air traffic controllers cleared the flight for take-off at the critical moment that it was taxiing towards Runway 05R. This reinforced the crew's belief that they were entering the correct runway. In low visibility conditions, air traffic controllers at CKS Airport are required to determine the position of the aircraft before issuing take-off clearances. They did not follow this procedure.
 

The ASC report makes particular mention of the para visual display (PVD). According to the report, the PVD should have provided a cue that the aircraft was not on Runway 05L. We wish to explain that the PVD, which is installed by very few airlines, is not designed to warn pilots that they are on the wrong runway. It is a secondary aid, meant to help the pilot track the runway centreline if he cannot see it clearly. As the captain was able to see the runway centreline, he had no reason to refer to the PVD.

Taipei's Chang Kai Shek Airport Runways
 

Following the accident, we studied the information available at that time to help us understand how it could have happened. We wanted to make sure that everything was being done to prevent this type of accident from happening again.

We traced the events leading up to the collision with construction equipment and reviewed all of our systems, procedures and practices. While we found that our practices were in line with generally accepted best practices in the industry at that time, we explored what more could be done.

For example, we have enhanced our take-off procedures to require all crew in the cockpit to visually confirm the correct runway designation before commencing take-off. We have also introduced a new module as part of our Crew Resource Management training to focus specifically on situational awareness.


Since the accident, we have also pressed manufacturers to develop new safety systems to prevent misidentification of runways and taxiways. We are the first airline to have placed an order for a newly-designed Boeing system to warn pilots if they are on the wrong runway.

We are committed to doing everything possible to prevent this type of accident in the future. We will study the recommendations in the ASC and the MOT reports in more detail, and we will implement any recommendations that would further enhance safety.
http://www.singaporeair.com/saa/app/saa

 

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