Investigation Summary
On October 26, 1989, the Boeing 737-200 was scheduled for a short domestic flight to Taipei-Sungshan Airport. The crew, consisting of an experienced captain and a novice first officer, departed from Runway 03 at Hualien Airport. However, they mistakenly followed the Standard Instrument Departure (SID) intended for Runway 21. While the correct procedure for Runway 03 required a right turn toward the open sea, the Runway 21 procedure dictated a left turn. This error directed the aircraft straight into the Chiashan mountains. The aircraft struck the terrain at an elevation of approximately 7,000 feet (2,100 meters) roughly three minutes after takeoff, approximately 5.5 km north to 10 km northwest of the airport. The impact and subsequent fuel explosion destroyed the aircraft, leaving no survivors. Contributing factors included poor flight preparation, failure to follow the pre-takeoff checklist, and limited visibility due to night conditions.
Final Conclusions
The investigation concluded that the primary cause was pilot error, specifically the failure to verify the correct runway for departure. A secondary factor was the failure of air traffic control to monitor the aircraft's taxi path and identify the runway excursion. The combination of these errors led to a Controlled Flight Into Terrain (CFIT) when the crew executed a turn into mountainous terrain while believing they were following a safe path over the ocean.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Standard Instrument Departure (SID)
The published flight path the crew followed, which was incorrect for their actual physical location.
Air Traffic Control (ATC)
Ground control failed to identify that the aircraft had taxied to and departed from the wrong runway.
Interesting Facts
- 01The aircraft was only three years old at the time of the accident.
- 02The crew mistakenly used the Runway 21 departure procedure while taking off from Runway 03.
- 03The correct procedure for Runway 03 required a right turn toward the sea to avoid terrain.
- 04The aircraft struck the mountain at an elevation of 7,000 feet.
- 05Contributing factors included poor crew coordination and failure to complete the pre-takeoff checklist.
Safety Actions & Advisories
Pilot Training and Verification
China Airlines implemented more rigorous simulator checks and runway verification procedures for all flight crews following the accident.