PETITION ON APPEAL FROM DECISION OF THE CIVIL AERONAUTICS ADMINISTRATION

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 02145420
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 19
• Document Creation Date: March 9, 2023
• Document Release Date: August 21, 2020
• Case Number: F-2015-00256
• Publication Date: November 26, 1964

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OFFICE SI-ENT AND SECRETARY
Translation No. C-2486
PETITION
On Appeal From Decision of the Civil AerotaUtid6 Administration
Date.; November 26, 1964
TO 4 Ministry of Commutieations
Air Asia Company Limited
From � .1 Civil Air Transport Company Limited
On June 20, 1964 at apprWcitately 540 piO4 4 C46, aircraft Owned by
Civil Adr Transport Compaty Limited (herefitafter.AT) and beating ,
aircraft registration number B.908 crashed neat TaidhUng, on a flight
from that city to Taipei. The flight WaS part 5f CA' S domestic
service which operated Taipei-TaichUng,.Taitat..MakUtig,,,KaohsiUng and
return via the same intermediate pointS. All 57 perSotS on .board
were killed, It was the first fatal ci ash. it the history of CArs
scheduled airline operations spanning Softie 15 year0f.and indeed in
the 15 years of Scheduled civil air operations' it Taiwati
Essential facts as to which there is no Controversy include the
following;
(a) The aircraft departed Taichung with almost a full load of passen-
gers (one vacant seat), bUt virtually no cargo, at abbUt 5;32 p;
(b) The aircraft took off it a southerly direction, then propeeded
to turn easterly and northerly t4htil it reached a general northerly
direction;
) In its last contact with ground eOttrol, the aircraft IreWf
several minutes after takeofff, Stated that all was
Distribution;
AACL MGDR (via President)
President
AVP
SA/P
A/P-P
VPFO
VPTS
VpT&S.
VPGA
T/C
DP (Safety Adviser)
DSY
File (2)
CATCL: CB
Retark:
This� Petition- (and copy thereof)
duly delivered to and redeipted
by MCC (and CAA) NdVetter 26, 1964
.-
for Office of Vice President and Sedretary
November 27, 1964
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�(d) Upon reaching a point approximately six miles north of the
Suinan airport (Taichung) and an altitude of approximately 1600
feet (some 5-6 minutes after take-off) the aircraft WS seen to
turn westward and shortly thereafter descend rapidly along
an apparently straight track and strike the ground at an
angle of about 30' with the loft wing .in a slightly low attitude
along an azimuth of approximately 280 degres;
(e) On crashing into a. rice paddyl the. aircraft disintegrated;
(f) Most parts .of the aircraft were recovered at the scene, one
notable exception being a portion of the left propeller power
unit. (This unit was obviously complete on impact, however,
as indicated by the fact that the spinner forming its cover
was recovered at the Site. . See pdhoto'of subject part appehded
as Appendix B and propeller assembly attachment to Ldninistra
tion's Report).
Quite understandably, the tragic loss of life in this accident gave
rise to feelings of horrified .shock in every quarter. These feelings
were rendered none the loss intense by the fact that the deceased
passengers included many important figures from the Asian motion
picture industry, who had just .concluded their participation in the
Asian Film Festival and were returning from a sight-seeing trip to.
Taichung. Among these. were Loke an Tho of Malaysia, one of Asia's
most important industrialists, his wife and several of his colleagues.
i,lso world-wide attention was made inevitable by the fact that 19
ilrericans were among .the dead.
Immediately, multi-faceted investigations were undertaken in an atros-.
phere of considerable strain and confusion. Responsibility for the
supervision of these investigations was assumed by the Civil 4.eronau-
tics Administration*. At the invitation of the Ministry and_pre-
sumably because of the lack of locally. avaiable personnel skilled in
*Unlike the basic aviation laws of certain other nations, the Civil
t,viation Code does not spell out the safety investigation responsi-
bilities of the hdministration or of the Ministry of Communications
(cf., e.g., Title. VII of the U.S. Federal Aviation Act of 1958).
Petitioners, however, dc not object -t,c. the fact that such investiga-
tions were ordered under the Ministry's and the Administration's
general powers of supervision of aviation and under the provisions
of the duly promulgated Civil Air Regulrtions. On the contrary,
petitioners, vitally concerned with the continuing safety of air'
transportation generally, welcomed the fact of these investigations
and undertook to cooperate wholeheartedly therewith.
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this field and the sizeable number of izoerican casualties, two
U.S. Civil L,eronrutics Board experts were brought from Washington
to join the investigation tear. ;.nalysis of evidence collected
at the scene of the crash was begun. After several days, the
wreckage was removed to Tainan to perrit more searching study.
the same time the first ixcident Board Meeting was convened on June
25, 1964 and inquiries were begun intc the history of the flight
and of the aircraft and into the backgrounds of the passengers.
Because cf pressure frcm various sources (including members of the
Legislative Yuan, the Control Yuan, various news media and re-
presentatives of persons killed in the crash) it proved impossible
to carry forward these investigations in the detached and analytical
atmosphere necessary to valid conclusicns. Drafts of various re-
ports of investigation were ccncluded as early as July 13, and a
second Lccident Beard Meeting held the following day*.
On July 15, 1964, the Minister of Communications, when called before
the Legisletive Yuan, summarized the findings of the Board under
the title "Salient Points of Investigation Report", as follows:
"1. The accident Inquiry Board is unanimous in eliminating the
following factors as possible causes of the accident:
(1) Weather;
(2) traffic control;
(3) Navigational aid;
(4) Age of plane or metal exhaustion of part of airframe
structure;
(5) In-flight fire;
(6) Crew time in excess of prescribed limits;
(7) Fuel.
"2. Mr. Pahl pointed cut that from an inspection made of all air-
frame strudural parts, there was no evidence that the aircraft
had any crack from metal exhaustion or any crack that could lead
to structural failure prior to crash, the burns and damages on
all airframe parts being all found as to have arisen from fire
upon impact with the ground.
"3. USCLB experts who tested on the control cables affirmed in a
report that the cable used for. control.of right elevator trim
*t this second Meeting, the Beard allowed virtually no participation
by the Petitioners in its analysis and deliberations. Only one
representative was perritted to attend and he was isolated from the
Board. Two others were called in for cursory questions only. No
opportunity was afforded to submit the results of Company investi-
r7ations in any detail.
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tab was broken upon inpact with the ground, net during flight,
but that the cable used for control of left elevator trim
tab showed substantial wear and tear, although the breakage
was more probably also due to impact with ground. The
majority board opinion is that even if these cables became
broken during flight prior to crash, the crew should have
encountered no particular difficulty in controlling the plane
in continued flight.
1'4. Mr. Hallman who inspected the two engines stated in his re-
port that the engines had no obvious trouble, but .that because
the power unit for left propeller was yet to be located from
scene of crash, search for the power unit should continue in
order to enable further study and .evaluation of condition of
flying for the very short moment just prior to crash.� Mr.
Hallran further pointed out that the engine ranifold gage
readings were similar for both engines and that blade butt
gear.darages sustained upon impact with ground were located
at approximately similar positicns and for an approximately
similar number of2partelthough there was a difference in,
REM of more than 1,000. The Board deemed-that such would
cbvicusly give rise to everspeeding of left propeller.
I5, Based on the substantial wear and tear of left centrel cable
and t;ne cverspeeding of left propeller, the Board deemed that
normal time maintenance for the aircraft was not attentively
carried out and that there was also indication of improper
handling en the part of the pilot."
Although these points (a) were arrived at in the hurried fashion
just described, (b) differed substantially from the reports of the
Lmerican experts to. the extent of reversing those experts' findings
cn crucial issues, (c)filed to accord with the available evidence
and (d) ignored vital areas of possible cause, they survive in only
slightly altered form in the C's final report, first made available
to Petitioners on October .271 1964, an abridged version of which
appears to have been furnished tc the Legislative Yuan on October 3,
1964. Their adverse effects upon Petitioners are widespread and
virtually irreparable, because they (a) severely and in unwarranted
fashion damage CO's worldwide reputation for scrupulous adherence
to safety standards in its flight operations and (b) .unfairly accuse
Lir Lsia Company Limited,,�one"cf the world's most highly regarded
maintenance ccrpanies2 of accomplishing CAT's aircraft maintenance
in "inattentive" fashion.
On the basis of the matters hereinafter discussed and of all of.the
evidence, the Ministry of Communications is respectfully asked to
rtmedy, to the extent new possible, these unwarranted findings and
to rule as follows;
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1. The investigation by the CA cf.this accident was not properly
pursued in numerous particulars, and the validity of its
findings are seriously compromised as a result thereof;
2. There is nc credible evidence that the accident resulted from
an cverspeeding left prop311er or a loss of power from the
left engine (or any other mechanical ralfunction);
3. There is no credible evidence that the accident was due to
poor piloting technique cr any other deficiency on the part of
the aircraft crew;
There is nothing in the condition of the left trim tab control
cable (or any other part of the aircraft, engines or propellers)
to suggest, much less establish, that raintenance of aircraft
B-908 was not carefully and properly accomplished.
5. On the basis of all the evidence, the cause of the crash re-
mains unknown, but investigation shculd be continued and even
brcadened to include, inter alia, more searching analysis into
the pessibilities et attempted high-jacking or other violent
develcprents aboard the aircraft.
I.
The Conduct of the Ci,Als Inquiry Renders .
Unreliable its Ccnclusions.
The atmosphere surrounding the investigaticn, outlined above,
ray tend tc excuse, but certainly not justigy,its premature con-
clusions with respect to the accident, from which it has consistently
refused to r treat. The errors cf substance to which this hasty
appracch has led are analyzed in later pertions of this petition.
For present purposes, attention is invited to the following defects
in investigative technique and evaluation that underlie its report;
A. The Ltterpt to Reach Early Conclusions.
The "Investigation and Werk ,genda" contained in the Adminis-
tration's report shows that in total 27 days in an elapsed
period of 30 days were expended in investigation and study of
this accident. Five such days were after the announcement
to the Legislative Yuan of the "Salient Points" and were taken
up largely, with documentation of those points, translaticns,
etc. By contrast, the U.S. Civil Aeronautics Beard (the
wcrld's most experienced body in ratters of this kind), for
example, invariably takes rany months and even years to
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pinpoint, when possible, the causes of air accidents*.
Moreover, the minutes of the Accident Board meeting of July
14, 1964 show numerous areas wherein the investigation was
incomplete, and the consensus of the meeting was that the
work of the Board was far frcr ccrpleted**, yet the CAAls
agenda shows that the "Salient Points" were prepared and
printed on July 14, 1964, following the meeting.
Intensive public pressure for irmr?diate answrs as to cause of
catastrophes that ray involve the human element i not con-
fined to aircraft accidents nor to the Republic of China. But
only by slow and painstaking collection of data from all
sources of conceivable relevancy and by careful analysis of
such data, free from pressures to reach quick conclusicns
and to avoid retreat from conclusions once reached, can ac-
cident investigaticn provide reaningful ccntributicns tc the
ultirat, purpose -- the prevention of reoccurrence. It is
respectfully submitted that the rush to pr,mature determinations
undoubtedly impelled by the inquiries of the Legislative Yuan,
largely defeated the essential purposes of the CAA, investi-
gaticn.
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B. The Failure to Utilize the Eyl,ertise cf the American Exerts.
It is clear from the minutes of the second Accident Board
Meeting that the .twO U. S. W.D experts invited to
assist in the accident investigation had reached no final
conclusions as to cause prior to the release of the "Salient
Points" on July 15, 1964. It is also the fact that the latter
portion of Point 4 and all of. Point 5 were prepared and re-
leased to the Legislative Yuen without the concurrence of
those experts and, as will be later explained, contrary to
their findings. Yet these were men whose careers are devoted
to the investigaticn of air crashes and analysis cf the re-
sults of those investigations. Their experience in this
field dwarfs any available to the petitioners, the Adrinistretion
*For example, the U.S. CAB Report of the Pacific Air Lines
accident of May 7,1961+ wherein the evidence pointed plainly
to murder of the pilot and the co-pilot by a despondent passen-
ger, was not released until October 30, 1964. The deliberate
nature of this process was noted for the Second kcident Board
Meeting by one et the American CAB experts.
**There are 'none the less disturbing signs of. prejudgment in
some of the statements at the meeting that "high-jacking as a
cause can be eliminated" despite an inconclusive report cf the
Police on this subject.
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or the Ministry. To have utilized these valuable ser-
vices and then cavalierly to have ignored their potential
contribution to a determination of the cause of the accident
is possibly the most regrettable aspect of the entire handling
of the ratter.
C. The Self-Imesed Strictures on _Investigation.
It appears that at an early point in its inquiry the ACrinis-
traticn sought and received police support in its investigation
of the presence of two stolen pistols carefully secreted
abcard the aircraft in artfully hcllcwed cut books, by one or
bcth of two passengers who had made simultaneous reservations.
At some point thereafter, however, it determined that this
aspect cf the case was not within its purview. Thus, the
fcllcwing exchange took place at the second meeting cf the
Accident Board;
"Mr. Chen: Ls a member of this committee, I am of the
cpinicn'that the security ratter should not be treated
in a hurried manner. We should allcw for sufficient tire."
"Mr. hsiac� LTeputy Director, CA7; This committee should
not intervene in the security aspects, but be concerned
with technical matters relating to the rishap."
asc, as previously noted, the �.drinistration had concluded as
early as July. l4, 1964 that high-jacking as a possible cause could
be disregarded, although the police repert at that tire stated
that further investigation was required.
Understandably, security ratters invclve �a sensitive area in any
country, but meaningful investigation cannot result if any factual
area is ruled "off-limits", sc to speak, before complete ex-
ploration.
D. Significant L1Lesaticn of Source Material.
As part of their contribution tc the investigation, the
i,rerican experts prepared careful reports of their findings
and furnished these tc the J...drinistration fcr its use.
As is made clear in later secticns, the Administration's
report accepts and uses authoritatively major 'portions
of these reports, but alters others and ignores the
remainder. Particularly since some of the niterec findings
relate to laboratory examinations made as far away as Washington,
D.C., U.S..*, the conclusion is inescapable that evidence was
*For exarrle, the laboratory findings tLat a cable showed "serious
wear" is altered in the CA.i. rert tc read "amevious. wear", to fit
a conclusion: that the wear antedated the accident. The labora-
tory report ccncluded the contrary.
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evaluated against a pre-conceived result, rather than the
ccnverse. (a detailed analysis of the charges made in the
reports and the effect of such charges is attached hereto
as Appendix ;,.)
E. The Failure to Follow hcce-,ted Medical Investigation Technizaes,
The Republic of China is a signatory of the Convention on In-
ternLtional aviation (commcnly called the Chicago Convention).
pursuant to hrticle 37 of the Convention, it thereby under-
taks.tc collaborate with other states to. assure the highest
degree of uniformity in inter alia investigation of air ac-
cidents. While it is true that B-908 was not being operated
in international aviation, it is nevertheless obvious that
the medical investigation procedures of other member countries
are a highly authoritative guide in this area and should
have been fcllowed, in substance at least, in the hdrinistra-
� tion's investigations. Possibly the most guide of an ICAO
rember.state is the handbook of the U.S. Federal Aviation
agency entitled "Aviation Medicine Participation in hircraft
hccident Investigations". The techniques outlined in that
handbook for use in all accidents were not follcwed in the
*following particulars:,
(1) Nc complete autopsy was performed on the first officer
and a corrL-te autopsy was not had of the captain until�
ten days after the accident (the latter fact invalidating
most chemical findings because of putrefaction, most
importantly the nitrate test for gun powder);
The ;,dministration's relort gives nc indication that
blood alcchcl tests were conducted on either crew mem-
bers or passengers;
The Administrations report gives no indication that
tests were ccnducted to determine the presence or
absence of carbon monoxide in the bodies of passengers
and crew, although this teSt ray provide valuable
information on the time element of incapacitation
(before or at impact)
The FiJa also suggests that where -hypoxia (lack -of oxygen)
is a possibility, a lactic acid analysis of brain or spinal
cord tissues is useful to establish whether such a conditicn
ray have disabled the crew members prior to i-lact.
Further, it is irportant., in the view, tc check for the
presence (in stomach contents, tissues of the liver, brain,
kidney, lung) cf any evidence of barbiturates, dexedrine,
tranquilizers or antihistarines.
hpparently none of these steps was accomplished in the course
of the i,frinistrationts investigation.
(2)
(3)
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There Is No Credible Evidence That Any Malfunction
Of The Left Propeller Or Left Engine Caused The .ixcident �
.In the "Salient Points" announced. on July 159 1964, it was concluded
that "left propeller had overspeeding trouble". A similar conclusion
is contained in the report to the Legislative Yuan cf October 3, 1964.
kJ-so it is concluded in the report to the Legislative Yuan that .
"B-908 lost power on the left". No valid support for either .conclusion
.is to be found in the record. Since .the propeller and the engine
form a single assembly, connected by a reduction pear which serves
to reduce propeller revolutions to 1/2 those of the engine, the
evidence on this score ray be analyzed simultaneously. Recovered
mechanisms of the left propeller showed damage closely paralleling
that of recovered right propeller like mechanisms and indicated a
similar pitch (approximately 300). This similarity was true not only
of the damage to the pear teeth themselves but also of the gouge
marks made by then in the steel propeller hubs when the blades were
forced therefrom on impact. These conditions were noted in the
Zrerican expertsr "hoport of Investigation of Power Plant" of July
14, 1964. Further, the manifold pressure gauge analyses appended to
the August 14, 1964 revision cf the original structures report showed
that both engines were developing approximately the same power at
the time of irpact as evidenced by the fact that their concentric-
shaft indicators were seized together at the same setting when bent
over the face .of the instrument by impact forces. The combination
of similar pitch plus similar'power settings points to the single
and inescapable conclusion that both engines and propellers, right
and left, were operated similarly at the time of impact.
Mcreover, the conclusions of the 4,,,erican experts, as evidenced by
their report just cited, is that at impact both power settings
approximated 40 inches (cf mercury). This reading would be approximate-
ly that tc be anticiprted for an aircraft of this type under. the
circumstances and attitude of flight obtaining at the time of impact.
The Administration's. Report failed to credit the analyses contained
in these reports; indeed, in incorporating the reports into its own,
it changed_them significantly. To the experts' finding that "this
position Lof the power gear and adapter plat/ was noted and subse-
quently determined to represent an approximate 300 blade angle,"
the Ldrinistration added "but did not agree with what was indicated
by the damaged root gears", a statement completely contradicted by
other portions of the experts' report. Similarly, the experts' re-
port that gear damage, when correlated with blade angle,. represented
angles of approximately 3009 was altered to. read that lithe place
of damage . . . was not all at 300 blade angle." And whereas the
experts' report concluded that left propeller damage represented blade
angle of 30c,, or essentially the sane as the right propeller, the
Administration's report described the damage marks on the teeth of
two blade gear as at low pitch positions" seemingly in an effort to
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differentiate these marks from those found on the right pro-
peller.
The source of the keministration's error in this regard may lie
in undue reliance on certain readings of the engine tachometer
,
(inaccurately described in the Adrinistraticnis report as a pro-
peller speed indicator). This instrument actually measures engine
4-- c)- speed, but since the two speeds are correlated, the instrument
q Q would under norral conditions alsc give a reliable indication of
� W propeller speed. The t.merican exert, after noting a wide range
Q) of possible conclusions from the damage tc the two tachometer
Q-i- drive Fears (one for each engine), stated as follows
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Des�ite this .g!iTaF (w.n i et-aino; n the expertsf report cf
the ..clrinistraticn concluded in its "Salient Pcints" that a
difference in RPM L'Ef /repl1es.7 of rcre than 1,000 (ir a difference
in engine speed of rcre than 2,000) Was being experienced at the
time cf the occident*. (kltheuFh the_sentence in which this con-
clusion is stated begins "LThe exper.t/ further pointed cut that
���� " the conclusion as tc RPM's is the kdrinistretion's and riot
that cf the experts.) Assuming normal operation of the right
engine (approximately 2,300 RPM under the circumstances) as
indicated by the dministration's report and all other sources,
the left engine at any such greatly excessive speed would quickly
destroy itself; yet the experts found no evidence of distress in
either engine. It was stated:
"Except for this cbvicus in, act damage, all observations
of the cylinder and listen assemblies and the interiors
of the crank case were normal."
"In cpereticn, the tachometer pcinters are relatively lightly
restrained at an indicating losition and sudden movement
'of the instrument will cause the point ,rs to swing widely.
This fact greatly compromises the reliability of any impact
induced damage as an RPM indicator. The multiple damage
areas on the teeth support this statement".
It also appears from the .i24ministretion's repert that its con-
clusion of oVerspeeding� cf the left propeller ray be based in
part on "unusual, loud sound" r.perted by seven of the 20 residents
*In its report it also ascribed 'Lc unidentified Ca technical
personnel a statement that the left propeller was developing
2500-2900 RPMfs at the tine of the accident (or an indicated.
enFine speed of 5000-5800 REM's). CATtsC-46 Flight
-Manual, on file with the kdr_inistraticn, is based on the ranu-
fecturer's applicable service bulletin, and provides:'
"The following engine speeds have been established as the
raximum cverspeed limits beyond which it is considered advi-
sable to disassemble and inspect subject engine;
� Engine 1:10del_R-2800:meximum limit 3100 RPM (with slight throttle
opening), 3i5u. Rpm (with large throttle opening)"
U.S. kir Force limits are identical.alearly, speeds of the order of
5000 RPM would have left indelible evidence in the engine or,more
likely, destroyed it completely. '
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in the neighborheod of the -crash, But, a_sense of "unusual,
loud sound" would of course be explained by the unaccustomed
closeness cf those near the descent of a large twin-enFine
aircraft with power cn. And the fact is that 'such great ever-
speeding of a prcpeller would be accompanied by a high pitched
whine, a circumstance nct reported by a single witness, according
to the C.I.D.� report attached to the .hdrinistrationTs report.
ii.theugh nowhere discussed in the text of the report as relating
tc the accident, certain statements in the reference data appended
tc the report required cerrentl- lest they be misunderstood. It
is suggested that a failure to effect certain modifications in the
Curtiss Wright Electric Prcpeller ray lead to "loss of power and
ccntrol" and to "pitch change- malfunction" and that such modifi-
cations were not made in B-908. The facts, hcwever, are:
(a) The modification referred to is a U.S. idr Force Technical
Order, never applied �by any civil aviation authority anywhere
prier tc June 203 1964, and the unmodified version (but not
the redification) is approved by the IfSFL, the country of
manufacture of the propeller;
(b) The i,drinistratienTs descripticn cf the modification is
inaccurate, including particularly the reference to 5/11"
screws;
(c) The fact is that the parts required to effect the modifica-
tion are not available from the manufacturer, because pro-
duced only for the idr Force;
(d) Contrary to. the J.drinistration.staterents,such modification
was not directed by the manufacturer, and ranufacturerTs
directicns do not have the fcrce of regulation;
(e) Failure of the brake assembly would only have negligible
effect upon aircraft performance, resulting only in a
variation from optimum propeller pitch of a fraction of
a degree;
(f) Beycnd the actien et the brake assembly, the propeller
mechanism incorporates two safety features, one electric and
the cther mechanical, assuring that the propeller blade .
angle does not assume an.inprcier setting;
damage-free condition was observed in the mechanical
safety features (two fixed metal steps on the left propeller
adapter plate, which were reccvered); such damage would in-
evitably occur if the propeller had tended te� move beyond
prescribed limits;.
(h) No history of "pitch change malfunction" by virtue of
electrical connections dr otherwise has bepn experienced in
the 20-year history. cf operaticn, so far as petitioners are
aware;
(g)
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(1) All evidence points to. a propeller pitch of 30 degrees on
both propellers at tire of,irpact, thus negating any malfunc-
tion of any portion of the propeller rechanism.
There Is �No Credible Evidence Of Imiroper,Piloting.
'Point y of the "Salient Pcints" contains the staterent."there was
also indication of irprcper handling cn the part of the pilot".
In the full report it is suggested .that this improper handling
consisted cf turning left, when power had been lost on the left
side. It has already been noted that the loss af power cn the
left side is not only unsupi:orted by, but alsc in direct. conflict
with., the available evidence. Mcreaver, even if the contrary
were assured amuendo, a left turn weuld violate none of the
ererpency procedures laid down for single engine operation cf
this aircraft. Nc twin-engine aircraft can be certificated for
transport operations in the United States (the country of ranu-
facture cf the C-46) unless it can ccntinue to curb in ncrral
fashion on a single engine up to its single-engine "service ceiling".
(In this case, at least 8,000 fet, cr several thousand. feet
higher than B-908's altitude prior to its descent and crash).
CAT's C-46 Flight Manual, on file with the ,drinistration, provides
that, when an engine failure is experienced in flight cn this type
of aircraft, normal traffic procedures are to be followed until
arrangerents can be rade for a landing, and cf course norral*
traffic procedures will often entail turns to the left. (This
manual is based upon an accurulation of two, decades of experience
with the basic aircraft and the operating specifications of the
manufacturarand the experience of other operators.) It follows,
therefore, that no distress sufficient to explain this accident
.would accorpany a loss of pcwer of one engine, even if complete,
particularly at the altitude already attained by B-908.
,Lgainst its unsulported findings of pilot error, the Administration
alsc failed to weigh the fact that both Captain Lin and First
Officer Kung had many thousands of heurs of piloting experience
(approximately 12,000 and 13p00 respectively) and had been soundly
educated and trained in their craft. The depth and breadth of
that experience alone suggests the peril of any conclusion that
both failed to react to a situatien which is fully covered in
all twin-engine pilct�training, and one in which CAT pilots are
drilled in their periodic (every six months) proficiency check
under much more unfavorable conditions in that loss of power is
induced during takeoff. Turns into the "bad" engine are also part
of this periodic drill, and the C-46 is noted for its stability
when operating on one engine and particularly when making turns
cr� even circling toward,the�"bad" engine. Thus it is
inconceivable that these two long-experienced,corpetent and well-
trained pilots would have been presented with any undue difficulty
by the loss of power of one engine or by turning in the direction
of it.
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. 13 -
IV.
There Is No Credible Evidence cf Inattentive
Maintenance of the 1.ircraft.
Following the accident, and as part cf the investigation, a
secticn cf control cable which had fractured was taken frcr the
wreckaFe for exarinaticn. This cable was composed of seven
strands Of steel wire, each strand in turn consisting cf seven
sraller strands. While in normal flight this type of cable
is subject to stresses of about 20 poi:Inds, it must, acccrding to
manufacturer's sp:?cificaticns sustain 920 pound loads and did in
actual tests, sustain icads.of more than 1,000 pcunds before
breaking.
In the examination of the cable, certain "wear" or damage marks
were noted on the exterior surface. This circumstance was cited
in the "Salient Points" as indicating "inattentive raintenance"
cf the aircraft. Jtheugh the full report in its conclusions
agrees with the experts' opinion that even a ccrplete failure of
the cable could not cause the pilot to loss contrcl, and hence
could offer no explanation of this accident, the wear of the cable
is still cited as evidencing "inattentive raintenance".
Again the dministration has ignored the experts t findings. on this
subject, which after U.S. CB laboratory exarinaticn, concluded as
follows;
"It is possible that'scre of the individual wire fractures
could have included fatigue cracking, with subsequent
obliteration of the characteristic fracture surfaces due
to rcving interference with a hard surface at high pressure.
However, it appears more ircbable that both the wire fractures
and the wearlike .darage on exterior wires of the cable
cocurred during the disintegration of the airplane on
impact with the ground. No positive indicaticn of signi-
ficant wear or other unairworthy conditicn.of this cable
prior to impact of the airplane with the ground was found
during this examination."
It is cbviusly impossible to harmonize the foregoing with the
J--dministration's statement in its recemmendations to the LegiS-
lative Yuan sore months after.the cited report that "substantial
wear and tear of control cable orior to crash has been noted at
time of inspection cf ilane rernants". But the 1:,drinistrationts
error goes deeper. While the preliminary findings of the ,,rerican
experts noted "serious wear", the idr.inistration's repert changed
the language to read "Lrevicus wear" (underscoring added). To this
date, so far as is known to Petitioners, the dministration has not
reanaXyzed its position to take into account the results of laboratory
examinations, which absolve Petitioners from the .very sericus charges
leveled at them by the cministration's report.
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The A.ministration's report. also states that in effect CT has
adritted "inattentive raintenance" by seekinF to attribute to Mr.
Gluskin of Ca, a CLJ, inspector, an admission shortly pricr to the
accident that an increasing frequency cf delays was being experi-
enced and that some of these were due to mechanical failures.
No such construction can fairly be put on Mr. Gluskin's language,
as a review thereof will show. Rather, Mr. Gluskin in response to
a letter from the J.ciministration on the subject expressed CO's
concern with any schedule delays2 and promised wholehearted
cooperation with the i.dministration in seeking to eliminate causes,
without col-promising safety standards. Further, an operator's
'decisicn to delay an aircraft for repair's when a defect. is detected,
rather than proceeding to fly It with some possibly unsafe but not
necessarily prchibitive defect, shows a concern fel., rather than
a disregard for, flight safety. enviable record of nearly
15 years scheduled operation without an accident (with there being
no credible evidence that this first accident was the fault of
the oprator and considrable evidence that it was not) .testifies
to a serious concern for safety of flight and impeccable maintenance.
No Cause of the B-908 -Icc.ident has been Established and
InvestiFaticn Should Continue, Particularly Into i�Ispects
hot Yet Fully Exulored.
.It is submitted that the technique of investigation and analyses
herein pursued, and the announcement of conclusions not rationally
supported, requires corrective acticn by this Ministry. Petitioners
have no desire to castipate anycne, although they have themselves
been castigated ben:re the public unfairly and unceasingly since
the accident. Rather it is their heee, as presumably it rust be
the hope of the i:dministration and of the Ministry, that, at the
very least, improvements in the safety of flight ray result from.
the tragedy that marked the crash of B-908.
Reanalysis of the available evidence should be undertaken in an
atmosphere of scientific detachment. Particularly the investiga-
tion of possible incapacitation of the crew members by violence,
or the threat cf violence, should be 1 ursued until the many ques-
tions remaining in this area are answerdd to the extent that they
can be answered.
It has been increasingly evident threughcut the world that the
threat of violence aloft is a real and alarming cne. high-jacking
of aircraft for various reasons, while perhaps nct cermunilace,
has occurred with considerable frequency. ,lsol several years eFc
near Denver, Celcradc, a ran murdered a ilane load cf people
to collect his mother's insurance. More recently, a despondent
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garbler .caused the death of 44, includini, himself, by sheeting
the pilot and the co-pilot in flirht near Stckstcn, California.
These and cther incidents suggest the importance of thorough
investigation cf the background of oil actual or suspicious
situations where violence ray have played a 1,Frt, with a view
to evolving prctective measures for the safety of air travel.
It is solely in the interest cf such improved safety that Peti-
tioners suggest that further _fficial inquiry appears vital intc
the actions of one or more passenF,:rs in bringing aboard in
secretive fashion two stelen _�istuls which were found in the
wreckage. confidirl report cf facts then at its disposal
bearing on this subject wrs furnished to the drinistration sore
tire ago by C.TO No analysis therecf is contained in the ,Idninis-
tration report, or elesvhere, to ,petitioners1 knowledge. It is
nc answer to say that this is not a field wherein the .;.drinistra-
ticn is expert; presumably, expert assistance can be borrowed from
ether agencies of government. The real paint is that the A,dminis-
traticn has the responsibility of investigation air accidents and
their causes; and divided responsibility ray well rean no respon-
sibility at all. very large gal; in the scheme of air transport
regulation will be opened up unless this Ministry assures that all
remotely pcssible causes et the B-908 tragedy are 'robed to the
fullest, particularly in the absence of vplid evidence of
mechanical or cperaticnal causes.
Evidence
The evidence upcn which Petitioners rely cLnsists of the C's
records and relorts relative to its decisicn and the reports cf
the U.S. Civil ,ercnautics Board experts incorporated therein and
as supplemented, all as contained in official files of the Govern-
ment of the Republic of China.
Air Asia ComIany Limited
Represented by Hugh L. Grundy, President
Civil Air �Transport Company Limited
Represented by densan Wang, Chairman of Board
cc; Civil Aeronautics Administration
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Conclusions
4
The CAA reports alter the statements on the left propeller blade angle and
the left elevator trim tab control cable in the U.S. CAB experts' reports to
give an entirely different meaning than that in the original reports. The
evidence on propeller blade angle and the left elevator trim tab control. cable
from the U.S.' CAB experts cited in the preceding analysis,alone,directly contra-
dicts the CAA reports' findings of "inattentive maintenance" and "improper
handing by the pilot". Air Asia Company Limited's examination of the left
propeller hub and power gear, cited in the preceding analysis, and additional
statements in the U.S. CAB experts' reports, correctly quoted in the body of
the CAA reports but ignored in their analysis, provide further evidence con-
tradicting the CAA reports' findings.
The U.S. CAB expert's report on powerplants found no evidence of failure or
distress of either engine. Examination of the engines indicated both were func-
tioning properly at the time of impact. There would certainly have been evidence
of damage to the nose section or other int6rnal parts of the left engine had
there occurred the overspeeding of the engine to the extent which would have
resulted had the alleged left propeller overspeed been even near the 1000 rpm
noted in the 130 page CAA report.
The U.S. CAB expert's "Report of Examination of Manifold Pressure Gage" attached
to the 14 August 1964 revision of the "Structures Investigation Report" and the -
earlier powerplant report both found that the damage to the manifold pressure
gage dial and pointers indicated the manifold pressures of both engines most .
probably were 40 inches (of mercury) at the time of impact. This indicates both
engines were developing normal power and that the propellers were rotating at
approximately the same speed. Any significant difference, especially one of
the magnitude suggested by the CAA reports, between the speeds of rotation of
the two propellers would have made the manifold pressures of the two engines
differ.
Furthermore, operating procedures prescribe that in the event of an overspeeding
propeller (an infrequent, but occasional happening faced by all operators of
propeller aircraft) the first corrective actions shall be pulling the aircraft
up and retarding the throttle of that engine (a change in manifold pressure is
one result) followed by actions to restore control of the propeller and, if
normal functioning is not promptly restored, to adjust directional trim of the
aircraft to compensate for loss of power or drag effects of the malfunctioned
powerplant on one side of the aircraft. CAT pilots are trained and drilled in
these emergency procedures and are required before being checked out as pilots-
in-command to demonstrate competency to safely fly the aircraft, under these
emergency conditions, not only in the relatively comfortable circumstances of
the on-course climb at some 1500 feet altitude estimated for B-908 but under
the far more exacting flight regime of take-off,where altitude; airspeed, and
time are critical factors. These pilots have repeatedly demonstrated, and were
required periodically to demonstrate, such competency. Unquestionably, then,
the pilot's first reaction would have been to reduce power on the left engine
(and thus reduce manifold pressure) had there occurred an overspeed of the left
propeller. The creditable evidence of the manifold pressures of the two engines
having been the saMe at time of impact, corroborated by the evidence of the
directional trim indicators having indicated a normal flight setting of about
zero trim, combines to reinforce other evidence that the left propeller was not
overspeeding as alleged and that the pilots did not mishandle the aircraft.
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5
The U.S. CAB expert concluded that not only the left propeller but also the
right propeller blade gear angle was approximately 300. With the same blade
angle the speeds of the two propellers would certainly be similar but the CAA
reports conclude that only the left propeller was overspeeding.
The CAA 130 page report in citing a "left propeller rpm indication" (page 65
of translation and page 91 of the Chinese version) indicates a lack of under-
standing of the C-46 engine. The crankshaft of the engine and the propeller
are coupled by a reduction .gear mechanism so that the speed of revolution of
the engine is always twice that of the propeller to which it is coupled..
Thus if the left propeller had attained the speeds cited the engine speed
would have been more than twice its normal 2300/2400 rpm for the phase of
flight involved. There was no evidence of the very severe damage to the engine
that would have occurred had there been such an overspeeding as alleged.
There in fact is no propeller speed indicator. A tachometer, however, indicates
engine rpm. The rpm indications referred to by the CAA 130 page report could
only have been among the multiple indications of engine rpm from the damaged
tachometer.
The CAA 130 page report cites the rpm indication as evidence of propeller
overspeeding. Yet in the same report it notes the U.S. CAB expert's finding
that further examination was required and that it might be difficult to reliably
determine rpm from the tachometer. The CAA 130 page report ignores the U.S.
CAB expertis conclusion (in the "Report on Tachometer" attached to the 14 August
1964 revision of the "Structures Investigation Report") after further examina-
tion that the indications of rpm from the tachometer are relatively unreliable.
Thus there is no reliable physical evidence to support and abundant physical
evidence to contradict the CAA report conclusion that the left propeller was
overspeeding and that the left elevator trim tab control cable was worn prior
to the crash and therefore there had been inattentive maintenance. And since
the reliable physical evidence shows the finding of left propeller overspeeding
to be erroneous there is no basis for the CAA finding that there was improper .
handing by the pilot.
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_ � SECRET �
MEMORANDUM FOR: Mr. Houston
ocd-4-4,5 'vi
28 September 1964
Attached is the HBIL1CA version of the B908 affair. As you will
recall, the Company has not submitted a report to the Ministry of Com-
munications or the Legislative Yuan. The Ambassador was opposed to
submitting a report of this nature.
We have asked by cable (la RI- wppk1 f the concurrence of the
Ambassador to submit a report, such
as the attached, to the Chinese Aeronautics Association and the Ministry
of Communications. There are valid points pro and con in doing this,
but I feel the weight of argument is to take a position and submit a re-
port.
I will be away for ten days to two weeks. Would you please follow
this and if no response from Taipei, send a follow-up query. Please
return the attachment when it has served your purpose.
Att:
As stated
R. L. Bannerman
(b)(1)
(b)(3)
SECRET
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SENDER WILL CHICK CLASSIFICATION TOP AND BOTTOM
UNCLASSIFIED CONFIDENTIAL SECRET
CENTRAL INTELLIGENCE AGENCY
OFFICIAL ROUTING SLIP
TO
NAME AND ADDRESS
DATE
INITIALS
1
,
Mr. Houston
2
3
4
r
5
6
,
ACTION
DIRECT REPLY
PREPARE REPLY
[
APPROVAL
DISPATCH
RECOMMENDATION
COMMENT
FILE
RETURN
CONCURRENCE
INFORMATION
SIGNATURE
Remarks:
-----, .
4 �
r
aced t�--44- - 6416( 5-
J:111 ,
FOLD HERE TO RETURN TO SENDER
FROM: NAME, ADDRESS AND PHONE NO.
DATE
Dec 614.
�1
._______7
UNCLASSIFIED 1-1-1C5MDENTIAL ( SECRET -
FORM NO. 2-61 037 Use previous editions
(40)
U.S. GOVERNMENT PRINTING OFFICE 1961 0-587580
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