The SQ006 Accident Investigation Report released by Taiwan's Aviation Safety Council (ASC) has created a surprising amount of controversy, most of which revolves around a section called "Findings Related to Probable Cause." \nWho was directly responsible for the Oct. 31, 2000, accident that killed 83 people? According to the ASC, which led the investigation, most of the fault lies with the Singapore Airlines (SIA) pilots: seven of the eight Probable Causes implicate the pilots, and the eighth faults the weather. According to the Singapore Ministry of Transport, much of the fault lies with faulty lighting and other deficiencies at CKS airport. They insist airport failures belong in the "probable cause" category, not in the "Findings Related to Risk" category. \nProbable cause identifies elements that have been shown to have contributed to the accident, while "Findings Related to Risk" identify elements that have the potential to degrade aviation safety. There is room for debate as to which factors belong where. \nBut lost in the debate is a key element of the ASC report: systemic failures at Singapore Airlines and the Civil Aviation Authority of Singapore (CAAS) are highlighted in the "Findings Related to Risk" category. In other words, SIA and CAAS deficiencies are as serious as the CKS airport deficiencies in contributing to the accident. These findings are remarkable, and they deserve more attention. The report clearly states that serious safety deficiencies existed at SIA and the CAAS. This is surprising, even shocking, given SIA's carefully cultivated reputation for safety. \nThe following "Findings Related to Risk" are taken directly from the SQ006 Accident Investigation Report. Concerning SIA: \n -- There was no procedure described in the SIA B747-400 Operations Manual for low visibility taxi operations. \n -- There was no formal training provided to SIA B747-400 pilots for low visibility taxi techniques. \n -- SIA did not have a procedure for the pilots to use the PVD as a tool for confirming whether the aircraft is in a position for takeoff in low visibility conditions. (PVD is Para-Visual Display, a device that confirms that an aircraft is correctly positioned on a runway.) \n -- At the time of the accident, SIA's Aircraft Operations Manual did not include "confirm active runway check." as a pre-takeoff procedure. \n -- The SIA typhoon procedure was not well defined, and the personnel who were obliged to use the procedure did not fully understand the procedure and their responsibilities. \n -- The SIA training and procedures for low-visibility taxi operations did not ensure that the flight crew possessed the appropriate level of knowledge and skills to accurately navigate the aircraft on the ground. \nAs regards CAAS, the report states: \n -- CAAS had not performed sufficient safety oversight of SIA's procedures and training, and deficiencies in SIA procedures and training were not discovered during routine CAAS safety oversight. \nThese last two assertions are especially worrisome: SIA procedures did not ensure that the flight crew had adequate levels of knowledge and skill to navigate the aircraft on the ground; and the CAAS did not perform sufficient safety oversight. Those are serious indictments of both organizations. A strong speculative argument can be made: had SIA not suffered these deficiencies, the pilots would not have turned onto the wrong runway and crashed, killing 83 people. The runway the pilots tried to use was closed from Sept. 13, 2000, until the accident on Oct. 31, yet no other airline crashed a plane attempting to take off from it. \nThe US National Transportation Safety Board (NTSB), and the Australia Transport Safety Bureau (ATSB) both participated in the SQ006 investigation, and both endorsed the results. \n"We wish to congratulate the ASC for an excellent job in conducting the investigation," says the NTSB in a letter that is included in the report. The ATSB comments are similar: "We find the report thorough and the conclusions fully supported." \nThe Singapore Ministry of Transport feels differently. There is scarcely a single finding that Singapore does not dispute to some extent. Much of this is legalistic quibbling, but the overall effect is a pattern of denial. No airline ever improved its safety record by denying that problems exist. Most airlines and aviation authorities are chastened after receiving such a critical report card from an independent accident investigation. Their usual reaction is to express sorrow for the lost lives, and vow to improve in the future. The purpose of these investigations is to prevent future accidents. Trying to spin the report in their favor may deflect attention away from their own flaws, but it doesn't improve safety. The Singapore authorities are playing a public relations game, when they should be working to prevent future accidents. \nBrent Hannon is a Taipei-based aviation writer.
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