A report by the Aviation Safety Council (ASC) investigating the TransAsia Airways plane crash on Feb. 4, 2015, which killed 43 and injured 17, has finally been released.

According to its findings, human error was the cause of the accident. “The accident was the result of many contributing factors, which culminated in a stall-induced loss of control,” the report says.

The direct cause of the crash, according to the report, is an automatic takeoff power control system (ATPCS) sequence that resulted from intermittent discontinuity in engine No. 2’s auto feather unit (AFU). However, the report also states that if the flight crew had stabilized the aircraft flight path beforehand, malfunction in the propulsion system could have been detected to prevent the accident.

Also, documented abnormal and emergency procedures should have been performed “to identify the failure and implement the required corrective actions,” the report says. However, the TransAsia Airways crew failed to do so.

The investigation results are categorized into three different categories: probable causes, findings related to risk, and other findings. The main problems lie in the first two.

With regards to probable causes, the report evaluated the elements that have been shown to have (or almost certainly did) operated in the occurrence.

When undergoing the takeoff checking procedure, the power control system push button did not light up, showing defects in the automatic takeoff system. But the crew did not reject the takeoff. This is due to a lack of clear documented company policy that lets the crew communicate fully.

In addition, a required failure identification procedure wasn’t performed, missing another chance to prevent the accident from happening. The ineffective management and non-compliance among the crew was also responsible for the accident.

Human error, combined with the loss of power from both engines, led to the crash.

‘Regulatory oversight’

As to risks, the crew was negligent in flight operations, airline safety management and their training programs, the report states.

The crew wasn’t mentally prepared to omit the required pre-takeoff briefing. Most importantly, the pilot made the wrong decision to disconnect the autopilot shortly after the first master warning, which increased his burden and led to a lower survival rate.

Some people have accused the two pilots, who also died in the crash, of carelessness, while others have defended them, saying they did everything in their power to avert the crash.

According to the investigation report, when selecting eligible pilots for the position, the company did not follow its own rules and downgraded the quality of the pilots. Defects were also identified in TransAsia Airways’ training programs, leading inexperienced pilots to neglect their duties, the report says.

To prevent future tragedies, the report recommends the Civil Aeronautics Administration (CAA) conduct a detailed review of TransAsia Airways. The ASC adds that a thorough “regulatory oversight” of TransAsia Airways’ operations is necessary.

The CAA should “identify and ensure that the known operational safety deficiencies, including crew noncompliance with procedures, nonstandard training practices, and unsatisfactory safety management, are addressed effectively,” the report concludes.

First Editor: J. Michael Cole
Second Editor: Olivia Yang