Taiwan's Aviation Safety Council (ASC) press release on the SQ006 Accident Report
26/4/2002

Findings related to risk

Risks related to CKS airport

Based on the current ICAO Annex 14 Standards and Recommended Practices (SARPs), the CKS Airport should have placed runway closure markings adjacent to the construction area on Runway 05R; however, there was no requirement to place runway closure markings near the threshold of Runway 05R. Although there are no clear ICAO regulations for placement of warnings on temporarily closed runways that are also used for taxi operations, the lack of adequate warnings at the entrance to Runway 05R did not provide a potential last defense. From an airport infrastructure perspective, to prevent the flight crew of SQ006 from mistakenly entering Runway 05R, the concrete barriers were used around the construction area on Runway 05R.

CKS Airport infrastructure did not meet the level of internationally accepted standards and recommended practices, among these items were unserviceable, densely spaced green centerline lights,N1 Taxiway centerline marking, runway guard lights and stop bars, alternate green/yellow taxiway centerline lights .The mandatory guidance signs installed location, no interlocking system installed ,lack of a continuous monitoring feature of individual lights, or percentage of unserviceable lamps, for any circuit of CKS Airport lighting. Appropriate attention given to these items could have enhanced the situational awareness of the flight crew while taxiing to Runway 05L; however, the absence of these enhancements was not deemed sufficient to have caused the loss of situational awareness of the flight crew.

The organization and system risks include: Being a non-contracting State, the CAA of ROC does not have the opportunity to participate in ICAO activities in developing its airport safety enhancement programs to correspond with international safety standards and recommended practices. However, lack of specified safety regulation monitoring organization and mechanism resulted in the absence of mechanism to highlight conditions at CKS airport for taxiways and runways lighting, marking and signage that did not meet international accepted safety standards and practices. The lack of a safety oversight mechanism within CAA that could have provided an independent audit/assessment of CKS Airport to ensure that its facilities met internationally accepted safety standards and practices.

Other risks include: Airport Surface Detection Equipment (ASDE), the forming of Service Movement Guidance and Control System working group, ATC issue as the local controller did not issue progressive taxi/ground movement instructions and did not use the low visibility taxi phraseology to inform the flight crew to slow down during taxi. CKS Airport emergency medical treatment procedures and Medical coordinator’s responsibilities, CKS Airport contingency procedures for medical treatment and rescue in adverse weather conditions. Airport fire-fighting department was understaffed in handling a major accident.

SIA, CAAS related risks

SIA

The lack of SIA and ATC procedures for quantitatively determining a “wet” versus “contaminated” runway, lack of low visibility taxi operations. Training, formal training for low visibility taxi techniques. SIA did not have a procedure for the pilots to use the PVD as a tool for confirming whether the aircraft is in a position for takeoff in low visibility conditions Aircraft Operations Manual did not include “confirm active runway check” as a before takeoff procedure. The SIA training and procedures for low visibility taxi operations, Cabin crewmembers emergency evacuation procedures and joint training.

CAAS oversight

CAAS approved SIA’s procedures, SIA documentation and operational practices of PVD operations and training safety oversight of SIA’s procedures and training.

Other Findings

The preponderance of evidence indicates that the Runway 05R edge lights were most likely not illuminated during the attempted takeoff of SQ006. The majority of the CKS Airport medical and rescue operations were not able to function in accordance with CKS Airport procedures because of strong wind and heavy rain emanating from approaching typhoon “Xangsane.” The Ministry of Transportation and Communications (MOTC) staff was not proactive in supporting CAA’s requests for the installation of ASDE at CKS Airport. All new CAA regulations are subject to lengthy formalities in the approval process by the MOTC. Singapore does not have an independent aviation accident investigation authority charged with making objective investigations, conclusions, and recommendations. International experience has shown that an independent investigation authority is a benefit to aviation safety, and many States have taken actions to ensure that investigations are conducted by a government agency that is functionally independent from the authority responsible for regulation and oversight of the aviation system.

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