Incident: Pilot Error Leads to TransAsia Airways ATR Crash in Taipei

Published Date: 2015-07-02

Postmortem Analysis
Timeline 1. The software failure incident happened on 4 February [37782].
System unknown
Responsible Organization 1. Captain Liao Jian-zong, who mistakenly switched off the plane's only working engine, leading to the crash [37782].
Impacted Organization 1. TransAsia Airways 2. Taiwan's Aviation Safety Council (ASC) 3. Taiwan’s Civil Aeronautics Administration [Cited from Article 37782]
Software Causes unknown
Non-software Causes 1. Insufficient knowledge and training of the captain on how to deal with an engine flame-out on take-off [37782] 2. Confusion in the cockpit between the two captains trying to regain control of the plane after one engine lost power [37782] 3. Captain's mistake of reducing the throttle on the working engine, leading to the crash [37782] 4. Lack of completion of procedures and checks, cockpit management, and flight planning issues by the captain [37782] 5. Tendency of the captain to be nervous, make oral errors, and lack confidence during training and evaluations [37782]
Impacts unknown
Preventions 1. Improved simulator training and evaluation procedures for pilots, especially focusing on critical scenarios like engine failures on take-off, could have potentially prevented the incident [37782]. 2. Enhanced cockpit resource management training to ensure effective communication and coordination among the flight crew during emergencies could have helped in avoiding the confusion and errors that led to the crash [37782]. 3. Regular and thorough performance evaluations of pilots to identify and address any recurring issues or deficiencies in their skills and decision-making abilities could have been a preventive measure [37782].
Fixes 1. Improved simulator training and evaluation processes for pilots to ensure they have sufficient knowledge and skills to handle critical situations like engine failures [37782]. 2. Enhanced cockpit management training to help pilots effectively manage and prioritize tasks during emergencies [37782]. 3. Regular proficiency tests and evaluations for pilots to maintain and improve their skills in handling aircraft during various scenarios, including engine failures [37782].
References 1. Taiwan’s Aviation Safety Council (ASC) [37782]

Software Taxonomy of Faults

Category Option Rationale
Recurring unknown The articles do not mention any software failure incidents related to either one_organization or multiple_organization.
Phase (Design/Operation) unknown The articles do not mention any software failure incident related to the development phases, whether design or operation. Therefore, it is unknown whether the incident was caused by contributing factors introduced during system development, system updates, or procedures to operate or maintain the system (design), or by contributing factors introduced during the operation or misuse of the system (operation).
Boundary (Internal/External) within_system The software failure incident reported in the article does not directly relate to a software failure within the system or outside the system. The incident primarily involves human error and operational issues in the context of aviation, specifically the mistaken shutdown of the plane's only working engine by the captain, leading to a tragic crash.
Nature (Human/Non-human) human_actions (a) The software failure incident in this case was not directly related to non-human actions but rather to human actions. The incident was caused by the captain mistakenly switching off the plane's only working engine seconds before the crash, as reported by the Taiwan Aviation Safety Council [37782]. The captain's error in pulling back the wrong side throttle led to the failure, indicating that the contributing factors were introduced through human actions rather than non-human actions.
Dimension (Hardware/Software) unknown (a) The software failure incident in the mentioned article is not related to hardware failure but rather to human error and lack of proper training on how to handle engine flame-out on take-off. The incident was caused by the captain mistakenly switching off the plane's only working engine seconds before the crash, leading to the tragic event [37782]. (b) The software failure incident is primarily attributed to human error and lack of knowledge on how to deal with an engine flame-out on take-off. The captain's mistake of pulling back the wrong side throttle, confusion in the cockpit, and failure to realize the error until it was too late were key factors contributing to the crash. The incident was not directly linked to a software failure but rather to pilot error and inadequate training [37782].
Objective (Malicious/Non-malicious) non-malicious The software failure incident reported in the provided article [37782] does not involve a malicious software failure. Instead, the incident was a non-malicious failure caused by human error, specifically the captain mistakenly switching off the plane's only working engine, leading to the tragic crash of the TransAsia Airways ATR. The failure was attributed to the captain's insufficient knowledge and mistakes during the flight, rather than any intentional act to harm the system.
Intent (Poor/Accidental Decisions) accidental_decisions The software failure incident reported in the article does not directly relate to either poor decisions or accidental decisions. The incident primarily involves human error in the operation of the aircraft, specifically the mistaken shutdown of the plane's only working engine by the captain, leading to the crash.
Capability (Incompetence/Accidental) accidental (a) The software failure incident in the TransAsia Airways ATR crash was not directly related to development incompetence but rather to pilot error and lack of proper training. The captain mistakenly switched off the plane's only working engine, leading to the crash. The pilot had failed simulator training previously due to insufficient knowledge on how to deal with an engine flame-out on take-off, indicating a lack of proficiency in handling such critical situations [37782]. (b) The software failure incident in the TransAsia Airways ATR crash was accidental in nature. The captain mistakenly pulled back the wrong side throttle, leading to the shutdown of the only working engine. This action was described as a mistake made in the heat of the moment, causing confusion in the cockpit and ultimately resulting in the tragic crash [37782].
Duration unknown The articles do not mention any software failure incident related to the TransAsia Airways ATR crash discussed in Article 37782. Therefore, the duration of the software failure incident in this case is unknown.
Behaviour omission, value (a) crash: The software failure incident in this case resulted in a crash of the TransAsia Airways ATR plane, leading to the death of 43 people. The crash occurred after the captain mistakenly switched off the plane's only working engine, causing the aircraft to stall and crash into a river in downtown Taipei [37782]. (b) omission: The omission of performing the intended functions is evident in the captain's actions, where he failed to correctly handle an engine flame-out on take-off, leading to the fatal mistake of reducing the throttle on the working engine instead of the malfunctioning one. This omission of correct actions contributed to the crash of the aircraft [37782]. (d) value: The software failure incident also involved the system performing its intended functions incorrectly. The captain's incorrect actions, such as reducing the throttle on the working engine instead of the malfunctioning one, led to the failure of the system to maintain proper flight and ultimately resulted in the crash of the aircraft [37782].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence death, harm (a) death: People lost their lives due to the software failure - The software failure incident involving the TransAsia Airways ATR led to a crash that resulted in the death of 43 people on board the plane [37782].
Domain transportation (a) The failed system was related to the transportation industry as it involved the crash of a TransAsia Airways ATR plane, resulting in the loss of 43 lives [37782]. The incident highlighted issues with the pilot's training and handling of engine failures during take-off, ultimately leading to the tragic crash.

Sources

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