Failure To Minimize Latent Hazards Cited In Taipei Tragedy Report

Air Safety Week, May 6, 2002

Although the full text of Singapore's comments were included as an appendix to the final report, the government of Singapore clearly is not happy. Complaining that its team was excluded from the analysis phase, leading to the "unbalanced nature" of the ASC's final report, Singapore's Ministry of Transport (MOT) released the results of a separate analysis performed by two experts it retained.

The MOT groused in its public statements that the ASC "glossed over key factors" in its analysis:

"The MOT team established that while the pilots took off from the wrong runway, they had followed all necessary procedures required of them and their conduct of the flight was not lacking in professionalism. On the other hand, the MOT team found that the systems, procedures and facilities at the CKS airport were seriously inadequate and that the accident could have been avoided if internationally accepted precautionary measures had been in place at the airport.

"If not for these deficiencies, the pilots would not have turned into the wrong runway and subsequently commenced taking off."

The MOT statements and a summary of the Singapore analysis does not address the question of why the pilots took off with only green taxiway lights ahead of them.

Crash causes correction

The international controversy aside, the lighting and emergency response situation at CKS already has improved. According to a source, guard lights have been installed for Runway 05L since the Flight SQ006 crash. In addition, all green taxiway lights are spaced the same 30-ft. distance apart. There are no longer any discontinuities between the curved and straight lines of taxiway lights.

Medical response planning also has been upgraded.

The ASC's recommendations go considerably beyond these modest immediate actions. The ASC wants to see moving map displays in the cockpit so pilots unambiguously know their position on the tarmac. The ASC is seeking a major upgrade to aircraft emergency evacuation and improvements to airport emergency response capability. These recommendations have worldwide importance for the present, for the design and operation of airports to be built in the future, and for the design of new airplanes like the A380 and Boeing's Sonic Cruiser.

Two basic messages emerge from the ASC report. First, latent hazards to airport and airline operations must be aggressively identified and minimized. Second, aircrews and controllers must be ever "alert to danger." Even a moment's confusion or loss of attention can court catastrophe. >> For the full ASC SQ006 investigation, http://www.asc.gov.tw. For Singapore MOT statements and alternative analysis, http://www.mot.gov.sg <<

'Second Right, That's Right'

Cockpit voice recorder transcript (extracts)

Time (local): 23:13:28
Source: TWR
Contents: Singapore six, good evening. Taipei Tower, hold short runway
zero five left

Time (local): 23:13:33
Source: F.O.
Contents: Hold short runway zero five left, Singapore six

Time (local): 23:14:41
Source: F.O.
Contents: Next one is November one [Taxiway N1]

Time (local): 23:14:42
Source: Capt.
Contents: OK, second right [apparently the airplane, on Taxiway NP, has
passed Taxiway N2 on the way to N1]

Time (local): 23:14:44
Source: F.O.
Contents: Second right, that's right

Time (local): 23:14:47
Source: Capt.
Contents: In Australia, to them, next one is this, first one you know

Time (local): 23:14:50
Source: F.O.
Contents: Next one this one

Time (local): 23:14:51
Source: Capt.
Contents: Yah..ha ha

Time (local): 23:14:52
Source: Capt.
Contents: Australian

Time (local): 23:14:53
Source: Capt.
Contents: I think the best is to say second right ah first right second right

Time (local): 23:15:04
Source: TWR
Contents: Singapore six roger, runway zero five left, taxi into position and
hold

Time (local): 23:15:50
Source: F.O.
Contents: OK green lights are here

Time (local): 23:15:52
Source: Capt.
Contents: It going to be very slippery I am going to slow down a bit,
slow turn here

Time (local): 23:16:07
Source: F.O.
Contents: And the PVD [Para-Visual Display] hasn't lined up ah

Time (local): 23:16:23
Source: Capt.
Contents: Not on yet er PVD huh never mind we can see the runway, not so bad