Incident Overview

Description
Air China flight 129, a Boeing 767-200, impacted a mountain while on approach to Busan-Gimhae, South Korea, killing 129 occupants; 37 survived the accident. Air China flight 129 departed Beijing at 08:37 on a scheduled flight to Pusan-Gimhae in South Korea. The en route part of the flight was uneventful. At 11:06 the second officer contacted Gimhae Approach. At that moment the airplane was 32 nm from the airport at an altitude of FL170. The approach controller cleared the flight to descend to 6000 feet. Runway 36L was in use and the crew could expect a straight-in approach. at 11:09 the controller notified the crew that the runway was changed to 18R, with winds 210 degrees at 17 kts. This meant a circling approach which none of the crew members had flown yet at Pusan. The captain and first officer then discussed the approach to be flown. The captain cautioned: “We won’t enlarge the traffic pattern, the mountains are all over that side.” At 11:13 the flight was further cleared down to 2600 feet. Two minutes later the approach controller radioed: “Air China 129, turn left heading 030 cleared for ILS DME runway 36L, then circle to runway 18 right, report field in sight.” At 11:17 they captured the ILS and were cleared further down to the circling altitude of 700 feet. The landing gear was extended and flaps set at 20 degrees. Then the controller instructed the flight to contact Gimhae Tower and to circle west. The second officer responded but did not read back the frequency change. The captain then instructed the first officer to disconnect the autopilot and turn left. From his position in the right hand seat the first officer was able to observe the runway. As the aircraft passed abeam the runway the autopilot was reengaged with heading select. At that moment the approach controller again contacted flight 129 instructing them to contact the tower. The crew were busy looking outside to see when they passed abeam the end of the runway. Simultaneously the Gimhae Tower controller contacted the flight using the emergency frequency. As they passed abeam the threshold at 11:20:02 they started timing to measure the commencement f turning to base. Eleven seconds after the call on the emergency frequency, the second officer reported to the Tower controller that they were on the circle approach. At 11:20:17 the captain took over control from the first officer and said he was going to turn base. He slowly began a widening turn, causing the first officer to urge him: “turn quickly, not too late.” Meanwhile the flight was cleared to land . At 11:20:32 the captain disconnected the autopilot and banked the plane to the right. Twenty-two seconds later the first officer cautioned: “Pay attention to the altitude keeping,” and the captain asked him to help him get a visual on the runway. Due to the limited visibility they were not able to see the runway. The first officer then advised the captain to initiate a go around, but the captain did not respond. At 11:21:15 the first officer said, “Pull up! Pull up!” Pitch attitude was increased to 11.4 degrees but thrust was not increased. Two seconds later the aircraft impacted a mountain, about 4.6 km from the runway. FINDINGS RELATED TO PROBABLE CAUSES: 1. The flight crew of flight 129 performed the circling approach, not being aware of the weather minima of wide-body aircraft (B767-200) for landing, and in the approach briefing, did not include the missed approach, etc., among the items specified in Air Chinas operations and training manuals. 2. The flight crew exercised poor crew resource management and lost situational awareness during the circling approach to runway 18R, which led them to fly outside of the circling approach area, delaying the base turn, contrary to the captains intention to make a timely base turn. 3. The flight crew did not execute a missed approach when they lost sight of the runway during the circling approach to runway 18R, which led them to strike high terrain (mountain) near the airport. 4. When the first officer advised the captain to execute a missed approach about 5 seconds before impact, the captain did not react, nor did the first officer initiate the missed approach himself.
Source of Information
http://www.skybrary.aero/index.php/B762,_vicinity_Busan_Korea,_2002_(CFIT_HF)http://www.skybrary.aero/index.php/B762,_vicinity_Busan_Korea,_2002_(CFIT_HF)Primary Cause
Poor Crew Resource Management and Lack of Situational Awareness during a Circling Approach to Runway 18R.Poor Crew Resource Management and Lack of Situational Awareness during a Circling Approach to Runway 18R.Share on: