1. The Fate of Flight SQ006
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2. 82 of the passengers & crew died in the crash
Singapore Airlines flight sq006 crashed soon after take-off on October 31 at 2318 hours
82 of the passengers & crew died in the crash
159 passengers were aboard.
They were trying to take off in near 0 visibility as a typhoon rolled into Taipei
On October 31, 2000, Singapore Airlines flight SQ006 crashed soon after if lifted off the ground. It was flying from Chiang Kai Shek airport in Taipei, Taiwan with an intended destination of Los Angeles.
A typhoon was eminent and weather conditions were far less than optimal.
82 passengers and crew members perished in the fiery crash that was initially believed to be the result of wind sheer. As the investigation into the event progressed it was clear that this accident was more the work of failed organizational factors and human error rather than an act of God.
All 3 pilots survived

3. Black Box
ATC - Singapore 6, runway 05 left. Wind 020 at 28. Gusts to 50. Clear for take off.
Captain - Clear for take off. Runway 05 left. Singapore 6.
Captain - We can see the runway not so bad. OK, I am going to put it to high first.
First Officer - 80 knots
Captain - OK, my control.
First Officer - V1
Captain - (expletive) Something there!
Banging sound
Captain says something unintelligible followed by a series of crashing sounds.
Recording stopped
Note reference to V1 is the speed at which the aircraft can no longer abort liftoff. For the 747 this is approximately 142 knots.

4.
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5. But remember the black box ......
Captain - (expletive) Something there!
Banging sound
Wrong Turn?
The ill-fated SQ006 was on the wrong runway before it crashed on Tuesday night, said Taiwan’s chief investigator at a news conference on Friday.
The statement by Taiwan’s Aviation Safety Council Managing Director, implied that pilot error played a major role in the crash of the Boeing 747, which lead to the death of 81 people.
The closed runway, number 05R, runs parallel to the one from which the plane should have taken off, 05L
The observation by the pilot is the identification of a concrete barrier which the main landing gear hit (tearing it from the aircraft) at This was the first of many collisions to be experienced by SQ006 before the nose of the aircraft finally came to rest at about 6000 feet down the runway. The debris of the rest of the aircraft were scattered for 2000 feet behind the nose.

6. Layout of Chiang Kai Shek Airport

7. Was pilot error the sole cause of the event?
Runways that are out of service are not lighted to make it clear to pilots they are not in use.
This is not the case at Chiang Kai Shek airport where one switch controls green lights on the common taxiway and down the middle of 05R.
Yellow barriers are generally used to block runways that are out of service.
This is not the case at Chiang Kai Shek airport where the strip under construction was still in use as a taxiway back to the terminal.
What are the Flawed Defenses?
Lights
Barriers
Where did the Flawed Defenses originate from?
Latent condition produced from the design of the airport that placed the taxiway / runway lights on the same switch. (LOW in design process)
Decision to not barrier off the runway so that it could be used as a taxiway by landing aircraft. (LOW in policies, maybe values?)

8. Was pilot error the sole cause of the event?
The pilot confirmed twice to the control tower that he understood he was to be on runway 05L.
Control Tower officials are unable to confirm aircraft location at Chiang Kai Shek airport where ground radar has yet to be installed and the runways are out of the line of tower sight.
Runway 05R was classified as a VFR runway only.
Due to the approaching typhoon visibility prior to take off was 600 meters.
The concrete barriers were placed about 4080ft down the runway.
What are the Error Precursors?
Assumption by pilot he was on correct runway.
Pilot on VFR (visual flight route) while visibility is limited.
What created these Error- Precursors?
Latent communications weakness caused by the absence of ground radar. (Design LOW again)
Lack of alternate indication to flight crew as a Defense (lights on, no barriers at runway threshhold)
Latent Organizational Weakness that allows flights under these conditions. Note: Consider the similarities here with our own US airlines blaming flight cancellation on refusal of pilots to work overtime. What is the real issue here besides the contract under negotiation. Do you want your pilot to be well rested/

9. Sketch of Wreckage
This slide can be used to walk the aircraft through the collisions.

10. What Really Happened?
What we find is a reaffirmation of the need to look past the obvious human error. It is far too easy for organizations to place sole responsibility for such unfortunate events on the people involved. Just as we define performance as behaviors plus results, we must consider events as organizational factors plus human error. Ignoring the organization’s role in events makes us vulnerable to our own fallibility.
Note once again that even though we look at different industries we continue to see the same Flawed Defenses, Error-Precursors, and Organizational Weaknesses in the events we use as case studies.

11.
All facts, figures, news footage used in this presentation are located on Channelnewsasia.com. The short cuts provided direct you to their web site. These videos are copy righted material and intended for your personal use only. You must have Windows media player 2 or higher to view and be connected to the web.
Note: Acknowledge the use of Channelnewsasia for data. The aviation safety authority in Taipei has not issued an investigation as of the presentation date. The findings of their investigation may bring other factors into the light.