SQ006 final report out 26/4/02 [Archive]

aviator_38

27th Apr 2002, 03:49

On the issue of the runway lighting for 05R: The following is from the Singapore's MOT analysis of the accident,which is available in their website.
........
......."

2.3.1.3 (8) Evidence from the Captain of SQ 006

The Captain of SQ 006 was the pilot conducting the take-off on the night of the accident. In his first interview with the ASC investigation team following the accident, the Captain recalled that both the runway centreline lights and the runway edge lights were illuminated. He said that he was eighty percent sure that the runway edge lights were illuminated. The lights presented the picture of a ‘normal image of runway’

2.3.1.3 (9) Previous incidents in which the Runway 05R edge lights and centreline lights were simultaneously illuminated. (Runway 05R was closed at the time).

a) On 23 October 2000, the captain of a freighter aircraft almost turned his aircraft onto Runway 05R instead of Runway 05L. This incident shows that the simultaneous illumination of the Runway 05R edge and centreline lights was definitely possible, had occurred recently, and in such situations other pilots had almost made the same mistake as the crew of SQ 006.

b) The following is a summary of an interview with the pilot concerned conducted at the ASC office on 5 July 2001 by ASC investigators, together with advisers from NTSB, ATSB, MOT and CAA Taiwan:

i) The captain had flown into CKS Airport from Subic Bay three or four times per month. Usually he would depart from Taipei in the evening 15 minutes after SQ 006. He estimated that he had flown into CKS Airport about 200 times in the past five years. He normally used Runway 05L in operations and therefore was thoroughly familiar with the northern Runway 05 configuration and movement areas.

ii) About a week before the SQ 006 accident, he was making a routine flight back to Subic Bay, departing at night. He had been given clearance to taxi for a take-off on Runway 05L. The taxi route was to proceed via Taxiway NS (the northern extension of Runway 05R) to back taxi along Runway 05R, turn left onto Taxiway N6, then turn right onto Taxiway NP, and proceed along Taxiway NP to turn onto Taxiway N1 for Runway 05L. The weather that evening was rainy with some wind, and the Captain pointed out that he had to use his windshield wipers.

iii) As he taxied along Runway 05R prior to Taxiway N6, he noticed that the centreline and edge lights of Runway 05R were both lit up in the direction of the runway threshold, as well as at the end of the Runway 05R. While on Taxiway NP, prior to reaching N2, he received take-off clearance, and so he instructed the First officer to complete the pre-takeoff checks. He recalled that as these checks were being carried out, he was looking in and out of the cockpit while he taxied the aircraft onto Taxiway NI. He recalled that he felt strongly compelled to turn onto Runway 05R as the active runway for the following reasons:

 Runway 05R was brightly lit with both centreline and edge lights;

 he could not see the Runway 05L runway lights clearly because they were partly obscured by the bright lights on RW 05R, and the rain;

 he could not see the barriers demarcating the works in progress area, nor the lights on the barriers, further down Runway 05R;

 the visibility from the cockpit was degraded due to the rain;

 the centreline lights on Taxiway NI which led onto Runway 05R;

 there were no cross markings at the Runway 05R threshold to indicate that the runway was closed.

iv) As a result of these compelling factors, he had to consciously reject his first impression that Runway 05R was the active runway. He had then remarked to his First Officer that for a ‘hot second’ he thought that Runway 05R was the active Runway 05L.

v) The captain said that pilots develop, and operate with, a series of complex behaviour patterns, standard operating procedures (SOPs) and checklists. Therefore, when he was presented with all the evidence to suggest that Runway 05R was the active runway, and he had been cleared to take off, it took additional willpower to reject the cues and continue further down Taxiway N1 to reach Runway 05L. He did not recall seeing the Runway 05R threshold lights, as he was concentrating on the runway lights.

vi) When he taxied further along Taxiway N1 he did not recall seeing the centreline lights of Taxiway N1 leading towards Runway 05L. He did see the blue Taxiway N1 taxiway edge lights. On proceeding further along Taxiway N1, he then saw the Cat II signboard, runway lights and touchdown zone lights of Runway 05L.

vii) He was able to reject the ‘compelling information’ which had drawn him to almost turn onto Runway 05R, because he had ‘paused to think’. He then became aware of some conflicts with what he had expected to see on approaching the take-off runway, that is, Runway 05L. These were that Runway 05R was too narrow; there were no touchdown zone lights; and he realised that the centreline lights were green instead of white in colour.

viii) The captain commented during interviews that it was common practice in the USA for ATC to clear aircraft when they are required to taxi across runways. Under this practice, ATC instructions at CKS Airport would have included a clearance to taxi across Runway 05R when proceeding to Runway 05L.

ix) He stated he could understand that, when presented with the compelling information that he had encountered on that night, there could be a strong tendency for pilots to mistake Runway 05R for Runway 05L.

x) The captain commented that in current two-pilot cockpits, when the first officer is completing the final items on the before take-off checklist, his attention is primarily focused inside the cockpit. As a result, unless the first officer detects the mistake prior to the captain calling for the final items on the checklist, the ‘chances are nil’ that he would notice the error after that time. This is because the next phase of operations would require the non-flying pilot to recheck the power settings and to monitor engine parameters, while making airspeed call-outs.

c) It should be noted that the captain observed that the centreline lights and edge lights of Runway 05R were simultaneously illuminated at two stages during his taxi to the take-off runway, which was Runway 05L. These were when he was backtracking down Runway 05R from Taxiway NS, and again, as he taxied onto Taxiway N1 from Taxiway NP.
d) This captain had the benefit of local knowledge of CKS Airport, having flown into CKS Airport approximately 200 times in the last five years. Freight operations mostly take place on Runway 05L. As a result, he was able to use his local knowledge of this section of CKS Airport to stop himself from mistakenly taking off from Runway 05R instead of Runway 05L.

e) The operational benefits of such local knowledge were further highlighted in a separate interview with the pilot of another airline, who was scheduled to take off from CKS Airport after SQ 006, in which he stated that:

“One has to have local knowledge and an alert mind otherwise one could mistakenly line up on Runway 05R.”

f) The crew of SQ 006 did not have the benefit of such local knowledge.

g) Another occurrence on 30 October 2000

i) There was a similar occurrence less than 24 hours before the accident to SQ 006, when it was reported that both the edge and centreline lights of Runway 05R had been simultaneously illuminated.

ii) The pilot involved in this occurrence reported that he had nearly mistaken Runway 05R for Runway 05L. In his words he ‘almost did the same thing’ as the pilot a week earlier.

h) In summary, these two occurrences were particularly significant to the SQ 006 investigation for the following reasons:

i) They show that both the centreline and edge lights of Runway 05R had been simultaneously illuminated on at least two occasions shortly before the accident to SQ 006.

ii) The two occurrences also demonstrate that, even with extensive local knowledge, it was possible for pilots who were thoroughly familiar with the northern runway and taxiway layout to line up on Runway 05R in mistake for Runway 05L.

2.3.1.3 (10) Summary of the evidence concerning Runway 05R edge lights

After reviewing all the scientific wire tests, the factual evidence from the accident site, the poor ergonomics of the lighting control panel, the work patterns of the controllers, the ATP-88, the first interview with the SQ 006 Captain, and the two previous occurrences within the two weeks prior to the accident, it can be reasonably concluded that the Runway 05R edge lights probably were illuminated at the time of the accident.
....."

On the otherhand. the Taiwanese ASC report has this to say:

2.3.4.2 Summarised analysis of the status of Runway 05R edge lights

All direct and indirect evidence regarding the Runway 05R power status are summarised in Table 2.3-1.
( Sorry not able to reproduced this table as the Taiwanese ASC pdf report has disallowed text and graphic selection ).
...........

In summary,although some of the evidence regarding the status of the runway 05R edge lights at the time of the takeoff of SQ006 is inconclusive,the Safety Council believes that the preponderance of evidence indicates more likely that the runway edge lights were off during the SQ006 takeoff. "

para 2.5.7.6 of the same report on " Runway 05R Edge light status "...stated:

" As stated earlier in section 2.3,after reviewing all available
information,the Safety Council was unable to positively determine the on/off status of the Runway 05R edge lights at the time of the accident.Therefore ,the Safety Council will discuss both possible situations in the following
sections. "

cheers

Four Seven Eleven

27th Apr 2002, 05:58

Alpha Leader

Accidents don't just "happen", they are caused by actions of real human beings.

I would take issue with this. To state that accidents are 'caused by the actions of real human beings' is an overly simplistic and blame oriented approach to accident investigation.

It would be more accurate to say that 'accidents arise from a compex interaction between people, systems, procedures, equipment, environment etc.'

I have not read the SQ006 reports, nor do I have any detailed knowledge of the accident, but it would seem that factors such as: crew familiarity, currency of documents, aerodrome design, weather, company policies, ATS procedures, design of runway and taxiway lighting systems, traffic, communications and a host of other factor would or may have contributed to this accident.

It requires careful and skilled analysis - not always possible in a highly charged and politicised environment - to determine which of these factors can be changed and controlled to prevent future accidents.

To attribute a single 'cause' to any accident risks rendering the investigation useless. To attempt to attribute 'blame' is, to my mind, a totally pointless exercise. 'Blame' is normally associated with crimes or negligent acts. These are not within the scope of profesional aviation safety investigators.

It is this 'no-blame' approach which has led pilots to agree to the use of levels of 'surveillence' (FDR, CVR etc) in their workplace, which would be almost unthinkable in any other. (Can you imagine working in an office where your every word and action was recorded? (Yes, security cameras are the exception, but they are normally used in action against criminal 'intruders', not the company employees.)

Hopefully the lessons of this accident will be learned and passed on to others.

G.Khan

27th Apr 2002, 07:36

Well, I have read it all through as well and what I understand is that Singapore are saying that Taiwan have totally glossed over any possibility that the airport was in any way deficient and have exonerated the airport from blame.

Singapore, not unreasonably, feel that, (and they admit), pilot error was the cause BUT the non standard lighting and marking of RW05R was not an insignificant factor but a major contributory factor.
Having operated in and out of CKS many times and experienced the weather and ATC there I am inclined to think that the airport are far from blameless.

NC1701

27th Apr 2002, 13:06

aviator_38,

Thanks for your posting on the status of the 05R edgelights.

So i guess the status of the edgelights is inconclusive. However, due to "the preponderance of evidence" ASC still concludes that the pilots took of from a 'taxiway'.
Guess the truth may never be known but the present conclusion will have very serious implications for the pilots.

penguin

27th Apr 2002, 13:51

What is status with the flight deck crew? Will they ever fly again?

Alpha Leader

28th Apr 2002, 00:36

Four Seven Eleven:

The systems, procedures, equipment etc. are all made, operated and maintained by real people.

You can't blame it on "the system" and leave it there.

hawkeye18

28th Apr 2002, 03:41

As pointed out by the Singaporean MOT:

The format for the Conclusions section of ASC report does not conform to Annex 13, which states that the investigation report should list ‘the findings and causes established in the investigation. The list of causes should include both the immediate and the deeper systemic causes’ (APP-2, 3).

"Instead of listing the findings established, immediate causes and deeper systemic causes, the ASC draft Final Report lists only findings, and under three major categories:

(1) “findings related to probable causes” which identify elements that have been shown to operate or almost certainly have operated in the accident;

(2) “findings related to risk” which cannot be clearly shown to have operated in the accident; and

(3) “other findings” that have the potential to enhance aviation safety, resolve an issue of controversy or clarify an issue of unresolved ambiguity.

Systemic factors which contributed to the accident, such as deficiencies in the design and layout of the airport, defective or inadequate runway lighting, signage and markings and their non-conformance with ICAO Standards and Recommended Practices, are listed as “findings related to risk” (ie cannot be clearly shown to have operated in the accident) while the Singapore team feels that these factors clearly played a major role in the accident. They should rightfully be categorised as “findings related to probable causes”. "

This format of reporting adopted by Taiwan ASC is rather unconventional especially under :

(1)“findings related to probable causes” which identify elements that have been shown to operate or almost certainly have operated in the accident; ( please note the operative word: operated.)

:(In short the causal factors relating to the accident will be entirely focused on the Pilot and the weather, and gloss over deficiencies of airport system and other contributing factors. The operative word here is "operated"

As a result the concluding "Probable causes" will , for all intents and purposes, always be on the weather and the pilot even before the ASC started its analysis of the Probable causes :eek: :rolleyes: :mad:

All Operators Beware!!!:( Any accidents in CSK will be yours and yours only, as far as causal factors is concerned!!:o :o :o

holden

28th Apr 2002, 16:43

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 couldnt 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 reports 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 shouldnt have been on relates to the setting of the trap that any of us might fall into,but it doesnt 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 couldnt
see out of the side windows(no wipers),and they
couldnt 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.

Gladiator

28th Apr 2002, 22:24

To some of us Singapore's reply is not a surprise.

The word on the street is that SIA "may" be making a serious attempt to give "safety" serious thought. This includes taking human factors seriously.

There are plenty of information in PPRuNe archives leaving no doubt that safety came last at SIA. It was always money first, safety last.

As for the government of Singapore and misinformation, amongst other things, through years of brain washing and lack of freedom of speech, they have managed to actually make the Singaporeans believe, 'Singapore and Singaporeans are perfect'.

Rockhound

29th Apr 2002, 00:54

I, for one, find Gladiator's sneering post totally uncalled for.
Rockhound

Alpha Leader

29th Apr 2002, 01:26

Spot on, Gladiator - good to see you posting again.

Perhaps safety did not come absolutely last, but certainly it seems that SIA have allowed significant trade-offs.

G.Khan

29th Apr 2002, 07:01

Gladiator - that is your personal and, I think, subjective view. How long did you actually work for SIA? The archives contain meggabytes of stuff that represents the views of some disenchanted ex pilots but not the views of any recognised safety authority.

I worked for SIA for over ten years and as a professional I find your remarks quite insulting. I certainly never felt that commercial pressure overcame safety, nor do I think that anyone else did either. Obviously it would have come to the surface occasionally - it does in all airlines but pilots discretion is always the last word.

You obviously didn't enjoy your time with SIA, possibly left under a cloud and have a very juandiced view of how things work there.

phd

29th Apr 2002, 12:46

My initial reaction on hearing about this tragic accident was to ask myself one simple question. I still believe this is the central question.

If aircraft were not supposed to use runway 05R, because it was covered in heavy plant & equipment, why the hell 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 with amber beacons on at each end with a big sign saying "Runway Closed". A ground radar system monitored by ATC would also have made a big difference, clearly.

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 there ground movements control, especially during runway/taxiway maintenance, and it is about time ground radar was installed and used at all international airports.

Alpha Leader

29th Apr 2002, 13:21

phd:

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.

Four Seven Eleven

29th Apr 2002, 13:46

Alpha Leader

It seems that our disagreement revolves around the word 'blame'. I take 'blame' to denote culpability, guilt or similar concepts. I agree that '(Y)ou can't blame it on "the system" and leave it there.' (There's that word again!) Certainly we achieve nothing if we 'leave it there.' The investigation must go further than that.

I just hope that we can fix the 'system' without destroying lives in the process. Too many 'investigations' in the past have led to criminal charges, sackings or other punitive actions.

All that is achieved in this manner is to ensure that those particular individuals -sacked, jailed or dead - will never have the same accident again. Nothing is achieved for the rest of us.

Once we move away from 'blame' and look for real solutions, we will start making some progress.

Rockhound

29th Apr 2002, 13:59

Alpha Leader,
There's no denying the SQ006 crew took a wrong turn and that they knew 05R was closed but it seems to me phd makes an excellent point: 05R was not clearly marked as being closed. Here in N America, at least, at any road works, a lane that is closed to traffic is clearly marked as such along its entire length (with barrels or other objects along the sides), even though there may be no barrier at either end. Surely 05R should have been unambiguously indicated as being a taxiway only (or even just prominently identified as 05R) and there should be no shadow of a doubt that the edge lights were off. I don't necessarily lay the blame on the CKS airport authorities. Perhaps ICAO regulations are not sufficiently stringent when it comes to runway markings.
Rockhound

gengis

29th Apr 2002, 14:46

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 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 any of you, 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.

hawkeye18

29th Apr 2002, 17:12

A slide presentation by the Singaporean MOT on the signage, marking and lighting leading to CKS 05 R/L on that faithful nite!!

http://www.sq006.gov.sg/ppt/SQ6_Runway%20Schematic%20Slides_Simplified.pps

(Right click on slide to advance to the next slide )

:rolleyes: I would have been a easy sucker as well under those weather condition!:(

Alpha Leader

30th Apr 2002, 03:24

Four Seven Eleven:

OK, for "blame" substitute "shoulder responsibility" - less daunting, I agree.

Rongotai

30th Apr 2002, 05:07

I always feel that discussions like this (where 'blame', 'responsibility', etc. become the focus of the debate) are more to do with retribution than with capturing learnings and trying to avoid repetition in the future.

I feel it is far more useful to think in terms of probabilities. We can use past data to figure out the probability that any given flight will be involved in an accident, and by looking at the circumstances we can quite accurately assign increased probabilities to the presence or absence of particular factors.

There were a whole raft of probability increasing factors present here (night, visibility, familiarity, quality of lighting, etc.). The useful question to ask is - given the vastly increased probability of an accident created by this heavy assembly of negative factors, was there any compensatory set of procedures, training, equipment, etc. that might have reduced the probability that SQ 006 would have done what it did?

We can include in such calculations operational culture, level of individual experience and other human factors.

For me considerations of blame or negligence come into the mix only if anybody (or any body) involved failed to do something they were specifically expected to do, or did something they were specifically expected not to do, or failed to adopt compensatory procedures for a reasonably predictable set of probability increasing circumstances. Only then does punishment, liability or retribution become an issue. For me mistaken perception is not negligence, but a manifestation of the presence of negative environmental factors that cause misperception.

In this case those questions concern whether the airport authorities and flight crew could reasonably have predicted the misperceptions that led to the fatal actions and, if so, whether they took adequate mitigating operational measures. Misperceptions, or signals that in the event turned out to be inadequate, are not of themselves reasons to apportion blame.

Alpha Leader

30th Apr 2002, 05:28

hawkeye 18: your link does not seem to work :(

hawkeye18

30th Apr 2002, 05:54

Alpha Leader,

I just tried it ...... and it is working!

Alternatively you can acsess it at the site itself ... it is at the bottom of the page at

http://www.sq006.gov.sg/final_draft/fr_final_draft.htm

"To view the simulation of the line of vision of the pilots on the night of the accident,click here."]

:)

Alpha Leader

30th Apr 2002, 06:00

Hawkeye 18:

Thanks, I tried again and also via your second link, but no joy. Might have something to do with the firewall on my server - I'll try from home tonight.:(

In the slot

30th Apr 2002, 10:16

:( :( It seems that a loss of situational awareness was a major contributary factor, and this was partly brought on by the spurious lighting/weather/markings, etc.
However, what do you do in aviation if you have ANY element of doubt. Well of course, the best answer is stop and reconfirm if operationally possible, even if that doubt is 1%.
I have many a time seen crew come off high speed taxiways and shoot off into a maze of taxiways, often making a mistake, or even had awareness problems taxiing from parking bays. Sitting and seeing this whilst operating, or observing from a jumpseat, highlights an issue which many are guilty of in many situations.
Let everyone learn once and for all if you are in doubt about anything STOP (if you can), ask, and re-orientate.
If we don't, people will continue to taxi to the wrong bays, turn into the wrong taxiways, line up to land on the wrong runways, bust flight levels, and very occasionally try to take off on the wrong runway.

Alpha Leader

30th Apr 2002, 13:56

hawkeye 18:

Good slideshow and very informative.

Beggers the question, though, as to how many flights SQ had operated out of CKS prior to the SQ006 crash without having raised any complaints to the airport operator about the non-ICAO-compliant situation.
:o

hawkeye18

30th Apr 2002, 15:51

Hi Apha Leader,

From what I gathered SQ operates mainly on the eastern side of the field hence their preference in using Runway 06/24.

They rarely if not never ( correct me if I am wrong) use Runway 05/23 for takeoff operation.

On that faithful nite, Captain of SQ006 elected to use the longer 05L due to the marginal weather condition.

During the investigation, 2 pilots came forward voluntarily and related their experiences at 05 R... one of them was from Fed EX whom nearly mistook 05R as 05L but managed to pullback at the last instance from committing.... ....this captain use 05L close to 200 instances during the last year of operation out of CKS!

However, these instances of confusion at the said 05R were only reported to their company and not the airport authority!!!

(all these are buried somewhere in the 2 reports, I am commiting them to writing from memory)

Cheers!

Rockhound

30th Apr 2002, 18:29

In the Slot,
What you say is all well and good but I believe you are missing the point here. I would maintain there was no doubt in the SQ006 pilots' mind that they were properly aligned for takeoff from the correct runway, just as in Tenerife in 1977, the KLM 747 commander was convinced he had been cleared for takeoff. (The PVD issue, which was debated at length in this forum last year, is a red herring. It is not meant as a tool with which to identify a runway). Surely the crucial question is, what circumstances led to this mindset? Why were the pilots satisfied that no error had been committed and all was in order?

Rockhound

Murrelet

30th Apr 2002, 21:39

Perhaps there is hope for Singapore yet. Take a look at the following for the 'real' story of SIA006 - humour at its blackest.

http://www.talkingcock.com/html/sections.php?op=viewarticle&artid=17

Gladiator

1st May 2002, 05:08

Interesting that Singapore is waiving the ICAO flag.

Not too long ago (it is all in the PPRuNe archives) when I fought SIA in the United States Federal court over SIA's unsafe flight operations (First officer in the Captain's seat without proper training and license as required by ICAO annexes), all the loyal soldiers of SIA in endless PPRuNe posts laughed at the ICAO annexes. They called it advisory only but not mandatory (are you reading this Si?).

Now they are waiving the ICAO flag and the attached annexes. After dealing with CAAS (CAA Singapore) and SIA I must express my opinion. They are a joke.

Outcome of the case, they had to stop this practice.

Rockhound

1st May 2002, 12:11

Hey, Gladiator, watch your spelling. In that first sentence you're actually writing the opposite of what you mean.
Cheers,
Rockhound :D

Alpha Leader

1st May 2002, 12:14

Hi Hawkeye 18,

Good background, thanks very much. Can't corroborate it or otherwise.

Interesting input from Gladiator on ICAO matters, though!

hawkeye18

1st May 2002, 13:42

Gladiator,

"""Interesting that Singapore is waiving the ICAO flag.

Not too long ago (it is all in the PPRuNe archives) when I fought SIA in the United States Federal court over SIA's unsafe flight operations (First officer in the Captain's seat without proper training and license as required by ICAO annexes), all the loyal soldiers of SIA in endless PPRuNe posts laughed at the ICAO annexes. They called it advisory only but not mandatory (are you reading this Si?).

Now they are waiving the ICAO flag and the attached annexes. After dealing with CAAS (CAA Singapore) and SIA I must express my opinion. They are a joke.

Outcome of the case, they had to stop this practice."""

Interesting that u brought up your court case with SIA.

So you won or lost!( u din come thru too clear there)

If U have won than SIA was wrong but if U have lost then SIA was right!! .....For that particular court case that is.

But to have a jundiced view of an establishment with reference to just an "unpleasant" encounter will be stretching things abit too far......( just a personal view without being employed by them nor have any vested interest of the company.)

I do admire them for their bussiness acutement and management and safety record prior to SQ006 ........ well I could be wrong here, if so , please do enlighten me with an airline that is as profitable and with a better safety record!

It appeared that u have an axe to grind with them hahhaa !! For whatever personal reasons......... I wun speculate!

Likewise, for whatever reason u call them a joke, be it You deal with them or They deal with you, do substaintiate it so that we can laugh at it along with you. If not , by inference, other lesser airliners or Aviation Authorities will be even worst then your joke..!!:D

:D See !!! I am also falling into the trap of concentrating on the tree and missing the wood............. arh!!! Or should it be the other way round in this case!!!! ... barking at the wood and missing the tree!:D

Cheers!!!!!!!!

Belgique

1st May 2002, 18:02

Rockhound
Re your comments above: "Surely the crucial question is, what circumstances led to this mindset? Why were the pilots satisfied that no error had been committed and all was in order?"

Although I realise that visibility was down to 400 to 600 metres, they only had visibility through the forward area of the windscreens being swept by the wipers. Sometimes, on a dark clear night you lose depth perception and a busy airfield can be swimming in a sea of lights.

And on a dark and rainy night, you can tend to be transfixed by (and fixate on) the few things that you can see.

I remain unconvinced that no runway edge lights were on. That conclusion seems to rest upon what was seen by distant security cameras.

But it doesn't change the fact that an opening was left and a crew was duped through it. I'd guess that the "dominant perception"

syllogism was operative and that what they were looking at simply failed to register against the background of "getting on with the show".

Syllogism: In Logic. A form of deductive reasoning consisting of a major premise, a minor premise, and a conclusion. It more often than not is a subconscious thought process.
(All humans are mortal, the major premise, I am a human, the minor premise, therefore, I am mortal, the conclusion)

begets in this case (subconsciously) the dismissive mindset of:

We are lined up for departure on the runway and cleared for take-off.
What we must be seeing out the front must be that runway.
Therefore there is no safety problem nor cause for alarm or query.

i.e. a simple failure to mentally register any inconsistency.... no alerting mechanisms present at all. Because the predominant concern is about darkness and weather and visibility, a perverse mechanism of reassurance is always tending to suppress any disquiet (the PVD....). That's the sentient side of human nature.

Alarm generators must be active stimulants. The singular red depressurisation warning light on a Beech 200 does not flash and is not attention-getting and, although double filamented, is no substitute for an aural alarm. That's probably what caused the "failure to pressurise" overflight (and death of eight) in the Payne Stewart type crash ex Perth last year. The sun was from over the pilot's shoulder and washing out that light as he climbed out in the late afternoon on an Easterly heading. It's a good example for the assertion that "alarm and warning generation" is a wholly active (and never a passive) affair. You can probably think of numerous other examples where this suppression syndrome consciously copes with the environmentals while the "dominant perception" syllogism perceptively accommodated the desired sense of well-being.

Simple Solutions in hindsight
They could have used a Dreadle Treadle hooked to pyrotechnics alongside the 05R threshold and still used it as an exit taxiway. (i.e. A B => A progression across the treadle lights off the fire-works yet an A => B progression for taxiing aircraft exitting 05R taxiway (across the same treadle) does nothing).

Gladiator

1st May 2002, 18:13

Don't worry too much about my spelling or grammer. It sucks.

Ax to grind or not I am still a former insider with certain information. In reference to ICAO and SQ006, let me inform you that the crewmember configuration on the ill fated flight or other SIA flights did not meet ICAO minimum standards.

ICAO requires certain licensing standards on aircraft certified to be operated by a two man crew. In the case of a B747-400, all crewmembers are required to hold an ATPL, or in the case of the first officer(s), a frozen ATPL.

SIA and CAAS (CAA Singapore) for years have/had ignored this minimum standard having the status of 'SHALL' as opposed to 'SHOULD' by ICAO.

SQ006 had a three crewmember configuration. One captain and two first officers. One or both of the first officers may or may not have met this standard, and even if those two particular first officers did, SIA's other B747-400 flights did not.

Therefore we are back to the original discussion. Singapore waiving the ICAO flag to show that Taiwan did not meet ICAO minimum standards in their airport markings while they themselves did not meet ICAO miminum standards in flight operations.

BTW reason behind SIA not meeting the minimum crewmember certification standards is/was obvious. It costs less. A first officer is cheaper than an additional Captain. A first officer qualified in the right hand seat is cheaper than a first officer qualified in both the left and right hand seat (in cruise). A first officer without the frozen ATPL costs less than one with a frozen ATPL. It goes on and on. To put this paragraph in simple form, it is/was possible for an SIA B747-400 to be in cruise, Captain sleep in the crewmember bunk (without quick doning oxygen), two 20 year old first officers without ATPL or frozen ATPL at the controls (Ofcourse the service in the cabin would be world class).

Reference was made to SIA's safety record and profits. SQ006 was only a matter of time, SIA's operation, particularly CRM was a ticking time bomb. We as insiders were surprised they got away with it for so long. Many times they came very very close.

Belgique

1st May 2002, 19:02

Alpha Leader

2nd May 2002, 05:57

One aspect of this tragic accident is, of course, that it not only puts SIA under global scrutiny but - by extension - "Singapore Inc.", a government-controlled business environment that by its own understanding can never do any wrong.

It's amazing how - for a wider international audience - SIA have been successful in limiting the fall-out from the Silk Air 185 crash. Even a very recent air safety "advisory" by an otherwise reputable German magazine (Focus), simply ignores the existence of MI and gives Singapore (as an aviation nation) a pre-SQ006 fatality-free bill of health. Amazing but sadly true.

Given such PR successes, we can all imagine how high the stakes must be on SQ006 at the Istana.

Rockhound

2nd May 2002, 12:24

Sorry, Glad, I don't see the relevance of your last post to the SQ006 accident. Both first officers held ATPLs.

Rockhound

2nd May 2002, 13:02

Belgique,
That's very interesting, although I must confess I don't understand the Dreadle Treadle (too technical for me, I guess).
Of course, my question was rhetorical. I disagreed with In the Slot's premise that one or more members of the SQ006 crew was unsure they were on the correct runway but, collectively, they decided, what the hell, it probably is, let's go. I don't think airline crews would do that but maybe that's wishful thinking on my part. (Then I hark back to the China Airlines crew taking off from a taxiway bearing 246 deg when cleared for a Rwy 32 departure at ANC in January and I don't know what to think).

hawkeye18

2nd May 2002, 13:29

Gladiator,

"Ax to grind or not I am still a former insider with certain information. In reference to ICAO and SQ006, let me inform you that the crewmember configuration on the ill fated flight or other SIA flights did not meet ICAO minimum standards. "

Obviously u are not that well informed on the crewing of SQ006 after all .... and I take it that your utterance "of the other flights not meeting ICAO minimum standards is also a pure conjecture on your part. :)

This is from the ASC report :

CM1 The Captain was issued an ATPL on Jan 3 1993

CM2 The First Officer was issued an ATPL on August 6,1999

CM3 The Relief Pilot was issued an ATPL on January 7,1997

There is a great difference between an insider and a use-to-be insider! :)

Therefore we are back to the original discussion. Singapore waiving the ICAO flag to show that Taiwan did not meet ICAO minimum standards in their airport markings while they themselves did not meet ICAO miminum standards in flight operations.

As Rockhound rightly pointed out what relevance are these with reference to the report on SQ006? Especially now we know the fact of crewing of SQ006 as reported in the ASC!??

By the way , have u thumb thru the ASC and MOT reports as yet... if u did then obviously u are "not reading" alot of things in them!

It appear to me that u are more interested in "SIA/Singapore Bashing" then what the reports could help to prevent another similar accident. :)

Alpha Leader,

One aspect of this tragic accident is, of course, that it not only puts SIA under global scrutiny but - by extension - "Singapore Inc.", a government-controlled business environment that by its own understanding can never do any wrong

If I am not mistaken they admitted it was pilot error right from the start ( to the effect that our pilot took off on the wrong runway) . And I dun think they operate SIA within the confine of Singpaore Airspace only........

So I an rather confuse as to your "a government-controlled business environment that by its own understanding can never do any wrong"

I think it is also not relevant to the topic we are on ......, with reference to the reports and what could be done to prevent another similar accident from happening.

..........hmmmm another case of wood and tree!;)

Solli Folks , no offense intended as I am more interested in the facts of the case rather than history, the company or the country........ perhaps some other times!!

Cheers!!:)

Rockhound

2nd May 2002, 15:34

Alpha Leader,
Like Hawkeye, I think your last post is off-topic but I am amazed that you are amazed that there's been so little fallout from Silk Air 185. Do you really believe that a significant proportion of the travelling public has anything but the vaguest notion of this accident, a crash of an airliner somewhere in SE Asia? Hell, half of them don't even know where Sumatra is and no way would they associate Silk Air with Singapore Airlines. A thriller writer would be hard-pressed to come up with the story behind the story of this accident, yet, as far as I am aware, not a single well-researched magazine article, let alone a book, has been published on it.
No, I'm afraid that all but a few outside the industry have the foggiest idea of the airliner-related incidents and accidents that so exercise us on PPrune. Do you think many people refused to fly KLM after Tenerife 1977, or Korean after Guam, or Qantas after QF1? Do people stop taking the train after seeing all the gory details of a fatal derailment or collision? Whether they admit it or not, people operate on the principle of when your number is up, your number is up.
And when all is said and done, SQ does have a good safety record, notwithstanding what Gladiator and others may say or impugn.
Sorry, I've ranted on long enough.
Rockhound

Slasher

2nd May 2002, 19:04

As in any final accident report its not who f*cked up thats of prime importance but what f*cked up. In the SQ006 prang there are many links in the chain which ultimately are part of the what. The what factors are the points that need to be learned so that the rest of us can recognise these same links and hopefuly prevent an accident like this one before it has a chance.

Unfortunatley the 2 countrys involved put loss of face ahead of pragmatism and safety. MI185 proved Singapore in that regard, and I expect the SQ006 reports to be but a stalemate with one side blaming the other with no solutions proffered, nor any real facts made public.

Belgique

2nd May 2002, 19:55

Rockhound

re Dreadle treadles

Try this link (http://www.iasa.com.au/folders/dreadle.html) with many other pages linking from that.

It also had a number of write-ups in Air Safety Week

In the slot

2nd May 2002, 20:21

:o ROCKHOUND...I do not miss the point. I think you are missing MY point! That is, probably something that BELGIQUE was referring to with blinding words of science.
In my informed opinion, the crew THOUGHT they were on the correct runway, but obviously they were not. What caused this spatial disorientation, to make 3 pilots all wrong. THINKING or BELIEVING you are somewhere is not enough!

HugMonster

2nd May 2002, 20:45

As the report points out, not only were the pilots convinced they were on the correct runway, but everything about the signage and lighting suckered them into the wrong one.

Of all that I have heard about SQ, much of it here, if there is only 50% truth then there is cause for concern with the airline's safety structure.

However, it does not appear to have been a factor in this incident.

There is never a single cause of any accident. There is a chain. "Pilot Error" is an exceedingly dangerous concept. What needs to be examined is what lead a pilot into making an error, and examining how it can be improved since, let's face it, no pilot ever wants an accident in which, at best, he may lose his job.

I have never flown in the Far East. Quite a few pilots here have, and will have flown into Taipei many times. How many, no doubt some PPRuNers among them, raised concerns about the lighting and signage with anyone in a position to address the problem? If you were there, saw it, and did nothing except tut-tut, then you are also part of the problem. You were a contributing cause of that accident.

Several times in this thread the word "fault" has been used. This also I have a big problem with. Only when we can move away from apportioning blame, finding fault with individuals' performances and looking at the inherent errors in the system will we be able to evaluate incidents with the sort of eye which can see how to avoid similar incidents in the future.

Alpha Leader

2nd May 2002, 22:49

Hawkeye 18:

The initial admission of pilot error notwithstanding, the fact remains that the Singapore side is now trying to make a case that this was virtually forced upon the crew.

G.Khan

2nd May 2002, 23:55

HugMonster - If most of what you have heard about SIA and safety has come from PPRuNe then you can indeed rest easy.

Most of what has been posted on PPRuNe has come from disenchanted ex SIA pilots who have their own personal agenda, often that they are being chased to pay their training bond having 'jumped ship' and respond by attacking the safety aspect of SIA and going to what they hope are friendly courts in foreign lands who will declare training bonds illegal.

Very little of what has appeared on PPRuNe is genuine concern for safety and has much more to do with saving their own face, having run away, and their guarantor's money.

I have worked for a few major carriers and SIA is no worse than any of the others, the overall experience of the few that choose to try and bash SIA is such that they often don't actually know what they are talking about, IMHO.

Murrelet

3rd May 2002, 01:24

Reading through the thread, I am struck by two things. Firstly that most of you have not read the reports (or you read different versions than I did), and secondly that some of you are falling for the SIA press strategem, and believing that the Sg and Tw reports are equally partisan documents.

Slasher for instance:

"Unfortunatley the 2 countrys involved put loss of face ahead of pragmatism and safety. MI185 proved Singapore in that regard, and I expect the SQ006 reports to be but a stalemate with one side blaming the other with no solutions proffered, nor any real facts made public."

I have read the reports, and think it might be useful to summarize at least the ASC report for all those too lazy to read it for themselves! You will see that Taiwan does not entirely escape blame in the ASC report.

1. The Pilots failed to determine that the runway condition should have been classified as ‘contaminated’ due to the inevitable buildup of standing water under cyclone conditions. This determination would have downgraded the cross-wind limit for takeoff from 45 knots (wet runway) to 15 knots (contaminated runway) and therefore prevented the scheduled departure.

2. The Pilots low-visibility taxiing performance was deficient during the final stage of taxi, and their navigation procedure was inadequate and did not utilize runway charts, signage, markings or cockpit instruments to guide them to the correct runway. The attention of the co-pilot Latiff and the relief pilot Ng was ‘inside’ the cockpit focused on the pre-takeoff checklist and calculating the cross-wind component. Only Captain Foong’s attention was ‘outside’ the cockpit focused on taxiing slowly in the slippery conditions and following the green taxiway lights to the runway.

3. The reason Captain Foong made a premature turn onto runway 05R was because:
i) he had the false impression that ATC could see the aircraft. He was under that impression because ATC issued his takeoff clearance just as he reached the end of the taxiway and was beginning his turn onto the runway. Co-pilot Latiff also confirmed that the timing of the takeoff clearance gave him the impression that everything was in order.
ii) the captain did not use the runway chart or the compass to guide him to the correct runway. Instead he stated that he “followed the green taxiway lights” despite the fact that this technique could not be used at CKS where visual navigation is required.
iii) he also failed to notice signs, markings and lights which indicated he was turning onto the wrong runway. These included the green taxiway lights to 05L (which were more widely spaced than normal), a clearly illuminated 05R sign as he turned into the runway, and the 05R marking painted on the runway in front of him as he lined up for take-off.

4. As they held for takeoff, all 3 pilots thought they saw a ‘normal runway scene’ and failed to recognize crucial indicators that they were on the wrong runway including:
i) that the center runway lights were green and not white (a printout record from calibration and maintenance equipment showed that the center runway lights were on 4 minutes before the crash)
ii) that it did not have touch-down lights or high-intensity runway edge lights (lack of evidence from security and passenger video, together with eyewitness testimony from the pilot of a plane on the taxiway 110m from the 05R indicated that the runway edge lights were almost certainly off).
iii) that the runway was 15m narrower than it should have been
iv) that the PVD instrument had not unshuttered.

5. Several factors were speculated to have led to these navigational deficiencies and observational failures including that:
i) the pilots were accustomed to using runway 06 and had not used 05L for 2-3 years and were therefore unfamiliar with it.
ii) Although having read a NOTAM concerning the construction on 05R, the pilots had not read the SIA INTAM that contained important information on the status of 05R’s center and edge lights
iii) Captain Foong had not been officially trained in low-visibility taxiing
iv) the pilots all had an incomplete understanding of why the PVD did not unshutter and incomplete training on the operational context of its usage.
v) the green taxiway lighting that led to 05L was abnormally spaced and instead of being 7.5 m apart, each light was 23 m apart
vi) All 3 pilots were fixated on taking-off quickly before the weather conditions deteriorated further and prevented takeoff (although there was no evidence of ‘organizational pressure’ on the pilots to take off that night).

6. The CKS airport authority was derelict in their maintenance and safety responsibilities. By not placing mandatory construction warnings at the entrance of 05R, they failed to address the risk that aircraft might inadvertently attempt to take off from a partially closed runway. They also failed to adequately maintain taxiway lights and marking to accepted international standards.

Maybe I am missing something, but this seems a pretty unbiased statement of facts. If you look at the NTSB comments in the appendix, they seem to think so too. Don’t be fooled by the spin doctors.

Rockhound

3rd May 2002, 04:19

In the Slot,
I don't wish to belabour this point, since we basically seem to be in agreement, but, with respect, although in your opening sentence you do acknowledge that the crew lost situational awareness, the rest of your post is concerned with what a crew should do if there is any element of doubt in their minds as to their position. I assumed you felt that they were unsure of where they were. I think they were, to a man, wholly satisfied that they were correctly positioned for takeoff but I realize others disagree. This point was debated in this forum at length last year; unfortunately, not all the protagonists of the opposing viewpoints have rejoined the fray.
Rockhound

Alpha Leader

3rd May 2002, 04:36

Murrelet:

Excellent posting - sums it up very well

Slasher

3rd May 2002, 05:40

Murrelet well said and most of those facts are well known alreadey, but I suggest you live and work in both countrys for a while to catch the drift on that paragraph of mine you quoted.

hawkeye18

3rd May 2002, 07:08

May I suggest that those interested in the subject matters , at least take the trouble of reading up the 2 reports ........

It just dawned on me from comments on extracts of the reports that some has not taken the trouble of understanding the whole sequence of events and its details ......... and started commmenting or give their views on the reports!

To me it appeared to be a very unprofessional approach to this disussion!!

Just my 2 cents worth!

Cheers

Slasher

3rd May 2002, 07:45

Hawkeye I think we are talking about the final analysis once the dust settles.

hawkeye18

3rd May 2002, 08:29

Slasher,

Thanks!!

That is exactly what I meant, The summary of Murrelet are all contained within the executive summary of the ASC reports.

And to think that I have been talking to people, that have not even read at least the executive summary of the report, and start blasting away their personal opinion of the accident , the comapny and the country!

What a waste of time!!

Cheers!!

NC1701

3rd May 2002, 11:12

sorry for not reading the 2 reports but still giving my 2 cents worth.

IMHO all parties involved with the investigation were satisfied with the factual part of the report. I believe even the S'pore team commented that it was a job well done. Even on contentious items such as status of the 05R edge lights many 'facts' were gathered which i believe were not disputed.

The problem as i understand it was the analysis part. As we can see, from the same facts, they can come to different conclusions regarding the status of the edgelights (although both sides did temper their conclusion with 'probably').

Also another main point of contention was the listing of probable causes attributing 7 of them to the pilots and 1 to weather, while airport deficiencies were listed as risks. IMHO this appears to be apportioning 'blame'. Although later on, ASC did come out to clarify that as stated earlier by them the report did not apportion blame to any parties. And that 'relief' shouldn't be the reaction from CKS airport authorities for it was not what the report intended. ASC also pointed out that the number of 'risk' factors listed were more than 'probable causes' and that this was not inconsequential.

All these reactions after the report was made public, imho stems from the choice of words and style of presentation (see hawkeye 18's 1st posting on pg 1). What is ASC's report really saying (or implying)? Leave it to the media and you have 'one sided' reports coming out (which is natural though not desirable and imho, NOT intentional 'brain washing').

With respect to SQ006, i think the wrong turn into 05R is not the BIG issue here. One can make a wrong turn (and i think this not as uncommon as one would have liked?) without the same disastrous outcome. eg:
i) realize the mistake and turn out again, or
ii)dont realize the mistake but still take off from the wrong but operational runway ..... (safely!?).

The big issue is taking off from a CLOSED runway. Some would insist that it was a PARTIALLY closed runway and therefore not technically 'CLOSED'. How is one supposed to make that distinction if the difference is only 'apparent' when you are passed 'V1'. Some would counter that the centre lights were not white and there were no touch-down lights and that the edge lights "were almost certainly off" that this was not a runway but a taxiway. Some will say that the PVD "had not unshuttered" hence this was a wrong runway. Then how come "all 3 pilots thought they saw a ‘normal runway scene’ " and thought they were on the correct runway?

Will the courts have the last say?

In the slot

3rd May 2002, 13:40

NC1701
Your second to last paragraph asks the much avoided chilling question. With all those inconsistencies, how come 3 pilots thought it was the correct view? It seems unbelievable if those facts mentioned are true, but then a China Airlines A340 recently departed Anchorage in an even more unbelievable scenario and no doubt they too THOUGHT they were in the correct place, even though it was a taxiway almost perpendicular to the intended departure runway! There were three pilots on that flight deck too.

In the slot

3rd May 2002, 14:13

Aha, gladioli, you've raised your ugly head again. Like a hungry hyena hanging around SQ postings, with all your usual negativity and bitterness. Seems you have very little constructive intelligent comment on ANY postings. Get over it, take a viagra, go and take your wife out for a nice meal, and enrol on a yoga class.
Would like to hear your view on the China Airlines incident in Anchorage, to see if you can enlighten us with your wisdom and knowledge from that part of the world, thats if you have anything constructive to add to the forum.

holden

3rd May 2002, 17:11

Murrelet mentioned something interesting about the timing of the takeoff clearance.

"Co-pilot Latiff also confirmed that the timing of the takeoff clearance gave him the impression that everything was in order."

However,if you look at the report,the elapsed time between clearance and start of the roll is relatively considerable..in the order of 80 seconds.Partly explained by the 5 kts taxi speed I know.But if their "ready" call was premature(clearly debatable),then ATC´s natural response to offer clearance(no traffic-they cant see them anyway) whilst still on NP might have induced the pilot to readily accept the picture he saw at N1/05R intersection,given the time elapsed between the two.The longer the time elapse is,the more willing he becomes to accept the notion that he is indeed on the correct runway.
If the takeoff clearance had just been issued (on the turn into N1),the pressure to accept those compelling green lights might have been less.
Perhaps an ATC can say if there is a finite time limit on a takeoff clearance?

In the slot

4th May 2002, 01:31

Holden,
Not sure if there is some sort of time constraint. However, as the tower could not see their whereabouts, and may have thought they were much closer to 05L, it was not unreasonable to be given a clearance to depart as soon as they reported ready considering there was no other traffic around.
We have, many a time, been given a take off clearance when switching from ground to the tower WELL before reaching the runway,similarly been cleared to land 8 or 9 miles out when there is plenty of other traffic around.

Gladiator

4th May 2002, 07:04

Singapore bashing, blah, blah, blah, ugly head, call it whatever you like.

Both first officers of SQ006 having had their ATPL was pure luck for SIA, and I mean pure luck. The facts remain documented, dozens more SIA B747-400 first officers on line did not at the time of SQ006 accident.

Therefore, once again we are at the same place, SIA's flight operations in breach of ICAO minimum safety standards at the time of SQ006 accident.

The facts are not in favor of Singapore and SIA, therefore viewed as bashing. Sometimes the truth does that.

As I always have in the past, I come armed with both internal and external numbered SIA documents. All challenges to prove me otherwise are welcome.

Captain Stable

4th May 2002, 07:47

Gladiator, your attitude is slightly less than helpful to establishing the numerous factors which contributed to this tragedy.

It is universally accepted that SIA are not perfect. How far from perfect they are is a matter of debate and opinion.

But as long as people on either side are prepared to say "There - look there - it's HIS fault" and dismiss other factors because they put the "blame" elsewhere, there is little hope of learning from the accident and making changes to the entire system that will prevent a recurrence.

There is never a single cause of an accident. I assume you are familiar with the "Swiss Cheese" model? It is not enough to plug one hole. We need to plug all holes that are shown up by the investigation.

hawkeye18

4th May 2002, 08:12

Apologies folks for littering the thread, but liar and purveyor of semi-truth and false information need to be exposed/curtailed to maintain professionalism in PRRuNe.

............................................................ .............................................
To Gladiator,

"As I always have in the past, I come armed with both internal and external numbered SIA documents. All challenges to prove me otherwise are welcome."

Are these so called documents,current or past records? If it is not current then they are history and please do specify so when u wave them at us.

You also claimed to have won a court case with SIA (1st May 2002 05:08 Hrs):

"Not too long ago (it is all in the PPRuNe archives) when I fought SIA in the United States Federal court over SIA's unsafe flight operations (First officer in the Captain's seat without proper training and license as required by ICAO annexes),

Outcome of the case, they had to stop this practice.

If u claimed you have won the case, then how come:"The facts remain documented, dozens more SIA B747-400 first officers on line did not at the time of SQ006 accident. " ???

Don't u think You are contradicting Yourself on the above ???!!!

............................................................ ............................................

As far as I am concerned, the facts has proven you wrong, and that u shot off your hips but instead had shot your own feet!!:D

For whatever your are worth , I rekon you are one that quote "false facts" from your own agenda ,and does not face up to facts.....current and recorded one that is !!

You are entitiled to your opinion in any case, and continue to lug your baggages and live in the past, but facts speaks louder than you!!!!!!![B]:D

[B]for the record:

Gladiator:

Ax to grind or not I am still a former insider with certain information. In reference to ICAO and SQ006, let me inform you that the crewmember configuration on the ill fated flight or other SIA flights did not meet ICAO minimum standards.

SQ006 had a three crewmember configuration. One captain and two first officers. One or both of the first officers may or may not have met this standard, and even if those two particular first officers did, SIA's other B747-400 flights did not.

Hawkeye 18 :

Obviously u are not that well informed on the crewing of SQ006 after all .... and I take it that your utterance "of the other flights not meeting ICAO minimum standards is also a pure conjecture on your part.

This is from the ASC report :

CM1 The Captain was issued an ATPL on Jan 3 1993

CM2 The First Officer was issued an ATPL on August 6,1999

CM3 The Relief Pilot was issued an ATPL on January 7,1997

There is a great difference between an insider and a use-to-be insider!

I rest my case !! On facts and nonsense!!

And now these!!!!!::D

Gladiator:"Both first officers of SQ006 having had their ATPL was pure luck for SIA, and I mean pure luck. The facts remain documented, dozens more SIA B747-400 first officers on line did not at the time of SQ006 accident. "

Judge Yourself folks!!!

:D :D :D :D :D :)

Rockhound

4th May 2002, 18:32

NC 1701,
By asserting that the big issue is taking off from a non-operational runway, not making the wrong turn, it seems to me you're treading on really dangerous ground. I don't see how you can separate the two actions and deem one to be more serious than the other. The wrong turn brought SQ006 onto a runway that, for their purposes, was CLOSED PERIOD but not easily recognizable as such (that it might have been officially only partially closed is immaterial). You're in effect saying to a pilot, don't worry about taking a wrong turn during taxi, if you wind up in the wrong place you'll be able to sort things out.
It seems to me that maintaining situational awareness AT ALL TIMES is, for an airman, paramount.

Gladiator

4th May 2002, 18:55

Here we go again, the disgrunteled employee drill.

May you would like to explain the reason for this internal note from CAAS to SIA, Pay close attention to the date of SQ006 accident and the date of this memo.

B747-412 Flight Staff Instruction

No: 00-14
Date: Nov, 7, 2000
To: All 744 Crew
From: Vice President/Chief Pilot 744
Subject: 3-pilot crew operation
Reason: To comply with CAAS requirement

The Civil Aviation Authority of Singapore has withdrawn the approval for the 3rd pilot of a 3-pilot crew to occupy the left-hand seat while the commander is taking in-flight relief during cruise.

The FAM will be amended in due course. Please be guided accordingly.

Captain Axx Cxx
For Vice President/ Chief Pilot B744

It does not take much to figure out someone was trying to cover their A55. Even after this memo the violation continued, for how long I do not know. As far as I know it could still be going on.

Care to challenge me on the contents of this memo and the reason for it. How come it was OK to do it for many years and all of a sudden it was not?

I am not discussing the reasons for the SQ006 accident. Back to the same issue again. SIA B747-400 operations were not in compliance with ICAO minimum safety standards at the time of SQ006 accident.

hawkeye18

5th May 2002, 04:24

Gladiator ,

The challenge was on this statement of yours:

"Ax to grind or not I am still a former insider with certain information. In reference to ICAO and SQ006, " let me inform you that the crewmember configuration on the ill fated flight or other SIA flights did not meet ICAO minimum standards."

And the answer was this:

Extracted from the Taiwanese ASC report :

CM1 The Captain was issued an ATPL on Jan 3 1993

CM2 The First Officer was issued an ATPL on August 6,1999

CM3 The Relief Pilot was issued an ATPL on January 7,1997

FULL STOP !

I have no wish to listen to your sob stories and conflicts with SIA.... u are on my ignore list!

Regards and Best of Luck!

hawkeye18

5th May 2002, 05:26

NC1701 & ROCKHOUND,

Turning onto the wrong runway was the cause of the accident and the main issue here !

The what and how that led the pilots into turning onto the wrong runway is what I think need to be scrutinised , to derive the causual factors that led them into the mistake, so as to preclude another similar accident from occurring.

from what I can see, the following are the main areas/factors:

The inclement weather,

The night enviroment,

Signages, lightings and markings of the taxiway and 05R Runway

Air Traffic controls : in bad weather taxy monitoring and takeoff clearance.

Take off procedures of SIA: in confirmation of correct runway.

The reports by ASC and MOT are very thorough and left no stones unturned on the above areas, and lots of lesson and actions have been taken by both CKS and SIA and to rectify the shortcomings .

Both approaches in investigations are correct .

But what alarmed me was the formating of the Final Analysis of ASC which classified the Casual Factors as:

"(1)“findings related to probable causes” which identify elements that have been shown to operate or almost certainly have operated in the accident; ( please note the operative word: operated.)

In short the investigation of the causal factors relating to the accident, will be entirely focused on the Pilot and the weather, and deficiencies of airport system and other contributing factors were delegated to Risks.

As a result the concluding "Probable causes" will , for all intents and purposes, always be on the weather and the pilot even before the ASC started its analysis of the Probable causes "

Though Dr Yong Kay the chairman has qualified subsequently that Risk Factor's play an equal and critical role as causal factors in the accident. Whether we like it or not, it is only natural for both sides to adopt a "self- protection" mode in this investigation.

At the end of the day, I hope the aviation communities will learn and benefit from these 2 excellent reports.

The Civil court will have to decide in the apportioning of liabilities and blames. ! :(

Regards!!

Hawkeye

Captain Stable

5th May 2002, 07:14

hawkeye, the cause of the accident was that the runway from which they tried to take off was obstructed. Turning onto the wrong runway was not the cause of the accident - many people have done that and survived - just by turning round again and taxying to the correct runway.

The problem was that their error was not spotted - by the pilots or by ATC, who did not have GM Radar, and the signage, far from indicating that this runway was not in use, actively led them to it and away from the active runway.

I agree with you that the wording of the report is very worrying. Neither Taipei's nor SIA's defensive attitudes will aid future safety, nor will this placatory answer.

hawkeye18

5th May 2002, 08:31

Thanks ! Captain Stable,

For the comments to my statement , to make it complete , it should be :

Turning onto the wrong runway( and took off from the obstructed runway ) was the cause of the accident and the main issue here !

Warmest Regards!!

Hawkeye.

PS:

Rockhound ,

The parentheses was meant to indicate that it was a subsequent add-on to make the statement more complete.:)

In the slot

5th May 2002, 08:55

Gladioli
Your sad nagging continues to the extent that I'm getting almost as bored replying to them as I am reading them. However, as your statements are SO sad, they always merit a comment from one of the more realistic and forward thinking amongst us. Your reference to the B744 circular and the CAAS statements on f/o's sitting in the left seat shows how inconsequential many of your ramblings are.
In a 2 man operation, if the captain goes to the toilet, one f/o is left in the right hand seat as the sole occupier of the flight deck. In a 3 man operation, if the capt left, there would be 2 f/o's in the flight deck, one in the right seat as the designated command f/o and the other POSSIBLY in the left seat, but not manipulating controls. Tat the CAAS then said that the "spare" f/o CANNOT sit in the left seat was hardly a major change operationally for any of us who FULLY UNDERSTOOD the correct practice of a 3 man crew in the first place. I suggest you think about your own obvious misunderstanding and unprofessional operation when part of a 3 man crew in the past. At the end of the day, the requirement, though not realised by yourself, has ALWAYS been that there is an f/o in the right seat, the only change was that the support f/o no longer has the option to sit in the left seat.

Do us ALL a favour and stop wasting the time of people with relevent and constructive things to say.

Sorry to all else if this went off the subject of the posting for a while.

Rockhound

5th May 2002, 15:22

I agree 100% with Hawkeye's last posting except that I would delete the parentheses. Making the wrong turn AND taking off from an obstructed runway are inextricably linked and confirm the old adage that accidents are rarely attributable to a single cause but result from a chain of events, as others have pointed out in this very same discussion.
With respect, Capt Stable, I don't agree with your flat declaration that turning on to the wrong runway was not the cause of the accident. Sure, if, say, one of the engines had quit during the turn, they would have aborted the takeoff, taxied back to the terminal, and no one would have been any the wiser. But an accident would have been avoided only by pure chance. On the other hand, had they executed the proper turn on to 05L, they would, in all probability, have taken off safely. I can't see how one can deny the close causal relationship between turning on to the wrong runway and taking off from that runway.
I also agree with Hawkeye and others that the format of the ASC report, which is otherwise so thorough and comprehensive, is unfortunate, in that it overzealously separates factors related to "cause" and to "risk". Murrelet's posting in which he summarized the main findings didn't make that distinction (rightly, in my opnion) but unfortunately the ASC did.

hawkeye18

5th May 2002, 17:10

From the the event logs of the accident, no mention was make whether the duty air traffic controller had SQ 006 in sight when he/she issued the takeoff clearance.

Taking into consideration a distance of close to 1 nm from the Air Traffic Tower to the threshold of 05R ,with prevaling visibilty of 400-450 meters (my assumption , actual vis believe was lesser at the time). It was doubtful that the duty air traffic controller had visual contact with SQ 006 as it approched 05R.

Isn't it a requirement for ATC to ascertain aircraft requesting for takeoff clearance is on the correct platformm prior to issue of takeoff clearance??

Especially so on a non- ASD airport under inclement weather , It should have been mandatory for ATC to visually confirmed aircraft is lineup on the correct runway prior to issuing takeoff clearance under such circumstances.

This could be the reason for the Singaporean MOT raising the issue under Safety Recommendation to ASC :

"4.CKS Airport should ensure that its Air Traffic Controllers adhere to their Standard Operating Procedures. In particular, when aircraft cannot be seen from the control tower, controllers should advise pilots of this situation, and that they should taxi with caution. "

Infering that the tower controller violated its standing SOPs in takeoff clearance under adverse weather.... not having visual contact with SQ006.:(

If that is so then it leads to another question , is the airport takeoff minimum comensurate with its controllers' ability in visually acquiring aircraft on the operating platform of the non-ASD airport??? eek:

Are all takeoff clearances in CKS " blind " clearances from the Tower under adverse weather when visibility falls below 600 meters !!!?? :(

Your comments will be most appreciated.

Cheers!

Hawkeye:

Gladiator

5th May 2002, 19:02

Both first officers of SQ006 had their ATPL, correct (by luck). Other first officers of other SQ B747-400 flights did not.

The word 'crew configuration' (in the beautiful color) in your post is exactly what the CAAS notice to SIA was all about, and SQ006 had that very crew configuration.

You are having trouble putting 2 and 2 together (are you a pilot?). If this was a court of law (not a court in Singapore), this memo would be a very important exhibit.

Mind you sir, it is now a part of PPRuNe archives. There is going to be litigation up the yeng yang over SQ006. Sharp lawyers read carefully, including PPRuNe.

Have a nice day.

lomapaseo

5th May 2002, 20:31

The purpose of accident investigation is prevention (of future accidents) and not blame.

So what is need here is the statements and analysis of recommendations stemming from this investigation.

I have seen neither as yet.

All I have seen so far in the various discussion forums is discussions of the wording of the accident reports.

Semaphore Sam

5th May 2002, 21:47

Does anybody have any idea when the last time 05R was actually used for takeoffs and/or landings? How long have the Taiwanese maintained this hazard to operations, a taxiway marked as an active runway? I started operating into there in '92; never saw it used as a runway, but it was marked & lighted as such, though always used as a taxiway. Might as well put vasi's on Mt. Fuji.

G.Khan

5th May 2002, 23:34

GLADIATOR - what you quoted is an instruction to the pilots on the B744 fleet from their fleet boss, it is definitely NOT the memo from the CAAS to SIA advising that the 3 crew concept as previously practiced by SIA was no longer approved.

You ask us to take special note of the date, (07 Nov) but for this to have any relevance at all can you please quote the actual memo from the CAAS to SIA and, most importantly, give the date of that memo?

hawkeye18

6th May 2002, 03:20

lomapaseo

The detailed analysis are voluminous, u can access them at the following links:

http://www.asc.gov.tw/asc/_file/2217/cache/web/pagesetup/page/3844_en.html

http://www.sq006.gov.sg/final_draft/fr_final_draft.htm

Cheers!

Hawkeye

In the slot

6th May 2002, 09:20

Semaphore Sam, not sure how long 05R had been inactive as a runway. Heard rumours it was as much as 12 years! Not sure though!
Hawkeye 18, your statement on some responsibility of the tower being able to see the aircraft it clears for take-off has some merit, though not sure if this is a regulation. However, your statement that the pilots should have been extra careful if they could not be seen by the tower does not quite coincide with my own operating point of view. To me, whether or not I can be seen for a takeoff or taxi, if I am cleared onto a runway or taxiway, I should always exercise maximum caution wherever I am. The tower may not have been able to help them. In Anchorage, the tower could see China Airlines, yet they too made a gross error and departed on a taxi way.
GLADIOLI, you seem to have much to say to others, but STILL waiting to hear about your misunderstanding of a 3 crew operation and your obvious malpractice of it in your days at SQ. You are obviously one of the confused who could not easily differentiate the subtleties between a 3 man (2 f/o's, 1 capt) and an augmented (2 capts, 1 f/o) crew operation. This explains your reaction, along with others, to the CAAS ruling. To me, and those in the know, it made LITTLE DIFFERENCE OPERATIONALLY.

lomapaseo

6th May 2002, 09:46

hawkeye18

Thanks for the link.

What I was trying to say was that I have yet to see any discussions on the forums of what recommendations are identified by the authorities that stem from the investigation. Lacking this, the forums (not just PPrune) in general seem to be caught up in the blame game led by the press.

holden

6th May 2002, 10:44

Lets not hijack the one decent thread and turn it into a slanging match between all and sundry.The important thing here is what happened and why?Gladiator is entitled to mention what he perceives as flaws in the operating environment at SIA.I dont know whether he´s correct or not.I do know he wouldnt be the first to cast a shadow on the operating psyche in SIA.

The report avoids unveiling the "golden nugget" and instead opts for a mish-mash of comments and diatribe on several elements that make up the whole.Yes,an accident is usually the result of a chain of events but the "probable cause" theory is still the best way to go,in my opinion.What was the last chain in the link that made the accident inevitable?Turning on to the wrong runway is about as clear an error as you can get.This was the last chain in the link,and if the NTSB had been at the helm,you can bet your bottom dollar that this would have been their conclusion.I see their recommendations centre almost entirely on developing cockpit moving-map nav displays for ground operations.

hawkeye18

6th May 2002, 13:16

lomapaseo,

All the recommendations and actioned items by the various parties are all within the 2 links I've mentioned:

For your benefits, and those that are too lazy to search for them , I attached the shorter of the appendix from the Singapore side (ASC report is 508 pages!):

Appendix to Part 1

Singapore Ministry of Transport Investigation Team’s Submission Relating to Safety Actions and Safety Recommendations

SAFETY ACTIONS

1 CKS Airport

CKS Airport has advised that since the accident, the following actions have been taken:

a) Efforts have been initiated to set up safety inspection teams and self audit programmes.

b) Runway 05R was decommissioned with effect from 1 February 2001 and has since been reopened as a taxiway.

c) The take-off minima for Runway 05L has been changed to 350m Runway Visual Range (RVR).

d) The Airport Emergency Handling Procedures, Civil Aircraft Accident Handling procedures, and the Emergency Airport Rescue Procedures have been revised.

e) CKS Airport is expediting the installation of Surface Movement Radar (SMR) at the airport.

2 CAA Taiwan

CAA Taiwan has advised that the following actions have been taken since the accident:

a) A review of ICAO Annexes and documents has been carried out, and a mechanism has been set up for follow-up action.

b) Expatriate advisors on airport standards have recently been appointed.

3 Singapore Airlines

SIA has advised that the following actions have been taken since the accident to SQ006:

a) A new CRM training programme for pilots has been developed and implemented, which includes situational awareness and error management training as separate modules.

b) Human factors and accident prevention training for inclusion in the pilot command training programme is being planned by SIA Flight Crew Training Centre.

c) A risk assessment tool to enable crew to manage risk in their operations has been developed and is being evaluated.

d) Redesign of the female cabin crew’s footwear had been initiated in December 1999. New footwear has been introduced.

e) Checklists have been amended to require all crew in the cockpit to visually confirm the correct runway designation before commencing the take-off run.

f) The Flight Crew Operating Manual has been amended to formally require the pilot taxiing the aircraft to refer to signage and markings. It also requires the other pilot to confirm the correct taxi route is being used with reference to airport charts.

g) The Flight Crew Training Manual has been amended to formally document procedures, instructions and the training curriculum for ground operations in poor visibility conditions.

h) The Cross Wind Limitation Policy has been revised and the Flight Crew Operating Manual has been amended accordingly. The revision has a more conservative limit for ‘wet’ runway conditions.

i) An airport specific operational information gathering process has been implemented to provide additional information with regard to operational procedures and facilities specific to the airport not routinely included in Jeppesen route manuals.

j) Boeing’s GPS based “Take-off Runway Disagree Alerting Function” has been accepted by the company for installation on B777 and B747-400 aircraft.

k) An Electronic Moving Map system which provides a pictorial depiction of airport movement areas is being evaluated for installation in SIA aircraft.

l) The FAA Advisory Circular on Runway Safety (FAA AC 120-74) has been reviewed with the objective of identifying useful points for incorporation in the SIA low visibility operations, training and procedures.

4 CAAS

CAAS has advised that the following actions have been taken since the accident:

a) Singapore operators have been required to review their ‘before take-off’ checklists.

b) Singapore operators have been required to update their CRM training programmes in keeping with current industry best practice.

c) Singapore operators have been required to review the FAA Advisory Circular (AC120-74) to assess its suitability to enhance their low visibility operations, training programmes and procedures.

d) A proposal to amend the current regulations to require earlier CVR power-on and later power-off times has been submitted to the Ministry of Transport.

SAFETY RECOMMENDATIONS

1. CKS Airport should ensure that, whenever runways or taxiways are closed to aircraft operations, be it partially or fully, suitable barriers are provided at locations that would physically prevent aircraft from entering such closed movement areas. The relevant ICAO standards and recommended practices (SARPs) concerning runway/taxiway closure markings should be adhered to.

2. A formal mechanism among international airlines needs to be developed by means of which operators can actively seek out and exchange local ‘intelligence’ on potential safety hazards, and ensure that such information is made available to crews. SIA should initiate coordination with other major airlines to better utilise the present “informal” and “ad hoc” exchange of local knowledge regarding operational safety hazards at airports.

3. SIA should review its emergency safety training programme to determine whether it is possible, and practical, to incorporate more realism, and to inculcate more awareness of the potential difficulties flight and cabin crew may encounter in catastrophic aircraft emergencies.

4. CKS Airport should ensure that its Air Traffic Controllers adhere to their Standard Operating Procedures. In particular, when aircraft cannot be seen from the control tower, controllers should advise pilots of this situation, and that they should taxi with caution.

5. CKS Airport should set up an integrated safety management system, so that systematic safety reviews, hazard analyses, and risk assessments are undertaken before implementing any airside work or changes that could affect aircraft operations.

6. CAA Taiwan and CKS Airport management should establish a joint task force to review the US FAA National Blueprint for Runway Safety (details at: www.faa.gov/runwaysafety), and wherever appropriate, adopt the safety philosophy and operational recommendations of that programme, so as to improve operational safety.

7. CKS Airport should ensure that the contents of all NOTAMs and AIP Supplements pertaining to airfield work contain clear and current information on the actual status of the taxiways/runways, and the configuration of the markings, signage and lighting. This will also facilitate the issuance of supplementary information by airport chart providers.

8. CKS Airport should utilise frangible barriers to demarcate work areas on the airfield.

9. The aviation industry should establish a working group, involving the airport authorities, airlines, regulators, ICAO, Flight Safety Foundation, IFALPA, Airports Council International and the IATA Safety Committee to develop a system to objectively determine whether a runway is “wet” or “contaminated” due to the presence of water. At present, there is no objective method by means of which this can be determined.

10. CKS Airport should formulate a written Surface Movement Guidance and Control System (SMGCS) plan to ensure the safety of aircraft movements on the ground.

11. CKS Airport should clearly define the operational responsibilities and safety accountabilities of the departments involved in the airside operations of the airport, so as to ensure that timely implementation of safety measures and improvements are not delayed due to ambiguities in areas of responsibility.

12. CAA Taiwan, in cooperation with the ASC, should establish and promote a more effective air safety incident reporting programme as part of an overall integrated safety management system. Such an incident reporting programme would provide a wide range of safety information, including data on airport safety issues.

13. CKS Airport should review its ARFF procedures to ensure that its personnel are able to carry out rescue operations inside aircraft using breathing apparatus.

14. ASC should coordinate with the relevant authorities to ensure that autopsies of all aircraft accident fatalities are performed to determine the survivability aspects of the accident.

15. ASC should ensure that blood toxicology tests are carried out on all relevant personnel such as pilots, air traffic controllers and apron controllers immediately after an accident.

16. ICAO should establish a study group to investigate the parameters affecting the functionality of aircraft escape slides in high wind conditions, with a view to determining a revised basis for the certification of these slides.

17. Aircraft manufacturers should review the design of public address systems so that these systems can continue to function largely independently of airframe or engine system condition in the event of an accident.

hawkeye18

6th May 2002, 14:36

Hi In The Slot,

I totally agree with you on the point that at all times we must be extra cautious, especially on wet and rainy nites!

I am quite certain that ATC procedures require the Tower controller to positively indetified a departing aircraft either visually or electronically (Surface Movement Radar - SMR ) prior to issuing of takeoff clearance.

The reason I mentioned takeoff mimima with reference to a non SMR equipped airfield is to highlight the difficult position the Tower controller will face,... when visibilty deteriorated below his maximum visual range but it is still within takeoff minima for departing aircraft.

When this occurs, like on the nite of SQ006, it effectively took the Tower controller out of the safety loop as he could not possibily see beyound the prevailing airfield visibility ., and in effect he was giving takeoff clearance "blind" ...... the only information/ feedback will be from the aircraft( pilot) which he is supposed to direct/control!!.

The same predicament will be face by the ground controller using good old "MK I eyeballs" in providing surface movement control.

So my point is :

Takeoff minima established for a non-SMR equipped Airports must be in touch with reality....... the limit of the human eyes , both pilots and controllers.

Dun expect the controller to have better eyesight then aircrew and be able to see thru rain and clouds!

Cheers!

Hawkeye

Gladiator

6th May 2002, 17:08

You can twist the story back and forth, say the dates are not relevant, etc.

The 3-pilot crew operation of SIA was flawed from day one. Make no mistake that I have a very comprehensive understanding of how it was conducted. In this regard I also have very good understanding of the ICAO safety requirements and how SIA goofed in reflecting them in their FAM (even though my spelling and grammer sucks).

The Captain going to the toilet is not an issue at all. Now you are giving yourself selective memory when it comes into the dark silent don't tell operations of SIA leaked by a whistleblower.

If you are real, and I presume you are, you know very well how the 3-pilot crew operations were conducted. At every fleet meeting the issue came up over and over again with the same result. One big grey area (intended to be so).

On line 99% of the time the captain of the 3-pilot operation ended in the bunkroom sleeping (without proper oxygen equipment), leaving two improperly licensed and trained first officers at the controls.

I suppose the next thing you want to say is that this never happened (then you will sound like SIA's lawyers).

Proper 3-pilot operations as intended by the design of the B747-400 (the crew bunk oxygen system) would assume that the relief first officer occupying the left hand seat is, a) properly licensed (regulatory requirement), and b) left seat trained (safety requirement).

Outside these parameters the left hand seat can be unattended for a period of time necessary for physiological needs (toilet) only.

SIA and your understanding is/was that if the Captain can go to the toilet and leave his duty station unoccupied, why can't he be gone for 3.5 hrs sleep in the bunkroom. Ken T of CAAS in front of an FAA representative tried to defend CAAS and SIA by saying that the Captain can be gone for 3.5 hrs (sleep in the bunkroom), since sleep is a physiological need. That would be OK if you leave a qualified crewmember in the left hand seat duty station (a first officer without left hand seat training and certainly without an ATPL does not qualify).

We can argue about this all day. One thing remains fact, CAAS did cover their backside and informed SIA that this practice is no longer allowed as well as finally taking the ATPL issue seriously (in a different notice).

Of course none of this would have happened, if this matter was not brought to the attention of ICAO, FAA and NTSB. SQ006 doesn't help as it had/has the potential to become a legal mine field.

May I suggest you read SIA's FAM (Flight operations Manual) previous to SQ006 with full attention in regards to 3-pilot crew operations and realize the flaws and inadequate attention to the ultimate goal, safety.

If you need the page numbers, let me know.

As for SQ006 cause of the accident discussion, etc, yes the swiss cheese is real and TPE airport markings may be one of the slices. However many flight crews that day looked out of the window of their hotel room and decided not to go.

Murrelet

6th May 2002, 19:25

Straits Times latest

Taiwan will let SQ 006 pilots go after interview
Taiwanese prosecutors say trio will not be indicted immediately after May 8 session; pilots to consult lawyer first

By GOH SUI NOI IN TAIPEI
AND DOMINIC NATHAN IN SINGAPORE

THE pilots involved in the Singapore Airlines SQ 006 crash will be free to leave Taiwan after their interview next week, Taiwanese prosecutors said yesterday.

Representatives for the pilots welcomed this but said that the trio - Captain Foong Chee Kong, and first officers Latiff Cyrano and Ng Kheng Leng - will meet their lawyer from Taiwan, who is flying down this weekend, before deciding if they will return for the interview.

Air Line Pilots Association Singapore vice-president (industrial affairs) Francis John said: 'The pilots would certainly be more favourable about returning with such an assurance, but they cannot decide based on media reports and will want to hear from their lawyer first.'

The next move of both the Taiwanese prosecutors and the pilots has become the focus of attention since the release of two conflicting investigation reports last week into the crash that killed 83 people on Oct 31, 2000.

Taiwan's Aviation Safety Council pinned the blame for the crash mainly on the pilots.

In its own investigation, a Singapore Transport Ministry team found that the crash was the result of a combination of many contributory factors, including deficiencies at Chiang Kai-shek airport.

After the reports were released, Taiwan's prosecutors summoned the three pilots to appear at a hearing in Taipei next Wednesday, fuelling speculation that the pilots may be detained right after their testimony.

The pilots, as well as airport personnel, are under investigation for possible professional negligence, which carries a jail sentence of not more than five years.

Yesterday, Mr Chiang Kuei-chang, spokesman for the Taoyuan prosecutors' office that is handling the case, said: 'The pilots will not be indicted immediately after the questioning and will be free to leave Taiwan after the session.'

Any decision to indict would be made about a fortnight after the May 8 interview, once prosecutors have completed their investigation and ascertained that their information was reliable, he added.

This would include interviews with airport personnel as well as contractors responsible for repairs on the partially closed runway that the pilots had tried to take off from.

The prosecutors will also refer to the factual portion of the recently released investigation report, which was the result of an 18-month probe by aviation experts.

Mr Chiang explained that the interview was to supplement information that had been gathered so far.

The pilots had attended a similar session in 2000, when they had been banned from leaving the island for about seven weeks after the crash.

'Since then, new questions have cropped up and new findings made,' he said.

'The session will also give the pilots a chance to make a full reply to queries and to state their views, which is their right,' he added.

This formal interview is part of the investigation process and no judge will be present. It is conducted by prosecutors and the pilots' lawyer will be present and will be allowed to speak for them.

The pilots' lawyer in Taipei, Mr Daniel Song, who has represented them since the crash, confirmed that he was preparing the logistics for the interview, including arranging for an interpreter for the pilots.

In the slot

6th May 2002, 19:48

Gladdy
Well I think I'm real. Saw a reflection in front of the mirror today, so I must be!!!! Won't insult the other readers by going off the subject again.

I wonder how much more the courts expect to glean from the pilots' testomonies next week, considering it is 18 months after the event, and in the 7 weeks right after the crash, there seemed to be confusion about certain facts. Are they expecting that this uncertainty will suggest incompetence and therefore negligence. I hope not.

Gladiator

7th May 2002, 16:21

Incompetence or negligence. My opinion only.

Crew incompetence, NO (even though SIA's operations did not meet ICAO minimum safety standards, inadequate CRM).

Negligence, possible but not the pilots. The negligence lies with the SIA management and the culture they cultivated through the years (money first, safety last), therefore the Captain's decision was the direct result of operational culture.

Where I work, for the purpose of safety, the Captain and or the first officer can simply say, NO GO. There will be no fear of getting fired, promotions destroyed for life, contracts not renewed, called to see the boss for an A55 chewing, or even ask why no go.

I started my original post by being fair and did particularly mention that SIA is making an honest effort to better themselves. This comes from the inside. So there is hope, however it is important to face reality.

Drop the 'LOSS OF FACE' and 'SAKKA' factor and get on with the business of airline pilotting. You cannot apply Lee Kuan Yew's economic secret of 'anxiety increases productivity'(quote) and apply it to the business of airline pilots.

To come back to the original discussion of SIA B747-400 operations not having met the ICAO minimum safety standards at least up to the date of SQ006 accident, I managed to dig through PPRuNe archives.

Posted December 7, 2000, Far East forum

The problem with SIA 3-pilot crew operation.

On long haul flights, B747-400, A-340, etc, it is normal and accepted practice for a carrier to use a pilot other than the Captain (pilot-in-command) as relief for the Captain during cruise only. However, common sense dictates that the relief pilot MUST meet pilot-in-command qualifications. The qualifications are not limited to the number of stipes or the rank of Captain; it is based on two criteria.

First, the relief pilot must meet the license requirement as pilot-in-command. This is a non-ambiguous clear-cut area; the relief pilot must hold an ATPL (frozen ATPL does not qualify).

Second, the relief pilot MUST receive training from the pilot-in-command duty station, the LHS. The training must include unusual attitude training as well as non-normal and emergency procedures.

In regards to long haul flights, the design of the Boeing B747-400 cockpit crew bunkroom was not intended for operation with only one qualified pilot-in-command. The reason is that the oxygen system in the crew bunkroom is the same as the passenger oxygen system. Therefore in the event of depressurization the crewmember in the bunkroom will be incapacitated and not considered fit to perform crewmember duties.

In regards to the B747-400 systems, the primary duty station is the LHS. Therefore, in certain non-normal situations (standby bus) both A/Ps as well as the RHS duty station instruments will be unusable. This situation would require the crewmember in the LHS duty station to manually fly the aircraft.

I would like to make reference to SIA’s own 1993 incident of the A-310 (yes, the famous Bay of Bengal acrobat) that lost control of the aircraft. If this were to happen with the pilot-in-command in the bunkroom, would the pilot-in-command be able to come out and exchange seats with the unqualified pilot in the LHS?The answer is a big NO.

In regards to relief pilot operations (3-pilot crew), SIA operated the largest B747-400 fleet in the world opposite the design philosophy of the aircraft thus seriously breaching passenger and cabin crew safety.

Passenger and cabin crew safety was breached when:1) SIA replaced the Captain (pilot-in-command) during Captain relief period, with a pilot only holding a CPL (commercial pilot license) as opposed to the required ATPL (Airline Transport Pilot License).

2) The pilots occupying the Captain (pilot-in-command) duty station, the LHS, received no training whatsoever in the LHS.

There is no possible explanation SIA, CAAS and ALPA-Singapore can give to explain why the above was allowed to continue for over 10 years.

The only explanation is that it was cheaper to replace a Captain during Captain relief period with a co-pilot. It was further cheaper to not train the co-pilot in the LHS.To make the argument stick SIA, CAAS and ALPA-Singapore came up with some unclear and muddy explanation of co-pilots trained to (Part1) the same standard as the Captain. The 3-pilot crew operation policy from day one was a conspiracy.

There was never a written policy in this regard. The only policy was a verbal policy that went something like this, “First, this time period is not ‘rest’ period, it is ‘relief’ period. Second, during this relief period the Captain will stay in the cockpit and seated in the observer’s seat".

In reality during this period the Captain would rest in the bunkroom (97% of the Captain would do this). This would be considered true rest/relief and the intended purpose of the cockpit crew bunkroom.

Please note below SIA’s only written policy in regards to 3-pilot crew operation,

FLIGHT ADMINISTRATION MANUAL, LINE OPERATIONS

Cockpit seats/A340 Crew Rest Facility Seats

Operating Crew

For take-off and landing, the required operating crew members of the minimum crew complement shall be in their assigned seats. In all other phases of flight, both pilot’s seats and, if applicable, the flight engineer’s seat must be manned by the operating crew except when:-

1. a crew member’s absence is necessary for the performance of duties in connection with the operation of the flight; or

2. a crew member’s absence is in connection with physiological needs.

In a 3-pilot crew operation, the third pilot may, at the Commander’s discretion, occupy either the left hand seat or the first observer’s seat during cruise, when the Commander is taking inflight relief. When the third pilot is in the left hand seat, the designated first officer must be in the right hand seat. In the event of an emergency, the third pilot, if he is in the left hand seat, shall be the pilot not flying. End.

Now please note the ALPA-Singapore policy,

Page 90.

Inflight relief and rest facilities on board –

(2) In the case of the “3-pilot” crew, the additional pilot allows in-flight relief from duty for each of the pilots. Rest facilities need not be provided for such a crew complement. End.

How do you like the last paragraph where it says, “need not be provided?”

In reality, the crew bunkroom is there, SIA replenishes the bed sheets, pillow covers, and blankets at every station, but hey, MUMS the word. Who is going to tell? No co-pilot in the right mind would tell, otherwise no promotion ever.

In the legal case Singapore Airlines vs. Gladiator (refer to PPRuNe search Singapore Airlines vs. Gladiator Parts 1, 2, and 3), SIA faced a big black hole.

SIA’s Flight Administration Manual not only was at best ambiguous in the 3-pilot crew policy, but the section; ‘Line Operations’ contradicted ‘Administration’,creating a legal mine field that left several SIA lawyers without legs.

Please note the following,

FLIGHT ADMINISTRATION MANUAL, LINE OPERATIONS

First Officer Route Flying

After taking all factors (such as airplane technical status, airport and environmental conditions, pilot experience, etc.) into consideration, a commander may at his absolute discretion permit First Officers to carry out route flying under his supervision, provided that the commander:-

1. occupies the left-hand seat during all phases of flight;
2. complies with the operations manual policy on the delegation of pilot-flying duties to the First Officer.

The Commander and First officer must ensure that the route flying is properly recorded in the Voyage Record, utilizing the appropriate codes, and in the flying log book. End.

Point number 1 contradicts the 3-pilot crew policy above when the First Officer is P1(U/S). It gets even worst on the last paragraph above where it states, “utilizing the appropriate codes” (logging of hours/Sectors).

Please note the following,

FLIGHT ADMINISTRATION MANUAL, ADMINISTRATION

Logging of Hours/Sectors

1. Commanders

P1 - when flying in command, under line check or when part of a 5-man crew.
P1(U/S) – when under training.
P2 – when flying as co-pilot2.

First Officers

P1(U/S) – when operating a sector under supervision.
P2 – when operating as a co-pilot in right hand seat or when operating as a Supervisory First Officer or when assisting the Training Captain who is in the right-hand seat checking or training a Captain in the left-hand seat.
P3 – when under training and occupying the jump seat with a Training Captain or Supervisory First Officer in the right-hand seat. End.

There are no codes or provisions to explain the capacity of a First Officer (co-pilot) occupying the Captain (pilot-in-command) duty station, the LHS.

In the case Singapore Airlines vs. Gladiator, the deficiencies in the SIA 3-pilot crew operation was presented as a counterclaim as follows:

“deny that the CPL license issued to XXX qualified him to: (a) act as a flight crewmember on the B747-400 aircraft in any capacity; (b) act as inflight relief for the pilot-in-command in the left pilot seat; and (c) be delegated responsibility for the operation and safety of the aircraft by performing the duties of Pilot-in-Command without supervision."

SIA repeatedly denied the defendants counterclaim as, “non-factual”.

These facts were brought to the attention of ICAO and FAA. Behind the curtain both organizations were outraged. In February 2000, at the request of Gladiator, FAA summoned CAAS to explain SIA’s operation in this regard. ICAO conducted an audit of CAAS in July/September 2000.

The bottom line is that in November 2000, CAAS, SIA and ALPA-Singapore finally stopped this 3-ring circus.

TE RANGI

8th May 2002, 15:24

A couple of years ago Insider 107 produced "SQ006 revisited", one of the finest threads ever on PPrune, at least from a flight safety standpoint.

His position was that SIA culture was a major contributing factor in the way events unfolded that evening. Some of us were unconvinced at first but must admit that Insider 107 proved his point in a very thoughtful and brilliant way.

It would be interesting to know other SIA insiders opinion and whether SQ culture has changed in any direction as a result of that accident.

G.Khan

9th May 2002, 10:10

Having been there and done it I don't think culture had very much at all to do with the demise of SQ6.
I can think of a number of possibilities that might have been seen to incur the wrath of the fourth floor and thus produce pressure on the crew but none of those possibilities pertain to the crash of SQ6.

The locals have a very healthy respect for typhoons and since some other operators had already cancelled this captain, who had reached his zenith as a B744 commander and was not destined to go much further, had little to fear, so no culture issue there either. An error of judgement and an error of skill, or so it would seem, could have happened to anyone of any nationality and any airline, but how easy it all is with 20/20 hindsight.

thegypsy

9th May 2002, 21:55

G.Khan You really are an apologist for SIA are you not. Would you by chance be related to the Ostrich with your head firmly in the sand and therefore blind to all things around you.

I cannot agree with your suggestion that all the bad facts about SIA are coming from disgruntled ex F/O who skipped bail.

As we inSIA all know these guys were all totally deceived by SIA who hid behind pages of small print in their contracts which any lawyer would say was totally one sided and they {SIA} took advantage of their predicament. When these young people arrived in SIA some spent a whole year in office work before which did not count for their bonds and when those on the B747-300 when it was phased out found that their bonds on that aircraft continued to run and new bonds on their next aicraft did not start until the end of the other one even though the aircraft was no longer in service. No wonder some of them decided enough was enough and did a runner after 5/6 years.

All F/O's in SIA National and expat {not that many of these are left} are treated absolutely apallingly by this company SIA, They have their leave cancelled at the last moment ,they get sent on leave without any warning when SIA don't require them, if they are on a type conversion I have seen some have been forced to take 2 days leave because SIA did not have a Sim slot for a few days.

Insider107

9th May 2002, 23:56

I regret my recent absence from cyberspace during the period covering publication of the Taiwanese ASC Draft Final Report on the SQ006 disaster and the subsequent comment generated on this thread.

Further, I’ve spent a couple of days looking over its 508 pages which include the entirely predictable criticism by Singapore of the report and I agree with a number of other contributors that the ASC’s efforts have been most thorough and correctly apportion responsibility for the accident to the relevant involved parties.

In particular I would commend Murrelet for his posting of 3 May 2002 in which he summarises the ASC report and comments on the even-handedness of the ASC. It would serve us all well to carefully re-read his post.

I would similarly commend Gladiator for his dogged determination in consistently reaffirming the malign corporate mindset of Singapore Airlines and that of a wider Republic that views profit as the sole determinant of organizational worth, unexplained “merit” the trigger for individual pilot promotional “reward” and punishment for all involved when things go wrong. It is a mindset that I know remains largely in place, despite SQ006 and the subsequent panicky “house cleaning” measures implemented, and which I am convinced was a potent causal factor leading to the accident.
I applaud his recent tour de force, posted 7 May 2002, which irrefutably serves to demonstrate SQ’s breathtaking arrogance in its historic and opportunistic disdain of ICAO recommendations, the relevance of which to this thread, lies in its revelation of a culture of duplicity, coercion and fear. SQ’s come-uppance in the particular matter, at the hands of truthful, honorable and determined individual is cause for both satisfaction and relief that at least one risky area of operation had been eliminated. It is a corollary matter of contempt that SQ cynically cites other ICAO recommendations to castigate a fair report that, unbesmirched, would leave it poorly placed in subsequent ferocious civil litigation.

In passing, perhaps I may be permitted to hope that years of SQ Airbus 310 over-water operation, similarly spurning ICAO’s recommendations in respect of ETOPS and exacerbated by its refusal to observe the Organization’s mandatory requirement to inform both it and SQ’s code-share partners of such non-observation will not be mirrored by the ethos currently crystallizing in the B777 ETOPS fleet and to which I have drawn early-warning attention in past postings. I feel certain that ICAO and FAA will be carefully scrutinizing the proposed operation plus IFSD’s to date and taking the keenest interest in any surprise award of 180 minutes clearance by CAAS, just prior to start of B777 LAS and SFO flights.

Moving on, I’d like to mention a couple of points that seem to have slipped by the ASC.
1. The captain of SQ006 was a day short of statutory rest prior to operating the flight on the fateful day. The rostering girl responsible was subsequently dismissed from her post but what the heck, that’s how we fix problems round here!
2. The ASC seems to have found no evidence that a call had been made to the crew by SQ Ops, prior to leaving the hotel, suggesting an expeditious departure ex CKS might have been in order, before the typhoon struck. However, the rumour persists. Have the hotel telephone records been scrupulously checked and subpoenaed?

Back to the ASC findings which indicate causes as “pilot error” and adverse weather. I’m intrigued by Belgique’s posting of 1 May 2002, for the crucial question is “why did the crew turn onto the incorrect runway for take-off but thought they were on the correct one despite numerous visual clues to the contrary?” Does his hypothesis of syllogism partially explain the phenomenon?
To quote Belgique: <the dismissive mindset of:
”We are lined up for departure on the runway and cleared for take-off. What we are seeing out the front must be the runway. Therefore there is no safety problem nor cause for alarm or query.”
Ie. a simple failure to mentally register any inconsistency…. no alerting mechanisms present at all. Because the predominant concern is about darkness and weather and visibility, a perverse mechanism of reassurance is always tending to suppress any disquiet (the PVD….). That’s the sentient side of human nature. >

Could this, coupled with the desire to move quickly beyond the looming prospect of a highly risky, on time take-off in the middle of a typhoon, so as not to incur the wrath of a punitive organization, be the reason for the accident? I have alluded to this cause in the “SQ006 Revisited” thread and rather than repeat megabytes of stuff here, perhaps I could direct interested readers there.

To conclude. We all know that error is part of the human condition and that current CRM teaching correctly points to a need for its management rather than its punishment. So if I may take that as a “given”, may I ask one question?
How can we possibly hope for the much needed enhancement to SQ’s flight safety environment, when, despite all that has happened, all that has been investigated internally by outside consultants, all that has subsequently been recommended and after the time, trouble and expense expended in the formulation of a new “state of the art” CRM regime, the core feature of which is non-punitive error management, do we still have handed down from the very highest level, the ideology of punishment being the required solution to perceived transgression?
Comments please.

G.Khan

10th May 2002, 00:26

Thegypsy - you have chosen to be highly selective in your memory I think, if you were to read back over posts made by me since I first came to PPRuNe in April 1997 you would find on many occasions I have been highly critical of SIA and its practises, however, when I think SIA are being unfairly slated then yes, I will post my opinions.

I cannot reprint it here but the editorial in this weeks Flight does not entirely agree with Insider107's view that the report from ASC and the way it has classsified its findings is correct and fair nor does it think that the exclusion of the SIA representative in the analysis phase of the investigation was in accordance with ICAO recommendations either. Trying to downplay the extent that the badly marked and lit RW05R was a contributing factor to the cause of this accident does ASC no credit at all.
This aspect, however, is really just nit-picking at the periphery, it is much more important to ensure that this sort of accident does not happen again and that both SIA and Taipei Airport get their respective acts together.

As far as Gladiator is concerned, had he not fallen foul of the system, (many do not), he would probably be a B744 captain now and you would not have heard a peep out of him. One might be forgiven for mistakenly thinking that Gladiator walked away from SIA solely on the grounds of his concern for flight safety.

Rockhound

10th May 2002, 14:13

It's nice to see the second coming of Insider 107 (I'd been wondering where he was) but for the life of me, even if all he and Gladiator say is true and accurate, I cannot see serious evidence of a connection between it and the SQ006 accident, which, it seems to me, was one waiting to happen and could so easily have happened to a crew from any nation or nationality.
Rockhound

highcirrus

10th May 2002, 18:00

Rockhound

Perhaps if you were a member of Singapore Airlines, you would have a clearer idea of Gladiator and Insider's premise?

Gladiator

10th May 2002, 20:23

I would not trade my right seat B737, 18 days off per month, 105,000 USD per year, fantastic quality of life (cost of living 1/5th of Singapore) for left seat B747-400 at SIA, not in a million years.

It is not your equipment or seat SIA, it is your attitude.

Tosh26

13th May 2002, 01:18

G.Khan

You say:

"The locals have a very healthy respect for typhoons and since some other operators had already cancelled, this captain....etc."
Perhaps if this particular captain had had such a healthy respect for typhoons, he too would have cancelled?

Could he have felt himself to be under pressure, subtle or otherwise, not to delay, or was his being at "his zenith as a B744 commander" sufficient reason for him not to ponder the no-go decisions, made by, perhaps, wiser heads at the time?

I understand that the captain of an SIA B744 freighter, due to leave CKS at about the same time as SQ6, was one of many who declined to depart until the weather improved. Can you or anyone else cast further light on this and would it be true to say that SIA felt no obligation to hotac the freight pallets on the night in question?

Regards.

G.Khan

13th May 2002, 10:25

Tosh26 - I take your point, mine was a personal opinion, based on what I know(knew) and my own personal experiences.
Given the system at CKS, (briefed at the gate by EVA), it is quite possible the crew of SQ6 didn't know others had cancelled - not that this should make any difference.

Tosh26

16th May 2002, 02:43

G.Khan

Yes, a “hermetically sealed” gate briefing by ground staff, eager to see an on-time dispatch of the flight could have reinforced a “go-mode” frame of mind in the crew, on the night in question.

Regards

holden

16th May 2002, 09:15

Gladiator,
You have elaborated on SIA's apparent "deficiencies" concerning licensing and crew complement.Perhaps you could comment on the already-implied notion that there is some pressure on crew to meet on-time departures regardless of safety considerations.This would be far more relevant to the causes of the crash.Did you ever experience such pressure yourself or did you know of any crews that were?

Gladiator

18th May 2002, 17:31

holden,

I was never put into that situation. However bad weather and the word 'no go' are part of flying 101, that applies to a Cessna 150 as well as a B747-400.

As far as pressure on other crew, Yes, most were fuel related. Dispatch with minimum fuel to Europe in winter where common place. Asking for more fuel could get you in trouble, you would need a better reason than just the word 'good judgement'.

Equipment safety, in my days, SIA used to have several questionable B747-200F aircraft that were dumped by FEDEX. They had so many MEL stickers one could qualify them as Christmas decoration.

smiths

18th May 2002, 17:56

Glady:

How's life at Alaska?

Just want to confirm - are you sure the SQ 742F's came from FDX/Flying Tiger?

G.Khan

18th May 2002, 23:39

Flew the B744 for ten+ years with SQ, never had extra fuel loaded queried once! Knew of a few on the B747-300 that did get into hot water but adding 5 to 10 tonnes on Japan and Australian flights and citing, "That's how I like to operate" isn't going to endear you to the management of any airline I would suggest!

Did get sent to Europe on re-dispatch with only 1000kgs contingency sometimes and was not too happy about that - but it wasn't an unsafe practice, if, at the re-dispatch point you had less than legal fuel required to reach final destination then you were obliged to tech stop and possibly require a crew change.
Provided you had your calculations correct there is no come back.

Farside

19th May 2002, 03:11

I have to agree here with Kahn. Although Gladiator very often is spot on in his observations I must say that in my 12 years with SQ I have never ever been asked to explain why I took extra fuel, or why I took a delay . As long as you VR your reasons there is no problem. I think that "feeling" pressure from management on fuel and on time departures is often something very personal and as long as there is a solid reason you shouldn't be worried . But again that is how I think about it.

Gladiator

19th May 2002, 17:25

Life is better than good, thank you. I am sure the 742F's did come from FEDEX, at least a few of them did.

Whiskery

19th May 2002, 23:44

You are right Habibi, 9V-SQT and 9V-SQU were both ex FEDEX.

Tosh26

22nd May 2002, 03:59

Gladiator

Re: Your posting of 18 May 2002

Most interesting that you mention “bad weather and the word 'no go' are part of flying 101, that applies to a Cessna 150 as well as a B747-400.”

I am aware of two SIA captains (ex-pats) who, on separate dates, declined to depart CKS on time, in weather conditions similar to those prevailing on 31 October 2000 and sensibly awaited improvements.

They both mentioned (the two conversations late at night and outside Singapore) feeling under inordinate pressure from dispatch staff, to depart on time, despite the dramatic met conditions and both subsequently fielded the inevitable, less than friendly ‘phone call, the following day, back at base, demanding details of events that had already been VR’d.

It was further interesting to hear that both captains were kindly tipped off by their respective FO’s (locals), to expect these calls, as they themselves had previously been quizzed for details before the captains were telephoned!

Regards

SQ6 Survivor

22nd May 2002, 17:22

It seems that much of this thread has revolved around blame. Are the pilots to blame for the SQ6 crash or did the environment and CKS conspire to force their mistake? Let me try and clarify the issue:

To err is to be human. Everyone makes mistakes. BUT when your mistake costs the lives of 83 men, women and children, not to mention horrific burns to 40 survivors, THEN something is going to hit the fan. People WILL blame you for making that mistake because you were in full controll and made all the decisions.

The fact is that blame for this accident lies squarely at the feet of Capt. Foong, and his crew, because they failed the basic test of navigation -- to use a map and compass to ensure that the a/c ended up on the correct r/w. The fact that 05R looked 'normal' or that the t/w and r/w markings were bad are IRRELEVANT because IF the Capt. had employed good navigation skills and not dead reckoning the crash would not have happened.

The fundamental objective of any investigation is to identify WHO made the mistake and then ask WHY it was made, and HOW to prevent it being made again. The ASC identified the WHO, were blurry on the WHY, and completely missed the HOW to prevent another. The WHY in this case was because the Capt.s navigation skills were poor or sloppy on the ground, and the HOW therefore should have been to make it mandatory to test Pilots' low-viz taxi skills on a regular basis to prevent the development of bad habits.

One final thing. A word of warning to all you pilots who use dead-reckoning in poor viz conditions -- there is a reason why they call it DEAD reckoning.

A summary of our argument and the ASC and MOT reports can be found on the SQ6 Survivor's web site:
www.anycities.com/sq006/crash.html

(P.S. this site is the source of Murrelet's earlier posting)

highcirrus

23rd May 2002, 09:17

Murrelet

In your post of 3 May 2002 you said:

"I have read the reports, and think it might be useful to summarize at least the ASC report for all those too lazy to read it for themselves! You will see that Taiwan does not entirely escape blame in the ASC report."

You then went on to post a cogent and persuasive summary that the words above seemed to imply you were author of and, indeed, following which posting, you silently accepted the plaudits of Alpha Leader, Slasher, Insider107 and similar luminaries.

It would now appear that you are guilty of the very laziness you ascribe to others, in that you in turn, could not be bothered to originate your own stuff but were happy to plagiarise the material of others, as pointed out by SQ6 Survivor.

Would it perhaps not have been better to acknowledge your source right from the start?

SQ6 Survivor

23rd May 2002, 14:07

Just so you know who you are talking to, Murrelet is also an SQ6 survivor and contributed significantly to the web site. Hence, there was no plagerism.

highcirrus

24th May 2002, 01:36

Murrelet

My apologies. Fools certainly do rush in don't they?

cirrus

Anotherpost75

26th May 2002, 01:54

SQ6 Survivor

I’ve flown a few times with captains who’ve lost the plot in LVP conditions and to a man they've instantly stopped and called for a follow-me truck to take them to the ramp. I’ve had to do the same a couple of times. The one thing we’ve all had in common though is that we’ve not been trying to race a typhoon to the take off position.

Frangible

26th May 2002, 12:45

SQ6 survivor's excellent web-site mentions Taiwan's non-membership of ICAO, the "real" China having the seat.

It's a toothless watchdog if ever there was one, but are there concrete examples of this making an important safety difference in Taiwan, in relation to this or any other crashes? Do the authorities there take advantage of this in any way, or do they behave "as if" they belonged?

SQ6 Survivor

27th May 2002, 00:45

Anotherpost

The observation that some pilots stop and ask for help when lost misses the point: Foong knew where to turn (the crew even joked about it), and he thought he knew where he was. And yet he still screwed up. Even if he was racing a typhoon, evidence indicates he had no low-viz taxi training and, worse still, there is no procedure or training requirement in SIA Ops for low-viz taxi (according to the ASC). Does this mean that all SIA pilots are still running around out there with the same low-viz taxi deficiencies? Safest airline my ass! This problem, and the general one of poor SA on the ground, can be addressed by simple proficiency testing: why not include a low-viz taxi routine in a simulator and test skills there?

Frangible

Your question is a little obtuse but I think I understand your point: does Taiwan fall through the cracks in terms of ICAO standards? Lacking any hard data, I can only speculate that, given their non-membership since 1971 (when they lost their seat to China), CKS is presently still in a standards time warp. It maybe some consolation that they've finally decided, in their infinate wisdom, to apply for "official observer" status, whatever that really means. So in answer to your question, I would guess that China's membership in ICAO means didley squat for Taiwan.

Gladiator

27th May 2002, 17:04

I am not sure membership to ICAO requires a seat. However Taiwan is recognized as a seperate state by the FAA and therefore most probably also considered a contracting state by ICAO.

Certainly Taiwanese aircraft have their own registration and recognized by other ICAO contracting states.

jimjam

30th May 2002, 17:05

SQ6 Survivor

Your question is; "Does this mean that all SIA pilots are still running around out there with the same low-viz deficiencies? Safest airline my ass!"

I'm afraid that the above is still the case and there seems to be no move to alter the situation. Your supplementary expression of feeling does seem to be valid.

Anotherpost75

1st Jun 2002, 07:24

SQ6 Survivor

I'm not too sure that I have missed the point.

Quote: "Foong knew where to turn (the crew even joked about it), and he thought he knew where he was. And yet he still screwed up."

At some stage, therefore, he must have been lost, surely, as he went from a situation of jocular confidence to completely losing the plot and turning onto the wrong "runway".

The point that I was making pre-supposes that pilots know where they are on the ground at all times (I think I do and if I don't, I damn well stop and then figure it out from there).

I would think that something distracted Foong at the time and he was probably vaguely aware that all wasn't correct with his nav (ie. lost) but he pressed on anyway, for reasons already postulated in this and other threads.

hawkeye18

2nd Jun 2002, 16:28

SQ Survivor and JimJam,

In oder to come to a balance view, please do read both sides of the official documents prior to coming to conclusion.

Failure to read both ASC and SIA/MOT document is as good as learning half the stories , and is no excuse for coming to the wrong conclusion ! :)

SQ survivor said:

"worse still, there is no procedure or training requirement in SIA Ops for low-viz taxi (according to the ASC). Does this mean that all SIA pilots are still running around out there with the same low-viz taxi deficiencies? Safest airline my ass! This problem, and the general one of poor SA on the ground, can be addressed by simple proficiency testing: why not include a low-viz taxi routine in a simulator and test skills there? "

JimJam said:

"Your question is; "Does this mean that all SIA pilots are still running around out there with the same low-viz deficiencies? Safest airline my ass!"

I'm afraid that the above is still the case and there seems to be no move to alter the situation. Your supplementary expression of feeling does seem to be valid."

SIA /MOT Singapore said

Prior to SQ006

"
Guidance information on low visibility taxi operations is provided in the SIA Flight Crew Training Manual, which is a part of the SIA B747-400 Operations Manual.

A captain who is qualified and current in Cat III operations would have received training in low visibility taxiing techniques as part of his training package. Taxiing the aircraft in low visibility is part and parcel of the overall training package for low visibility operations.

Regarding training in low visibility taxiing, as noted in MOT’s earlier response to the ASC’s preliminary draft report, MOT has explained that there is no specific formal training for taxiing in low visibility. Taxiing is part of basic airmanship. Throughout their career, flight crews undergo various training courses and taxiing is part and parcel of such training. Taxiing skills are further reinforced in the course of their flying experience when they operate to different airports in all sorts of weather conditions. There are no International Civil Aviation Organisation Standards and Recommended Practices (ICAO SARPs) or internationally agreed norms on the level and amount of flight crew training in low visibility taxi procedures and practices.

However, taxiing in low visibility conditions was, and continues to be, a normal part of an SIA pilot’s introduction to training in low visibility operations." [B]

[B]Remedial actions taken after SQ006:

The Flight Crew Training Manual has been amended to formally document procedures, instructions and the training curriculum for ground operations in poor visibility conditions."

Boeing’s GPS based “Take-off Runway Disagree Alerting Function” has been accepted by the company for installation on B777 and B747-400 aircraft.

An Electronic Moving Map system which provides a pictorial depiction of airport movement areas is being evaluated for installation in SIA aircraft.

The FAA Advisory Circular on Runway Safety (FAA AC 120-74) has been reviewed with the objective of identifying useful points for incorporation in the SIA low visibility operations, training and procedures.

http://www.sq006.gov.sg/final_draft/fr_final_draft.htm:

The above are self-explanatory.

Gladiators

Perhaps you can help to sustantiate with your personal low vis taxying training whilst You were with SIA. :D

Cheers!!!

Hawkeye 18

Gladiator

2nd Jun 2002, 17:20

I can only speak for dates until end of 1997. SIA's training did not include low visibility taxi procedures. The CAT III training was conducted with the simulator set up on final approach at approx 1,500 AGL.

Here in the US we use a special dedicated chart for low visibility taxi. However the bottom line is when the WX gets nasty we grab a latte (vanilla) and call it a 'NO GO'.

True that taxiing is part of airmanship but not when the visibility is so bad you cannot see your own hand.

hawkeye18

2nd Jun 2002, 17:30

Posting move to later section!

SQ6 Survivor

3rd Jun 2002, 20:12

Your colors show through loud and clear. And your attempt to switch topics after Gladiators confirmation of SIA's lack of low-viz training is particularly telling.

As you will see on the SQ6-Survivors web site, I HAVE read the findings and arguments from BOTH reports and even summarized them in an objective and unbiased fashion. I ignored the pathetic face-saving and biased way in which the MOT tried to distort the ASC findings and divert attention from SIA failings, AND I duly noted the way in which the ASC side-lined the unsafe conditions at CKS. But the conclusion was obvious and, with the risk of boring the rest of you, I repeat, the fundamental failing was that, when the going got tough the Crews 'training' failed them and they made a BASIC navigational error.

I certainly didn’t do these analyses for my health, nor to castigate SIA or CKS. I did it so that the FUNDAMENTAL FAILING can be identified and the DEFICIENCY addressed.

Your MOT 'quotations' to the effect that SIA does give low-viz taxi guidence in their OPS manual but do not require training because it's ‘part of basic airmanship', does NOT reassure me in any way whatsoever. Indeed, it makes me feel even worse about SIA pilots because it implies that their basic airmanship must be deficient too.

Obviously, I know (hope) that this is not the case, and that the basic airmanship of SIA pilots compares with other companies. To remove any trace of subjectivity therefore I will re-phrased my question:

Are there other pilots running around out there with the same low-viz taxi deficiencies as Captain Foong?

Does the lack of low-viz taxi training at most airlines mean that other crews are destined to repeat history or add further to the r/w incursion stats?

How many of you pilots can say that when weather conditions are marginal that you NAVIGATE to the r/w, rather then depending on dead reckoning?

hawkeye18

4th Jun 2002, 02:34

SQ Survivor,

No intention at all to distract with the ATC posting ,it was related to Gladiator's comments:

" True that taxiing is part of airmanship but not when the visibility is so bad you cannot see your own hand "

So as not to confuse you ,it has been moved to later section.

............................................................ ............................................

My comments on your last posting are:

Please read carefully what Gladiator has posted.... when he was last with SIA ,captain or first officers not elaborated, was 1997 ....

"the fundamental failing was that, when the going got tough the Crews 'training' failed them and they made a BASIC navigational error. "

The pilot of SQ 006 failed and there's no denying that.....that is the subjective conclusion specific to Cpt Fong, the inference that crew training (fleetwide) failed needs substantiation.

This is a case of navigational error induced by poor weather condition, wrong/deficient runway,taxiway, signage/markings and lighting. Basic navigational training, be it on the ground or in the air are based on the assumption that all corect signages ,aids , visual features are in place. Name me an airline with low-vis taxy training with intentional wrong markings of runway and lighting, to train pilot to preclude such an accident. .....from what I known..none

"Your MOT 'quotations' to the effect that SIA does give low-viz taxi guidence in their OPS manual but do not require training because it's ‘part of basic airmanship', does NOT reassure me in any way whatsoever. "

Guidance in Ops manual and Training Syllybus are two different things, what ASC said is it is not in the ops manual and NOT they do not train .... and from what I have found out , they do such low vis taxying training prior to SQ006 as stated and is still continuing to have such low vis taxy training... ..( I have just checked with a current pilot of the comapny).

They have since amended their Ops manual to include low vis taxy as a procedures in their 747 Ops manual instead of just guidance.

The only point of contention is how much more of such training is required .... as there are no international norms nor standard estalished by ICAO, unlike those of airfield markings and procedures. And whether such training will be effective in preventing another such an accident from happening around the globe.

On a more positive note , the implementation of Wrong Runway warning devices and GPS based ground navigation system in their fleet of aircraft , to aid pilot in navigating is seem as a positive approach to prevent such future accident.

"Indeed, it makes me feel even worse about SIA pilots because it implies that their basic airmanship must be deficient too. "

Other major airlines have had accidents indentified or associated with airmanship too . Can we also safely say these accidents also "implies that THEIR basic airmanship MUST be deficient too"??
I think to come to such an inference is rather presumptuous !!!

Pilot tranining syllybus the world over are tailored to cover ICAO /FAA proficiency /airmanship requirement in the air transportation industry..... Pilots' are either FAA or ICAO qualified and are regularly checked and renew.

By extension, you inference also implies that under the present guidlines set out by both authorities, these are not sufficiently stringent to preclude airmanship error. As these Qualification requirements are applicable airline wide. My suggestion to you is take other means of transport other than air just to be safe.

"Are there other pilots running around out there with the same low-viz taxi deficiencies as Captain Foong? "

Specific to the deficient conditions at CKS airport and your definition of " low vis taxying dificiencies as a captain" , yes there are , me included , and there were others that were suckered into taxying into that 05R as well, under less severe weather conditions.

"Does the lack of low-viz taxi training at most airlines mean that other crews are destined to repeat history or add further to the r/w incursion stats"

Yes there will be!! No amount of Training in low vis taxying will TOTALLY negate the possibility of it happening again,.. ...when all the other factors converged.

"How many of you pilots can say that when weather conditions are marginal that you NAVIGATE to the r/w, rather then depending on dead reckoning?"

DR is the basis of visual Navigation.... the cross-refering of visual objects to what is tabulated in maps or chart form, to establish your actual position.

Cheers!

Hawkeye18

note: I have no vested interest either as an employee or shareholder.

Apologies for the amendment ....my English and typing suck!!

hawkeye18

4th Jun 2002, 02:49

Air Traffic Controller /Aircrew

Anyone has view on the following post.

Thanks!

posted 6th May 2002 04:10
--------------------------------------------------------------------------------

From the the event logs of the accident, no mention was make whether the duty air traffic controller had SQ 006 in sight when he/she issued the takeoff clearance.

Taking into consideration a distance of close to 1 nm from the Air Traffic Tower to the threshold of 05R ,with prevaling visibilty of 400-450 meters (my assumption , actual vis believe was lesser at the time). It was doubtful that the duty air traffic controller had visual contact with SQ 006 as it approched 05R.

Isn't it a requirement for ATC to ascertain aircraft requesting for takeoff clearance is on the correct platformm prior to issue of takeoff clearance??

Especially so on a non- ASD airport under inclement weather , It should have been mandatory for ATC to visually confirmed aircraft is lineup on the correct runway prior to issuing takeoff clearance under such circumstances.

This could be the reason for the Singaporean MOT raising the issue under Safety Recommendation to ASC :

"4.CKS Airport should ensure that its Air Traffic Controllers adhere to their Standard Operating Procedures. In particular, when aircraft cannot be seen from the control tower, controllers should advise pilots of this situation, and that they should taxi with caution. "

Infering that the tower controller violated its standing SOPs in takeoff clearance under adverse weather.... not having visual contact with SQ006.

If that is so then it leads to another question , is the airport takeoff minimum comensurate with its controllers' ability in visually acquiring aircraft on the operating platform of the non-ASD airport??? eek:

Are all takeoff clearances in CKS " blind " clearances from the Tower under adverse weather when visibility falls below 600 meters !!!??

Your comments will be most appreciated.

Cheers!

Hawkeye:

[Last edited by hawkeye18 on 6th May 2002 at 05:04]

SQ6 Survivor

4th Jun 2002, 18:17

You said: "DR [dead reckoning] is the basis of visual Navigation.... the cross-refering of visual objects to what is tabulated in maps or chart form, to establish your actual position."

Dead Reckoning: the process of determining one's position, especially at sea, by guessing the direction and distance travelled rather than by using landmarks and astronomical observations. Oxford English Dictionary.

You just failed basic airmanship! Lets hope to god you are not flying a commercial airliner.

hawkeye18

5th Jun 2002, 03:03

SQ Survivor,

"Dead Reckoning: the process of determining one's position, especially at sea, by guessing the direction and distance travelled rather than by using landmarks and astronomical observations. Oxford English Dictionary. "

Apollogies!!! My mistakes! You are right!!:o :o :o :o

The setence:

"DR is the basis of visual Navigation.... the cross-refering of visual objects to what is tabulated in maps or chart form, to establish your actual position. "

Should had been:

either:

DR is the basis of visual ground Navigation??? ..... ground taxy involved the cross-refering of visual objects to what is tabulated in maps or chart form, to establish your actual position. "

or

The basic techniques on Ground taxy is..... the cross-refering of visual objects to what is tabulated in maps or chart form, to establish your actual position. "

So what lead u to conclude that SQ006 was using DR (by guessing the direction and distance travelled rather than by using landmarks ) on the Taxying to Ruway 05??

Were they??!!!

Cheers!

Hawkeye

PS : Please check feedback email on SQ006 Survival site.

SQ6 Survivor

5th Jun 2002, 16:18

Taipei Times: Op-Ed, May 23, 2002.

Re: Crash of SIA SQ-006, 31st Oct. 2000

Dear Sir or Madam,

In the mistaken belief that apportioning blame serves no purpose, both the ASC and the MOT failed to reach any clear or objective conclusion about the crash of SQ-006 at Chiang Kai Shek International Airport on October 31st 2000. We believe that failure was a result of political interference. To set the record straight, and provide some closure for the victims of this accident, we have closely studied the evidence and claims in the ASC and MOT reports, and have reached several conclusions about the cause of the crash and who was to blame.

First, it is clear from the factual evidence that the pilots did not use all the resources available to them in navigating to the runway that night when conditions clearly required it. In fact, they failed the basic requirement of any kind of navigation task—to follow a compass heading and estimate distance. That deficiency led them to make a continuous 180 degree turn onto runway 5-Right when they should have only made a 90 degree turn, continued for 200 m, and then made a final 90 degree turn onto runway 5-Left. At no stage did the taxi require a continuous 180 degree turn. Although this navigation failure was identified by the ASC, it was not adequately highlighted as the main cause of the crash. By contrast the MOT report concentrated on all the correct actions that the crew made during the taxi but conveniently ignored the action that led to the mistake. In fact, when the crew were questioned about what information they should use for taxi navigation, only the relief-pilot stated that it should include the compass to confirm the correct heading. Unfortunately, the relief-pilot played no part in navigation that night because he was preoccupied with estimating the cross-wind component.

Second, claims by the MOT that the pilots could not see signs, or that Air Traffic Control misled them, or that the taxi lights led them onto the runway and presented no other option, are bogus because navigation skills are a fundamental component of basic airmanship. If a captain of a 747 can’t follow a compass heading to the correct runway then he has no business being in the cockpit. Furthermore, the crew must have known that Chiang Kai Shek airport was rundown, low tech, poorly maintained, and badly managed because they all flew out of there on a regular basis. Why then did they expect that such an inadequate system would lead them to an unfamiliar runway, at night, and under such poor visibility conditions? In our view, highly-trained pilots such as these have no excuse for failing these basic rules of navigation.

Third, evidence indicates that the principle factor compounding the pilots’ navigational mistake was that runway 5-Right looked like a normal runway and not like a partially-closed runway strewn with construction equipment. In their interviews, all of the pilots stated that the runway looked ‘operational’. And yet both the ASC and MOT reports spent considerable effort arguing if the runway edge-lights were on or off, since this would signify an active runway. But the fact is that 3 experienced pilots, with thousands of hours of commercial flying, should be able to recognize an active runway when they see it. Therefore, it is highly likely that runway 5-Right did look like an active runway that night -- and also on other occasions -- but not like the taxiing runway that it was.

From the sum of this evidence, we can only conclude that blame for this accident lies squarely at the feet of the pilots of SQ-006 because if their navigation skills were fully employed that night they would have realized that, at no point did the taxi require a 180 degree turn. By knowing that simple fact, they would have passed runway 5-Right, and perhaps been surprised that it was lit up, but carried on to runway 5-Left nonetheless. The bad taxiway lights and lack of markings would have made no difference whatsoever. Indeed, the fact that another plane took off 16 minutes prior to SQ-006 under identical conditions indicates that good navigation was employed by other crew and they were not drawn into 5-Right. But for all those pilots who got into the bad habit of navigating to runways using dead reckoning, the trap provided by runway 5-Right constituted an accident waiting to happen ‘one dark and stormy night’.

SQ006 Survivors

hawkeye18

5th Jun 2002, 18:28

DR Paul Blanchon (Ph.D)/ SQ survivor

With reference to this Summary under: "Cause of the crash: Survivors speak out" on your web site.

""Summary

We conclude therefore that the blame for this accident lies squarely at the feet of the pilots of SQ-006 because if their navigation skills were fully employed that night they would have realized that all they needed to do was make a 90 degree turn when they reached the end of taxiway NP. At no point did the taxi require a continuous 180 degree turn. By knowing this simple fact, they would have passed 05R, and perhaps been surprised that it was lit up, but carried on to 05L nonetheless. The bad runway lights and lack of markings would have made no difference whatsoever. Indeed, the fact that another plane took off 16 minutes prior to SQ-006 under identical conditions indicates that good navigation was employed by other crew and they were not drawn into 05R. But for all those pilots who got into the bad habit of navigating to runways using dead reckoning, the visual trap provided by 05R constituted an accident waiting to happen ‘one dark and stormy night’. "

I have provided feedback on your web site with reference to the term DEAD REKONING in the highlighted paragraph.

As I mentioned in the email , I feel that the term DEAD RECKONING used in the ground taxying context is inappropriate and wrong.

Dead rekoning is a simple method of determining the position of a ship or aircraft by charting its course , speed and elapsed time (distance travelled)from a previously known position.

It is mainly an AIR navigational technique used before the advent of modern navigational aids like DME,INS and GPS based navigation systems. Such technique is not use on the ground for aircraft taxy.

In ground taxying , the whole process is conducted visually usin g airport terminal ground charts, visual cues such as singnages, markings , lightings to guide the pilot from point to point . Pilots do not use Dead Reckoning ( heading, speed and elasped time) to arrived/derive at their intented position during ground taxying.

In fact this is the first time I heard the term being use in the ground taxying context.

I concurred with your comment that :" , the visual trap provided by 05R constituted an accident waiting to happen ‘one dark and stormy night’ "

As to your other comments /conclusions under the summary , it is easy for any armchair critics or non- pilot to arrive at such conclusions. .... as such I would leave it to the more experienced amongst the pilots' community here to decide whether it deserve their further feedbacks / comments.

Regards!

Hawkeye

SQ6 Survivor

7th Jun 2002, 18:18

I find your comments poetic considering that two posts back you hadn't a clue what dead reckoning was! So, before we start again, lets look at that definition and others that you'll need to follow what I am going to say:

Dead Reckoning: determining one's position... by guessing the direction and distance travelled rather than by using landmarks, [maps compass bearings etc.]
Navigate: plan or direct the route or course...using instruments or maps
Navigation: process or activity of accurately ascertaining one's position and planning and following a route. Oxford English Dictionary.

I know this is a difficult pill for you to swallow, so I will sugar-coat it this time: Evidence that Foong was using dead reckoning to get to the runway include:

1. He made a 180 degree turn when none was called for. A quick glance at the Jeppesen would have told him that there was a good 200 m between r/w 05R and 05L. If he had used this map and not tried to GUESS his position he would have realized he only needed to make a 90 degree turn at the end of t/w NP and then travel 200 m before turning 90 degrees into 05L. The fact that he screwed up and turned into 05R PROOVES HE WAS GUESSING and NOT NAVIGATING using map and compass heading.

2. he failed to confirm his position using t/w signs, or r/w markings because either he could not see them due to bad viz, or he was hubristicly assuming he knew where he was...ie GUESSING! (...do you remember...guessing and not confirming your position using landmarks = dead reckoning)

3. His jocular comments with the crew about first right, next right etc shows his method of getting to the r/w involved the same technique as if he was casually taking directions from a passer by on how to get to a new store...first right at this junction and right again at the next etc. THIS IS NOT NAVIGATING, IT'S DEAD RECKONING.

I think it's pretty clear, even to a non-pilot such as myself, that Foong was guessing instead "accurately ascertaining one's position and planning and following a route" using map, compass bearing, distance travelled, signage and other landmarks. IF OTHER PILOTS THINK I'M OUT TO LUNCH HERE, PLEASE, FEEL FREE TO STEP IN ANY TIME....I'M ASSUMING THE SILENCE SO FAR IS A SIGN OF AGREEMENT?

Hawkeye18, if you want to argue further with me on this, FIRST address each one of the points above and then I will consider any other arguments you make (if you can call them that). And since you have 'discovered' who I am (...tremendous bit of sleuthing there old chap...), perhaps you can enlighten us all on your qualifications.

HugMonster

7th Jun 2002, 22:40

Sorry, SQ6, but I disagree quite strongly with many of your assertions. Pilots quite often "lose the plot". When they carry on, not realising they have done so, it is not hubris. It is, quite simply, a mistake. You clearly have no idea of how difficult it is to taxy a large aircraft, particularly in low visibility conditions. Apart from anything else, you have very little idea at all of your speed over the ground, so your idea about "dead reckoning" is totally invalid. In low visibility you rely very heavily upon the lines and lights. As has been shown already, all these cues were directing SQ006 away from the active runway and onto the blocked one. You are drawing invalid conclusions from his actions - "He was guessing" - that are not proven by the evidence. "Second right then first left" etc. is a perfectly acceptable way for two pilots to refer to taxying directions. It's done all the time. If you have difficulty handling this concept, then you've never spent any time whatsoever on a flight deck, and your criticisms are therefore ill-judged. Furthermore, it still doesn't make it DR. Particularly in low-visibility conditions, it is vitally important that the HP maintains a lookout. In the conditions at the time of this accident, it would have been even more important. When much of the signage, landmarks etc. are all obliterated by the visibility, he (unfortunately) used the visual clues available to him. These led him to the wrong runway.It appears to me that you wish to lay the blame squarely on the Captain's shoulders, without examining the environmental capture elements, the poor signage, all the other elements that provided the chain of events at the end of which was the accident.

And that is not a valid way to go about ensuring this sort of accident does not reoccur.

mole

8th Jun 2002, 01:35

Hug Monster,

I believe you may not have fully understood the point that SQ6 is making. He does not fully blame the Captain and does accept that the signage was a contributory cause. The point that I receive loud and clear from him is that an accident like this WILL happen again if pilots continue to taxi in low viz in the same way that this unfortunate captain did. If there is WIP and/or confusing signals around then the pilot must be particularly cautious in low viz and use all tools available to him. On this occassion surely the most important tool available was the 05L localizer. If he had concentrated on this and ignored everything else then the accident could not have happened.

The reference to him using DR only may have some merit, clearly he wasn't using the localizer, he wasn't using the Jepp chart effectively either, so what was he using? Please don't reply and say the signage because you would be ignoring fundamental airmanship principles.

I don't wish to heap blame on any particular individual as there are so many other factors that come into play. I just thought your criticism of SQ6 survivor was uncalled for. Just about all the points you raised are exactly why extreme caution was needed on that dreadful night. I hope I never have to deal with conditions like those.

G.Khan

8th Jun 2002, 05:36

SQ6 Survivor, sorry but you are guilty of a little learning being a dangerous thing.
In aviation DR navigation ONLY refers to navigation in the air, an accurate definition of which is given above in Hawkeye18's post. It is carried out using speed, compass headings and a stop watch and is in no way relevant to taxying an aircraft on the ground.

Taxying at an airfield is carried out in accordance with ATC instructions/directions, reference to an airfield chart AND by following the signs, lights and markings pertinent to the route required - in the case of SQ6 the lights, signs and ground markings were incorrect for the operations in progress and therefore a contibutory factor to the accident.

CKS airport will naturally want to minimise the amount that their failure is deemed to have contributed to the accident as this will also minimise the extent of their Underwriters liability to pay out under their airport insurance, ( an insurance that the Taiwanese authorities may have elected to underwrite themselves rather than go to the international aviation insurance market).

If you are planning on going to court I strongly suggest you should delete any reference to "Dead Reckoning" or "DR" as a sharp lawyer will tear you to bits.

mole

8th Jun 2002, 06:29

G Khan,

You are arguing semantics nothing more. If SQ6 wishes to call the taxi technique on that fatefull night DR then he is possibly correct in doing so. The OED definition certainly would support his view. The tools available to the crew were not fully utilised viz a viz the 05L localizer and the Jepp charts. SQ6 has obviously looked at the charts and has seen that the turn onto 05L requires a 90 degree right a straight bit and then another 90 degree right turn. It does not show a continuous 180 turn from the taxi way to 05L. The co-pilot did mention the PVD had not unshuttered and that should have meant something don't you agree? I am unfamiliar with the PVD fitted to SQ aircraft but I would assume that the ILS has to be tuned in order for it to work. Therefore a raw data display of localizer deflection should also have been available. If the PVD is armed by selection of the runway in the FMS and does not require manual tuning on the NAV RAD page then perhaps the SQ procedures should be changed to require manual tuning of the ILS for low viz procedures. Can someone familiar with the SQ low viz taxi technique (pertaining to use of the LOC) let us know the procedure used prior to this accident and that currently in use now?

SQ6 Survivor

9th Jun 2002, 01:12

Score so far:

Dead Reckoning 2, Semantics 2

G.Khan

9th Jun 2002, 07:19

Hardly a semantics issue is it SQ6? Semantics is about using different words to mean the same thing, not about using the same words to mean different things, as is the case here with "Dead Reckoning".

Many professional aviators on this thread have tried, quite politely, to explain that, in aviation the term Dead Reckoning has a specific and incontrovertible meaning and should not be confused or misappropriated to mean anything else - somehow these explanations have fallen on deaf ears, (even Mole's who is an aviator?).

The blame cannot and will not be placed solely at the feet of Capt. Foong and crew and "My Learned Friends" won't allow it, since it would be tantamount to admitting total and exclusive liability which the airline insurers won't buy, the airline insurers will be looking to make certain that all contibuting factors to the accident are placed at the correct doors and that the owners of these factors, (or their insurers), collect their fair share of the bill.

mole

9th Jun 2002, 15:46

G Khan,

Semantics - Is the branch of the science of linguistics that is concerned with the meaning of words.

Now what did you say above?

I don't think any lawyer will quibble about the OED definition of dead reckoning, if we aviators only think of it as the calculation of position without celestial observations then so be it. In a wider context it surely means guessing position without reference to other navigational tools such as a localizer or Jepp charts. I really didn't want to get into this sort of argument but you are forcing the issue. Please tell us why you think the captain on this terrible night did not use the localizer to establish that he was correctly positioned on the threshold of runway 05L.

SQ6 Survivor

9th Jun 2002, 15:57

I don't give a rats ass how pilots use the term dead reckoning. I'm trying to point out here that Captain Foong DID NOT NAVIGATE to the runway and GUESSED his position. Why don't you address the issue instead of trying to divert attention away to some ridiculous semantic side issue.

(And I suggest YOU get your facts right: semantic, relating to meaning in language or logic; semantics, branch of linguistics and logic concerned with meaning....analysis of word meanings and relations between them.... OED.)

I'm sure the poor bastards who burn't to death that night, and their families reading this thread, deserve a better response from a professional pilot than "My Learned Friends won't allow it".

Perhaps you should remind yourself of another word, 'INTEGRITY, the quality of being honest and having strong moral principles'. Who cares what the insurers and lawyers think, anyone with an ounce of integrity will tell you that the thing to do if you screw-up is admit your mistake and take measures to ensure that you don't make it again (and do everything in your power to make sure nobody else does either). Everybody makes mistakes, and I'm sure Foong is a man of integrity who will do the right thing when the time comes. If he looses his job and can't fly again, then these are the consequences he will have to accept for his mistake. But if he is sent to jail for admitting his mistake, I will be the first to shout up. Thinking about the 83 men, women and children, who died as a result of that mistake is punishment enough for any man.

Belgique

9th Jun 2002, 21:37

Semantics and pedantry aside, I think that the discussion on taxiing DRnav and the responsibility for getting to the right runway is missing the point by a country mile.

1. If Capt Foong had requested a "Follow Me" truck because of the reduced visibility, he may well have been within his rights to do so - albeit that it would have been a very very unusual request in my experience. But to take that a bit further, if Capt Foong had blindly followed the "Follow Me" truck and ended up (along with it) in a ditch (because the FM
truck-driver was an irresponsible idiot or himself lost), well we'd probably not have been too harshly critical of Capt Foong.

But let's say that it was that self-same idiot that painted the "Follow Me" taxiway markings (and installed the deceptive lights and signage) on the path that Foong followed to 05R - well, is it really all that different? A come-on "sucker trap" by any other name will always be a garden path that one in ten (or more) will be able to be led up - like lambs to the slaughter. If that sucker trap is also so immaculately designed that there are no active alerts (such as a lit obstacle or strobe-lit hazard sign) to the erroneous path (once entered), then we are obviously well along an exculpatory path for the aircrew. And therefore we should be rounding up those who created that trap..... and mindlessly left it there in place for many years - just awaiting the right conditions.

These miscreants might include:

a. Other pilots who themselves nearly "fell for it" in similar conditions - yet said/did nothing.

b. ATC operators and Ops staff at CKS who are very familiar with the airfield, its deficiencies and should have been daily on the qui vive for such errors....and the traps that might lead to them.

c. ATC Supervisors at CKS who should have been ensuring that their airfield was properly marked or NOTAMED as NOT being so (ICAO signatory status notwithstanding).

d. Construction supervisors for the 05R Works in Progress who might have thought it all through to a worst case, risk management / hazard elimination responsible decision not to abide by any such possibilities.

e. ICAO Safety Inspectors and Audit Teams who never really "look" at what they are inspecting for its potentials - and write glowing politically acceptable reports (ever see the one Ansett maint got from them just before it was twice grounded for shonky maint practices and failings?).

f. SIA OPS Management and Safety Staff who should have had a safety team flying the routes and looking out for the pitfalls and taking them up with airport management; but in the interim, briefing their crews on them.

So perhaps Capt Foong and his two yea-sayers upfront were insufficiently alert - but then again, to understand how that process works, look again at my earlier posts on this thread (pgs 3,4 & 7). I guess you could say (with the benefit of hindsight) that a most excellent captain would have had a standard pre-start mini-brief and said to his two understudies. "Well what do you think boys? What are the tricks and traps that we've got to look out for on this trip?". A little militaristic I guess, yet captains do have the responsibility of properly indoctrinating tomorrow's captains..... and that's a good way of doing it. It also lets the two F/O's know that you have a high regard for your own fallibility.

All very Utopian, I know.... but the only worthwhile aviation safety programs are the pro-active ones. One of the best flight safety programs that I ever ran with had crews doing just that (actively seeking the potential pitfalls) - and regularly writing down and anonymously submitting their opinions on "where the next accident was coming from". It all stemmed from a horrendous run of fatalities, so I guess it wasn't really pro-active. But I never went to another funeral whilst on that type a/c.

In fact the only non-guilty parties are the passengers. They just get to wear the outcome of the ongoing litany of half-truths that masquerade as airline industry aviation safety programs.

2. The ability to easily set up these types of multi-contributor errors is brought home best by examination of these next two incidents and the linked documents (at b & c).

a. In January 2000 an American Airlines [AMR] B777 took off on a closed runway at Chicago’s O’Hare airport.

b. the (524kb Word Document) record (http://www.iasa.com.au/folders/Publications/pdf_library/UPS896%20DIA%20RI%20Ops%20Report%20Lite.doc) of the NTSB investigation into UPS 896 (B757) take-off on a closed runway at Denver International on September 25, 2001. They missed the well-lit construction equipment in the darknesss by an observed three (3) feet - yet knew nothing about it until the next day. The litany of errors that brought it about is in my commentary at

c. this link (http://www.iasa.com.au/folders/Safety_Issues/others/UPS896Denver.html) (html file)

SQ006 in Microcosm: Systemic Failings Across a Broad Spectrum

It’s convenient to blame the captain when it was really
the support structure that failed him. Some of those
factors involved the inattention of Singapore Airlines (SIA)
to low visibility procedures (and para-visual device
training), slackness of the Chiang Kai-Sheck airport
authority, the urgency predicated by an approaching
typhoon, the decision to use Runway 05L instead of the
more familiar Runway 06, and damning discrepancies
such as the crosswind threatening to exceed
contaminated runway limits. Nothing was “broken,” just
systemic failings across a broad spectrum. Capt. Foong
was simply sitting at the apex of that rickety pyramid.

G.Khan

10th Jun 2002, 03:23

I really dont want to detract from Belgique's excellent post. it stands in a league of it's own.

SQ6 I appreciate that as a survivor of an horrific accident, caused by your fellow man, you feel you have been violated in a terrible way, I don't know of many people who would not sympathise with you totally. Myself particularly, some of the other posters here and collegues I have spoken with are under the impression that you are using your own web-site and this aviation BB to gather as much relevant information as you can prior to going to court ? If that assumption is wrong then I apologise immediately.

Should you go to court you will find that there will be a positive attempt to discredit you and your evidence, the lawyers involved in major claims are a hard nosed bunch with no apparent humanity at all, money is their sole consideration. Should you use any aviation expressions in evidence it would be to your advantage that they are used in a context that agrees with the lawyers own interpretation. The lawyers will be hand picked and well versed in most matters aviation.

My references in my previous post to lawyers and insurance were simply to illustrate that there will be a fight to ensure that all parties deemed in any way guilty will pay their proportionate share, nothing more. Having lived and worked in Singapore for over ten years I believe Capt. Foong and his two first officers are men of integrity who will never forget or cease to regret the dreadful accident of Flight SQ6.
All professional aviators, world wide, cannot help but feel an element of guilt that our profession has let you and the other passengers down, very badly.

The intention of my post was actually to help by providing background for an expression used in aviation and at the same time explain how the blame is likely to be shared out, regardless of sentiment. If you do not plan to go to court and your motives are purely altruistic then, once again, I apologise unreservedly and withdraw.

Best wishes for the future. GK.

mole

10th Jun 2002, 04:03

G Khan,

Why do you not answer the question which I posed three posts earlier?

I would like to read your thoughts on this and I am sure SQ6 Survivor would be interested to see your answer too.

hawkeye18

10th Jun 2002, 04:45

SQ survivor,

Red = SQ Survivor, Blue = Hawkeye18

"I find your comments poetic considering that two posts back you hadn't a clue what dead reckoning was! So, before we start again, lets look at that definition and others that you'll need to follow what I am going to say:[B] "

Yes ! I had goofed in making that initial statement, confusing visual navigation with Dead Reckoning, and I had subsequently apologised and corrected for the mistake, but in no way will that mistake of mine makes your dead reckoning defination more correct.

On your web site you stated:

"Our hope in providing these analyses is that all 96 survivors including the crew will read this report and provide feedback so that it can be as accurate as possible and represent our collective experience.

Disgusted by the inconclusive and politically-influenced outcome of these reports, we present here our own investigation into the cause of the SQ-006 disaster. We used our own eyewitness accounts ..... Our qualifications are that we were there and know what happened, and that many of us are research scientists trained to look at evidence and judge the validity of claims and conclusions made from it. "

Disgusted,Used own witness,our own investigation + vested interests !!! And dun even have the courtousy of acknowledging email feedback to your site ( was trying to help), On reflection ,-----your actual intention of the site is to harness supports to your "expert"' conclusion rather then asking for objective feedbacks!!

Your present here is more to sell your conclusion then objectively discussing what actually led to the accident to help yourself and other survivors in their legal cause!

As to following your defination of Dead Reckoning ......may I ask, what is your background in aviation to have the galls to dictate to the forum here to adhere to your defination of Dead Reckoning in this discussion!! Get real Doctor!

Dead Reckoning: determining one's position... by guessing the direction and distance travelled rather than by using landmarks, [maps compass bearings etc.] ....Oxford English Dictionary.

Go ahead SQ Survivor, use your defination of using Dead Reckoning from the the oxford dictionary, with an ancient defination of the terms...... and Good luck in court !

I know this is a difficult pill for you to swallow, so I will sugar-coat it this time: Evidence that Foong was using dead reckoning to get to the runway include:

1. He made a 180 degree turn when none was called for. A quick glance at the Jeppesen would have told him that there was a good 200 m between r/w 05R and 05L. If he had used this map and not tried to GUESS his position he would have realized he only needed to make a 90 degree turn at the end of t/w NP and then travel 200 m before turning 90 degrees into 05L. The fact that he screwed up and turned into 05R PROOVES HE WAS GUESSING and NOT NAVIGATING using map and compass heading.

2. he failed to confirm his position using t/w signs, or r/w markings because either he could not see them due to bad viz, or he was hubristicly assuming he knew where he was...ie GUESSING! (...do you remember...guessing and not confirming your position using landmarks = dead reckoning)

I have no hangup nor any vested interest in the case except the learning of the chain of mistakes/discrepencies on that faithful nite that culminated to the tragedy....unlike you and the survivors of the tragic accident which have personal vested interest. May I suggest that your conclusions are naturally biased.

Let me state it again Doctor, in case u have difficulty understanding or reading:

the following were my reply to your following ASSERTION:

"the fundamental failing was that, when the going got tough the Crews 'training' failed them and they made a BASIC navigational error. "

The pilot of SQ 006 failed and there's no denying that.....that is the subjective conclusion specific to Cpt Fong, the inference that crew training (fleetwide) failed needs substantiation.

This is a case of navigational error induced by poor weather condition, wrong/deficient runway,taxiway, signage/markings and lighting. Basic navigational training, be it on the ground or in the air are based on the assumption that all corect signages ,aids , visual features are in place. .....

What I am more interested in, is what led the crew of SQ006 to make those silly mistakes. To just concentrate on the pilots' actions without consideration or regards to what the visual picture presented by the weather and singnage (or lack of it ) to the pilots, would be falling into the provebial trap of "aiming for the tree and missing the wood" .

"guessing and not confirming your position using landmarks = dead reckoning"

If you have , as you claimed to have read thru and analysed the evidences, surely you would not have missed the argurment of the deficient/wrong taxiway marking lighting etc that disorentated and misled the pilots onto 05R...or you just refused to see it as it was!!!

Hence, your statement above is just putting forth what you want forumers to agree ... instead of objectively assessing what the crew were doing in reaction to what they saw. .....I think you are doing more "dead Reckoning"( your defination of gussing and....) in that conclusion then the crews of SQ006!!.

Because, if you have read and analysed the evidences, they also point out clearly that the crews was Navigating using the deficient runway marking and lightings and ended up on the wrong runway.

PRRuNe is not a kangaroo court ....so let's leave it to the aviation experts, the lawyers of both side and the judge to earn their dues , to figure out the defination, final aportioning of blames and liabilities when it reach the civil court.

3. His jocular comments with the crew about first right, next right etc shows his method of getting to the r/w involved the same technique as if he was casually taking directions from a passer by on how to get to a new store...first right at this junction and right again at the next etc. THIS IS NOT NAVIGATING, IT'S DEAD RECKONING.

I think it's pretty clear, even to a non-pilot such as myself, that Foong was guessing instead "accurately ascertaining one's position and planning and following a route" using map, compass bearing, distance travelled, signage and other landmarks. IF OTHER PILOTS THINK I'M OUT TO LUNCH HERE, PLEASE, FEEL FREE TO STEP IN ANY TIME....I'M ASSUMING THE SILENCE SO FAR IS A SIGN OF AGREEMENT?

Good luck to u again! IF U USE THE ABOVE arguement in the COURT OF LAW, as it was pointed out the lawyer will have ur ass for lunch......ever heard of expert witness and opinions in the court of law, Doctor??!!

[B] Doctor Blanchon , dun make urself too important, I am not here to argur with you, merely sharing my perspective of what caused the accident.

The feeling is mutual in as far as far as"FIRST address each one of the points above and then I will consider any other arguments you make (if you can call them that)." is concerned . Hope u too , live up to ur own standard !!

I had tried to provide objective answers to your assertion, but on second thoughts .... I am wasting my time in trying to help a closed mind!

You are on my ignore list as far as reasoning on the causes of the accident is corncened.

Your attempt to be an aviation expert , investigator, and a lawyer is both laudable and laughable, and unfortunately a dis-service to the rest of the survivors for their cause. You are totally unqualified to do so, other than your unfortunate present in SQ006. !

As to your comments:[B]And since you have 'discovered' who I am (...tremendous bit of sleuthing there old chap...), perhaps you can enlighten us all on your qualifications.

DR Paul Blanchon , you really gave me too much credit for your own pompous and all-knowing approach, and the relentless promotion your own conclusion.... which will not stand up to scrutiny in my humble opinion.

[B]Let me quote your goodself:

"Just so you know who you are talking to, Murrelet is also an SQ6 survivor and contributed significantly to the web site. Hence, there was no plagerism."

"A summary of our argument and the ASC and MOT reports can be found on the SQ6 Survivor's web site: "

"As you will see on the SQ6-Survivors web site,[B] I HAVE read the findings and arguments from BOTH reports and even summarized them in an objective and unbiased fashion. I ignored the pathetic face-saving and biased way in which the MOT tried to distort the ASC findings and divert attention from SIA failings, AND I duly noted the way in which the ASC side-lined the unsafe conditions at CKS. But the conclusion was obvious and, with the risk of boring the rest of you, I repeat, the fundamental failing was that, when the going got tough the Crews 'training' failed them and they made a BASIC navigational error. "

Well I am an aviator for more than 30 years , in both military and civil aviation , have some accident investigation experience,and I am still learning what causes accidents.

Take care Doctor! My heartfelt sympathies to the victims and survivors of SQ006, and good luck in court!

Hawkeye

G.Khan

10th Jun 2002, 07:49

MOLE Your question was, I thought, a rhetorical one, given that you are a pilot, (professional?).

It is possible that the crew elected to ignore the PVD display because having, so they thought turned onto the correct runway they then may have assumed that the PVD was giving out duff information and chosen to discount it. I have no idea what the serviceability state of the aircraft was, nor its recent history with respect to its ancillery systems and in particular the PVD system.

That is only my opinion and I have no doubt that Capt Foong will be giving his reasons in due course. It helps not at all for you or I to simply guess.

As an aviator I reasonably expected you to:

a). draw your own conclusions about the PVD and

b). appreciate that whatever conclusion you come to it is, (just as it is as to whether or not SQ6 Suvivor is interested in my opinion)
TOTALLY IRRELEVANT.

HotDog

10th Jun 2002, 09:07

SQ006 CVR transcript Pt.I

Legenda
RDO - Radio transmission from accident aircraft
CAM - Cockpit Area Microphone sound or source
-1 - Voice identified as Captain (left seat)
-2 - Voice identified as First Officer (right seat)
-3 - Voice identified as Observer/Relief pilot
TWR - Taipei Tower
time source content
23:08:27 CAM-3 Hongkong closed ah
23:08:27 CAM-1 That's what he said not accepting any
23:08:29 CAM-2 I see
23:08:30 CAM-1 I think some people might have diverted there lah I think
23:08:40 CAM-2 Ok column coming back
23:08:47 CAM-1 If the RVR five left was two hundred right just now we checked
23:08:50 CAM-3 RVR yah two hundred
23:08:50 CAM-1 Correct, yah two hundred meters ah, ok lah
23:08:54 CAM (Sound similar to that of seat motor)
23:08:55 CAM-1 Ok man before takeoff checklist
23:08:56 CAM-2 Roger sir
23:08:58 CAM-2 Before takeoff checks, flaps
23:09:02 CAM-1 Twenty green
23:09:03 CAM-2 Twenty green
23:09:06 CAM-2 Flight control
23:09:07 CAM-1 Check
23:09:07 CAM-2 Check
23:09:08 CAM-2 EPR and speeds
23:09:09 CAM-1 Ok, EPR one point five two ah, Vee one, one forty two, Vee R one five six and Vee two, one six nine set
23:09:15 CAM-2 EPR one point five two ah, Vee one, one forty two, rotate one five six and Vee two, one six nine
23:09:19 CX 2043 (Cathay two zero four three conversation with ground control)- -
23:09:22 CAM-2 Speed set
23:09:24 CAM-2 Departure routing
23:09:25 CAM-1 Ok ah Taipei runway zero six left huh
23:09:27 CAM-2 Zero five left
23:09:28 GND (Ground control conversation with Cathay two zero four three)
23:09:29 CAM-1 Zero five left
23:09:29 CAM-3 Zero five left
23:09:31 CAM-1 And er we got Anpu three departure Kikit transition huh
23:09:32 CX 2043 (Cathay 2043 conversation with ground control)
23:09:34 GND (Ground control conversation with Cathay 2043)
23:09:35 CX 2043 (Cathay 2043 conversation with ground control)
23:09:38 CAM-1 Looks like I got to go
23:09:40 CAM-2 Next one got to go right is it
23:09:41 CAM-1 Yah, go right turn right here, all the way to West Cross lah right turn here
23:09:46 CAM-2 Runway is zero five left. Kikit transition initially two hundred ah level alpha one squawk two six five seven, will be two nine zero by Bulan
23:09:58 CAM-1 A lot of rudder work man here... really ah
23:10:01 CAM-3 Cross wind ah
23:10:02 CAM-1 Yah
23:10:03 CAM-2 Transponder TA RA, set, checks down to the line
23:10:06 CAM-1 Ok, thanks.
23:10:08 CAM-2 West Cross correct, Sierra Sierra West Cross
23:10:14 CAM-1 Everybody waiting for each other for takeoff you see haha
23:10:18 CAM-1 The ****** heard us ... er going... that fellow also
23:10:21 CAM-3 Yah, it is coming in ah, the longer they delay the worse it is lah
23:10:23 CAM-1 Yah, worse if we are going to get out, if don't take off ah .going to go very slow here, ok, because you going get skid
23:10:24 CAM-2 Ok nine knots
23:10:33 CAM-3 Ok, to catch the wind
23:10:35 CAM-2 That's all the moisture
23:10:41 CAM-2 Turning left skidding er turning right err skidding left two seven zero
23:10:42 CAM-3 The weather radar will be all red ha ha
23:10:43 CAM-1 Ok, passing ah two eight zero now, ah needles tracking and turn right skidding left now ah, past heading of about two.. three hundred now ah
23:10:45 CAM-2 Yah that's right ah
23:10:56 CAM (Sound of clicks)
23:11:00 CAM-2 My speed excursion is more than the left side, because the wind is coming from here
23:11:03 CAM-1 Ah, yah
23:11:03 CAM-3 Your pitot on the other side ah ... just pick up
23:11:10 CAM-2 Roger that
23:11:12 CAM-1 For the takeoff use autopilot better
23:11:22 CAM-1 Typhoon man, ok tomorrow the guys coming in will be "terok" (terrible) man
23:11:28 CAM-3 Yah, tomorrow morning Singapore five
23:11:29 GND (Ground control conversation with Cathay two zero four three)
23:11:36 CX 2043 (Cathay two zero four three conversation with ground control)
23:11:38 GND (Ground control conversation with Cathay two zero four three)
23:11:42 CX 2043 (Cathay two zero four three conversation with ground control)
23:11:47 CX 2043 (Cathay two zero four three conversation with ground control)
23:11:49 CAM-1 The five left also imp... imp... improve already the visibility to five hundred fifty meters
23:11:52 GND (Ground control conversation with Cathay two zero four three)
23:11:54 CX 2043 (Cathay two zero four three conversation with ground control)
23:11:55 CAM-3 Five left... wait ah
23:11:56 CAM-1 Ya, the guys said improved already went up
23:11:59 CAM-3 Now is four fifty
23:12:00 CAM-1 Just now the guys ask him over the tower
23:12:01 CAM-2 Yah
23:12:02 ATIS Taipei Chiang Kai Shek International Airport information uniform one five zero zero zulu runway zero six for departure only runway zero five left for category two approach and departure wind zero two zero at three six gust five six visibility six hundred meters runway zero five RVR four hundred fifty meters downward runway zero six RVR five hundred fifty meters downward with heavy rain cloud broken two hundred feet overcast five hundred feet temperature two one dew point two zero QNH one zero zero one Hectopascal
23:12:06 CAM-2 Coming up er... November Papa eh
23:12:07 CAM-1 Ok, all the way down left turn all the way down
23:12:10 CAM-2 Left ah
23:12:10 CAM-1 Yah
23:12:17 CAM-2 One two five one departure
23:12:20 GND (Ground control conversation with Cathay 2043)
23:12:21 CAM (Sound similar to that of radio frequency selection)
23:12:22 CAM-1 Ok, first left
23:12:23 CX 2043 (Cathay 2043 conversation with ground control)
23:12:23 CAM-2 Affirm first left
23:12:24 CAM-1 Left
23:12:25 CAM-2 Left
23:12:26 GND (Ground control conversation with Cathay 2043)
23:12:33 CAM (Sound similar to that of seat motor)
23:12:38 CX 2043 (Cathay 2043 conversation with ground control)
23:12:41 CAM (Sound similar to that of nose gear scrubbing)
23:12:47 CAM (Sound similar to that of nose gear scrubbing)
23:12:47 GND (Ground control conversation with Cathay 2043)
23:12:56 CAM-3 The latest QNH is one zero zero one
23:12:56 CAM-2 Clearing that huh
23:12:58 GND Singapore six contact tower one two nine point three, good day.
23:13:02 RDO-2 One two nine point three good day sir, Singapore six.
23:13:13 CAM-2 One zero zero one one two nine point one two nine point three ah ... ok ah
23:13:25 RDO-2 Taipei Tower, good evening, Singapore six.
23:13:28 TWR Singapore six, good evening, Taipei Tower hold short runway zero five left.
23:13:33 RDO-2 Hold short runway zero five left, Singapore six.
23:13:38 TWR Singapore six, for information now surface wind zero two zero at two four, gust four three, say intention.
23:13:44 CAM-1 Gusting four three ah
23:13:46 RDO-2 Thank you sir, Singapore six.
23:13:47 CAM-1 Ok, ok better less
23:13:48 CAM-3 Less, less gust already
23:13:54 CAM-1 Zero two zero it's from left lah
23:13:56 CAM-3 Two four gust four three
23:14:05 CAM-2 Zero two zero
23:14:08 CAM-1 Ok this one will be here ah
23:14:18 CAM-1 Zero two zero
23:14:20 CAM-3 Ya, left lah
23:14:21 CAM-1 Go right to the end of the runway, end of the runway then turn, ok.
23:14:31 CAM-3 Quite a bit of aileron for the takeoff
23:14:35 CAM-2 OK
23:14:40 CAM-2 The next one
23:14:41 CAM-2 Next one is November one
23:14:42 CAM-1 Ok second right
23:14:44 CAM-2 Second right, that's right
23:14:47 CAM-1 In Australia, to them, next one is this, first one you know
23:14:50 CAM-2 Next one this one
23:14:51 CAM-1 Yah ha ha
23:14:52 CAM-1 Australian
23:14:53 CAM-1 I think the best is to say second right ah first right second right ah
23:14:55 CAM-2 Clearing that Satvoice
23:14:58 CAM-1 Tell them we are ready lah
23:15:02 RDO-2 Singapore six ready.
23:15:04 TWR Singapore six roger, runway zero five left, taxi into position and hold.
23:15:08 RDO-2 Taxi into position and hold, Singapore six
23:15:12 CAM-2 I get them seated ah
23:15:12 CAM-1 Ok below the line please
23:15:15 CAM-2 Cabin crew to your takeoff station thanks
23:15:20 CAM (Sound similar to that of door closing)
23:15:21 CAM (Sound of chime)
23:15:22 TWR Singapore six, runway zero five left, wind zero two zero at two eight, gust to five zero, cleared for takeoff.
23:15:30 RDO-2 Cleared for takeoff, Runway zero five left Singapore six.
23:15:31 CAM-1 OK man
23:15:34 CAM-2 OK checks below the line, cabin announcement complete
23:15:39 CAM-2 Norm
23:15:40 CAM-2 Strobes on, landing lights all on
23:15:44 CAM-2 Takeoff clearance
23:15:45 CAM-1 Obtained hah
23:15:46 CAM-2 Obtained sir
23:15:47 CAM-1 OK thanks
23:15:48 CAM-2 Before takeoff checklist completed
23:15:50 CAM (Sound of click)
23:15:50 CAM-2 OK green lights are here
23:15:52 CAM-1 It going to be very slippery I am going to slow down a bit, slow turn here
23:15:53 CAM-2 Turning that
23:16:07 CAM-2 And the PVD hasn't lined up ah
23:16:10 CAM-1 Yeah we gotta line up first
23:16:12 CAM-3 We need forty five degrees
23:16:15 CAM-2 I see, excellent man
23:16:16 CAM-1 Yah
23:16:23 CAM-1 Not on yet er PVD huh never mind we can see the runway, not so bad. Ok, I am going to put it to high first. OK ready eh, so zero one zero is from the left lah Ok
23:16:27 CAM-2 Ok
23:16:30 CAM (Sound similar to that of wipers going to high speed)
23:16:31 CAM-2 Ready sir zero two zero check ok
23:16:33 CAM-1 Left wing into aileron, left aileron into wind. Huh OK Cabin reported eh
23:16:37 CAM-3 Yah cabin is ready.

HotDog

10th Jun 2002, 09:15

SQ006 CVR transcript Pt.2

23:16:37 CAM-1 Ok thanks
23:16:37 CAM-2 Yup thanks
23:16:43 CAM-3 Ok -thrust ref toga toga
23:16:43 CAM-2 Thrust ref toga toga
23:16:44 CAM-1 Ok -thrust ref toga toga
23:16:44 CAM (Sound similar to that of engines spooling up)
23:16:54 CAM-3 Hold
23:16:54 CAM-2 Hold
23:16:54 CAM-1 Roger
23:16:55 CAM-3 Eighty knots
23:16:55 CAM-2 Eighty knots
23:16:56 CAM-1 Ok my control
23:17:13 CAM-2 Vee one
23:17:13 CAM-3 Vee one
23:17:16 CAM-1 **** something there
23:17:17 CAM Sound of the first impact
23:17:18 CAM ****waaah****
23:17:18 CAM Sound of a series of impacts
23:17:22 End of Recording

[disclaimer]

--------------------------------------------------------------------------------

Copyright © 1996-2002 Harro Ranter / Fabian Lujan
Aviation Safety Network; 04 May 2002

mole

11th Jun 2002, 00:44

G Khan

I repeat the question below:

"Can someone familiar with the SQ low viz taxi technique (pertaining to use of the LOC) let us know the procedure used prior to this accident and that currently in use now?"

I may have wrongly assumed that you are involved with SQ but the nature of your postings do suggest this. In my company tuning of the localizer is a requirement for all low viz departures. Could you tell us if this was/is a requirement in SQ. I also asked how the PVD is armed, is it by runway selection in the FMS or manual tuning of the localizer. If the latter then there would have been raw data localizer presented on the PFD in addition to the PVD remaining unshuttered. One final question if I may? The above CVR transcript indicates they were using 1.52 EPR for T/O perhaps fortunate on this occassion as they would have been slower at impact; but isn't this rather a low T/O power in such weather conditions? On a R/R the EPR for a situation like this would be around 1.72 I believe (ATIS 020 deg 36 gusting 56)

I do not understand how you could think my questions were rhetorical. Perhaps semantics raising its head again!

Sorry another final question. How do you conclude that any discussion of localizer use in these conditions is irrelevant? Surely use of the localizer to establish correct runway centreline will stop this sort of accident ever happening again.

HotDog

11th Jun 2002, 02:06

23:16:07 CAM-2 "And the PVD hasn't lined up."

23:16:23 CAM-1 "Not on yet er PVD, huh never mind we can see the runway, not so Bad".

It would not have mattered whether they had the localizer tuned or not ( which they probably did have tuned) as they convinced themselves they were lined up on 05L.

mole

11th Jun 2002, 03:17

Hello Hot Dog,

Unfortunately you are probably right. The point surely though is that which SQ Survivor is trying to make and for which he has been very rudely shot down. I am disappointed that the two gentleman from Singapore have arrogantly dismissed him rather than discuss his views affably. Even non aviators can hold valid points of view Hawkeye and Mr Khan! The point is that until it becomes SOP for every operator to insist on the use of all the tools available in bad viz then accidents like this will happen again. On every line up there should be a call of "localizer moving" or something similar.

I am extremely surprised that SQ have PVR fitted and yet apparently do not require them to be serviceable and used in CAT 2 conditions (ATIS)(G Khan says they might have thought it was inoperative)

How can any pilot be convinced he is on the correct parallel runway in bad visibility without either positively identifying the runway from the numbers or by use of the localizer? Complacency may have been an issue and certainly the pressures of operating in those conditions would have been a significant one. These factors form the pyramid or as it used to be called in the RAF the duck syndrome (enough ducks nibbling at you will eventually sink you) But at the end of the day there has to be a mechanism for stopping all the pressures/errors ending up as an accident. Hence it boils down in this case to either SQ not having effective procedures for LWMO taxi-ing or they did have procedures which this crew decided to ignore (unlikely I would think) SQ Survivor is certainly entitled to know which of the two scenarios actually applied in this case.

Gladiator

11th Jun 2002, 04:08

In order for the PVD to work you have to manually enter the localizer frequency into the box.

It is armed by selecting PVD (push of a button), once within a certain number of degrees of the runway (usually having entered the runway and about to line up) the PVD window (on the glareshield) will automatically open up.

In order to make a PVD takeoff, the airport and the intended runway has to be PVD approved, otherwise the PVD becomes a backup tool only.

The use of the localizer works just as good in keeping the centerline, except you can execute an RTO in zero zero by using the PVD.

PVD is a nice tool to have but FAA never certified it. I have no idea why.

It is obvious that SQ006 crew had utilized this tool as a back up but ignored the indications. The F/O was correct to point out that PVD was not lined up, the Captain was obviously experiencing anxiety due to the conditions and let the final hole of the swiss cheese line up.

This brings us back to CRM or lack of it. If the F/O sees something he or she does not like, it is time to say,

"Captain I am not comfortable with this, can we please first discuss it."

The ATC system can wait for as long as it takes. Airlines should look into their CRM culture. Asian carriers often miss the CRM point altogether, the above statement of an assertive F/O at SIA would be almost a 'no no' causing the Captain to lose face.

Our briefings go something like this,

"if you see something you don't like please let me know as loud as possible and I will do the same for you, please let's help keep each other out of the chief pilot's office and CNN".

hawkeye18

11th Jun 2002, 06:09

Mole

Just to set the record straight!

Sorry to disappoint you I am not from Singapore neither is GKhan ( as I came to understand).

I am not trying to shot down anyone, SQ6 is more than welcome to voice his assertion, and discuss rationally based on facts and not mere conjectures. If one cannot stand up to scrutiny in a public forum then it speaks volume of his homework .

If you feel that his defination of DR and assertion : that the crew of SQ006 was utilising Dead Rekoning in navigating was correct, or for that matter any other points he mentioned, you are most welcome to assit in subtantiating his assertion /conclusion.

If you follow the exchanges, you would have noticed that, while every effort was made to answer him point-to-pont, he refuses to acknowledge counter points to his assertion and conclusion.

In a discussion, when one put forth a points for discussion it is obvious that one is prepared to defend his opinion ( irregardless of his background). As one would have been convinced that his point/conclusion is correctly based on facts. And he is testing its robustness by inviting counter points or supporting infor for further enhancement.

Unless one is abstaining from commenting, it will be either one agree or disagree on the point(s) raised , if so one would rationalise his mis-giving/support and state the precise reasons why he had chosen to agree/disagree. Only then will there be a fruitful exchange of ideas.

Without refuting most (if not all ) of my counter-points and out of the blue came the following arrogant statement of SQ6 Survivor:

"Hawkeye18, if you want to argue further with me on this, FIRST address each one of the points above and then I will consider any other arguments you make (if you can call them that). "

I would have thought HE was the arrogant one and trying to shut me up! I guess you are disorientated and pointing in the wrong direction as far as who is being arrogant !!

I have replied him point by point again on all his querries ! If he chooses not to refute them , that is his decision for not replying ....but not anyone of us shutting him down..... that must be clear!

If he came in rattling off his flawed conclusion again without answering my points , that would prove my point that he is not interested in listening nor discussing, but only promoting his own flawed "expert" conclusion.

Cheers!

Hawkeye

hawkeye18

11th Jun 2002, 06:47

Mole

The PVD is not a mandatory instrument, and is not designed for runway identification.

It is designed and certified to aid runway centreline steering and is only to be used for takeoff on a Cat III runway.

It is not supported by the manufacturer as a runway indentifier as it is outside the scope of its design specifications. Hence FAA would not approved it.

That is the reason for it to be delegated as revertionary rather than a primary tool in lining up. Most airline do not use it that is what I came to undertand. Agreed that it could be utilised to supplement the crews' visual cues in low vis line up.

The PVD will un-shutter anywhere along the runway within the capture zone of the ILS localizer. It will therefore operate at any point along the runway.

At the point of the transcript as posted (i f I rememberit correctly) the aircraft was effecting a turn onto 05R and still outside the capture zone.

The primary means for runway identification are the pilots’ normal visual cues, hence the crew thinking they have the correct runway in sight continue to maintain the primary visual cues of the (wrong) runway and disregarded the shuttled PVD

Personally , I felt that the implementation of the Boeing’s GPS based “Take-off Runway Disagree Alerting Function” device and moving map display system to assist the flight crew would be much welcome by pilots and provided another layer of defence to old "Murphy's Law"

Nonetheless, the responsibilities of utilising these devices still rest with a well co-ordinated crew and hence I agreed with Gladiator that CRM training is vital onboard any aircraft.

The NTSB investigation into UPS 896 (B757) take-off on a closed runway at Denver International on September 25, 2001, and an American Airlines [AMR] B777 took off on a closed runway at Chicago’s O’Hare airport in January 2000 , clearly illustrated that CRM weakness is a world wide shortcoming and not neccessarily a regional or airline specific concern.

Cheers!

Hawkeye

Traffic

11th Jun 2002, 07:04

It is interesting to speculate how different the two reports would be if the accident had happened at Changi.

I guess this is a real strretch as accidents don't happen on Fantasy Island.

hawkeye18

11th Jun 2002, 07:22

Traffic ,

what did ur insurance comapny tell you??!! If and when u get into a motor accident ? ;)

For that matters what if it happened in New York, London, Bangkok , LA etc. And what would be the reports like?

That is the reason for the ICAO Standard Format on Accident Investigation and Reporting. Hoping that it will enhance/focus on truthful fact finding, to prevent similar accident, instead of degenerating into blame apportioning.

The possibility of air accident is always present as long as there are aircraft flying , no imaginary dreamlands or Fantasy Islands are immuned .... dun let ur imagination run wild! :)

Hawkeye

G.Khan

11th Jun 2002, 07:48

Mole

I was SIA but not for quite a while.

Gladiator has given a precise description of the operation of the PVD.

If 05L at Taipei is not a Cat III runway then PVD can only be advisory as the indications will not have been calibrated.

The SIA Ops. manual that I have access to is now out of date but does state:

"A Takeoff using PVD is not permitted:

When the cross wind exceeds 10kts." -

the crew were well within their remit to ignore it, whether the crew used it or not is irrelevant, it was not a requirement, the weather was outside limits.

I don't think I have been rude to SQ6 Survivor at all - please re-read.

Can't remember the EPR settings now but they would have been doing a full PW4056 take-off with no derate in those wx conditions. They were relatively light.

SQ6 Survivor

11th Jun 2002, 17:20

Gentlemen,

Since my motives have been questioned, perhaps I should clarify the reasons why I signed up to Pprune and started asking uncomfortable questions. First let me dispel the wild speculation:

For all SIA sycophants and sympathizers on this thread, I am NOT on this list to gather facts for litigation, and any idea that information from a chat list could be used in court is, by the way, utterly ridiculous. Nor am I here to obtain sympathy (I escaped physically uninjured).

And, as far as the question of how a non-pilot is qualified to offer an opinion on an airline accident, well, all accident investigations employ the scientific method to discover what happened and why. They establish the facts and draw conclusions from them. As a scientist, this is my bread and butter. Each working day I look at facts, scientific arguments and the resulting claims and ask are the facts reliable and relevant, is the quality of the reasoning satisfactory and are the claims valid. This is what I did with the ASC and MOT reports.

So why am I doing this, and why am I asking questions on Pprune?
1. All of the injured survivors I know are either extremely angry with SIA for various understandable reasons, or want to forget about their terrible ordeal and get on with the rest of their lives. Neither of these groups are consequently interested in reading accident reports and trying to understand why it happened or, if they are, their anger presents an unsurmountable barrier to objectivity. I bear no malice toward SIA because they are, in my opinion, the same as any other airline and subject to the same failings. In other words I'm assuming that their failings represent an industry-wide failing (since I have no reason to believe that they are unrepresentative of that industry). Also, being uninjured allows me to revisit the accident with the less mental distress than most. As a result, I was the only one who remained objective and was willing to read and clarify the cause of this accident. My personal motive? I think the families of the dead deserve to know in basic terms why this accident happened, who or what was to blame, and that it won't happen again. Don't you?

2. After reading both reports I was extremely dissatified, as were other survivors, with the lack of clear conclusions on the ASC's part and the obvious attempt by the MOT to muddy the waters even further and absolve themselves of responsibility. So in consultation with my fellow survivors, I suggested that we summarize the reports for the families of the dead so they could understand the arguments raised by both sides. I also suggested that we make our own analysis of the arguments in an attempt to provide some conclusions on who or what was at fault and therefore provide some closure for the victims families. Both these efforts are available on our web site and I have invited you all to point out errors in our arguments.

So my motive for asking questions on Pprune is that I want to know if:
a. other pilots accept our conclusion on the fundamental cause (ie. the Pilot did not read his Jepp and guessed his position)
b. the pilots in other airlines are suseptable to the same mistakes (ie. do you all rely on lights and signs under low viz and forget to check the map?)
c. testing low-viz taxi in unfamiliar aerodromes using the simulators would improve ground accident stats (ie to renew pilot certification you would have to pass a low-viz taxi routine in the simulator)

I guess I should not be suprised that the first question would draw in SIA and/or pilot sympathizers who either towed the party line or refused to accept the failing (ie. Belgique, “sucker trap” and “systematic failings accross a broad spectrum”; Hawkeye18, navigational error induced by poor weather, inadequate ground conditions etc; HugMonster, “environmental capture elements”, G.Khan “My Learned Friends" won't allow it”). For those aforementioned, consider another question: for how long have the signs, markings and lights leading to 05L been bad at CKS and how many aircraft have mistakenly taken off on 05R during that time? The answer is NONE. Yes some NEARLY did, but MOST did not. Even on the same night, under identical conditions, other pilots were not drawn in to the “trap”. Now ask yourself WHY Foong was the first.

Captain Stable

11th Jun 2002, 18:23

SQ6, you need to accept that there are quite a few experts in aviation safety here. Some are investigation specialists, some experts in aviation medicine and pharmacology, some physiology, some psychology, some materials and design, etc. etc.

The one thing that (I am sure) all will agree upon is that there is never one single, simple cause of any accident. You appear to dismiss all who disagree with you as "SIA Sympathisers". This is not what I am reading, however. Many have tried to persuade you to see that, while the crew on that ill-fated flight made an error, there were all sorts of reasons why that error was made. This is the "sucker trap". You need to examine the psychology of it.

Put anyone in a stressful situation, pile on the pressure from all sorts of sources, hassle them. Keep it up for the duration of their career. Sooner or later they will make a mistake. You cannot then justifiably leap on them saying "AHA! Gotcha!"

You appear to wish to continue in blaming Capt. Foong solely for the crash. Apart from the fact that you will be very unlikely to get much support on a Pilots' Forum for such a view, to make such a claim stick you would have to provide the sort of proof that he was criminally negligent to the point that he did not care if he was killed or not.

As for your question about those who nearly took off on 05R and why Capt. Foong was the first... Are you 100% sure of that?

Further, are you aware of the "Swiss Cheese" model of incident and accident causation? If not, I suggest you do a little more research.

SQ6 Survivor

11th Jun 2002, 20:08

Indeed, as you point out my task is a difficult one. I'm trying because pilots are highly trained professionals capable of critical thinking and therefore can judge the facts for themselves. And when one makes a mistake, they can admit it and take stock (see Moles comments).

And of course I realize that Pprune is a microcosm of the aviation industry and all sorts of experts are listening. However, in my profession, everyone is an 'expert' and yet science is still littered with blunders, some which also cost lives. Moral of the story: being an expert is not carte blanche for clear thinking. Many scientists and experts are so wrapped up in their own little world that they can't see the wood for the trees. So forgive me if I don't bow down in face of the 'expert' opinion.

Clearly, you accept the 'swiss cheese model' and believe that there is "never one single, simple cause". You perhaps accept that model because it is preached by an industry where absolute blame is an anathema for legal and PR reasons. (Who wants to fly with an airline who admits that one of their pilots was to blame that for a horrific crash where many died?). But you must also realize that although 'models' are useful and designed to guide us in complex analyses, you cannot shoe-horn ALL accident analyses into these models. There ARE accidents caused by "single and simple causes". And by the same token, there are others where many holes line up and the unlucky pilot finds himself in the wrong place at the wrong time. My contention is that SQ6 was not one of these unlucky accidents. In fact, as far as I can see only 3 holes lined up: the weather was ****ty, the ground conditions were poor, and the pilot was sloppy or stressed or both. Given that the first two conditions are common shouldn't we ask if the third is true also?

So, as far as me wishing to "continue blaming Capt. Fong" in the face of 'expert' comment on this thread, I am not wishing anything of the sort. I am guided by the facts and if one of you can provide me with an acceptable explanation as to why Capt. Foong made a 180 degree turn when only a 90 degree turn was shown on the Jeppsen then I will gladly accept that it was not his fault. And I am not, repeat NOT, trying to proove that his is criminally negligent. My only accusation is that he got into some bad habits on the ground which, from the discussion so far and the stats on r/w incursions, seem to be a common problem in the cockpit.

Am I 100% sure that nobody before Foong took off from 05R while it was a taxiway? Well, that fact is reported by the ASC including all experts involved in the investigation (NTSB, ATSB etc). Although I might question their arguments and conclusions, I am in no position to verify their facts. So, I have no choice but to accept this particular fact as fact.

Captain Stable

11th Jun 2002, 21:49

Only three factors? I would strongly disagree. So have many other contributors here, who have pointed out a lot of others, which you appear to have discounted, and stuck to the one you hold before you like a beacon, lighting your way - that Capt. Foong failed in his duty.

Nobody is denying he did. But sole blame is not to be laid at his door, and I don't know of any court that would do so.

I fear you are flogging a dead horse here. You may discount the opinion of experts. Courts do not do so. In fact, they pay for the opinions of expert witnesses.

Your thesis is, in my opinion, over-simplified. Yes, we'd all like life to be simple. It rarely is.

What was the cause of the Kegworth BM 737 crash? The crew shut down the wrong engine, having misidentified which one had failed. There were, however, a host of other factors - training of pilots, company SOPs, engine design, testing of new engines, flightdeck to cabin communications and vice versa, ATC procedures, "environmental capture", CRM, etc. etc. etc.

Because Capt. Foong was the first to fall fatally into the trap that had been set did not mean there was not an accident waiting to happen for some time. Others were lucky.

A pilot will underperform if he is fatigued or had worries at home, or is concerned about a medical coming up or questions about a medical just gone, or for a hundred other reasons. I don't know, and you can't tell me you know Capt. Foong was clear of any such worries. A normally perfectly competent captain will probably not be challenged on an error by a reticent FO, and this is even less likely in the Far East. Give the same captain a more proactive, thrusting FO, and the accident doesn't happen. Have a different captain and it doesn't happen.

People make mistakes. Get used to it. Unless you expect a pilot to give 100% every time, all the time throughout his career? Impossible. Just sometimes the other circumstances are wrong, and he's unlucky. So, tragically, were those who died. But the purpose of accident investigation is not to pin blame. If it were, nobody would ever fly for a living, for fear of the civil lawsuits later. Its purpose is to identify what led the people concerned to make those mistakes, and remove those factors in the future.

SQ6 Survivor

12th Jun 2002, 01:39

Lets agree to disagree on how many factors were involved. I have laid bare my argument, you and others disagree and feel it's oversimplified. Fine. I disagree with these views because they ignore my basic point and they are all factors that were faced by every other pilot who took off from 05L at night under poor viz. So in absence of agreement, let's move on.

We both agree he made a mistake. Fine. You tell me people make mistakes, sh*t happens, get used to it, and don't expect the investigation to blame him. Fine. So lets forget about blame for the sake of those worried about litigation and concentrate on what led him to make the mistake. This forum is not a court so we can discuss it openly and objectively. Right? You argue your points and show how mine don't jibe with the facts and I'll reciprocate.

Questions: was Capt. Foong guessing his position that night rather than following sops and navigating, and was this due to bad habits that he and other pilots develop over time? In other words, are pilots in other airlines suseptable to the same mistakes? Do they rely too much on lights and signs under low viz and minimize instruments and maps? Is this a major contributory factor in the alarming rise in ground accidents? If they do and it is, could testing and certification in low-viz taxi procedures in unfamiliar aerodromes using the simulators improve the situation?

rehkram

12th Jun 2002, 05:24

I haven't seen 'perceptual narrowing' mentioned as a primary factor except by general implication.

...perceptual narrowing being the mental phenomenon that can occur in situations of fast diminishing envelope, exascerbated by perceived need to hurry. Negative spiral ensues if not recognised immediately.

Symptoms are a porthole effect, over reliance on familiar action before thought, mild panic. Usual advice once recognised is stop, breathe, think, act.

Surely SQ006 is a classic case, pure and simple? No blame. my respects to all concerned.

Edited to insert 'stop' before 'breathe'

hawkeye18

12th Jun 2002, 14:19

Rehkram,

This might provide a clue as to why your point on " perceptual narrowing " and that of CRM was seldom featured and mentioned in the ASC reports .

ASC commissioned an independent investigation team from Wayne State University to conduct an analysis of the CVR obtained on SQ 006.

The study used an analysis technique termed ‘linguistic discourse analysis’. This independent analysis showed no evidence of any external pressures affecting the performance of the crews.

The findings of the linguistic discourse analysis were examined and studied by the ASC .

Below is the concluding summary of the CVR analysis team :

Overall, the impression of the SQ 006 crew is that they are professional and they work well together as a team. The frequent latchings of utterances of the Captain and the First Officer indicate that they are in tune with each other, they are able to predict the length of each other’s utterances in talk and to respond immediately, both in talk directed by procedure and in other talk as well. The ability of the First Officer to directly correct the Captain, and the Captain to directly correct the First Officer, with added anecdote for softening, both speak to a relationship without stress. This in no way suggests equality, for the authority of the Captain is clear throughout. But the comfort with which they interact shows just that. The relationship is clear. The relationship of the Captain and the Relief Pilot is also clear with the Relief Pilot assisting in monitoring the changing wind and visibility conditions. The relationship of the First Officer and the Relief Pilot is less comfortable. They interact much less frequently than the other dyads (Captain & First Officer, Captain & Relief Pilot). There is a certain formality from the First Officer in responding to comments by the Relief Pilot regarding the pitot and the PVD. ’

The linguistic discourse analysis showed that, in considering the amount of verbal interaction between the crew members, and excluding interaction with others, such as ATC, the percentage of intonation units spoken by each crew member was as follows:

Captain: 49%

First Officer: 39%

Relief Pilot: 12%

Total: 100%

The analysis commented that the above distribution appears appropriate"

I believe the full report of this analysis was also available to the Singpapore MOT analysis team ...as it was refered to a couple of times on the CRM aspects within the MOT report.

Cheers!

Hawkeye

Gladiator

12th Jun 2002, 17:10

SQ6 survivor,

I thought you would have figured it out by now. Put any airport anywhere in the world under a microscope and an improvement would surface.

However, SQ006 is as clear as day. To my opinion here are 7 slices of swiss cheese.

1) SIA's culture of, 'must go' and 'must be on time'.
2) SIA's culture of, 'we are (were) the best and therefore invincible'.
3) SIA's lack of culture of, 'if you do not feel comfortable, don't go'.
4) Bad visibility.
5) Non assertive first officer.
6) Decision to go (bad judgment by the Captain due to fear of having to answer to the chief pilot)
7) Bad CRM (Fear of losing face. Captain would not imagine going half way to the runway and realize, may be this is not such a good idea).

Here is an example of a simple PA (public address) that would have saved lives. Such PA however WOULD NOT be imaginable on an SIA flight.

"Ladies and Gents, this is your Captain, the weather has further deteriorated and for your safety we have decided to return to the gate, sorry for any inconvenience ......"

The issue of 180 degree turn comes long after the holes had already lined up. Given the weather conditions, in the back of his mind the Captain most probably knew he had no business being there.

May be unsure, may be a little scared, anxious, may be confused, slightly disoriented, he was like being stuck in a dark cave gasping for air.

Seeing runway 05R was like seeing a light in that dark cave, he ran to the light in the dark (took 05R) without the tought that it may be dangerous to run in the dark specially in a cave. Unfortunately caves have holes in the ground (taxi in very low visibility) and he fell into one of them.

rehkram

12th Jun 2002, 20:25

Thank you hawkeye18 that does explain a lot. I have to wonder whether linguistic discourse analysis would be able to reveal all the guys were feeling and thinking, but it's the best we've got.

Gladiator, your 'dark cave' analogy is quite compelling and incidentally describes the experience of perceptual narrowing to a 'T'. I will now butt out, thank you for your consideration.

SQ6 Survivor

13th Jun 2002, 01:05

Yes, everybody seems to have their own pet theory.

Do I think that CM was a problem here? Maybe.
But is there any evidence for it contributing to this accident? Well, loath as I am for doing so, I have to agree with my good friend Hawkeye18 and reiterate that the ASC report found no evidence to support this. And it does look like they tried to assess CM from the LDA.

I accept that you have you have first hand experience of the SIA 'culture' and that such an environment cannot be good in terms of safety. Unfortunately it takes a hell of a lot of work to remove a cultural trait but it's relatively easy to test skills. My feeling is that inadequacies in CM and ground navigation could easily be exposed in the simulator.

Finally, I think there is more evidence in the ASC report to support the 'perceptual narrowing' idea from rehkram. I'll look into it.

AtlPax

13th Jun 2002, 04:41

I still feel the airport should have marked the closed runway a little bit more obviously.

23:15:50 CAM-2 OK green lights are here
23:15:52 CAM-1 It going to be very slippery I am going to slow down a bit, slow turn here
23:15:53 CAM-2 Turning that
23:16:07 CAM-2 And the PVD hasn't lined up ah
23:16:10 CAM-1 Yeah we gotta line up first
23:16:12 CAM-3 We need forty five degrees
23:16:15 CAM-2 I see, excellent man
23:16:16 CAM-1 Yah
23:16:23 CAM-1 Not on yet er PVD huh never mind we can see the runway, not so bad. Ok, I am going to put it to high first. OK ready eh, so zero one zero is from the left lah Ok
23:16:27 CAM-2 Ok

"Hey! What's that big blinking "X" there ahead? Wait! Is this the R/W we're supposed to be on? Hold on a sec . . . "

hawkeye18

13th Jun 2002, 06:45

Closed Runway Markings: ASC: Closure was temporary , no actions was require!!!

ASC:"There is ambiguity in ICAO Annex 14 Standards and recommended Practices (SARPs) regarding a temporarily closed runway because the term “short term” is not defined. "

The above analysis in ASC report which classified the work on 05R and closure as temporary in nature, hence no requirement to conform to the SARPs is pathetic.... as the following evidences show:

NOTAMs and company Internal Notices to Airmen (INTAMs).

1. NOTAM A0606, issued on 31 August 2000, advised that a portion of Runway 05R was closed due to works in progress from 13 September 2000 to 22 November 2000. (more than 30 days)

2. The INTAM, taken directly from the CAA Taiwan AIP Supplement A007 C015/00 dated 3 October 2000, stated that the Runway 05R would be redesignated as a taxiway with effect from 1700 UTC on 1 November 2000 and that the runway markings would be changed to taxiway markings.

3. NOTAM A0740 dated 23 October 2000 stated that the re-designation of Runway 05R to Taxiway NC had been postponed until further notice.

and

MInutes of ‘CKS Aerodrome Engineering Group’

On 17 October 2000, a meeting to discuss the proposed re-designation of Runway 05R/23L at CKS airport toTaxiway NC, with effect from 1700 UTC on 1 November 2000 was conducted, the minutes of the meeting stated:

‘"Regarding the conversion of secondary Runway 05R/23L to a taxiway, our group hopes that Flight Services HQ and CKS Airport will change the signages and the runway surface markings to taxiway surface markings. On completion of the change, we will request Flight Control Unit to issue an AIP Supplement. "

Runway 05R was therefore permanently closed as an operational runway for all intent and purposes. It has not being used for that purpose(takeoff) for at least 10-12 years( my recollection) and it was not close for a period of ‘short duration’ as a runway.

It should have been clearly demarcated with closure markers, and the runway designation marking and threshold markings and lighting removed. :(

A slice of the swiss cheese in place.!

Hawkeye

hawkeye18

13th Jun 2002, 13:01

First Lucky Miss -- 23 October 2000

The captain of a freighter aircraft almost turned his aircraft onto Runway 05R instead of Runway 05L.

The following is a summary of an interview with the pilot concerned conducted at the ASC office on 5 July 2001 by ASC investigators, together with advisers from NTSB, ATSB, MOT and CAA Taiwan:

i) The captain had flown into CKS Airport from Subic Bay three or four times per month. Usually he would depart from Taipei in the evening 15 minutes after SQ 006. He estimated that he had flown into CKS Airport about 200 times in the past five years. He normally used Runway 05L in operations and therefore was thoroughly familiar with the northern Runway 05 configuration and movement areas.

ii) About a week before the SQ 006 accident, he was making a routine flight back to Subic Bay, departing at night. He had been given clearance to taxi for a take-off on Runway 05L. The taxi route was to proceed via Taxiway NS (the northern extension of Runway 05R) to back taxi along Runway 05R, turn left onto Taxiway N6, then turn right onto Taxiway NP, and proceed along Taxiway NP to turn onto Taxiway N1 for Runway 05L. The weather that evening was rainy with some wind, and the Captain pointed out that he had to use his windshield wipers.

iii) As he taxied along Runway 05R prior to Taxiway N6, he noticed that the centreline and edge lights of Runway 05R were both lit up in the direction of the runway threshold, as well as at the end of the Runway 05R. While on Taxiway NP, prior to reaching N2, he received take-off clearance, and so he instructed the First officer to complete the pre-takeoff checks. He recalled that as these checks were being carried out, he was looking in and out of the cockpit while he taxied the aircraft onto Taxiway NI. He recalled that he felt strongly compelled to turn onto Runway 05R as the active runway for the following reasons:

• Runway 05R was brightly lit with both centreline and edge lights;

• he could not see the Runway 05L runway lights clearly because they were partly obscured by the bright lights on RW 05R, and the rain;

• he could not see the barriers demarcating the works in progress area, nor the lights on the barriers, further down Runway 05R;

• the visibility from the cockpit was degraded due to the rain;

• the centreline lights on Taxiway NI which led onto Runway 05R;

• there were no cross markings at the Runway 05R threshold to indicate that the runway was closed.

iv) As a result of these compelling factors, he had to consciously reject his first impression that Runway 05R was the active runway. He had then remarked to his First Officer that for a ‘hot second’ he thought that Runway 05R was the active Runway 05L.

v) The captain said that pilots develop, and operate with, a series of complex behaviour patterns, standard operating procedures (SOPs) and checklists. Therefore, when he was presented with all the evidence to suggest that Runway 05R was the active runway, and he had been cleared to take off, it took additional willpower to reject the cues and continue further down Taxiway N1 to reach Runway 05L. He did not recall seeing the Runway 05R threshold lights, as he was concentrating on the runway lights.

vi) When he taxied further along Taxiway N1 he did not recall seeing the centreline lights of Taxiway N1 leading towards Runway 05L. He did see the blue Taxiway N1 taxiway edge lights. On proceeding further along Taxiway N1, he then saw the Cat II signboard, runway lights and touchdown zone lights of Runway 05L.

vii) He was able to reject the ‘compelling information’ which had drawn him to almost turn onto Runway 05R, because he had ‘paused to think’. He then became aware of some conflicts with what he had expected to see on approaching the take-off runway, that is, Runway 05L. These were that Runway 05R was too narrow; there were no touchdown zone lights; and he realised that the centreline lights were green instead of white in colour.

viii) The captain commented during interviews that it was common practice in the USA for ATC to clear aircraft when they are required to taxi across runways. Under this practice, ATC instructions at CKS Airport would have included a clearance to taxi across Runway 05R when proceeding to Runway 05L.

ix) He stated he could understand that, when presented with the compelling information that he had encountered on that night, there could be a strong tendency for pilots to mistake Runway 05R for Runway 05L.

x) The captain commented that in current two-pilot cockpits, when the first officer is completing the final items on the before take-off checklist, his attention is primarily focused inside the cockpit. As a result, unless the first officer detects the mistake prior to the captain calling for the final items on the checklist, the ‘chances are nil’ that he would notice the error after that time. This is because the next phase of operations would require the non-flying pilot to recheck the power settings and to monitor engine parameters, while making airspeed call-outs.

He was lucky having the benefit of local knowledge of CKS Airport, having flown into CKS Airport approximately 200 times in the last five years. His local knowledge stop himself from mistakenly taking off from Runway 05R instead of Runway 05L.

2nd Miss.... 30 October 2000

i) There was a similar occurrence less than 24 hours before the accident to SQ 006, when it was reported that both the edge and centreline lights of Runway 05R had been simultaneously illuminated.

ii) The pilot involved in this occurrence reported that he had nearly mistaken Runway 05R for Runway 05L. In his words he ‘almost did the same thing’ as the pilot a week earlier.

And God knows how many other unreported misses, and possibly even successfully takeoffs from 05R over the years, without even realising the error by both pilots and ATC!!!

Frightening isn't it !!!!!!!!

Hawkeye

HotDog

13th Jun 2002, 14:34

vii) He was able to reject the ‘compelling information’ which had drawn him to almost turn onto Runway 05R, because he had ‘paused to think’. He then became aware of some conflicts with what he had expected to see on approaching the take-off runway, that is, Runway 05L. These were that Runway 05R was too narrow; there were no touchdown zone lights; and he realised that the centreline lights were green instead of white in colour.

The captain commented during interviews that it was common practice in the USA for ATC to clear aircraft when they are required to taxi across runways. Under this practice, ATC instructions at CKS Airport would have included a clearance to taxi across Runway 05R when proceeding to Runway 05L..

23:15:50 CAM-2 OK green lights are here
Why didn't he get clearance to cross 05R? Because it was not a runway. It was a taxyway, as notamed.

hawkeye18

13th Jun 2002, 16:33

If I have to choose my piece of cheese :

The mother of all cheese and with the biggest hole was the non- conformance of CSK 05R to ICAO Annex 14 SARPs , the requirement for a closed runway.... .

The non conformance of the above to the ICAO requirement was the cause for having to call on all other pieces of cheese to be lineup and tested, when the aircraft turn from NP onto N1.

If all the ICAO requirements were in place at 05R:

1. The missing Jeppesen Yellow page supplement for CKS Airport on 05R CKS on SQ006 crews’ Jeppesen chart will remain missing with no one in CKS nor CAA Taiwan the wiser.

2. The CKS Airport ATC procedures in ATP-88 (paragraph 3-1-7) require the air traffic controllers to ‘determine the position of an aircraft before issuing take-off clearances’, will not be call upon to be tested and failed.

3. The crew will not be call upon to be tested on their skill on the 05R trap and failed. They would have been given zero chance to lineup on 05R by those implements under ICAO Annex 14 SARPs . And all the lost lives will be still living.

4. The question of crew competency, training for low vis taxing will not arise, so weree other related area pertaining to SIA/ MOT and CKS / CAA Taiwan.

5. The question of whether 05R edge light was on or off would be irrelevant. And CKS will happily continue to operate the way it was, with officials sitting on their fat bums collecting pay doing little.

6 The missing line, lights signages on N1 leading to 05L as require under ICAO will remain missing and aircrews operating from it not caring 2 hoots of its absent.

7. CKS/CAA Taiwan would continue to hide behind the we- are- not- in ICAO bush while operating deficient system ......but accepting and modifying ICAO standard when it is convenient and suits them.

8. This topic and all of us should not be here! :D

A superior pilot is one who use his superior judgment to prevent situations that require the use of his superior skills!!

Similarly, A superior airport management, syetem , support groups using their superior judgments to prevent those superior pilots from having to use their superior skills is required to maintain them in superior condition, for the safety of aircraft and passengers!

Take care friends!

Hawkeye

SQ6 Survivor

13th Jun 2002, 21:01

Looks like several others thought the Pilot may have been affected by perceptual narrowing too. Here's a reasonable definition, and a remarkably perceptive story of how it relates to SQ6.

Perceptual narrowing or tunnel vision: Overwhelming anxiety tends to cause an individual to focus inwardly and thus away from the task at hand. This overly anxious state can lead to the cognitive and perceptual narrowing where the individuals attention shifts onto a specific task causing him to overlook critical elements.

RUSHING TO DIE: The crash of Singapore Airlines Flight 006
Robert J. Boser, Editor-in-Chief, AirlineSafety.Com

Now that it is clear that the tragic crash of SQ flight 006 at Taipei airport was caused by the captain’s attempting to takeoff on a runway that was closed, dark and under construction, the question is, how could he have made such an egregious error?

My immediate answer is: A severe case of tunnel vision.

Tunnel vision is a phrase pilots and accident investigators have used for many years to describe a pilot’s mental state, which apparently focuses on a single goal or outcome with such intensity, that other important information is blocked out of the mental process. Such blocked-out information can sometimes be crucial to a safe operation, as this accident proves once again.

While we will have to wait for the findings and conclusions of the official accident report, to fully appreciate all factors that contributed to such a fatal error, it is already apparent why tunnel vision might have occurred.

All airliners have safety crosswind limits for both takeoff and landings. The eye of Typhoon Xangsane was moving toward the Taipei airport and producing winds up to 90 mph. The reported winds and visibility at the airport were still below the plane’s safety limits, when it pushed back from the gate. But, as time elapsed, the winds were bound to increase as the eye of the storm moved closer.

The captain knew the longer it took them to taxi out and takeoff, the more likely it was that those winds might reach or exceed the airplane’s safety limits. If that happened before he commenced the takeoff roll, he would be forced to return to the gate. If he did that, it would be many hours before they would be able to safely depart Taiwan. It probably would have required passengers and crew to go to hotels for many hours because the legal duty times of the flight crew would be exceeded. All that would cost Singapore Airlines a lot of money and would probably produce hostility among many passengers who deemed it imperative to arrive at their destination on time.

Thoughts like that were likely paramount in the captain’s mind and the key to why he failed to see the “red flags” all around him as he moved from the gate to the takeoff roll.

RED FLAGS:
(1) Taxi chart warning:
The TPE airport pilot information chart has the cryptic warning, for pilots encountering limited visibility conditions, as did the pilots of SQ 006:
"When runway 05R/23L is used as a taxiway, the green centerline lights are illuminated. When it is used as a runway, both the green centerline lights and the white runway edge lights are illuminated. Exercise extreme caution during periods of reduced visibility when taxiing to, from or on runway 05R/23L and runway 05L/23R. Ensure proper taxiway/runway identification before proceeding."

(2) Runway Lighting System:
The correct runway (05L), had high intensity white lights (HIRL) marking both edges of that runway and also white centerline lights, turned on for the full length. Both those edge and centerline lights were required for takeoff and landings after dark and, additionally, because of the very limited visibility. And, the touchdown zone lights (TDZ) would also be visible, to any pilot lining up on runway 05L for takeoff.

The wrong runway (05R), where SQ 006 crashed, should have had only green centerline lights turned on, indicating to all pilots it was being used solely as a taxiway, not a runway. The white edge lights, should not have been turned on, and there were no TDZ lights. Investigators are attempting to determine if the tower had turned on the white runway edge lights for runway 05R. If tower personnel had made the mistake of turning on those white edge lights, then that would be considered a contributing factor in reinforcing the captain's belief that he was lined up on runway 05L. However, NBC news interviewed one lady who survived the crash without significant injury. She stated she enjoyed night takeoffs because she loved to watch the runway edge lights speed by as the takeoff roll accelerated. But, she didn't see any such lights this time; it was dark as she looked out her window while the plane raced down the runway, prior to impact.

(3) Approach Lighting System (ALS):
Since the active runway (05L), was in use for both landing and departing aircraft, the approach lighting system for that runway would have been visible (it's very bright and can penetrate fog) to the captain of SQ 006, out his left cockpit window as he made a right turn onto what he thought was runway 05L. But, he would not have seen any ALS lights, for the runway he selected, because none was installed on the approach to runway 05R. That runway can be used only for landings in visual conditions and only with special permission (usually for smaller aircraft).

(4) Runway Number Designations:
Both runways were properly marked with very large white numbers painted on the surface at the end. SQ Flight 006 had to taxi over the numbers that read “05R” to begin its fatal takeoff roll. Those numbers could be clearly read by the pilots as they were illuminated with the taxi headlights on that 747-400. [But, see question "e" below in REVISIONS section.]

(5) Notams:
The flight papers, that provided all the necessary information to plan and conduct that flight, included the notification to airmen that runway 05R was closed for construction work and that only a portion of it could be used for taxi purposes. The captain planned for and knew that he was required to use runway 05L for takeoff. [However, see REVISIONS section below]

Yet, with all those red flags, all three pilots in that cockpit failed to recognize that the plane was lined up to takeoff on 05R, instead of the planned and required runway, 05L.

HABIT PATTERN:

The captain was highly experienced and had been through the Taipei airport many times before. It is a very common operation, at Taipei, for planes to push back from the gate and then to taxi down runway 23L/05R, on their way for takeoff on runway 05L. It is likely those pilots had done so numerous times before. When that procedure is followed, the plane makes a right turn off of the end of 23L, at taxiway N1, and then stops short of 05L until cleared to taxi onto 05L. Most importantly, when that common taxi procedure is followed (using 23L as a taxiway, as opposed to using it as a runway), the plane does not have to cross any other runway before arriving at runway 05L.

But if, after pushing back from the gate, they taxied down the NP taxiway (sometimes called the "ramp" taxiway), instead of down runway 23L, and if the minds' of the captain and the two first officers were highly preoccupied with the deteriorating weather while also calculating the crosswind component -- to determine if the wind was still below the safety crosswind limit of that 747-400 -- then they might have mentally reverted to the habit pattern of taxiing down 23L. If so, then they subconsciously expected to turn right off that taxiway and then make another immediate right turn into the takeoff position on runway 05L. In other words, their common previous experience, at the Taipei Airport, might have overruled their awareness that they were following a different taxi route than normal and that they had to first cross runway 05R, before they would be in position to turn right onto runway 05L

Read the rest of this article on their website, AirlineSafety.Com

OldAce999

19th Jun 2002, 07:35

Just my 2cents here:

Not many pilots carry their own airport charts of the airport they are operating and give themselves a self-brief before the flight. Many rely on the co-pilot to tell them when to turn during ground navigation. No doubt they had a general view of the airport layout but not the nooks and corners.

So when it comes to Runway 05L I had to tell myself and verbally sound it to the rest of the crew "it is the 2nd right turn after the turn into N1" on a dark and stormy night.

It was mentioned somewhere that the Captain had only operated 9 flights out of CKS Taipei. (Correct me if I'm wrong here) and all of them are out of Runway 06. From the CVR transcript the Captain is not fully conversant with the runway designations.

23:09:24 CAM-2 Departure routing
23:09:25 CAM-1 Ok ah Taipei runway zero six left huh
23:09:27 CAM-2 Zero five left
23:09:29 CAM-1 Zero five left
23:09:29 CAM-3 Zero five left

He mentioned Runway 06L when there is no such runway in CKS only Runway 05L. This could be a slip of the tongue or unfamiliarity with the airport runways.

His senses could have told him he only made a 90 degree turn after NP unto the Runway 05L when he had actually made 180 degree turn into Runway 05R unless he was actually monitoring the compass heading before the turn. The co-pilot at this time was busy looking inside to prepare for the final take-off checks and not monitoring the Captain's ground maneuver. The 3rd pilot could have been seated too high or too low or could have been monitoring the ATIS to also miss the direction the a/c is turning.

23:14:21 CAM-1 Go right to the end of the runway, end of the runway then turn, ok.
23:14:31 CAM-3 Quite a bit of aileron for the takeoff
23:14:35 CAM-2 OK
23:14:40 CAM-2 The next one
23:14:41 CAM-2 Next one is November one
23:14:42 CAM-1 Ok second right
23:14:44 CAM-2 Second right, that's right
23:14:47 CAM-1 In Australia, to them, next one is this, first one you know
23:14:50 CAM-2 Next one this one
23:14:51 CAM-1 Yah ha ha
23:14:52 CAM-1 Australian
23:14:53 CAM-1 I think the best is to say second right ah first right second right ah
23:14:55 CAM-2 Clearing that Satvoice
23:14:58 CAM-1 Tell them we are ready lah
23:15:02 RDO-2 Singapore six ready.
23:15:04 TWR Singapore six roger, runway zero five left, taxi into position and hold.
23:15:08 RDO-2 Taxi into position and hold, Singapore six
23:15:12 CAM-2 I get them seated ah
23:15:12 CAM-1 Ok below the line please
23:15:15 CAM-2 Cabin crew to your takeoff station thanks
23:15:20 CAM (Sound similar to that of door closing)
23:15:21 CAM (Sound of chime)
23:15:22 TWR Singapore six, runway zero five left, wind zero two zero at two eight, gust to five zero, cleared for takeoff.
23:15:30 RDO-2 Cleared for takeoff, Runway zero five left Singapore six.
23:15:31 CAM-1 OK man
23:15:34 CAM-2 OK checks below the line, cabin announcement complete
23:15:39 CAM-2 Norm
23:15:40 CAM-2 Strobes on, landing lights all on
23:15:44 CAM-2 Takeoff clearance
23:15:45 CAM-1 Obtained hah
23:15:46 CAM-2 Obtained sir
23:15:47 CAM-1 OK thanks
23:15:48 CAM-2 Before takeoff checklist completed
23:15:50 CAM (Sound of click)
23:15:50 CAM-2 OK green lights are here
23:15:52 CAM-1 It going to be very slippery I am going to slow down a bit, slow turn here
23:15:53 CAM-2 Turning that
23:16:07 CAM-2 And the PVD hasn't lined up ah
23:16:10 CAM-1 Yeah we gotta line up first
23:16:12 CAM-3 We need forty five degrees
23:16:15 CAM-2 I see, excellent man
23:16:16 CAM-1 Yah
23:16:23 CAM-1 Not on yet er PVD huh never mind we can see the runway, not so bad. Ok, I am going to put it to high first. OK ready eh, so zero one zero is from the left lah Ok

So it looks like the other 2 pilots were of no help when they are really required when he turned into Runway 05R instead of Runway 05L.

The other factor I would like to bring up is were any of the crew by then had suffered from ground motion sickness. I know my own colleague laughed me off when this was mentioned. After sitting in the cockpit at the ramp for about an hour when the wind outside was gusting from 25-45 kts I got this clammy feeling in the stomach and a floating head on a few of that occasion. Not that I ever get this feeling in the air when even encountering continous turbulence for more than an hour.

I can see here how much more effort the Captain is making with the unfamiliar runway and the poor visibility and not forgetting the a/c swaying and the correction he got to make on the nosewheel steering. Was he suffering from ground motion sickness by then ? This could lapse into "tunnel vision or perceptual narrowing" of the mind and caused the hurried take-off.

runway zero six left

aviator_38

19th Jun 2002, 15:06

Am just wondering:

" 23:14:21 CAM-1 Go right to the end of the runway, end of the runway then turn , ok. "

Could this mean that the Capt had ,for a split moment , thought that they were taxing down the 23L/05R runway ? If so, any taxi lights at the end would lead straight to O5L,hence a continuous turn through 180 degrees ,would appear normal to the subconcious mind.

On the otherhand,the use of the word "runway" may have just been an inadvertent slip.

Cheers

Alpha Leader

21st Jun 2002, 04:25

SIA told to hand over crash data to Nolan Law Group

Report in today's Straits Times on an LA court's ruling forcing SIA to hand over documents relating to SQ6 crash to Chicago-based Nolan Law Group, who represent 44 survivors and families including Singaporeans and SIA crew members, all of whom have refused SIA's compensation offers.

Click here for full online news report (http://straitstimes.asia1.com.sg/singapore/story/0,1870,127396,00.html)

Murrelet

23rd Jun 2002, 00:21

Taiwan probes SQ 006 captain for abandonment

Todays Straits Times

A man who lost his sister in the October 2000 crash files a complaint which prosecutors in Taoyuan are investigating

By Goh Sui Noi
TAIWAN CORRESPONDENT
TAIPEI - Taoyuan prosecutors are investigating the captain of Singapore Airlines Flight SQ 006 that crashed here more than a year ago for abandonment after a relative of a victim lodged a report on Friday.
Mr Chou Yue-tsan, who lost his sister Chou Yue-shun, 44, in the crash, made the complaint at the Taoyuan prosecutors' office because he was unhappy with the decision to suspend prosecution of the aircraft's pilots.
'They should at least have prosecuted the captain, he was the person in charge,' he told The Sunday Times, adding that an investigation report out in April stated clearly that pilot error was the cause of the crash.
An official investigation report by Taiwan's Aviation Safety Council (ASC) blamed the crash on the pilots and bad weather, but Singapore's Ministry of Transport disputed this, citing a combination of factors including deficiencies at Chiang Kai-shek airport.
The aircraft had tried to take off from a partially closed runway in typhoon weather on Oct 31, 2000 and crashed into construction equipment left on the runway.
Mr Chou, whose sister was returning to the US where she lived after attending their mother's 72nd birthday party, had named only Captain Foong Chee Kong in his complaint, as 'the others took instruction from him'.
Spokesman for the Taoyuan prosecutors' office Chiang Kuei-chang yesterday confirmed that the report was being investigated.
He said that under Taiwanese law, in an accident, the person who caused the accident was obliged to help the victim if the latter's life was in danger.
Failure to do so will be tantamount to abandonment, which is a crime.
He added that the prosecutors' office would investigate the case, and that it would take about half a month to a month.
The ASC report, which also dealt with survival factors of the crash, would be used as reference.
Whether the pilots would be recalled for questioning depended on the preliminary investigation.
Prosecutors investigating the pilots for possible negligence in the crash had earlier this month decided to suspend for three years prosecution of Captain Foong Chee Kong and First Officer Latiff Cyrano, given mitigating factors such as bad weather and the two's excellent flight record.
They would face prosecution if they commit any crime in Taiwan within the three years.
Otherwise, the case would be closed after that period.
They were also banned from flying civilian airliners into Taiwan for one year.
First Officer Ng Kheng Leng was cleared of all charges as he was not at the controls during the crash.