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Accident Final Report

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Accident Final Report According to the International Civil Aviation Organization (ICAO) Annex 13, Chapter 3, Section 3.1; The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability. Further, according to the Civil Aviation Law of The Republic of China, Article 84; ASC shall focus on the identification, investigation and cause assessment of aircraft accident or serious incident on preventing the recurrence of similar accident or serious incident, rather than on dispensing penalty or pursuing responsibility. Thus, based on Both the ICAO Annex 13, as well as the Civil Aviation Law of the Republic of China, this accident investigation report, as the result of the investigation effort of SQ006, shall not be used for any other purpose than to improve safety of the aviation community. AIRCRAFT ACCIDENT REPORT CRASHED ON A PARTIALLY CLOSED RUNWAY DURING TAKEOFF SINGAPORE AIRLINES FLIGHT 006 BOEING 747-400, 9V-SPK CKS AIRPORT, TAOYUAN, TAIWAN OCTOBER 31, 2000 AVIATION SAFETY COUNCIL TAIWAN, REPUBLIC OF CHINA AIRCRAFT ACCIDENT REPORT Crashed on a Partially Closed Runway during Takeoff, Singapore Airlines Flight 006, Boeing 747-400, 9V-SPK, CKS Airport, Taoyuan, Taiwan, October 31, 2000 Editor：Aviation Safety Council Copyright © 2002 Aviation Safety Council 16th Floor, 99 Fu-Hsing North Road Taipei 105, Taiwan, R. O. C. Tel：+886-2-25475200 Fax：+886-2-25474975 URL：www.asc.gov.tw GPN 1009101135 ISBN 957-01-0999-8 NT$1500 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. According to Article 84 of ROC’s Civil Aviation Law, and Annex 13 to the Convention on International Civil Aviation (Chicago Convention), which is administered by the International Civil Aviation Organization (ICAO), the Aviation Safety Council (ASC), an independent government agency of ROC, which is responsible for civil aircraft accident investigation in the territory of ROC, immediately launched an investigation of this accident. The State of Operator, represented by the Ministry of Communications and Information Technology (MCIT)1 of Singapore, and the State of Manufacture, represented by the National Transportation Safety Board (NTSB) of USA, were invited 1 Since November 23, 2001, MCIT has been changed to Ministry of Transportation (MOT) due to Singapore Government’s re-organization. Since MCIT was the name of the investigation authority at the time of the accident, this report still retains the use of MCIT throughout. i as the Accredited Representatives to participate in the investigation. The Australian Transport Safety Bureau (ATSB) of Australia was later on added as an Accredited Representative in accordance with Chapter 5.23 of ICAO Annex 13. The Civil Aeronautics Administration (CAA) of ROC was also invited to participate in the investigation. The on-scene portion of the investigation was completed on November 13, 2000, and two days later, the ASC officially returned the crash site to the CAA. On the same day, each investigation group, led by ASC investigators, completed the on-scene investigation factual report. The fact-gathering phase of the investigation continued, including a trip by ASC investigators to Singapore to understand the operation of SIA and to conduct interviews of SIA and Civil Aviation Authority of Singapore (CAAS) personnel. All the factual data from each group was assembled into factual reports prepared by the ASC group chairmen. On February 20, 2001, ASC held a two-day “Factual Data Verification Meeting” in Taipei to verify the factual information collected up to that point. All members of the investigation team including NTSB, MCIT, ATSB and CAA of ROC were invited to attend that meeting. On February 23, 2001, ASC released a “Factual Data Report of SQ006 Accident” to the public and posted on the ASC website. The analysis phase of the investigation was officially commenced on March 1, 2001. Chapter 5, paragraph 5.25, of Annex 13 specifies that: “Participation in the investigation shall confer entitlement to participate in all aspects of the investigation, under the control of the Investigator-in-Charge, in particular to: a) Visit the scene of the accident; b) examine the wreckage; c) obtain witness information and suggest areas of questioning; d) have full access to all relevant evidence as soon as possible; e) receive copies of all pertinent documents; f) participate in read-outs of recorded media; g) participate in off-scene investigative activities such as component examinations, technical briefings, tests, and simulations; h) participate in investigation process meetings including deliberations related to analysis, findings, causes and safety recommendations; and i) make submissions in respect of the various elements of the investigation. Note 1 - It is recognized that the form of participation would be subject to the procedures of the State in which the investigation, or part thereof, is being conducted.” ii Therefore, ICAO Annex 13 makes it clear that the State conducting the investigation (the State of Occurrence) has the full right to decide the extent of participation of the Accredited Representatives, based on the investigating State’s procedures. According to the investigation procedures of the Aviation Safety Council, and following a deliberation and decision made in the 27th ASC Council Meeting, ASC allows Accredited Representatives’ teams to participate in all aspects of the investigation, as stated in items mentioned in Annex 13, paragraph 5.25 with the exception of item (h). It was deliberated in the 27th ASC Council Meeting that, in order to maintain its independence, ASC shall independently conduct the analysis, causal factors determination, and safety recommendation portion of the investigation, based on the factual data collected, and it shall not be influenced by anyone else, as long as proper feedback processes are available to the participants. Based on this fundamental guiding principle, the investigation team initiated the analysis phase independently. On July 4, and 5, 2001, ASC held a “Technical Review Meeting” in Taipei to go over ASC’s analysis to date. All members of the investigation team were invited to attend the meeting, and officials from ATSB, CAA OF ROC, MCIT, and NTSB attended. The first day of the meeting consisted of an ASC briefing to all members about its analysis to that point. The second day was spent receiving feedback from all participants to ASC’s analysis presented on the first day and reviewing additional factual evidence collected after February 23, 2001. After the ASC had evaluated the feedback provided by all participants at the July 4 and 5, 2001, Technical Review Meeting, on September 30, 2001, the ASC issued a “Preliminary Draft Report” to all the participants for their comments. The ASC gave the participants 30 days to provide comments. On November 1, 2001, ASC received comments from all the participants and subsequently spent three months reviewing the comments received and modifying the Preliminary Draft Report. On January 31, 2002, ASC issued the “Final Draft Report” of the SQ006 investigation to all participants and granted 60 days for comment, in accordance with Annex 13, paragraph 6.3. ASC also invited all participants to interact directly with the ASC Council Members at the Council’s 42nd Meeting held on March 26, 2002. The Singapore MCIT and CAA of ROC accepted the opportunity to present their opinions about the report to the Council Members on that day. Written comments on the Final Draft Report were received from all participants by March 30, 2002. Based on a review of those comments and verification of factual evidence, the ASC completed its investigation report, which was approved by the ASC Council Members on April 23, 2002, at the 43rd Council Meeting. Chapter 6, paragraph 6.3, of Annex 13 specifies, in part, that: iii “The State conducting the investigation shall send a copy of the draft Final Report to…all States that participated in the investigation, inviting their significant and substantial comments on the report as soon as possible…. If the State conducting the investigation receives comments within sixty days of the date of the transmittal letter, it shall either amend the draft Final Report to include the substance of the comments received or, if desired by the State that provided the comments, append the comments to the final report….” In summary, the ASC offered multiple opportunities for the participants to comment on the factual and analysis phases of the investigation and that exceeded the requirements of Annex 13, paragraph 6.3. This report was completed after a thorough review and consideration of all of the factual record of the investigation and the comments submitted by all organizations involved in the investigation. Although a significant number of the comments were accepted, wholly or in part, by the ASC, in accordance with Annex 13, paragraph 6.3, the comments submitted by NTSB of US, ATSB of Australia, MCIT of Singapore, as well as CAA of ROC are attached as submitted as an Appendix to this report (Appendix 7).
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