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China Airlines Flight CI611 Aviation Occurrence Report Release Press

Conference

China Airlines Flight CI611 Aviation China Airlines Flight CI611 Aviation Occurrence Report ReleaseOccurrence Report Release Press Press

ConferenceConference

2005/02/252005/02/25

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Background Information of the Background Information of the OccurrenceOccurrence

On May 25 2002, China Airlines Flight CI611, a Boeing 747On May 25 2002, China Airlines Flight CI611, a Boeing 747--200 , 200 , bearing ROC registration number Bbearing ROC registration number B--18255, crashed into the 18255, crashed into the Taiwan Strait approximately 23 nautical miles northeast of Taiwan Strait approximately 23 nautical miles northeast of MakungMakung, , PenghuPenghu Islands at 1529 Taipei local time (Coordinated Islands at 1529 Taipei local time (Coordinated Universal Time, UTC 0729). Universal Time, UTC 0729).

The aircraft was a scheduled passenger flight from CKS The aircraft was a scheduled passenger flight from CKS International Airport, Taipei, ROC to International Airport, Taipei, ROC to ChekChek Lap Lap KokKok International International Airport, Hong Kong, China. Airport, Hong Kong, China.

Radar data indicated that the aircraft experienced an inRadar data indicated that the aircraft experienced an in--flight flight breakup at an altitude of 34,900 feet.breakup at an altitude of 34,900 feet.

225 occupants on board the CI611 flight, which included 206 225 occupants on board the CI611 flight, which included 206 passengers and 19 crewmembers, sustained fatal injuries.passengers and 19 crewmembers, sustained fatal injuries.

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Animation - Ballistic Trajectory Analysis

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CI611 Occurrence InvestigationCI611 Occurrence Investigation

According to Aviation Occurrence Investigation Act, Article 3, According to Aviation Occurrence Investigation Act, Article 3, Aviation Safety Council (ASC), an independent government Aviation Safety Council (ASC), an independent government agency, is responsible for investigating civil aircraft occurrenagency, is responsible for investigating civil aircraft occurrence ce within the territory of ROC.within the territory of ROC.Parties invited to the investigation team include:Parties invited to the investigation team include:

National Transportation Safety Board (NTSB), USA National Transportation Safety Board (NTSB), USA ––Accredited Representative (AR)Accredited Representative (AR)

Federal Aviation Administration (FAA), USAFederal Aviation Administration (FAA), USABoeing Airplane CompanyBoeing Airplane CompanyPratt & Whitney CompanyPratt & Whitney Company

Civil Aeronautics Administration (CAA), ROCCivil Aeronautics Administration (CAA), ROCChina AirlinesChina Airlines

Totally Totally 68 68 people involved in this investigationpeople involved in this investigation

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Objective of Aviation Occurrence Objective of Aviation Occurrence InvestigationInvestigation

Aviation Occurrence Investigation Law - Article 5

The objective of investigation of aviation occurrence is to prevent recurrence of similar occurrences. It is not the purpose of such investigation to apportion blame or liability.

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Organization ChartOrganization Chart

IIC Kay Yong / Thomas Wang

Deputy IIC / KF Chou Deputy IIC / Phil Tai

Survival Factors Group Chairman / James Fang

Recorders Group Chairman / Steven Su

Maintenance Log Group Chairman / James Fang

Org. & Management Group Chairman /

Thomas Wang

System Group Chairman / Wen-Huan

Chang

Performance Group Chairman / Michael

Guan

Structure Group Chairman / David Lee

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CI611 Wreckage RecoveryCI611 Wreckage Recovery

Wreckage RecoveryWreckage RecoveryPhase IPhase I（（20022002 05/25 05/25 -- 06/1006/10））

Floating debris and body recovery, the search for the recordersFloating debris and body recovery, the search for the recorders’’ ULB ULB signal, and mapping of the wreckage spread.signal, and mapping of the wreckage spread.

Phase IIPhase II （（20022002 06/02 06/02 -- 07/0307/03））

Wreckage recovery by AsiaWreckage recovery by Asia--Pacific Inc..Pacific Inc..

Phase IIIPhase III （（20022002 06/14 06/14 -- 09/1609/16））

Jan Steen Salvage Ship Operation and the recovery of the two Jan Steen Salvage Ship Operation and the recovery of the two recorders by Chinese Navy and Jan Steen. recorders by Chinese Navy and Jan Steen.

Phase IVPhase IV（（20022002 09/09/16 16 -- 10/1710/17））

Wreckage recovery via trawling.Wreckage recovery via trawling.

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Phase IPhase IPhase I

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Phase IIPhase IIPhase II

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Phase IIIPhase IIIPhase III

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Phase IVPhase IVPhase IV

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Summary of Wreckage RecoverySummary of Wreckage Recovery

175 bodies and approximately 1,500 pieces of 175 bodies and approximately 1,500 pieces of wreckage (about 75% of the whole structure) were wreckage (about 75% of the whole structure) were recovered as a result. recovered as a result.

Wind Direction Wind direction@35000 ft.

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Temporary stored place of the wreckage Temporary stored place of the wreckage at Chinese Navyat Chinese Navy’’s port in s port in MakungMakung

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The storage of the wreckage at The storage of the wreckage at TaoyuanTaoyuanAir Force Base Hanger #1Air Force Base Hanger #1

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The storage of the wreckage at The storage of the wreckage at TaoyuanTaoyuanAir Force Base Hanger #2Air Force Base Hanger #2

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Process of the CI611 InvestigationProcess of the CI611 Investigation

The factual data collection report was released on 06/02 2003. The factual data collection report was released on 06/02 2003.

Tests at labs in Chung Shan Institute of Science and Tests at labs in Chung Shan Institute of Science and Technology (CSIST), Boeing Material Technology (BMT) and Technology (CSIST), Boeing Material Technology (BMT) and Equipment Quality Analysis (EQA)Equipment Quality Analysis (EQA)

Two test flight for data collection. Two test flight for data collection.

2D and 3D wreckage reconstruction2D and 3D wreckage reconstruction

Four Technical Review Meetings (TRM)Four Technical Review Meetings (TRM)

Three times of comment feedback from the stakeholders of Three times of comment feedback from the stakeholders of the draft report.the draft report.

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Scanning Electron Microscopic (SEM) Scanning Electron Microscopic (SEM) ExaminationExamination

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33--D Wreckage ReconstructionD Wreckage Reconstruction

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Final ReportFinal Report

1. The Occurrence Report Volume I contents factual information, analysis, findings, recommendation and all parties’ feedbacks on the report

Chinese version: 246 pages

English version: 318 pages

2. The Occurrence Report Volume II includes all the appendicesChinese version: 348 pages

English version: 346 pages

3. This report is published in English and Chinese. Chinese version is the official version.

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FindingsFindings

The Safety Council presents the findings derived The Safety Council presents the findings derived from the factual information gathered during the from the factual information gathered during the investigation and the analysis of the CI611 accident. investigation and the analysis of the CI611 accident. The findings are presented in three categories: The findings are presented in three categories:

Findings related to probable causes: 6 itemsFindings related to probable causes: 6 items

Findings related to risk : 7 itemsFindings related to risk : 7 items

Other findings: 16 itemsOther findings: 16 items

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Interim Safety BulletinInterim Safety Bulletin

1. Issued on 21 March 2003 to CAA and ICAO

2. ASC-ISB-003-001

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Aviation Safety Recommendations Aviation Safety Recommendations (21 items(21 items))

To:To:China Airlines China Airlines CAACAABoeing Commercial Airplane Boeing Commercial Airplane Company Company FAA, USA FAA, USA ASC, Ministry of National Defense, ASC, Ministry of National Defense, and Ministry of Justiceand Ministry of Justice

6 items6 items8 items8 items22 items items

3 items 3 items 2 items2 items

In addition to the safety recommendations, the Safety Council also includes the safety actions already taken or planned by thestakeholders.

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Findings & Aviation Safety Recommendations

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Findings Related to Probable Causes (6 items)Findings Related to Probable Causes (6 items)

The findings related to the probable causes identify elements that have been shown to have operated in the accident, or almost certainly to have operated in the accident. These findings are associated with unsafe acts, unsafe conditions, or safety deficiencies that are associated with safety significant events that played a major role in the circumstances leading to the accident.

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1.1. Based on the recordings of CVR and FDR, radar Based on the recordings of CVR and FDR, radar data, the dado panel opendata, the dado panel open--close positions, the close positions, the wreckage distribution, and the wreckage wreckage distribution, and the wreckage examinations, the inexaminations, the in--flight breakup of CI611, as it flight breakup of CI611, as it approached its cruising altitude, was highly likely approached its cruising altitude, was highly likely due to the structural failure in the aft lower lobe due to the structural failure in the aft lower lobe section of the fuselage. section of the fuselage.

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Possible Scenarios of the InPossible Scenarios of the In--Flight BreakupFlight Breakup

Based on the radar track data, the accident aircraft suffered Based on the radar track data, the accident aircraft suffered an inan in--flight breakup as it approached its cruising altitude of flight breakup as it approached its cruising altitude of 35,000 ft. the Safety Council following 9 possible scenarios 35,000 ft. the Safety Council following 9 possible scenarios that might have led to the inthat might have led to the in--flight breakup:flight breakup:

1.1. Midair collisionMidair collision

2.2. Weather/natural phenomenaWeather/natural phenomena

3.3. Explosive deviceExplosive device

4.4. Fuel tank explosionFuel tank explosion

5.5. Engine failure/separationEngine failure/separation

6.6. Cargo door openingCargo door opening

7.7. Cabin overpressureCabin overpressure

8.8. Hazardous cargo/dangerous goodsHazardous cargo/dangerous goods

9.9. Structural failureStructural failure

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Structural Failure AnalysisStructural Failure Analysis

Flight Recorders & Radar DataFlight Recorders & Radar DataInitial breakup point between recorders and Initial breakup point between recorders and powerplantspowerplants..

Dado PanelsDado PanelsThe open status of the recovered dado panels indicated that the The open status of the recovered dado panels indicated that the aft lower lobe of the fuselage encountered rapid decompression. aft lower lobe of the fuselage encountered rapid decompression.

CVRCVR SignatureSignatureThe signature of the CVR recording suggested that the initial The signature of the CVR recording suggested that the initial breakup occurred in the compression area.breakup occurred in the compression area.

Wreckage Examination & DistributionWreckage Examination & DistributionThe breakup initiated from the aft fuselage. The breakup initiated from the aft fuselage.

Data collection for BData collection for B--1825518255 RAPRAPThere was possibility hidden skin damage beneath the There was possibility hidden skin damage beneath the doublerdoubler in in the vicinity of STA 2100.the vicinity of STA 2100.

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2.2. In February 7 1980, the accident aircraft suffered a tail strikeIn February 7 1980, the accident aircraft suffered a tail strikeoccurrence in Hong Kong. The aircraft was ferried back to occurrence in Hong Kong. The aircraft was ferried back to Taiwan on the same day unTaiwan on the same day un--pressurized and a temporary pressurized and a temporary repair was conducted the day after. A permanent repair was repair was conducted the day after. A permanent repair was conducted on May 23 through 26, 1980.conducted on May 23 through 26, 1980.

3.3. The permanent repair of the tail strike was not accomplished The permanent repair of the tail strike was not accomplished in accordance with the Boeing SRM, in that the area of in accordance with the Boeing SRM, in that the area of damaged skin in Section 46 was not removed (trimmed) and damaged skin in Section 46 was not removed (trimmed) and the repair the repair doublerdoubler did not extend sufficiently beyond the entire did not extend sufficiently beyond the entire damaged area to restore the structural strength. damaged area to restore the structural strength.

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2300站2000站

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1980 Tail Strike Event in Hong Kong1980 Tail Strike Event in Hong Kong

The occurrence caused abrasion damage on aft The occurrence caused abrasion damage on aft fuselage portion bottom skin between STA 2080 fuselage portion bottom skin between STA 2080 and STA 2160, and between STA 2578 and 2658. and STA 2160, and between STA 2578 and 2658. The aft drain mast was missing and the left The aft drain mast was missing and the left outflow valve door inboard corner was partially outflow valve door inboard corner was partially cut.cut.

According to the aircraft log book, BAccording to the aircraft log book, B--18255 was 18255 was grounded for permanent repair from May 23 to grounded for permanent repair from May 23 to May 26, 1980 per Boeing Structure Repair May 26, 1980 per Boeing Structure Repair Manual.Manual.

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Item 640Item 640

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Item 640From fuselage skin STA 1920 to 2180 and stringer 23R to 49L (about 260 by

200 inches)

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Scratches near SAT 2080Scratches near SAT 2080

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Examination of wreckage Examination of wreckage item 640 indicated that the item 640 indicated that the maximum depth of maximum depth of scratches after the clean up scratches after the clean up was about 15.5% (0.0096 was about 15.5% (0.0096 inch) of the skin thickness inch) of the skin thickness and the length of the and the length of the scratches on the damaged scratches on the damaged skin was more than 20 skin was more than 20 inches. The damage was inches. The damage was beyond the allowable beyond the allowable damage specified by the damage specified by the SRM.SRM.

Repair of the Tail Strike OccurrenceRepair of the Tail Strike Occurrence

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Repair of the Tail Strike OccurrenceRepair of the Tail Strike Occurrence

SRM specifies that the scratches should be removed if the SRM specifies that the scratches should be removed if the damage is within the limit. If not, thedamage is within the limit. If not, the damaged area should be damaged area should be cut out before the application of a cut out before the application of a doublerdoubler or the piece of or the piece of damaged skin be replaced to restore the structural strength.damaged skin be replaced to restore the structural strength.

After the repair, the scratches still existed. The After the repair, the scratches still existed. The doublerdoubler was was installed to cover the scratches but could not covered the installed to cover the scratches but could not covered the whole damaged area. Some scratches still existed beyond the whole damaged area. Some scratches still existed beyond the peripheral fasteners of the peripheral fasteners of the doublerdoubler..

The Safety Council believed that tThe Safety Council believed that the repair did not executed he repair did not executed in accordance with Boeing SRM.in accordance with Boeing SRM.

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Interim Safety BulletinInterim Safety Bulletin

In 21 March 2003, the Safety Council issued the following InteriIn 21 March 2003, the Safety Council issued the following Interim m Flight Safety Bulletin to ICAOFlight Safety Bulletin to ICAO[1][1]::

1.1. all civil aviation accident investigation agencies to collaboratall civil aviation accident investigation agencies to collaborate e with their regulatory authorities to take appropriate action with their regulatory authorities to take appropriate action requiring all operators of transportrequiring all operators of transport--category aircrafts with category aircrafts with pressure vessel repairs. Identified as a result of structural pressure vessel repairs. Identified as a result of structural damage other than those covered by Boeing service bulletin damage other than those covered by Boeing service bulletin documentation ASB B747documentation ASB B747--53A2489 for an immediate inspection 53A2489 for an immediate inspection on the repaired area to determine whether any hidden damage on the repaired area to determine whether any hidden damage is present.is present.

2.2. An improperly treated scratch on the aircraft pressure vessel An improperly treated scratch on the aircraft pressure vessel skin, especially if covered under a repair skin, especially if covered under a repair doublerdoubler, could be a , could be a hidden damage that might develop into fatigue crack eventually hidden damage that might develop into fatigue crack eventually causing structure failure.causing structure failure.

[1] A Chinese version of Interim Flight Safety Bulletin was issued to CAA ROC.

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To China AirlinesTo China Airlines

Perform structural repairs according to the SRM Perform structural repairs according to the SRM or other regulatory agency approved methods, or other regulatory agency approved methods, without deviation, and perform damage without deviation, and perform damage assessment in accordance with the approved assessment in accordance with the approved regulations, procedures, and best practices. regulations, procedures, and best practices. ReRe--assess the relationship with the assess the relationship with the manufacturermanufacturer’’s field service representative to s field service representative to actively seek assistance and consultation from actively seek assistance and consultation from manufacturersmanufacturers’’ field service representatives, field service representatives, especially in maintenance and repair operations.especially in maintenance and repair operations.

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To Boeing Commercial Airplane To Boeing Commercial Airplane CompanyCompany

ReRe--assess the relationship of Boeingassess the relationship of Boeing’’s s field service representative with the field service representative with the operators such that a more proactive operators such that a more proactive and problem solving consultation effort and problem solving consultation effort to the operators can be achieved, to the operators can be achieved, especially in the area of maintenance especially in the area of maintenance operations. operations.

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4.4. Evidence of fatigue damage was found in the lower Evidence of fatigue damage was found in the lower aft fuselage centered about STA 2100, between aft fuselage centered about STA 2100, between stringers Sstringers S--48L and S48L and S--49L, under the repair 49L, under the repair doublerdoubler near its edge and outside the outer row of near its edge and outside the outer row of securing rivets. Multiple Site Damage (MSD), securing rivets. Multiple Site Damage (MSD), including a 15.1including a 15.1--inch through thickness main inch through thickness main fatigue crack and some small fatigue cracks were fatigue crack and some small fatigue cracks were confirmed. The 15.1confirmed. The 15.1--inch crack and most of the inch crack and most of the MSD cracks initiated from the scratching damage MSD cracks initiated from the scratching damage associated with the 1980 tail strike incident.associated with the 1980 tail strike incident.

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Item 640C1 AppearanceItem 640C1 Appearance

640C1 640C2

53Numbering of the holes/fasteners along the fracture surface

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Examination and Structural Analysis of Item 640Examination and Structural Analysis of Item 640

Evidence of fatigue crack was found and confirmed by both CSIST Evidence of fatigue crack was found and confirmed by both CSIST and BMT on the piece of wreckage identified as Item 640 , and BMT on the piece of wreckage identified as Item 640 , including a 15.1including a 15.1--inch continuous fatigue crack and other smaller inch continuous fatigue crack and other smaller fatigue cracks aft and forward extending from hole +14 to hole 5fatigue cracks aft and forward extending from hole +14 to hole 51.1.

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Origin and Pattern of the Fatigue CrackOrigin and Pattern of the Fatigue Crack

many longitudinal scratches (fore to aft) existed on the faying surface of the skin.

The laboratory observations showed that the main fatigue crack and most of the MSD aft and forward were initiated from the scratches that existed at or just beyond the peripheral row of fasteners common to the repair doubler.

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5.5. Residual strength analysis indicated that the main fatigue crackResidual strength analysis indicated that the main fatigue crack in in combination with the Multiple Site Damage (MSD) were of sufficiecombination with the Multiple Site Damage (MSD) were of sufficient nt magnitude and distribution to facilitate the local linking of thmagnitude and distribution to facilitate the local linking of the fatigue e fatigue cracks so as to produce a continuous crack within a twocracks so as to produce a continuous crack within a two--bay region bay region (40 inches). Analysis further indicated that during the applica(40 inches). Analysis further indicated that during the application of tion of normal operational loads the residual strength of the fuselage wnormal operational loads the residual strength of the fuselage would ould be compromised with a continuous crack of 58 inches or longer be compromised with a continuous crack of 58 inches or longer length. Although the ASC could not determine the length of cracklength. Although the ASC could not determine the length of cracking ing prior to the accident flight, the ASC believes that the extent oprior to the accident flight, the ASC believes that the extent of hoopf hoop--wise fretting marks found on the wise fretting marks found on the doublerdoubler, and the regularly spaced , and the regularly spaced marks and deformed cladding found on the fracture surface suggesmarks and deformed cladding found on the fracture surface suggest t that a continuous crack of at least 71 inches in length, a crackthat a continuous crack of at least 71 inches in length, a crack length length considered long enough to cause structural separation of the considered long enough to cause structural separation of the fuselage, was present before the infuselage, was present before the in--flight breakup of the aircraft.flight breakup of the aircraft.

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Residual Strength AnalysisResidual Strength Analysiswhen the crack was over 58 inches, the residual strength of the when the crack was over 58 inches, the residual strength of the skin assembly would go below the operating stress, therefore skin assembly would go below the operating stress, therefore caused the skin assembly beyond the capability limit under the caused the skin assembly beyond the capability limit under the application of normal operational loadsapplication of normal operational loads

Residual Strength with Doubler

0 10 20 30 40 50 60 70 80 90 100

w ithout MSD up to40 w ith doubler

beyond 40 w ithdoubler

OperatingStress

Crack Length, in

Resi

dual

stre

ngth

, ksi

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PrePre--existing continuous crack before the existing continuous crack before the inin--flight breakupflight breakup

Fretting damage observed on faying surface Fretting damage observed on faying surface of the repair of the repair doublerdoubler along the fracture along the fracture surfacesurface

Compressive deformation of Compressive deformation of the aluminum cladding along the aluminum cladding along the edge of the fracture the edge of the fracture common to the faying surfacecommon to the faying surface

The presence of regularly spaced The presence of regularly spaced marks on the fracture surface marks on the fracture surface

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斷裂面附近多處局部性磨擦損傷斷裂面附近多處局部性磨擦損傷

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The Safety Council believes that all these indications mentioned above were most likely caused by the repetitive opening and closure of the pre-existing crack

the length of the crack before the aircraft in-flight breakup was at least 71 inches.

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6.6. Maintenance inspection of BMaintenance inspection of B--18255 did not 18255 did not detect the ineffective 1980 structural repair detect the ineffective 1980 structural repair and the fatigue cracks that were developing and the fatigue cracks that were developing under the repair under the repair doublerdoubler. However, the time . However, the time that the fatigue cracks propagated through that the fatigue cracks propagated through the skin thickness could not be determined.the skin thickness could not be determined.

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B747B747--200 Structural Inspection200 Structural Inspection

Structure Inspection Program, SIPStructure Inspection Program, SIP

Corrosion Prevention and Control Program, CPCPCorrosion Prevention and Control Program, CPCP

Supplemental Structure Inspection, SSISupplemental Structure Inspection, SSI

Airworthiness Directive (AD) and Service Bulletin (SB)Airworthiness Directive (AD) and Service Bulletin (SB)

Repair Assessment Program, RAPRepair Assessment Program, RAP

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To Boeing Commercial Airplane To Boeing Commercial Airplane CompanyCompany

Develop or enhance research effort for Develop or enhance research effort for more effective nonmore effective non--destructive destructive inspection devices and procedures.inspection devices and procedures.

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To CAA, ROCTo CAA, ROC

Closely monitor international technology Closely monitor international technology development regarding more effective development regarding more effective nonnon--destructive inspection devices and destructive inspection devices and procedure. procedure.

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Findings Related to Risk (7 items)Findings Related to Risk (7 items)

The findings related to riskThe findings related to risk identify elements of identify elements of risk that have the potential to degrade aviation risk that have the potential to degrade aviation safety. Some of the findings in this category identify safety. Some of the findings in this category identify unsafe acts, unsafe conditions, and safety unsafe acts, unsafe conditions, and safety deficiencies that made this accident more likely; deficiencies that made this accident more likely; however, they can not be clearly shown to have however, they can not be clearly shown to have operated in the accident. They also identify risks operated in the accident. They also identify risks that increase the possibility of property damage that increase the possibility of property damage and personnel injury and death. Further, some of and personnel injury and death. Further, some of the findings in this category identify risks that are the findings in this category identify risks that are unrelated to the accident, but nonetheless were unrelated to the accident, but nonetheless were safety deficiencies that may warrant future safety safety deficiencies that may warrant future safety actions.actions.

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1.1. The first Corrosion Prevention and Control Program (CPCP) The first Corrosion Prevention and Control Program (CPCP) inspection of the accident aircraft was in November 1993 inspection of the accident aircraft was in November 1993 making the second CPCP inspection of the lower lobe making the second CPCP inspection of the lower lobe fuselage due in November 1997. CAL inspected that area 13 fuselage due in November 1997. CAL inspected that area 13 months later than the required fourmonths later than the required four--year interval. In order to fit year interval. In order to fit into the CAL maintenance schedule computer control system, into the CAL maintenance schedule computer control system, CAL estimated the average flight time or flight cycles for each CAL estimated the average flight time or flight cycles for each aircraft and scheduled the calendar year based inspection. aircraft and scheduled the calendar year based inspection. Reduced aircraft utilization led to the dates of the flight hourReduced aircraft utilization led to the dates of the flight hourinspections being postponed, thus the simultaneous CPCP inspections being postponed, thus the simultaneous CPCP inspection dates were passed. CALinspection dates were passed. CAL’’s oversight and s oversight and surveillance programs did not detect the missed inspections.surveillance programs did not detect the missed inspections.

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Review the selfReview the self--audit inspection audit inspection procedures to ensure that all the procedures to ensure that all the mandatory requirements for continuing mandatory requirements for continuing airworthiness, such as CPCP, are airworthiness, such as CPCP, are completed in accordance with the completed in accordance with the approved maintenance documents.approved maintenance documents.

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2.2. According to maintenance records, starting from According to maintenance records, starting from November 1997, BNovember 1997, B--18255 had a total of 29 CPCP 18255 had a total of 29 CPCP inspection items that were not accomplished in inspection items that were not accomplished in accordance with the CAL AMP and the Boeing 747 accordance with the CAL AMP and the Boeing 747 Aging Airplane Corrosion Prevention & Control Aging Airplane Corrosion Prevention & Control Program. The aircraft had been operated with Program. The aircraft had been operated with unresolved safety deficiencies from November unresolved safety deficiencies from November 1997 onward. 1997 onward.

3. The CPCP scheduling deficiencies in the CAL maintenance inspection practices were not identified by the CAA audits.


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88 years29Total

86 years125 years

14 years

Overdue ItemsCheck Interval

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Consider reviewing its inspection procedure for Consider reviewing its inspection procedure for maintenance records. This should be done with maintenance records. This should be done with a view to ensuring that the carriersa view to ensuring that the carriers’’ systems are systems are adequate and are operating effectively to make adequate and are operating effectively to make certain that the timeliness and completeness of certain that the timeliness and completeness of the continuing airworthiness programs for their the continuing airworthiness programs for their aircraft are being met.aircraft are being met.Encourage operators to establish a mechanism Encourage operators to establish a mechanism to manage their maintenance record keeping to manage their maintenance record keeping system, in order to provide a clear view for system, in order to provide a clear view for inspector/auditors conducting records reviews.inspector/auditors conducting records reviews.

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4.4. The determination of the implementation of the The determination of the implementation of the maximum flight cycles before the Repair maximum flight cycles before the Repair Assessment Program was based primarily on Assessment Program was based primarily on fatigue testing of a production aircraft structure fatigue testing of a production aircraft structure (skin, lap joints, etc.) and did not take into account (skin, lap joints, etc.) and did not take into account of variation in the standards of repair, maintenance, of variation in the standards of repair, maintenance, workmanship and followworkmanship and follow--up inspections that exist up inspections that exist among air carriers. among air carriers.

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20,00019,44719,447 22,00022,000

Maximum threshold

Designed service life

20,40220,402

2000 05/25

One year

Tolerance period

21,39821,398

Accident Occurred2002 05/25

6C 7C

Execution threshold2000 05/25

flight cycles

RAP ThresholdRAP Threshold

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To the FAA of the U.S. To the FAA of the U.S.

Ensure that the process for determining Ensure that the process for determining implementation threshold for mandatory implementation threshold for mandatory continuing airworthiness information, such as continuing airworthiness information, such as RAP, includes safety aspects, operational RAP, includes safety aspects, operational factors, and the uncertainty factors in factors, and the uncertainty factors in workmanship and inspection. The information workmanship and inspection. The information of the analysis used to determine the threshold of the analysis used to determine the threshold should be fully documented. should be fully documented.

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Assess and implement safety related Assess and implement safety related airworthiness requirements, such as the airworthiness requirements, such as the RAP, at the earliest practicable time. RAP, at the earliest practicable time.

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Ensure that the process for determining Ensure that the process for determining implementation threshold for mandatory implementation threshold for mandatory continuing airworthiness information, such as continuing airworthiness information, such as RAP, includes safety aspects, operational RAP, includes safety aspects, operational factors, and the uncertainty factors in factors, and the uncertainty factors in workmanship and inspection. The information workmanship and inspection. The information of the analysis used to determine the threshold of the analysis used to determine the threshold should be fully documented. should be fully documented.

Encourage operators to assess and implement Encourage operators to assess and implement safety related airworthiness requirements at the safety related airworthiness requirements at the earliest practicable time. earliest practicable time.

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5.5. Examination of photographs of the item 640 repair Examination of photographs of the item 640 repair doublerdoubler on the accident aircraft, which was taken in on the accident aircraft, which was taken in November 2001 during CALNovember 2001 during CAL’’s structural patch s structural patch survey for the Repair Assessment Program, survey for the Repair Assessment Program, revealed traces of staining on the aft lower lobe revealed traces of staining on the aft lower lobe fuselage around STA 2100 were an indication of a fuselage around STA 2100 were an indication of a possible hidden structural damage beneath the possible hidden structural damage beneath the doublerdoubler..

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Enhance maintenance crewEnhance maintenance crew’’s awareness s awareness with regard to the irregular shape of the with regard to the irregular shape of the aircraft structure, as well as any aircraft structure, as well as any potential signs that may indicate hidden potential signs that may indicate hidden structural damage. structural damage.

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6.6. CAL did not accurately record some of CAL did not accurately record some of the early maintenance activities before the early maintenance activities before the accident, and the maintenance the accident, and the maintenance records were either incomplete or not records were either incomplete or not found. (1.6, 2.4)found. (1.6, 2.4)


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Review the record keeping system to Review the record keeping system to ensure that all maintenance activities ensure that all maintenance activities have been properly recorded. have been properly recorded.

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7.7. The bilge area was not cleaned before The bilge area was not cleaned before the 1st structural inspection in the the 1st structural inspection in the 1998 MPV. For safety purpose, the 1998 MPV. For safety purpose, the bilge area should be cleaned before bilge area should be cleaned before inspection to ensure a closer inspection to ensure a closer examination of the area. (1.6,2.4)examination of the area. (1.6,2.4)


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A CAL B747-200 aircraft bilge area with the CIC and dust removed

A CAL B747-400 aircraft bilge area without removing CIC and dust

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Aviation Safety Recommendations Aviation Safety Recommendations (21 items(21 items))

To:To:China Airlines China Airlines CAACAABoeing Commercial Airplane Boeing Commercial Airplane Company Company FAA, USA FAA, USA ASC, Ministry of National Defense, ASC, Ministry of National Defense, and Ministry of Justiceand Ministry of Justice

6 items6 items8 items8 items22 items items

3 items 3 items 2 items2 items

In addition to the safety recommendations, the Safety Council also includes the safety actions already taken or planned by thestakeholders.

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Objective of Aviation Occurrence Investigation

The objective of investigation of aviation occurrence is to prevent recurrence of similar occurrences. It is not the purpose of such investigation to apportion blame or liability.

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