LEVEL 3 Final report

Based on the investigation authority's final report.

Date
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Occurrence
Wrong runway takeoff and collision with construction equipment
Location
Runway 05R, CKS Airport, Taoyuan, Taiwan
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Operator
Singapore Airlines Limited
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Aircraft
Boeing 747-412B
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Registration
9V-SPK
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Route
Taipei CKS to Los Angeles
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People aboard
179: 159 passengers and 20 crew
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Fatalities
83: 79 passengers and 4 cabin crew
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Survivors
96: 71 injured and 25 uninjured
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Topics
Crew coordination, Emergency evacuation, Runway identification, Severe weather, Airport guidance and warnings

This photograph is cropped for the banner. See the full photograph, credit, licence and what it shows.

Photographs and geographic context

Singapore Airlines Boeing 747 9V-SPK in the colorful Raffles livery at Manchester.

9V-SPK at Manchester before the accident.

Photo: Ken Fielding, CC BY-SA 3.0

Image info

The accident aircraft, photographed at Manchester on 5 August 2000.

Image source

Original photograph unchanged. Responsive WebP copies resized without cropping.

Geographic context

Geographical orientation for Singapore Airlines 006CKS Airport, Taoyuan; Los Angeles International Airport. Flight 006 was scheduled from Taipei CKS to Los Angeles. The collision occurred on Runway 05R between Taxiways N4 and N5. Airport markers show approximate geographic positions.12NORTH UP / SCHEMATIC / NOT A RECORDED FLIGHT TRACK
  1. CKS Airport, Taoyuan
  2. Los Angeles International Airport
Flight 006 was scheduled from Taipei CKS to Los Angeles. The collision occurred on Runway 05R between Taxiways N4 and N5. Airport markers show approximate geographic positions. Basemap: Natural Earth, public domain.
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What happened

Flight 006 was cleared to take off from Runway 05L. During taxi in darkness, heavy rain and strong winds, the captain followed green lights through a continuous right turn onto parallel Runway 05R. Part of 05R was closed for construction. The aircraft accelerated into barriers, construction pits and heavy equipment, broke apart and caught fire.

Read the full incident Follow what happened, from the flight to the investigation findings.

What investigators concluded

ASC found that the crew lost situational awareness and took off from the wrong runway. It identified deficiencies in airport guidance, warnings, airline procedures and oversight as risks. Singapore's Ministry of Transport argued that the airport deficiencies were major causal factors.

Evidence behind this explanation

Flight 006 and the turn onto Runway 05R

1,780 words / about 9 minutes to read. Based on the investigation records cited below.

A departure in typhoon weather

On the night of 31 October 2000, Singapore Airlines Flight 006 was preparing to leave Chiang Kai-Shek International Airport in Taoyuan for Los Angeles. The aircraft was 9V-SPK, a Boeing 747-400 identified in the aircraft records as a Boeing 747-412B. There were 179 people aboard: 159 passengers, three pilots and 17 cabin crewmembers. Heavy rain, strong winds and reduced visibility accompanied the approaching typhoon Xangsane. The aircraft carried approximately 124,800 kilograms of fuel for the flight across the Pacific.

The pilots had flown the preceding sector from Singapore to Taipei and rested at a hotel. They reported for duty at 21:53 and reviewed their departure documents before boarding at Bay B5. Those documents included a notice that construction had closed part of Runway 05R between Taxiways N4 and N5. The crew knew about the closure and understood that the remaining portions of 05R were available for taxiing. The captain would taxi the aircraft and conduct the takeoff.

Runway 05R lay beside the intended departure runway, 05L. It had originated as a parallel taxiway in the airport design and retained green taxiway centerline lights. A plan to redesignate it as Taxiway NC had been delayed. On the accident night, it still carried runway markings while sections outside the construction area continued to serve taxi traffic.

Sources for this section

The route to Runway 05L

After pushback, the crew received taxi clearance at 23:05:57. The controller initially named Runway 06, immediately corrected the instruction to 05L, and specified Taxiways Sierra Sierra, West Cross and November Papa. The first officer acknowledged November Papa for Runway 05L after the captain repeated the route. As they taxied, the pilots discussed slippery pavement, crosswind and alternate airports. Kaohsiung and Hong Kong had closed, adding to the operational decisions they were making during the ground movement.

At 23:12:58, shortly after the aircraft turned onto November Papa, the crew changed to the tower frequency. The tower told Flight 006 to hold short of Runway 05L. Approaching the southwest end of November Papa, the pilots discussed the next turn as November One. At 23:14:58 the captain asked the first officer to report that they were ready. The tower then cleared them to enter Runway 05L and hold, followed by takeoff clearance for 05L. The wind was reported from 020 degrees at 28 knots, gusting to 50.

Reaching 05L required a right turn of about 90 degrees from November Papa onto November One, followed by a straight section past the threshold area of 05R. The aircraft needed to continue toward 05L before turning onto its centerline. That intermediate straight section was missed. The captain followed the curved green lights through a continuous right turn of about 180 degrees and lined up on 05R.

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Lineup and the takeoff roll

The before takeoff checklist was completed at 23:15:48. Two seconds later the first officer referred to the green lights. The captain slowed for the turn because of the slippery surface. None of the three pilots verified the taxi route during the continuous turn or orally confirmed which runway they had entered. All three believed the aircraft was on the cleared departure runway.

The first officer then observed that the Para-Visual Display, or PVD, had not lined up. This instrument used the instrument landing system localizer signal to provide centerline guidance. The captain and first officer had activated it as an additional reference. ASC found that it remained shuttered because the aircraft was outside the valid localizer region for 05L. The crew continued preparing for a visual takeoff, increased the windshield wiper speed and accepted the runway view ahead.

Engine noise increased at 23:16:44 as the takeoff roll began. Both the first officer and relief pilot called 80 knots eleven seconds later. At 23:17:16, the captain reacted to an obstacle ahead; the first impact sound followed a second later. The aircraft had accelerated for about 33 seconds before reaching the construction area. At the end of the flight data recording, indicated airspeed was about 158 knots and ground speed about 131 knots.

Sources for this section

Collision and breakup

The aircraft struck concrete barriers and heavy equipment in the closed section between N4 and N5. The obstacles included two excavators, two vibrating rollers, a bulldozer, an air compressor cart and a pile of reinforcing steel. ASC reconstructed the breakup from the wreckage distribution, marks on the pavement, equipment positions and the site survey.

The reconstruction began with a body landing gear door striking a concrete barrier and the left body gear crossing a construction pit. Its forward tires hit the far edge, causing at least one tire to fail. One excavator then damaged the lower left fuselage and main equipment center as it moved beneath the aircraft. It subsequently struck the horizontal stabilizer, damaging the structure and compromising its fuel supply.

The left engines struck reinforcing steel and a second excavator and separated from the wing. Impacts on the left side and unequal thrust began a counterclockwise rotation. The right inboard engine also struck the ground and separated. After further collisions, the aft fuselage most likely broke away before Taxiway N6 and rolled onto its left side. Additional impacts tore away the left wingtip and the remaining engine as the wreckage continued moving. Fuel spilled and burned along the path. Impact forces and the resulting fire destroyed the aircraft.

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Escape, fire fighting and the toll

The breakup left occupants facing damaged exits, dense smoke, fire, unusual cabin attitudes and strong wind outside. The public address system failed. ASC could not determine whether that failure significantly delayed evacuation or affected survival. Much of the evacuation equipment and training was overwhelmed by the combined conditions. No escape slide remained fully functional for the survivors. Wind blew the left upper deck slide over the fuselage, while lateral impact forces caused the slides at doors 4R and 5R to inflate inside the cabin.

At 23:17:36, the tower controller activated the emergency bell after seeing explosions and fire along the aircraft's path. Airport rescue and fire fighting personnel reached the site in approximately three minutes. They extinguished a small fire in the tail section immediately. In severe weather, the forward and middle fuselage fires were suppressed in 15 minutes and brought under positive control in 40 minutes. Strong wind and heavy rain disrupted medical and rescue procedures; the first ten survivors taken to hospital in airport ambulances had received no proper triage.

Eighty-three people died: 79 passengers and four cabin crewmembers. Thirty-nine people suffered serious injuries and 32 had minor injuries. Twenty-five were uninjured, giving a total of 96 survivors. The concentration of fire strongly affected survival. In the main deck cabin between rows 31 and 48, 64 of 76 passengers died and the remaining twelve were seriously injured. All passengers in the tail section survived, where there was less fire.

Sources for this section
Singapore Airlines Flight 006, collision on a partially closed runway during takeoff2.6.1 Emergency Evacuation Operations and Training | Printed page 223 | PDF page 246Find this passage in evidence search

ASC findings on the wrong runway

ASC found that the crew lost situational awareness and commenced takeoff from the wrong runway. The taxi route had not been reviewed sufficiently to ensure that every pilot understood the need to pass 05R before reaching 05L. Charts were available, but the pilots did not verify the route during the turn or confirm the runway aloud. The captain's expectation of reaching the departure runway and the conspicuous curved green lights directed his attention toward 05R. The other two pilots did not challenge the takeoff.

The council placed the effects of weather and moderate pressure to depart before the typhoon among its findings related to probable causes. It found that strong crosswind, low visibility and slippery pavement subtly affected decisions and situational awareness. The aircraft was airworthy before the accident. ASC also found no undue organizational pressure from the airline to depart that evening.

Separate findings related to risk covered deficiencies in the airport and airline systems. The straight section toward 05L had only four unevenly spaced centerline lights where ASC said sixteen closely spaced lights were appropriate. Guard lights and stop bars were absent. Warnings at the entrance to 05R failed to provide a final defense against mistaken entry. Airline procedures lacked an active runway confirmation check and detailed low visibility taxi procedures. The relief pilot's duties also depended on the captain's discretion; the captain had assigned him to check crosswind limitations.

Sources for this section

Singapore's separate disagreement

Singapore's Ministry of Transport investigation team disputed the balance and causal classification of ASC's conclusions. Its comments were appended to the final report. The Singapore team accepted that the pilots mistakenly attempted takeoff from 05R while believing they were on 05L. It argued that major deficiencies in airport design, lighting, signs and markings played a critical causal role and belonged among the findings related to probable causes.

The team said that there were no visual warnings or physical barriers preventing lineup on 05R. It described missing or defective guidance toward 05L and concluded that the crew had followed a single visible line of lights onto 05R. Its comments emphasized the runway threshold markings that remained in place, the powerful visual impression of an operating runway, and airport defenses that could have interrupted the error.

Singapore also challenged ASC's investigation method and some cockpit instrument analysis. It objected to exclusion of accredited representatives from deliberations about analysis, causes and recommendations. On the PVD, it argued that the approved flight manual supplement did not refer to using the instrument to identify the correct departure runway. ASC's position was that the display provided information about whether the aircraft was correctly positioned for takeoff. The authorities therefore differed over both the contribution of airport deficiencies and the interpretation of some indications available to the crew.

Sources for this section

Runway confirmation and airport defenses

ASC approved its final investigation report on 23 April 2002. Its recommendations to Singapore Airlines included a surface movement training program, progressive taxi instructions in low visibility, closer attention to relevant instrument indications and a checklist item requiring positive visual identification of the departure runway. It also called for improved crew resource management and an alternate method of commanding evacuation after public address failure. Recommendations to Taiwan's CAA addressed progressive taxi guidance, airport surface detection equipment and stronger safety oversight.

The report recorded changes submitted by the participating authorities. According to Singapore's ministry, checklists had been amended to require everyone in the cockpit to visually confirm the runway designation before takeoff. Operating instructions now required the taxiing pilot to refer to signs and markings, and the other pilot to confirm the route against airport charts. Training documentation had also been amended to cover ground operations in poor visibility.

Taiwan's CAA reported new markings, additional taxiway centerline lighting from N1 and runway guard lights, with several installations recorded as completed by 31 January 2002. Stop bars were still listed as planned. ASC stated that it had not verified the safety actions submitted for this part of the report. The recommendations addressed the navigation error, airport guidance and warning systems, crew coordination, and the difficulties of escaping a damaged aircraft in severe weather.

Sources for this section

Return to the short summary / Source status and limitations

How the sequence developed

Follow the main stages, then open the evidence beneath each step.

  1. A cleared route past 05R

    The intended route to 05L passed the threshold area of 05R, where aircraft could still taxi outside the construction closure.

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  2. Continuous turn toward green lights

    The captain followed the curved lights onto 05R. The crew did not verify the route or confirm the runway aloud.

    Read supporting evidence
  3. Conflicting cockpit indication

    The PVD remained shuttered outside 05L's valid localizer region. The crew continued with the takeoff preparations.

    Read supporting evidence
  4. Acceleration into construction

    The takeoff roll ended in collision with barriers, equipment and construction pits in the closed section of 05R.

    Read supporting evidence
  5. Breakup and fuel fire

    The impacts tore away engines and separated the fuselage. Fire and severe weather restricted escape and rescue.

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A simplified reading of the investigation findings. The sequence does not replace the full report or imply that every contributing factor is shown.

Sequence of events

Times are Taipei local time, UTC plus 8 hours. The first impact was recorded at about 23:17:17. Expand an event to see its evidence.

  1. 21:53Departure preparation

    The pilots reported for duty and reviewed the dispatch documents, including the notice of partial closure of Runway 05R.

  2. 23:05:57Taxi clearance for 05L

    The controller corrected the runway from 06 to 05L and cleared Flight 006 via Sierra Sierra, West Cross and November Papa.

  3. 23:12:58Contact with the tower

    After turning onto November Papa, the crew changed to the tower frequency and received an instruction to hold short of 05L.

  4. 23:15:22Takeoff clearance

    The tower cleared Flight 006 for takeoff on 05L with wind from 020 degrees at 28 knots, gusting to 50.

  5. After 23:15:48Turn onto 05R

    After completing the checklist, the crew followed the green lights through a continuous right turn from NP through N1 onto 05R.

  6. 23:16:07PVD indication discussed

    The first officer said the PVD had not lined up. The crew continued preparing for takeoff.

  7. 23:16:44Takeoff roll begins

    Engine noise increased as the aircraft began its takeoff roll on 05R.

  8. 23:17:17First impact

    The aircraft struck the construction area. Recorded airspeed was about 158 knots at the end of the data recording.

  9. 23:17:36Emergency alarm

    The controller activated the fire station bell after seeing explosions and fire along the takeoff path.

  10. 23 April 2002Final report approved

    ASC approved its investigation report. Singapore's comments challenging its analysis were included in Appendix 7.

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Search extracted report prose, with original page references. Short results link to the full document.

Questions readers ask

How did Flight 006 reach the wrong runway?

The aircraft turned continuously from Taxiway NP through N1 onto 05R. The route to 05L required a right turn onto N1 and then a straight section past 05R. None of the pilots confirmed the runway aloud.

Why were the evacuation slides ineffective?

ASC found that impact forces, fire and strong wind prevented every slide from being fully functional. The upper deck slide blew over the fuselage, and two main deck slides inflated inside the cabin.

Why did Singapore dispute the ASC findings?

Singapore's investigation team said the airport guidance led the crew along a single visible line of lights onto 05R. It argued that airport deficiencies played a critical causal role and should be included among the findings related to probable causes.

What the evidence can and cannot establish

Safety follow-up

Actions and recommendations are described at the dates of the cited records. A recommendation is not proof of implementation.

Positive runway confirmation

ASC recommended a formal checklist item for positive visual identification of the takeoff runway and a surface movement training program.

Read supporting evidence

Changes reported at CKS

Taiwan's CAA reported new N1 centerline lighting, signs, markings and runway guard lights. Stop bars were listed as planned. ASC had not verified the submitted safety action status.

Read supporting evidence

Classifications, with reasons

These labels organise the evidence. They are not a ranking of causes. A shared label means a shared research topic, not an identical mechanism.

CauseRunway identification

ASC found that the pilots failed to verify the taxi route and runway before beginning takeoff on 05R.

Circumstance and causal influenceSevere weather

Heavy rain, strong wind, low visibility and slippery pavement affected the crew's workload and situational awareness during taxi and lineup.

Risk finding and disputed causal contributionAirport guidance and warnings

ASC identified deficient lighting, markings and runway entrance warnings as risks. Singapore's team considered airport deficiencies major causal factors.

Cause and riskCrew coordination

The pilots did not confirm their runway or challenge the takeoff. The airline lacked specific relief pilot duties and an active runway confirmation checklist item.

Survival factorEmergency evacuation

Breakup, fire, smoke and strong wind damaged escape routes and prevented the slides from being fully functional.

Read alongside

These comparisons connect specific research topics. Shared circumstances do not establish identical causes. Evidence from both investigations is provided below.

Comair Flight 5191

Comair 5191 also began takeoff from the wrong runway. The NTSB attributed that accident to failures to use available location cues and crosscheck the runway before takeoff. Flight 006 collided with construction equipment on partially closed 05R in typhoon weather. Comair's causal findings additionally included nonpertinent cockpit conversation and the clearance rules for runway crossings.

Read supporting evidence

Further investigation records

Explore the records below for additional context. They open on the publisher's site and are not all included in our report search. Source reuse terms apply.

  • ASC final report and Singapore comments

    NTSB / investigation record

    The investigation covers the taxi route, cockpit indications, airport facilities, breakup, survival and safety recommendations. Appendix 7 contains the participating authorities' comments.

  • TTSB investigation record

    NTSB / investigation record

    The authority's record for the 31 October 2000 accident and its final report.

Sources and transparency

ASC approved the final investigation report on 23 April 2002. Singapore's Ministry of Transport comments are appended to it.

Source limitations

ASC could not determine whether airport surface detection radar would have provided useful warning in the heavy precipitation.

Singapore Airlines Flight 006, collision on a partially closed runway during takeoff

Aviation Safety Council, Taiwan
Final report ASC-AAR-02-04-001, approved 23 April 2002, English edition

Official report PDF, hosted by ttsb.gov.tw

Open source document

508 PDF pages.

Copyright 2002 Aviation Safety Council. Short excerpts support original analysis; the full report and its figures remain with the authority. Source terms.

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Editorial record

Kevin Murphy writes the incident accounts on AirlineIncidents.com, out of a long interest in aviation safety and the lessons each investigation leaves behind.

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Revision history

: ASC final investigation findings and the appended Singapore Ministry of Transport disagreement.

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