Singapore Ministry of Transportation's comments on the final report of the investigation into the SQ006 accident
26/4/2002

The Taiwan Aviation Safety Council (ASC) has today released the Final Report of the investigation into the SQ006 accident at Chiang Kai-Shek (CKS) Airport on 31 October 2000.

The Singapore Ministry of Transport (MOT) has received a copy of the Final Report this afternoon. The MOT's investigation team finds the ASC final report incomplete, as it does not present a full account of the accident. The report attributes pilot error to be the main cause of the accident. It downplays significant systemic factors which contributed to the accident, such as deficiencies in CKS Airport and its non-conformance with ICAO Standards and Recommended Practices. It also does not adequately address the lessons learnt.

The MOT team recognises that the flight crew of SQ006 took off from the wrong runway 05R on the night of the accident. However, even after the accident, the flight crew firmly believed that they were on the correct runway 05L. MOT investigators are of the view that CKS Airport was lacking in crucial details that could have led the pilots onto the correct runway, or prevented them from entering the wrong runway, or alerted them of their error. These deficiencies were major contributory factors to the accident.

First, the runway and taxiway lighting, signage and markings at CKS Airport did not conform to international standards, and some critical taxiway guidance lights and markings leading to the correct takeoff runway were either missing or unserviceable. Such deficiencies provided compelling cues that led the flight crew to turn into the wrong runway, and yet firmly believe that they were turning into the correct runway. There were no visible alternative pathways presented to the pilots.

Second, contrary to international practice, CKS Airport did not have physical barriers at the start of the closed Runway 05R. Such barriers would have alerted the flight crew to their error and prevented the takeoff.

These key factors are glossed over in the ASC's analysis of the accident. What happened to the flight crew of SQ006 could have happened to any other flight crew - in fact, the investigation team recorded testimonies from two other pilots who nearly made the same mistake, one of them as recent as the day before the accident.

The fact that CKS Airport has taken action to rectify some of these deficiencies immediately after the accident demonstrates that they are major contributory factors which could have prevented the SQ006 tragedy. Some of these steps include renaming Runway 05R as a taxiway called "NC"; painting the missing segment of Taxiway N1 centreline marking leading to Runway 05L; adding to taxiway centreline lights from Taxiway N1; removing the Runway 05R threshold markings and designator markings; and disconnecting the Runway 05R runway edge lights.

Over the past months, MOT investigators have highlighted these facts to the ASC but their views have either not been incorporated or incorporated in a different context from what they were intended to be. This stems in part from the ASC excluding the MOT team from the analysis phase of the investigation, contrary to international practice.

The MOT team is therefore issuing an alternative analysis to explain why an experienced flight crew made such an error and to address the lessons learnt. The analysis has been prepared with the assistance of two ICAO-appointed independent safety consultants. The MOT team hopes that this alternative analysis could lead to a better understanding of why the accident happened and how similar incidents could be prevented.

The SQ006 accident should not be seen as an isolated event specific to CKS Airport. Rather, it is a symptom of the global problem of runway safety. The confusion of runways and taxiways is an increasingly serious problem facing the airline industry worldwide. The US FAA has specified runway safety as one of its top five priorities. We hope our alternative analysis would enable the international aviation community to benefit from the lessons learnt, and help to prevent similar tragedies in the future.

More information on MOT's analysis of the accident can be found at www.sq006.gov.sg.

On behalf of the people and the Government of Singapore, we would like to thank the people and the Taiwanese authorities for their invaluable assistance and support since the accident. We would also like to thank the Taiwan Aviation Safety Council for their hard work in preparing the Final Report. We understand that it was a complex and difficult task.