Transasia AT72 at Makung on Jul 23rd 2014, impacted buildings on approach

Last Update: January 29, 2016 / 16:39:31 GMT/Zulu time

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Incident Facts

Date of incident
Jul 23, 2014

Classification
Crash

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

On Jan 29th 2016 the ASC released their final report, the first time ever in English (requiring some praise), concluding the probable causes of the crash were:

Findings Related to Probable Causes

Flight Operations

- The flight crew did not comply with the published runway 20 VOR non-precision instrument approach procedures at Magong Airport with respect to the minimum descent altitude (MDA). The captain, as the pilot flying, intentionally descended the aircraft below the published MDA of 330 feet in the instrument meteorological conditions (IMC) without obtaining the required visual references. (1.1, 1.18.1.4, 2.2.1.1, 2.3.1)

- The aircraft maintained an altitude between 168 and 192 feet before and just after overflying the missed approach point (MAPt). Both pilots spent about 13 seconds attempting to visually locate the runway environment, rather than commencing a missed approach at or prior to the MAPt as required by the published procedures. (1.1, 2.2.1.1)

- As the aircraft descended below the minimum descent altitude (MDA), it diverted to the left of the inbound instrument approach track and its rate of descent increased as a result of the flying pilot’s control inputs and meteorological conditions. The aircraft’s hazardous flight path was not detected and corrected by the crew in due time to avoid the collision with the terrain, suggesting that the crew lost situational awareness about the aircraft’s position during the latter stages of the approach. (1.1, 1.11.4.2, 2.2.1.1, 2.9)

- During the final approach, the heavy rain and associated thunderstorm activity intensified producing a maximum rainfall of 1.8 mm per minute. The runway visual range (RVR) subsequently reduced to approximately 500 meters. The degraded visibility significantly reduced the likelihood that the flight crew could have acquired the visual references to the runway environment during the approach. (1.7, 2.2.1.1, 2.8)

- Flight crew coordination, communication, and threat and error management were less than effective. That compromised the safety of the flight. The first officer did not comment about or challenge the fact that the captain had intentionally descended the aircraft below the published minimum descent altitude (MDA). Rather, the first officer collaborated with the captain’s intentional descent below the MDA. In addition, the first officer did not detect the aircraft had deviated from the published inbound instrument approach track or identify that those factors increased the risk of a controlled flight into terrain (CFIT) event. (1.1, 1.18.7, 2.2.1.1, 2.3.1, 2.4.1, 2.4.2, Appendix 3)

- None of the flight crew recognized the need for a missed approach until the aircraft reached the point (72 feet, 0.5 nautical mile beyond the missed approach point) where collision with the terrain became unavoidable. (1.1, 1.18.1.4, 2.2.1.1)

- The aircraft was under the control of the flight crew when it collided with foliage 850 meters northeast of the runway 20 threshold, two seconds after the go around decision had been made. The aircraft sustained significant damage and subsequently collided with buildings in a residential area. Due to the high impact forces and post-impact fire, the crew and most passengers perished. (1.11.4.2, 1.12.1, 1.13, 2.2.1.1)

- According to the flight recorders data, non-compliance with standard operating procedures (SOPs) was a repeated practice during the occurrence flight. The crew’s recurring non-compliance with SOPs constituted an operating culture in which high risk practices were routine and considered normal. (1.18.1.4, 2.3.1)

- The non-compliance with standard operating procedures (SOPs) breached the obstacle clearances of the published procedure, bypassed the safety criteria and risk controls considered in the design of the published procedures, and increased the risk of a controlled flight into terrain (CFIT) event. (1.18.7, 2.2.1.1, 2.3.1)

Weather

- Magong Airport was affected by the outer rainbands of Typhoon Matmo at the time of the occurrence. The meteorological conditions included thunderstorm activities of heavy rain, significant changes in visibility, and changes in wind direction and speed. (1.7, 2.2.1, 2.8)

Findings Related to Risk

Flight Operations

- The captain did not conduct a descent and approach briefing as required by standard operating procedures (SOPs). The first officer did not question the omission of that required briefing. That deprived the crew of an opportunity to assess and manage the operational risks associated with the approach and landing. (1.1, 1.18.1.4, 2.2.1.1, 2.3.1, Appendix 3)

- The captain was likely overconfident in his flying skills. That might lead to his decision to continue the approach below the minimum descent altitude (MDA) without an appreciation of the safety risks associated with that decision. (1.18.8.2, 2.4.3)

- The results of the fatigue analysis indicated that, at the time of the occurrence, the captain’s performance was probably degraded by his fatigue accumulated from the multiple sectors/day flown and flight and duty times during the months preceding the occurrence. (1.5.5, 1.17.3.2.1, 2.3.3.3, 2.4.4)

- The TransAsia Airways observation flights conducted by the investigation team and the interviews with members of the airline’s flight operations division show prevalent tolerance for non-compliance with procedures within the airline’s ATR fleet. (1.16.4, 1.18.8.2, 2.3.3)

- The non-compliances with standard operating procedures (SOPs) during the TransAsia Airways’ ATR simulator training sessions were observed by the investigation team but not corrected by the instructors. The tolerance for or normalization of SOPs non-compliance behaviors was symptomatic of an ineffective check and training system with inadequate supervision by the airline’s flight operations management. (1.16.5, 2.3.3.2)

- The non-compliance with standard operating procedures (SOPs) was not restricted to the occurrence flight but was recurring, as identified by previous TransAsia Airways ATR occurrence investigations, line observations, simulator observations, internal and external audits or inspections, and interviews with TransAsia Airways flight operations personnel, including managers. The non-compliant behaviors were an enduring, systemic problem and formed a poor safety culture within the airline’s ATR fleet. (1.16.4, 1.16.5, 1.17.1.1, 1.17.8.2.1, 1.17.10, 1.18.8.2, 2.3.2, 2.4.2)

Airline Safety Management

- The TransAsia Airways’ inadequate risk management processes and assessments, ineffective safety meetings, unreliable and invalid safety risk indices, questionable senior management commitment to safety, inadequate safety promotion activities, underdeveloped flight operations quality assurance (FOQA) system, and inadequate safety and security office and flight operations resources and capabilities constituted an ineffective safety management system (SMS). (1.17.4, 1.17.5, 1.17.6, 1.17.7, 1.17.9, 1.17.10, 2.3.3.1,2.3.33, 2.5)

- The safety risks associated with change within the TransAsia Airways were not assessed and mitigated. For example, the company did not assess or mitigate the safety risks associated with the increase in ATR operational tempo as a result of the recent increase in ATR fleet size and crew shortage that, in turn, elevated crew flying activities and the potential safety risks associated with crew fatigue. (1.17.3.2.1, 2.3.3.3)

- Findings regarding non-compliance with standard operating procedures (SOPs) during operations by the TransAsia Airways’ ATR crews had been identified by previous Aviation Safety Council occurrence investigations. The proposed corrective safety actions were not implemented by the airline. (1.17.10, 2.3.2, 2.7.5)

- TransAsia Airways self-audits were mostly spot checks rather than system audits or system self-evaluations. The self-audits failed to assess and address those safety deficiencies, including standard operating procedures non-compliance behaviors, lack of standardization in pilot check and training activities, and high crew flying activities on the ATR fleet. Such deficiencies had been pointed out in previous occurrences and audits and were considered by senior flight operations managers as problems. (1.17.8, 2.5.4)

- The TransAsia Airways annual audit plan did not include an evaluation of the implementation and/or effectiveness of corrective actions in response to the safety issues identified in previous audits, regulatory inspection findings, or safety occurrence investigation recommendations. The airline’s self-audit program was not consistent with the guidance contained in AC-120-002A. (1.17.8, 2.5.4)

- The TransAsia Airways had not developed a safety management system (SMS) implementation plan. This led to a disorganized, nonsystematic, incomplete and ineffective implementation, which made it difficult to establish robust and resilient safety management capabilities and functions. (1.17.2, 2.6.1)

- The Civil Aeronautics Administration’s (CAA) safety management system (SMS) assessment team had identified TransAsia Airways’ SMS deficiencies, but TransAsia Airways failed to respond to the CAA’s corrective actions request. That deprived the airline of an opportunity to improve the level of safety assurance in its operations. (1.17.2, 2.6.2)

- The TransAsia Airways did not implement a data-driven fatigue risk management system (FRMS) or alternative measures to manage the operational safety risks associated with crew fatigue due to fleet expansion and other operational factors. (1.17.3.2.1, 2.4.4)

- The ATR flight operation did not include in its team a standards pilot to oversee standard operating procedures (SOPs) compliance, SOP-related flight operations quality assurance (FOQA) events handling, and standard operations audit (SOA) monitoring before the GE222 occurrence. (1.17.3.1, 1.17.6.3, 2.3.3.1, 2.5.3)

- The safety and security office, due to resource and capability limitations, was unable to effectively accomplish the duties they were required to undertake. (1.17.4.2, 2.5.1)

- The safety and security office staff was not included in the flight safety action group. That deprived the airline of an opportunity to identify, analyze and mitigate flight safety risks more effectively in the flight operations. (1.17.4.1.1, 2.5.1)

- The TransAsia Airways’ safety management system was overly dependent on its internal reactive safety and irregularity reporting system to develop full awareness of the airline’s safety risks. It did not take advantage of the instructive material from external safety information sources. That limited the capability of the system to identify and assess safety risks. (1.17.5, 1.17.7.1, 2.5.2)

- The TransAsia Airways’ flight operations quality assurance (FOQA) settings and analysis capabilities were unable to readily identify those events involving standard operating procedures (SOPs) non-compliance during approach and likely other stages of flight. The FOQA events were not analyzed sufficiently or effectively, leaving some safety issues in flight operations unidentified and uncorrected. Some problems with crew performance and reductions in safety indicated in the FOQA trend analyses were not investigated further. Clearly, the airline’s FOQA program was not used to facilitate proactive operational safety risk assessments. (1.17.6, 2.5.3)

Civil Aeronautics Administration

- The Civil Aeronautics Administration’s oversight of TransAsia Airways did not identify and/or correct some crucial operational safety deficiencies, including crew non-compliance with procedures, non-standard training practices, and unsatisfactory safety management practices. (1.17.1, 1.17.2.2, 2.7)

- To develop and maintain a safety management system (SMS) implementation plan at TransAsia Airways was not enforced by the Civil Aeronautics Administration. That deprived the regulator of an opportunity to assess and ensure that the airline had the capability to implement a resilient SMS. (1.17.2.2, 2.6.1)

- Issues regarding the TransAsia Airways’ crew non-compliance with standard operating procedures (SOPs) and deficiencies with pilot check and training had previously been identified by the Aviation Safety Council investigation reports. However, the Civil Aeronautics Administration (CAA) did not monitor whether the operator has implemented the recommended corrective actions; correlatively, the CAA failed to ensure the proper measures for risk reduction have been adopted. (1.17.10, 2.7.6)

- The Civil Aeronautics Administration provided limited guidance to its inspectors to enable them to effectively and consistently evaluate the key aspects of operators’ management systems. These aspects included evaluating organizational structure and staff resources, the suitability of key personnel, organizational change, and risk management processes. (1.17.1, 2.7)

- The Civil Aeronautics Administration did not have a systematic process for determining the relative risk levels of airline operators. (1.17.1, 2.7)

Air Traffic Service and Military

- The runway visual range (RVR) reported in the Magong aerodrome routine meteorological reports (METAR) and the aerodrome special meteorological reports (SPECI) was not in accordance with the requirements documented in the Air Force Meteorological Observation Manual. (1.7.2, 1.18.6, 2.8.3.2)

- The discrepancies between the reported runway visual range (RVR) and automated weather observation system (AWOS) RVR confused the tower controllers about the reliability of the AWOS RVR data. (1.18.8.8, 2.8.3.1)

- During the final approach, the runway 20 runway visual range (RVR) values decreased from 1,600 meters to 800 meters and then to a low of about 500 meters. The RVR information was not communicated to the occurrence flight crew by air traffic control. Such information might influence the crew’s decision regarding the continuation of the approach. (1.7.4, 2.8.3.1)

Other Findings

- The flight crew were properly certificated and qualified in accordance with the Civil Aeronautics Administration and company requirements. No evidence indicated any pre-existing medical conditions that might have adversely affected the flight crew’s performance during the occurrence flight. (1.5, 1.13, 2.1)

- The airworthiness and maintenance of the occurrence aircraft were in compliance with the extant civil aviation regulations. There were no aircraft, engine, or system malfunctions that would have prevented normal operation of the aircraft. (1.12, 2.1)

- All available evidence, including extensive simulations, indicated that the enhanced ground proximity warning system (EGPWS) functioned as designed. (1.6.3, 1.16.1, 1.16.2, 2.10.2)

- The enhanced ground proximity warning system (EGPWS) manufacturer’s latest generation EGPWS equipment would have provided flight crews with an additional warning if aircraft encountered similar circumstances to the occurrence flight. Installing the latest EGPWS equipment on the occurrence aircraft would have required approved modifications. (1.6.3, 1.16.2, 2.10.3)

- According to the Civil Aeronautics Administration (CAA) regulations, a 420 meter simple approach lighting system should have been installed to help pilots visually identify runway 20. The CAA advised that the Runway End Identification Lights, a flashing white light system, was installed at the runway’s threshold as an alternative visual aid to replace the simple approach lighting system. (1.10.2, 2.12.1)

- From the perspective of flight operations, the location of the runway 20 VOR missed approach point (MAPt) was not in an optimal position. With the same Obstacle Clearance Altitude, if the MAPt had been set closer to the runway threshold, it would have increased the likelihood of flight crews to visually locate the runway. (1.18.3, 1.18.4, 2.12.3)

- During holding, the occurrence flight crew requested the runway 02 instrument landing system (ILS) approach after receiving the weather information that the average wind speed for runway 02 had decreased to below the tailwind landing limit. While the decision for the use of the reciprocal runway was still under consideration by the Magong Air Force Base duty officer, the weather report indicated that the visibility had improved to 1,600 meters, which met the landing visibility minimal requirement for an approach to runway 20. The flight crew subsequently amended their request and elected to use runway 20. (1.1, 1.18.5, 2.8.4)

- At the time of the occurrence, the weather information exchange and runway availability coordination between civil and military personnel at Magong’s joint-use airport could have been more efficient. (1.18.8.6, 1.18.8.7, 2.8)

- ATR’s flight data recorder (FDR) readout document contained unclear information. That affected the efficiency of the occurrence investigation. (1.11.2, 2.11.1)

27 safety recommendations were issued to the airline, to Taiwan's Civil Aviation Authority, the aircraft manufacturer and Taiwan's Air Force Command/Ministry of Defense.

The ASC reported that the captain (60,ATPL, 22,994 hours total, 19,069 hours on type) was pilot flying, the first officer (39, CPL, 2,392 hours total, 2,083 hours on type) was pilot monitoring. Taiphoon Matmo was about 142nm northnorthwest of the aerodrome and moving away at the time of the occurrence, the taiphoon warning for the aerodrome had been cancelled.

While on approach to Makung the crew was informed that the weather was below minima for an ILS approach to runway 02 as well as below minima for a VOR approach to runway 20. The crew decided to enter a hold. Subsequent weather information indicated that the tail wind component for runway 02 reduced to a point that the weather conditions permitted an approach to runway 02, the crew therefore requested an ILS approach to runway 02. While Makung officials were still discussing to clear the flight for the ILS approach, the weather improved further, the visibility improved from 800 to 1600 meters permitting the VOR approach to runway 20, the crew therefore amended their request and commenced the VOR appraoch to runway 20 (MDA 330 feet).

Shortly before overflying the final approach fix the crew started the final descent from 2000 feet and selected 400 feet into the altitude window. After the automated call "500 feet", while descending through 450 feet, the captain reselected the altitude window to 300 feet, then while descending through 345 feet the captain selected 200 feet into the altitude window. There was no discussion regarding the MDA, lack of required visual reference permitting descent below MDA etc. in the cockpit.

At 219 feet MSL the captain disengaged the autopilot stating "maintain 200 feet", the aircraft was between 168 and 192 feet in the next 10 seconds. The captain inquired with the first officer whether he had seen the runway, over the next 13 seconds the crew engaged in attempting to locate the runway, the aircraft's attitude and course changed during these attempts unnoticed by the crew. At 72 feet AGL both crew called "Go Around", the power levers were advanced and both engines accelerated but two seconds later the aircraft collided with foliage about 850 meters northeast of the runway 20 threshold receiving substantial damage and subsequently collided with buildings in a residential area destroying the aircraft and property on the ground.

All 4 crew and 44 passengers perished in the crash, 9 passengers received serious, one passenger received minor injuries, 5 people on the ground received minor injuries, too.

The ASC analysed: "There was no discussion by the crew on whether the required visual references had been obtained before the captain as the pilot flying (PF) continued to descend the aircraft below the MDA. The first officer, in his capacity as the pilot monitoring (PM) did not object or intervene but rather coordinated with the captain’s decision to descend below the MDA in contravention of standard operating procedures (SOPs). When the aircraft had descended to 249 feet, the first officer illustrated the position of the MAPt by saying “we will get to zero point two miles”. At 1905:44, altitude 219 feet, the captain disengaged the autopilot. Four seconds later, the captain announced “maintain two hundred”. The captain maintained the aircraft’s altitude between approximately 168 and 192 feet in the following 10 seconds (see Table 2.2-3). The flight crew intentionally operated the aircraft below the MDA. They then maintained about 200 feet while attempting to visually sight the runway so they could land the aircraft. Even though no conversation regarding the MAPt was mentioned on the CVR, the captain asked the first officer “have you seen the runway” when the aircraft passed the MAPt (1905:57.8, 0.1 NM behind MAPt). At almost the same time the yaw damper was disengaged without any announcement. Instead of commencing a missed approach at or prior to the MAPt in accordance with company SOPs, both pilots spent about 13 seconds attempting to locate the runway. During their search for the runway, the heavy thunderstorm rain activity intensified with a maximum rainfall of 1.8 mm per minute. That further reduced the visibility to 500 meters108. The UNI Airways flight crew, who had landed a few minutes before the occurrence, stated that there was sudden heavy rainfall with an associated deterioration in visibility. The degraded visibility impeded the GE222 flight crew’s ability to visually locate the runway. From the MAPt, while the autopilot was disengaged, the occurrence aircraft’s altitude, course, and attitude started to conspicuously deviate from the intended settings and flight crew’s expectations. The flight data recorder (FDR) data (see Table 2.2-4 and Figure 2.2-2) indicated that the aircraft’s heading changed from 207° to 188° as a result of the bank angle changing from approximately wings level to 19° left and then decreasing to 4° left, which was consistent with the aircraft commencing a left turn away from the required approach course. The aircraft also commenced a descent from previously maintained altitude of 200 feet. The aircraft pitch angle decreased from 0.4° nose up to 9° nose down then returned to 5.4° nose down which produced a reduction altitude from 179 feet to 72 feet. ... The captain diverted the aircraft from the published runway 20 VOR non-precision approach procedure by descending below the published MDA before obtaining the required visual references. The aircraft also diverted to the left of the inbound instrument approach track as a result of several factors but the crew did not identify and/or correct that deviation. The first officer did not challenge the captain’s violation of the MDA. The crew’s decision to continue the approach below the minima provided the crew with no margin for avoidance maneuvering and exponentially increased the risk of controlled flight into terrain (CFIT). The flight crew did not appear to identify the hazards associated with the approach and were therefore not in a position to manage the associated risks."

With respect to standard operating procedures the ASC analysed: "The flight crew’s compliance with procedures was not at a level to ensure the safe operation of the aircraft. The captain did not conduct an approach briefing before he commenced the descent into Magong. The CVR data revealed that the first officer did not comment on the omission of this procedure, which would have provided the crew with an opportunity to assess the risks for the approach to Magong. ... Had the flight crew followed the runway 20 VOR approach procedure as published on either the Jeppesen or CAA charts, and not descended below the MDA but conducted a go around in accordance with the published missed approach procedures, the accident would not have occurred. There was no evidence of any inflight emergency that would have warranted the flight crew of the occurrence aircraft to disregard or deviate from the published inflight procedures."

The ASC thundered: "The airline observation flights conducted by the investigation team and interviews with members of the airline’s flight operations division supported the conclusion that there was a tolerance for non-compliance with procedures within the ATR72 operation. That is, routine violations of procedures were normal. In particular, the flight crew were known to descend below the minima before acquiring the required visual references. If the airline had implemented a line operations safety audit (LOSA) program, it would have readily identified the magnitude and frequency of the systemic routine SOP non-compliance committed by crews at the airline."

The ASC continued analysis: "Inadequate flight crew monitoring and cross-checking has been identified as an aviation safety problem. To ensure the highest levels of safety, each flight crewmember must carefully monitor the aircraft’s flight path and systems, and actively cross-check the actions of other crewmembers. This monitoring function is always essential, and particularly so during approach and landing when CFIT occurrences are most common."

The ASC also analysed: "Interviews with ATR line pilots indicated that the captain had good flying skills. Some interviewees further stated that the captain had landed safely in adverse weather conditions previously because of his proficiency where some pilots might have initiated a missed approach. The interviews indicated that the captain was quite confident of his flying skills. This might be one of the factors that explained why the captain intentionally flew below the MDA and tried to visually locate the runway while maintaining 200ft."

The ASC analysed: "The TNA FOQA (Transasia Flight Operations Quality Assurance) team did not have a flight operations or technical specialist embedded in the SSO. The absence of such specialists made it difficult for the designated FOQA officer to fully understand and analyze the data from an operational perspective."

The ASC analysed: "Despite the constraints, the CAA still had significant interactions with TNA, through the conduct of scheduled in-depth and cockpit en-route inspections, monitoring the implementation of corrective actions in response to inspections and safety occurrences, SMS assessment, and other approval activities. As a result of these interactions, the CAA had identified some areas for improvement in TNA’s SMS, flight crew training, procedures and practices, and FOQA program. However, it did not detect fundamental problems associated with the airline’s risk management of flight operations, such as systemic problems with flight crew not complying with SOPs, lack of standardization in pilot checking and training activities, SSO organizational structure and capability, and demonstrated management commitment to safety. Given the significance of the problems within TNA, and the amount of interactions CAA had with the airline, it is reasonable to conclude that some of these problems should have been detected by the CAA."

The ASC analysed: "The use of other direction of runway application procedures for the civil/military joint-use airport indicated that, when the military aircrafts stationed at the airport, the application could only be authorized by the Magong Air Force Base (AFB) duty officer. At 1833:35, the AFB duty officer received the use of other direction of runway application because three inbound aircraft had requested the runway 02 ILS approach due to runway 20 was no longer suitable given the landing minima visibility requirements. While the decision for the application was still under consideration, the 1840 weather report indicated that the visibility had improved to 1,600 meters, which met the landing visibility minima requirements for an approach to runway 20. The crews subsequently amended their request and elected to use runway 20."

The ASC analysed: "An examination of flight data from the occurrence aircraft and from aircraft landing at Magong shortly before the occurrence aircraft indicated no evidence that the occurrence aircraft encountered windshear129 or microburst130 activity."

The ASC analysed: "Magong runway 20 has a non-precision approach and is used for night operations. There is approximately 500 meters of extended space along the runway 20 centerline within the airport area. According to the regulations, a 420 meter simple approach lighting system should be installed to help pilots visually identify the runway. Runway 20 did not have the required lighting system installed. The CAA advised that the Runway end identification lights (REIL), a flashing white light system, was installed at the runway’s threshold as an alternative visual aid to replace the simple approach lighting system. ... The MAPt for the runway 20 VOR approach was about 2,000 meters from the threshold. The visibility landing minima was 1,600 meters. There is a high likelihood that the occurrence flight crew would not have been able to visually identify the runway at the MAPt when the visibility was just above landing minima."
Incident Facts

Date of incident
Jul 23, 2014

Classification
Crash

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

This article is published under license from Avherald.com. © of text by Avherald.com.
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