The downing of Malaysian Airlines MH17 as it flew over eastern Ukraine in July 2014 was a tragic event that raised the public’s awareness of the many difficulties faced by aircraft accident investigators. This particular incident drew the focus on the political sensitivities, conflicting governmental responses and also the media’s desire (and need) for quick information while reporting on this high-profile multi-national incident. Another aspect that quickly gained attention during this incident was the actual safety of the respective accident investigators – especially while conducting a major investigation in what was regarded as an active war-zone.
While the MH17 incident is identified as a high-profile accident unfortunately it is not the only one where investigators have faced difficulties or issues. This paper will focus on the difficulties relating to two other aviation accidents – namely the TransAsia Airways Flight 235 (that was dramatically filmed crashing into the Keelung River shortly after take-off from Taipei’s Songshan Airport in February 2015) and Turkish Airlines Flight 6491 (a cargo flight that crashed into a residential area while attempting to land in thick fog in Kyrgyzstan in January 2017). These accidents may not have triggered the same level of public interest compared to MH17, but they still highlight the potential difficulties that investigators face when conducting an investigation – particularly one that concerns multiple international and political players. This paper will analyse both the facts and reports of these incidents and will relate some of the difficulties raised during these investigations to the current accident investigation protocols, techniques and legislation. Suggestions on how to overcome these difficulties will also be presented.
TransAsia Airways Flight 235
Approximately 10.54am on February 4, 2015, TransAsia Airways (TNA) commercial flight GE235, took off from Taipei’s Songshan airport on a regular public transport service towards the Taiwanese island resort of Kinmen Island.
The Taiwanese based Aviation Safety Council (ASC) reported the facts of the accident as follows:
“The aircraft experienced a loss of control during initial climb and crashed into the Keelung River – three nautical miles east from its departure point of runway 10 at Taipei’s Songshan Airport. Forty-three occupants were fatally injured, including three flight crew, one cabin crew, and 39 passengers. The remaining 13 passengers and one cabin crew sustained serious injuries. One passenger received minor injuries. The aircraft was destroyed by impact forces. The aircraft’s left-wing tip collided with a taxi on an overpass before the aircraft entered the river. The taxi driver sustained serious injuries and the only taxi passenger sustained minor injuries”.
The final report describes the accident as being the result of many contributing factors which culminated in a “stall-induced loss of control”.
“Following the uncommanded autofeather of engine number 2 propellers, the flight crew did not perform the documented abnormal and emergency procedures to identify the failure and implement the required corrective actions…. The crew did not respond to the stall warnings in a timely and effective manner… The remaining altitude and time to impact were not enough to successfully restart the engine and recover the aircraft”.
The investigation was led by the Taiwanese Aviation Safety Council (ASC). Other parties that took part in the investigation include:
- The French based Bureau of Enquiry and Analysis for Civil Aviation Safety (representing the country of manufacture for the aircraft)
- The Transportation Safety Board of Canada (country of manufacture for aircraft engines)
- The Taiwanese Civil Aeronautics Administration (responsible for the regulation of civil aviation in Taiwan)
- TransAsia (the operator)
- ATR (French based manufacturer of the aircraft)
- Pratt and Whitney (Canadian based engine manufacturer)
- Transport Canada (Canadian regulator of transport services)
- United Technologies Aerospace Systems (USA based supplier of aviation systems and components)
Taiwan, and the subsequent air carriers based therein – including TransAsia, are not signatories to the various charters of the United Nations led International Civil Aviation Organization (ICAO). This exclusion is not due to policies of the Taiwanese government but is a consequence of Taiwan being diplomatically excluded and isolated from United Nations membership due to external factors.
Turkish Airlines Flight 6491
In January 2017, Turkish Airlines Flight TK6491 was transporting cargo from Chek Lap Kok Airport (Hong Kong) to Ataturk Airport (Istanbul). The flight (and respective crew and aircraft) was operating under a “wet lease” arrangement by ACT Airlines (a separate Turkish cargo operator) on behalf of Turkish Cargo. In essence, Flight TK6491 was an aircraft owned, operated and crewed by ACT Airlines (the lessor) but was operating using a flight number from Turkish Airlines (the lessee).
The flight plan included a transit stop/layover at Manas Airport for refueling and crew change. Manas Airport is the main international airport of Kyrgyzstan and is located approximately 25km north-northwest of the capital Bishkek.
“Weather at Bishkek was poor with winds from 60°at 1 m/s and a visibility of 400m at the beginning of the runway; 350m at the mid-point and 400m at the end of the runway. Vertical visibility was 50 m.”.
The aircraft was initially cleared for an ILS approach to the runway however the crew realized that the reported flight altitude was above the recommended level as defined by the airport’s STAR chart. Tower Control cleared the aircraft for further descent and the glideslope signal was captured. The aircraft automatically initiated descent with a vertical speed of 1425 ft/min however the angle of descent was above the recommended angle as defined by the approach chart. Specific automated alerts and cautions were raised in the cockpit due to the angle of descent and the aircraft’s location and altitude. The aircraft resultingly overflew the departure end of the runway at an altitude higher than the specified decision height. This triggered the captain in stating that there was no visual contact and called for a go-around.
The crew increased power and the aircraft was climbing for the go-around but impacted with a concrete fence and rolled into a holiday village. The crew of 4 all perished and 35 fatalities were also recorded from ground casualties.
The investigation was led by the Interstate Aviation Committee (MAK) which is an executive body of the Russian Civil Aviation and Airspace Use Council of the Commonwealth of Independent States. Other parties that took part in the investigation include:
- ACT Airlines (the operator)
- Turkish Accident Investigation Board (KAIK)
- Turkish Transportation Ministry (Turkish regulator of transport services)
- Turkey’s Directorate General of Civil Aviation (DGCA)
- National Transport and Safety Board (NTSB)
- Federal Aviation Administration (FAA)
- Boeing (aircraft manufacturer)
- Kyrgyzstan and Turkey are both member states of the ICAO.
A preliminary report was released in March 2017 however, as of 22nd June 2019, no final report for this accident has been published or distributed.
Analysis
In accordance to Section 5.1 of ICAO Annex 13 (Aircraft Accident and Incident Investigation), the States where the reviewed accidents occurred initiated investigations and invited representatives from organisations (and countries) that have a direct interest in the respective accident to participate in the investigation under the guidance of the investigator-in-charge.
In the instance of TransAsia’s Flight GE235, Taiwan is not a contracted state to ICAO however Taiwan’s Civil Aeronautics Administration (CAA) does use informal channels to try and maintain the standards and regulations as defined by ICAO – but these measures are, in some case, incomplete and lack transparency. Taiwan has previously been granted “observer” and “guest” status at the ICAO Assembly meetings however this limits Taiwan’s direct access to current information and the inability to formulate or participate in discussions related to aircraft safety, investigation techniques and security. This may mean that any accident investigation or safety/security concern related to aviation in the Taiwanese airspace or to Taiwanese carriers may not be completed as per current guidelines/policies and nor may it utilise the latest developments, techniques or current technical information.
The CAA (and subsequently ASC) do strive to adhere to ICAO guidelines and policies (and to follow current information/practices) but the lack of direct access to ICAO guidelines, policies and technical information may hinder investigators in adequately completing their investigations. Additionally, by being denied active participation in the ICAO Assembly, Taiwanese investigators are not able to participatein technical meetings and training courses.
Overcoming Taiwan’s entry into ICAO as a contracted State (and therefore providing Taiwanese accident investigators with the full coverage of current information, policies and training courses) is not a simple process. Political powers and partnerships outside of Taiwan’s control are the primary reasons for this lack of entry and overcoming these factors may cause possible instability to the international “partnerships” that ICAO requires. A possible solution is to re-invite Taiwan to the ICAO Assembly and increase the coverage and/or amend the definition and limitations of the current “observer” status however this increase or change in status may not be met with full agreement from existing contracted States.
In the case of Turkish Airlines Flight TK6491, within three hours of the accident occurring, Kyrgyzstan’s then Deputy Prime Minister Muhammetkaly Abulgaziyev publicly declared to local media that “pilot error” was the cause of the crash and he used the evidence of 11 other aircraft also landing at the same airport in the previous 24 hours in the same weather conditions to support his claim.
While there is a strong demand for information during the early stages of an investigation, the “distraction” of public officials making any form of comment relating to an accident or investigation may conflict with the actual investigation process – especially when information provided by the public official is speculative in nature and is not accredited or accurate. In turn, the release of premature (and erroneous) information by public officials may lead to public confusion, disappointment or even non-acceptance of the actual investigation process.
Unfortunately, the announcement by Kyrgyzstan’s then Deputy Prime Minister regarding Turkish Airlines Flight TK6491 is not the only example of a public official making unauthorized announcements during an investigation. During the intense search for Malaysian Airlines MH-370, former Australian Prime Minister Tony Abbott declared in a press conference that investigators had detected signals from the respective black boxes – and on a second occasion, also stated that satellite footage had depicted debris from the missing flight. Both statements were presented without the authorization, approval or even input from the investigation team.
There are many factors involved when attempting to override the release of non-accredited or inaccurate information during an accident investigation. Investigators do need to manage the release of information to the media in a positive, flexible and regular manner and also be able to manage the relationship of the media in a positive and respectful way. The media in turn, should be mindful that accurate and current information relating to an accident should only come from one source and to not “insist” on gaining any further insight from any other party. Regrettably, market forces, media deadlines and consumer demand for more information may override any form of control of this factor – therefore putting the onus on investigators in correcting information that may be released by unauthorised parties that are external to the investigation process.
Final Thought
As per ICAO Annex 13, the sole objective on an investigation is to prevent further accidents and incidents. It is not the purpose of any investigation to apportion blame or liability.
Both the TransAsia Airways Flight 235 and Turkish Airlines Flight TK6491 accidents are examples where an investigation commenced but various factors were presented that may have caused difficulties for the respective investigators. In the instance of the TransAsia Airways accident, due to external political factors outside of local control, the investigators may not have had access to the current procedures, technical information and correct investigation techniques. In turn, the public’s perception of the Turkish Airlines Flight TK6491 may have been influenced by erroneous information that was broadcast without the approval or authentication of the investigator-in-charge or the investigation team (the erroneous information also laying blame on the pilots).
It is possible to overcome these factors though. Broadening Taiwan’s status with the ICAO will bypass the need for Taiwanese investigators to use informal channels while attempting to obtain updated information. This will also allow them to actively participate in discussions and training forums. The role of the media in receiving and presenting information comes into play with Turkish Airlines Flight TK6491. This factor may prove more difficult to overcome due to market forces but it does highlight how an investigation team needs to build and maintain quality relationships with the media.
Overcoming these factors will allow investigating teams (regardless of political background) to utilize the full resources and knowledge of ICAO guidelines during the investigation process – without the release or distraction of inaccurate information. Afterall, the goal of any investigation is to prevent further accidents or incidents, and by providing investigators with the full capability in doing their work without distraction or misinformation can only be beneficial for all.
