国航129事故,即国航415空难的调查官方结果报告(英文原文)

By crystalsn at 251.2天前 • 4031点击 • 1收藏

国航129事故,即国航415空难的调查官方结果

韩国调查结论如下

KAIB
AIRCRAFT ACCIDENT REPORT
C CO ONT TR RO OL LLED FLIIIGHT IIINTO TERRAIIIN
AIR CHINA INTERNATIONAL FLIGHT 129
B767-200ER, B2552
MOUNTAIN DOTDAE, GIMHAE
APRIL 15, 2002

Findings Related to Probable Causes
1. The flight crew of flight 129 performed the circling approach, not being aware of the
weather minima of wide-body aircraft (B767-200) for landing, and in the approach
briefing, did not include the missed approach, etc., among the items specified in Air
China’s operations and training manuals.
2. The flight crew exercised poor crew resource management and lost situational
awareness during the circling approach to runway 18R, which led them to fly outside
of the circling approach area, delaying the base turn, contrary to the captain’s
intention to make a timely base turn.
3. The flight crew did not execute a missed approach when they lost sight of the runway
during the circling approach to runway 18R, which led them to strike high terrain
(mountain) near the airport.
4. When the first officer advised the captain to execute a missed approach about 5
seconds before impact, the captain did not react, nor did the first officer initiate the
missed approach himself.
3.2 Findings Related to Risk
1. The flight crew’s training for the circling approach was conducted with the simulator
only for Beijing airport, and they had never been trained for the circling approach to
Gimhae airport’s runway 18R.
2. The crew resource management (CRM) training of Air China was insufficient for the
three flight crew complement.
3. Air China did not perform the improving action for Service Bulletin (SB)
767-34-0067(May 31, 1989), which was issued by the Boeing Company for the
reinforcement of the GPWS functions.
4. Air China provided one set of Jeppesen manuals to the flight crew, which the captain
was using during the instrument approach, making it difficult for the other flight
crewmembers to crosscheck the information in the manuals.
5. Instrument approach chart used by the flight crew of flight 129 did not depict the
high terrain north of the airport.
Conclusions Aircraft 140 Accident Report
6. During the circling approach, the flight crew of flight 129 did not use standard
callouts defined by Air China.
7. Flight 129 was flown between 150 and 160 kt on the downwind leg, which exceeded
the maximum speed of 140 kt of Gimhae airport’s circling approach category “C,”
and the width of the downwind leg was narrower than normal, for which corrective
actions were inappropriate.
8. The second officer, tasked with handling radio communications, did not reply
correctly to controllers’instructions a number of times, however, the captain and
first officer did not correct the second officer’s inappropriate replies.
9. When the tower controllers lost visual contact with the flight 129 aircraft on the
downwind and base legs, they tried to find the flight 129 aircraft visually, however,
they did not use the tower BRITE, which is an aid to complement visual
observations.
10. The flight crew did not reply appropriately to the local controller’s question when
the controller asked them the possibility of landing, because the local controller did
not have the flight 129 aircraft in sight after issuing the landing clearance.

18 回复 | 直到 240.5天前

11. The approach controller felt that the flight 129 aircraft was flying on a longer pattern
than normal, so he asked the local controllers via intercom, “Does it seem go
around?”however, the local controllers stated that they did not hear this question.
12. The local controller asked a question to the flight crew to confirm the position of the
aircraft, however, the local controller did not issue any direct warning or advice
based on his own subjective awareness of the situation.
13. “The Korean Standard Air Traffic Control Procedures”and “Gimhae Base Local
Procedures”did not specify radar monitoring of the aircraft on a circling approach
by means of the BRITE and MSAW systems.
14. The MSAW system installed in Gimhae tower at the time of the accident was
designed only with the function of visual warning, which was not consistent with
the ICAO recommendation to include an aural warning also. Thus, the low altitude
(LA) warning would not have been noticed in a timely manner, unless the
controller monitored the BRITE closely.
Conclusions Aircraft 141 Accident Report
15. The MSAW activation area was programmed in the vicinity north of the circling
approach area of Gimhae airport, which was set to be higher than the altitude of the
circling approach pattern, and the MSAW would be activated in the case of a
normal base turn in close proximity to the MSAW activation area within the
circling approach area due to its predictive warning function.
16. When the aircraft disappeared from radar, and radio communication was lost
between the tower and the aircraft, the tower controllers did not notify the search
and rescue department in a timely manner.
17. The measuring equipment of runway visual range (RVR) of Gimhae airport runway
(18R/36L) had been out of order for a considerable time period, thus it had not been
operated appropriately for the purpose of category II runway-use.

crystalsn at 251.2天前
1

3.3 Other Findings
1. The flight crew and flight attendants received training in accordance with the CAAC
and Air China regulations and procedures, and they were certified and qualified for
this flight.
2. The flight crew took an adequate rest before the flight.
3. There was no evidence of any medical problems that would have affected the flight
crew’s performance.
4. Toxicological test results of the captain were negative for alcohol and drugs.
5. Autopsies performed on the victims of the accident revealed severe burn injuries,
however, it could not be determined with a certainty whether the causes of death
were from the impact trauma, fire, or a combination of both.
6. Airworthiness certificate of the flight 129 aircraft was valid, and its weight and
balance were within the specified limits.
Conclusions Aircraft 142 Accident Report
7. In the preflight aircraft maintenance inspection prior to departure from Beijing
airport, no defects were found in the fuselage of the aircraft, or its systems and
engines. During flight, the crew did not report any malfunction, and the examination
of the aircraft wreckage did not show any possible malfunction.
8. The GPWS installed on the flight 129 aircraft operated as designed, and it did not
generate any warning before the ground impact, because the aircraft was configured
for landing, and the terrain closure rate was insufficient to trigger the Mode 2
warning.
9. The controllers handling flight 129 were properly qualified to perform their duties.
10. The weather forecast and ATIS broadcasts available to the flight crew were accurate
and up to date.

crystalsn at 251.2天前
2

11. The south wind was strong and there were low clouds and precipitation near Gimhae
airport at the time of the accident, and the mountainous area in the north was covered
with cloud and fog.
12. There were no international requirements that the aircraft’s approach category (ies)
and/or weather minima for a circling approach should be informed officially to the
air traffic control authority.
13. The pilot should determine the official or existing weather adequate for approach or
landing based on the approach category and landing minima, and the controller
should take actions such as issuing appropriate instructions to the aircraft to hold or
proceed to another airport when reported by the pilot that the weather conditions are
below the landing minima of the aircraft.
14. In accordance with Airforce regulations, it was a normal procedure for the approach
controller to ask and confirm with flight 129 about its approach category in order to
determine whether to issue the approach clearance, considering the weather
conditions at that time.
15. When the approach controller issued flight 129 a control transfer instruction to the
tower for the first time, the flight did not change to the tower frequency accordingly,
of which the reason could not be confirmed. And 1 minute and 8 seconds after
issuing the first control transfer instruction, the delayed initial contact with the tower
was established upon receiving the second control transfer instruction, however, the
landing clearance to flight 129 was issued by the tower controller at the usual
position.
Conclusions Aircraft 143 Accident Report

crystalsn at 251.2天前
3

16. The local controller had flight 129 in sight briefly at the point passing nearly mid
point on the downwind leg, and at the time of issuing the landing clearance, the flight
disappeared from his sight. Thus, the local controller issued the landing clearance to
the flight including the term, “Not in sight.”
17. The local controller could not be precisely aware that the aircraft was dangerously
approaching mountainous terrain, as he lost visual contact with flight 129 from the
time of landing clearance issuance until crash on the base turn, due to poor visibility.

18. All of the Korean, ICAO, and FAA procedures for the use of BRITE or Surveillance
Radar describe that the local controller may use the BRITE optionally, as an aid
augmenting “visual observation”function.
19. Circling approach is visual maneuvering, which the pilot has to confirm ground
obstacles visually in the circling approach pattern, and is an extension of an
instrument approach procedure which provides for visual circling of the aerodrome
prior to landing.
20. The circling approach area and terrain in the vicinitywere not depicted on the Gimhae
radar video map. So the tower controller was in a poor environment to accurately
identify the situation that an aircraft was flying outside the circling approach area
and approaching dangerous obstacles, so he could issue a warning or advice by
monitoring the BRITE.

crystalsn at 251.2天前
4

21. The use of the certified BRITE was described in the Korean Standard Air Traffic
Control Procedures. The certification standard of the BRITE installed in the tower at
the time of the accident was not specifically described, however, the tower BRITE
could be used as the technically certified BRITE, since it was certified for the
completion of installation in accordance with the specifications and design drawing
of the ordering authority (Seoul Regional Aviation Bureau), and was regularly
maintained and inspected by qualified technicians.
22. The differences between the ICAO and Korean criteria for the flight procedure
establishment of Gimhae airport were not described in the ROK AIP effective at the
time of the accident.
23. The flight information material used by the flight crew of flight 129 was Jeppesen
manual, and it was described in the manual that the circling approach procedure of
Gimhae airport was established in accordance with the FAA criteria.
24. The procedure for the circling approach to runway 18R at Gimhae airport was a
general circling approach procedure, without the prescribed circling approach track
established using the ground visual references, which could cause difficulties in
conducting a circling approach flight in poor visibility.
Conclusions Aircraft 144 Accident Report
25. Gimhae airport has the instrument approach procedure only to runway 36, thus in the
case of runway 18 in use, it requires more time to separate aircraft approaching
runway 36 before making a circling approach to runway 18 from the aircraft
departing from runway 18.

crystalsn at 251.2天前
5

26. The visual weather observation site at Gimhae airport did not deviate from the
establishment requirements of a weather observation site, but as its northern airspace
was partially obscured, the weather observer had to move to the observation site
located in the ramp to observe the weather, which could be considerably
inconvenient.
27. At Gimhae tower operated by the Airforce, a Korea MOCT civil air traffic control
coordinator was assigned to be on duty in accordance with a related mutual consent,
however, the civil controller was not positioned in the tower at the time of the
accident. And due to the system of non-authorization of relevant ratings for the
substantial air traffic control services, the civil controller was not able to
appropriately carry out the supervision of the regulatory compliance of civil aircraft
pilots, and coordination with the civil aviation related organizations, which were
described in the mutual consent.
28. The clock installed in the recording equipment of the automatic on-off lighting
system of Gimhae airport had been running fast by 19 minutes, which no one was
aware until the accident investigation.
29. Air China had not designated Gimhae airport as a “special airport,”which would have
required the additional preflight training and procedures for the flight crew.
30. The Korea MOCT designated Gimhae airport as a special airport in Flight Safety
Regulations, however, it did not include the detailed information in consideration of
the characteristics and requirements of the airport, and the required pilot
qualification for this information.
31. All the in-flight public announcements of flight 129 were conducted only in English
and Chinese, not in Korean for many Korean-speaking passengers, who could not
understand the meaning of those announcements clearly.
32. A local resident called 119 immediately after the accident, so the rescue guard could
be dispatched expeditiously.
33. Because of no regulation specified for assisting accident victims and their families of
aircraft operating to Korea, there were difficulties with assisting the victims and their
families.

crystalsn at 251.2天前
6

中国民航局并不认同韩方的调查结果

纷争如下:

3.4 Consultation of Draft Final Report
In accordance with Annex 13, Paragraph 6.3, the KAIB forwarded copies of the
Draft Final Report to China (State of Registry and Operator) and the United States (State
of Design and Manufacture) inviting their significant and substantiated comments on
June 8, 2004. The KAIB accepted all of the comments204 returned by the United States
(NTSB) on August 8, and made appropriate revisions to the Draft Final Report.
The KAIB received comments from China (CAAC Aviation Safety Committee) on
August 5, 2004, but the KAIB could not accept all of the comments returned by China.
Therefore, the KAIB and CAAC held a technical meeting to discuss the differences from
August 26 to 30, 2004. Following the meeting, the KAIB made several changes to the
report. A second Draft Final Report was then forwarded to China (CAAC Aviation Safety
Committee) for additional consultation in a technical meeting held from November 1 to 4,
2004.
China (CAAC Aviation Safety Committee) could not fully accept the KAIB’s
second Draft Final Report, therefore, a second response was forwarded to the KAIB on
December 19, 2004. The KAIB held a third technical meeting from February 17 to18,
2005, and a fourth technical meeting from March 31 to April 1, 2005, on the second
comments returned by China (CAAC Aviation Safety Committee). However, the KAIB
and CAAC still could not reach agreement on certain parts of the factual information,
analysis, and conclusions.
In spite of several technical meetings held by the KAIB of the State responsible for
the conduct of the flight 129 accident investigation, the KAIB was not able to accept all
of the comments returned by China (CAAC Aviation Safety Committee). Therefore, in
accordance with Annex 13, Paragraph 6.3, the comments from China (CAAC Aviation
Safety Committee) are included in Appendix 6 to this report.

crystalsn at 251.2天前
7

中方调查结果结论如下:

Comments on KAIB Aircraft Accident Report (Draft)
Aviation Safety Committee of CAAC

CONCLUSION
3.1 Findings of the Investigation
1. The flight crewmembers and flight attendants had received training. They were certified and qualified for this flight.
2. The aircraft was certified airworthy; weight and balance were within the specified limits.
3. In the final preflight maintenance inspection prior departure at Beijing Capital International Airport, any defects were not found in the fuselage of the aircraft as well as its systems and engines. During flight, the crew didn\'t report any malfunctions, and the examination of the aircraft wreckage did not show any possible malfunctions.
4. The south wind was strong at Gimhae airport when the accident occurred. There was low clouds and precipitation. The mountainous area in the north was shaded by cloud and fog. The circling approach was difficult under such weather condition.
5. The air traffic of Gimhae Airport was controlled by Air Force. It was appropriate in accordance with the related regulations and procedures of Korea for the Air Force controller to provide services to civil aircraft.
6. When the tower controllers lost the visual contact of CA129, they failed to use radar to determine the location of aircraft, and when low altitude warning displayed, they did not issue a safety alert.
7. When the approach controller found that the downwind leg of CA129 was longer than the normal and MSAW warning, he reminded the tower controllers, but no response received. The approach controller failed to take further measures to alert the flight crew.
8. The functions of Minimum Safe Altitude warning system (MSAW) at Gimhae airport did not conform to the relevant prescription of ICAO, for it was not equipped with aural alert.
9. Transfer instruction issued by the approach controller was hard to recognize, resulting in the short interruption in ATC process.
10. On the control radar display, the boundaries of the protected area of circling approach for all categories of aircraft were not depicted, and the marks of obstacles in the mountainous north of the airport were not complete.

crystalsn at 251.2天前
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11. In the Jeppesen approach chart used by CA129 flight crew, the position relationship between the runway and the key obstacles relating the site of the accident was wrongly marked.
22
12. The flight crew’s training in circling approach was conducted in the simulator, but they had never conducted the training of circling approach to Gimhae Airport\\\'s runway 18R.
13. Air China provided an insufficient Crew Resource Management (CRM) training for the three-pilot crew.
14. The flight crew participated in classes of various legal regulations according to Air China\\\'s operational requirements, but during this flight they performed its circling approaching in violation of the circling minimum of wide-body aircraft.
15. When the crew performed circling approach to enter the downwind leg, the width was narrower than normal, and no corrections were made.
16. It cannot be confirmed that the circling guidance lights was turned on when the aircraft was approaching.
17. The contents of Automatic Terminal Information Service manually recorded at Gimhae airport was hard to comprehend, and the controller did not use VHF to inform the crew of the important information that the weather conditions were below the minima of circling approach for Category “D”.
18. The ground proximity warning system (GPWS) installed at the aircraft, due to the fact that the terrain warning was inhibited when aircraft had been in landing configuration, , did not generate any warning just before the ground impact.
19. As of April 15th, 2002, there was no recording of any difference from ICAO Standard on aircraft category in ROK AIP.
20. The visual field of meteorological observation site of Gimhae Airport did not meet the appropriate requirements of 《Guide to practices for meteorological offices serving aviation》of World Meteorological Organization.
21. When the aircraft disappeared from radar and radio contact of the aircraft with tower was lost, the tower didn\\\'t notify search and rescue department in time, while local residents called 119 about the case.
22. The Korean Civil Aviation Authority did not inform the CAAC and Air China of listing the Gimhae airport as a “special airport”.

crystalsn at 251.2天前
9

中方的几条基本是
中方确认自己飞行员机组的人员训练和资质合格,飞机配载合格
飞机失联后韩方机场并未使用雷达搜索
韩方雷达给机型归类有问题
天气不好等情况韩方塔台并未通知飞机
等等

最后,算是个双结论报告吧!

影片中并未说明上述内容,仅作为但结论拍片

毕竟是第一次拍涉及中国的记录,看片的还是有必要补充一下具体细节的。

有兴趣的可以直接看 8-9楼
也希望有人能翻译 ,让更多人知道影片中未涉及的内容。

crystalsn at 251.2天前
10

关于空管问题简单说几句:

韩方报告承认塔台没有在飞机失去视线接触后继续使用雷达辅助设施监测飞机动向,导致没有及时向飞机发出警告。
韩方同时承认当地空管系统没有依据ICAO建议,监测到飞机进入近地警告状态时发出声音提示,只有屏幕上的视觉提示,最终相关空管没有把这一警告信息告知机组。
韩方报告表示事发时塔台和近进控制的职守人员均为军方人员,有空管执照,但没有韩国建设运输部发出的空管认证。根据韩方法律规定,这些军方人员有资质进行民航空管工作。但是,根据韩国地方和军方的合作规定,地方飞管局也应当有一名空管些协调员在场进行监管和协调,然而这位地方空管在事发时并不在塔台,事发后七分钟才回到塔台,其人辩称自己当时去别处填写文件去了。

以上这几点不知是否在中方提出修改意见后才承认的,但至少是承认了。不过韩方报告中是把这些问题归类在「风险因素」和「其他发现」中,没有归类于「可能的事发原因」,显然有淡化责任之嫌,这大概就是中韩调查组最终分歧所在。中方并没有否认机组在事故中的主要责任,并没有说要把所有锅都推给韩国空管,我个人在看完这些材料后也认为机组的主责是推脱不得的,但是中方应该是觉得韩方报告过度淡化空管问题了。

回到这个记录片的问题,弹幕、留言中很多人说由于CAAC或擦航不透明不配合,所以节目绝口不提空管一方的问题就是你国活该。然而这种逻辑是错误的,因为即使在韩方的报告中也是不得不承认空管存在相关「风险因素」的,而且韩方报告的附录也是明确记录了中方意见的,因此「节目组拿不到空管问题的相关信息」这个借口是完全不成立的。有几个环节如果空管能做的更好些,是完全有可能避免事故的,所以这些因素并不是无关紧要的,节目对此不作任何提及,不得不说是有所偏颇的。

至于这种偏颇是出于政治原因,还是因为中方不配合而反感,还是因为别的什么,我就不作无谓的动机猜测了。只希望大家能更客观地认识到事件的全貌,不要被节目片面带歪就好。

beachletter at 251.1天前
11

@beachletter 个人觉得节目组ATC的事只字不提是不严谨的,但看了这么多集ACI,发现节目组可能是时间有限,特别会抓主要矛盾:如全美1549里A320后舱结构问题,还有那个DICH按钮只字未提,再比如圣安185的法庭证据。所以,“风险因素”只字未提是不正确的,但是可以理解的

拥风入怀 at 250.9天前
12

还有英仑92的发动机

拥风入怀 at 250.9天前
13

所以现在看好ACI后再要去看原文报告

babysergio32 at 250.3天前
14

我覺得看ACI看這麼多年應該就很清楚空難發生一定是一連串事情造成的
CA129這事情ACI想要強調的事情順序在於
1. 沒有approach briefing 所以大家不清楚approach procedure
2. lost visual contact 沒有馬上 go around (不管從CAAC還是ICAO的角度來看都是違規)
3. 沒有按照approach procedure (這點就強調了 briefing 的重要性) 而且飛到自己在哪裡都不知道 ?

但是你說韓國那邊的ATC怎樣怎樣的
有一點很重要的是 circling approach都已經歸類在Visual flight maneuver 裡面了
這代表ATC只提供"advisory"
所以按照這些理由 韓國的ATC本來就不構成問題
怪ATC的理由就像是自己走路不看路摔下山谷然後抱怨沒有人提醒你 ?
(另外有點不確定的事情是 是不是個個航空公司circling approach的程序都一樣 如果不一樣的話請問ATC要怎麼記牢全世界各航空公司approach的procedure ..... 而且根據ACI影片的內容看起來是每個航空公司有自己的approach procedure 但是這點有待專家確認)

天氣不好然後塔臺未告知 那請問ATIS的目的是甚麼
而且如果真的是天氣的問題 那不是更應該misapproach ?
加上當天也有不少飛機執行一樣的approach 然後 misapproach
其他飛機按照規定都沒問題就只有CA129有問題 ?

我個人倒是認為報告書裡面只說風險因素本來就是合理的
我倒不覺得這跟政治相關

kevin5345179 at 249.3天前
15

cfit,无论何种空管和机场,飞行员都要背主要责任

ninteo at 247.9天前
16

@kevin5345179 我觉得你总结的很有道理

fricked at 245.9天前
17

@kevin5345179
很有道理,事实上这片子并非单方面略去韩方管理的问题,对于中方一些令人诟病的地方也同样略去了,比如原定飞这趟的机长因为酒醉彻夜不归,临时换了个超负荷飞行还不熟悉釜山机场状况的机长(只飞过釜山两次,又缺乏类似环境的降落经验),事发后国航传真给韩国方面的机长资料都不是机长本人的,比如机长英文不过关,重复的指令和空管说的不一样,不回答空管的指令有可能是分心的情况就没听懂空管在说什么(而非片子推测的顾不上回答)……略去这些是因为事故主要责任非常清楚,所以片方没有纠结那些和事故没有直接关系的状况,并非只对韩方如此。

longchengfeidu at 240.5天前
18
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