ANDREW DOYLE / SINGAPORE & DAVID LEARMOUNT / LONDON
Dispute over Taiwan investigation of SIA 747 Taipei crash threatens to overshadow efforts to improve runway safety
Debate over the conclusions of the Taiwan Aviation Safety Council's (ASC) final report into the Singapore Airlines (SIA) Boeing 747-400 crash at Taipei in October 2000 has degenerated into a war of words after the Singapore government harshly criticised the ASC's conduct of the investigation and its principal findings.
The aircraft slammed into construction equipment as the crew attempted to take off from closed runway 05R at Chiang Kai-shek (CKS) Airport during a heavy rainstorm on the night of 31 October, 2000, killing 83 of the 179 people on board. It had been cleared to take off on the parallel runway 05L.
"It would be a waste of the huge investigation effort that has been expended on this accident if blame and liability became the focus of attention, instead of safety improvements for the benefit of the travelling public," says the ASC in response to Singapore government criticism.
However, the report is so manifestly careful to exclude many issues relating to the airport from its definitions of what constitutes a contributory factor, that the ASC lays itself open to the same charge that it directs at Singapore.
For example, facts that might be considered to be contributory include poorly maintained taxiway markings, unserviceable taxiway centreline lights at critical points, and no attempt to mark the entrance to 05R - part of which was usable, but only as a taxiway - with any warning.
While "recognising" that the pilots took off from the wrong runway, Singapore's ministry of transport (MoT) says it refuses to accept that pilot error was the "main cause" of the accident, an interpretation that is difficult to understand given the crew mistakes that the report establishes and their outcome. It accuses the ASC of producing an "incomplete" report which "downplays significant systemic factors such as deficiencies at CKS Airport". Indeed, Singapore claims that action taken by CKS Airport to rectify infrastructure deficiencies immediately after the crash "demonstrates they are major contributory factors".
The MoT's comments have prompted an angry rebuttal from the ASC. It slams the Singapore ministry for releasing its own report into the accident despite the fact its comments were included in a lengthy annex to the official report, in accordance with International Civil Aviation Organisation (ICAO) guidelines. Furthermore, the ASC categorically rejects the Singapore MoT's claim that it was improperly excluded from the analysis phase of the investigation.
The ASC's report distinguishes itself with the quantity of its recommendations and the fact that no conceivable party to the event escapes its advice. Recipients include the airport authorities, the Taiwan Civil Aeronautics Administration, Taiwan's transport ministry, SIA, the Singapore civil aviation authority, the Singapore government, ICAO, Boeing, the International Air Transport Association and the US Federal Aviation Administration.
In summary, the recommendations say that anything that was broken on the day should be fixed, anything that was wrong should be put right and any potentially useful cockpit situational awareness equipment which does not exist should be developed and fitted.
The only strategic advice is that CKS should be equipped with surface movement radar and that Taiwan, although not accepted as an ICAO contracting state because of mainland China's objection, should ensure that all ICAO standards and recommended practices are adopted and implemented at its airports. Some salient points in the report, such as the fact that the rescue services could hardly operate in the appalling weather, and a recommendation that "guidance should be given" on the use of escape slides when the wind exceeds their deployment limitations, simply admit to the system's virtual helplessness in the face of really bad weather. The latter poses challenges to the industry at large.
But as far as Singapore is concerned, the biggest bone of contention is that seven of the ASC's eight probable-cause findings focus on mistakes made by the three flight crew. The only non-pilot-related finding was that poor weather resulting from the approach of typhoon Xangsane was a contributory factor.
The report presents the failure of CKS Airport to indicate, by surface markings and/or signs, that runway 05R was not operating as a runway as a factor "related to risk". ASC defines such findings as having "the potential to degrade aviation safety", but which "cannot be clearly shown to have operated in the accident alone". Although there are "no clear ICAO regulations" about warning signs at the entrance to a limited-use runway, the ASC admits that signs could have provided a "potential last defence" to alert the SQ006 pilots to their error.
The disagreement between the two states over the significance of deficiencies in surface markings, lighting and signage is unlikely ever to be resolved, but this should not detract from Taiwan's determination to tackle those deficiencies. Runway incursion accidents - including wrong-runway usage - are recognised at the world's major aviation agencies to be one of the greatest actual and potential killers, and unambiguous, standardised signage can play a vital part in reducing it.
One of the ASC's recommendations reasonably asks ICAO to develop "clear standards for defining and protecting a partially closed runway that may be used for taxi purposes".
SIA says it has already acted on the ASC report's recommendations that it amend its take-off procedures to require all cockpit crew to visually confirm the correct runway designation before starting to roll. The airline has also introduced a new module in its crew resource management training focusing specifically on situational awareness, and says it has placed the first order for a Boeing-developed, global positioning system-based take-off runway disagreement alerting function to be installed on its 747-400 and 777 fleets.
Fortunately, Taiwan has resisted countering with the charge that SIA's action proves its point about pilot error, because the noise this argument has already generated threatens to drown constructive debate over how to prevent accidents like this in the future.
Source: Flight International
