NTSB Factual Report

HISTORY OF FLIGHT

On January 25, 2002, at 0243 Alaska standard time, an Airbus Industrie A-340-300 airplane, Taiwanese registration B-18805, was cleared for takeoff on runway 32 from the Ted Stevens Anchorage International Airport, Anchorage, Alaska. The airplane, call sign Dynasty 011, subsequently departed from a taxiway. The airplane was being operated as an instrument flight rules (IFR) scheduled international passenger flight under Title 14, CFR Part 129, when the incident occurred. The airplane was operated as Flight 011, by China Airlines, Taiwan. The 3 cockpit crew members, 12 cabin crew members, and 237 passengers, were not injured. The airplane was not damaged. Dark night visual meteorological conditions prevailed. An IFR flight plan was filed from Anchorage to the Chiang Kai-Shek International Airport, Taipei, Taiwan.

The incident airplane was parked at the Anchorage International Airport's north terminal, gate N4. At 0221, the first officer of Dynasty 011 contacted Anchorage Air Traffic Control Tower (ATCT) clearance delivery and stated: "Dynasty 011 heavy, clearance, flight level 320 to Taipei, information Juliet, Bay N4." The clearance delivery controller stated: "Dynasty 011 Heavy, cleared to the Taipei Airport via Anchorage Three Departure, then as filed. Climb and maintain flight level 200, departure frequency will be 118.6, squawk 4032."

At 0224, the first officer contacted ground control, advising the controller that they were ready for their push-back from gate N4. The ground controller responded by stating: "Dynasty 011 heavy, Anchorage ground, good morning sir, push back is approved, plan runway 32 for departure." The first officer acknowledged the clearance by stating: "…runway 32, Dynasty 011."

At 0232, the first officer of Dynasty 011 contacted the Anchorage ATCT local controller, advising that they were ready for taxi. The local controller responded by stating: "Dynasty 011 heavy, taxi runway 32 at Kilo, taxi via Mike, Romeo, Kilo." The incident airplane then began to taxi away from the N4 gate, turning south on taxiway Romeo. The airplane proceeded southbound on taxiway Romeo, and made a right turn from Romeo onto taxiway Kilo.

The incident airplane was cleared for takeoff on runway 32 by the ATCT local controller at 0240:06, as the airplane was southbound on taxiway Romeo, preparing to turn right onto taxiway Kilo. The controller stated: "Dynasty 011 heavy, wind 360 at seven, runway 32 at Kilo, cleared for takeoff." The first officer responded by stating: "Cleared for takeoff, 32, Kilo, Dynasty 011 heavy."

A review of the airplane's flight data recorder (FDR) information provided by the Aviation Safety Council of Taiwan (ASC), disclosed that at 0240:06, the airplane was taxiing at 8 knots on a 141 degree heading. The FDR data indicated that at 0241, the airplane began a right turn to a heading of 244 degrees, and came to a stop at 0241:58. The airplane stopped on taxiway Kilo at the hold line, east of the extended portion of runway 32. The airplane was expected by the ATCT local controller to continue west on Kilo into the extended portion of runway 32, and then turn right (north) onto the approach end of runway 32. Instead, at 0242:10, the airplane began accelerating west on taxiway Kilo.

The departure roll was noticed by the ATCT local controller at 0242:45, when he stated to the north radar approach controller: "No, he's goin on the wrong..." The north radar controller, who noticed the departure on his radar screen, and the airport surface detection equipment (ASDE), replied: "He's on a taxiway." A radio call to the crew to abort the takeoff was not made by either controller, but the airport's emergency phone to the fire department was activated.

After lift-off at 0243, the airplane crew stated: "Tower, Dynasty 011 heavy airborne." The local controller replied: "Dynasty 011 heavy roger, fly heading 240." The crew acknowledged the magnetic heading assignment.

The ATCT controller cancelled the airport fire department's response, but contacted Anchorage Airport operations personnel (Airport 10) who examined taxiway Kilo for any evidence of airplane damage. None was found. Main landing gear tire impressions were found in a snow berm at the west end of taxiway Kilo. The available taxiway distance from Romeo to the end of Kilo is about 6,800 feet.

The airplane proceeded to Taipei and landed without incident.

PERSONNEL INFORMATION

The Government of Taiwan's Aviation Safety Council of Taiwan (ASC), and Taiwan's Civil Aeronautics Administration (CAA), were notified of the incident. ASC and CAA investigators interviewed the flight crew in Taiwan. During the interview, the airplane crewmembers stated that the captain conducted the taxi from the north terminal to taxiway Kilo. All three crew members utilized an airport configuration diagram of the Anchorage International Airport published by Jeppesen Sanderson Inc., as a guide as they taxied for takeoff.

Crew Information

The captain (crew member 1, CM-1) held an airline transport pilot certificate issued by Taiwan. He occupied the left seat. The incident flight was the captain's first trip from Anchorage. It was the first time he flew with the first officer. He had flown with the reserve captain on numerous occasions.

The captain's training at China Airlines, for operations into Anchorage, was received during A-340 simulator training July 27 to 31, 2001.

During an interview in Taiwan with a representative from the ASC, the captain reported that he taxied the airplane, and was the non-flying pilot for this flight. The captain reported that as the airplane was turning onto taxiway Kilo, he noticed bright centerline lights and blue edge lights. He then requested the "before takeoff checklist." The captain did not see any runway threshold markings, or a runway number, but he did not think it was unusual since he believed the threshold for runway 32 was further ahead. The captain reported that the centerline lights were very bright, and he believed that it indicated an active runway. He said that he did not check the heading indicator. The captain recalled seeing an airport runway sign with "K." Other information on the sign was not recalled. The captain noted that his navigational display was set on the 10 nautical mile range in the arc mode.

The first officer (crew member 2, CM-2) held an airline transport pilot certificate issued by Taiwan. He occupied the right seat. The incident flight was the first officer's third trip from Anchorage.

His training at China Airlines, for operations into Anchorage, was received during A-340 simulator training October 13 to 17, 2001, and during an airport route briefing on October 31, 2001.

The first officer was the flying pilot for this segment of the flight. During an interview in Taiwan with the ASC representative, the first officer said that as the airplane was turning from taxiway Romeo, onto taxiway Kilo, he was performing the "before takeoff" checklist. Following his completion of the checklist, the captain stated, "You have control." The first officer estimated the time between the completion of the checklist, and his taking control, was about 3 to 4 seconds. He noted that the airplane was aligned with bright centerline lights that started some distance from the airplane. He did not recall seeing edge lights. He said he thought the airplane only turned about 100 degrees (Romeo to Kilo), but when he saw the bright centerline lights, he believed he was on runway 32. The first officer then initiated the takeoff. He said he did not check the heading indicator. His navigational display was set on the 10 nautical mile range in the arc mode.

The reserve captain, (crew member 3, CM-3) held an airline transport pilot certificate issued by Taiwan, and was a China Airlines check airman. He occupied the cockpit jump seat, centered in the cockpit behind the pedestal. The incident flight was the reserve captain's second trip from Anchorage.

The reserve captain's training at China Airlines, for operations into Anchorage, was received during A-340 simulator training October 13 to 17, 2001, and during an airport route briefing on September 21, 2001.

Prior to the flight from Anchorage, the reserve captain conducted a route check with the captain on the flight from Taipei to New York. During an interview in Taiwan with the ASC representative, the reserve captain said he assisted the crew with airfield orientation during the taxi, and would call out the name of taxiway locations. He said he recalled seeing a sign for taxiway Kilo, and told the captain that the first right turn was taxiway Kilo. The Anchorage ATCT issued the takeoff clearance and he then focused his attention on the actions of the first officer. He said he stopped monitoring the taxi route. When the reserve captain glanced back outside the airplane, he noticed bright centerline lights. The reserve captain commented that he observed the centerline lights on taxiway Kilo on a previous trip to Anchorage and described them as green. On the incident flight, the reserve captain described the centerline lights as white.

Company Information

China Airlines holds a U.S. operating certificate issued under CFR Part 129 (Foreign Air Carrier) regulations.

According to China Airlines personnel, flight crewmembers receive training about airport configurations during simulator training for the airport, by reviewing airport diagrams, or during flights as pilots (accompanied by an instructor pilot) to international destinations.

Chapter 6.3, "Pushback and Taxi," of the China Airlines Procedures and Techniques manual for the Airbus airplane states, in part: "F. Normally, CM1 will taxi the aircraft. Both CM1 and CM2 should have the taxi chart available and in view at all times. The flight crew should exercise vigilance, and always orient the aircraft's position and direction with the taxi chart. G. Flight crewmembers must work as a team during taxi, particularly at unfamiliar airports or in conditions of low visibility. If any doubt exists as to aircraft position or taxi clearances, the aircraft should be brought to a stop and ATC assistance should be requested. Request 'progressive taxi instructions' if necessary."

In the China Airlines aircraft operating manual for the Airbus A-340 airplane fleet, under Normal Procedures, Taxi and Takeoff, the Takeoff Briefing items include a review of taxi routes, and takeoff runway. If CM-2 is the flying pilot, CM-1 will transfer control of the airplane to CM-2, and then announce "Takeoff." The takeoff procedure includes a scan of the Primary Flight Display/Navigational Display (PFD/ND) to check the Flight Management Guidance System Position update and ensure the airplane is on the runway centerline.

The aircraft operating manual for the Airbus did not contain a checklist requirement for the crew to verbalize and verify the runway in use before takeoff.

The aircraft operating manual for China Airlines Boeing 747-200 airplane fleet, under Normal Procedures, Taxi and Takeoff, has a section that reviews taxi routes, and the runway for departure. The procedure states, in part: "1. Before enter the runway: …To corroborate the following required visual reference is established: …the designation of the takeoff runway. 2. After enter the runway: …Make sure active runway marking are being checked as follows: threshold marking; runway designation marking by calling out the runway number; verify runway in use by localizer bearing or GPS coordinates; runway centerline marking; runway touchdown zone markings and fixed distance markings; runway lighting systems are as illuminated as expected."

As a result of this incident, China Airlines revised the Airbus aircraft operating manual to include verbalization and verification of the runway in use.

AIRCRAFT INFORMATION

The cockpit display for the Airbus A340 has electronic generated displays. The selection of the navigation display (ND) depicts the airplane's position as a yellow airplane symbol. Runways are displayed as white symbols. In the arc mode, the heading of the airplane is displayed along a rotating arc near the top of the navigational display. The minimum scale of the display is 10 miles. The airplane symbol remains the same size at all range settings. The runway symbol gets progressively smaller as the range increases. The relationship of the airplane's position (yellow) to a runway (white) will move in the display as the airplane moves on the ground to provide the pilot with a view of how the airplane is oriented to a runway.

Application of takeoff power will produce a primary flight display (PFD) that pictorially centers the airplane symbol on the runway symbol at the threshold, if the airplane is aligned with a runway. If not aligned, the airplane orientation and the runway orientation will remain unchanged.

China Airlines provided data about the incident airplane. The takeoff gross weight was 571,505 pounds. The takeoff distance was calculated as 7,746 feet. The accelerate-stop distance was calculated as 9,007 feet. The takeoff speeds were: V1, 141 knots; VR, 150 knots; V2, 157 knots.

METEOROLOGICAL INFORMATION

At 0253, an Aviation Routine Weather Report (METAR) at Anchorage was reporting in part: Wind, 030 degrees (true) at 5 knots; visibility, 10 statute miles; clouds and sky condition, clear; temperature, 3 degrees F; dew point, -13 degrees F; altimeter, 29.91 inHg.

The natural ambient light condition at the airport consisted of a dark night without any moon illumination. No meteorological obstructions to visibility were present.

COMMUNICATIONS

Review of the air to ground radio communications tapes maintained by the FAA at the Anchorage International Airport ATCT facility, revealed that the airplane crew successfully communicated with the positions of clearance delivery and local control. Timing of the takeoff clearance issued by the ATCT local controller, indicated that it was given as the crew was on taxiway Romeo, preparing to turn right onto taxiway Kilo.

The incident airplane crew did not utilize a radio operator. All on-ground communications were conducted with CM-2.

A transcript of the air to ground communications between the flight crew and the Anchorage ATCT is included in the public docket for this investigation.

AERODROME AND GROUND FACILITIES

The Ted Stevens Anchorage International Airport is owned and operated by the State of Alaska, Department of Transportation. The published elevation of the airport is 152 feet mean sea level. The airport is a 14 CFR 139, Index E facility.

The airport is equipped with two parallel hard-surfaced runways on a 060 to 240 degree magnetic orientation, and a single hard-surfaced runway on a 140 to 320 degree magnetic orientation. Runway 32 is 150 feet wide, and is equipped with high intensity runway and centerline lights. The intensity of runway lighting is variable through five settings.

The north airline terminal, from which the airplane began its taxi for takeoff, is situated east of taxiway Romeo, about one-half mile north of taxiway Kilo.

Taxiway Romeo is 80 feet wide, and parallels runway 32, about 540 feet east of the runway. It is equipped with blue taxiway edge lights, and green centerline lights. The in-ground centerline light fixtures on taxiway Romeo, manufactured by Honeywell, consist of two opposing green lenses, each powered by a 48 watt halogen bulb. The taxiway has yellow edge stripes and a yellow centerline stripe.

Taxiway Kilo is 75 feet wide, and parallels runway 6L/24R, about 480 feet north of the runway. It is equipped with blue taxiway edge lights, and green centerline lights. The in-ground centerline light fixtures on taxiway Kilo, manufactured by Crouse Hinds, consist of a single bi-directional green lens, powered by a single 65 watt halogen bulb. Green in-ground taxiway centerline light fixtures do not extend through the extended portion of runway 32. The taxiway has yellow edge stripes and a yellow centerline stripe.

Illumination of taxiway Romeo and Kilo edge lights is either on or off.

The intensity of illu

NTSB Probable Cause

The captain's selection of a taxiway instead of a runway for takeoff and the flightcrew's inadequate coordination of the departure, which resulted in a departure from a taxiway. A factor in the incident was inadequate airline operator's procedures that did not require the crew to verbilize and verify the runway in use prior to takeoff.