AA2009-7

AIRCRAFT ACCIDENT

INVESTIGATION REPORT

CHINA AIRLINES B 1 8 6 1 6

August 28, 2009

Japan Transport Safety Board

The investigation for this report was conducted by the Japan Transport Safety Board, JTSB, about the aircraft accident of China Airlines, Boeing 737-800 registration B18616 in accordance with the act for the Establishment of the Japan Transport Safety Board and Annex 13 to the Convention on the International Civil Aviation for the purpose of determining causes of the aircraft accident and contributing to the prevention of accidents/incidents and not for the purpose of blaming responsibility of the accident.

This English version of this report has been published and translated by the JTSB to

make its reading easier for English speaking people who are not familiar with Japanese. Although efforts are made to translate as accurately as possible, only the Japanese version is authentic. If there is any difference in the meaning of the texts between the Japanese and English versions, the text in the Japanese version prevails.

Norihiro Goto, Chairman, Japan Transport Safety Board

AIRCRAFT ACCIDENT INVESTIGATION REPORT

CHINA AIRLINES (TAIWAN) BOEING 737-800, B18616

SPOT 41 AT NAHA AIRPORT AUGUST 20, 2007, AT ABOUT 10:33 JST

August 21, 2009

Adopted by the Japan Transport Safety Board (Aircraft Subcommittee)

Chairman Norihiro Goto Member Yukio Kusuki Member Shinsuke Endo Member Noboru Toyooka Member Yuki Shuto Member Akiko Matsuo

1. PROCESS AND PROGRESS OF AIRCRAFT ACCIDENT INVESTIGATION..................1 1.1 Summary of the Accident..............................................................................................1 1.2 Outline of the Accident Investigation...........................................................................1

1.2.1 Investigation Organization .........................................................................................1 1.2.2 Representatives and Advisers from Foreign Investigation Authorities....................1 1.2.3 Implementation of the Investigation ..........................................................................1 1.2.4 Provision of Information to Civil Aviation Bureau of Japan (JCAB) ........................2 1.2.5 Interim Report.............................................................................................................2 1.2.6 Comments from Parties Relevant to the Cause of the Accident................................2 1.2.7 Comments from the Participating Investigation Authorities....................................2

2. FACTUAL INFORMATION....................................................................................................3 2.1 History of the Flight .....................................................................................................3

2.1.1 History of the Flight Based on the Records of DFDR, QAR and CVR, ATC Communication Records, Statements of Persons Involved, Video Camera Images and so on .....................................................................................................................3

2.1.2 Statements of Flight Crew Members about the History of Flight ............................7 2.1.3 Statements of Cabin Crew Members about the Accident ..........................................8 2.1.4 Statements of Ground Crew Members about the Accident .....................................10 2.1.5 Statements of Controllers about the Accident .........................................................13 2.1.6 Statements of Airport Fire Station Staff about the Accident ..................................16 2.1.7 Passenger Questionnaire on Circumstances Related to the Accident.....................18

2.2 Deaths, Injuries and Missing Persons........................................................................19 2.3 Damage to the Aircraft ...............................................................................................19

2.3.1 Extent of Damage......................................................................................................19 2.3.2 Damage to the Aircraft Components ........................................................................19

2.4 Other Damage.............................................................................................................20 2.5 Personnel Information ................................................................................................20 2.6 Aircraft Information ...................................................................................................22

2.6.1 Aircraft.......................................................................................................................22 2.6.2 Engines ......................................................................................................................22 2.6.3 Weight and Balance...................................................................................................22 2.6.4 Fuel and Lubricating Oil...........................................................................................22 2.6.5 Passenger Seats and Doors .......................................................................................23

2.7 Meteorological Information ........................................................................................23 2.8 Communication Information ......................................................................................24 2.9 Information on the Airport and Its Ground Facilities................................................26 2.10 DFDR, CVR and Other Data Recorders ...................................................................27

70

2.11 Accident Site and Wreckage Information .................................................................27 2.11.1 Accident Site Information .......................................................................................27 2.11.2 Handling of the Wreckage .......................................................................................28

2.12 Inspection of the Right Wing ....................................................................................28 2.12.1 Location of Fuel Leakage ........................................................................................28 2.12.2 Conditions of the Puncture Hole.............................................................................28 2.12.3 Conditions of the Downstop Assembly....................................................................28

2.13 Maintenance Information .........................................................................................29 2.13.1 Maintenance Work ..................................................................................................29 2.13.2 Maintenance Staff of the Company ........................................................................30 2.13.3 Maintenance Quality Control of the Company ......................................................31 2.13.4 Evaluation of the Engineering Order by ASC........................................................31

2.14 Fire Fighting Information ........................................................................................31 2.14.1 Fire-Fighting and Rescue System at Naha Airport ...............................................31 2.14.2 Performed Fire-Fighting Operations......................................................................33 2.14.3 Japanese Regulations regarding Fire-Fighting Operations..................................36 2.14.4 International Provisions regarding Fire-Fighting Operations..............................37 2.14.5 Travel Time of the Airport Fire Engines ................................................................39

2.15 Information on Search, Rescue and Evacuation related to Survival, Death and Injury ........................................................................................................................39

2.15.1 Progress of Emergency Evacuation ........................................................................39 2.15.2 Emergency Evacuation Procedures ........................................................................40

2.16 Tests and Research for Fact Finding ........................................................................42 2.16.1 Examination by the Japan Aerospace Exploration Agency ...................................42 2.16.2 Records of Video Camera Images............................................................................46

2.17 Other Relevant Information .....................................................................................46 2.17.1 Difference in Fuel Quantity between Left- and Right-Wing Tanks ......................46 2.17.2 Slat Mechanism.......................................................................................................46 2.17.3 Downstop Assembly.................................................................................................47 2.17.4 Issues with the Downstop Assembly Experienced Prior to this Accident and

Corrective Action Taken .........................................................................................47 2.17.5 Other Traffic at the Airport around the Time of the Accident...............................48 2.17.6 Interruption of CVR Operation...............................................................................48

3. ANALYSIS .............................................................................................................................50 3.1 Crew Qualifications ...................................................................................