Accident ATR 72-212A (ATR 72-500) B-22810,

ASN Wikibase Occurrence # 320476

Date:	Wednesday 23 July 2014
Time:	19:06
Type:	ATR 72-212A (ATR 72-500)
Owner/operator:	TransAsia Airways
Registration:	B-22810
MSN:	642
Year of manufacture:	2000
Total airframe hrs:	27039 hours
Cycles:	40387 flights
Engine model:	Pratt & Whitney Canada PW127F
Fatalities:	Fatalities: 48 / Occupants: 58
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	0,8 km NE of Magong Airport (MZG) - Taiwan
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Kaohsiung International Airport (KHH/RCKH)
Destination airport:	Magong Airport (MZG/RCQC)
Investigating agency:	ASC
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A TransAsia Airways ATR-72 passenger plane was destroyed in an accident near Magong Airport (MZG), Taiwan. There were 58 persons on board. Ten passengers survived the accident.
Flight GE222 had departed from Kaohsiung International Airport (KHH) at 17:43 on a scheduled domestic flight to Magong Airport, Penghu Islands, Taiwan. The flight had been delayed from 16:00 hours because of poor weather as a result of Typhoon Matmo that was passing through the area.
The flight arrived near the Penghu Islands at 18:11 and entered a holding pattern to the northeast. The Magong airport has a single runway 02/20. Runway 02 offers an ILS approach, while for runway 20 a VOR/DME approach is available.
At 18:27 the following weather information was passed on to the crew: runway 02: wind from 210 degrees at 5 knots, gusting to 11 knots; runway 20 wind from 190 degrees at 11 knots, gusting to 15 knots. Visibility was 800 meters.
The crew then requested a runway 02 ILS approach and proceeded towards the south. At 18:43 a preceding UNI Air ATR-72-600, flight 647, requested a VOR approach to runway 20. This probably made the crew change their minds, since they subsequently also requested a VOR approach to runway 20. This was approved. The UNI Air flight landed at 18:56.
At 19:03 the controller cleared the flight to land on runway 20, reporting wind from 250 degrees at 19 knots.
At 19:05:44 the autopilot was disengaged an at about 19:05:58, the aircraft began to deviate to the left, descending below the glidepath. The flight had deviated about 340 m the left of the extended runway centreline when, at 19:06:11, the flight crew reported they were going around. About two seconds later the airplane contacted 5-6 m high trees, cutting a swath for about 100 meters. The airplane remained airborne for about 200 m until impacting a residential area.

According to the Magong Airport flight schedule, 55 out of 66 flights to Magong were cancelled on July 23.

Findings Related to Probable Causes

Flight Operations
1. The flight crew did not comply with the published runway 20 VOR non-precision instrument approach procedures at Magong Airport with respect to the minimum descent altitude (MDA). The captain, as the pilot flying, intentionally descended the aircraft below the published MDA of 330 feet in the instrument meteorological conditions (IMC) without obtaining the required visual references.
2. The aircraft maintained an altitude between 168 and 192 feet before and just after overflying the missed approach point (MAPt). Both pilots spent about 13 seconds attempting to visually locate the runway environment, rather than commencing a missed approach at or prior to the MAPt as required by the published procedures.
3. As the aircraft descended below the minimum descent altitude (MDA), it diverted to the left of the inbound instrument approach track and its rate of descent increased as a result of the flying pilot's control inputs and meteorological conditions. The aircraft's hazardous flight path was not detected and corrected by the crew in due time to avoid the collision with the terrain, suggesting that the crew lost situational awareness about the aircraft's position during the latter stages of the approach.
4. During the final approach, the heavy rain and associated thunderstorm activity intensified producing a maximum rainfall of 1.8 mm per minute. The runway visual range (RVR) subsequently reduced to approximately 500 meters. The degraded visibility significantly reduced the likelihood that the flight crew could have acquired the visual references to the runway environment during the approach.
5. Flight crew coordination, communication, and threat and error management were less than effective. That compromised the safety of the flight. The first officer did not comment about or challenge the fact that the captain had intentionally descended the aircraft below the published minimum descent altitude (MDA). Rather, the first officer collaborated with the captain's intentional descent below the MDA. In addition, the first officer did not detect the aircraft had deviated from the published inbound instrument approach track or identify that those factors increased the risk of a controlled flight into terrain (CFIT) event.
6. None of the flight crew recognized the need for a missed approach until the aircraft reached the point (72 feet, 0.5 nautical mile beyond the missed approach point) where collision with the terrain became unavoidable.
7. The aircraft was under the control of the flight crew when it collided with foliage 850 meters northeast of the runway 20 threshold, two seconds after the go around decision had been made. The aircraft sustained significant damage and subsequently collided with buildings in a residential area. Due to the high impact forces and post-impact fire, the crew and most passengers perished.
8. According to the flight recorders data, non-compliance with standard operating procedures (SOPs) was a repeated practice during the occurrence flight. The crew's recurring non-compliance with SOPs constituted an operating culture in which high risk practices were routine and considered normal.
9. The non-compliance with standard operating procedures (SOPs) breached the obstacle clearances of the published procedure, bypassed the safety criteria and risk controls considered in the design of the published procedures, and increased the risk of a controlled flight into terrain (CFIT) event.

Weather
10. Magong Airport was affected by the outer rainbands of Typhoon Matmo at the time of the occurrence. The meteorological conditions included thunderstorm activities of heavy rain, significant changes in visibility, and changes in wind direction and speed.

Accident investigation: