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| Title: | Crash on a paritally closed runway during takeoff, Singapore Airlines Flight 006, Boeing 747-400, 9V-SPK, CKS Airport, Taoyuan, Taiwan, October 31, 2000 (Recommended) |
| Micro summary: | A Boeing 747-400 ploughs through construction equipment. |
| Event Time: | 2000-10-31 at 1517 UTC |
| File Name: | 2000-10-31-TW.pdf |
| Publishing Agency: | Aviation Safety Council (ASC) |
| Publishing Country: | Taiwan |
| Report number: | ASC-AAR-02-04-001 |
| Pages: | 508 |
| Site of event: | Chiang Kai-Shek International Airport |
| Departure: | Taipei Chiang Kai Shek International Airport, Taiwan |
| Destination: | Los Angeles International Airport, Los Angeles, California, USA |
| Airplane Type(s): | Boeing 747-400 |
| Flight Phase: | Takeoff |
| Registration(s): | 9V-SPK |
| Operator(s): | Singapore Airlines |
| Type of flight: | Revenue |
| Occupants: | 179 |
| Fatalities: | 89 |
| Serious Injuries: | 71 |
| Minor/Non-Injured: | 25 |
| Other Injuries: | 0 |
| Executive Summary: | On October 31, 2000, at 1517 Coordinated Universal Time (UTC), 2317 Taipei local time, Singapore Airlines (SIA) Flight SQ006, a Boeing 747-400 aircraft, bearing Singapore registration No. 9V-SPK, crashed on a partially closed runway at Chiang Kai-Shek (CKS) International Airport during takeoff. Heavy rain and strong winds from typhoon “Xangsane” prevailed at the time of the accident. SQ006 was on a scheduled passenger flight from CKS Airport, Taoyuan, Taiwan, Republic of China (ROC) to Los Angeles International Airport, Los Angeles, California, USA. The flight departed with 3 flight crewmembers, 17 cabin crewmembers, and 159 passengers aboard. The aircraft was destroyed by its collision with construction equipment and runway construction pits on Runway 05R, and by post crash fire. There were 83 fatalities, including 4 cabin crewmembers and 79 passengers, 39 seriously injured, including 4 cabin crewmembers and 35 passengers, and 32 minor injuries, including 1 flight crewmember, 9 cabin crewmembers and 22 passengers. Findings Related to Probable Causes 1. At the time of the accident, heavy rain and strong winds from typhoon “Xangsane” prevailed. At 2312:02 Taipei local time, the flight crewmembers of SQ006 received Runway Visual Range (RVR) 450 meters on Runway 05L from Automatic Terminal Information Service (ATIS) “Uniform”. At 2315:22 Taipei local time, they received wind direction 020 degrees with a magnitude of 28 knots, gusting to 50 knots, together with the takeoff clearance issued by the local controller. (1.1; 1.7) 2. On August 31, 2000, CAA of ROC issued a Notice to Airmen (NOTAM) A0606 indicating that a portion of the Runway 05R between Taxiway N4 and N5 was closed due to work in progress from September 13 to November 22, 2000. The flight crew of SQ006 was aware of the fact that a portion of Runway 05R was closed, and that Runway 05R was only available for taxi. (1.18.2.6; 2.5.2.1; 2.5.3) 3. The aircraft did not completely pass the Runway 05R threshold marking area and continue to taxi towards Runway 05L for the scheduled takeoff. Instead, it entered Runway 05R and CM-1 commenced the takeoff roll. CM-2 and CM-3 did not question CM-1’s decision to take off. (1.1; 1.18.1.1) 4. The flight crew did not review the taxi route in a manner sufficient to ensure they all understood that the route to Runway 05L included the need for the aircraft to pass Runway 05R, before taxiing onto Runway 05L. (1.18.1.1; 2.5.3) 5. The flight crew had CKS Airport charts available when taxing from the parking bay to the departure runway; however, when the aircraft was turning from Taxiway NP to Taxiway N1 and continued turning onto Runway 05R, none of the flight crewmembers verified the taxi route. As shown on the Jeppesen “20-9” CKS Airport chart, the taxi route to Runway 05L required that the aircraft make a 90-degree right turn from Taxiway NP and then taxi straight ahead on Taxiway N1, rather than making a continuous 180-degree turn onto Runway 05R. Further, none of the flight crewmembers confirmed orally which runway they had entered. (1.18.1.1; 2.5.2.2; 2.5.4.3) CM-1’s expectation that he was approaching the departure runway coupled with the saliency of the lights leading onto Runway 05R resulted in CM-1 allocating most of his attention to these centerline lights. He followed the green taxiway centerline lights and taxied onto Runway 05R. (1.18.1.1; 2.5.7) The moderate time pressure to take off before the inbound typhoon closed in around CKS Airport, and the condition of taking off in a strong crosswind, low visibility, and slippery runway subtly influenced the flight crew’s decision-making ability and the ability to maintain situational awareness. (1.18.1.1; 2.5.6; 2.5.7) On the night of the accident, the information available to the flight crew regarding the orientation of the aircraft on the airport was: • CKS Airport navigation chart • Aircraft heading references • Runway and Taxiway signage and marking • Taxiway N1 centerline lights leading to Runway 05L • Color of the centerline lights (green) on Runway 05R • Runway 05R edge lights most likely not on • Width difference between Runway 05L and Runway 05R • Lighting configuration differences between Runway 05L and Runway 05R • Para-Visual Display (PVD) showing aircraft not properly aligned with the Runway 05L localizer • Primary Flight Display (PFD) information The flight crew lost situational awareness and commenced takeoff from the wrong runway. (1.1; 1.18.1; 2.5) Findings Related to Risk 1. Based on the current ICAO Annex 14 Standards and Recommended Practices (SARPs), the CKS Airport should have placed runway closure markings adjacent to the construction area on Runway 05R; however, there was no requirement to place runway closure markings near the threshold of Runway 05R. (1.10.4.2; 2.3.3) 2. There is ambiguity in ICAO Annex 14 SARPs regarding a temporarily closed runway because the term “short term” is not defined. (1.10.4.2; 2.3.3) 3. ICAO Annex 14 SARPs, regarding a temporarily closed runway that is still used as a taxiway, do not provide adequate information with respect to warning flight crews that the runway is closed for other than taxi operations. (1.10.4.2; 2.3.3) 4. Although there are no clear ICAO regulations for placement of warnings on temporarily closed runways that are also used for taxi operations, the lack of adequate warnings at the entrance to Runway 05R did not provide a potential last defense, from an airport infrastructure perspective, to prevent the flight crew of SQ006 from mistakenly entering Runway 05R. (1.10.4.2; 2.3.3) 5. Based on ICAO SARPs, the barriers placed around the construction area on Runway 05R should have been frangible. However, the concrete barriers were used around the construction area on Runway 05R. (1.10.4.2; 2.3.3) 6. At the time of the accident, there were a number of items of CKS Airport infrastructure that did not meet the level of internationally accepted standards and recommended practices. Appropriate attention given to these items could have enhanced the situational awareness of the flight crew while taxiing to Runway 05L; however, the absence of these enhancements was not deemed sufficient to have caused the loss of situational awareness of the flight crew. Among these items were: • Four days after the accident, the investigation team found that a green centerline light immediately after the Runway 05R entry point along Taxiway N1 leading to Runway 05L was unserviceable and the following light was dim. It could not be determined what the status of those lights was on the night of the accident. (1.10.3.2.4; 2.3.1.2.3) • The green centerline lights leading from Taxiway NP onto Runway 05R were more visible than the Taxiway N1 centerline lights leading toward Runway 05L because they were more densely spaced. There should have been 16 centerline lights spaced 7.5 meters apart along the straight segment of Taxiway N1 where the curved Taxiway centerline marking from Taxiway NP meets Taxiway N1 up to the Runway 05L holding position, rather than 4 centerline lights spaced at 30 meters, 55 meters, 116 meters, and 138 meters. (1.10.3.2.4; 2.3.1.2.2) • Segments of the straight portion of the taxiway centerline marking on Taxiway N1 did not extend all the way down to the Runway 05L threshold marking with interruption stops beginning 12 meters before the Runway 05R threshold marking and ending 12 meters after the Runway 05R threshold marking. (1.10.3.1.2; 2.3.1.1) • Runway guard lights and stop bars were not provided at CKS Airport. (1.10.3.2.2; 1.10.3.2.3; 2.3.2) • Alternate green/yellow taxiway centerline lights to demarcate the limits of the ILS sensitive area were not installed. (1.10.3.2.4) • The mandatory guidance signs installed on the left and right sides of Taxiway N1 were located after the holding position for Runway 05L and not collocated with the runway holding position marking. (1.10.3.1) • There was no interlocking system installed at CKS Airport to preclude the possibility of simultaneous operation of the runway lighting and the taxiway centerline lighting. (1.10.5.1.1; 2.3.1.2.1) • The serviceability monitoring mechanism of the CKS airfield lighting system was accomplished both electronically and manually. However, there was a lack of a continuous monitoring feature of individual lights, or percentage of unserviceable lamps, for any circuit of CKS Airport lighting. (1.10.5.1.2) 7. Airport Surface Detection Equipment (ASDE) is designed to reduce the risk of airport ground operations in low visibility, but there is no ICAO SARPs requiring the installation of ASDE at airports. The Safety Council was not able to determine whether ASDE would have provided information to the Air Traffic Controllers (ATC) about SQ006 taxiing onto the incorrect runway, because signal attenuation from heavy precipitation diminishes the effectiveness of the radar presentation. (1.18.2.4; 2.4.2) 8. There was a lack of a safety oversight mechanism within CAA that could have provided an independent audit/assessment of CKS Airport to ensure that its facilities met internationally accepted safety standards and practices. (1.17.9; 2.3.5.2.1; 2.3.5.3.2; 2.3.6) 9. There was a lack of a specified safety regulation monitoring organization and mechanism within the CAA that resulted in the absence of a mechanism to highlight conditions at CKS Airport for taxiways and runways lighting, marking, and signage that did not meet internationally accepted safety standards and practices. (1.17.9; 2.3.6) 10. The CAA had not formed a working group for the derivation of a complete Surface Movement Guidance and Control System (SMGCS) plan according to guidance provided by ICAO Annex 14. (1.10.5.2) 11. Being a non-contracting State, the CAA of ROC does not have the opportunity to participate in ICAO activities in developing its airport safety enhancement programs to correspond with international safety standards and recommended practices. (1.17.10; 2.3.5.2.2) 12. The local controller did not issue progressive taxi/ground movement instructions and did not use the low visibility taxi phraseology to inform the flight crew to slow down during taxi. (1.18.2.3; 2.4.1) 13. The flight crew did not request progressive taxi instructions from Air Traffic Controller (ATC). (1.1; Appendix 3) 14. Reduced visibility in darkness and heavy rain diminished, but did not preclude, the flight crew’s ability to see the taxiway and runway lighting, marking, and signage. (1.18.1.1; 2.5.7.1) 15. The SIA crosswind limitation for a “wet” runway was 30 knots and for a “contaminated” runway was 15 knots. CM-1 assessed that the runway condition was “wet” at the time he prepared for takeoff and determined that the crosswind was within company limitations. The lack of SIA and ATC procedures for quantitatively determining a “wet” versus “contaminated” runway creates ambiguity for flight crews when evaluating takeoff crosswind limitations. (1.18.4; 2.5.8) 16. There was no procedure described in the SIA B747-400 Operations Manual for low visibility taxi operations. (1.17.4.5; 2.5.4) 17. There was no formal training provided to SIA B747-400 pilots for low visibility taxi techniques. (1.18.1.1.1) 18. SIA did not have a procedure for the pilots to use the PVD as a tool for confirming whether the aircraft is in a position for takeoff in low visibility conditions such as existed for the operation of SQ006 on the night of the accident. (1.18.5.1; 2.5.6.3.3) 19. SIA procedures and training documentation did not reflect the CAAS approved B-747-400 AFM supplement regarding use of the PVD for confirming the correct aircraft takeoff position. (1.18.5.3; 2.5.6.3.3) 20. CAAS oversight of SIA operations and training did not ensure that the approved B747-400 AFM supplement regarding use of the PVD for determining whether the aircraft is in a correct position for takeoff was incorporated into the SIA documentation and operational practices. (1.18.5.3; 2.5.10) 21. At the time of the accident, SIA’s Aircraft Operations Manual did not include “confirm active runway check” as a before takeoff procedure. (1.18.1.1; 2.5.5) 22. The SIA training and procedures for low visibility taxi operations did not ensure that the flight crew possessed the appropriate level of knowledge and skills to accurately navigate the aircraft on the ground. (1.17.4.5; 2.5.4.5) 23. CAAS had not performed sufficient safety oversight of SIA’s procedures and training and the deficiencies in SIA procedures and training were not discovered during routine CAAS safety oversight. (1.17.1; 2.5.10) 24. The SIA typhoon procedure was not well defined and the personnel who were obliged to use the procedure did not fully understand the procedure and their responsibilities. (1.17.7; 2.7.4) 25. The severe impact forces and rapidly spreading fire and smoke rendered much of the existing emergency evacuation training, hardware, and procedures ineffective. (1.15.1.2, 1.15.1.3; 1.15.1.4, 2.6.1) 26. CM-1 did not order cabin crewmembers and passengers to initiate the emergency evacuation when the Passenger Address (PA) system was found inoperative. (1.15.1.2; 2.6.1) 27. During the annual recurrent emergency evacuation training, which was integrated with the cabin crew, the flight crew played the role of passengers. The SIA procedures did not require the flight crew to give the evacuation command. (1.15.1.1) 28. A majority of the cabin crewmembers’ performance was affected because of the unexpected dynamics of the accident. (1.15.1; 2.6.1) 29. The dense smoke made breathing difficult and the emergency lights less visible for the survivors during the evacuation. (1.15.1; 2.6.3.1; 2.6.3.2) 30. During the evacuation in dark conditions, only CM-3, CM-2, and 5L crewmembers carried flashlights. The 5L cabin crewmember used the flashlight to assist during the passenger evacuation. (1.15.1.6) 31. CKS Airport did not prescribe in detail the emergency medical treatment procedures and the responsibilities of a medical coordinator or the interim coordinator in accordance with the ICAO recommendations. (1.15.3.6; 2.6.4.1) 32. CKS Airport did not provide contingency procedures for medical treatment and rescue in adverse weather conditions in accordance with the ICAO recommendations. (1.15.3.6; 2.6.4.1) 33. The “CKS Airport Civil Aircraft Accident Handling Procedures and Regulations” contained incomplete features of the surrounding hospitals (such as neurosurgical ability ) as suggested in the ICAO recommendations. (1.15.3.5; 2.6.4.2) 34. The manufacturer of the emergency evacuation slides did not provide information on the effects of high wind in the operator’s manual. (1.15.1.3; 1.12.2.3.2; 2.6.2.1) 35. The high lateral G forces associated with the accident produced an unexpected self-inflation of the 4R and 5R slides in the cabin. (1.15.1.5; 2.6.2.2) 36. The CKS Airport fire-fighting department was understaffed in handling a major accident. (1.14.1.2; 1.15.3.2; 2.6.4.3) |
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