264 fatalities

1994-04-26: Airbus A300-600 (B-1816) — China Airlines — Nagoya-Komaki, Japan

Nagoya-Komaki, JapanLanding (descent or approach)

On April 26, 1994, an Airbus A300-600 (registration B-1816) operated by China Airlines was involved in an aviation accident near Nagoya-Komaki, Japan during landing or approach. 264 people were killed. Investigators recorded the probable cause as: The AAIC determined that the accident was caused by a chain or combination of the following factors: (1) The first officer inadvertently triggered the GO lever, with its design contributing to inadvertent activation. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 16 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781209033Data APIEditorial standards

On April 26, 1994, China Airlines Flight 140 (B-1816) crashed during an ILS approach to Nagoya Airport. The aircraft, carrying 271 people, was destroyed. Seven passengers were seriously injured; the other 264 occupants were killed.

Background

China Airlines Flight 140 was a scheduled passenger flight from Taipei International Airport to Nagoya Airport, operated with aircraft registration B-1816. On April 26, 1994, at 0853 UTC (1753 JST), the aircraft departed Taipei carrying 271 persons: 2 flight crew, 13 cabin crew, and 256 passengers (including 2 infants). The flight plan specified an IFR route at FL330 with an estimated enroute time of 2 hours 18 minutes.

Flight History

The DFDR recorded the aircraft reaching FL330 at about 0914. At 1047:35, Tokyo Area Control Center cleared the flight to descend to FL210. The captain briefed the first officer on approach procedures during the descent. At 1058:18, contact was established with Nagoya Approach Control. The aircraft descended and reduced speed per clearances.

At 1107:14, the crew was cleared for an ILS approach to Runway 34 and instructed to contact Nagoya Tower. The No. 2 autopilot had been engaged since climb, and at 1107:22 the No. 1 autopilot was also engaged. At 1111:36, the first officer disengaged both autopilots. The aircraft passed the outer marker at 1112:19 and received landing clearance at 1113:39, with reported winds 290° at 6 knots. The approach under manual control was normal.

Accident Sequence

At 1114:05, while crossing approximately 1,070 feet pressure altitude, the first officer inadvertently triggered the GO lever. This shifted the aircraft into GO AROUND mode, increasing thrust. The captain cautioned the first officer and instructed him to disengage it. The aircraft leveled off at about 1,040 feet for 15 seconds. The captain directed the first officer to correct the descent path; the first officer applied nose-down elevator input, gradually regaining the glide path. The captain warned twice about the GO AROUND mode.

At 1114:18, both autopilots were engaged almost simultaneously at about 1,040 feet, 1.2 dots above the glide slope. For the next 18 seconds, the horizontal stabilizer (THS) moved from -5.3° to -12.3° (near max nose-up). The elevator moved continuously nose-down. At 1115:02, at about 510 feet, the captain told the first officer he would take over after being informed that the thrust levers had been latched. The thrust levers moved forward greatly, increasing EPR above 1.5, then were retarded to 1.3. The elevator moved near its nose-down limit.

At 1115:11, immediately after the captain called "Go lever," thrust levers moved forward again, increasing EPR above 1.6. The aircraft climbed steeply. The first officer reported a go-around to Nagoya Tower. Angle of attack increased sharply, calibrated airspeed decreased rapidly. The THS moved from -12.3° to -7.4°, and slats/flaps retracted from 30/40 to 15/15. At 1115:17, the GPWS activated a "Glide Slope" warning once. At 1115:25, the stall warning sounded for about 2 seconds. At 1115:31, after reaching about 1,730 feet pressure altitude (1,790 feet radio altitude), the aircraft lowered its nose and began to dive. The GPWS activated "Terrain, Terrain" at 1115:37, and the stall warning sounded continuously from 1115:40 until impact.

At about 1115:45, the aircraft crashed within the landing zone, approximately 110 meters east-northeast of the center of Runway 34 end. Seven passengers sustained serious injuries; all 264 other occupants were killed.

Probable cause

The AAIC determined that the accident was caused by a chain or combination of the following factors: (1) The first officer inadvertently triggered the GO lever, with its design contributing to inadvertent activation. (2) The crew engaged the autopilots while GO AROUND mode was still engaged and continued the approach. (3) The first officer continued pushing the control wheel despite strong resistive force. (4) The movement of the horizontal stabilizer conflicted with that of the elevators, causing an abnormal out-of-trim situation. (5) There was no warning or recognition function to alert the crew directly to the abnormal out-of-trim condition. (6) The crew did not sufficiently understand the flight director mode change and autopilot override function, partly due to unclear descriptions in the aircraft manufacturer's Flight Crew Operating Manual.