1994-04-26
China Airlines
Flight CI140
Departure
Chiang Kai-shek International Airport, Taoyuan, Taiwan
Destination
Nagoya Airport, Nagoya, Japan
Causation Breakdown
Recurrence Likelihood Today
Very Low
The specific autopilot conflict has been eliminated by a mandatory design change. Modern Airbus aircraft automatically disconnect the autopilot when TOGA is activated. Training on automation modes is now a core element of all type-rating courses.
Summary
During approach to Nagoya, an inadvertent TOGA activation caused the autopilot to pitch the nose up while the crew pushed forward on the controls. The conflicting inputs stalled the aircraft at low altitude. Only 7 of 271 aboard survived. Airbus subsequently redesigned the autopilot logic, and the accident became a landmark case study in automation-induced accidents.
Cause & Investigation
Determined cause
Pilot error — TOGA mode conflict with autopilot
During approach to Nagoya, the first officer accidentally activated the takeoff/go-around (TOGA) mode. Rather than disconnecting the autopilot, the crew fought against it by pushing the control yoke forward while the autopilot pitched the nose up. The opposing control inputs placed the aircraft in an increasingly nose-high attitude. The aircraft stalled and crashed near the runway threshold.
Investigation body
Aircraft Accident Investigation Commission (AAIC), Japan.
Timeline & Safety Improvements
Flight CI140 disaster
Airbus A300B4-622R operating for China Airlines. 264 fatalities, 7 survivors.
Formal investigation opened
Conducted by: Aircraft Accident Investigation Commission (AAIC), Japan.
Cause determined: Pilot error — TOGA mode conflict with autopilot
During approach to Nagoya, the first officer accidentally activated the takeoff/go-around (TOGA) mode. Rather than disconnecting the autopilot, the crew fought against it by pushing the control yoke forward while the autopilot pitched the nose up. The opposing control inputs placed the aircraft in an increasingly nose-high attitude. The aircraft stalled and crashed near the runway threshold.
Improvement implemented
Airbus redesigned A300 autopilot engagement logic so that TOGA activation automatically disconnects the autopilot.
Improvement implemented
Crew training on go-around mode management and autopilot disconnect procedures was overhauled.
Improvement implemented
ICAO issued guidance on the hazards of fighting automation rather than disengaging it.
Improvement implemented
China Airlines underwent a comprehensive safety review of crew training and CRM practices.