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Publish Factual Data Reports, TransAsia Airways Flight GE222 Occurrence


Publication Date 2014-12-26
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On July 23, 2014, TransAsia Airways passenger flight GE222, an ATR-72 airplane, registration number B-22810, took off from Kaohsiung International Airport for Penghu Magong Airport. There were 58 people on board, including 2 flight crewmembers, 2 cabin crewmembers and 54 passengers. The aircraft crashed at 19:06L in Xixi Village, northeast of Magong Airport Runway 20 threshold, caused 48 fatalities and 10 serious injuries. 5 residents on ground suffered minor injuries. (Please refer to Table 1 for highlights of flight history)

According to the ROC Aviation Occurrence Investigation Act and relevant procedures, the Aviation Safety Council (ASC) initiated the investigation team to conduct the investigation. The members from domestic include Civil Aeronautics Administration, Ministry of Defense (Air Force and Tri-Service General Hospital), Ministry of Justice (Institute of Forensic Medicine), and TransAsia Airways. International members include experts from the Bureau d'Enquêtes et d'Analyses (BEA), Avions de Transport Régional (ATR), Transportation Safety Board, Canada (TSB), Pratt & Whitney Canada (P&WC), National Transportation Safety Board of United States (NTSB), and Honeywell Aerospace. The team set up 9 working groups in areas of expertise in flight operations, site survey, aircraft system, wreckage recovery, air traffic service/weather, airport/Nav-Aids, survival factors, organization/management factors, and flight recorders, consisting of a total of 56 people.

Through 4 months of on-scene investigations and follow-up practices, the ASC completed the Factual Data Reports. After reviewed and verified by the whole team, as well as approved by ASC’s 29th Board Meeting on December 23, the reports were published on December 26, 2014. (Please refer to Table 2 for List of Investigation Activities and Documentations Collected)

For the convenience of international members to discuss and verify the contents, the reports were written in English and separated in 10 files as bellow:

00 General Information 
01 Flight Operations 
02 Site Survey 
03 Aircraft System 
04 Wreckage Recovery 
05 ATS / Weather 
06 Airport / Nav-Aids 
07 Survival Factors 
08 Organization Factors 
09 Fight Records 

The ASC will conduct analysis to conclude the causes, deliberate recommendations, and propose draft final report in June, 2015. The final report shall be published in October, 2015, both in English and Chinese. 

Full investigation report is available for download at ASC website: www.asc.gov.tw/

Sherry Liu, Engineer
Tel: 89127388-330  
Email:sherry@asc.gov.tw


Table1 - Highlights of GE222 Flight History

Before takeoff, the crew members recognized that Magong airport was under landing minimum requirement. They decided to take off and then requested to hold near Magong. 

The flight took off at 1745:02 hrs, climbed westward, and then turned northwest to 7,000ft, heading Magong airport.

Starting around 1811:17 hrs, the flight was in holding pattern for about 34 minutes. During holding the crew applied for Runway 02 ILS1 approach twice, but their requests were never approved due to the communication (with military office) for changing runway permission.

About 1855:10 hrs, the flight was cleared for Runway 20 VOR2 approach.

At 1859:03 hrs, the crew set aircraft heading to 201 degrees.

At 1859:21 hrs, the aircraft descent altitude was set to 400 ft.

At 1901:00 hrs, ADU3 showed approach track established.

At 1901:30 hrs, ADU showed the aircraft was on approach track.

At 1903:39 hrs, the flight was cleared to land. Wind information: 250 degrees, 19 knots.

At 1905:09 hrs, the aircraft descended to 500 ft. At 479 ft, ADU showed approaching the set altitude of 400 ft.

At 1905:12 hrs, Captain called “300”, then the set altitude on ADU was set to 300 ft.

At 1905:24 hrs, the aircraft passed 355 ft, ADU showed approaching the set altitude of 300 ft.  Captain called “… 200”, then the set altitude on ADU was set to 200 ft.

At 1905:44 hrs, the autopilot was disengaged at altitude of 219 ft and descent rate was -100 ft/min.

At 1905:54 hrs, the aircraft reached MAP4 at an altitude of 176 ft.

At 1905:58 hrs, Captain asked his First Officer “Have you seen the runway yet”

At 1905:59 hrs, the aircraft climbed to 192 ft and yaw damper was disengaged. The aircraft heading changed from 207 degrees to 188 degrees with a left bank between 10 and 20 degrees. The pitch also changed from 0.5 degree nose up to a nose down attitude with maximum of 9 degrees pitch down.

At 1906:03 hrs, the aircraft’s altitude was at 162 ft, heading 197 degrees, bank to the left at 19 degrees.

At 1906:07 hrs, the First Officer answered “No.” One second later Captain also said “No”, two seconds later the First Officer answered again “No sir.”

At 1906:11 hrs, the aircraft’s altitude was at 72 ft. Both crew members called out “go around” and the throttle was levered up.

At 1906:13 hrs, an unidentified sound was recorded by CVR.

At 1906:16 hrs, the First Officer called to Magong tower “go around go around.”

At 1906:18.9 hrs, both flight recorders stopped recording.

1. ILS: Instrument Landing System.  

2. VOR: VHF Omni-directional Range.  

3. ADU: Advisory Display Unit.  

4. MAP: Missed Approach Point.


Table 2 - List of GE222 Investigation Activities and Documentations Collected

Item

Content

Number

1

Interview notes

75

2

Transcripts

24

3

Flight crew records(personal information、schedule、training)

23

4

Inspection records(routine、main base、operator in-depth、SMS、airport)

8

5

Technical log book

12

6

Cockpit line observations

24

7

Performance simulator session

3 flight 8hrs

8

Simulator training observations

3 flight 12hrs

9

Flight test recorders

12

10

Flightcrew notices

36 pages

11

Manuals、documents、protocols(flight operations、maintenance、ATC、SMS、inspector)

32

12

Tests and examinations(wreckage structure、oil filter、fuel、oil)

19

13

Flight recorder decoding、process、analysis、animation

104 flights

14

Site survey conducted by UAV

4 flights

15

Wreckage database

1

16

Reconstruction of cockpit instrument panel

1

17

Wreckage storage(20 ft container)

5

18

Weather Data

35

19

ATC Radar Data

2

20

Records, rosters, and logs of ATC controllers

20

21

Evaluation report, inspection records of Nav-Aids

4

22

Surveillance video films of flightcrew dorm, airport, ambulance

3

23

Medical records, autopsy and toxicology examination reports

78

24

Manifest、cabin wreckage、ambulance duty reports

3

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