Pilot error and airline violations were to blame for the July 2014 crash of TransAsia Airways Flight 222 in Penghu that killed 48 people, the Aviation Safety Council (ASC) said yesterday as it released the findings of its investigation into the crash.
The pilots’ repeated violations of standard operating procedures were indicative of an operational culture “in which high-risk practices were routine and considered normal,” the council said in its report.
The ATR 72-500 carrying 54 passengers and four crewmembers on a flight from Kaohsiung went down near Magong Airport on July 23, 2014. The 10 survivors all suffered injuries in the crash.
Pilot Lee Yi-liang (李義良), who was 60 at the time, had 15 years of experience in flying civilian aircraft, while his copilot was 39-year-old Chiang Kuan-hsing (江冠興). Both died in the crash.
The council said it found nine problems pertaining to flight operations, including the pilots’ failure to comply with the published procedures regarding the minimum descent altitude (MDA).
Lee took the aircraft below the MDA of 330 feet (100.6m) without obtaining the required visual references, and as the plane continued to descend, the pilots did not detect and correct that hazardous path in time, suggesting that they were not aware of the aircraft’s position, it said.
The weather was also a probable cause of the tragedy, as Penghu was being affected by the outer rim of Typhoon Matmo, and heavy rain and abrupt changes in wind speed and direction contributed to the poor control of the plane, the council said.
The captain was “likely overconfident in his flying skills,” which might have led to his decision to descend below 330ft without an appreciation of the safety risks, while a fatigue analysis indicated that his performance had probably been affected by fatigue, it said.
The report also mentioned a number of risks that might have contributed to the accident, including the tower’s failure to inform the pilot that the runway visual range values had decreased from 1,600m to 800m and then to about 500m.
While that may have influenced the pilot’s decision on whether to continue the approach, that piece of information was not vital enough to cause the tragedy, council Executive Director Thomas Wang (王興中) said.
If the pilot had followed standard operating procedures, he might have had a chance to turn around when he reached the MDA, Wang said.
The minimum visibility standard for landing at Magong Airport is 1,600m.
The report said the airline needed to take responsibility for its safety management.
“TransAsia Airways had not developed a safety management system implementation plan,” the council said. “This led to a disorganized, nonsystematic, incomplete and ineffective implementation, which made it difficult to establish robust and resilient safety management capabilities and functions.”
The council made 10 recommendations, including the need for TransAsia to review its safety protocols, pilot training program and hiring practices to reduce “imminent risks.”
It also said the airline needed to hire more staff, including flight training and safety management personnel as well as pilots.
The report casts a spotlight once again on pilot training and decision-making at TransAsia, which lost an ATR 72-600 in another fatal crash just less than seven months after the Magong tragedy, when the plane crashed soon after taking off from Taipei, killing 43 passengers and crew.
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