ANC02IA011

NTSB incident investigation · Airbus Industrie A-340-300 · Anchorage, AK · January 25, 2002

Incident · No injuriesIncident investigationFinal report
Date
January 25, 2002, 02:43 local (06:43 UTC)
Place
Anchorage, AK
Injuries
252 uninjured
Damage
No damage
Phase of flight
Takeoff
Aircraft
B-18805Airbus Industrie A-340-300
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 30, 2003
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA-AAL-206, CIVIL AERONAUTICS ADMINISTRATION, TAIWAN, AVIATION SAFETY COUNCIL, TAIWAN
Safety recommendations
Yes
Case key
54077

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The captain's selection of a taxiway instead of a runway for takeoff and the flightcrew's inadequate coordination of the departure, which resulted in a departure from a taxiway. A factor in the incident was inadequate airline operator's procedures that did not require the crew to verbilize and verify the runway in use prior to takeoff.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Miscellaneous/otherTakeoff
Wrong runway - selectedPilot in commandCause
Crew/group coordination - inadequateFlightcrewCause
Procedures/directives - inadequateCompany/operator managementFactor

Analysis

During clear dark night visual meteorological conditions, the crew of an Airbus A-340-300 airplane was given a clearance to taxi to runway 32 via taxiway Romeo, and Kilo. The captain, the non-flying pilot, taxied the airplane. A relief captain occupied the center cockpit seat, and the first officer occupied the right seat. The airplane proceeded southbound on taxiway Romeo, a heading of 140 degrees, and was cleared for takeoff on runway 32 by a tower controller as the airplane was approaching taxiway Kilo. The airplane made a right turn from taxiway Romeo onto taxiway Kilo, a heading of 240 degrees, and came to a stop at the lighted hold line east of the runway 32 extension. The airplane was expected to have continued west on Kilo into the extended portion of runway 32, and then turned right (north) onto the approach end of runway 32, but the captain requested the "before takeoff checklist," and the first officer, the flying pilot, complied. Following his completion of the checklist, the captain stated, "You have control." The airplane accelerated west on taxiway Kilo. Tower controllers noticed the departure roll, and the airport's emergency phone to the fire department was activated. The local controller did not make a radio call to the crew to abort the takeoff as he felt it was too late. The airplane took off, proceeded to its destination and landed without further incident. After departure, main landing gear tire impressions were found in a snow berm at the west end of taxiway Kilo. The available taxiway distance from Romeo to the end of Kilo is about 6,800 feet. The calculated takeoff distance for the airplane was 7,746 feet. The cockpit navigation display for the Airbus A340 depicts the airplane's heading along a rotating arc near the top of the navigational display, along with a yellow airplane symbol and a white runway symbol. Taxiway Romeo and Kilo are equipped with green centerline lights having variable illumination intensity through three settings. The taxiway centerline lights for Romeo and Kilo were set on the standard (level 1) intensity level. The intersection of taxiway Kilo and Romeo has a yellow centerline stripe in the radius of the turn from Romeo to Kilo, but no centerline lights along the radius of the turn. The intersection of Kilo and the extended portion of runway 32 have a yellow centerline stripe in the radius of the turn from Kilo onto the extended centerline of runway 32, but no centerline lights along the radius of the turn. The centerline lights of Kilo did not extend through the extended portion of runway 32. Some reflective material of each taxiway centerline marking was indistinct, missing, or obscured by small patches of ice. The incident flight was the captain's first trip from Anchorage. It was the first time he flew with the first officer, and he had flown with the reserve captain on numerous occasions. The operator's aircraft operating manual for the Airbus fleet did not contain a checklist requirement for the crew to verbalize and verify the runway in use before takeoff.

Factual narrative

History of flight

On January 25, 2002, at 0243 Alaska standard time, an Airbus Industrie A-340-300 airplane, Taiwanese registration B-18805, was cleared for takeoff on runway 32 from the Ted Stevens Anchorage International Airport, Anchorage, Alaska. The airplane, call sign Dynasty 011, subsequently departed from a taxiway. The airplane was being operated as an instrument flight rules (IFR) scheduled international passenger flight under Title 14, CFR Part 129, when the incident occurred. The airplane was operated as Flight 011, by China Airlines, Taiwan. The 3 cockpit crew members, 12 cabin crew members, and 237 passengers, were not injured. The airplane was not damaged. Dark night visual meteorological conditions prevailed. An IFR flight plan was filed from Anchorage to the Chiang Kai-Shek International Airport, Taipei, Taiwan.

The incident airplane was parked at the Anchorage International Airport's north terminal, gate N4. At 0221, the first officer of Dynasty 011 contacted Anchorage Air Traffic Control Tower (ATCT) clearance delivery and stated: "Dynasty 011 heavy, clearance, flight level 320 to Taipei, information Juliet, Bay N4." The clearance delivery controller stated: "Dynasty 011 Heavy, cleared to the Taipei Airport via Anchorage Three Departure, then as filed. Climb and maintain flight level 200, departure frequency will be 118.6, squawk 4032."

At 0224, the first officer contacted ground control, advising the controller that they were ready for their push-back from gate N4. The ground controller responded by stating: "Dynasty 011 heavy, Anchorage ground, good morning sir, push back is approved, plan runway 32 for departure." The first officer acknowledged the clearance by stating: "…runway 32, Dynasty 011."

At 0232, the first officer of Dynasty 011 contacted the Anchorage ATCT local controller, advising that they were ready for taxi. The local controller responded by stating: "Dynasty 011 heavy, taxi runway 32 at Kilo, taxi via Mike, Romeo, Kilo." The incident airplane then began to taxi away from the N4 gate, turning south on taxiway Romeo. The airplane proceeded southbound on taxiway Romeo, and made a right turn from Romeo onto taxiway Kilo.

The incident airplane was cleared for takeoff on runway 32 by the ATCT local controller at 0240:06, as the airplane was southbound on taxiway Romeo, preparing to turn right onto taxiway Kilo. The controller stated: "Dynasty 011 heavy, wind 360 at seven, runway 32 at Kilo, cleared for takeoff." The first officer responded by stating: "Cleared for takeoff, 32, Kilo, Dynasty 011 heavy."

A review of the airplane's flight data recorder (FDR) information provided by the Aviation Safety Council of Taiwan (ASC), disclosed that at 0240:06, the airplane was taxiing at 8 knots on a 141 degree heading. The FDR data indicated that at 0241, the airplane began a right turn to a heading of 244 degrees, and came to a stop at 0241:58. The airplane stopped on taxiway Kilo at the hold line, east of the extended portion of runway 32. The airplane was expected by the ATCT local controller to continue west on Kilo into the extended portion of runway 32, and then turn right (north) onto the approach end of runway 32. Instead, at 0242:10, the airplane began accelerating west on taxiway Kilo.

The departure roll was noticed by the ATCT local controller at 0242:45, when he stated to the north radar approach controller: "No, he's goin on the wrong..." The north radar controller, who noticed the departure on his radar screen, and the airport surface detection equipment (ASDE), replied: "He's on a taxiway." A radio call to the crew to abort the takeoff was not made by either controller, but the airport's emergency phone to the fire department was activated.

After lift-off at 0243, the airplane crew stated: "Tower, Dynasty 011 heavy airborne." The local controller replied: "Dynasty 011 heavy roger, fly heading 240." The crew acknowledged the magnetic heading assignment.

The ATCT controller cancelled the airport fire department's response, but contacted Anchorage Airport operations personnel (Airport 10) who examined taxiway Kilo for any evidence of airplane damage. None was found. Main landing gear tire impressions were found in a snow berm at the west end of taxiway Kilo. The available taxiway distance from Romeo to the end of Kilo is about 6,800 feet.

The airplane proceeded to Taipei and landed without incident.

Personnel information

The Government of Taiwan's Aviation Safety Council of Taiwan (ASC), and Taiwan's Civil Aeronautics Administration (CAA), were notified of the incident. ASC and CAA investigators interviewed the flight crew in Taiwan. During the interview, the airplane crewmembers stated that the captain conducted the taxi from the north terminal to taxiway Kilo. All three crew members utilized an airport configuration diagram of the Anchorage International Airport published by Jeppesen Sanderson Inc., as a guide as they taxied for takeoff.

Crew Information

The captain (crew member 1, CM-1) held an airline transport pilot certificate issued by Taiwan. He occupied the left seat. The incident flight was the captain's first trip from Anchorage. It was the first time he flew with the first officer. He had flown with the reserve captain on numerous occasions.

The captain's training at China Airlines, for operations into Anchorage, was received during A-340 simulator training July 27 to 31, 2001.

During an interview in Taiwan with a representative from the ASC, the captain reported that he taxied the airplane, and was the non-flying pilot for this flight. The captain reported that as the airplane was turning onto taxiway Kilo, he noticed bright centerline lights and blue edge lights. He then requested the "before takeoff checklist." The captain did not see any runway threshold markings, or a runway number, but he did not think it was unusual since he believed the threshold for runway 32 was further ahead. The captain reported that the centerline lights were very bright, and he believed that it indicated an active runway. He said that he did not check the heading indicator. The captain recalled seeing an airport runway sign with "K." Other information on the sign was not recalled. The captain noted that his navigational display was set on the 10 nautical mile range in the arc mode.

The first officer (crew member 2, CM-2) held an airline transport pilot certificate issued by Taiwan. He occupied the right seat. The incident flight was the first officer's third trip from Anchorage.

His training at China Airlines, for operations into Anchorage, was received during A-340 simulator training October 13 to 17, 2001, and during an airport route briefing on October 31, 2001.

The first officer was the flying pilot for this segment of the flight. During an interview in Taiwan with the ASC representative, the first officer said that as the airplane was turning from taxiway Romeo, onto taxiway Kilo, he was performing the "before takeoff" checklist. Following his completion of the checklist, the captain stated, "You have control." The first officer estimated the time between the completion of the checklist, and his taking control, was about 3 to 4 seconds. He noted that the airplane was aligned with bright centerline lights that started some distance from the airplane. He did not recall seeing edge lights. He said he thought the airplane only turned about 100 degrees (Romeo to Kilo), but when he saw the bright centerline lights, he believed he was on runway 32. The first officer then initiated the takeoff. He said he did not check the heading indicator. His navigational display was set on the 10 nautical mile range in the arc mode.

The reserve captain, (crew member 3, CM-3) held an airline transport pilot certificate issued by Taiwan, and was a China Airlines check airman. He occupied the cockpit jump seat, c

Aircraft

Registration
B-18805
Reported as
Airbus Industrie A-340-300
Category
Airplane
Serial number
415
Airframe hours
2,321
Engine
General Electric CFM56-5C4, 34,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 129
Operator
China Airlines Ltd.
Registered owner
Golden Dragon Limited
Airworthiness certificate
Standard, Transport
Departed
PANC · Anchorage, AK
Destination
RCTP · Taipei
Flight plan
IFR
Airport
PANC · Anchorage International

Flight crew · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
January 20, 2002
Seat
Left
Flight hours
13,635 total · 419 in this make and model
Role
Co-pilot
Age
35
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
October 2, 2001
Seat
Right
Flight hours
2,193 total · 210 in this make and model
Role
Other flight crew
Age
54
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
October 9, 2001
Seat
Center
Flight hours
14,173 total · 558 in this make and model

Weather

Conditions
Visual (VMC) · Night/dark
Wind
7° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
3 °F, dew point -13 °F
Altimeter
29.90 inHg
Observed at
PANC

Docket · 33

The files NTSB released with the investigation on April 24, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.6 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 324 KBATC 3 - Factual Report of Group ChairmanItem 2 · .PDF · 158 KBATC 3 - Attachment 1 - ATC TranscriptsItem 3 · .PDF · 426 KBCrew Statements from Aviation Safety Council (Government of Taiwan)Item 4 · .PDF · 77 KBAirport DiagramsItem 5 · .PDF · 279 KBAirplane ground path from Aviation Safety Council. (Government of Taiwan)Item 6 · .PDF · 516 KBRadar and FDR data logItem 7 · .CSV · 216 KBVideo Documentation of Aircraft TaxiItem 8 · .PDF · 62 KBWeather ReportsItem 9 · .PDF · 66 KBFAA Personnel StatementsItem 10 · .PDF · 140 KBTaxiway Lighting DiagramItem 11 · .PDF · 33 KBPANC Airfield Inspection ReportItem 12 · .PDF · 280 KBPANC Airport Police ReportItem 13 · .PDF · 110 KBExcerpt of China Airlines FDRItem 14 · .PDF · 269 KBA-340 ChecklistItem 15 · .PDF · 84 KBChina Airlines ProceduresItem 16 · .PDF · 94 KBChina Airlines B747-200 proceduresItem 17 · .PDF · 43 KBChina Airlines Crew NotamItem 18 · .PDF · 63 KBAirport Lighting & Marking StandardsItem 19 · .PDF · 263 KBStatement of Party Representatives to NTSB InvestigationItem 20 · .PDF · 302 KBPhoto 1. View of taxiway Romeo looking north from taxiway Kilo. (ASC photo, no neg.)Item 21 · .PDF · 100 KBPhoto 2. View of in-ground centerline lighting fixture on taxiway Romeo. (ASC photo, no neg.)Item 22 · .PDF · 236 KBPhoto 3. View of in-ground centerline lighting fixture on taxiway Kilo. (ASC photo, no negative)Item 23 · .PDF · 205 KBPhoto 4. View of taxiway Kilo hold-short line, looking west, at runway 32. (ASC photo, no negative)Item 24 · .PDF · 103 KBPhoto 5. View looking west, toward the west end of taxiway Kilo. (Anchorage Airport Police, no negative)Item 25 · .PDF · 107 KBPhoto 6. View of small snow berm at west end of taxiway Kilo with right main landing gear tire impressions in the berm. (Anchorage Airport Police photo, no negative)Item 26 · .PDF · 134 KBPhoto 7. Closer view of right main landing gear tire impressions in snow berm. (Anchorage Airport Police photo, no negative)Item 27 · .PDF · 150 KBPhoto 8. Close-up view of right main landing gear tire impressions in snow berm. (Anchorage Airport Police photo, no negative)Item 28 · .PDF · 164 KBPhoto 9. Left main landing gear tire impressions approaching west end of taxiway Kilo; long view. (Anchorage Airport Police, no neg.)Item 29 · .PDF · 170 KBPhoto 10. Left main landing gear tire impressions approaching west end of taxiway Kilo, and into the snow berm. (Anchorage Airport Police, no neg.). (Anchorage Airport Police photo, no negative)Item 30 · .PDF · 163 KBPhoto 11. Left main landing gear tire impressions approaching west end of taxiway Kilo. Note: no damage to taxiway edge lighting fixture located between the two tire impressions. (APP, noneg.)Item 31 · .PDF · 184 KBPhoto 12. Left main landing gear tire impressions approaching west end of taxiway Kilo. (Anchorage Airport Police, no neg.)Item 32 · .PDF · 166 KBAirport Group Factual Report from Aviation Safety Council (Government of Taiwan)Item 33 · .PDF · 5.9 MB