SMS Final Project Report

Accident Boeing 747 at taipie International Airport

Group Members
1) Shahraiz (62644)
2) Hodan Abdullah(62304)
3) Fariha Mohamed(62305)
4) NehaSehar()
5) Hafiz Khadim()

Details of accident:
Singapore Airlines Flight SQ006 with registration 9V-SPK left Singapore for a flight to Los Angeles from Taipei on October
31, 2000. Scheduled departure time at Taipei was 22:55. The flight left Gate B-5 and taxied to taxiway NP, which ran
parallel to runway 05L and 05R. The crew had been cleared for a runway 05L departure because runway 05R was closed
due to construction work. CAA had issued a notice on 31 August 2000 indicating that part of runway 05R between
taxiways N4 and N5 was closed for construction from 13 September to 22 November 2000. Runway 05R was to have
been converted and redesignated as taxiway and on that day the visibility was not clear and the aircraft was going on
runway lines and immediately made a 180-degree turn to runway 05R. After approximately six second hold, SQ006
started its takeoff roll at 23:15:45. Weather conditions were very poor because of typhoon “Xiang Sane” in the area.
METAR at 23:20 included Wind 020 degrees at 36 knots gusting 56 knots, visibility less than 600 meters, and heavy
rainfall. On takeoff, 3.5 seconds after V1, the aircraft hit concrete barriers, excavators and other equipment on runway
05R. The plane crashed back onto the runway, breaking up and bursting into flames while sliding down the runway and
crashing into other objects related to work being done on runway 05R. The aircraft wreckage was distributed along
runway 05R beginning at about 4,080 feet from the runway threshold. The airplane broke into two main sections at about
fuselage station 1560 and came to rest about 6,480 feet from the runway threshold.

Possible hazards:
1) The first hazard was the weather which was not clear and on the time of accident as in the weather only lights and
markings can help to cross or to take turn on the runway or we can say that the lights and signs are the means of
communication for the pilots and aircraft crew.
2) The second hazard is that pilot can see only the some feet in front of his eyes on runway and rest of the things
were just invisible.
3) Third possible hazard is that there were no sign board on the starting of 05R runway. Because there should be the
visible sign for the construction on the turning start of the runway.
4) There was FOD which was the concrete barriers and then there were also hazards on the runway.
5) There were complete Miscommunications between the pilot and air traffic controllers as the duty of ATC to clear
this message to the pilots that there is construction work.
6) There were also the sign was not preset on the runway and the location of the sign 05R was not on the right
location.

Consequences:
1) The consequences were so much severe as the completely aircraft was destroyed moreover that resulted the 83
deaths and complete damage of an aircraft.
2) The Weather condition was severe and the typhoon was going on on that time and the visibility was just not clear
as they cannot see the signs and the runway.
3) Construction equipment was placed in between the runway and it was also a big hazard for them as consequences
of that the aircraft completely destroyed.
4) Missing section of center line markings were present as the markings are the only signs for taxi and runway for the
worst weather conditions.
5) There were also dim taxi centerline lights and the runway lights were dim And lights are also helpful for the worst
weather conditions.

Probability of occurrence:
1) On the side of weather the probability of this accident was occasional as no one thought that it can be happen on
this runway as the Pilot and flight crew just ignored the instructions of Air Traffic Control and they did not focused
on the 05L and they thought they are turning on the 05R.
2) The Construction Equipment probability was remote because there was construction work is going on and
everyone knows about this so nobody will go to that runway so that’s why the probability of construction equipment
was remote. But there is one important point that there should also be the visible sign boards of construction as the
barriers were present on the runway.
3) The probability of foreign object damage was Occasional because Foreign Object was present in the center of the
runway.
4) Missing sections of Central Line Markings were there as they had to follow those lines in that worst weather
condition.

Severity of consequences:
1) The Weather severity consequences were so much catastrophic as the visibility was just not available.
2) Signs were not there as the line markings on the runway and the lights present on the runway were dim so it
resulted them to turn to the 05R.
3) Construction Equipment was present there as the presence of construction equipment was catastrophic and it was
clear that if someone use this runway it will be a very big disaster.
4) The Miscommunication was also very catastrophic as it resulted the multiple deaths and damage to the aircraft.

Risk severity:
1) The risk severity for weather was 5A as Weather was catastrophic as there were typhoon going on in that area on
the time of departure the heavy rain was there on that time so these all conditions were catastrophic any pilot or
ATC crew have to take these all things very seriously.
2) Construction Equipment was also present on the 05R runway as it is also very clear that presence of any
equipment on the runway is also very catastrophic. As if some barriers are present on any kind of runway it can
destroy any aircraft and very placed in 05A.
3) The Miscommunication was placed in 4C as this was the miscommunication as it was the duty of the air traffic
controllers to ensure that the pilot completely understood that they cannot use the runway 05R.
4) Unavailability of the signs was 4C as the unavailability of signs is a common thing around the world and it is still
present on many airports in the world.

Intolerable regions:
The weather was the intolerable as they had to take it very seriously and they just ignored the
Miscommunication

Tolerable regions:
Investigators found several other lighting and marking problems. Some of the runway edge lights on both 05L and 05R
were either broken or "aligned away from the direction of the runway length," report said. Also, there was nothing over the
05R threshold markings that indicated the runway was closed.

Runway 05R had been closed since mid-September for needed pavement repairs. The plan was to convert it into a full-
time taxiway on November 1, but the timeline was pushed back before the SQ006 crash. Before being closed, it was used
for visual departures only.

The SQ006 PIC told investigators he was aware of 05R's status. He had used the runway in the past; his last departure
on it was "two or three years" ago, report said. The PIC's last flight to CKS Airport before October 31 was sometime in
early to mid-September, the report said.

Singapore Airlines most often used runway 06, the parallel runway south of CKS Airport terminal, because it is "closer to
the parking bays used by the company," the SQ006 PIC told. But runway 06 is a Category I ILS runway, and the weather
on October 31 persuaded the pilot to request runway 05L, a Category II runway, because it is "longer and would therefore
afford better margins for the prevailing wet runway conditions
Assessment Risk index:
Type of
Specific components of
Nº operation or Generic hazard
the hazard
activity
Lighting system
1. Inadequate taxi and
runway light system
2. Stop bar lights were in
the wrong position
2 Aerodrome Aerodrome Lighting system
operator construction
1. Inadequate taxi and
runway light system
Stop bar lights were in
the wrong position
2. Weather (Typhoon)
Existing defences to Further action to reduce
Hazard-related
control risk(s) and risk risk(s) and resulting risk
consequences
index
index
Taxing into the closed
runway Risk index: 3A Risk index: 2A
Risk tolerability: Risk tolerability: Acceptable
Unacceptable under the based on risk mitigation. It
Loss of situational existing circumstances might require management
awareness decision
Taxing into the closed
runway
Damage to equipment and
runway 1. Runway & taxiway 1. Replace the missing
signage and markings lights
1. Loss of life 2. Colour of runway centre More frequent
lights (green and not 2. inspection
2. Damage to aerodrome/
white) on 05R
construction equipment/
Aircraft 3. Ensure the aerodrome
lighting and signage
meets ICAO annex 14
requirements
4. Runway closed marker
missing X (05R)
5. Use of follow me car
1. Loss of situational during low visibility
operations
awareness
Risk index: 3A
2. Taxing into the closed
Risk tolerability: Risk index: 1A
runway
Unacceptable under the Risk tolerability:
existing circumstances Acceptable
 Type of Existing defences to Further action to reduce
Specific components of Hazard-related
Nº operation or Generic hazard control risk(s) and risk risk(s) and resulting risk
the hazard consequences
activity index

1
. Requirement by ATC for
3 Air traffic Aerodrome
Aerodrome procedures • Take-off on the closed ATIS confirmation by crew
controller construction
coupled by Weather runway before clearance for
(Typhoon) take-off
• Time pressure to ATC
2
Aerodrome (poor) visibility due to possible . Use of surface
and deteriorating conditions aerodrome closure movement radar

3. Use of Low visibility

Procedures
Risk index: 3B Risk index: 1B
Risk tolerability: Risk tolerability:
Acceptable based on risk Acceptable
mitigation. It might require
management decision

---------------

Organizational processes

Activities over which any organization has a reasonable degree of direct control

- Planning

- Scheduling

- Failure to install Surface Movement Radar (SMR), and special taxiway-lighting

facilities for use under low visibility-conditions,

- Air Traffic Control at Anyfield is slightly understaffed,

- consecutive nightshifts,

- Time pressure to the pilot to have the aircraft back asap

Safety Measures:

Workplace conditions

Factors that directly influence the efficiency of people in

aviation workplaces

OJT

Obstructed by the newly constructed extension to the terminal building at Anyfield Airport.

The pilot of the twin-engined piston-driven aircraft was unfamiliar with Anyfield Airport,
Inexperienced ATC in operating in this specified Wax conditions

TWR is not equipped with Frequency coupling

Latent conditions

Conditions present in the system before the accident, made evident by triggering factors

ATC understaffing

They were both completing their third consecutive nightshift

Absence of the signage to various TWY intersection

Unproper scheduling of atc

Criteria
- ATCO did not challenge ambiguous position report by twin-engine pilot
- intruded the departure-runway
-
- ATC failure to locate the actual position of the pilo

- Progressive taxi instructions

- (Technology) Surface Movement Radar (SMR), special taxiway-lighting facilities for use under low visibility-conditions

- proper scheduling of atc

- Signage in grass

- Proper taxi-instructions could have been given to the "lost" aircraft

Findings:
1. At the time of the accident, heavy rain and strong winds from typhoon "Xiang Sane" prevailed. At 23:12:02 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 23:15:22 Taipei local 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.
2. On 31 August 2000, the CAA issued a Notice to Airmen (NOTAM) A0606 indicating that a portion of the runway
05R between taxiway N4 and N5 was closed due to work in progress from 13 September to November 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.
3. The aircraft did not completely pass the runway 05R threshold marking area and continue to taxi towards runway
05L for the scheduled takeoff. Instead, it entered runway 05R and the Pilot-in-command (PIC) commenced the
takeoff roll. The pilot second-in command (SIC) and the third pilot did not question the PIC's decision to take off.
4. The flight crew did not review the taxi route in 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.
5. The flight crew had CKS Airport charts available when taxing from the parking bay to the departure runway;
however, 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 the aircraft make a 90-degree right turn from 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.
6. The PIC's expectation that he was approaching the departure runway coupled with the saliency of the lights leading
onto runway 05R resulted in the PIC allocating most of his attention to these centreline lights. He followed the
green taxiway centreline lights and taxied onto runway 05R.
7. The moderate time pressure to take off before the inbound typhoon closed in around CKS Airport, and the
condition of taking off in a strong crosswind, low visibility, and slippery runway subtly influenced the flight crew's
decision influencing the ability to maintain situational awareness.
8. On the night of the accident, the information available to the flight crew regarding the orientation of the aircraft on
the airport was: a) CKS Airport navigation chart b) Aircraft heading references c) Runway and taxiway signage and
marking d) Taxiway N1 centerline lights leading to runway 05L e) Color of the centerline lights (green) on runway
05R f) Runway 05R edge lights most likely not on g) Width difference between runway 05L and runway 05R h)
Lighting configuration differences between runway 05L and runway 05R i) Para-Visual Display (PVD) showing
aircraft not properly aligned with the runway 05L localizer j) Primary Flight Display (PFD) information The flight
crew lost situational awareness and commenced takeoff from the wrong runway. The Singapore Ministry of
Transport (MOT) did not agree with the findings and released their own report. They conclude that the systems,
procedures and facilities at the CKS Airport were seriously inadequate and that the accident could have been
avoided if internationally-accepted precautionary measures had been in place at the CKS Airport.
9. Weather at the time of the crash, which happened at 11:17 p.m. local time October 31, was rainy and windy due to
a typhoon bearing down on CKS. Visibility was about 500 meters. Facts gathered by investigators and released
by CAA show that, because of the poor weather and night-time conditions, the PIC and SIC elected to switch on
the PVD. The PVD, a mechanical instrument mounted on a panel in front of each pilot position that helps the pilot’s
line up and stays on a given runway's centerline, works with the plane's instrumentation to monitor a runway's
Instrument Landing System (ILS) signal. The PVD resembles a barber pole sitting on its side, with black stripes on
a white background. It is not mandatory equipment, and carriers that use it only require it to be activated.