Singapore Airlines Flight 006

SYNOPSIS

1315742.jpg
Singapore Airlines 9V-SPK in Tropical Livery (image embedded from [http://cdn-www.airliners.net/aviation-photos/small/2/4/7/1315742.jpg] on 19 August 2010)
Satelite_picture_Taipei_Taiwan_05R.jpg
SQ006 turned into closed Runway 05R (used as a temporary taxiway at the point of accident) instead of Runway 05L. (image embedded from [http://www.skybrary.aero/images/Satelite_picture_Taipei_Taiwan_05R.jpg] on 19 August 2010)

On October 31, 2000, a Boeing 747-400 aircraft with the Singaporean aircraft registration of 9V-SPK crashed during takeoff at Chiang Kai Shek (CKS) Airport. At 2317 Taipei Local time (1517 UTC), Flight SQ006 operated by Singapore Airlines (SIA), struck construction barriers and equipment during takeoff on Runway 05R, which is partially closed for maintenance. As a result of typhoon “Xangsane”, torrential rain, poor surrounding visibility as well as strong gusts of winds prevailed when the accident occurred.

The flight was a scheduled international civilian commercial service departing from CKS Airport (the international aerodrome serving Taipei), in Taoyuan county of Taiwan, Republic of China (ROC) to Los Angeles International Airport (LAX) in Los Angeles, California, United States of America (USA). The flight manifest revealed a total number of three flight crew members, 17 cabin crew members, and 159 passengers on board the flight.

The accident occurred as the aircraft was taking off from the partially closed runway 05R. The aircraft collided with a cluster of heavy construction machineries and construction trenches. Upon immediate impact, the aircraft fuselage was torn into two parts. The landing gear, engines and left wing were separated from the aircraft too. The aircraft was subsequently destroyed by intense crash fire. The passengers were evacuated through the emergency exits. 83 fatalities, 39 serious injuries and 32 minor injuries were sustained.

The official accident report concludes that the mishap was the unfortunate result of inadequate situational awareness displayed by the pilots. The flight crew was compelled by considerable amount of psychological stress to takeoff in time before the airport was closed by the arrival of typhoon “Xangsane”. The safety of the aircraft, crew members and passengers were further compromised by the presence of hazardous weather conditions such as strong gusty crosswinds, poor visibility and a wet runway. In addition, the infrastructure design and navigational support by the Air Traffic Control (ATC) of CKS airport were not able to provide sufficient proper guidance, which eventually led them to commence takeoff from the wrong runway.

ACCIDENT ANALYSIS

Errors Committed

Like many other aircraft mishaps, the crash of SQ006 was not due to a single event. In fact, according to James Reason's Swiss Cheese Model, accidents are caused by multiple errors.
Errors exist in the form of latent and active errors.

In each layer of defence against potential error that could impact the outcome, opportunities (the "holes") for a process to fail, are present. While a particular erroneous action may be able to pentrate through a layer, the presence of other layers act as a precaution to ensure that the action does not penetrate through all the layers, to become a catastrophic error. However, when a series of actions penetrate through the multiple layers successfully, an accident occurs.

Latent Errors

1) Absence of Runway Guard Lights (RGL)

The lack of support for ROC Civil Aeronautics Administration (CAA) ’s safety enhancement project to install RGL lowered CKS Airport’s ability to alert flight crews of their wrong position during inclement weather conditions of low visibility.

2) Non-standard Taxiway Centreline Lights

The taxiway centreline lights from the start of the curve from Taxiway NP through Taxiway N1 to Runway 05R should have been spaced at less than 7.5 metres with a total of 16 lights along this section under International Civil Aviation Organisation (ICAO) standard. However, only 4 lights were installed with uneven distances spaced. A reduced spacing of the centreline lights on Taxiway N1 could assist flight crews to maintain awareness and would reduce the likelihood of taxiing errors especially during low visibility.

3) Absence of Airport Surface Detection Equipment (ASDE)

The lack of an ASDE system prevented the ATC from obtaining accurate information in determining exact location of aircraft and vehicles and therefore having a reference in monitoring compliance by aircraft and vehicles with ATC’s instructions. This ability is specifically important and essential during low visibility when aircraft goes out of sight from the ATC tower.

Active Errors

1) Inadequate Review of Taxi Route

The CAA of the ROC had earlier circulated one Notice to Airmen (NOTAM) to inform the closure of a portion of Airstrip 05R as construction work was being executed between Taxiway N4 and N5. The pilots of SQ006 acknowledged the knowledge of the closure of Runway 05R. However, the aircraft did not completely cross Taxiway N1 towards Runway 05L for takeoff but instead executed a continuous right turn onto Runway 05R after turning right from Taxiway NP onto Taxiway N1. The pilots of SQ006 henceforth failed to check and revise the taxi route in a way that was adequate to assure that the three of them fully comprehended the need for the aircraft to cross the threshold of Runway 05R before onto Runway 05L.

2) Poor Crew Resource Management (CRM)

Poor CRM was demonstrated when the First Officer and Relief Pilot failed to question the Captain despite noticing instrumental signs on the Paravisual Display (PVD) as well as the Primary Flight Display (PFD) that they were on the wrong runway.

3) Misperception & Automaticity (Complacency)

In addition to the light saliency guiding onto Runway 05R, the captain’s anticipation that the aircraft was reaching the departure runway resulted in him designating a majority of his concentration to the Runway 05R centreline lights to incur a incorrect perception. Automaticity and excessive complacency of always following the green taxiway centreline lights onto a departure airstrip further caused him to taxi onto Runway 05R without much consideration.

4) Time Pressure (Poor Decision Making & Situational Awareness)

The considerable amount of psychological stress to takeoff in time before the airport was closed by the arrival of typhoon “Xangsane” adversely affected the pilots’ capability to execute appropriate decisions and to maintain good situational awareness. The safety of the aircraft, crew members and passengers were further compromised by the hazardous weather conditions of strong gusty crosswinds, poor visibility and a wet airstrip.

LESSONS LEARNT:

1) Airlines should review their standard operational procedures for poor surrounding visibility ground movements, which must involve a compulsory requirement to request the ATC for progressive taxi assistance to move around the airport accurately and safely.

2) Airlines should revise current PVD indoctrinations, usage procedures as well as to ensure that all operational documentation and practices reflect the PVD supplement approved by the aircraft manufacturer, which involved the utilisation of the supplement to confirm the correct position of the aircraft in an accurate and reliable manner, especially before taking off in low visibility situations.

3) Airlines should ensure the strict presence of a pre-takeoff checklist item requiring the formal acquisition of correct visual confirmation to assure that they are on the right takeoff runway.

4) Airlines should instill additional CRM training programmes to reflect current CRM practices and reinforce the importance of CRM, and assure that such training are consistently reviewed to reflect contemporary changes in the field of CRM.

5) Aviation authorities should ensure that all commercial airline operators under their regulatory responsibility enforce the above implementation of the Advanced CRM programmes to show contemporary practices and assure that these programs are consistently followed up and reviewed to indicate contemporary changes in the field of CRM.

6) Aviation authorities should re-highlight the ideology, indoctrination and usage of taxi/ ground movement assistance while executing ground movements in low visibility.

7) Aviation authorities should prioritize budget expenditure on the immediate setup of ASDE at airports with heavy traffic and during low visibility.

8) Aviation authorities should organise a programme to systematically oversee ICAO Standards And Recommended Practices (SARPS) and other relevant good practices in the industry, in order to enhance operational safety and share them with all relevant organisations for the necessary revision, decision and monitoring of their performance.

9) Aviation authorities should set up a programme that integrates both assessment and management of operational safety risk, as well as a monitoring system to overlook all implementations and plans.
10) Aviation authorities should remove or revise all unacceptable standards, at their airports that do not comply with ICAO SARPS immediately without further delay.

11) Aircraft manufacturers should plan the incorporation of cockpit ground navigation and guidance technological systems, such as electronic moving map display, as well as to assist airlines in their installation, into all aircraft to assist surface movements during low visibility.

12) ICAO should develop SARPS that would demand ASDE or similar technology as compulsory equipment at busy civilian aerodromes with heavy traffic.

13) ICAO should indicate clear statements in Annex 14 towards the definition and protection of a partially unused airstrip that are instead being utilised temporarily as a taxiway.

14) ICAO should promote and instill the essential SARPS to its member states’ aviation authorities and urge the practice of the essential administration towards supporting the set up and wide utilisation of aircraft cockpit-based ground navigation and guidance technologies, such as the electronic moving map display.

15) ICAO should urge its signatory states to include the set up of aircraft cockpit ground surface navigation and guidance technological systems, such as electronic moving map display, in commercial passenger aircraft for usage during airport taxiing.

16) ICAO should encourage its member states’ signatory authorities to assure the research and development of the relevant ground taxiing technologies, such as airport and terrain databases.

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