The Aviation Safety Council （ASC） releases final report on investigation of a TransAsia Airways （TNA） ATR72-212A （ATR72） aircraft, registration number B-22810, impacted terrain and collided with a residential area on northeast of the threshold of runway 20 at Magong Airport.

On July 23, 2014, an ATR-GIE Avions de Transport Régional ATR72-212A （ATR72）  passenger aircraft, flight number GE 222, took off from Kaohsiung Airport to Magong in the Penghu archipelago to execute a schedule transportation mission. There were 2 flight crews, 2 cabin crews and 54 passengers, total 58 people on board. At 1906 Taipei Local Time, the aircraft impacted terrain approximately 850 meters northeast of the threshold of runway 20 at Magong Airport and then collided with a residential area on the outskirts of Xixi village approximately 200 meters to the southeast of the initial impact zone. The aircraft was destroyed by impact forces and a post-impact fire. Ten passengers survived the occurrence and five residents on the ground sustained minor injuries.

The occurrence was the result of controlled flight into terrain （CFIT）, that is, an airworthy aircraft under the control of the flight crew was flown unintentionally into terrain with limited awareness by the crew of the aircraft's proximity to terrain. The crew continued the approach below the minimum descent altitude （MDA） when they were not visual with the runway environment contrary to standard operating procedures. The investigation report identified a range of contributing and other safety factors relating to the flight crew of the aircraft, TransAsia's flight operations and safety management processes, the communication of weather information to the flight crew, coordination issues at civil/military joint-use airport, and the regulatory oversight of TransAsia by the Civil Aeronautics Administration （CAA）.

The ASC is an independent agency responsible for civil aviation, public aircraft and ultra-light vehicle occurrences investigation. According to the Republic of China Aviation Occurrence Investigation Act and referencing to the related content of Annex 13 to the Convention of International Civil Aviation Organization （ICAO）, the ASC launched an occurrence investigation by law. The organization or agency been invited to join the investigation team also included: BEA （Bureau d'Enquêtes et d'Analyses, France）, TSB （Transportation Safety Board, Canada）, NTSB （National Transportation Safety Board, USA）, ATR （Avions de Transport Régional）, P&WC （Pratt & Whitney Canada）, Honeywell Aerospace/USA, CAA Taiwan, Ministry of National Defense ROC, and TNA.The Final Report was reviewed and approved by ASC's 41th Council Meeting on January 26, 2015.

There are a total of 46 findings from the Final Report, and 29 safety recommendations issued to the related organizations.

Findings Related to Probable Causes

Flight Operations

1. The flight crew did not comply with the published runway 20 VOR non-precision instrument approach procedures at Magong Airport with respect to the minimum descent altitude （MDA）. The captain, as the pilot flying, intentionally descended the aircraft below the published MDA of 330 feet in the instrument meteorological conditions （IMC） without obtaining the required visual references.
2. The aircraft maintained an altitude between 168 and 192 feet before and just after overflying the missed approach point （MAPt）. Both pilots spent about 13 seconds attempting to visually locate the runway environment, rather than commencing a missed approach at or prior to the MAPt as required by the published procedures.
3. As the aircraft descended below the minimum descent altitude （MDA）, it diverted to the left of the inbound instrument approach track and its rate of descent increased as a result of the flying pilot's control inputs and meteorological conditions. The aircraft's hazardous flight path was not detected and corrected by the crew in due time to avoid the collision with the terrain, suggesting that the crew lost situational awareness about the aircraft's position during the latter stages of the approach.
4. During the final approach, the heavy rain and associated thunderstorm activity intensified producing a maximum rainfall of 1.8 mm per minute. The runway visual range （RVR） subsequently reduced to approximately 500 meters. The degraded visibility significantly reduced the likelihood that the flight crew could have acquired the visual references to the runway environment during the approach.
5. Flight crew coordination, communication, and threat and error management were less than effective. That compromised the safety of the flight. The first officer did not comment about or challenge the fact that the captain had intentionally descended the aircraft below the published minimum descent altitude （MDA）. Rather, the first officer collaborated with the captain's intentional descent below the MDA. In addition, the first officer did not detect the aircraft had deviated from the published inbound instrument approach track or identify that those factors increased the risk of a controlled flight into terrain （CFIT） event.
6. None of the flight crew recognized the need for a missed approach until the aircraft reached the point （72 feet, 0.5 nautical mile beyond the missed approach point） where collision with the terrain became unavoidable.
7. The aircraft was under the control of the flight crew when it collided with foliage 850 meters northeast of the runway 20 threshold, two seconds after the go around decision had been made. The aircraft sustained significant damage and subsequently collided with buildings in a residential area.  Due to the high impact forces and post-impact fire, the crew and most passengers perished.
8. According to the flight recorders data, non-compliance with standard operating procedures （SOPs） was a repeated practice during the occurrence flight. The crew's recurring non-compliance with SOPs constituted an operating culture in which high risk practices were routine and considered normal.
9. The non-compliance with standard operating procedures （SOPs） breached the obstacle clearances of the published procedure, bypassed the safety criteria and risk controls considered in the design of the published procedures, and increased the risk of a controlled flight into terrain （CFIT） event.

Weather

10. Magong Airport was affected by the outer rainbands of Typhoon Matmo at the time of the occurrence. The meteorological conditions included thunderstorm activities of heavy rain, significant changes in visibility, and changes in wind direction and speed.

Findings Related to Risk

Flight Operations

1. The captain did not conduct a descent and approach briefing as required by standard operating procedures （SOPs）. The first officer did not question the omission of that required briefing. That deprived the crew of an opportunity to assess and manage the operational risks associated with the approach and landing.
2. The captain was likely overconfident in his flying skills. That might lead to his decision to continue the approach below the minimum descent altitude （MDA） without an appreciation of the safety risks associated with that decision.
3. The results of the fatigue analysis indicated that, at the time of the occurrence, the captain's performance was probably degraded by his fatigue accumulated from the multiple sectors/day flown and flight and duty times during the months preceding the occurrence.
4. The TransAsia Airways observation flights conducted by the investigation team and the interviews with members of the airline's flight operations division show prevalent tolerance for non-compliance with procedures within the airline's ATR fleet.
5. The non-compliances with standard operating procedures （SOPs） during the TransAsia Airways’ ATR simulator training sessions were observed by the investigation team but not corrected by the instructors. The tolerance for or normalization of SOPs non-compliance behaviors was symptomatic of an ineffective check and training system with inadequate supervision by the airline's flight operations management.
6. The non-compliance with standard operating procedures （SOPs） was not restricted to the occurrence flight but was recurring, as identified by previous TransAsia Airways ATR occurrence investigations, line observations, simulator observations, internal and external audits or inspections, and interviews with TransAsia Airways flight operations personnel, including managers. The non-compliant behaviors were an enduring, systemic problem and formed a poor safety culture within the airline's ATR fleet. 

Airline Safety Management

7. The TransAsia Airways’ inadequate risk management processes and assessments, ineffective safety meetings, unreliable and invalid safety risk indices, questionable senior management commitment to safety, inadequate safety promotion activities, underdeveloped flight operations quality assurance （FOQA） system, and inadequate safety and security office and flight operations resources and capabilities constituted an ineffective safety management system （SMS）.
8. The safety risks associated with change within the TransAsia Airways were not assessed and mitigated. For example, the company did not assess or mitigate the safety risks associated with the increase in ATR operational tempo as a result of the recent increase in ATR fleet size and crew shortage that, in turn, elevated crew flying activities and the potential safety risks associated with crew fatigue.
9. Findings regarding non-compliance with standard operating procedures （SOPs） during operations by the TransAsia Airways’ ATR crews had been identified by previous Aviation Safety Council occurrence investigations. The proposed corrective safety actions were not implemented by the airline.
10. TransAsia Airways self-audits were mostly spot checks rather than system audits or system self-evaluations. The self-audits failed to assess and address those safety deficiencies, including standard operating procedures non-compliance behaviors, lack of standardization in pilot check and training activities, and high crew flying activities on the ATR fleet. Such deficiencies had been pointed out in previous occurrences and audits and were considered by senior flight operations managers as problems.
11. The TransAsia Airways annual audit plan did not include an evaluation of the implementation and/or effectiveness of corrective actions in response to the safety issues identified in previous audits, regulatory inspection findings, or safety occurrence investigation recommendations. The airline's self-audit program was not consistent with the guidance contained in AC-120-002A.
12. The TransAsia Airways had not developed a safety management system （SMS） implementation plan. This led to a disorganized, nonsystematic, incomplete and ineffective implementation, which made it difficult to establish robust and resilient safety management capabilities and functions.
13. The Civil Aeronautics Administration's （CAA） safety management system （SMS） assessment team had identified TransAsia Airways’ SMS deficiencies, but TransAsia Airways failed to respond to the CAA's corrective actions request. That deprived the airline of an opportunity to improve the level of safety assurance in its operations.
14. The TransAsia Airways did not implement a data-driven fatigue risk management system （FRMS） or alternative measures to manage the operational safety risks associated with crew fatigue due to fleet expansion and other operational factors.
15. The ATR flight operation did not include in its team a standards pilot to oversee standard operating procedures （SOPs） compliance, SOP-related flight operations quality assurance （FOQA） events handling, and standard operations audit （SOA） monitoring before the GE222 occurrence. 
16. The safety and security office, due to resource and capability limitations, was unable to effectively accomplish the duties they were required to undertake.
17. The safety and security office staff was not included in the flight safety action group. That deprived the airline of an opportunity to identify, analyze and mitigate flight safety risks more effectively in the flight operations.
18. The TransAsia Airways’ safety management system was overly dependent on its internal reactive safety and irregularity reporting system to develop full awareness of the airline's safety risks. It did not take advantage of the instructive material from external safety information sources. That limited the capability of the system to identify and assess safety risks.
19. The TransAsia Airways’ flight operations quality assurance （FOQA） settings and analysis capabilities were unable to readily identify those events involving standard operating procedures （SOPs） non-compliance during approach and likely other stages of flight. The FOQA events were not analyzed sufficiently or effectively, leaving some safety issues in flight operations unidentified and uncorrected. Some problems with crew performance and reductions in safety indicated in the FOQA trend analyses were not investigated further. Clearly, the airline's FOQA program was not used to facilitate proactive operational safety risk assessments.

Civil Aeronautics Administration

20. The Civil Aeronautics Administration's oversight of TransAsia Airways did not identify and/or correct some crucial operational safety deficiencies, including crew non-compliance with procedures, non-standard training practices, and unsatisfactory safety management practices.
21. To develop and maintain a safety management system （SMS） implementation plan at TransAsia Airways was not enforced by the Civil Aeronautics Administration. That deprived the regulator of an opportunity to assess and ensure that the airline had the capability to implement a resilient SMS.
22. Issues regarding the TransAsia Airways’ crew non-compliance with standard operating procedures （SOPs） and deficiencies with pilot check and training had previously been identified by the Aviation Safety Council investigation reports. However, the Civil Aeronautics Administration （CAA） did not monitor whether the operator has implemented the recommended corrective actions; correlatively, the CAA failed to ensure the proper measures for risk reduction have been adopted.
23. The Civil Aeronautics Administration provided limited guidance to its inspectors to enable them to effectively and consistently evaluate the key aspects of operators’ management systems. These aspects included evaluating organizational structure and staff resources, the suitability of key personnel, organizational change, and risk management processes.
24. The Civil Aeronautics Administration did not have a systematic process for determining the relative risk levels of airline operators.

Air Traffic Service and Military

25. The runway visual range （RVR） reported in the Magong aerodrome routine meteorological reports （METAR） and the aerodrome special meteorological reports （SPECI） was not in accordance with the requirements documented in the Air Force Meteorological Observation Manual. 
26. The discrepancies between the reported runway visual range （RVR） and automated weather observation system （AWOS） RVR confused the tower controllers about the reliability of the AWOS RVR data.
27. During the final approach, the runway 20 runway visual range （RVR） values decreased from 1,600 meters to 800 meters and then to a low of about 500 meters. The RVR information was not communicated to the occurrence flight crew by air traffic control. Such information might influence the crew's decision regarding the continuation of the approach.

Safety Recommendations

To TransAsia Airways

1. Implement effective safety actions to rectify the multiple safety deficiencies previously identified by the Aviation Safety Council investigations, internal and external Civil Aeronautics Administration audit and inspection findings, and deficiencies noted in this report to reduce the imminent safety risks confronting the airline.
2. Conduct a thorough review of the airline's safety management system and flight crew training programs, including crew resource management and threat and error management, internal auditor training, safety management system （SMS） training and devise systematic measures to ensure:

• Flight crew check and training are standardized;
• All flight crews comply with standard operating procedures （SOPs）;
• Staff who conduct audits receive appropriate professional auditor training;
• All operational and senior management staff receive SMS training, including thorough risk assessment and management training; and
• Proportional and consistent rules, in accordance with a “Just Culture”, are implemented to prevent flight crew from violating the well-designed SOPs and/or being engaged in unsafe behavior.

3. Conduct a rigorous review of the safety management system （SMS） to rectify the significant deficiencies in:

• Planning;
• Organizational structure, capability and resources;
• Risk management processes and outputs;
• Flight operations quality assurance （FOQA） limitations and operations, including inadequate data analysis capabilities;
• Safety meetings;
• Self-audits;
• Safety performance monitoring, including risk indices;
• Safety education; and
• Senior management commitment to safety.

4. Rectify the human resources deficits in the flight operations division and the safety and security office, including:

• Crew shortages;
• Inadequate support staff in the Flight Standards and Training Department, including insufficient standards pilots and crew to conduct operational safety risk assessments; and
• Safety management staff with the required expertise in flight operations, safety and flight data analytics, safety risk assessment and management, human factors, and safety investigations.  

5. Review and improve the airline's internal compliance oversight and auditing system and implement an effective corporate compliance and quality assurance system to ensure that oversight activities provide the required level of safety assurance and accountability. 
6. Implement an effective safety management process, such as a data-driven fatigue risk management system （FRMS）, to manage   the flight safety risks associated with crew fatigue.
7. Provide flight crew with adequate fatigue management education and training, including the provision of effective strategies to manage fatigue and performance during operations.
8. Implement an effective change management system as a part of the airline's safety management system （SMS） to ensure that risk assessment and mitigation activities are formally conducted and documented before significant operational changes are implemented, such as the introduction of new aircraft types or variants, increased operational tempo, opening new ports, and so on. 
9. Implement a more advanced flight operations quality assurance （FOQA） program with adequate training and technical support for the FOQA staff to ensure that they can exploit the analytical capabilities of the program. As such, the FOQA staff can more effectively identify and manage the operational safety risks confronting flight operations.  
10. Implement an effective standard operating procedures （SOPs） compliance monitoring system, such as the line operations safety audit （LOSA） program, to help identifying threats to operational safety and to minimize the associated risks. The system should adopt a data-driven method to assess the level of organizational resilience to systemic threats and can detect issues such as habitual non-compliance with SOPs.

To Civil Aeronautics Administration

1. Strengthen surveillance on TransAsia Airways to assess crew's discipline and compliance with standard operating procedures （SOPs）.
2. Implement a more robust process to identify safety-related shortcomings in operators’ operations, within an appropriate timescale, to ensure that the operators meet and maintain the required standards.
3. Provide inspectors with detailed guidance on how to evaluate the effectiveness of an operator's safety management system （SMS）, including:

• Risk assessment and management practices;
• Change management practices;
• Flight operations quality assurance （FOQA） system and associated data analytics; and
• Safety performance monitoring.

4. Provide inspectors with comprehensive training and development to ensure that they can conduct risk-based surveillance and operational oversight activities effectively. 
5. Enhance inspector supervision and performance evaluation to ensure all inspectors conduct surveillance activities effectively and are able to identify and communicate critical safety issues to their supervisors.
6. Enhance the oversight of operators transitioning from traditional safety management to safety management systems.
7. Develop a systematic process for determining the relative risk levels of airline operators.
8. Review the current regulatory oversight surveillance program with a view to implementing a more targeted risk-based approach for operator safety evaluations.
9. Ensure all safety recommendations issued by the occurrence investigation agency are implemented by the operators.
10. Develop detailed guidance for operators to implement effective fatigue risk management processes and training.
11. Review runway approach lighting systems in accordance with their existing radio navigation and landing aids to ensure that adequate guidance is available for pilots to identify the visual references to the runway environment, particularly in poor visibility condition or at night.
12. Review the design procedures for determining the location of missed approach point with the intention of increasing the likelihood of pilots to locate the runway without compromising the required obstacle clearance altitude. 
13. Request tower controllers to advise the flight crews of aircraft on final approach of the updated information in accordance with the provisions of the air traffic management procedures （ATMP）.   
14. Coordinate with Air Force Command Headquarters to review and improve the weather information exchange and runway availability coordination between civil air traffic control and military personnel at Magong Airport.  

To ATR-GIE Avions de Transport Régional

1. Evaluate the feasibility of a modification to allow the new enhanced ground proximity warning system （EGPWS） to be fitted on all ATR72-500 aircraft.
2. Review the flight data recorder （FDR） readout document for any erroneous information and provide timely revisions of the manual to assist airline operators and aviation occurrence investigation agencies.

To Air Force Command Headquarters, Ministry of National Defense

1. Coordinate with the Civil Aeronautics Administration to ensure the reliability and validity of automated weather observation system （AWOS） runway visual range （RVR） sensors and their data.
2. Conduct the runway visual range （RVR） reporting operations and requirements in accordance with the provisions of the Air Force Meteorological Observation Manual.
3. Coordinate with the Civil Aeronautics Administration to review and improve the weather information exchange and runway availability coordination between civil air traffic control and military personnel at Magong Airport.

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

All information published by press conference is also available to download from the following cloud drive.

Google Drive：https://goo.gl/psQeDo
OneDrive：https://goo.gl/GEx82t
Dropbox ：https://goo.gl/GPGGfO
Mega：https://goo.gl/B9uFhg

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