Airprox Accident Boeing 757-27A B-27015, Thursday 16 November 2006

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Date:	Thursday 16 November 2006
Time:	02:07 UTC
Type:	Boeing 757-27A
Owner/operator:	Far Eastern Air Transport - FEAT
Registration:	B-27015
MSN:	29609/876
Year of manufacture:	1999
Total airframe hrs:	15258 hours
Cycles:	15547 flights
Fatalities:	Fatalities: 0 / Occupants: 137
Other fatalities:	0
Aircraft damage:	Minor, repaired
Category:	Accident
Location:	99 NM South of Jeju Island - South Korea
Phase:	En route
Nature:	Passenger - Scheduled
Departure airport:	Taipei-Taiwan Taoyuan International Airport (TPE/RCTP)
Destination airport:	Jeju (Cheju) International Airport (CJU/RKPC)
Investigating agency:	ASC
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
Far Eastern Air Transport Flight EF306, a Boeing 757-200 (B-27015), departed TPE at 08:41 Taipei local time and bound for Jeju International Airport, Korea.
On the way to the destination, about 99 NM south of Jeju Island, over the open sea area during its descent to FL 310 from FL390 following the instruction of the Incheon area control center (Incheon ACC), the Traffic Alert and Collision Avoidance System (TCAS) issued the Traffic Advisory (TA)/Resolution Advisory (RA) warning.
The crew manipulated the aircraft to descend for an avoidance maneuver following the TCAS RA ‘DESCEND’ warning. During the avoidance maneuver, 4 passengers were seriously injured, 10 passengers and 6 cabin crew sustained minor injury, and the interior of the aircraft sustained minor damage.
The other aircraft involved was Thai Airways flight TG659, a Boeing 777-3D7 (HS-TKF).
The Closest Point of Approach (CPA) was registered at 02:07:36 with a relative distance, relative altitude and closure rate of the two aircraft of 0.85 NM, -2,611 ft, and 655 knots, respectively.

The findings related to the probable causes identify elements that have been shown to have operated in the accident, or almost certainly 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.
1. ICN control made a non-standard call and gave a confusing instruction to the EF306 during its descent when passing FL340. EF306 flight crew did not fully comprehend the ATC instructions, failed to confirm the instructions and stopped descending at 33,800 ft. Both parties did not apply standard radiotelephony procedures and phraseologies. These anomalies contributed to the TCAS event between EF306 and TG659.
2. The EF306 flight crew did not complete the TCAS RA standard operation procedures and commenced an excessive high rate descent. The induced negative G-force resulted in the occupants’ injury.

The findings related to risk identify elements of risk that have the potential to degrade aviation safety. Some of the findings in this category identify unsafe acts, unsafe conditions, and safety deficiencies that made this accident more likely; however, they can not be clearly shown to have operated in the accident. They also identify risks that increase the possibility of property damage and personnel injury and death. Further, some of the findings in this category identify risks that are unrelated to the accident, but nonetheless were safety deficiencies that may warrant future safety actions.
1. The EF306 flight crew did not adequately exhibit good CRM performance in this occurrence.
2. While concentrating on the radar identification of other aircraft, SSRC momentarily missed monitoring the approaching situations developed between EF306 and TG659.
3. About 20 seconds after stopping descent, the pilot of EF306 notified SSRC of climbing in accordance with TCAS instructions, but descended actually. At that time, SSRC did not provide traffic information but attempted to modify the aircraft flight path instead. SSRC did not comply with ATC TCAS operating procedures.
4. The human capability of South Sector radar control position could be limited when the control services are performed by only one controller who is paying attention continuously to a large number of aircraft in a relatively broad service area, particularly during a sudden occurrence of abnormal situation.
5. Applying RVSM operations, the air traffic on B576 to and from Jeju airport is increasing rapidly.
6. Most of the injured passenger did not have their seat belts fastened and lost their protection while the fasten seat best sign was still on.
7. The cabin crewmembers did not provide timely injury information to the flight crew, that would have allowed the flight crew to request sufficient medical assistance before landing.
8. The controllers did not aware the importance of the number of injuries and the need for more ambulances to meet the flight upon landing. This caused the necessary number of ambulances to arrive at the airport with delay.

Accident investigation: