TransAsia ATR crash largely blamed on crew actions

TransAsia 235 crashed into the Keelung River on February 4, 2015 after losing power on takeoff. The investigation has found a number of factors involved led to the crash, but the largest factor were the actions of the crew during the time between the start of the takeoff, and impact with the river.

During the takeoff, there was an intermittent disconnect in the right engine auto feather unit that may have activated the automatic take-off power control system and feathered the right prop. The crew failed to take the time to identify the problem, resulting in the left hand engine power lever being pulled back and the engine shut down. The stall warning system activated, and the crew continued to not recognize the problem.

Transcripts derived from the cockpit voice recorder suggest the crew, speaking in a mixture of English and Mandarin, failed to grasp the nature of the situation. There were three people in the cockpit: two captains and a first officer in the jump seat as an observer pilot.

“Had the crew prioritised their actions to stabilise the aircraft flight path, correctly identify the propulsion malfunction… then take actions in accordance with procedure of engine number 2 flame-out at take-off, the occurrence could have been prevented,” says the report.

“Flight crew coordination, communication, and threat and error management were less than effective, and compromised the safety of the flight.”

Besides crew error, investigations also identified other contributing factors such as the airline’s flight operations processes and regulatory oversight of TransAsia by the Civil Aeronautics Administration.

The report adds that the intermittent signal discontinuity in the right engine’s AFU may have caused the ATPCS to not be armed during take-off roll, or was activated during the initial climb, which resulted in a complete ATPCS sequence including autofeathering. Evidence indicated that the discontinuity was likely caused by compromised soldering joints inside the AFU.

www.flightglobal.com...

a reply to: Zaphod58

Was that the flight where it clipped a taxi on a freeway before hitting the river? Was quite incredible footage that one.

a reply to: mclarenmp4

Yes.

It's sad that Human Factors continue to take so many lives in aviation. This type of mishap is not new. Airlines don't prioritize safety cultures.

a reply to: cosmania

I wrote a thread last year I think it was, crew coordination accidents are on the rise again. We're going to end up back where we were in the 70s and have another Tenerife.

Let's hope not. I think the regionals have really hit the bottom of the barrel. Not sure of TransAsia's hiring practices, but I know the US domestic regional carriers have really low hour requirements (I think some as low as 500 hours) and pay next to nothing. Some of the regional pilots make around $25k.
The systems that the airlines have set up are not built around safety. Although I don't see how TransAsia survives this. It's not as bad as ValuJet, but it reeks of poor maintenance and poor training systems.

a reply to: cosmania

Poor training at least. I'm not sure maintenance would have caught bad solder joints, at least without being told to look for them.

The regionals don't really have a choice. They have to survive, and the only way to do that is by contracting to a major, who have allowed the pilot unions to dictate to them to the point that the regionals are being told that they can only fly certain size aircraft, to "protect the jobs of pilots at the major carriers". That limits the ability to regional pilots to advance to the major carriers, and get to better paying jobs, which limits the hiring pool and is leading to very low numbers, especially now that school costs are going up. JetBlue has started taking people that have no experience, running them all the way through type training and putting them to work, but you have to finance $250,000 to do it.

a reply to: Zaphod58


How many seconds did the crew have to recognize the problem, understand the problem and make adjustments that would have recovered some semblance of control? I would blame the crew as the last place to lay the blame. And, evidently, the exact events prior to the failure of the engine/prop seems in doubt. The report you provide used the word "flameout."

That seems to be a rather imprecise term for what is discussed. Yes, it is jargon, but in an official report of this nature?

a reply to: Aliensun

Because that's exactly what happened. Flameout is the technical term for an engine losing combustion.

The crew failed to recognize that the right engine was the engine that had the problem. They failed to follow any sort of checklist, or double check the engine instruments properly. The aircraft was still flying, even with one engine out, until they pulled the power back on the left engine, which was the operating engine. They reacted too quickly, and pulled the wrong power lever.

a reply to: Zaphod58

but you have to finance $250,000 to do it.

That much for flight training? damn. I would think a lot of pilots leaving military service would take jobs, but are they typically officers and in for life or at least long time?

We did an Erikson air crane lift years ago and I was talking to the pilot (or co-pilot) he took a pell grant and got licensed for choppers, said most of the Viet Nam era pilots were retiring. Obviously that is helicopter pilot not fixed wing nor major airline.

I also remember watching a news show were they interviewed a commercial airlines pilot who also worked at Taco bell.
I want to say made 19k a year.

a reply to: tinner07

That's from no experience, through your Instructor rating, up through ATP, and type certified on Airbus aircraft that they fly.

The military actually has a pretty hard time keeping pilots most of the time. They want to get out and get on with the airlines, especially transport pilots.

a reply to: Zaphod58


Still, training is no substitute for faulty equipment.

a reply to: Aliensun

Training is supposed to teach you how to deal with faulty equipment. If they had followed their training, and run their checklists, then there's a good chance the aircraft doesn't end up in the river, with most of the passengers and crew dead.

Asian aircrews are notorious for being very hierarchical. Cockpit resource management would be difficult at best in such an environment during an emergency.

In the video, the airplane looks as if the engine closest to the camera is feathered as does the left one. IIRC, the airplane looks like it stalled causing the right wing to drop onto the bridge.

Training is very expensive and most companies do the absolute minimum that law allows. Both regionals that I flew for you would take you semiannual check rides cold with no preparation at all. If you passed your check rides ... great! If you were weak and needed some review you would get 2 hours in a sim. then another check ride. If you failed you would get fired.

a reply to: buddah6

The right engine was auto feathered on takeoff, due to a faulty control unit. The crew pulled the left engine back by mistake and feathered it, because on the way in they had problems with that engine. So they assumed that was the faulty one.

really poor flying....from two pros....the third couldn't feel the rudder pedals.....in a twin, when one engine has trouble and one side pulls, the pedal you step on is the side with the turbine working...then add wings level...

originally posted by: GBP/JPY
really poor flying....from two pros....the third couldn't feel the rudder pedals.....in a twin, when one engine has trouble and one side pulls, the pedal you step on is the side with the turbine working...then add wings level...

Dead foot...dead engine. Identify, verify...feather.