July 19, 1996

This report on the accident of China Airlines B 1816 has been prepared based upon the investigation carried out by the Aircraft Accident Investigation Commission, in accordance with Annex 13 to the Convention on International Civil Aviation and Article 20 of Aircraft Accident Investigation Commission Establishment Law of Japan.

Kazuyuki Takeuchi
Chairman
Aircraft Accident Investigation Commission

Summary of the Aircraft Accident

China Airlines Airbus Industrie A300B4-622R B 1816 took off from Taipei International Airport at 0853 UTC (1753 JST) on April 26, 1994 and continued flying according to its flight plan. About 1116 UTC (2016 JST), while approaching Nagoya Airport for landing, the aircraft crashed into the landing zone close to E1 taxiway of the airport.

On board the aircraft were 271 persons: 256 passengers (including 2 infants) and 15 crew members, of whom 264 persons (249 passengers including 2 infants and 15 crew members) were killed and 7 passengers were seriously injured. The aircraft ignited, and was destroyed.

Flight History

China Airlines' Flight 140 (from Taipei International Airport to Nagoya Airport), B 1816, took off from Taipei International Airport at 0853 UTC (1753 JST) on April 26, 1994 (hereinafter all times shown are Coordinated Universal Time, unless otherwise specified), carrying a total of 271 persons consisting of 2 flight crew members, 13 cabin crew members and 256 passengers (including 2 infants).

The flight plan of the aircraft, which had been filed to the Taiwanese civil aviation authorities, Zhongzheng International Airport Office, was as follows:

Flight rule: IFR, Aerodome of departure: Taipei International Airport, Destination@Aerodome: Nagoya Airport, Cruising speed: 465 knots, Level: FL 330, Route: Al SUC-JAKAL-KE-SIV-XMC, total estimated enroute time: 2 hours and 18 minutes, Alternate Aerodome: Tokyo International Airport.

CAUSES

While the aircraft was making an ILS approach to Runway 34 of Nagoya Airport, under manual control by the F/O, the F/O inadvertently activated the GO lever, which changed the FD (Flight Director) to GO AROUND mode and caused a thrust increase. This made the aircraft deviate above its normal glide path.

The APs were subsequently engaged, with GO AROUND mode still engaged. Under these conditions the F/O continued pushing the control wheel in accordance with the CAP's instructions. As a result of this, the THS (Horizontal Stabilizer) moved to its full nose-up position and caused an abnormal out-of-trim situation.

The crew continued approach, unaware of the abnormal situation. The AOA increased the Alpha Floor function was activated and the pitch angle increased.

It is considered that, at this time, the CAP (who had now taken the controls), judged that landing would be difficult and opted for go-around. The aircraft began to climb steeply with a high pitch angle attitude. The CAP and the F/O did not carry out an effective recovery operation, and the aircraft stalled and crashed.

PROPOSALS

In view of the China Airlines accident, the Aircraft Accident Investigation Commission proposes the following to Minister of Transport of Japan.

1. Standardization of AFS specification for advanced technology aircraft

With regard to the AFS functions of advanced technology aircraft presently operated by Japanese airlines, there exist functions, the details of which, with the present level of education and training, cannot easily be understood or used by crew members, such as: man-machine interface-related functions, e.g., the function, display and operational procedure for flight mode, and AP override and disconnect functions; flight-protection functions.

There also exist differences in the above AFS functions among different aircraft manufacturers.

The above functions are directly linked to flight safety, and are deeply connected with the theory of how to carry out aircraft-type transition training for airline pilots. Considering these points a study should be conducted, from the standpoint of the state of operator, as to the following, in relation to the AFS functions described above:

1)

Items to be covered by crew training;

2)

Items to be considered in AFS design.

As to the items of which the specifications are desired to be standardized, an appropriate measures should be taken, via relevant international organizations or other appropriate bodies, to encourage such standardization to be incorporated, by the state of design and manufacture, into AFS specifications.

2. Reinforcement of the fire fighting and rescue system

As to the civil aviation fire fighting and rescue systems at airports in Japan, an urgent review should be made and the necessary measures taken in relation to the following, taking into account possible accident scenarios:

reinforcement of the command system in an emergency;

(1)

facilities and equipment required for fire fighting and rescue operations;

(2)

cooperation with related authorities and parties;

(3)

periodic training, and so on.

The Airbus had 8550 flying hours and 3910 cycles. The weather was fine: wind 290°/6kts (varying between 230° and 320°) >10 km visibility; scattered clouds at 3000ft.

CAPTAIN: 'Engage it. Push it.'
CAPTAIN: 'It's too high. You ... on go-around mode'
CAPTAIN: 'Don't worry, slowly, slowly, begin it. Support it firmly with your hand. Push, push it.'
1ST OFFICER: 'It could not be pushed.'
CAPTAIN: 'Don't worry, do it slowly.'
CAPTAIN: 'Ok, I try.'
1ST OFFICER: 'I engage it. I engage it.'
CAPTAIN: 'What is this?'
1ST OFFICER: 'I engage it.'
CAPTAIN: 'Goddamn it! Why it comes in this way?'
...
TOWER: 'Standby further instruction.'
xxx: 'Aircraft will stall at this rate.'
1ST OFFICER: 'No way! No way!'
CAPTAIN: 'Set, set, set it.'
CAPTAIN: 'Don't worry. Don't worry. Don't upset. Don't upset.'
GPWS: 'Terrain, Terrain'
xxx: 'Power!'
stall warning
xxx: 'Ah... no way! No way!'