Find an Aircraft accident and do the 5- Model Analysis, Swiss Cheese Model Analysis, and SHELL model Analysis
Synopsis
On 31 Oct 2000, Singapore Airlines Flight 006, a Boeing 747-400 aircraft, scheduled for Taipei to Los Angeles, took off on the wrong runway 05R (that was closed for maintenance works and parallel to runway 05L which they had intended to take off) in bad meteorological conditions. Whilst on the take-off roll, the aircraft collided with construction equipment and crashed, resulting in 83 out 179 people being killed.
Analysis using 5-M Model/ Swiss Cheese Model/ SHELL Model
FINDINGS
Man
Qualification and Flying Record of the Crew
The primary flying crew consisted of the Pilot and Co-pilot. The aircraft captain had been a Captain for the Boeing 747-400 fleet since 1998 and had a total of 11235 hours of flying time.
The Co-pilot had been a First Officer since 2000 and had a total of 2442 hours of flying time.
Currency and Proficiency
From the aircrew records, both pilots were qualified and current for their flight. They were also current in simulator training. From interviews, both involved were assessed to be confident in carrying out their assigned duties.
Medical Status
Both pilot and co-pilot were physically well at the time of the flight. On review of past medical records, both pilots did not have any significant medical conditions of note. Both pilots reported that they had not consumed any medications or intoxicating beverage 72 and 48 hrs prior to the flight. There was no evidence to suggest alcohol or drugs were factors in the accident.
Physiological and Psychological Fitness
Both pilot and co-pilot were assessed to be psychologically and physiologically fit for the flight. The 2 crew had adequate sleep for the past 72 hrs prior, and were not fatigued on the day of the flight.
Machine
Aircraft Damage
The Aft fuselage separated from the remainder of the fuselage and was generally intact. The mid and forward fuselage suffered extreme fire damage. The left and right wing were heavily damaged by fire.
Aircraft History
The incident aircraft was serviceable on the day of the accident and the last maintenance performance was the A check at 17838 hrs, on 29 Oct 2000. The current airframe hours is 18459 hrs, 621 hrs since last service. A review of the maintenance logbooks revealed no related defects in the 30 days of Tech Log entries and showed no evidence that the aircraft was not airworthy.
Medium
Weather
Taiwan was affected by north-east monsoon flow and typhoon "Xangsane". The Taipei Meteorological Service issued a SIGMET for cumulonimbus, together with several gale and typhoon warnings which was applicable to the airport at the time of the accident.
Surface Weather observations at the time of the accident varied with winds at 020 degrees, 30 kts gusting to 61 kts, visibility was 450m, RVR was 450m, there was heavy rain, with broken clouds at 200ft and overcast at 500ft.
Airfield Lightings/ Markings/ Signages
The green taxiway lights immediately after 05R entry point into 05L were not serviceable and the following lights leading to 05L were degraded and dim.
There were no runway guard lights to depict that they the active runway way was ahead.
Taxiway centre line markings did not extend all the way down to the runway 05L threshold marking with interruption stops before the 05R threshold marking.
No runway markings to indicate that runway 05R was closed.
No visual warning/ signages or physical barriers to indicate maintenance works was in progress to prevent aircraft from lining up on wrong runway.
Due to heavy winds and rain, concrete barriers instead of frangible ones with red obstruction lights (that were not visible in low visibility) were used to demarcate the construction areas.
Management
The flight crew received a pre-flight briefing package with pertinent information such as weather and NOTAMs highlighted; they were aware of the NOTAMs that stated that runway 05R was closed and takeoffs and landings were prohibited and certain sections were available for taxy.
Ground radar to pick up aircraft's position in low visibility was not installed due budgetary constraints. Hence there was no concrete plan to deal with low visibility operations.
Mission
The mission complexity was getting higher due to weather conditions deteriorating with the typhoon getting closer to the airport.
ACCIDENT ANALYSIS [2]
Investigations deemed that Machine was non-contributory. However, Man, Medium, Mission and Management had varying degrees of involvement toward the outcome of this flight. Significantly, Man and Management were pivotal factors, both of which could have mitigated the risks involved.
Man
The pilot and co-pilot did not review the taxy route in a sufficient manner by making use of airport charts available to ensure that the route entailed taxiing pass 05R before entering 05L.
The pilot did not make use of the Para-visual display in the cockpit prior to take off which would have indicated that he had lined up on the wrong runway.
Medium
Reduced visibility in darkness and heavy rain diminished pilot's ability to see airfield's markings, lightings and signages.
Management
Airport Management failed to conform to ICAO Annex 14 (Aerodrome Standards) in its airfield markings, lightings and signages.
Airport Management failed to notice these deficiencies during design verification, work completion certification and in day to day maintenance and inspection.
Airport Management did not cater for an independent audit/ assessment of airport to ensure facilities met international safety standards and practices.
Mission
Due to worsening weather conditions, pilot's hastened their departure to avoid flight delay which could have influenced pilot's decision making and loss of situational awareness in the airfield.
