AIRCRAFT ACCIDENT INVESTIGATION REPORT 96-5

China Airlines
Airbus Industrie A300B4-622R, B1816
Nagoya Airport
April 26, 1994

Aircraft Accident Investigation Commission
Ministry of Transport
[Japan]

Prepared for the WWW by

Hiroshi Sogame
Safety Promotion Comt.
All Nippon Airways

Peter Ladkin
Universität Bielefeld
Germany

Section 1

July 19, 1996

AIRCRAFT ACCIDENT INVESTIGATION REPORT

China Airlines
Airbus Industrie A300B4-622R, B1816
Nagoya Airport
APRIL 26, 1994

July 15, 1996
Decision by the Aircraft Accident Investigation Commission
Chairman Kazuyuki Takeuchi
Member Tetsuichi Kobayashi
Member Tsutomu Kawai
Member Minoru Higashiguchi
Member Yasuhiko Aihara

1. PROGRESS AND PROCESS OF THE AIRCRAFT ACCIDENT INVESTIGATION

1.1 Summary of the Aircraft Accident

China Airlines Airbus Industrie A300B4-622R B 1816 took off from Taipei International Airport at 0853 UTC (1753 JST) on April 26, 1994 and continued flying according to its flight plan. About 1116 UTC (2016 JST), while approaching Nagoya Airport for landing, the aircraft crashed into the landing zone close to E1 taxiway of the airport.

On board the aircraft were 271 persons: 256 passengers (including 2 infants) and 15 crew members, of whom 264 persons (249 passengers including 2 infants and 15 crew members) were killed and 7 passengers were seriously injured. The aircraft ignited, and was destroyed.

1.2 Outline of the Aircraft Accident Investigation

1.2.1 Organization for Investigation

1.2.1.1

On April 26, 1994, the Aircraft Accident Investigation Commission assigned an investigator-in-charge and nine investigators.

1.2.1.2

The following nine technical advisors were appointed for the investigation of specialized matters with regard to the accident (titles are as of the date of appointment):

(1) For analysis of damage to the airframe structure and related matters
Shojiro Kaji, Professor, Department Aeronautics and Astronautics, Faculty of Engineering, the University of Tokyo
Tetsuhiko Ueda, Head, Flight Load Laboratory, Airframe Division, National Aerospace Laboratory, Science and Technology Agency
Makoto Sasaki, Head, Engine Performance Laboratory, Aeroengine Division, National Aerospace Laboratory, Science and Technology Agency
Keiji Tanaka, Head, Human Engineering Laboratory, Control Systems Division, National Aerospace Laboratory, Science and Technology Agency
Kouhei Funabiki, Human Engineering Laboratory, Control Systems Division, National Aerospace Laboratory, Science and Technology Agency

(2) For analysis of flight performance
Nagakatsu Kawahata, Professor, Dept. of Science and Engineering, Nihon University
Shigeru Saito, Head, Flight Test Laboratory, Flight Research Division, National Aerospace Laboratory, Science and Technology Agency

(3) For analysis of operations
Atsushi Toriya, Captain, Japan Air Lines Co., Ltd.(retired)
Shigeyuki Yagura, Commander, Aeromedical Laboratory Unit, Air Self-Defense Force (retired)

1.2.1.3

For specialized studies, a Structural Investigation Group, a Flight Performance Investigation Group and an Operations Investigation Group were established.

1-1

1.2.1.4

Upon occurrence of the accident, chairman, members, investigator-in-charge and investigators, etc. were dispatched to the crash site, and at the same time, an investigation team was set up on site. The team remained on site until may 20 to continue their investigations.

1.2.1.5

During the fact-finding investigation, cooperation was given by a number of related organizations and personnel including Police Agency, Defense Agency, Science and Technology Agency, Meteorological Agency, and local governments and fire squadrons of Aichi Prefecture and so on.

1.2.1.6

Accredited Representatives from France as the state of aircraft manufacture, the U.S.A as the state of engine manufacture, and Taiwan as the operations authority, participated in the factual investigation.

1.2.2

Implementation of Investigation
April 26 - May20, 1994 On-site investigation
April 27 - May 1, 1994 Interview with eye witnesses
April 27 - September 27, 1994 Interview with aircraft passengers
April 27, 1994 - November 29, 1995 DFDR retrieval
April 27, 1994 - November 29, 1995 CVR transcripts
September 4 - September 9, 1994 Visit to Taiwan by investigators and a technical advisor
September28, 1994 - January 27, 1995 Disassembly Investigation of engines
November 6 - December 4, 1994 Visit to U.S.A. by investigators and technical advisors
November 14 - November 28, 1994 Visit to France by a commission member, investigators and technical advisors
January 6 - February 28, 1995 Investigation of the equipment by disassembly, etc.
January 6 - February 28, 1995 Investigation of reconstructed airframe
January 17 - March 24, 1995 Investigation of flight performance

1.2.3 Hearings from Persons Relevant to the Cause of the Accident

Hearings were held.

1.2.4 Public Hearing

The AAIC published a draft of Factual Investigation Report on January 9, 1995, and held a public hearing on February 7 to hear the accounts of 12 persons (either directly connected with the incident or who had knowledge and experience relevant to the investigation, etc.).

(1) Date: 10:30- 16:30February7, 1995

(2) Place: Assembly Hall, 10th Floor, Ministry of Transport

1-2

(3)Hearing chairman: Tohru Toyoshima, Director-General, Secretariat of AAIC

(4) Witnesses (in order of speech):
Dr. Jiro Kouo, Witness asked by AAIC. Doctor of Mechanical Engineering, Professor, Tokai University
Capt. Taketoshi Udo, Witness asked by AAIC. Captain, President, Japan Airline Pilots Association
Mr. Ange Ortega, Witness asked by AAIC. Deputy to Senior Vice President, Airbus Industrie.
Mr. Kuang- Feng Chang, Speaker asked by AAIC. Vice President-Operation, China Airlines.
Mr. Wataru Habuka, Company Executive.
Mr. Noriyasu Shirai, Company Employee.
Mr. Takao Kawakita, Chairman, Organizing Committee, International Rally of Endeavors to Improve Air Safety.
Capt. Ryohei Yabuno, President, Airline Pilot Association of Japan, Captain, Japan Air Lines.
Mr.. Kazuya Chikamura, Deputy President, Flight Crew Union's Federation of Japan, Flight Engineer, Japan Airlines.
Mr. Shujiro Okuno, Chairman, Federation of Aviation Worker's Union, Captain, Japan Air System.
Mr. Tsung-Li Kow, Doctor of Medicine, Professor, Postgraduate Medical School, Taiwan University.
Mr. Norman D. Hull, Partner of Accident Investigation and Research Inc.

(5) Summary of Statements
Omitted (See the stenographic transcriptions of the hearing.)

1.2.5 Reporting and Publication

The progress of the investigation, including principal facts which came to light through the factual investigation, was reported to Minister of Transport and published on May 10, 1994 and January 9, 1995.