JOHN
J. NANCE
UPDATES & ANALYSES
The
Singapore Airlines 006 Accident - October 31, 2000
As I'm sure you're aware, Singapore Flight 006 crashed on
takeoff Tuesday night at Taipei's Chiang Kai-shek International
Airport on Taiwan. A 1997 model Boeing 747-400, the flight
carried only 179 passengers and 20 crewmembers, but could
have held nearly 400 people. At least 79 people have lost
their lives in this accident, and that is probably not the
final figure. Of those who survived, some are grievously
injured.
There was a Typhoon moving across the southern end of Taiwan
at the time of the crash, creating winds reported at approximately
40 knots with gusts as high as 73 knots. (Taipei is at the
northern end of the island). Heavy rain was reported on
the airport at the same time.
Survivors of the flight say they felt the aircraft constantly
buffeted and shaken by the heavy winds before and after
they left the gate, a fact which - when coupled with the
weather report - clearly raises the question of whether
or not the conditions were too bad to meet the criteria
used by Singapore pilots and dispatchers for departure.
In other words, was the decision to attempt takeoff appropriate
or not under the existing procedures and rules. We simply
don't know the answer to this as yet, and I would caution
everyone not to jump to any conclusions, because the information
is still too sketchy. For instance, we do not yet know whether
the winds were straight down the runway or whether there
were heavy crosswinds (IE the wind blowing at an angle to
the runway). Clearly the idea of taking off in the leading
edge of a typhoon with wild winds seems violative of common
sense, but we can't judge that without knowing the entire
matrix of cockpit procedures, training, company regulations,
and dispatcher information which formed the culture within
which this crew was operating. Decisions aren't made in
a vacuum, they result from practiced application of regulations,
habits, and accepted assumptions, all of which are part
of the specific operational culture of an airline. Therefore,
a wrong decision is not just the mistake of a single pilot
or crew, it is a mistake by the entire culture and/or team,
and thus a system problem. Blaming a single individual for
a systemic problem is at once simplistic and unproductive,
and again, we're not sure here whether any part of the departure
decision was incorrect.
Now, one additional point here: even if it turns out that
the winds had no connection to the accident in causative
terms, it is vital that the accident investigators thoroughly
examine the takeoff decision, because if it was collectively
flawed, the system will fail again in the future in some
other situation and could directly create an entirely different
sort of disaster.
It has been reported that the captain told the tower that
he was trying to leap over (or get over or fly over or avoid)
some object he saw in the runway ahead of him. If this is
true, it raises two basic issues: 1) What did he see on
the runway and how did it come to be there? [this could
be an instance of "runway incursion," an unauthorized entrance
of something or someone to a runway in use; and 2) What
did he do to evade it?
This was a very heavy aircraft getting ready to fly for
nearly 14 hours to Los Angeles. It was carrying upwards
of 200,000 pounds of Jet A jet fuel, in addition to the
weight of the aircraft, bags, cargo, and people, all of
which may have totaled somewhere close to 800,000 gross
weight. Thus, such a heavy 747-400 would need somewhere
in the vicinity of 145 knots or greater to fly and sustain
flight. If the captain tried to raise the nose and, in essence,
"leap over" whatever object he saw, and if his airspeed
was too low, the 747 might have momentarily become airborne
in a close-to-the-runway phenomenon we call "ground effect"
and then slammed back to the runway on its main gear. If
that return impact was too great (and since this aircraft
would almost certainly have been significantly over its
maximum landing weight), that return to the runway might
have triggered the collapse of a main landing gear assembly
or strut, thus causing the aircraft to veer to one side
and leave the runway at somewhere above a hundred knots.
Even if the aircraft did not get off the ground or return
to the runway with enough vertical drop to break anything,
it is highly possible that one of the main landing gear
assemblies slammed into whatever the captain saw on the
runway, creating great drag and skidding on that side, and
veering the aircraft off the runway at above a hundred knots.
Now, however it happened, when a fully loaded 747-400 leaves
a runway and enters soft ground, or impacts against the
side of a runway structure under construction, the possibility
of a massive and rapid progressive breakup of the aircraft
is high. While it is certainly too soon to know the exact
sequence here, the principle is this: The broken structure
of the 747 as we saw it in the aftermath could potentially
be explained by either scenario, a collapsed landing gear
strut, or a damaged landing gear strut.
The last chapter is the presence of 200,000 plus of volatile
fuel in disintegrating wings causing and feeding a massive
fire, and the separation of the rear section of the aircraft
(which saved most occupants from the fire that was consuming
the forward section).
These are the parameters. We have a large aircraft that
could not remain on the runway. Precisely why and how it
left the runway will take time to discover, and in the meantime
we simply must resist the temptation to ask or try to answer
the question "who's wrong," and instead ask "what was wrong."
Only by knowing all systemic causal factors can investigators
appropriately reconstruct what happened, and when they do,
you'll find a multitude of causes, not just one, and not
just a singular pilot mistake.
There is a report rattling around that because damaged construction
equipment was found on an adjacent runway, perhaps the aircrew
tried to takeoff on that closed, under-construction runway.
True or not? I can't tell you yet, but I seriously doubt
the report because in most cases internationally the closed
runway would not be lighted with runway lights, and it is
difficult to imagine a captain choosing to takeoff in a
fully loaded 747-400 on an unlighted runway (it was night).
Take such reports with great caution. Although it is a possibility
(wrong runway takeoff), it's highly unlikely and would require
a widespread failure of "systems" and training to explain.
More later.
John J. Nance
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