Crash of a Boeing 747-409 in Hong Kong

Date & Time: Nov 4, 1993 at 1136 LT
Type of aircraft:
Operator:
Registration:
B-165
Survivors:
Yes
Schedule:
Taipei - Hong Kong
MSN:
24313
YOM:
1993
Flight number:
CI605
Country:
Region:
Crew on board:
22
Crew fatalities:
Pax on board:
274
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12469
Captain / Total hours on type:
3559.00
Copilot / Total flying hours:
5705
Copilot / Total hours on type:
908
Aircraft flight hours:
1969
Aircraft flight cycles:
359
Circumstances:
China Airlines' scheduled passenger flight CAL605 departed Taipei (TPE), Taiwan at 02:20 for the 75-minute flight to Hong Kong-Kai Tak (HKG). The departure and cruise phases were uneventful. During the cruise the commander briefed the co-pilot on the approach to Hong Kong using the airline's own approach briefing proforma as a checklist for the topics to cover. The briefing included the runway-in-use, navigation aids, decision height, crosswind limit and missed approach procedure. He paid particular attention to the crosswind and stated that, should they encounter any problem during the approach, they would go-around and execute the standard missed approach procedure. The commander did not discuss with the co-pilot the autobrake setting, the reverse thrust power setting or their actions in the event of a windshear warning from the Ground Proximity Warning System (GPWS). Weather reports indicated strong gusty wind conditions, rain and windshear. On establishing radio contact with Hong Kong Approach Control at 03:17, the crew were given radar control service to intercept the IGS approach to runway 13 which is offset from the extended runway centreline by 47°. After intercepting the IGS localiser beam, the pilots changed frequency to Hong Kong Tower and were informed by the AMC that the visibility had decreased to 5 kilometres in rain and the mean wind speed had increased to 22 kt. Two minutes before clearing CAL605 to land, the air traffic controller advised the crew that the wind was 070/25 kt and to expect windshear turning short final. During the approach the pilots completed the landing checklist for a flaps 30 landing with the autobrakes controller selected to position '2' and the spoilers armed. The reference airspeed (Vref) at the landing weight was 141 kt; to that speed the commander added half the reported surface wind to give a target airspeed for the final approach of 153 kt. Rain and significant turbulence were encountered on the IGS approach and both pilots activated their windscreen wipers. At 1,500 feet altitude the commander noted that the wind speed computed by the Flight Management Computer (FMC) was about 50 kt. At 1,100 feet he disconnected the autopilots and commenced manual control of the flightpath. A few seconds later at 1,000 feet he disconnected the autothrottle system because he was dissatisfied with its speed holding performance. From that time onwards he controlled the thrust levers with his right hand and the control wheel with his left hand. Shortly afterwards the commander had difficulty in reading the reference airspeed on his electronic Primary Flying Display (PFD) because of an obscure anomaly, but this was rectified by the co-pilot who re-entered the reference airspeed of 141 kt into the FMC. Shortly before the aircraft started the visual right turn onto short final, the commander saw an amber 'WINDSHEAR' warning on his PFD. A few seconds later, just after the start of the finals turn, the ground proximity warning system (GPWS) gave an aural warning of "GLIDESLOPE" which would normally indicate that the aircraft was significantly below the IGS glidepath. One second later the aural warning changed to "WINDSHEAR" and the word was repeated twice. At the same time both pilots saw the word 'WINDSHEAR' displayed in red letters on their PFDs. Abeam the Checkerboard the commander was aware of uncommanded yawing and pitch oscillations. He continued the finals turn without speaking whilst the co-pilot called deviations from the target airspeed in terms of plus and minus figures related to 153 kt. At the conclusion of the turn both pilots were aware that the aircraft had descended below the optimum flight path indicated by the optical Precision Approach Path Indicator (PAPI) system. The air traffic controller watched the final approach and landing of the aircraft. It appeared to be on or close to the normal glidepath as it passed abeam the tower and then touched down gently on the runway just beyond the fixed distance marks (which were 300 metres beyond the threshold) but within the normal touchdown zone. The controller was unable to see the aircraft in detail after touchdown because of water spray thrown up by it but he watched its progress on the Surface Movement Radar and noted that it was fast as it passed the penultimate exit at A11. At that time he also observed a marked increase in the spray of water from the aircraft and it began to decelerate more effectively. The commander stated that the touchdown was gentle and in a near wings level attitude. Neither pilot checked that the speed brake lever, which was 'ARMED' during the approach, had moved to the 'UP' position on touchdown. A few seconds after touchdown, when the nose wheel had been lowered onto the runway, the co-pilot took hold of the control column with both hands in order to apply roll control to oppose the crosswind from the left. The aircraft then began an undesired roll to the left. Immediately the commander instructed the co-pilot to reduce the amount of applied into-wind roll control. At the same time he physically assisted the co-pilot to correct the aircraft's roll attitude. Shortly after successful corrective action the aircraft again rolled to the left and the commander intervened once more by reducing the amount of left roll control wheel rotation. During the period of unwanted rolling, which lasted about seven seconds, the aircraft remained on the runway with at least the left body and wing landing gears in contact with the surface. After satisfactory aerodynamic control was regained, the co-pilot noticed a message on the Engine Indicating and Crew Alerting System (EICAS) display showing that the autobrake system had disarmed. He informed the commander that they had lost autobrakes and then reminded him that reverse thrust was not selected. At almost the same moment the commander selected reverse thrust on all engines and applied firm wheel braking using his foot pedals. As the aircraft passed abeam the high speed exit taxiway (A11), the commander saw the end of the runway approaching. At that point both he and the co-pilot perceived that the distance remaining in which to stop the aircraft might be insufficient. At about the same time the co-pilot also began to press hard on his foot pedals. As the aircraft approached the end of the paved surface the commander turned the aircraft to the left using both rudder pedal and nose wheel steering tiller inputs. The aircraft ran off the end of the runway to the left of the centreline. The nose and right wing dropped over the sea wall and the aircraft entered the sea creating a very large plume of water which was observed from the control tower, some 3.5 km to the northwest. The controller immediately activated the crash alarm and the Airport Fire Contingent, which had been on standby because of the strong winds, responded very rapidly in their fire vehicles and fire boats. Other vessels in the vicinity also provided prompt assistance. After the aircraft had settled in the water, the commander operated the engine fuel cut-off switches and the co-pilot operated all the fire handles. The commander attempted to speak to the cabin crew using the interphone system but it was not working. The senior cabin crew member arrived on the flight deck as the commander was leaving his seat to proceed aft. The instruction to initiate evacuation through the main deck doors was then issued by the commander and supervised by the senior cabin crew member from the main deck. Ten passengers were injured, one seriously.
Probable cause:
The accident was the consequence of the combination of the following factors:
- The commander deviated from the normal landing roll procedure in that he inadvertently advanced the thrust levers when he should have selected reverse thrust.
- The commander diminished the co-pilot's ability to monitor rollout progress and proper autobrake operation by instructing him to perform a non-standard duty and by keeping him ill-informed about his own intentions.
- The copilot lacked the necessary skill and experience to control the aircraft during the landing rollout in strong, gusty crosswind conditions.
- The absence of a clearly defined crosswind landing technique in China Airline's Operations Manual deprived the pilots of adequate guidance on operations in difficult weather conditions.
Final Report:

Crash of a McDonnell Douglas MD-82 in Fuzhou: 2 killed

Date & Time: Oct 26, 1993 at 1304 LT
Type of aircraft:
Operator:
Registration:
B-2103
Survivors:
Yes
Schedule:
Shenzhen - Fuzhou
MSN:
49355
YOM:
1985
Flight number:
MU5398
Location:
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
71
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The descent to Fuzhou Airport was completed in poor weather conditions with limited visibility due to heavy rain falls. On short final, the aircraft was too high and about 350 metres to the right of the extended centerline. The captain realized he could not land in such conditions so, at a height of 20 metres, he decided to initiate a go-around procedure, increased engine power and retracted the flaps. The aircraft continued to descend so the crew finally decided to land. The aircraft touched down 1,983 metres past the runway threshold. On a wet runway surface, it was unable to stop within the remaining distance, overran, lost its undercarriage and came to rest in a swamp located 385 metres past the runway end, broken in three. Two passengers were killed while 25 others were injured.
Probable cause:
Wrong approach configuration on part of the flying crew. The braking coefficient was reduced because the runway surface was wet. The crew failed to initiate a go-around procedure earlier.

Crash of a BAe 146-300 in Yinchuan: 55 killed

Date & Time: Jul 23, 1993 at 1441 LT
Type of aircraft:
Operator:
Registration:
B-2716
Flight Phase:
Survivors:
Yes
Schedule:
Yinchuan - Beijing
MSN:
E3215
YOM:
1992
Flight number:
WH2119
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
108
Pax fatalities:
Other fatalities:
Total fatalities:
55
Circumstances:
During the takeoff roll on runway 36 at Yinchuan Airport, at Vr speed, the pilot-in-command pull up the control column to rotate but the aircraft failed to respond. Following a lack of crew coordination and inappropriate decisions, the crew failed to abort the takeoff procedure. After a long roll, the nose gear lifted off but the aircraft entered a high nose attitude, causing the tail to struck the runway surface. The aircraft then overran runway 36, collided with various obstacles and eventually crashed in a lake. 58 occupants were injured while 55 others were killed, among them one crew member. Weather conditions were good with OAT +27° C and an excellent visibility. Runway 36 is 2,160 metres long.
Probable cause:
It was determined that the accident was the consequence of a wrong takeoff configuration on part of the crew. For unknown reasons, both leading edge and trailing edge flaps were not properly deployed for the takeoff procedure. Due to lack of coordination, the crew failed to proceed to cross checks prior to departure and failed to realize that the aircraft was not properly configured for takeoff. Nevertheless, it was not established if the flaps warning sounded or not prior to the accident.

Crash of a Britten-Norman BN-2A-7 Islander off Hong Kong

Date & Time: Dec 15, 1992
Type of aircraft:
Registration:
HKG-7
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hong Kong - Hong Kong
MSN:
615
YOM:
1970
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight in Hong Kong on behalf of the Royal Hong Kong Auxiliary Air Force. An engine failed en route and the aircraft crashed in the Tolo harbour, north of Hong Kong. Both pilots were rescued and the aircraft was damaged beyond repair.
Probable cause:
Engine failure for unknown reasons.

Crash of a Boeing 737-3Y0 near Guilin: 141 killed

Date & Time: Nov 24, 1992 at 0752 LT
Type of aircraft:
Operator:
Registration:
B-2523
Survivors:
No
Site:
Schedule:
Guangzhou - Guilin
MSN:
24913
YOM:
1991
Flight number:
CZ3943
Location:
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
131
Pax fatalities:
Other fatalities:
Total fatalities:
141
Aircraft flight hours:
4165
Aircraft flight cycles:
3153
Circumstances:
At a distance of 40 km from the airport, at an altitude of 7,800 feet, the crew was cleared to make a visual approach and to descent to 7,000 feet. Three minutes later, the aircraft went out of control and crashed on a mountain slope (1'600 metres high) located 27 km south from runway 36. The aircraft was totally destroyed and all 141 occupants were killed. It was reported that the captain attempted to level off the plane by raising its nose. The autothrottle responded by advancing the throttles. The n°2 power lever however remained at idle. The crew apparently did not notice this. With the right engine at idle, the autothrottle further advanced the left engine power lever in order to obtain the correct airspeed. The asymmetrical power condition was not corrected and the airplane rolled to the right and crashed.

Crash of an Avia 14M near Dingxi: 14 killed

Date & Time: Oct 8, 1992 at 1531 LT
Type of aircraft:
Operator:
Registration:
B-4211
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Lanzhou - Xi'an
MSN:
109 807 113
YOM:
1958
Location:
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
The aircraft departed Lanzhou around 1445LT on a flight to Xi'an, carrying 28 passengers and a crew of seven. About 45 minutes into the flight, the crew informed ATC about the failure of the left engine and was cleared to return to Lanzhou. Unable to maintain a safe altitude, the aircraft struck a hilly terrain and crashed near Dingxi, about 72 km southeast of Lanzhou. 14 people were killed and 21 others were injured.
Probable cause:
Failure of the left engine in flight for unknown reasons.

Crash of a Yakovlev Yak-42D in Nankin: 107 killed

Date & Time: Jul 31, 1992 at 1512 LT
Type of aircraft:
Operator:
Registration:
B-2755
Flight Phase:
Survivors:
Yes
Schedule:
Nankin - Xiamen
MSN:
21 16 644
YOM:
1992
Flight number:
GP7552
Location:
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
116
Pax fatalities:
Other fatalities:
Total fatalities:
107
Circumstances:
During the takeoff roll on runway 06, after passing decision speed, the crew started to rotate but the aircraft failed to respond. The crew aborted takeoff and initiated an emergency braking procedure. Unable to stop within the remaining distance, the aircraft overran and rolled for about 420 meters. At a speed of 210 km/h, it struck successively a 6,7 metres deep drainage ditch and a 2 metres high embankment before coming to rest, bursting into flames. 19 people including one crew member were injured while 107 other occupants were killed.
Probable cause:
It was determined that the crew did not prepare the flight according to published procedures and failed to follow the pre-takeoff checklist. As a result, the aircraft was unable to takeoff because the elevator trim was set in a landing configuration.

Ground accident of a Boeing 757-21B in Guangzhou: 46 killed

Date & Time: Oct 2, 1990 at 0904 LT
Type of aircraft:
Operator:
Registration:
B-2812
Flight Phase:
Survivors:
Yes
Schedule:
Guangzhou - Shanghai
MSN:
24758
YOM:
1990
Flight number:
CZ2812
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
106
Pax fatalities:
Other fatalities:
Total fatalities:
46
Circumstances:
While parked at Guangzhou Airport, ready for flight CZ2812 to Shanghai-Hongqiao, Airport, the aircraft was struck by a Xiamen Airlines B737 that crashed upon landing after being hijacked. 46 passengers were killed and all other occupants were injured. The aircraft was destroyed.
Probable cause:
Struck by a B737 that crashed upon landing after being hijacked.

Ground accident of a Boeing 707-3J6B in Guangzhou: 1 killed

Date & Time: Oct 2, 1990 at 0904 LT
Type of aircraft:
Operator:
Registration:
B-2402
Flight Phase:
Survivors:
Yes
Schedule:
Guangzhou - Chengdu
MSN:
20714
YOM:
1973
Flight number:
SZ2402
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
122
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While parked at Guangzhou-Baiyun Airport, ready for taxi, the B707 was struck by a Boeing 737-327 operated by Xiamen Airlines that crashed upon landing after being hijacked. The B737 struck the cockpit of the B707, killing one of the crew member. All 130 other occupants were evacuated safely and the aircraft was damaged beyond repair.

Crash of a Boeing 737-247 in Guangzhou: 83 killed

Date & Time: Oct 2, 1990 at 0904 LT
Type of aircraft:
Operator:
Registration:
B-2510
Survivors:
Yes
Schedule:
Xiamen - Guangzhou
MSN:
23189
YOM:
1984
Flight number:
MF8301
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
93
Pax fatalities:
Other fatalities:
Total fatalities:
83
Circumstances:
En route from Xiamen to Guangzhou, the aircraft was hijacked by a young man who wanted to fly to Taiwan. He took the place of the copilot who left the cockpit and continued the flight with the captain. On short final to Guangzhou-Baiyun Airport, the hijacker realized he was not in Taiwan and started to fight with the captain who lost control of the airplane. Upon touchdown, the B737 veered off runway to the right at high speed, rolled through the apron, struck the cockpit of a parked B707 operated by China Southwest Airlines (registered B-2402), rolled over a truck and eventually collided with a parked B757 operated by China Southern Airlines (registered B-2812). All three aircraft were destroyed and 130 people were killed, 82 on board the B737, one pilot on board the B707, one driver on the ground and 46 passengers on board the B757.
Probable cause:
Loss of control upon landing after being hijacked.