Date of Accident: 23 July 2014
Aircraft Type: ATR-72-500
Operator: TransAsia Airways
Flight Number: GE222
Departure Airport: Kaohsiung International Airport (RCKH)
Destination Airport: Magong Airport (RCQC), Penghu Island
Passengers and Crew: 54 passengers, 4 crew members
Fatalities: 48
Survivors: 10
Weather Conditions: Adverse due to Typhoon Matmo
Phase of Flight: Approach/Landing
Summary of Event:
On 23 July 2014, TransAsia Airways Flight GE222, operating a short domestic flight from Kaohsiung to Penghu’s Magong Airport, crashed during its second approach attempt amidst severe weather conditions influenced by Typhoon Matmo. The ATR-72-500 twin-engine turboprop was carrying 54 passengers and four crew members, of which 48 lost their lives due to the crash. The accident occurred as the aircraft was attempting to land in low visibility, high winds, and heavy rain. The plane crashed into a residential area, causing significant damage on the ground as well.
Weather and Approach Conditions:
Upon departure from Kaohsiung, the flight was already delayed by approximately two hours due to inclement weather conditions caused by the passing typhoon. Although the typhoon had mostly passed Penghu at the time of arrival, the residual effects included gusting winds, turbulence, and low visibility.
The initial approach was aborted after the flight crew determined that conditions were too challenging to continue the landing. After executing a go-around, the flight crew attempted a second approach, but during this attempt, the aircraft impacted the ground short of the runway, crashing into residential buildings. Witnesses and data suggest that reduced visibility, poor communication between the flight crew, and the deteriorating weather played significant roles in the crash.
Analysis of Contributing Factors:
1. Weather-Related Challenges:
• The presence of Typhoon Matmo in the region created challenging and deteriorating weather conditions that severely affected visibility and crosswind components during the approach.
• Analysis of weather reports indicated that conditions during the second landing attempt were below standard minima for visual reference, forcing the crew to rely solely on instrumentation.
2. Flight Crew Decision-Making:
• The flight crew opted to continue with the landing attempt despite the challenging weather and the availability of diversion airports. This decision is suspected to have been influenced by operational pressures, as delays and potential diversions could have caused further scheduling disruptions.
• During the approach, cockpit recordings suggested decision fatigue and miscommunication between the captain and first officer regarding whether conditions were suitable for landing.
3. Crew Resource Management (CRM):
• The investigation revealed lapses in CRM, particularly in the communication between the captain and first officer during critical moments. The decision to execute a second landing attempt despite poor weather conditions was not fully supported by a proper cross-check of all available instruments and communication with air traffic control (ATC).
• CRM failures led to insufficient teamwork and lack of assertiveness in decision-making during this critical phase of flight.
4. Instrument and Altitude Monitoring:
• Analysis of flight data indicated that the aircraft descended below the Minimum Descent Altitude (MDA) without visual confirmation of the runway environment, a critical error when conducting instrument approaches.
• The descent profile of the aircraft was inconsistent, suggesting that the crew had difficulty maintaining the appropriate glide path due to both environmental and human factors.
Investigation Findings:
The investigation, conducted by the Aviation Safety Council (ASC) of Taiwan, confirmed that the crash resulted from a combination of poor weather conditions, pilot decision-making errors, and improper coordination between the flight crew.
• Typhoon Influence: The aircraft faced residual weather impacts from Typhoon Matmo, which included strong crosswinds, reduced visibility, and moderate to severe turbulence. Despite this, the decision to proceed with the second approach and land was taken without adequate consideration of these factors.
• Human Factors: The flight crew was found to have mismanaged the approach. The decision to continue the landing despite deteriorating weather conditions, combined with ineffective communication, contributed to the outcome. The crew’s failure to maintain situational awareness and reliance on inadequate visual cues resulted in the aircraft’s descent below the minimum safe altitude.
• CRM Deficiencies: The cockpit voice recorder revealed breakdowns in communication and situational assessment, particularly during the approach to Magong Airport. These shortcomings in CRM affected the crew’s ability to make a sound, timely decision regarding the go-around and potential diversion options.
Recommendations:
Following the findings, the ASC made several recommendations to enhance flight safety and prevent future accidents under similar circumstances:
1. Enhanced Weather Monitoring Systems:
• Airlines and ATC need to establish more robust weather monitoring and reporting systems, particularly during adverse weather conditions. Real-time updates and alerts should be communicated to flight crews more effectively, especially when operating near or within typhoon-prone regions.
2. Revised Crew Resource Management (CRM) Training:
• Airlines should review and enhance CRM training to ensure that pilots can effectively communicate and make joint decisions during high-pressure situations. This training should emphasize assertiveness, clear communication, and effective cross-verification procedures.
3. Emphasis on Diversion Protocols:
• Airlines should reinforce policies regarding diversions during adverse weather. Diversion should be considered the safest option in cases where weather minima are not met, and crews should be supported in making these decisions without fear of operational or financial repercussions.
4. Pilot Decision-Making in Severe Weather:
• Improved training in decision-making under duress is essential. Crews should be trained to assess situations holistically, factoring in weather, aircraft performance, and fuel levels to make safe, informed decisions. Emphasis should also be placed on understanding when it is safer to divert rather than to attempt a landing in compromised conditions.
Conclusion:
The tragic crash of TransAsia Airways Flight GE222 highlights the vulnerabilities of aircraft operations in extreme weather conditions, particularly when human factors and decision-making breakdown under pressure. This incident reinforces the need for robust CRM practices, enhanced weather reporting, and a stronger emphasis on diversion protocols during challenging weather conditions. Through the implementation of these safety recommendations, the aviation industry can aim to reduce the risk of similar occurrences in the future.
Final Safety Message:
The aviation industry must always prioritize passenger and crew safety by fostering a culture that supports informed decision-making, even when operational pressures and environmental challenges exist. Strict adherence to weather-related flight protocols and better crew coordination are essential in preventing future accidents.
