A catalogue of errors led the pilot of a passenger plane that crashed in Taiwan to shut down the only working engine, exclaiming: "Wow, pulled back wrong throttle," a damning report said Thursday.
TransAsia Airways Flight GE235 clipped a bridge and plunged into a river shortly after take-off from Taipei's Songshan airport last February, killing 43 on board. Only 15 people survived the crash.
The final report by Taiwan's Aviation Safety Council confirmed that after one engine had failed, the pilot had mistakenly shut down the other and the plane had stalled.
It also revealed how that pilot had shown "continued difficulties" in handling emergency situations during training, but was still allowed to fly.
The report described him as posing an "evident and imminent flight safety risk" and urged TransAsia to review its training programmes and safety culture.
Earlier findings by the council last year told how the pilot had exclaimed: "Wow, pulled back wrong throttle," just seconds before the crash.
The final, more detailed, investigation report Thursday said there were "many contributing factors" behind the tragedy, which was captured in dramatic car dashcam footage as the plane lurched to one side, clipped an elevated road and crashed into the Keelung River.
One of the engines malfunctioned shortly after the plane took off, according to the report, but the crew failed to carry out the right procedures to deal with the problem.
"The flight crew did not perform the documented abnormal and emergency procedures to identify the failure and implement the required corrective actions," it said.
This led to the two pilots' confusion over which engine was malfunctioning and shutting down the wrong one.
By the time the crew realised both engines were down, it was too late to restart the plane.
Cockpit recordings revealed the pilots could not decide which engine had failed, Thomas Wang, managing director of the council, told reporters.
"They kept communicating with each other, but to no avail," he said.
The head of the council, Huang Huang-hui told reporters that "human factors" were the overriding cause of the accident.
Poor safety record
TransAsia has seen several accidents in recent years that have raised concern about the airline's safety standards.
The aviation council said the airline should look at why its flight safety performance was failing.
It also urged TransAsia to conduct a "thorough review" of its flight crew training programmes as well as improving its oversight and auditing procedures so recurring safety and training problems are spotted and rectified.
Taiwan's Civil Aeronautics Administration (CAA) must also ensure safety improvements are implemented after investigations, the report added.
"The purpose of the report is to avoid the recurrence of similar incidents," said Wang.
The airline had already been asked to review its safety procedures after a TransAsia crash in the Penghu islands in 2014 that killed 49.
Two air traffic control officers were charged in April over that crash.
Along with the aircraft's two pilots they were found to have been "negligent in their duties," prosecutors said.
In response to Thursday's findings, TransAsia said it has introduced six training programmes following the two fatal incidents.
As of June, it has reached agreements with 70 percent of the victims' families. Each of them was paid Tw$14.9 million ($460,000.)