Remembering China Airlines Flight 140

April 26, 1994

China Airlines Flight 140

http://www.keyt.com/OTD-April-26-China-Airlines-Flight-140/19879940

Flight 140 was a regularly scheduled passenger flight from Chiang Kai-shek International Airport in Taipei, Taiwan, to Nagoya Airport in Nagoya, Japan. It was the fifth China Airlines’ plane to crash since 1986.

On April 26, 1994, the Airbus A300B4-622R was completing a routine flight and approach, when, just before landing at Nagoya Airport, the First Officer inadvertently pressed the Takeoff/Go-around button(also known as a TO/GA) which raises the throttle position to the same as take offs and go-arounds.

With insufficient altitude to recover from this condition, the subsequent crash killed 264 people, 15 crew and 249 passengers, of the people aboard. 7 miraculously survived, though critically injured.

To date, the accident remains the deadliest accident in the history of China Airlines, and the second-deadliest aviation accident on Japanese soil, behind Japan Airlines Flight 123. It is also the third-deadliest aviation accident or incident involving an Airbus A300, after Iran Air Flight 655 and later American Airlines Flight 587.

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Photo of China Airlines A300 takeoff, copyright Gordon Tan.

The Incident

Flight 140 departed from Taipei International Airport, Taiwan on April 26, 1994 towards its destination of Nagoya Airport, Japan.

After initial descent and contact with Nagoya Approach Control, the flight was cleared for the Instrument Landing System (ILS) approach to runway 34 (ILS 34 approach) and was switched to the Nagoya tower frequency at approximately 2007 local time.

It was nighttime, and Nagoya airport weather at the time was reported as winds from 280 degrees at 8 knots, visibility of 20 kilometers, cumulus clouds at 3,000 feet and a temperature of 20 degrees Celsius.

During the initial phase of the approach, both autopilot systems (AP1 and AP2) were engaged as well as the auto throttles. After passing the ILS outer marker and receiving landing clearance, the first officer, who was the pilot flying, disengaged the autopilot system and continued the ILS approach manually.

When passing through approximately 1,000 feet on the approach glidepath, the first officer inadvertently triggered the GO levers, placing the auto throttles into go-around mode, which led to an increase in thrust.

This increase in thrust caused the aircraft to level off at approximately 1,040 feet for 15 seconds, and resulted in the flight path becoming high relative to the ILS glideslope.

The captain recognized that the GO lever had been triggered and instructed the first officer to disengage it and correct the flight path down to the desired glide slope.

While manually trying to correct the glide path with forward yoke, the first officer engaged the autopilot, causing it to be engaged in the go-around mode as well.

As he manually attempted to recapture the glide slope from above, by reducing thrust and pushing the yoke forward, he was providing pitch inputs to the elevator that were opposite the autopilot commands to the THS, which was attempting to command pitch up for a go around.

The THS progressively moved from -5.3 degrees to its maximum nose-up limit of approximately -12.3 degrees as the aircraft passed through approximately 880 feet.

During this period, the first officer continued to apply increasing manual nose-down command through forward yoke control which resulted in increasing nose-down elevator movement, opposite the THS movement, masking the out-of-trim condition.

The first officer attempted to use the pitch trim control switch to reduce the control force required on the yoke. However, because pitch trim control of the THS is inhibited during autopilot operation, it had no effect. In a normal, trimmed condition the THS and elevator should remain closely aligned.

However, because of the opposing autopilot (nose up) commanded THS and manually commanded elevator (nose down) for approximately 30 seconds, the THS and elevator became “mis-trimmed”.

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Photo of A300 Cockpit, copyright John Padgett.

Passing through approximately 700 feet, the autopilot was disengaged but the THS remained at its last commanded position of -12.3 degrees. Also at this time, due to the thrust reduction commanded by the first officer, the airspeed decreased to a low level, resulting in an increasing angle of attack (also termed alpha, or AOA).

As a result, the automatic alpha floor function of the aircraft was activated, causing an increase in thrust and a further pitch-up. The alpha floor function of the A300 is an AOA protection feature intended to prevent excessive angles of attack during normal operations. Because of the greater size of the THS relative to the elevator (approximately three times greater in terms of surface area), the available elevator control power or authority was overcome as the aircraft neared 570 feet on the approach.

Upon hearing the first officer report that he could not push the nose further down and that the throttles had latched (alpha floor function engaged), the captain took over the controls, unaware of the THS position.

Upon assuming control, the captain initially attempted to continue the approach, but was surprised by the strong resistive force to his full nose-down control inputs. He retarded the throttles in an attempt to recapture glide slope.

Unable to control the increasing nose-up pitch, which had reached 22 degrees, he called for the GO-lever shortly thereafter in attempt to execute a go around. The increasing thrust added additional nose-up pitch moment and resulted in an uncontrolled steep climb, as airspeed continued to decrease and AOA continued to rise.

During the attempted go-around, the captain only operated the pitch trim briefly, indicating he was unaware of the mis-trimmed position (extreme nose-up) of the THS. Furthermore, flaps/slats had been retracted two positions (30/40 to 15/15) to the go-around setting, which increased the airplane pitch up and reduced the stall margin.

The aircraft continued to climb steeply up to 1,730 feet with AOA rapidly increasing and airspeed decreasing, reaching a maximum pitch angle of approximately 53 degrees until the stall warning and subsequent stall.

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Once stalled, the aircraft nose lowered to a steep dive and the captain applied full aft yoke in an attempt to recover from the dive; however, the aircraft remained stalled until impact.

The captain, Wang Lo Chi, radioed ‘Going around’, indicating that he was aborting the landing and about to turn for another attempt. The tower responded ‘Roger, stand by for further instructions.’ This was the last contact with China Airlines Flight 140. Thirty seconds later, it crashed in a ball of flames to the right of the runway.

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An animation of the accident flight path and factors which contributed to the accident are available here. The plane went down tail first, and burst into fire. The impact occurred at approximately 15:45.

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Rescue

Parts of this information is sensitive in nature. Proceed with personal caution.

According to the accident investigation report, “Fire broke out, and flames as high as a three-storied building enveloped an area more than 100 meters wide.” This was caused not only by jet fuel, but also by cargo carried on the flight. The fire was totally extinguished only at 2148, 93 minutes after the crash. The fire had, of course, implications for the search and rescue operation, complicating the entry to the plane of emergency response personnel.” (Ladkin, 1996)

Jet fuel poses a relatively small danger to the environment, according to reports of course, because “(1) it evaporates relatively quickly, and (2) it is almost insoluble in water and floats on the surface of water (hence it causes minimal underwater damage). On land free liquid is collected, then efforts are made to encourage evaporation and biodegradation.

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Rescue workers searching for survivors after the China Airlines Airbus A300 on a flight from Taiwan crashed at Nagoya airport, in central Japan. (Associated Press) Maps show the location of Nagoya, Japan.

Junji Nagamori, head of a local fire department, said he arrived at the scene about 15 minutes after the crash. “I could see many dead people lying on the ground,” he said. Mr. Nagamori said that rescuers carried out people who seemed like they would have a chance to survive. He said that many of the bodies were burned beyond recognition.

Fire fighting personnel who were dispatched from the standby station of Fire Fighting Platoon described the fire fighting activities as follows:

  • At approximately 2016 of that day, the Controller informed the Fire Fighting Platoon via an emergency telephone that “a China Airlines’ aircraft has burst into flames on the runway” and requested fire services.
  • The Fire Fighting Platoon dispatched three chemical fire vehicles around 2017.
  • The Fire Fighting Platoon personnel, who were at their standby station, had not heard the impact sound of the aircraft crash.
  • Upon receipt of the report, two chemical fire vehicles left the station and sped along Taxiway E4 and the runway to the southern end of the airport where flames and smoke were billowing in the air. About 2019, another chemical fire vehicle arrived at the site via Taxiway EP 1.
  • The aircraft had fragmented into pieces, losing its original shape so badly that the only way to distinguish the wings was by identifying the vague shape of the engines.
  • Fire broke out, and flames as high as a three-storied building enveloped an area more than 100 meters wide. Booming sounds were heard three times at internals.
  • Going into action immediately, the Fire Fighting Platoon, staying clear of widely scattered aircraft fragments, advanced to about 20 meters from the wing and discharged fire extinguishing agents.
  • At approximately 2027, a chemical fire vehicle, a water tank truck and a ladder truck from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, plus two chemical fire vehicles and two water tank trucks from the Kasugai City Fire Fighting Headquarters arrived at the crash site and went into action.
  • Flames under the wings, however, did not abate easily.
  • About 2030, a second party dispatched by the Fire Fighting Platoon, consisting of two chemical fire vehicles, one water supply truck, one ordinary fire vehicle, one cargo truck and so on arrived at the site. They backed up the chemical fire vehicles that had arrived earlier and provided them with additional water and fire extinguishing agents.
  • Around 2042, a chemical fire vehicle and a water tank truck from the Komaki City Fire Fighting Headquarters arrived at the crash site and joined the fire extinguishing activities.
  • Later, about 2054, a chemical fire vehicle from the Nagoya City Fire Fighting Bureau arrived at the site and also joined the fire fighting activities.
  • About 2110, aircraft components smoldering near the irrigation water channel were cut open with axes and tobiguchi (fireman’s hooks) and sprayed with agents and water.
  • The fire was finally extinguished around 2148.

Information on Search, Rescue and Evacuation Relevant to Survival, Death or Injury. The following information contains details that may be sensitive to some readers, found in the final report, concerning injuries:

  • After confirming the crash site, the personnel from the Self-Defense Force, Neighboring Fire Fighting Organizations, Police, and Airport Office conducted search and rescue activities throughout the area.
  • Ambulances from Komaki Air Base arrived at the crash site at about 2019 and 2023.
  • At about 2027, ambulances and other vehicles from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association and the Kasugai City Fire Fighting Headquarters entered the airport through the No.2 West Gate and, upon arriving at the site, commenced search and rescue operations promptly.
  • At approximately 2031, ambulances from Nagoya City Fire Fighting Bureau entered the airport through the No.2 West Gate and proceeded to the crash site. Upon arrival, the ambulance men started confirming whether there were any survivors and conducting first aid to the injured.
  • Actual work to confirm the presence of survivors began about 2032. However, flames raging in the central part of the fuselage hampered search and rescue activities.
  • A male passenger was found around 2035, and two female passengers and an infant were removed from the site about 2037. These four people were carried to hospital in an ambulance from Komaki Air Base.
  • Around 2042, ambulances from the Komaki City Fire Fighting Headquarters entered the airport through the main gate of Komaki Air Base and commenced search and rescue activities.
  • Two injured passengers, who had received first aid from the rescue personnel assigned to a Nagoya City Fire Fighting Bureau ambulance, were rushed to hospital.
  • Around 2049, an ambulance from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association carried three passengers to hospital.
  • Around 2055, two ambulances from the Kasugai City Fire Fighting Headquarters took three passengers to hospital.
  • Around 2100, a male passenger about 40 years old, trapped between seats, was rescued by removing the seats with a power cutter. A female passenger about 35 years old was also rescued. Those two passengers were carried to hospital in an ambulance from the Kasugai City Fire Fighting Headquarters.
  • Around 2100, a male child passenger was taken to hospital in an ambulance from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association.
  • At approximately 2122, an emergency medical treatment and transport vehicle arrived at the crash site.
  • Around 2124, an ambulance from Nagoya City Fire Fighting Bureau carried a male passenger to hospital.
  • Around 2140, rescue teams began setting up rescue stations (three air tents).
  • Around 2148, the fire was finally extinguished. Wreckage was pulled up from the irrigation water channel with cranes and other equipment, and the search for missing persons continued.
  • From about 2220 the remains found around the wings and the irrigation water channel were taken to the rescue stations (air tents).
  • On request from the Airport Office Administrator, troops of 10th Division, with Ground Self-Defense Force, from Monyama Base, arrived at the site about 2225, and commenced search and rescue activities.
  • Around 2325, the remains of persons considered to be crew members were found near the cockpit and taken to a rescue station (air tent) set up near the crash site.
  • Around 0445 on April 27, transfer of remains from the rescue stations (air tents) to Hangar No. 1 at Komaki Air Base, for temporary storage, started.
  • Around 1340, the final remain was transferred from the site.

Rescue activities conducted by the organizations involved:

  • On April 26, based on a decision made at a cabinet meeting immediately after the accident, Japan’s national government established “China Airlines Aircraft Accident Countermeasure Headquarters”, with the Minister of Transport as its head. The government decided to spare no effort in rescuing survivors, recovering the remains and keeping close contact with the organizations involved.
  • Immediately after the accident, the Airport Office set up “Accident Emergency Countermeasure Headquarters” with the Airport Office Administrator as its head and mobilized 119 employees through emergency call. The Airport Office also organized “Nagoya Airport Aircraft Rescue Unit” and conducted its activities using the following personnel, materials and equipment: 406 personnel (including 102 of Rescue Unit and other airport personnel concerned), 28 vehicles (including an emergency medical treatment and transport vehicle) and 3 air tents.
  • With a request from the Airport Office Administrator for disaster dispatch immediately after the accident, the 10th Division of Ground Self Defense Force and the 1st Air Transport Squadron of Air Self-Defense Force participated in the rescue and other activities by providing 1,900 personnel (1,200 at the site and 700 for backup duties), 25 vehicles and 16 floodlight projectors.
  • The Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, Kasugai City Fire Fighting Headquarters, Komaki City Fire Fighting Headquarters, and Nagoya City Fire Fighting Bureau participated in rescue and other activities at the request of the Airport Office, by providing 546 personnel (534 dispatched and 12 on standby), 116 vehicles, and 1 helicopter (operated by Nagoya City Fire Fighting Air Force; used illuminate the crash site and assess the scope of the disaster by flying over the site)
  • In accordance with the “Agreement on Medical Treatment and Rescue Activities at Nagoya Airport” made with the Airport Office, the Aichi Prefecture Medical Association conducted their rescue activities by providing 64 personnel (47 doctors and 17 nurses) and 164 on standby (76 doctors, 51 nurses and 37 clerks and others).
  • The Aichi Prefecture Branch of Japanese Red Cross Society conducted activities, including autopsies, post-mortem examinations, reconstruction, cleansing and identification, by providing 102 personnel (14 doctors, 55 nurses and 33 clerks and others).
  • The Aichi Prefectural Police Medical Association performed post-mortem examinations by providing 79 personnel.
  • The Aichi Prefecture Dental Association was engaged in identification activities by providing 134 personnel (107 dentists, 7 dental hygienists, and 20 police doctors).
  • Upon receipt of the accident report from the Airport Office immediately after the crash, the Aichi Prefectural Police Headquarters conducted rescue activities and policed the site of disaster by providing 1,700 personnel (1,100 dispatched and 600 others).

Burials and Memorials

According to the Houston Chronicle archives, more than 300 family members of Taiwanese killed in the crash returned home to Taipei by Saturday, April 30, with many carrying the ashes of their loved ones.

The same May 1, 1994 article stated that, in a ceremony at Taipei’s airport, airline officials displayed banners with the words, “We beg apologies from the victims.”

On April 26, 2014, 300 mourners gathered in Kasugai, Aichi Prefecture for a memorial to the crash. The mourners in Kasugai, Aichi Prefecture, observed a minute of silence at 8:15 p.m., when the plane crashed. Noboru Yamamoto, head of the families’ group, told reporters, “We aim to create a society where the sorrow of the families will be eased, even if slightly.”

The Victims

Parts of this information is sensitive in nature. Proceed with personal caution.

The plane was carrying 271 passengers total: 2 flight crew members, 13 cabin crew members and 256 passengers, including 2 infants.

Most of the passengers were Taiwanese and Japanese; 153 Japanese and 101 non-Japanese were on the flight. Most of the Japanese passengers were returning from package tours. An official from the airline said that 63 of the passengers were Taiwanese.

The following paragraph (until ending italics) contains details that may be sensitive to some readers, found in the final report, concerning autopsies and injuries of survivors:
Of the 271 persons aboard –256 passengers and 15 crew members –16 passengers were taken to hospital by ambulance. Six of them were found dead on arrival at the hospitals. In addition, three passengers died after hospitalization, on April 27, April 28, and May 1, respectively. Seven passengers survived – all of them had been seated in Rows 7 through 15. Four had been in the right block of seats, two in the center block, and one in the left block. At the time of hospitalization, all seven survivors were suffering from traumatic shock to various degrees. Various external wounds, primarily bone fractures caused by the impact, were found among the survivors, the locations of which differed from one to another. According to the diagnosis, those serious injuries would take from two months to a year to heal completely. According to the autopsy reports, a great number of the remains were bruised all over and had suffered multiple fractures caused by the impact. Nearly half of the remains had been burnt to various degrees.

Flight Crew:

The captain, Wang Lo-chi, was aged 42, with a total flight time of 8,340h and 19m, of which 1,350h and 27m were flown on the A300-600R type. 71h and 11m were flown in the 30 days prior to the accident. The captain joined the company in February 1989.

The co-pilot, Chuang Meng-jung, was aged 26, with 1,624h and 11m flight time, with 1,033h and 59m on the A300-600R type. 71h and 53m were flown in the 30 days leading up the impact. His last training emergency procedure was a day before the captain’s on September 14, 1993. He had a 39 hour rest period before the flight, compared the captain’s 15h and 30m rest period. The co-pilot joined the company on April 16, 1990.

The following paragraph (until ending italics) contains details that may be sensitive to some readers, found in the final report, concerning autopsies:
The captain’s body had open wounds running from the right shoulder to the right breast. Open wounds were also found from the left breast to the left abdomen of the first officer’s body, and his stomach and intestines were damaged. Open damage was barely noticeable on the breast and abdomen of the purser’s body. The three remains were placed in Hangar 1 of the Komaki Air Base immediately after their recovery. Later, no special measures, such as preservation by freezing, were taken for the remains prior to their transfer to three medical colleges/university for judicial autopsies. Eighteen to twenty-two hours elapsed from the time of the accident to the transfer of the remains to the autopsy sites. During this period, the lowest and highest temperatures at Nagoya Airport were approximately 1 0°C and 23°C, respectively. The temperature in Hangar 1 of the Komaki Air Base, where remains were placed, is considered to have been “somewhat higher than the value above”. Judicial autopsies and extraction of samples for alcohol reaction tests (times are JST). A post-mortem examination was conducted on the captain’s body at a dissection room of legal medicine at Department of Medicine, Nagoya University, between 17:55 and 23:00 on April 27. Test samples were taken from the thoracic cavity, using an anatomical spoon, in a period between 20:00 and 21:00. Some 24 to 25 hours had elapsed from the time of the accident to when the samples were taken. A post-mortem examination was conducted on the first officer’s body at a dissection room of legal medicine and pathology at Aichi Medical College, between 14:00 and 17:00 on April 27. Test samples were taken from the thoracic cavity with an anatomical spoon at about 15:00. This was done approximately 19 hours after the time of the accident. A post-mortem examination was conducted on the purser’s body at a dissection room of legal medicine at School of Medicine, Fujita-Gakuen Health College, between 14:00 and 17:00 on April 27. Test samples were taken from the heart, using an anatomical spoon, about 15:30, approximately 19 hours after occurrence of the accident. The test samples taken from the three remains were immediately placed in special plastic containers and sealed. After dissection, technical officers from Aichi Prefectural Police Headquarters, who had witnessed the dissection, took the samples to Scientific Investigation Laboratory of Aichi Prefectural Police Headquarters for storage in a refrigerator. The concentration of ethanol in each of the test samples was as follows: (a) CAP: 13mg/l00ml (b) F/O: 55mg/l00ml © Purser: No ethanol detected.

The Survivors

The next day on April 27, 1994, officials said there were ten survivors (including a 3-year-old) and that a Filipino, two Taiwanese, and seven Japanese survived. By May 6, only seven remained alive, including three children. A doctor expressed surprise in response to the survival of two of the children.

All seven passengers who survived the accident were seated in rows 7 through 15.

On Thursday April 28, 1994, The Independent ran an article on three children, two of them brothers, who were among “the nine survivors of the crash” at the time (sadly, two of these survivors would not make it much longer, with a tenth survivor having died in a hospital just the previous night). The nine survivors at this point had all been seated in the front of the cabin.

This article contains sensitive information. Read italicized paragraph with caution.

The two brothers, Yuji and Seiji Nakayama, six and three years old, were travelling with their mother and uncle, who both died. Their father, Tatsumi, who was waiting at the airport, said it was ‘perhaps a miracle of God’ that they survived. Sadashige Kikuyama, a fireman who rescued one of the boys, said he was trapped under one of the plane’s tyres. ‘I just happened to hear this faint call of a boy saying ‘Mama, mama, it hurts’. Both boys are in hospital, but doctors said they were expected to recover.

Both were in critical condition at the time of the article, according to another from St. Louis on the same day:

Dr. Toshio Sugiyama, who operated on Seiji, said he was in serious condition but should live. “It is a miracle that he was spared. If all goes well, he should be able to leave the hospital in about a month.” The boys’ Filipino mother, Daisy, was among the dead. The boys’ father, Tatsumi Nakayama – who was not on the plane – said, “I’m just happy that they’re alive. We lost their mother, but God spared me my boys.”

It is highly debated if children are more likely to survive plane crashes.

The last death attributed to the accident occurred on May 6.

The Aircraft

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Figure of Control Wing Surfaces of A300

The Airbus A300B4-622R, registered B-1816, was owned by China Airlines, based in Taiwan. Air China is the standard-bearer for the People’s Republic of China.

Eyewitnesses interviewed shortly after the accident disagreed over whether the plane had an engine fire before it crashed, but all said the plane was pulled up at a very steep angle before crashing backwards onto its tail. Some witnesses quoted on television also said they saw flames shooting out of the engines. Some reports said the plane apparently tried to abort the landing and take off again, but failed. Aerial photographs of the crash site showed the impact mark of the tail, apparently confirming that the plane had stalled after attempting to climb too steeply.

New York Times reported:

Masumi Inazumi, who had just arrived on another flight and was in a bus to the terminal, told a television station that she had watched the China Airlines plane descend.
“Suddenly, when the plane was just at the edge of the runway, it began to move strangely and wobble and its nosed crashed into the ground,” she said. “Mushroom-like flames came out.” ‘Flashes From the Wings’
Another witness, Minoru Furuta, told a television station that he saw “flashes from the two wings.” The plane rolled to the right and crashed on its right side, he said. Then he saw flames and heard explosions.

Aircraft information as listed in the final report:

2.6.1 Aircraft
Type Airbus Industrie || A300B4-622R
Serial No. || 580
Date of manufacture || January 29, 1991
Certificate of airworthiness || 83-01-05
Valid until || January 15, 1995
Total aircraft flight time || 8,572 h 12 min

2.6.2 Engines
Type || Pratt and Whitney PW-4 158
Serial No. || 724082(No.1) 724025(No.2)
Date of manufacture || December 13, 1990(No.1) October 5, 1989(No.2)
Total hours of operation || 5,776 h(No.1) 8,783 h(No.2)

2.6.3 Weight and Center of Gravity
The weight of the aircraft at the time of the accident is estimated to have been approximately 290,900 lbs, with its center of gravity at 30.6% MAC, both being within permissible limits (maximum landing weight being 308,651 lbs, with the allowable range of center of gravity corresponding to the weight at the time of landing, 20.0 to 33.6% MAC).
According to the Flight Clearance and Log of China Airlines, the aircraft loaded approximately 50,7OOlbs of fuel before takeoff The amount of fuel remaining at the time of the accident is estimated to have been approximately 22,000lbs.

2.6.4 Fuel and Lubricating Oil
The fuel on board was JET A-1, and the lubricating oil was Esso Turbo Oil 2380 (MIL-L-23699), both being authorized for aircraft use.

You can read an entire factual description of what happened to the plane here, in the final report.

Distribution of wreckage:

Before the investigation started, some pieces of wreckage had been moved from their original positions in order to facilitate rescue activities. At the time of investigation, the wreckage was scattered as follows in the final report:

Due to the impact of the crash, the wreckage of the aircraft, except the RH and LH wings, the vertical and horizontal tail planes, the tail section of the fuselage, and the engines, was scattered over an approximately 140 meters long and 60 meters wide area to the east-northeast of the LH main landing gear’s ground scar.

Fragments of the destroyed skin of the nose and forward fuselage sections were strewn over an approximately 40 meters long and 30 meters wide area, some 120 meters away from the LH main landing gear’s ground scar to the east-northeast direction.

No signs of damage by fire were found on the nose and forward sections of the fuselage. The lower skin of the fuselage center and aft sections, almost entirely fragmented, were scattered over an approximately 40 meters wide area that extended approximately 60 meters to the east-northeast from the LH main landing gear’s ground scar. Other parts of the center and aft fuselage sections except a part of the skin, were almost entirely ruined by fire.

The wings, ripped from the fuselage, were found at a point approximately 80 meters to the east-northeast of the LH main gear’s ground scar. The LH outer wing was torn from the wing, and the RH outer wing, broken into several fragments, was also separated from the wing. They were burnt and discovered near the wings and the water gate, respectively.

The LH engine was torn from the wing pylon and was found near the wing, while the RH engine remained barely attached to its pylon. The fan hubs of both engines were broken and detached.

The horizontal tail plane and tail cone were broken and torn from the fuselage, and were found at a point approximately 30 meters to the east-northeast of the LH main landing gear’s ground scar.

The vertical tail plane was broken and separated from the fuselage together with the upper rear part of the fuselage. It was burnt and found over the irrigation water channel approximately 65 meters to east-northeast of the LH main landing gear’s ground scar.

An approximately 50 meters long and 20 meters wide scorch mark of fire were detected on the ground, each extending to the east-northeast from the vicinities of the ground scars of the LH and RH wing flap tracks, and the trees near the water gate were burnt.

Signs of fire were also detected on the ground near where the wings were found.

Damage other than the aircraft:

A stretch of the lawn under cultivation in the landing zone was burnt and flowed off within an approximately 10,300 m2 area.

The protection wall of the irrigation water channel at Komaki Air Base of the Air Self-Defense Force (hereinafter referred to as “Komaki Air Base”) was destroyed over a length of 30 meters, and the water gate was damaged.

Of the trees in the soundproofing tree fence in the Komaki Air Base, those within an approximately 2,000 m2 area were burnt.

Cause

Questions about the crash focused on two issues: Why did the pilot try to abort his landing? And once he decided to make a second approach, why did the airplane lose power and crash about 200 yards short of the runway?

The incident, which destroyed the aircraft (delivered fewer than 3 years earlier in 1991), was attributed to crew error for their failure to correct the controls as well as the airspeed.

Isao Kuroda, professor of aeronautics at Waseda University, said that to abandon a landing with the Airbus A300, a pilot presses a lever that automatically puts the jet into what is called “go-around mode.” That quickly increases the engines thrust and causes the plane to begin climbing. If the plane is also in autopilot mode, the rate of climb is automatically controlled. If not, it can rise too sharply and stall.

Two witnesses quoted on NHK television said the aircraft’s approach was higher than usual, which could mean the pilot feared that he would overshoot the correct landing spot.

The investigation concluded that effective crew resource management was not practiced by the crew. Areas identified by the investigation involved task sharing, standardization of terms used for instruction, response, confirmation and execution of operations, in order to assure that crews maintain appropriate situational awareness. Further identified by the investigation was the manner in which the captain assumed control of the airplane, and a lack of preflight discussion and agreement as to the situations where it might be appropriate for the captain to assume control.

This and several other accidents involving human errors in using aircraft automation sparked increased focus on consideration of human factors and automation in the design of transport aircraft.

There had been earlier “out-of-trim incidents” with the Airbus A300-600R. Airbus had the company that made the flight control computer produce a modification to the air flight system that would disengage the autopilot “when certain manual controls input is applied on the control wheel in GO-AROUND mode”.

This modification was first available in September 1993, and the aircraft that had crashed had been scheduled to receive the upgrade. The aircraft had not received the update at the time of the crash because “China Airlines judged that the modifications were not urgent”.

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Illustration of Pitch Effects

For aircraft with engines below the wing, as is the case with the under-wing mounted engines of the A300, a rapid increase in thrust creates a significant increasing pitch. While the crew was struggling to manually reduce pitch during the approach, the activation of the alpha-floor function, resulting thrust increase, and positive pitch moment further compromised the flight crew’s ability to control pitch. As the captain took over control and attempted a go around, the further increase in thrust by the ATS, coupled with the out-of-trim THS, quickly overcame the manual control authority on the elevator and allowed for a severe increase in pitch attitude and accompanying rapid increase in AOA towards stall.

Aftermath

Japanese prosecutors declined to pursue charges of professional negligence on the airline’s senior management as it was “difficult to call into question the criminal responsibility of the four individuals because aptitude levels achieved through training at the carrier were similar to those at other airlines.”

The pilots could not be prosecuted since they died in the accident.

A class action suit was filed against China Airlines and Airbus Industrie for compensation. In December 2003, the Nagoya District Court ordered China Airlines to pay a combined 5 billion yen to 232 people, but cleared Airbus of liability. Some of the bereaved and survivors felt that the compensation was inadequate and a further class action suit was filed and ultimately settled in April 2007 when the airline apologized for the accident and provided additional compensation.

On May 3, 1994, the Civil Aeronautics Administration (CAA) of the Republic of China (Taiwan) orderedChina Airlines to modify the flight control computers following Airbus’s notice of the modification.

On May 7, the CAA ordered China Airlines to provide supplementary training and a re-evaluation of proficiency to all A300-600R pilots.

The flight numbers CI140/141 were retired after the accident and were replaced with CI150/151.

In 1994, the FAA launched a study to evaluate all flight crew/flight deck automation interfaces of current generation transport category airplanes. The FAA chartered a human factors team to conduct the study. Team members included experts from the FAA, the European Joint Airworthiness Authorities (JAA), and academia. The objective of the study was to examine the contributing factors from the perspective of design; flight crew training and qualifications; operations; and regulatory processes. The FAA also tasked the team to develop recommendations to address any problems identified.

With regard to autopilot issues, the team identified several specific problematic issues, including:

  • Pilot/autopilot interactions that create hazardous out-of-trim conditions
  • Autopilots that can produce hazardous speed conditions and may attempt maneuvers that would not normally be expected by a pilot; and
  • Insufficient wording in the Airplane Flight Manual regarding the capabilities and limitations of the autopilot.

The full text of this team’s report issued in 1996 is available here.

China Airlines officials again avoided charges over 1994 crash in an April 10, 2001 article by The Japan Times, stating that the Nagoya District Public Prosecutor’s Office said it had again opted not to indict four senior China Airlines officials over the April 1994 crash of the Airbus A300-600R at Nagoya airport that killed 264 passengers and crew members. The decision followed a reinvestigation, prompted by the 11-member No. 2 Nagoya Committee after relatives of crash victims called for further investigation, for the Inquest of Prosecution in January 2000. The panel said an earlier decision not to indict the four was inappropriate. As part of the renewed probe, prosecutors examined crew training procedures and evaluation methods used by Japan Air System Co., which introduced the same type of aircraft around the time of the accident. A commission investigating the appeal determined in January 2000 that the decision not to indict was inappropriate because it was hard to prove the four officials in question provided sufficient training for the pilots. While some relatives agreed on damages with CAL, several groups still had cases before the Nagoya District Court at the time of this 2001 article.

The Japan Times reported again on October 26, 2002, that relatives of 38 people who died in the 1994 plane crash at Nagoya airport reached a compromise settlement with China Airlines, lawyers for the plaintiffs affirmed. The two parties agreed that the Taiwanese airline would pay each family 16.4 million yen plus an undisclosed sum, in line with an earlier offer tabled by the firm. The company also expressed remorse over the crash and pledged to prevent a recurrence of the accident. It was finalized after the group’s leader, Noboru Yamamoto, finally dropped his suit against the defendants.Yamamoto himself, however, refused to accept the terms of the compensation accord. “The plaintiffs are growing old, and some have even died,” said Yukihiko Nishio, one of the plaintiffs’ lawyers. “Some plaintiffs want to be released from the emotional pressures of the lawsuit and a solution thorough settlement is the proper way.” The 38 people for whom that settlement was reached were employees of Nittoseito, a ceramics maker in Toki, Gifu Prefecture, and its affiliated companies. Yet another suit filed by relatives of some 120 victims from Japan and Taiwan was still pending at the time of this 2002 article. Yamamoto, 49, said he could not bring himself to settle the matter, adding that he hoped the remaining group would continue the battle.

The settlement was reached six years and 10 months after the 105 relatives sued China Airlines and Airbus Industrie, the manufacturer of the crashed jet, in December 1995, seeking a total of 4.1 billion yen in compensation.

By November 28, 2003, the Japan Times reported that settlements had been reached by 79 out of 315 plaintiffs in the civil suit with Taiwan carrier China Airlines and European aircraft manufacturer Airbus Industrie over the fatal crash in 1994.

Reporting again on April 20, 2007, the settlements were concluded (a week away from the 13th anniversary of the fateful incident) with the last 27 plaintiffs reportedly in agreements.

Cockpit Voice Recorder

The transcript shows the pilot, Wang Lo-chi, giving orders in Chinese to co-pilot Chuang Meng-jung, who had 1,629 hours of flying experience compared with 8,410 for Wang.

About two minutes before the crash, one of the two – the transcript does not make clear which – says “Too high, too high.” Wang then orders Chuang to abandon the landing attempt and try again, an indication the jet may have been unable to land properly because excessive altitude put it in danger of overshooting the runway.

Wang then repeatedly ordered the co-pilot to “push” or “connect” something, but the transcript does not make clear what. The co-pilot says at one point, “I can’t push it.”

On the tapes, the noise of the engine can be heard getting louder. An automatic warning system says, “Terrain, terrain.” One of the pilots calls out, “Oh, it’s over, it’s over.”

According to a Houston Chronicle article from May 1, 1994, the last words before the crash were, “Power, power.”

The voice records on CH2 and CH3 of CVR, including radio communications, were identical because the cockpit intercom transmission system was always used by the CAP and the F/O. So which of the two seats the CAP or the F/O occupied could not be determined from the CVR.

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!’

Further Reading

Wikipedia
Case Details
Air Disasters
ILS 34 Approach
Plane Crash Info
Lessons Learned
LA Times 4-28-94
Accident Animation
The Flight Route Plan
NY Times April 27, 1994
ABC News Video Report
Nagoya A300 Accident Report
The Official Report (in Japanese)
’94 China Air Crash Remembered
Airbus A300 Inflight Safety Videos
Air Disaster Accident Photo Gallery
How Do People Survive Plane Crashes?
April 10, 2001 article by the Japan Times
April 20, 2007 article by the Japan Times
October 26, 2002 article by the Japan Times
November 28, 2003 article by the Japan Times
Are Children More Likely To Survive Plane Crashes? Forum
SUN 05/01/1994 HOUSTON CHRONICLE, Section A, Page 30
Transportation Disaster Response Handbook by Jay Levinson
FAA Report: Flightcrew Interfaces and Modern Flight Deck Systems
The Independent – Archive 4/28/94 – Brothers Survive Airbus Disaster

Books:

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