Description

On 31 October 2000, a Boeing 747-400 (9V-SPK) being operated by Singapore Airlines on a scheduled passenger flight from Taipei, Taiwan to Los Angeles as SQ006 commenced a night take off on a partially closed runway in reduced (but not low) visibility instead of on the runway instructed by ATC who were unaware of the error. The subsequent collision with construction equipment on the closed section of the runway used and the resultant severe post crash fire destroyed the aircraft fatally injuring 83 of the 170 occupants, seriously injuring 39 more and causing minor injuries to 32 others. All three flight crew survived and two of them as well as 23 passengers were uninjured.

Investigation

Although Taiwan is not an ICAO Contracting State, an Investigation into the accident was carried out in all critical respects in accordance with Annex 13 principles by the designated investigation body in Taiwan, the Aviation Safety Council. Some differences in the presentation of the Findings in the concluding Report were acknowledged. The FDR, CVR and QAR were all recovered and their data were successfully downloaded.

It was confirmed that with the Captain as PF, the aircraft had failed to follow its correctly acknowledged ATC clearance along taxiway N1 and onto runway 05L, a 60 metre wide instrument runway with Cat 2 signage, markings and lighting. Instead, after turning right onto taxiway N1, at which point it should have continued straight ahead to reach the parallel Runway 05L from which it had been cleared to take off, it had turned prematurely to the right onto Runway 05R, a temporarily closed 45 metre wide non-precision runway. Impact with concrete barriers and construction equipment had occurred as the aircraft, at high speed, had approached a position abeam the terminal buildings situated between the two main parallel runways, 05L/23R and one designated 06/24. The impact and immediate fire which followed completely destroyed the aircraft. The Airport Rescue and Fire Fighting Services' reported that the fire which broke out had initially been brought as under control after 10 to 15 minutes, but then "flashback and re-ignition occurred" and it had not been fully extinguished until 40 minutes after the collision. There was only minor exterior fire damage to the rear section of the aircraft which had detached and become separated from the rest of the aircraft during the collision.

Although Runway 05R was subject to a Notice To Airmen available to the crew advising that it was closed part way along its length with the initial section available for taxi use only, it was found that there were no indications of its non-runway status readily available at the point on taxiway N1 where it was reached, which was almost immediately after turning right onto taxiway N1 from taxiway NP. It was also noted - and considered of significance - that there was no taxiway centreline marking across the 05R threshold, only one leading onto the 05R runway centreline. This latter centreline was also much more clearly lit than the continuation of the unmarked taxiway centreline straight ahead towards runway 05L, which had just one distant light operative preceded by one inoperative one. The diagram below shows the vicinity of the point where the wrong turn occurred and the disposition of taxiway centreline lighting.

It was noted that permanent conversion of Runway 05R to the status of a taxiway to be designated NC, was pending at the time of the accident and no change had been made to the runway status lighting at the south-western end of the runway.

All three pilots on the flight deck - an augmenting First Officer was occupying one of the supernumerary seats because of the intended long flight to Los Angeles - were found to have been employed by Singapore Airlines since being recruited as cadets. The aircraft commander, a Malaysian national born in 1959, had first qualified as a First Officer on the 747-300 in 1986 and had been promoted to Captain on the A310 in 1995 and had transferred to the 747-400 in 1998. He had accumulated 11235 flying hours including 2017 on the 747-400. The First Officer, a Singaporean born in 1964, had first qualified in that rank on the Airbus A310 in 1997 before serving on the Boeing 777 and then joining the 747-400 fleet in February 2000. He had accumulated 2442 flying hours including 552 on the 747-400. The Supernumerary First Officer had also first qualified on the Airbus A310 before joining the 747-400 fleet in 1995, he had accumulated 5508 flying hours including 4518 on the 747-400.

Whist forward visibility was found not to have been such as to preclude normal taxiing, around the time of the attempted take off it was being reported as 600 metres in heavy rain, with similar RVRs given for both in-use runways. It was found from the CVR that the Captain had been reminded by his First Officer as the aircraft reached the end of taxiway NP that "next is November 1" and had responded " OK, second right" which had then been confirmed as correct by the First Officer. Take off clearance for runway 05L had just been received after changing to the TWR frequency when the aircraft reached the closely spaced illuminated green centreline lights leading onto runway 05R - the first rather than the second right turn. The Captain had proceeded to taxi the aircraft (slowly due to the potentially slippery wet surface) into position on runway 05R with no challenge from either of the other pilots except to note the failure of the aircraft position to match the Para Visual Display (PVD) which appeared to have been discounted by the Captain. Take off was commenced in the normal way soon afterwards but 21 seconds after the 80 knots call, the CVR recorded the Captain uttering an 'expletive' and exclaiming that there was "something there". One second later (some 33 seconds after the take off roll had commenced) the sound of the first impact occurred; the FDR recorded a ground speed of approximately 131 knots at the end of the recording.

It was concluded that the crew had failed to review their 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”. It was accepted that the limited forward visibility had prevented recognition of the obstructions further down the runway and considered that the association of the deteriorating weather with a typhoon approaching had constituted “moderate time pressure” to take off before the inbound typhoon closed in. The latter was considered likely to have “subtly influenced the flight crew’s decision making ability and the ability to maintain situational awareness.” However, it was also concluded that the “reduced visibility in darkness and heavy rain" had "diminished, but did not preclude, the flight crew’s ability to see the taxiway and runway lighting, marking and signage. In particular, centreline lighting on runway 05R was green rather than white and the edge lights "were most likely not on".

No evidence that the performance of any of the crew had been affected by fatigue or any other pre existing medical, behavioural or physiological factors or that there was any element of causation arising from lack of aircraft airworthiness.

Findings of the Investigation related to underlying Risk which had provided the context for the accident were noted as including:

• The absence of any requirement in ICAO Annex 14 SARPs current at the time for any runway closure markings to be provided near the threshold of a partially closed runway.

• ICAO ambiguity in respect of what a 'temporarily closed runway' was because of the absence of any definition of the phrase 'short term'.

• The barriers around the work in progress part way down the runway were of concrete rather than the frangible type required in ICAO SARPs.

• Although "there were a number of items of Airport infrastructure that did not meet the level of internationally accepted standards and recommended practices (and) appropriate attention given to these items could have enhanced the situational awareness of the flight crew while taxiing to Runway 05L....the absence of these enhancements was not deemed sufficient to have caused the loss of situational awareness of the flight crew".

• There was "a lack of safety oversight mechanism with (the Taiwan) CAA that could have provided an independent audit/assessment of the Airport to ensure its facilities met internationally accepted safety standards and practices".

• The absence of any ASDE equipment at the airport which, given the prevailing poor visibility, had precluded ATC awareness of the crew taxiing error.

• The Operator's procedures and training documentation did not reflect the content of the 747-400 AFM Supplement detailing with the use of the PVD to confirm the correct position of an aircraft about to commence takeoff.

• The Singapore CAA had approved the PVD AFM Supplement but had not ensured that it was adopted by the Operator.

• The Operator's Operations Manual did not specify that a "confirm active runway check" should be made by a crew as part of the required before take off procedures.

• Progressive taxi instructions were neither given by ATC nor requested by the aircraft crew.

Other Findings included that the Operators flight crew SOPs did not assign any specific duties to the augmenting First Officer present in the flight deck.

Notwithstanding these and other observations, the overall Finding Related to Probable Cause was that “the flight crew lost situational awareness and commenced take off on the wrong runway”.

A total of 59 Safety Recommendations were issued as a result of the Investigation as follows:

• that Singapore Airlines develop and implement a comprehensive surface-movement training program that reflects the current practice in this area, such as the recommendations contained in the FAA’s National Blueprint for Runway Safety and FAA Advisory Circular 120-74. [ASC-ASR-02-04-01]

• that Singapore Airlines ensure that procedures for low visibility taxi operations include the need for requesting progressive taxi instructions to aid in correct airport surface movement. [ASC-ASR-02-04-02]

• that Singapore Airlines review the adequacy of current SIA PVD training and procedures and ensure that SIA documentation and operational practices reflect the CAAS approved B747-400 AFM PVD supplement, which included the use of the PVD to indicate whether the aircraft is in a correct position for takeoff. [ASC-ASR-02-04-03]

• that Singapore Airlines develop and implement a clear policy that ensures that flight crews consider the implications of the relevant instrument indications, such as the PFD and PVD, whenever the instruments are activated, particularly before commencing takeoff in reduced visibility conditions. [ASC-ASR-02-04-04]

• that Singapore Airlines include in all company pre-takeoff checklists an item formally requiring positive visual identification and confirmation of the correct takeoff runway. [ASC-ASR-02-04-05]

• that Singapore Airlines implement an Advanced Crew Resource Management program to reflect current practices in this area, and ensure that such programs are regularly revised to reflect new developments in CRM. [ASC-ASR-02-04-06]

• that Singapore Airlines review the adequacy of current runway condition determination procedures and practices for determining a water-affected runway to “wet” or “contaminated” in heavy rain situations, by providing objective criteria for such determinations. [ASC-ASR-02-04-07]

• that Singapore Airlines conduct a procedural audit to eliminate existing conflicts in the guidance and procedures between the company manuals, the managers’ expectations, and the actual practices, such as those contained in the Typhoon Procedures and dispatch briefing policy. [ASC-ASR-02-04-08]

• that Singapore Airlines modify the emergency procedures to establish an alternate method for initiating the emergency evacuation command in the event of a PA system malfunction. [ASC-ASR-02-04-09]

• that Singapore Airlines review its procedures and training for the flight and cabin crewmembers to effectively handle diversified emergency situations. [ASC-ASR-02-04-10]

• that the CAA Singapore require SIA to develop and implement a comprehensive surface-movement training program, to include a procedure to request progressive taxi instructions during low visibility ground operations. [ASC-ASR-02-04-11]

• that the CAA Singapore review the adequacy of current SIA PVD training and practices and require that SIA revise, if necessary, procedural and training documentation and operational practices to reflect the CAAS approved B747-400 AFM PVD supplement. [ASC-ASR-02-04-12]

• that the CAA Singapore review the current system of managing AFM supplement document approval, control, distribution, and enactment policies and procedures for operators and make appropriate changes as necessary to ensure that revisions to airline AFMs are adequately managed. [ASC-ASR-02-04-13]

• that the CAA Singapore ensure that all Singaporean commercial airline operators under its regulatory responsibility implement Advanced Crew Resource Management programs to reflect current practices and ensure that such programs are regularly monitored and revised to reflect new developments in CRM. [ASC-ASR-02-04-14]

• that the CAA Singapore evaluate and support appropriate research to develop technologies and methods for enhancing flight crews’ abilities for objectively determining a water-affected runway condition in heavy rain situations. [ASC-ASR-02-04-15]

• that the CAA Singapore amend the CAAS Air Navigation Order paragraph 37 (3) to require an earlier power-on and later power-off times for CVRs. [ASC-ASR-02-04-16]

• that the Government of Singapore establishes an independent aviation accident/incident investigation organization consistent with many other countries in the world. [ASC-ASR-02-04-17]

• that the Taiwan CAA requires that the control tower chiefs re-emphasise the concept, training and the use of progressive taxi/ground movement instructions during low visibility ground operations. [ASC-ASR-02-04-18]

• that the Taiwan CAA places a priority on budgetary processes and expedites the procurement and installation of ASDE at airports with high traffic volume. [ASC-ASR-02-04-19]

• that the Taiwan CAA clearly redefines its Divisions’ job functions to stipulate each individual unit and personnel responsibilities. [ASC-ASR-02-04-20]

• that the Taiwan CAA specifically appoints an organisation within the CAA for the development, modification, and issuance of civil aviation regulations. [ASC-ASR-02-04-21]

• that the Taiwan CAA organises a program to continuously monitor ICAO SARPs and industry best practices for safety improvement and distribute them to the relevant organisations for applicable review, necessary action and oversight of their progress.[ASC-ASR-02-04-22]

• that the Taiwan CAA establishes an integrated risk assessment and management program and oversight mechanism to supervise all plans and implementations. [ASC-ASR-02-04-23]

• that the Taiwan CAA evaluates and supports appropriate research to develop technologies and methods in providing objective information to pilots regarding water-affected runway conditions (wet versus contaminated) in heavy rain situations.[ASC-ASR-02-04-24]

• that the Taiwan CAA immediately implements all items, or acceptable alternative standards at Taipei and other airports that are not in compliance with ICAO SARPs and applicable documents, such as the SMGCS plan, the emergency medical procedure, etc. [ASC-ASR-02-04-25]

• that the Taiwan CAA ensures that the ARFF have the necessary manpower to perform their assigned tasks, as compared to similar level 9 international airports.[ASC-ASR-02-04-26]

• that the Taiwan CAA reviews the communication system at Taiwan airports to develop an integrated plan for improved communications between all agencies involved during emergency fire and rescue operations. [ASC-ASR-02-04-27]

• that the Taiwan CAA establishes a reliable incident reporting system, promotes the system to the users’ groups and places a higher priority to the use of such a system. [ASC-ASR-02-04-28]

• that the Taiwan CAA reviews the FAA National Blueprint for Runway Safety and relevant Advisory Circulars with a view toward implementation. [ASC-ASR-02-04-29]

• that the Taiwan CAA ensures that appropriate surface movement technology enabling infrastructure, such as airport and terrain databases, is developed for all airports. [ASC-ASR-02-04-30]

• that the Taiwan CAA issues the necessary regulations to support the installation of cockpit-based surface guidance and navigation technologies, such as electronic moving map display, in Taiwan-registered aircraft engaged in regular public transport for use during airport surface movements. [ASC-ASR-02-04-31]

• that the Ministry of Transport and Communications Taiwan establishes professional oversight capabilities for the CAA’s safety improvement actions and programs for promoting flight safety. [ASC-ASR-02-04-32]

• that the Ministry of Transport and Communications Taiwan proactively provides support to the CAA’s safety action plans, such as the ASDE procurement process. [ASC-ASR-02-04-33]

• that the Ministry of Transport and Communications Taiwan grants full authorisation to the CAA to avoid lengthy waiting periods for improvement and implementation of technical safety regulations. [ASC-ASR-02-04-34]

• that Boeing provide airline operators with appropriate guidance information, including cautions to be observed, when required to operate emergency evacuation slides in wind gusts that exceed the certified limit. [ASC-ASR-02-04-35]

• that Boeing review the effectiveness of cabin emergency lights to ensure that maximum conspicuity is achieved in dense smoke following survivable accidents. [ASC-ASR-02-04-36]

• that Boeing consider incorporating cockpit surface guidance and navigation technologies, such as an electronic moving map display, into all proposed and newly certified aircraft. [ASC-ASR-02-04-37]

• that Boeing develop and issue the necessary technical support to airline customers to aid in the installation of cockpit surface guidance and navigation technologies, such as (an) electronic moving map display, for use during airport surface movements. [ASC-ASR-02-04-38]

• that Boeing develop a means to reduce failure of PA systems during survivable accidents and provide modified systems to operators. [ASC-ASR-02-04-39]

• that ICAO develops Standards that would require ASDE or comparable equipment as standard equipment at civil airports with high traffic volume. [ASC-ASR-02-04-40]

• that ICAO amends Annex 14 to include clear Standards for defining and protecting a partially closed runway that may be used for taxi purposes. [ASC-ASR-02-04-41]

• that ICAO considers accepting the participation of Taiwan in various ICAO activities as an observer, for the purpose of safety improvement, even though Taiwan is not a contracting State. [ASC-ASR-02-04-42]

• that ICAO supports the establishment of a government/industry program involving the Flight Safety Foundation, IFALPA, Airport Operations Association, and IATA to develop objective methods to assist pilots in assessing whether a runway is “wet” or “contaminated” due to the presence of water. [ASC-ASR-02-04-43]

• that ICAO encourages and supports the establishment of research by governments and industry to improve passenger smoke protection and improve emergency evacuation slide performance in heavy winds and post-accident fire. [ASC-ASR-02-04-44]

• that ICAO develops and issues the necessary SARPs to ICAO Member States’ regulatory authorities to encourage them to adopt the necessary regulations to support the installation and use of cockpit-based surface guidance and navigation technologies, such as (an) electronic moving map display. [ASC-ASR-02-04-45]

• that ICAO encourages all ICAO Member States to consider the installation of cockpit surface guidance and navigation technologies, such as (an) electronic moving map display, in commercial airliners for use during airport surface movements. [ASC-ASR-02-04-46]

• that ICAO encourages all their Member States’ regulatory authorities to ensure that appropriate surface movement technology enabling infrastructure, such as airport and terrain databases, is developed. [ASC-ASR-02-04-47]

• that IATA provides support to an international joint government/industry program to develop possible improvements to emergency evacuation equipment and procedures for the prevention of future injuries and death following an aircraft accident. [ASC-ASR-02-04-48]

• that IATA provides its member airlines with appropriate guidance information, including cautions to be observed, when required to operate emergency evacuation slides in wind gusts that exceed the certified limits. [ASC-ASR-02-04-49]

• that IATA urges its member airlines to work with their (respective) regulatory agencies to ensure that airports into which they operate meet the Standards and Recommended Practices of ICAO Annex 14 and urges its member airlines to work with their prospective regulatory agencies to develop procedures for evaluating the airport infrastructure as part of their out-station audits. [ASC-ASR-02-04-50]

• that IATA encourages its member airlines to consider equipping their aircraft with cockpit surface guidance and navigation technologies, such as (an) electronic moving map display, for use during airport surface movements.[ASC-ASR-02-04-51]

• that the FAA provides support to an international joint government/industry program to develop possible improvements to emergency evacuation equipment and procedures for the prevention of future injuries and death following an aircraft accident. [ASC-ASR-02-04-52]

• that the FAA reviews emergency slide design to reduce the potential for uncommanded inflation resulting from lateral impact forces. [ASC-ASR-02-04-53]

• that the FAA reviews the effectiveness of cabin emergency lights to ensure that maximum conspicuity is achieved in dense smoke following survivable accidents. [ASC-ASR-02-04-54]

• that the FAA initiates rulemaking action to require the installation, on Boeing aircraft, of public address systems that continue to function following survivable accidents. [ASC-ASR-02-04-55]

• that the JAA provides support to an international joint government/industry program to develop possible improvements to emergency evacuation equipment and procedures for the prevention of future injuries and death following an aircraft accident. [ASC-ASR-02-04-56]

• that the JAA reviews emergency slide design to reduce the potential for uncommanded inflation resulting from lateral impact forces. [ASC-ASR-02-04-57]

• that the JAA reviews the effectiveness of cabin emergency lights to ensure that maximum conspicuity is achieved in dense smoke following survivable accidents. [ASC-ASR-02-04-58]

• that the JAA should initiate rulemaking actions to require the installation, on Boeing aircraft, of public address systems that continue to function following survivable accidents. [ASC-ASR-02-04-59]

The Final Report was approved by the Council on 23 April 2002 and subsequently released on 30 April 2002.

Further Reading/Related Articles

• Wrong Runway Use
• Runway Incursion
• Runway Identification
• Runway Maintenance
• Situational Awareness (OGHFA BN)
• Crew Resource Management (OGHFA BN)