SQ006 final report out 26/4/02
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Taiwanese report will be at www.asc.gov.tw
It is scheduled for release at 11 p.m. PST
SIA alternative report will be at www.sq006.gov.sg
It will be released at 1.30 a.m. PST
It is scheduled for release at 11 p.m. PST
SIA alternative report will be at www.sq006.gov.sg
It will be released at 1.30 a.m. PST
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Not surprisingly, regional media reports ahead of the release have already indicated that there will be "no direct apportioning of blame" in the official report.
So what's the whole point of the report?
So what's the whole point of the report?
Last edited by Alpha Leader; 26th Apr 2002 at 08:31.
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Pilot blamed for Taiwan runway crash
The aircraft was packed with fuel
Pilot error and bad weather were the most probable causes of the crash in October 2000 of a Singapore Airlines jumbo jet in Taiwan, according to the final investigation report.
The airplane had tried to take off on the wrong runway in Taipei and slammed into construction equipment before bursting into flames.
Eighty-three people lost their lives in the accident at Chiang Kai-shek airport, which happened during a typhoon.
The report also found that confusing runway markers and broken taxiway lights created a risk for the pilots in the Los Angeles-bound Flight SQ006.
Taiwan's Aviation Safety Council said in a statement: "The flight crew did not review the taxi route in a manner sufficient to ensure they all understood" they were taking off on the correct runway.
The runway they were using had been partially closed for repair and was littered with equipment.
The report said the pilots had failed to realise they were on the wrong runway despite at least 10 opportunities en route to spot their mistake.
They had even been warned in a pre-flight briefing that a runway next to the one they were supposed to take off from was out of use, the report said
Ninety-six people survived the crash including the captain and two other flight deck crew.
More at
Airline News
Pilot error and bad weather were the most probable causes of the crash in October 2000 of a Singapore Airlines jumbo jet in Taiwan, according to the final investigation report.
The airplane had tried to take off on the wrong runway in Taipei and slammed into construction equipment before bursting into flames.
Eighty-three people lost their lives in the accident at Chiang Kai-shek airport, which happened during a typhoon.
The report also found that confusing runway markers and broken taxiway lights created a risk for the pilots in the Los Angeles-bound Flight SQ006.
Taiwan's Aviation Safety Council said in a statement: "The flight crew did not review the taxi route in a manner sufficient to ensure they all understood" they were taking off on the correct runway.
The runway they were using had been partially closed for repair and was littered with equipment.
The report said the pilots had failed to realise they were on the wrong runway despite at least 10 opportunities en route to spot their mistake.
They had even been warned in a pre-flight briefing that a runway next to the one they were supposed to take off from was out of use, the report said
Ninety-six people survived the crash including the captain and two other flight deck crew.
More at
Airline News
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Alpha Leader
I'm not sure if this was a serious question or not, but I'll answer it just in case:
The "whole point" is hopefully to determine what factors contributed to the accident and to initiate changes which will help prevent a recurrence.
Not surprisingly, regional media reports ahead of the release have already indicated that there will be "no direct apportioning of blame" in the official report.
So what's the whole point of the report?
So what's the whole point of the report?
The "whole point" is hopefully to determine what factors contributed to the accident and to initiate changes which will help prevent a recurrence.
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Having just sat through the Channel News Asia broadcast here in Singapore, I am staggered as to what they are telling the public. It would seem they do not agree with the report, yet imply that is was pilot error and at the same time want drill down on the Taiwan's responsibilities.
Having read the summary report which without a doubt is very good and in my mind unbiased as both SIA and the airport authority were brought to task, they just want to brain wash the public here it was all Taipei's fault.
As an erlier post stated, nothing changes and nothing is ever learnt, Singapore is perfect....
Having read the summary report which without a doubt is very good and in my mind unbiased as both SIA and the airport authority were brought to task, they just want to brain wash the public here it was all Taipei's fault.
As an erlier post stated, nothing changes and nothing is ever learnt, Singapore is perfect....
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The Singapore Ministry of Transport has issued its comments and analysis of the events surrounding SQ006,in response to the Draft Final report. Makes interesting reading.
See
http://www.sq006.gov.sg/final_draft/fr_final_draft.htm
Cheers
See
http://www.sq006.gov.sg/final_draft/fr_final_draft.htm
Cheers
Last edited by aviator_38; 26th Apr 2002 at 14:19.
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I’ve spent some time today going through the 508 pages of pdf file of the official report. It includes all the criticisms from Singapore of the draft report, and which show that the Singapore authorities have lost no opportunity to nit pick the detailed findings and conclusions in a way which seems to be designed to disagree rather than to say what the Singaporeans would have said if they had been writing the report. So whilst the report may not have been perfect (and I’m not qualified to judge), I don’t think an unconstructive attack is going to benefit anyone.
Looking at the intro to the official site noted by aviator_38 above, it’s a very clever piece of sophistry designed to deflect the blame away from anything or anyone Singaporean.
I agree with Itman that report brings both SIA and the airport authority to task, and that there were a number of causal factors, the absence of any one of which may have prevented the accident.
Cur
Looking at the intro to the official site noted by aviator_38 above, it’s a very clever piece of sophistry designed to deflect the blame away from anything or anyone Singaporean.
I agree with Itman that report brings both SIA and the airport authority to task, and that there were a number of causal factors, the absence of any one of which may have prevented the accident.
Cur
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Curmudgeon: I too have waded through both the ASC and the Singapore government sites. I agree completely with your opinions on both: the TW investigation is throrough and apportions blame to everyone involved. The Singapore site is, as you say, clever sophistry. This is made particularly apparent when one reads the appendices to the TW report. It is revealing to see the difference between the comments of NTSB and others, which are for the main part in agreement with the report, and then the Singapore response which is nitpicking and carping. It's all just spin for domestic and legal purposes, I guess.
The ASC is to be congratulated for doing a good job.
The ASC is to be congratulated for doing a good job.
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Can anyone who has read the relevant reports clarify the status of the edge lights of O5R on that night? Were they On or Off or unable to be established??
Sorry for taking the easy way out but the reports are looong man.
Sorry for taking the easy way out but the reports are looong man.
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Four Seven Eleven:
Accidents don't just "happen", they are caused by actions of real human beings.
If the point of an accident report is, therefore, to determine what actions contributed to the disaster, then it is axiomatic that the initiators of these actions have to be identified, too.
Accidents don't just "happen", they are caused by actions of real human beings.
If the point of an accident report is, therefore, to determine what actions contributed to the disaster, then it is axiomatic that the initiators of these actions have to be identified, too.
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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
........
......."
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
Last edited by aviator_38; 27th Apr 2002 at 04:45.
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Alpha Leader
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.
Accidents don't just "happen", they are caused by actions of real human beings.
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.
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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.
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.
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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.
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.
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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
All Operators Beware!!! Any accidents in CSK will be yours and yours only, as far as causal factors is concerned!!:o :o :o
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
All Operators Beware!!!
Any accidents in CSK will be yours and yours only, as far as causal factors is concerned!!:o :o :o
Last edited by hawkeye18; 28th Apr 2002 at 07:05.
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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.
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.