TransAsia Airways Flight 235
|Date||4 February 2015|
|Summary||Engine failure leading to pilot error|
|Site||Keelung River, Taipei, Taiwan |
|Aircraft type||ATR 72-600|
|IATA flight No.||GE235|
|ICAO flight No.||TNA235|
|Call sign||TRANSASIA 235|
|Flight origin||Taipei Songshan Airport, Songshan, Taipei, Republic of China (Taiwan)|
|Destination||Kinmen Airport, Kinmen, Republic of China (Taiwan)|
TransAsia Airways Flight 235 was a TransAsia Airways domestic flight from Taipei to Kinmen (Quemoy), Republic of China. On 4 February 2015, the aircraft serving the flight, a ten-month-old ATR 72-600, crashed into the Keelung River shortly after takeoff from Taipei Songshan Airport, 5.4 km (3.4 mi; 2.9 nmi) to the west of Songshan in Taiwan. The aircraft had 53 passengers and five crew on board; there were 15 survivors.
Two minutes after takeoff, the pilots reported an engine flameout. Flight 235 climbed to a maximum height of 1,510 feet (460 m), then descended. The other engine, still working, was shut down mistakenly. Immediately before crashing into the river, it banked sharply left and clipped a taxi travelling west on the Huandong Viaduct (causing two more injuries), then the viaduct itself, with its left wing.
Flight 235 was the second fatal accident involving a TransAsia Airways ATR aircraft within seven months: Flight 222 had crashed on 23 July 2014, killing 48 of the 58 on board.
Flight 235 departed Taipei Songshan Airport at 10:52 Taiwan time (02:52 UTC), for its destination of Kinmen Airport, with 53 passengers and five crew members on board. Shortly after take-off, a fault in the auto-feather unit of the number 2 engine caused the automatic take-off power control system to auto-feather that engine.:146[a] The flight crew misdiagnosed the problem, and shut down the still-functioning number 1 engine.:146 The aircraft reached an altitude of 1,630 feet (500 m) and then began descending until it crashed.:3 The last pilot communication to air traffic control was: "Mayday, mayday, engine flameout." At 10:55,:4 the aircraft crashed into the Keelung River, on the border of Nangang District of Taipei and Xizhi District of New Taipei.
The crash was recorded by dashcams in several cars travelling west along the elevated Huandong Viaduct next to the river. The aircraft, flying level, first cleared an apartment building. Then it rolled sharply, at nearly a 90-degree bank angle, left wing down. As the aircraft flew low over the elevated viaduct, its left wingtip struck the front of a taxi travelling west on the viaduct, and the outboard section of the wing was torn off when it struck the concrete guardrail at the edge of the viaduct. The aircraft continued its roll and struck the water upside down, breaking into two main pieces. Two people in the taxi suffered minor injuries.
At the time of the accident, no adverse weather phenomena were observed. At 11:00, the cloud base at Songshan was about 1,500 feet (460 m), the visibility was unlimited, and a light breeze was blowing from the east at 10 knots (19 km/h; 12 mph). The temperature was 16 °C (61 °F).
The aircraft involved in the accident was an ATR 72-600 twin turboprop, registration B-22816, MSN 1141. It first flew on 28 March 2014, and was delivered to TransAsia Airways on 15 April 2014. Both Pratt & Whitney Canada PW127M engines were replaced due to technical issues on 19 April 2014,[dubious ] and the left engine was replaced again in August.:15
Passengers and crew
The passenger manifest was composed of 49 adults and four children. Thirty-one passengers were mainland Chinese; many were visitors from Xiamen on a six-day tour of Taiwan. The remaining 22 passengers were Taiwanese.
The flight crew consisted of two pilots, both ranked as captains; the captain was Liao Chien-tsung, 42, with a total of 4,914 flying hours (including 3,401 hours on the ATR 72) and the co-pilot was Liu Tze-chung, 45, with a total of 6,922 flying hours, including 5,314 hours on the ATR 72. There was also an observer, Hung Ping-chung, 63, seated in the cockpit jump seat, who had a total of 16,121 flying hours, 6,482 of them on the ATR 72. There were also two flight attendants as cabin crew. All crew members were Taiwanese citizens; the co-pilot was a dual New Zealand–Taiwanese citizen.
|Taiwan and New Zealand||-||1||1|
Rescue and recovery
Taipei police and fire departments received dozens of calls from eyewitnesses, almost immediately after the crash. The Taipei Fire Department, military and volunteer rescue workers arrived at the crash scene only minutes later,:49 and reached the survivors by boat around 35 minutes after the crash.:45 They began removing survivors from the rear section of the semi-submerged fuselage and ferried them to shore in inflatable boats. Divers were forced to cut the seat belts of dead passengers, located mostly in the front section, to remove their bodies. That work was made difficult by low visibility underwater.:48–50
An unnamed source was reported to have claimed that the pilot had complained of "engine abnormalities" and requested an urgent inspection of the aircraft shortly before its final take-off, but had been rebuffed. This assertion has been denied by both TransAsia Airways and the Civil Aeronautics Administration, the former of whom has released the maintenance records for both powerplants, both propellers, and the airframe.
Following the accident, TransAsia Airways changed its website and social media branding to greyscale images, in mourning for the presumed deaths of the passengers. On 5 February, TransAsia retired the flight number GE235, changing it to GE2353.
The spokesperson of the Office of the President of the Republic of China reported that President Ma Ying-jeou was very concerned about the accident and had given orders to the Executive Yuan and related authorities to provide maximum assistance with the rescue. Immediately after the accident, the President of the Executive Yuan, Mao Chi-kuo, contacted the Ministry of Transportation and Civil Aeronautics Administration to instigate an investigation into the crash, and the minister of national defense to prepare the military for the rescue.
Over half of the passengers on board the aircraft were mainland Chinese. On 5 February 2015, Xi Jinping, the president of China, released a statement, ordering that accurate information on the aircraft be obtained as quickly as possible, and that "assistance [be provided] in treating the injured". On the same day, Chinese Premier Li Keqiang instructed relevant departments to obtain accurate information from Taipei as quickly as possible.
The Taiwanese Aviation Safety Council (ASC) led the investigation into the accident. The French BEA represented the country of manufacture, and the Transportation Safety Board of Canada represented the country of engine manufacture. Other parties to the investigation included the Taiwanese Civil Aeronautics Administration, the operator (TransAsia), the aircraft (ATR) and engine (Pratt & Whitney Canada) manufacturers, and Transport Canada.:v The cockpit voice recorder and flight data recorder were recovered on the evening of 4 February, and the data was analysed. According to the executive director of the ASC, Thomas Wang, the aircraft's right engine triggered an alarm just 37 seconds after takeoff. Whereas the crew reported a flameout, according to Wang, data showed one of the engines had in fact been moved into idle mode. Soon the right engine failed to produce enough thrust for its rotating propeller, lapsing into auto-feathering. A restart was attempted, but the aircraft crashed 72 seconds later.
On 6 February, investigators revealed that the left engine, which does not appear to have had suffered a malfunction, had been manually shut off, while cautioning that it was "too early to say if human error was a factor". Investigators released the following preliminary sequence of events. All times are local (UTC+8).
- 10:51:13 – Crew receives take-off clearance
- 10:52:34 – Tower asks crew to contact Taipei Departure
- 10:52:38 – Right engine failure alert; master warning sounds for 3s
- 10:53:04 – Crew reduces power to the left engine
- 10:53:12–18 – Stall warning sounds
- 10:53:24 – Crew cuts power to the left engine
- 10:53:34 – Crew declares emergency: "Mayday, mayday, engine flameout"
- 10:54:09 — Crew calls for restarting the left engine multiple times
- 10:54:20 — Left engine is restarted
- 10:54:34 — Master warning sounds again
- 10:54:35 — An unidentified sound is heard
- 10:54:36 — Recordings end
The ASC issued an interim report on 2 July. Without assigning responsibility for the crash, the report confirmed that a still-functional engine number one was incorrectly shut down by the pilot following the failure of engine number two. The report also stated that the pilot in command had failed to pass a simulator test in May 2014, partly due to his insufficient knowledge about the procedure for handling an engine flameout during takeoff. He retook the test the following month, however, and successfully passed. The ASC released a draft report in November 2015 and published the final version in July 2016.
The final report found that, following the uncommanded autofeather of engine number 2, the pilot flying the aircraft reduced power and subsequently shut down the operative engine number 1. The flight crew failed to perform the failure identification procedure and did not comply with standard operating procedures. As a result, the pilot flying the aircraft became confused regarding the identification and nature of the propulsion system malfunction. The autofeathering was caused by compromised soldering joints in the auto feather unit. During the initial stages of the take-off roll the flight crew did not reject the take off when the automatic take off power control system ARM pushbutton did not light, and TransAsia did not have a clear requirement to do so. The loss of engine power during the initial climb and inappropriate flight control inputs by the pilot flying generated stall warnings and activation of the stick pusher to which the crew did not respond in a timely and effective manner. The loss of power from both engines was not detected and corrected by the crew in time and the aircraft stalled during the attempted restart at an altitude from which they could not recover. Ineffective flight crew coordination, communication, and threat and error management compromised the safety of the flight. The crew failed to obtain relevant data from each other regarding the status of both engines. The pilot flying did not appropriately respond to input from the pilot monitoring.
During the investigation, Transasia Airways disclosed confidential information from the draft report to Next magazine, which published a story in its issue of 11 May 2016. This was an attempt to influence the investigation into the accident. Transasia Airways were fined NT$ 3,000,000 (US$ 92,000).
The Civil Aeronautics Administration announced it would subject all TransAsia Airways ATR pilots to supplementary proficiency tests between 7 and 10 February, resulting in the cancellation of more than 100 TransAsia flights. Ten pilots who failed the engine-out oral test and a further nineteen who did not attend were suspended for one month, pending a re-test. TransAsia subsequently demoted one pilot from captain to vice-captain. Reuters reported that the government ordered all Taiwanese airlines to "review their safety protocols". The Taiwanese CAA announced that it is focusing its attention on TransAsia's training and operations and the country's labor ministry fined the airline for breaches of the labor code over excessive working hours.
On 11 February, TransAsia offered 14.9 million New Taiwan dollars (about US$475,000) in compensation to the family of each of the dead. This amount includes emergency relief and funeral allowance, totalling NT$1.4M (US$44,300), already paid to each family. Not all of the families have accepted the offer.
Before this accident, TransAsia Airways Flight 222 which involved another ATR 72-500 crashed during approach due to pilot error. The airline ceased its operations and shut down indefinitely on 22 November 2016.
In popular culture
The Canadian TV series Mayday (also known as Air Crash Disaster and Air Emergency in the US and Air Crash Investigation in the UK and the rest of the world) covered Flight 235 in episode 7 of series 17, called "Caught on Tape", which was first broadcast on 19 September 2017 in Australia.
- Kegworth air disaster, another case of wrong engine shutdown
- 2010 Karachi Beechcraft 1900 crash
- PIA Flight 661
- Aeroflot Flight 68
- The auto-feather unit is supposed to cut in automatically so as to minimize the drag from a windmilling propeller in the event of a single engine failure.:79
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Media related to TransAsia Airways Flight 235 at Wikimedia Commons
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- 復興航空說明 2015-02-06 1930 版 [Revival Aviation Description 2015-02-06 1930 Edition] (in Chinese) – TransAsia Airways
- "News Releases." Aviation Safety Council
- "Flight GE 235 on 4 February 2015, ATR 72–600 (72-212A)" (Archive) – Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile