Failure To Minimize Latent Hazards Cited In Taipei Tragedy Report

Air Safety Week, May 6, 2002

Airports might be considered potential "accident factories" requiring all concerned to be especially "alert to danger." The report of investigation into the fatal crash of a Singapore Airlines (SIA) B747-400 at Taipei makes the point in telling detail.

The phrase "accident factories" comes from a U.S. naval officer, who described aircraft carriers, the floating airports of sea power, as accident factories featuring fuel, ordnance, hot gas turbines, nuclear reactors and thousands of people operating in extremely close proximity. For this reason, he explained, safe operations are best assured by all hands being continuously "alert to danger" and acting accordingly. A moment's inattention can open the door to disaster.

The same applies to commercial airline operations, where mistakes and momentary lapses can be equally unforgiving. In the case of the SIA crash, investigators found deficiencies from the cockpit to the carrier to the country. Two countries, actually - the airport and regulatory authorities in the Republic of China (Taiwan), and the regulatory authorities in Singapore. The accident occurred in Taiwan and involved the crash of an airplane registered and operated by Singapore.

The Aviation Safety Council (ASC) of Taiwan investigated the case. The ASC's final 250-page report, released April 26, itemizes dozens of safety deficiencies and contains some 60 recommendations. The findings are blunt. The recommendations reveal the scope of work to be done to prevent a recurrence of the tragic accident involving a mistaken attempted takeoff on a closed runway.

The case has global implications for the safety of airline operations. In two other recent instances, pilots have been lost or disoriented on the airport. Most recently, an Air France A320 began its takeoff roll on the taxiway parallel to Runway 03 at Lisbon. This past Jan. 25, a China Airlines A340 took off on a taxiway at Anchorage, Alaska, on a non-stop flight to Taipei. The crew took off on a short taxiway oriented almost 90? from the assigned runway (see ASW, March 25). That case provides new investigative work for the ASC. And, this past September, a Cessna Citation II taxied onto Runway 36R/18L at Italy's Linate airport, right into the path of an oncoming Scandinavian Airways System (SAS) MD-87. The Cessna pilot was on taxiway R6 instead of where he should have been on R5, even though on that foggy morning he'd confirmed the tower's instruction to use R5, saying tersely, "I am familiar with the airport." (See ASW, Oct. 22, 2001). In January 2000 an American Airlines [AMR] B777 took off on a closed runway at Chicago's O'Hare airport.

The case at hand involves the Oct. 31, 2000, nighttime departure of SIA Flight SQ006 from Taipei to Los Angeles. The crew was cleared to take off on Runway 05L at Taipei's Chiang Kai-Shek International Airport (CKS). Runway 05L is 12,000 feet long. Unfortunately, the crew turned onto the parallel runway 05R, which was littered with concrete barriers and construction equipment about halfway down its 9,000-ft. length.

Wrong turn

Why they turned onto the wrong runway was of course the major focus of the investigation. To simplify, the ASC inquiry examined the outside situation - the runway signage and lighting the crew would have seen - and the inside situation - the information provided on their cockpit displays and the crew's comments captured on the cockpit voice recorder (CVR).

One thing is clear. The crew received correct routing instructions from the tower and confirmed those instructions in First Officer Latiff Cyrano's readback (with a typhoon approaching, and the airport already subjected to strong gusty winds and heavy rain, Capt. Chee Kong Foong had elected to fly the takeoff). A relief pilot also was in the cockpit.

To taxi to the correct runway from Taxiway NP, the crew had to pass Taxiway N2 and make a 90-degree right turn onto Taxiway N1 on their way to Runway 05L. Indeed, Foong and Cyrano joked about the significance of taking the second right turn as they taxied along. However, it also was important for them to be aware that once on Taxiway N1, the second right turn was the correct one.

For the night taxi with rain reducing their visibility, the airport lighting was particularly important. ASC investigators determined that the green taxiway lights were properly illuminated on the approaches to both Runways 05L and 05R. The white centerline, edge lights and touchdown zone lights for Runway 05L also were illuminated. The question is whether edge lights on Runway 05R had seduced the crew into turning prematurely onto the wrong runway. The ASC concluded that the white edge lights probably were not illuminated at the time (airport security cameras and other sources indicated the 05R edge lights were not turned on).

Thus, as the Flight SQ006 crew lined up for takeoff, with the white "piano keys" on the runway flashing by their view, the only lights ahead of them were the distinct green centerline lights denoting a taxiway. Because of the "dark and stormy night," they did not see the construction site looming in the distance.