What happened
On May 24, 2008, at approximately 00:15, a BK-117 helicopter, registration B-77008, operated by China Airlines (Zhongxing Airlines), crashed while attempting to land at Kinmen/Shang-yi Airport. The aircraft was conducting an ILS approach to runway 06 under weather conditions that were below established flight visibility limits. The helicopter struck the ground approximately 20 meters south of the runway 24 threshold, roughly 2,900 feet from the runway head. The crew, consisting of two pilots and one paramedic, all sustained serious injuries, and the aircraft was destroyed.
The investigation
The Taiwan Transportation Safety Board (formerly ASC) conducted an investigation involving international experts from Japan, the United States, and Germany. The investigation examined the flight' and weather data, cockpit voice recordings, and the operational procedures of the operator. Investigators reviewed the flight preparation, including the lack of updated weather reports for the destination and alternate airports, and analyzed the communication between the Taichung Approach, Kinmen Tower, and the flight crew. The investigation also looked into the organizational safety management of the operator and the adequacy of emergency services at Kinmen Airport.
Findings
- The crew failed to follow instrument flight rules by proceeding with the approach despite visibility being below the required minimums for the destination airport.
- The pilots did not execute the missed approach procedure once they failed to maintain visual contact with the runway at the decision height, likely leading to spatial disorientation and a high rate of descent prior to impact.
- Pre-flight preparations were incomplete; the crew departed Taipei/Songshan International Airport without obtaining valid weather reports for the destination or alternate airports.
- There were significant gaps in the operator's weather management, including failures to monitor the latest ATIS or weather broadcasts, which prevented the crew from recognizing the deteriorating conditions.
- The investigation identified several organizational risks, including potential pilot fatigue due to mission time pressures and the lack of effective measures to manage the risks of flying on an empty stomach.
- Safety was further compromised by the fact that the crew members were not wearing seatbelts properly, which exacerbated their injuries during the impact.