Aviation Operation Management

1. Bangabandhu Sheikh Mujibur Rahman Aviation & Aerospace University
Department of Aviation Operations Management
MBA in Aviation Management
Course Name: Airport Operations & Management
Course Code: AVM-6604
Course Work: Assignment
Submitted To:
Mohammed Ali Reza Khan
Senior ANS and AGA Consultant/Inspector
and
Deputy Head AAIG-BD
Civil Aviation Authority, Bangladesh
Faculty Member, Department of AVOM, BSMRAAU
Submitted By:
Sahib Jada Eyakub Khan
Student ID: 20016017, MBA in AVM, BSMRAAU

2. Assignment:
Read the following scenario and try to find out what were the probable causes of this accident
and how it could have been avoided. Identify the probable causes, note down each of these and
against each cause write down your solutions which could have been useful to avoid or mitigate
the accident.
Scenario: On October 31, 2000, Singapore Airlines (SIA) Flight SQ006, a Boeing 747-400
aircraft, bearing Singapore registration No. 9V-SPK, crashed on a partially closed runway during
takeoff. Heavy rain and strong winds from typhoon “Xangsane” prevailed at the time of the
accident.
SQ006 was on a scheduled passenger flight from Chiang Kai-Shek International Airport (CKS
Airport), Tao-Yuan, Taiwan, Republic of China (ROC) to Los Angeles International Airport, Los
Angeles, California, USA.
The flight departed with 3 pilots, 17 cabin crewmembers, and 159 passengers aboard.
The aircraft was destroyed by its collision with construction equipment and runway construction
pits on Runway 05R, and by post impact fire.
There were 83 fatalities, including 4 cabin crew members and 79 passengers, 39 seriously
injured, including 4 cabin crew members and 35 passengers, and 32 minor injuries, including 1
flight crew member, 9 cabin crew members and 22 passengers.
Important to note that:
a) The flight crew did not review the taxiing route, despite having all the relevant charts,
and as a result did not know the aircraft had entered the wrong runway (the aircraft
entered runway 05R instead of runway 05L).
b) Upon entering the wrong runway, the flight crew had neglected to check the Para Visual
Display (PVD) and the Primary Flight Display (PFD) as it would have supposedly told
them that the aircraft was lined up on the wrong runway.
Note:
i) The Para Visual Display (PVD) is used to verify the correct departure
runway.
ii) Primary Flight Display (PFD) is linked to the aircraft AFM
iii) CAAS approved B747-400 AFM PVD supplement allows the use of the
PVD to verify the correct departure runway.
c) Due to the Typhoon Xangsane's imminent arrival and the poor ambient conditions, the
flight crew lost situational awareness and attempted to take off from the wrong runway.

3. d) The first series of taxiway lights leading to 05L were damaged.
e) The flight crew did not look for the runway markings and signage to locate their position
by scanning the outside scene.
f) The visibility conditions were rapidly changing on the night of the accident.
g) The CM-1 (the commander) followed the most dominant previously formed mental model
to follow the green taxiway centerline lights.
h) Approximately ninety percent of the airports to which SIA crews operate do not have a
“follow the green” taxiway light guidance system.
i) The painting of the segment of the Taxiway N1 centerline marking leading to Runway 05L
was missing.
j) The Runway 05R threshold markings were not removed.
Note: Threshold markings designate the beginning of a Runway. When a threshold marking to a
runway is no longer valid, it should have been removed
k) The Runway 05R runway edge lights adding to taxiway centerline lights from Taxiway
N1were not disconnected.
l) The information that the typhoon would hit the airport within 48 hours was a potential
threat to the situation.
Answer:
The outcomes related to probable causes determine essential elements that have been shown to
have intervened in the accident or certainly operated in the accident. These causes are associated
with unsafe acts, unsafe conditions, or safety deficiencies associated with safety significant
events that played a major role in the circumstances leading to the accident.
Probable causes of the accident
1. At the time of the accident, heavy rain and strong winds from typhoon “Xangsane”
prevailed. At 2312:02 Taipei local time, the flight crewmembers of SQ006 received
Runway Visual Range (RVR) 450 meters on Runway 05L from Automatic Terminal
Information Service (ATIS) “Uniform”. At 2315:22 Taipei local time they received wind
direction 020 degrees with a magnitude of 28 knots, gusting to 50 knots, together with the
takeoff clearance issued by the local controller.
2. On August 31, 2000, CAA of ROC issued a Notice to Airmen (NOTAM) A0606
indicating that a portion of the Runway 05R between Taxiway N4 and N5 was closed due
to work in progress from September 13 to November 22, 2000. The flight crew of SQ006
was aware of the fact that a portion of Runway 05R was closed, and that Runway 05R
was only available for taxi.

4. 3. The aircraft did not completely pass the Runway 05R threshold marking area and
continue to taxi towards Runway 05L for the scheduled takeoff. Instead, it entered
Runway 05R and CM-1 commenced the takeoff roll. CM-2 and CM-3 did not question
CM-1’s decision to take off.
4. The flight crew did not review the taxi route in a manner sufficient to ensure they all
understood that the route to Runway 05L included the need for the aircraft to pass
Runway 05R, before taxiing onto Runway 05L.
5. The flight crew had CKS Airport charts available when taxing from the parking bay to
the departure runway; however, when the aircraft was turning from Taxiway NP to
Taxiway N1 and continued turning onto Runway 05R, none of the flight crewmembers
verified the taxi route. As shown on the Jeppesen “20-9” CKS Airport chart, the taxi
route to Runway 05L required that the aircraft make a 90-degree right turn from Taxiway
NP and then taxi straight ahead on Taxiway N1, rather than making a continuous 180-
degree turn onto Runway 05R. Further, none of the flight crewmembers confirmed orally
which runway they had entered.
6. CM-1’s expectation that he was approaching the departure runway coupled with the
saliency of the lights leading onto Runway 05R resulted in CM-1 allocating most of his
attention to these centerline lights. He followed the green taxiway centerline lights and
taxied onto Runway 05R.
7. The moderate time pressure to take off before the inbound typhoon closed in around CKS
Airport, and the condition of taking off in a strong crosswind, low visibility, and slippery
runway subtly influenced the flight crew’s decision-making ability and the ability to
maintain situational awareness.
8. On the night of the accident, the information available to the flight crew regarding the
orientation of the aircraft on the airport was:
 CKS Airport navigation chart
 Aircraft heading references
 Runway and Taxiway signage and marking
 Taxiway N1 centerline lights leading to Runway 05L
 Color of the centerline lights (green) on Runway 05R
 Runway 05R edge lights most likely not on
 Width difference between Runway 05L and Runway 05R
 Lighting configuration differences between Runway 05L and Runway 05R
 Para-Visual Display (PVD) showing aircraft not properly aligned with the
Runway 05L localizer
 Primary Flight Display (PFD) information
The flight crew lost situational awareness and commenced takeoff from the wrong runway.

5. Solutions to avoid or mitigate the probable causes of accident for Singapore Airlines (SIA)
1. Singapore Airlines management body could develop and implement a comprehensive
surface-movement training program that reflects the current practice in this area, such as
the recommendations contained in the FAA’s (Federal Aviation Administration) National
Blueprint for Runway Safety and in compliance with FAA Advisory Circular No. 120-74.
2. Ensure that procedures for low visibility taxi operations include the need for requesting
progressive taxi instructions to aid in correct airport surface movement.
3. Review the adequacy of current SIA PVD training and procedures and ensure that SIA
documentation and operational practices reflect the CAAS approved B747-400 AFM
PVD supplement, which included the use of the PVD to indicate whether the aircraft is in
a correct position for takeoff.
4. Develop and implement a clear policy that ensures that flight crews consider the
implications of the relevant instrument indications, such as the PFD and PVD, whenever
the instruments are activated, particularly before commencing takeoff in reduced
visibility conditions.
5. Include in all company pre-takeoff checklists an item formally requiring positive visual
identification and confirmation of the correct takeoff runway.
6. Implement an Advanced Crew Resource Management (CRM) program to reflect current
practices in this area, and ensure that such programs are regularly revised to reflect new
developments in CRM.
7. Review the adequacy of current runway condition determination procedures and practices
for determining a water-affected runway to “wet” or “contaminated” in heavy rain
situations, by providing objective criteria for such determinations.
8. Conduct a procedural audit to eliminate existing conflicts in the guidance and procedures
between the company manuals, the managers’ expectations, and the actual practices, such
as those contained in the Typhoon Procedures and dispatch briefing policy.
9. Modify the emergency procedures to establish an alternate method for initiating the
emergency evacuation command in the event of a PA system malfunction.
10. Review its procedures and training for the flight and cabin crewmembers to effectively
handle diversified emergency situations.