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Without fear nor favour - Final Report is out on TransAsia ATR72-600 crash...
 Via ATW online:

Final report: TransAsia ATR 72-600 crash ‘could have been prevented’
Jun 30, 2016 Victoria Moores


Emergency workers clear debris on Feb. 5, 2015, a day after the TransAsia Airways ATR 72-600 crash in Taipei, Taiwan.
Getty Images/ChinaFotoPress

Taiwan’s Aviation Safety Council (ASC) has concluded the TransAsia Airways ATR 72-600 crash on Feb. 4, 2015 was caused by the crew shutting down the wrong Pratt & Whitney PW127 engine after a technical fault.

The ATR 72-600 was operating as flight GE235 between Taipei’s Songshan Airport and Kinmen with 58 people on board, when the crew lost control during the initial climb. The aircraft stalled and crashed into the Keelung River in Taipei, killing 43 people and injuring 15.

In its final report, released June 30, ASC said: “The accident was the result of many contributing factors which culminated in a stall-induced loss of control.”

ASC said engine 2 was automatically shut down during the initial climb, possibly triggered by an “intermittent signal discontinuity” in its auto-feather unit. The pilots did not follow company procedure and incorrectly shut down engine 1.

“The flight crew’s non-compliance with TransAsia Airways ATR 72-600 standard operating procedures—abnormal and emergency procedures for an engine flameout at takeoff—resulted in the pilot flying reducing power on and then shutting down the wrong engine,” ASC said.

The aircraft stalled, but the crew did not respond to warning signals “in a timely and effective manner,” and there was not enough time to restart the healthy engine before impact.

“Had the crew prioritized their actions to stabilize the aircraft flight path, correctly identified the propulsion system malfunction—which was the engine number 2 loss of thrust—and then had taken actions in accordance with procedure of engine number 2 flameout at takeoff, the occurrence could have been prevented,” the final report stated.

ASC also criticized the pilots for poor communication and coordination. “The pilot flying did not appropriately respond to, or integrate input from the pilot monitoring,” it said.

The final report, which follows a provisional version released in January, includes 25 findings and 16 safety recommendations, covering the auto-feather unit, human error, flight operations processes and regulatory oversight.

ASC said it has “issued a series of safety recommendations to TransAsia Airways, CAA and aircraft/engine/component manufacturers to correct the serious safety deficiencies identified during the investigation. The manufacturers of aircraft, engine and auto-feather unit have also implemented various safety actions in response to the occurrence.”
TransAsia Airways was criticized for human resources, training and crew resource management weaknesses and ASC called for a “thorough review” of the airline’s flight crew training.
ASC also said the CAA’s oversight was “in need of improvement” and that TransAsia Airways should undergo a “detailed review.”

“The systemic TransAsia Airways flight crew non-compliances with standard operating procedures identified in previous investigations, including GE222 [fatal TransAsia ATR 72-500 crash in July 2014], remained unaddressed at the time of the GE235 occurrence,” ASC said.

Now that's how an investigation should be conducted and in less than 514 days - WOW!


MTF...P2