China Airlines Flight 006 Incident - February 19, 1985

Background

• China Airlines Flight 006 was en route from Taiwan to Los Angeles.
• Two-man relief crew was in charge of the plane, allowing the main crew to rest.
• Captain Moon Hyun-ho was off-duty but returned to the cockpit.
• Passengers included Sexan Canio celebrating his birthday.

The Incident

• The plane encountered strong winds making it hard to maintain speed.
• Engine Malfunction: Engine 4 began to lose thrust, eventually failing.
• The plane started losing speed and began to roll to the right.
• The captain disengaged autopilot and took manual control, but was unable to see the horizon.

Nosedive and Recovery

• The aircraft stalled and fell from the sky, causing chaos in the cabin.
• Emergency efforts led to the plane spinning out of control and descending rapidly.
• The crew managed to regain control just before crashing into the ocean at 9,500 feet.
• Engines 1, 2, and 3 regained power, and Engine 4 was successfully reignited later.

Aftermath

• The plane was severely damaged, with parts of the tail missing.
• The crew managed to land at San Francisco despite damage to the landing gear and hydraulic system.
• Only one passenger needed hospitalization, with minor injuries to others.

Investigation by NTSB

• Initial focus was on Engine 4 due to past issues but was found to be repaired correctly.
• Pilot Error: The crew failed to follow engine-out procedures and mismanaged the plane's control during the engine failure.
• Autopilot Mismanagement: Captain Ho failed to take immediate manual control and didn't use the rudder to stabilize the plane.
• Loss of Spatial Orientation: The crew misread ADI instruments, believing them to malfunction.
• Failure to Monitor Instruments: The crew was possibly suffering from fatigue, leading to poor decision-making.

Human Factors

• Circadian rhythms and fatigue were investigated as contributing factors.
• The crew faced desynchronosis/jet lag, affecting their performance.

Changes and Learnings

• Automation and Pilot Control: Emphasized the need for pilots to have full authoritative control over flight systems.
• Boeing reviewed design systems post-incident to ensure pilots have ultimate control.
• The incident highlighted the importance of crew vigilance and instrument trust.

Conclusion

• The crew ultimately managed to save the plane and passengers, showcasing commendable flying skills under duress.
• The Boeing 747 aircraft demonstrated resilience and structural integrity despite extreme stress.