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1、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,
2、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 purs
3、uing 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. AI
4、RCRAFT 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
5、, 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
6、 1009101135 ISBN 957-01-0999-8 NT$1500 iExecutive 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
7、 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, Cal
8、ifornia, 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 crewme
9、mbers 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 ROCs Civil Aviation Law, and Annex 13 to the Convention on International Civil Aviat
10、ion (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 investi
11、gation 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 ch
12、anged to Ministry of Transportation (MOT) due to Singapore Governments 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. iias the Accredited Representatives to participate in the investigation. T
13、he 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 investiga
14、tion 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, inclu
15、ding 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, 20
16、01, 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 R
17、eport 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 o
18、f 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
19、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, find
20、ings, 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.” iiiTher
21、efore, 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 States procedures. According to the investigation procedures of the Aviatio
22、n 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 deliberate
23、d 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 lo
24、ng 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 ASCs analysis to date. All members of
25、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
26、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 Rep
27、ort” 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
28、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 Councils 42nd Meeting held on March 26,
29、 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 f
30、actual 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: iv “The State conducting the investigation shall send a copy of the draft Final R
31、eport toall 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
32、 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 t
33、hat 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
34、 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). A table indicating the acceptance status
35、of the comments from each organization is also attached. This investigation report follows the format of ICAO Annex 13 with few minor modifications. First, in Chapter 3, Conclusions, the Safety Council decided in their 39th Council Meeting that in order to further emphasize the importance that the p
36、urpose of the investigation report is to enhance aviation safety, and not to apportion blame and liability, this report presents the findings in three categories: findings related to the probable causes, findings related to risks, and other findings. Second, in Chapter 4, Safety Recommendations, oth
37、er than the safety recommendations suggested to the relevant organizations, the Safety Council also lists the safety actions already taken or being undertaken by both MCIT of Singapore and CAA of ROC. The Safety Council believes this modification would better serve the purpose of improving aviation
38、safety. It should also be noted that the Safety Council encourages the participants to take initiatives in safety improvements before the release of this report. Therefore, based upon the analysis by the Safety Council, the following are the key findings of this accident investigation. Findings as t
39、he result of this Investigation There are three different categories of findings as the result of this investigation, findings related to probable causes, findings related to risks, and other findings: The findings related to probable causes identify elements that have been shown to have operated in
40、 the accident, or almost certainly operated in the accident. These findings are associated with unsafe v acts, unsafe conditions, or safety deficiencies associated with safety significant events that played a major role in the circumstances leading to the accident. The findings related to risk ident
41、ify elements of risk that have the potential to degrade aviation safety. Some of the findings in this category identify unsafe acts, unsafe conditions, and safety deficiencies, including organizational and systemic risks, that made this accident more likely; however, they cannot be clearly shown to
42、have operated in the accident alone. Further, some of the findings in this category identify risks that are unrelated to this accident, but nonetheless were safety deficiencies that may warrant future safety actions. Other findings identify elements that have the potential to enhance aviation safety
43、, resolve an issue of controversy, or clarify an issue of unresolved ambiguity. Some of these findings are of general interests that are often included in the ICAO format accident reports for informational, safety awareness, education, and improvement purposes. Findings Related to Probable Causes 1.
44、 At the time of the accident, heavy rain and strong winds from typhoon “Xangsane” prevailed. At 2312:02 Taipei local time, the flight crewmembers of SQ006 received Runway Visual Range (RVR) 450 meters on Runway 05L from Automatic Terminal Information Service (ATIS) “Uniform”. At 2315:22 Taipei local
45、 time, they received wind direction 020 degrees with a magnitude of 28 knots, gusting to 50 knots, together with the takeoff clearance issued by the local controller. (1.1; 1.7) 2. On August 31, 2000, CAA of ROC issued a Notice to Airmen (NOTAM) A0606 indicating that a portion of the Runway 05R betw
46、een Taxiway N4 and N5 was closed due to work in progress from September 13 to November 22, 2000. The flight crew of SQ006 was aware of the fact that a portion of Runway 05R was closed, and that Runway 05R was only available for taxi. (1.18.2.6; 2.5.2.1; 2.5.3) 3. The aircraft did not completely pass
47、 the Runway 05R threshold marking area and continue to taxi towards Runway 05L for the scheduled takeoff. Instead, it entered Runway 05R and CM-1 commenced the takeoff roll. CM-2 and CM-3 did not question CM-1s decision to take off. (1.1; 1.18.1.1) 4. The flight crew did not review the taxi route in
48、 a manner sufficient to ensure they all understood that the route to Runway 05L included the need for the aircraft to pass Runway 05R, before taxiing onto Runway 05L. (1.18.1.1; 2.5.3) 5. The flight crew had CKS Airport charts available when taxing from the parking bay to the departure runway; howev
49、er, when the aircraft was turning from Taxiway NP to Taxiway N1 and continued turning onto Runway 05R, none of the flight crewmembers verified the taxi route. As shown on the Jeppesen “20-9” CKS Airport chart, the taxi route to Runway 05L required that vi the aircraft make a 90-degree right turn fro
50、m Taxiway NP and then taxi straight ahead on Taxiway N1, rather than making a continuous 180-degree turn onto Runway 05R. Further, none of the flight crewmembers confirmed orally which runway they had entered. (1.18.1.1; 2.5.2.2; 2.5.4.3) 6. CM-1s expectation that he was approaching the departure ru