July 19, 1996

2. FACTUAL INFORMATION

2.1 Flight History

The flight plan of the aircraft, which had been filed to the Taiwanese civil aviation authorities, Zhongzheng International Airport Office, was as follows:

Flight rule: IFR, Aerodome of departure: Taipei International Airport, Destination@Aerodome: Nagoya Airport, Cruising speed: 465 knots, Level: FL 330, Route: Al SUC-JAKAL-KE-SIV-XMC, total estimated enroute time: 2 hours and 18 minutes, Alternate Aerodome: Tokyo International Airport.

DFDR shows that the aircraft reached FL 330 about 0914 and continued its course toward Nagoya Airport in accordance with its flight plan.

DFDR and CVR show that its flight history during approximately 30 minutes prior to the accident progressed as follows:

The aircraft which was controlled by the F/O, while cruising at FL 330 was cleared at 1047:35 to descend to FL 210 by the Tokyo Area Control Center and commenced descent.

For about 25 minutes from a few minutes before the aircraft began its descent, the CAP briefed the FIO on approach and landing.

At 1058:18, communication was established with Nagoya Approach Control. The aircraft began to descend and decreased its speed gradually, in accordance with the clearances given by Approach Control.

At 1104:03, the aircraft was instructed by Nagoya Approach control to make a left turn to a heading of 0100. Later, at 1107:14, the aircraft was cleared for ILS approach to Runway 34 and was instructed to contact Nagoya Tower.

After the aircraft took off from Taipei International Airport, from 0854 when the aircraft had passed 1,000 ft pressure altitude, AP No.2 was engaged during climb, cruise and descent. At 1107:22, when the aircraft was in the initial phase of approach to Nagoya airport, AP No.1 was also engaged. Later, at 1111:36, both AP No.1 and 2 were disengaged by the FIO.

The aircraft passed the outer marker at 1112:19, and at 1113:39, received landing clearance

from Nagoya Tower. At this time, the aircraft was reported of winds 290 degrees at 6 knots.
  Under manual control, the aircraft continued normal ILS approach.
  At 1114:05, however, while crossing approximately 1,070 ft pressure altitude, the FIO inadvertently triggered the GO lever. As a result the aircraft shifted into GO AROUND mode leading to an increase in thrust.
  The CAP cautioned the FIO that he had triggered the GO lever and instructed him, saying "disengage it". The aircraft leveled off for about 15 seconds at approximately 1,040 ft pressure altitude (at a point some 5.5 km from the Runway).
  The CAP instructed the F/O to correct the descent path which had become too high. The FIO acknowledged this. Following the instruction, the F/O applied nose down elevator input to adjust its descent path, and consequently the aircraft gradually regained its normal glide path.
  During this period, the CAP cautioned to the FIO twice that the aircraft was in GO AROUND Mode.
  At 1114:18, both AP No.2 and No.1 were engaged almost simultaneously when the aircraft was flying at approximately 1,040 ft pressure altitude, a point 1.2 dots above the glide slope. Both APs were used for the next 30 seconds. There is no definite record in the CVR of either the crew expressing their intention or calling out to use the AP. For approximately 18 seconds after the AP was engaged, the THS gradually moved from 5~30 to 12.30, which is close to the maximum nose-up limit. The THS remained at 12.30 until 1115:11. During this period, the elevator was continually moved in the nose-down direction.

In this condition, the aircraft continued its approach, and at 1115:02, when it was passing about 510 ft pressure altitude (at a point approximately 1.8 km from the runway), the CAP, who had been informed by the F/O that the THR had been latched, told the FIO that he would take over the controls. Around this time, the THR levers had moved forward greatly, increasing EPR from about 1.0 to more than 1.5. Immediately afterwards, however, the THR levers were retarded, decreasing EPR to 1.3. In addition, the elevator was moved close to its nose-down limit when the CAP took the controls.

At 1115:11, immediately after the CAP called out "Go lever", the THR levers were moved forward greatly once again, increasing EPR to more than 1.6. The aircraft therefore began to climb steeply. The FIO reported to Nagoya Tower that the aircraft would go around, and Nagoya Tower acknowledged this. The aircraft started climbing steeply, AOA increased sharply and CAS decreased rapidly. During this period, the THS decreased from 12.30 to 7~40, and SLATS/FLAPS were retracted from 30/40 to 15/15 after the FIO reported "Go Around" to Nagoya Tower.

At 1115:17, the GPWS activated Mode S warning "Glide Slope" once, and at 1115:25, the stall warning sounded for approximately 2 seconds.

At 1115:31, after reaching about 1,730 ft pressure altitude (about 1,790 ft radio altitude), the aircraft lowered its nose and began to dive.

At 1115:37, the GPWS activated Mode 2 warning "Terrain, Terrain" once, and the stall

warning sounded from 1115:40 to the time of crash.

At about 1115:45, the aircraft crashed into the landing zone close to the E1 taxiway.

The accident occurred within the landing zone approximately 110 meters east-northeast of the center of the Runway 34 end at Nagoya Airport. It occurred at about 1115:45 (2015:45 JST) (see attached Figures 1,2,3,4,5 and Photographs 1, 2 and 3).

2.2 Injuries to Persons

2.3 Damage to aircraft

2.3.1 Extent of damage

2.3.2 Damage to Aircraft by Part

(1) Flight control system

• l Aileron
  Both the RH and LH ailerons were in their down positions and were burnt. (See attached Photographs 5 and 6)
• 02 Spoilers
  
  • The No.1 and No.2 LH spoilers were missing.
  • All the LH roll spoilers (No.3 through No.7) were almost completely destroyed by fire.
  • The No.3 and No.7 LH actuators were found in their stowed positions, while the No.4 through No.6 actuators were in their extended positions.
  • The No.1, No.2, and No.5 RH spoilers had fallen away and were burnt.
  • The No.3 and No.4 RH spoilers remained attached to the wing, while the No.6 and No. 7 spoilers had torn off together with their adjacent wing structural elements.
  • All the RH actuators were in their stowed positions.
    (See attached Photograph 7)
• 03 Rudder
  
  • The rudder was burnt and remained attached to the vertical stabilizer.
    (See attached Photograph 8)

• 04 Elevators
  
  • The elevators remained attached to the THS, but were damaged.
  • Both the RH and LH elevators had scratches on their leading edge lower surfaces, but none on the trailing edge lower surface.
    (See attached Photographs 9,10)
• 05 THS
  
  • The THS had separated at its joint to the fuselage, and was fractured at its central section.
  • The screw jack was fractured and had torn off at the screw shaft section near the actuator's bottom end; it was bent near the nut.
    (See attached Photographs 11 and 12)
• 06 Flaps
  
  • The LH inner flap was fractured at the outside of the No.2 track beam and burnt; no other LH flap parts were found.
  • The LH No.1 and No.2 track beams had been ripped oft; and were fractured and burnt.
  • The LH center flap had torn off from the wing together with the No.3 and No.4 track beams and was burnt.
  • The LH outer flap was burnt and had separated from the wing with the No.5 and No.6 track beams attached on it.
  • The RH inner flap had separated from both the wing and track beams and was fractured and burnt.
  • The RH No.1 and No.2 track beams had torn off and the No.1 beam was burnt.
  • The RH center flap had separated from the wing with the No.3 and No.4 track beams attached to it and was burnt.
  • The RH outer flap had separated from the wing, and was burnt and fractured on the inboard side of the No.6 track beam.
  • The RH No.5 track beam had torn off and was burnt.
    (See attached Photographs 13,14 ,l5 and 16)
• 07 Slats
  
  • The LH inner slat was fractured at the outboard track attaching point, with its outboard section separated from the wing.
  • The LH center slat was burnt, remained attached to the wing.
  • The LH outer slat was fractured in three places and separated from the wing; scratches were found on its leading edge.
  • The RH inner slat had separated from the wing with two track rails attached to it.
  • The RH center slat was fractured at the No.3 screw jack attaching point; its outboard section was burnt and had separated from the wing with a track rail attached on it.
  • The RH outer slat was fractured at two points, had separated from the wing, and was burnt.
    (See attached Photographs 17 and 18)

• 08 Krüger flaps
  
  • Both the RH and LH Krüger flaps were in their extended positions.
• 09 Notch flaps
  
  • Both the RH and LH notch flaps were in their extended positions.

(2)Wings

• Ol LH wing
  
  • The main spar and upper skin in the upper section of the pylon (between W. STA 400 and 485) were fractured.
  • The skin in the rear part of the aft main spar, on the inboard side of the aileron, was destroyed by fire.
  • The lower skin had been exposed to flames and was burnt.
  • The upper skin between W.STA 940/RIB 13 and W.STA 1567/RIB 23 had melted.
  • The wing tip was fractured near W.STA 1567/RIB 23, and had separated from the main wing and burnt.
  • The tip fence was fractured and burnt, and had separated with its lower part deformed.
    (See attached Photograph 19)
• 02 RH wing
  
  • Almost all portions of the leading edge located on the inboard side of the No.2 engine pylon were destroyed by fire.
  • The skin in the rear part of the aft main spar, inboard the aileron, was partly destroyed by fire.
  • The upper skin and the aft main spar near W.STA 879/RIB 12 were cracked.
  • The RH wing was fractured and had torn off near W.STA 1132/ RIB 16; the detached wing outboard structure had fragmented into small pieces, some of which were burnt.
  • The wing tip was fractured, had torn off near W.STA 1624/RIB 24, and was burnt.
  • Tip fence was fractured and had torn off with its top deformed.
    (See attached Photograph 20)
• 03 Center box section
  
  • The center box section was burnt.
  • Almost all thrust work ribs of the center-box lower structure had buckled and fractured by an upward force (see attached Figure 19).

(3) LH main landing gear

• The upper section of the shock strut was fractured, and had broken off and burnt.
• Fractured drag strut and torque link remained attached to the lower section of the shock strut.
• The shock strut was fractured; its upper section was partly burnt and had been detached with the actuating cylinder, fractured drag strut and other parts still attached to it.

• The wing side rear mount was fractured and remained attached to the aft hinge point in the upper section of the shock strut.
• The shock absorber had been displaced from the shock strut and was detached.
• The shock absorber contained pieces of the fractured bogey beam and torque link still attached to it.
• The shock absorber's piston was detached from the cylinder.
• The lower strut of the folding brace was fractured and detached.
• The lock link assembly was fractured and detached, with the cylinder and the strut of the folding brace (fractured) still attached to it.
• Both of the two cross braces had separated and burnt.
• The bogey beam was fractured at both its front and rear sections, with the outer brake assemblies (No.1 and No.5 assemblies) of both sections detached from their axles. Tires and wheels were also detached.
• No.6 break assembly, as well as corresponding tire and pieces of bogey beam, etc, were found at a point about 190 meters away from where the LH main landing gear had hit the ground.
• No.1 and No.5 tires were burnt.
  (See attached Photographs 21 and 22)

(4) RH main landing gear

• The shock strut was partly burnt and detached, with parts including the actuating cylinder and fractured drag strut, etc., still attached to its upper section.
• The drag strut, torque link, and part of the folding brace strut, all fractured, remained attached to the lower section of the shock strut.
• The shock strut rear mount, fractured and detached from the wing, remained attached to the aft hinge point in the upper section of the shock strut.
• The shock absorber had been displaced from the shock strut and was detached.
• The shock absorber had the fractured bogey beam and pieces of torque link still attached to it.
• The shock absorber's piston had torn off
• The folding brace had a fractured lower strut, and was burnt and detached with a part of airframe structural element still attached to it.
• Both cross braces had separated and were burnt.
• The lock link was fractured and found at a point about 170 meters away from where the RH main landing gear had hit the ground.
• The bogey beam was fractured at both its front and rear sections. The No.3 and No.4 brake assemblies of the front section had come off their axles, and the tires and wheels were detached and destroyed.
• The No.7 and No.8 brakes, as well as the corresponding tires and wheels (two each) were burnt in an assembled state.
• The No.3 and No.4 tires had burst, and the No.4 tires were burnt.
  (See attached Photographs 23 and 24)

(5) Nose landing gear

• The shock strut was fractured at its upper and lower sections.
• The upper section of the barrel had fragmented into small pieces.
• The telescopic drag strut was found bent in the down-lock state and was burnt.
• The lower part of the torque link was fractured.
• Both tires and wheels were in place on the axle and were found in the irrigation water channel. The axle was bent and the LH tire had burst.
  (See attached Photographs 25 and 26)

(6) Fuselage

• O1 Nose section
  
  • The entire nose section had fragmented into small pieces, except the ceiling section above the front windshield, which barely retained its original form.
• 02 Forward section
  
  • The bottom skin was fractured at a location between Stringers 38 and 42. It was found near where the aircraft had hit the ground together with the bottom skin of the aft fuselage. The skin above that section was fractured at locations corresponding to Frames 18,26, and 40.
• 03 Center section
  
  • The bottom skin was fractured at a location between Stringers 38 and 42, but remained connected to the bottom skin of the aft fuselage.
  • Almost the entire center section of the fuselage was destroyed by fire except a portion of the side skin.
• 04 Aft section
  
  • The aft fuselage section was almost entirely destroyed by fire except a part of the RH side skin.
• 05 Tail
  
  • The tail was fractured at locations corresponding to Frames 72 and 92 with the vertical stabilizer attached to it. It was partly burnt and was found in the irrigation water channel.
  • The upper joints of the tail section had separated. The APU compartment was damaged at its bottom with the APU still inside, and was found partly overlapping the THS.
  • The bottom skin was fractured at a location corresponding to Frame 78, and was found together with fragments of the other bottom skin near where the aircraft had hit the ground.
    (See attached Figures 16, 17 ,18 and Photographs 27,28,29 and 30.)

(7) No.1 engine

• 01 Low-pressure compressor
  
  • The fan case was detached from the intermediate case and was deformed.
  • The nose cone had fallen away.
  • The fan blades were torn or bent in the direction opposite to that of rotation. Among the blades torn, only one was fractured at its root.
  • The No.1.6, 2, and 3 stage LPC blades were torn or bent in the direction opposite to that of rotation.
  • Approximately one third of No.4 stage LPC blades were bent in the direction opposite to that of rotation, and the rest were torn off
  • The No.1, 2 and 3 stage LPC stators had fallen away or were bent in the direction of rotation.
  • All but a few of the No.4 stage LPC stators had fallen away or were deformed.
  • All the fan exit guide vanes had fallen away.
  • Approximately three-fifths of the LPC rotor was cracked at the No.3 and No.4 stage labyrinth seal locations. Within the cracked area, approximately one third of the total circumference had been pressed inward; the No.4 stage disk was detached and had fallen away.
  • The LPC-LPT coupling was fractured and found inside the fan hub.
  • The inner race of the No. 1.5 bearing remained attached to the LPC-LPT coupling, but all the rollers had fallen away.
• 02 Intermediate case
  
  • The No.1 bearing rear support had torn off at the flange that had connected it to the No.1 bearing front support.
  • The struts were broken.
• 03 High pressure compressor
  
• The HPC front case had torn off from the rear case at the intervening joint and remained attached to the intermediate case.
• All the No.5, 6, 7, and 8 stage HPC blades had fallen away.
• All the HPC stator vanes on the IGV, except about 20 of them, were broken.
• The No.5, 6, and 7 stage HPC stator vanes were broken or deformed.
• The unison rings on the IGV, No.5 stage, and No.6 stage stators were deformed, and the lower half of the ring on the No.7 stage stator had torn off
• The HPC rear case was detached from the HPC front case at the intervening joint, and remained attached to the diffuser case.
• 04 Diffuser case and combustor
  
  • Borescopic inspection of the interior of the combustor did not reveal any abnormalities.
  • Borescopic inspection of the No.1 stage turbine nozzles did not reveal any abnormalities.

• 05 High-pressure turbine
  
  • The tips of the No.1 stage turbine blades had broken off
  • The No.2 stage turbine nozzle blades had slightly chipped off at their trailing edges. All the No.2 stage turbine blades had broken and fallen away.
  • The No.2 stage turbine disk had deep scratches running in the direction of rotation on its rear section.
  • The HPT case was detached from the LPT case at the flange section.
• 06 Low-pressure turbine
  
  • All the No.3, 4, 5, and 6 stage turbine blades had fallen away.
  • All the No.3, 4, 5 , and 6 stage turbine vanes had fallen away.
  • The forward end of the LPT case was detached from the LIPT case at the connecting flange section, and its rear end was detached from the turbine exhaust case at a section near the connecting flange. The case had separated, and was severely cracked and deformed.
  • The No.6 stage LPT disk was detached from the No.5 LPT disk at the intervening joint, and the No.6 stage disk was broken and detached.
  • The labyrinth seal in the forward section of the LPT had been pushed rearward by a strong force, and was in close contact with the No.3 stage LPT disk.
  • The LPT shaft was broken in its front section.
  • The LPT rotor was out of its original position toward the rear.
• 07 Exhaust case
  
  • The exhaust case remained attached to the pylon, and many of its struts were fractured. The case was significantly deformed.
  • The inner race of the No.4 bearing remained attached to the LPT shaft, and 3 cm of its track was partially lost; but the track surface displayed no other abnormalities. The outer race and the roller cage sections were filled with mud, and no rollers were found.
    (See attached Figures 20 ,2 1 and Photograph 31.)

8 No.2 engine

• 01 Low-pressure compressor
  
  • The fan case was almost completely detached from the intermediate case and was significantly deformed.
  • The nose cone had fallen away.
  • The fan blades either had torn off or were bent in the direction opposite to that of rotation.
  • The fan hub had separated from the LPT rotor at the intervening joint.
  • The No.1.6, 2 and 3 stage LPC blades either had torn off or were bent in the direction opposite to that of rotation.
  • All the No.4 stage LPC blades had fallen away.
  • Some No.1.6, 2 and 3 stage LPC stator vanes had fallen away and all the remaining

vanes were bent in the direction of rotation.

• The No.4 stator vanes between the 10 and 2.5 o'clock positions remained attached but the other vanes had broken off.
• All the fan exit guide vanes had fallen away.
• The LPC rotor was separated at the rear of the labyrinth seal located between the No.3 and 4 stage disks, and the No.4 stage disk had fallen away.
• The LPC-LPT coupling was fractured at its front section and had fallen away. A remnant of the broken LPT shaft was found attached inside the coupling.
• The outer race of the No. 1 bearing was partially broken as wide as 18 balls, but remaining ball-bearings displayed no abnormalities.
• The inner race of No.1.5 bearing remained attached to the LPC - LPT coupling, but the rollers had fallen away. The track surface of the inner race displayed no abnormalities.
• There was a through crack running in the axial direction at the 3 o'clock position.
• The leading edges of the No.5 stage HPC blades were damaged.
• All the HPC stators vanes of the IGV had fallen away.
• Borescopic inspection revealed that molten metal had adhered to the trailing edge of the No. 15 stage stator.
• 02 Intermediate case
  
  • The No.1 bearing rear support had separated from the No.1 bearing front support at the mounting flange section, and its rear end had separated at the section in front of the flange that had connected it to the intermediate case. The rear support had fallen away.
  • The strut at the 10 o'clock-position remained extended almost straight as far as the outer contour of the case, but the strut at the 8 o'clock position was bent. All other struts were fractured at their root sections.
• 03 High-pressure compressor
  
  • The bolts on the upper half of the joint between the HPC front case and the HPC rear case were broken, and there was an about three-centimeter wide gap in the upper half of the joint. There was a through crack running in the axial direction at the 3 o'clock position.
  • The leading edges of the No.5 stage HPC blades were damaged.
  • All the HPC stators vanes of the IGV had fallen away.
  • Borescopic inspection revealed that molten metal had adhered to the trailing edge of the No.15 stage stator.
• 04 Diffuser case and combustor
  
  • The bottom of the diffuser case was dented.
  • Borescopic inspection of the interior of the combustor did not reveal any particular abnormalities.
  • Borescopic inspection of the No. 1 stage turbine nozzles revealed no particular abnormalities.
• 05) High-pressure turbine
  
  • The trailing edges of the No.1 turbine blades were slightly chipped off.

• The No.2 stage turbine nozzles in the section between the 10 o'clock and 12 o'clock positions were damaged in their rear portions.
• All the No.2 stage turbine blades were broken and had fallen away.
• The No.2 stage turbine disk had deep scratches all over its rear section, running in the direction of rotation.
• The HPT case was detached from the LPT case at the connecting flange section.
• 06 Low-pressure turbine
  
  • All the No.3, 4, 5 and 6 stage turbine blades had fallen away.
  • All the No.3, 4, 5 and 6 stage turbine vanes had fallen away.
  • The forward section of the LPT case had separated from the FIPT case at their connecting flanges, and its rear section was detached from the turbine exhaust case in the vicinity of their connecting flanges. The case had fallen away and was severely cracked and deformed.
  • The No.6 stage LPT disk was detached from the No.5 stage disk at the intervening joint, and the disk itself was cracked.
  • The labyrinth seal in the forward section of the LPT had been strongly pushed rearward and was in close contact with the No. 3 stage LPT disk.
  • The LPT shaft was broken in its forward section.
  • The LPT rotor had come off rearward, together with the LPT shaft, and had fallen away.
• 07 Exhaust case
  
  • The exhaust case remained attached to the pylon. The case had through cracks running in axial directions at the 1 o'clock, 3 o'clock, and 11 o'clock positions. It was deformed extensively.
  • The inner race of the No.4 bearing was lost, preventing its track surface malfunctions from being determined. The bearing's outer race and rollers remained in the exhaust case and the rollers showed no abnormalities.
    (See attached Figures 20, 21 and Photographs 33 and 34.)

(9) Cockpit

• Almost all the instruments and instrument panels were broken.
• Both RH and LH control column were broken.
• The center pedestal panel was damaged and detached.
• The circuit-breaker panel was broken and many circuit breakers had been thrown out.
• Almost all the components of the flight control system, electric and electronic systems, and their accessories were broken.
• The LH(Captain) and the RH(F/O) crew seats were broken.
  (See attached Photographs 35,36,37,38,39,40,41,42,45 and 46)

(10) Cargo-related

• The forward cargo compartment had been loaded with three containers and four palettes,

and the rear compartment with nine containers. The bulk cargo compartment had contained 39 corrugated cardboard boxes in bulk.
• All of the recovered containers were found so extensively destroyed that they no longer retained their original forms. As to the palettes, only their floorboards retained their original forms.

(11) Others

• The DFDR and CVR were separated from the airframe, together with some of their mounting parts. Their outer cases, deformed and partly covered with soot, were discovered near the THS.
• Most of the recovered electronic components were damaged and deformed. Some components were demanded too severely to identify what they were. Their inside printed-circuit boards had fragmented, and the internal wiring of major devices, including computers, were also found broken.
• Relatively heavy accessories were torn from the airframe and strewn about.
• The legs of almost all the cabin seats were fractured.
  (See attached Photographs 43,44,47 and 48.)

2.3.3 Distribution of Wreckage, etc.

Before the investigation started, some pieces of wreckage had been moved from their original positions in order to facilitate rescue activities. At the time of investigation, the wreckage was scattered as follows:

Due to the impact of the crash, the wreckage of the aircraft except the RH and LH wings, the vertical and horizontal tail planes, the tail section of the fuselage, and the engines, was scattered over an approximately 140 meters long and 60 meters wide area to the east-northeast of the LH main landing gear's ground scar. Fragments of the destroyed skin of the nose and forward fuselage sections were strewn over an approximately 40 meters long and 30 meters wide area, some 120 meters away from the LH main landing gear's ground scar to the east-northeast direction. No signs of damage by fire were found on the nose and forward sections of the fuselage. The lower skin of the fuselage center and aft sections, almost entirely fragmented, were scattered over an approximately 40 meters wide area that extended approximately 60 meters to the east-northeast from. the LH main landing gear's ground scar. Other parts of the center and aft fuselage sections except a part of the skin, were almost entirely ruined by fire. The wings ripped from the fuselage, were found at a point approximately 80 meters to the east-northeast of the LH main gear's ground scar. The LH outer wing was torn from the wing, and the RH outer wing, broken into several fragments, was also separated from the wing. They were burnt and discovered near the wings and the water gate, respectively. The LH engine was torn from the wing pylon and was found near the wing, while the RH engine remained barely attached to its pylon. The fan hubs of both engines were broken and detached.

The horizontal tail plane and tail cone were broken and torn from the fuselage, and were

found at a point approximately 30 meters to the east-northeast of the LH main landing gear's ground scar. The vertical tail plane was broken and separated from the fuselage together with the upper rear part of the fuselage. It was burnt and found over the irrigation water channel approximately 65 meters to east-northeast of the LH main landing gear's ground scar.

An approximately 50 meters long and 20 meters wide scorch mark of fire were detected on the ground, each extending to the east-northeast from the vicinities of the ground scars of the LH and RH wing flap tracks, and the trees near the water gate were burnt. Signs of fire were also detected on the ground near where the wings were found (see attached Figures 11 ,12 and Photographs 2 and 3).

2.4 Damage to Other than the Aircraft

A stretch of the lawn under cultivation in the landing zone was burnt and flowed off within an approximately 10,300 m2 area.

The protection wall of the irrigation water channel at Komaki Air Base of the Air Self-Defense Force (hereinafter referred to as "Komaki Air Base") was destroyed over a length of 30 meters, and the water gate was damaged.

Of the trees in the soundproofing tree fence in the Komaki Air Base, those within an approximately 2,000 m2 area were burnt.

2.5 Crew Information

2.5.1 Flight Crew

Commercial pilot license No.30701 Issued September 5, 1992

Type rating

Airbus A300-600R Issued December 29, 1992

Term of validity Until December 28, 1994

Class 1 airman medical certificate Issued March 1, 1994

Term of validity Until September 30, 1994

Total flight time 1,624h 11 min

Total hours on A300-600R 1,033 h 59 min

Flight time during the last 90 days 196 h 30 min

Flight time during the last 30 days 71 h 53 min

Latest training on emergency procedures September 14, 1993

Rest period prior to the flight 39 h 00 min

Note: The copilot joined the company on April 16, 1990

2.5.2 Cabin Attendants

	Latest training on emergency procedures	June 29, 1993
	Rest period prior to the flight	More than 18 h
F.	Flight attendant (female, aged 28)
	Qualification as attendant	Issued May 18, 1989
	Total flight time	3,545 h
	Latest training on emergency procedures	July 19, 1993
	Rest period to the flight	More than 18 h
G.	Flight attendant (female, aged 24)
	Qualification as attendant	Issued September 5, 1989
	Total flight time	3,306h
	Latest training on emergency procedures	July 5, 1993
	Rest period prior to the flight	More than 18 h
H.	Flight attendant (female, aged 27)
	Qualification as attendant	Issued September 5, 1989
	Total flight time	3,306h
	Latest training on emergency procedures	July 9, 1993
	Rest period prior to the flight	More than 18 h
I.	Flight attendant (female, aged 24)
	Qualification as attendant	Issued May 4,1992
	Total flight time	1,513 h
	Latest training on emergency procedures	July 2, 1993
	Rest period prior to the flight	More than 18 h
J.	Flight attendant (female, aged 25)
	Qualification as attendant	Issued June 2, 1992
	Total flight time	1,401 h
	Latest training on emergency procedures	July 1, 1993
	Rest period prior to the flight	More than 18 h
K.	Flight attendant (female, aged 24)
	Qualification as attendant	Issued August 20, 1992
	Total flight time	1,289h
	Latest training on emergency procedures	July 14, 1993
	Rest period prior to the flight	More than 18 h
L.	Flight attendant (female, aged 23)
	Qualification as attendant	Issued April 26, 1993
	Total flight time	720 h
	Latest training on emergency procedures	June 30, 1993
	Rest period prior to the flight	More than 18 h

M.	Flight attendant (female, aged 23)
	Qualification as attendant	Issued January 4, 1994
	Total flight time	170h
	Latest training on emergency procedures	January 4, 1994
	Rest period .pnor to the flight	More than 18 h

2.6 Aircraft Information

2.6.1 Aircraft

2.6.2 Engines

2.6.3 Weight and Center of Gravity

The weight of the aircraft at the time of the accident is estimated to have been approximately 290,900 lbs, with its center of gravity at 30.6% MAC, both being within permissible limits (maximum landing weight being 308,651 lbs, with the allowable range of center of gravity corresponding to the weight at the time of landing, 20.0 to 33.6% MAC).

According to the Flight Clearance and Log of China Airlines, the aircraft loaded approximately 50,7OOlbs of fuel before takeoff The amount of fuel remaining at the time of the accident is estimated to have been approximately 22,000lbs.

2.6.4 Fuel and Lubricating Oil

The fuel on board was JET A-1, and the lubricating oil was Esso Turbo Oil 2380 (MIL-L-23699), both being authorized for aircraft use.

2.7 Meteorological Information

2.7.1 Synoptic Weather

A region of high atmospheric pressure, centered above the Korean Peninsula and the East China Sea covers almost all of Japan. Meanwhile, a front associated with a low pressure system hovers above the ocean to the south of Japan, and another low pressure system is centered over the ocean to the northeast of Hokkaido. Thus, the weather is fine throughout the country, except on the Pacific side of eastern Japan, and northern Japan, where it is cloudy.

Weather is fine in the Chubu region, in both the Tokai and Hokuriku areas. Also, the temperature is high. (See attached Figures 6 and 7).

2.7.2. Aeronautical Meteorological Observations and Reports

(2) Aeronautical meteorological reports at Taipei International Airport
Aeronautical meteorological reports by the Taiwanese civil aviation authorities in the time zones relating to the departure of the aircraft were:

8:00	Wind direction/speed:	50°/14 kt
	Visibility:	8 km, light rain
	Cloud:	SCT 600 ft, BKN 1,000 ft, OVC 4,OOOft
	Temperature/dew point:	23°C/19°C QNH: 29.83 inHg
8:30	Wind direction/speed:	050°/11 kt Gust 22 kt
	Visibility:	8 km, light rain
	Cloud:	SCT 500 ft, BKN 1,000 ft, OVC 4,000 ft
	Temperature/dew point:	22°C/19°C QNH: 29.83 inHg
9:00	Wind direction/speed:	070°/8 kt Gust 18 kt
	Visibility:	5 km, light showery rain
	Cloud:	SCT 500 ft, BKN 1,000 ft, OVC 4,000 ft
	Temperature/dew point:	23°C/19°C QNH: 29.82 inHg

2.8 Navigation Aids

All navigation aids at Nagoya Airport required for aircraft the operation of the aircraft concerned were in working normally during the time zone related to the flight.

2.9 Communications

2.10 Airport and Ground Facility Information

Field elevation of the airport is 14 meters. The runway, 16 and 34, is 2,740 meters long and 45 meters wide. It is paved with asphalt concrete, and has grooving over a 2,708-meter long and 30-meter wide area.

The runway was in normal operation at the time that the aircraft was making its landing approach. (See attached Figure 8.)

2.11 Information on DFDR and CVR

The aircraft was equipped with a Sundstrand model 980-4100-BXUS DFDR (serial No. 1006) and a Fairchild model Al OOA CVR (serial No. 25153).(See attached Photographs 43 and 44)

The DFDR case was partially crushed and damaged when recovered. However, its magnetic tape that had recorded signals during the flight, was found intact.

The DFDR record is attached herewith as Appendix 6.

The CVR was also recovered with its case partially crushed and damaged, but its tape, containing a record of voices and sounds was not damaged.

The CVR had four recording channels, each channel being assigned to an input source as shown below, and recorded radio communication and other voices.
The CVR transcriptions are shown in Appendix 7.

Channel 1: Input from the audio selector panel of the jump seat (3rd)
Channel 2: Input from the audio selector panel of F/O's seat (F/O)
Channel 3: Input from the audio selector panel of CAP's seat (CAP)
Channel 4: Input from the area microphone (AREA MIC)

It should be noted that Channels 2 and 3, including radio communication, are identical because the CAP and the F/O always used the cockpit intercom system.

2.12 Medical Information

2.12.1 Autopsies of CAP, FIO and Purser

Information supplied by Aichi Prefectural Police Headquarters is as follows:

(1) Damage to bodies and handling of remains prior to autopsies

The CAP's body had open wounds running from the right shoulder to the right breast.

Open wounds were also found from the left breast to the left abdomen of the F/O's body, and his stomach and intestines were damaged. Open damage was barely noticeable on the breast and abdomen of the purser's body.

The three remains were placed in Hangar 1 of the Komaki Air Base immediately after their recovery.

Later, no special measures, such as preservation by freezing, were taken for the remains prior to their transfer to three medical colleges/university for judicial autopsies.

From 18 to 22 hours had elapsed from the time of the accident to the transfer of the remains to the medical colleges/university for autopsy. During this period, the lowest and

highest temperatures at Nagoya Airport were about 1 0°C and 23°C, respectively.
The temperature in the Hangar 1 of the Komaki Air Base, where remains were placed, is considered to have been somewhat higher then the value above.

(2) Judicial autopsies and extraction of samples for alcohol reaction tests (times are JST)

(3) Alcohol reaction test

The test samples taken from the three remains were immediately placed in special plastic containers and sealed. After dissection, technical officers from Aichi Prefectural Police Headquarters who had witnessed the dissection, took the samples to Scientific Investigation Laboratory of Aichi Prefectural Police Headquarters for storage in a refrigerator.

1	Date of test and organization involved
	An alcohol reaction test was conducted at the above-mentioned Scientific Investigation Laboratory in a period between 17:00 and 20:00 on April 28.
02	Test method
	One milliliter of each test sample was subjected to test by the gas chromatography method using n-propanol as an internal standard. The concentration of ethanol was calculated by the calibration curve method.

(3)	Test results
	The concentration of ethanol in each of the test samples was as follows:
	(a) CAP    : 13mg/l00ml
	(b) F/O      : 55mg/l00ml
	(c) Purser : No ethanol detected

2.12.2 Injuries to survivors

2.12.3 Damage to Bodies

2.13 Fire and Fire Fighting

2.13.1 Fire Fighting and Rescue System at Nagoya Airport

The fire fighting and rescue service for civil aircraft at Nagoya Airport is to be provided by the Nagoya Airport Office (hereinafter referred to as "Airport Office") with assistance rendered to the office by the Komaki Air Base, in accordance with an agreement on mutual assistance in fire fighting and rescue activities made between the Administrator of Nagoya Airport Office of Osaka Regional Civil Aviation Bureau (hereinafter referred to as "Airport Office Administrator") and the commander of Komaki Air Base of Air Self-Defense Force.

Also, an agreement was made with respect to the fire fighting service in and around Nagoya Airport between the Airport Office Administrator, and the Chief of Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, the Chief of Komaki City Fire Fighting Headquarters, the Chief of Kasugai City Fire Fighting Headquarters, and the Chief of Nagoya City Fire Fighting Bureau (hereinafter referred to as "Neighboring Fire Fighting Organizations"). This agreement allows the Airport Office Administrator to request assistance to these Neighboring Fire Fighting Organizations when necessary. Furthermore, an ambulance loaded with emergency medical materials and equipment was stationed at Nagoya Airport from March 1992, and the Airport Office commissioned the Air Safety Foundation to operate this vehicle.

(2) Fire fighting equipment and personnel at Nagoya Airport

The fire fighting equipment was not provided at the Airport Office. The Fire Fighting Platoon of the Base Operation Facilities Company of First Air Transport Squadron at Komaki Air Base (hereinafter referred to as "Fire Fighting Platoon"), is equipped with five chemical fire vehicles and one water supply wagon. This Fire Fighting platoon operates 24 hours a day, in shifts, at the station which contains a fire trucks and a command office, and is situated in the eastern part of Nagoya Airport.
Meanwhile, according to "Level of Protection to be provided" specified as a recommended practice in Annex 14 ("AERODROMES") to the Convention on International Civil Aviation, Nagoya Airport is classified as a Category 9 Airport. Nagoya Airport complies with the applicable level in terms of the amounts of water for foam production, fire-extinguishing agents and complementary agents, and response time. However, the airport did not meet the level in respect of the discharge rate for foam solution.
The chemical fire vehicles had a discharge distance of 30 m.

(3) Fire fighting and rescue training for aircraft accidents

Fire fighting and rescue training for aircraft accidents were held at Nagoya Airport on October 16, 1989 and May 24, 1993, under the auspices of the Airport Office. Personnel from Self-Defense Force, Neighboring Fire Fighting Organizations, Airport Police Station, Aichi Prefecture Medical Association, and other organizations participated in these training.
In order to train its fire fighting personnel, the Fire Fighting Platoons conduct drills involving actual fires once a quarter-year and practice water spraying once a week.

2.13.2. Fire Fighting Activities (times are JST)

(1) Request for mobilization and turning out of fire vehicles

At about 2016, via an emergency telephone call, an Air Traffic Controller of the Airport Office ( hereinafter referred to as "Controller" ) requested the Fire Fighting Platoon and an Air Traffic Information Officer (hereinafter referred to as "Information Officer") to dispatch fire

services for an aircraft crash in which fire had broken out.
At about 2017 the Fire Fighting Platoon dispatched three chemical fire vehicles.
Meanwhile, as specified in the emergency notification network chart, the Information Officer requested the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association and Airport Police Station to request assistance.
The Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association relayed the information to the Kasugai city Fire Fighting Headquarters, Nagoya City Fire Fighting Bureau, and the Komaki City Fire Fighting Headquarters.
At about 2019 three chemical fire vehicles of Fire Fighting Platoon were the first to arrive at the crash site, and immediately began fire extinguishing activities.
At approximately 2027, one chemical fire vehicle, one water tank truck, one rescue vehicle, and one ladder truck, all from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, as well as two chemical fire vehicles, two water tank trucks, and two rescue vehicles from the Kasugai City Fire Fighting Headquarters, entered the airport through the No.2 West Gate and proceeded to the crash site under the guidance of Airport Office personnel, where they commenced fire extinguishing activities.
Around 2030 two chemical fire vehicles, one ordinary fire vehicle, one water supply wagon, one cargo truck, one water spray truck, two mobile cranes, one light wrecker, one fork-lift, and one tractor, all from the Fire Fighting Platoon, reached the site as second group, and commenced fire fighting activities.
At approximately 2042, one chemical fire vehicle, one water tank truck, and one rescue vehicle from the Komaki City Fire Fighting Headquarters entered the airport after cutting two sets of security chains at the North Gate and opening the gate, arrived at the crash site, and commenced fire fighting activities. In addition, about 2054, a chemical fire vehicle from the Nagoya City Fire Fighting Bureau entered the airport through the No.2 West Gate and went into action at the crash site.

(2) Fire extinguishing activities

Fire fighting personnel who were dispatched from the standby station of Fire Fighting Platoon described the fire fighting activities as follows:
At approximately 2016 of that day, the Controller informed the Fire Fighting Platoon via an emergency telephone that "a China Airlines' aircraft has burst into flames on the runway" and requested fire services. The Fire Fighting Platoon dispatched three chemical fire vehicles around 2017.
The Fire Fighting Platoon personnel, who were at their standby station, had not heard the impact sound of the aircraft crash.
Upon receipt of the report, two chemical fire vehicles left the station and sped along Taxiway E4 and the runway to the southern end of the airport where flames and smoke were billowing in the air. About 2019, another chemical fire vehicle arrived at the site via Taxiway EP 1.
The aircraft had fragmented into pieces, losing its original shape so badly that the only way to distinguish the wings was by identifying the vague shape of the engines.
Fire broke out, and flames as high as a three-storied building enveloped an area more than 100 meters wide. Booming sounds were heard three times at internals.

Going into action immediately, the Fire Fighting Platoon, staying clear of widely scattered aircraft fragments, advanced to about 20 meters from the wing and discharged fire extinguishing agents.
At approximately 2027, a chemical fire vehicle, a water tank truck and a ladder truck from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, plus two chemical fire vehicles and two water tank trucks from the Kasugai City Fire Fighting Headquarters arrived at the crash site and went into action. Flames under the wings, however, did not abate easily.
About 2030, a second party dispatched by the Fire Fighting Platoon, consisting of two chemical fire vehicles, one water supply truck, one ordinary fire vehicle, one cargo truck and so on arrived at the site. They backed up the chemical fire vehicles that had arrived earlier and provided them with additional water and fire extinguishing agents.
Around 2042, a chemical fire vehicle and a water tank truck from the Komaki City Fire Fighting Headquarters arrived at the crash site and joined the fire extinguishing activities.
Later, about 2054, a chemical fire vehicle from the Nagoya City Fire Fighting Bureau arrived at the site and also joined the fire fighting activities.
About 2110, aircraft components smoldering near the irrigation water channel were cut open with axes and tobiguchi (fireman's hooks) and sprayed with agents and water. The fire was finally extinguished around 2148.

2.14 Information on Search, Rescue and Evacuation Relevant to Survival, Death or Injury

2.14.1 Information on Search and Rescue Activities (times are JST)

(1) Removal of passengers After confirming the crash site, the personnel from the Self-Defense Force, Neighboring Fire Fighting Organizations, Police, and Airport Office conducted search and rescue activities throughout the area.
Reports from the various parties are summarized as follows:
Ambulances from Komaki Air Base arrived at the crash site at about 2019 and 2023.
At about 2027, ambulances and other vehicles from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association and the Kasugai City Fire Fighting Headquarters entered the airport through the No.2 West Gate and, upon arriving at the site, commenced search and rescue operations promptly.
At approximately 2031, ambulances from Nagoya City Fire Fighting Bureau entered the airport through the No.2 West Gate and proceeded to the crash site. Upon arrival, the ambulance men started confirming whether there were any survivors and conducting first aid to the injured. Actual work to confirm the presence of survivors began about 2032. However, flames raging in the central part of the fuselage hampered search and rescue activities.
A male passenger was found around 2035, and two female passengers and an infant were removed from the site about 2037. These four people were carried to hospital in an ambulance from Komaki Air Base.
Around 2042, ambulances from the Komaki City Fire Fighting Headquarters entered the airport

through the main gate of Komaki Air Base and commenced search and rescue activities.
Two injured passengers, who had received first aid from the rescue personnel assigned to a Nagoya City Fire Fighting Bureau ambulance, were rushed to hospital.
Around 2049, an ambulance from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association carried three passengers to hospital.
Around 2055, two ambulances from the Kasugai City Fire Fighting Headquarters took three passengers to hospital.
Around 2100, a male passenger about 40 years old, trapped between seats, was rescued by removing the seats with a power cutter. A female passenger about 35 years old was also rescued. Those two passengers were carried to hospital in an ambulance from the Kasugai City Fire Fighting Headquarters.
Around 2100, a male child passenger was taken to hospital in an ambulance from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association.
At approximately 2122, an emergency medical treatment and transport vehicle arrived at the crash site.
Around 2124, an ambulance from Nagoya City Fire Fighting Bureau carried a male passenger to hospital.
Around 2140, rescue teams began setting up rescue stations (three air tents). Around 2148, the fire was finally extinguished. Wreckage was pulled up from the irrigation water channel with cranes and other equipment, and the search for missing persons continued. From about 2220 the remains found around the wings and the irrigation water channel were taken to the rescue stations (air tents).
On request from the Airport Office Administrator, troops of 10th Division, with Ground Self-Defense Force, from Monyama Base, arrived at the site about 2225, and commenced search and rescue activities.
Around 2325, the remains of persons considered to be crew members were found near the cockpit and taken to a rescue station (air tent) set up near the crash site.
Around 0445 on April 27, transfer of remains from the rescue stations (air tents) to Hangar No. 1 at Komaki Air Base, for temporary storage, started.
Around 1340, the final remain was transferred from the site. (See attached Photograph 4.)

(2) Rescue activities conducted by the organizations involved

1	On April 26, based on a decision made at a cabinet meeting immediately after the accident, Japan's national government established "China Airlines Aircraft Accident Countermeasure Headquarters", with the Minister of Transport as its head. The government decided to spare no effort in rescuing survivors, recovering the remains and keeping close contact with the organizations involved.
2	Immediately after the accident, the Airport Office set up "Accident Emergency Countermeasure Headquarters" with the Airport Office Administrator as its head and mobilized 119 employees through emergency call. The Airport Office also organized "Nagoya Airport Aircraft Rescue Unit" and conducted its activities using the following personnel, materials and equipment:

        Personnel         406 persons (including 102 of Rescue Unit and other

	airport personnel concerned)
Materials and equipment	28 vehicles (including an emergency medical treatment and transport vehicle) and 3 air tents

03	With a request from the Airport Office Administrator for disaster dispatch immediately after the accident, the 10th Division of Ground Self Defense Force and the 1st Air Transport Squadron of Air Self-Defense Force participated in the rescue and other activities by providing:

	Personnel	1,900 persons (1,200 at the site and 700 for backup duties)
	Materials and equipment	25 vehicles
	Floodlight projectors	16

04	The Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, Kasugai City Fire Fighting Headquarters, Komaki City Fire Fighting Headquarters, and Nagoya City Fire Fighting Bureau participated in rescue and other activities at the request of the Airport Office, by providing:

	Personnel	546 persons (534 dispatched and 12 on standby)
	Materials and equipment	116 vehicles
	Helicopter	1 (operated by Nagoya City Fire Fighting Air Force; used illuminate the crash site and assess the scope of the disaster by flying over the site)

(5)	In accordance with the "Agreement on Medical Treatment and Rescue Activities at Nagoya Airport" made with the Airport Office, the Aichi Prefecture Medical Association conducted their rescue activities by providing:

	Dispatched	64 persons (47 doctors and 17 nurses)
	On standby	164 persons (76 doctors, 51 nurses and 37 clerks and others)

(6)	The Aichi Prefecture Branch of Japanese Red Cross Society conducted activities, including autopsies, post-mortem examinations, reconstruction, cleansing and identification, by providing:

Personnel

102 persons (14 doctors, 55 nurses and 33 clerks and others)

07	The Aichi Prefectural Police Medical Association performed post-mortem examinations by providing:

Personnel

79 persons

(8)	The Aichi Prefecture Dental Association was engaged in identification activities by providing:

Personnel

134 persons (107 dentists, 7 dental hygienists, and 20 police doctors)

(9)	Upon receipt of the accident report from the Airport Office immediately after the crash, the Aichi Prefectural Police Headquarters conducted rescue activities and policed the site of disaster by providing:

Personnel

1,700 persons (1,100 dispatched and 600 others)

2.15 Tests and Research to Find Facts

2.15.1 Investigation of Traces Left on the Ground

The aircraft first impact point was in the landing area, some 110 meters east-northeast from the center of the end of Runway 34. The crash site was covered with earth and sand, and the ground was relatively soft.

Measurements of the major marks are as follows:

	Width (cm)	Length (cm)	Depth (cm)	Angle of Entry(°)
Nose landing gear	130 to 150	440	41	42
LH main landing gear	170 to 220	470	67	23
RH main landing gear	30 to 210	500	38	16
LH engine	150 to 320	920	73	10
RH engine	170 to 390	910	68	12
LH No.2 flap track	27 to 46	375	10	24
LH No.3 flap track	21 to 38	510	29	34
LH No.4 flap track	26 to 47	570	--	25
LH No.5 flap track	25 to 43	560	21	26
LH No.6 flap track	20 to 46	540	30	30
RH No.2 flap track	38 to 48	--	20	14
RH No.3 flap track	27 to 38	210	10	14
RH No.4 flap track	28 to 44	530	18	20
RH No.5 flap track	24 to 39	410	24	16
RH No.6 flap track	33 to 80	270	33	20

The positions of the marks left by the nose landing gear, LH and RH main landing gears, LH and RH engines, LH and RH wingtips, and THS are as shown in attached Figure 10.

The direction of the linear marks which are made when the center section of the fuselage scratched the ground, coincided with magnetic bearing of about 220. (See attached Figures 9 ,10, and Photographs 49 and 50.)

2.15.2 Indications of Major Instruments and Positions of Switches and Levers

1) Indications of major instruments

Altimeter (unknown whether LH or RH):	QNH 29.82/1010 80 ft
Rate of climb indicator (unknown whether LH or RH):	-6,000 ft
RMI (unknown whether LH or RH):	Heading 020°
ENG oil pressure indicator/oil quantity gauge:	No.1 225 psi/12.5 Qr No.2 -/-

(2) Positions of switches and levers

IRS mode selectors:	No.1: OFF, No.2: ATT, No.3: NAV
ENG IGN selectors:	No.1: Cont Relight, No.2: Cont Relight
L/G lever:	Intermediate position between Neutral and Down
SLTS/FLPS lever:	15/20°
THS trim indicators 9.4°/9.5°
SPD brake lever:	RET
ENG SWs:	No.1:ON, No.2:ON
THR levers:	No.1: 34°, No.2:34°
THR reverser levers RET
Fire handles:	Handles for No.1 engine, No.2 engine and APU had not been activated. (See attached Photographs 35,36,37,38,39,40 and 41.)

2.15.3 Disassembly Inspection of Engines

(2)	Rotor blades had been torn/deformed in the direction opposite to that of engine rotation. Stator vanes and nozzle guide vanes had been torn/deformed in the direction of engine rotation.
(3)	The external surfaces of both engines showed evidence of burns. The No.2 engine was burnt more extensively than the No. 1 engine, with its HPC blade surface, front case and so on surfaces partially blackened. There was no indication of in-flight fire; all signs of fire indicated that fire had broken out only after the engines were destroyed.
(4)	Nothing indicative of operational abnormality was found in the damage to major accessories. The fracture surfaces of all broken and damaged accessories showed signs of rapid destruction.
(5)	All oils collected at the crash site (fuel, engine oil, and hydraulic fluid) contained a great deal of foreign matter such as water, mud, grains of sand, and other fiber-like objects, and they were found polluted and deteriorated, making it difficult to determine the conditions they had been in before the crash. (See Attached Figure 20 and 21.)

2.15.4 Investigation of FADECs

The aircraft engines were equipped with Full Authority Digital Electronic Controls (FADECs) manufactured by Hamilton Standard of United Technologies Corp. (Serial No.: 4000-0519 for No.1 engine and 4000-0674 for No.2 engine).

The connectors of both FADECs had broken; the FADEC for the No.2 engine was recovered with its case cracked.

The FADECs had a dual system consisting of channels A and B. Their disassembly inspection showed that the processor boards for both channels in each FADEC were in good conditions. The fault memories storing the engine control failure condition records were readable on all the channels. As a result of the analysis of these records, evidence of surges which indicate a rapid drop of pressure in the engine combustor in flight before crash, was detected in channels A and B of the FADEC for both engines (See Photograph 32).

2.15.5 Investigation of Computer Memories

Computers with non-volatile memories, which are considered useful for crash cause determination, were recovered, from the site.

All these computers were damaged by the impact. The memories from all recovered computers, except heavily damaged ones, were investigated. These computers are the following.

Marked with asterisks (*) are computers whose memories were not readable owing to internal damage.

*	(1)	Flight control computer (FCC)	1 pc
	(2)	Flight augmentation computer (FAC)	2 pcs
	(3)	Flight management computer (FMC	1 pc
*	(4)	Center of gravity control computer (CGCC)	1 pc
	(5)	Symbol generating unit - Electronic flight instrument system (SGU-EFIS)	3 pcs
	(6)	Symbol generating unit - Electronic centralized aircraft monitor (SGU-ECAM)	2 pcs
	(7)	Flight warning computer (FWC)	1 pc
	(8)	Air data computer (ADC)	2 pcs
	(9)	Inertial reference unit (IRU)	3 pcs
	(10)	Generator control unit (GCU)	2 pcs
*	(11)	Maintenance and test panel (MTP)	1 pc
*	(12)	Ground proximity warning computer (GPWC)	1 pc
	(13)	Instrument landing system (ILS) receiver	1 pc

2.15.6 Information on Seating Positions of CAP and FIO

2.15.6.1 CVR records

(1)	Conversation made between 1046:59 and 1047:35
	The conversation is concerned with the operation of "lights".
	Lights in the cockpit consists of the following:

	(1)	Lights operated from CAP's seat through controls on CAP and center light panel located at the left end of the instrument panel:
		- CAP and center instrument light
		- Main instrument panel floodlight
		- Console floodlight
		- Map light
	(2)	Lights operated from F/O's seat through controls on F/O instrument light panel at the right end of the instrument panel:
		- F/O instrument light
		- Console floodlight
		- Map light
	(3)	Lights operated from CAP's or F/O's seat through a knob located at the center of the overhead panel:
		- Reading light

	(4)	Lights operated from CAP's or F/O's seat through a knob on the pedestal:
		- Pedestal and overhead panel light
	(5)	Lights operated from CAP's seat (also from F/O's seat) through controls on the 'cockpit light panel in front of the overhead Panel CAP's seat:
		- Dome light
		- Storm light
	(6)	Lights operated from CAP's or F/O's seat through theglareshield lightning controls:
		- Each window of the glareshield panel
		- Push-button switch integrated light (See attached Figure 23 and Photograph 42.)

(2)	Conversation started at 1100:02
	The conversation was concerned with the wearing of shoulder harnesses.

2.15.6.2 Setting of CAP's seat and F/O's seat

	Column assembly	Seat position track
LH (Captain) Seat	Approx. 70 mm upward from the lowest position	Probably near the forward-most position
RH(F/O) Seat	Approx. 30 mm upward from the lowest position	Approx. 33mm rearward from the forward-most position

Note: The mark found at a point 170 mm from the forward limit position of the LH(Captain) seat is not considered to be primary damage caused by the crash impact -- it is regarded as secondary damage caused afterward.

The position where the LH side rudder pedals had been placed was judged to be approximately 17 mm forward of its rearmost position, based on a mark left on the recovered rudder pedal adjuster. The right-side rudder pedal adjuster was not recovered.

According to their airman medical certificates, the CAP and the F/O were 162.5 cm and 178.1 cm tall, respectively. (See attached Figures 24 and 25.)

2.16 Other necessary Information

2.16.1 Flight Experience of CAP and FIO

The following information has been obtained from China Airlines:

• (1) The CAP joined China Airlines on February 1, 1989. Before this, he had served in the Taiwanese Air Force as a pilot from September 1970 to January 1989. During his military service, he had accumulated 4,826.5 hours' flight experience with C-47s and other aircraft. After joining the airline, he served as F/O for B747-200 and B747-400. During this pen od, he underwent CAP training for A300-600R at China Airlines and qualified as CAP for the aircraft type on July 31, 1992. He was promoted to CAP for A300-600R on December 1, 1992. His flight hours until April 25, 1994, the day preceding the accident were:

  Duty/Aircraft type	Air Force	B747-200	B747-400	A300-600R	Total
  CAP	4826+30	--	--	1089+34	5916+04
  CAP training	--	--	--	260+53	260+53
  F/O	--	668+35	1494+47	--	2163+22
  Flight time	4826+30	668+35	1494+47	1350+27	8340+19

  
  (Total flight hours in China Airlines: 3513+49)
  
• (2) The F/O joined China Airlines as a candidate pilot on April 16,1990. He received flight training at University of North Dakota (UND), tinder the airline's training program, from August 4, 1991 to August 30, 1992, flying some 590 hours on C-90A, C-i 900, and other aircraft. He obtained a commercial pilot's license after completing the program. He underwent classroom and simulator training and three hours' flight training for A300-600R at Aeroformation in France. China Airline contracted this trainings to Airbus Industrie and then Airbus Industrie subcontracted these to Aeroformation. Subsequently the F/O underwent four hours' basic flight training at China Airlines, and qualified as F/O for the aircraft type on December 29, 1992; he was promoted to F/O for A300-600R on March 22, 1993. His flight hours until April 25, 1994, the day before the accident was:

  Duty/Aircraft type	UND	A300-600R	Total
  CAP	343+30	--	343+30
  F/O	246+42	1033+59	1280+41
  Flight time	590+12	1033+59	1624+11

2.16.2 Qualification Requirements for CAP and FIO, and Promotion System

the type in question.

(1) Qualification Requirements

1	CAP
	Age:	54 or younger
	Competence qualification:	Airline transport pilot
	Experience:	Not less than 2 years' service as F/O with qualification for promotion to CAP
	Medical certificate:	Class 1
	Flight hours:	Not less than 3,500 hours
(2)	F/O
	From military service
	Academic background:	Graduate of Aviation Department of Air Staff College, Air Force
	Age: 33 to 45
	Competence qualification:	Commercial pilot
	Medical certificate:	Class 1
	Flight hours:	Not less than 1,300 hours : age 33
		Not less than 1,400 hours : age 34
		Not less than 2,500 hours : age 45
	Trained by the Chinese Airline
	Academic background:	Graduate of Engineering Department of Junior College or higher
	Age:	Less than 28
	Competence qualification:	Commercial pilot
	Airman medical certificate:	Class 1
	Flight hours:	Not less than 588 hours

(2) Promotion system to F/O and CAP

F/O for light aircraft type (C-90A, C-i 900, etc.)

F/O for lower-ranked aircraft type (B737, A300B4, A300-600)

F/O for higher-ranked aircraft type (B747-200, B747-400, MD1 1)

F/O recommended as candidate for CAP by the company

CAP for lower-ranked aircraft type (B737, A300B4, A300-600)

CAP for higher ranked aircraft type (B747-200, B747-400, MD1 1)

(Note): Depending on education and career, some pilots may become F/O for higher ranked aircraft from the start.

2.16.3 Automatic Flight System (AFS) ( See Attachment 1)

---

Peter B. Ladkin, 1999-02-08
	Last modification on 1999-06-15