Air China 767 crash crew inadequately prepared: investigators

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South Korean air accident investigators have recommended that Air China and the Civil Aviation Administration of China (CAAC) review training programmes for circling approaches following the crash of an Air China Boeing 767 in South Korea in 2002.

The country’s accident investigation board, KAIB, today released a final report into Air China flight 129 which crashed on 15 April 2002, killing 129 of the 166 occupants. The Boeing 767-200, registered B-2552, crashed into a hill 2.5nm (4.6km) north of runway 18R at Busan city’s Gimhae International Airport while performing a circling approach.

Weather conditions at the time of the accident included strong southerly winds, rain, low clouds as well as fog around the mountainous area where the crash occurred. KAIB says the flight crew performed a circling procedure while “not being aware of the weather minima” for landing and adds that their approach briefing “did not include” a missed approach.

In its report the KAIB says: “The crew exercised poor resource management and lost situational awareness during the approach to runway 18R which led them to fly outside the circling approach area, delaying the base turn, contrary to the captain’s intention to make a timely base turn.

“The flight crew did not execute a missed approach when they lost sight of the runway during the circling approach to runway 18R which led them to strike high terrain near the airport.”

It adds: “The first officer advised the captain to execute a missed approach about five seconds before impact [but] the captain did not react – nor did the first officer initiate the missed approach himself.”

KAIB’s report also raises issues about pilot training in China. It says: “The flight crew’s training for the circling approach was conducted with the simulator only for Beijing Capital International Airport and they had never been trained for the circling approach at Gimhae Airport’s runway 18R.”

It adds that crew resource management training was “insufficient” for the three-strong flight crew complement. Air China provided one set of Jeppesen manuals to the flight crew, says the report. The captain was using these during instrument approach, it adds, making it “difficult” for the other crew members to cross-check the information. KAIB adds that the instrument approach chart used by the crew “did not depict” the high terrain of the airport.

The report also discussed the crew’s behaviour saying that the pilots failed to use standard call outs, as defined by Air China, during the circling approach.

“The second officer, tasked with handling radio communications, did not reply correctly to controller’s instructions a number of times,” says the report, adding that the captain and first officer failed to correct him.

“The flight crew did not reply appropriately to the controller’s question when asked …[about] the possibility of landing because the local controller did not have the [aircraft]…in sight after issuing the landing clearance.”

KAIB says that when the tower controllers lost visual contact with the aircraft on the final legs, they tried to locate the flight visually and did not make use of automatic visual aids designed to complement observations. It adds that when the aircraft disappeared from radar, and radio communication was lost, the tower controllers failed to notify the search and rescue department in a “timely manner”.

In its recommendations the KAIB calls on Air China and the CAAC to ensure that circling procedures are fully understood. It highlights the need to ensure that pilots understand flap configurations for circling manoeuvres, radii of turns, obstruction clearance altitudes and minimum obstruction clearances – as well as clarifying the procedures for missed approaches if visual contact is lost during the circle-to-land manoeuvre.

While the KAIB report makes a dozen recommendations to Air China and nine to the CAAC, it also makes recommendations to other parties such as the South Korean ministry of construction and transportation, Korea Airports and the Korean ministry of defence. It urges the ministry of construction and transportation, for example, to examine a method to depict the circling approach area or safety line on radar video maps. This would enable controllers to be precisely aware of the position of the aircraft in relation to terrain.

KAIB adds: “Establishment of instrument approach procedures to runway 18 at Gimhae Airport should be examined and a method should be developed to introduce radar monitoring or other safety alert systems in consideration of terrain in the vicinity of the final approach course.”