Aviation Safety Council (ASC) release the investigation report of an EVA Airways (EVA Air)Airbus A330-203, affected by low altitude clouds and local fog during final approach. Flight crews’ improper judgments and handling to the change of weather resulted in the aircraft skidded off the runway during landing.

On February 26 2011, EVA Air flight BR 757, an Airbus A330-203 (bearing national registration number B-16303), the aircraft was on a scheduled passenger flight from Hangzhou Xiaoshan Airport, China to Taoyuan International Airport of Taiwan, Republic of China(ROC). There were 2 pilots, 8 cabin crewmembers, and 135 passengers on board. Before take-off the flight crew acknowledged that the visibility at the destination airport had tendency to get lower due to influence from fog. When the aircraft landed at Taoyuan International Airport Runway 06, the left main gear skidded off the runway temporarily, during landing roll. The aircraft had no damage and all people on board were safe.

The ASC launched investigation according to the Aviation Occurrence Act after the occurrence. Several departments were invited for joint investigation, including: Civil Aeronautics Administration (CAA), EVA Air and Taoyuan International Airport Company. Investigation report was published after approval by the ASC council members on February 21, 2012, at the 152nd Council Meeting.

Findings related to probable causes: During final approach, the aircraft might encounter low-level clouds and local fog, and affected to a temporary loss of visual reference intermittently and insufficient visual reference to operate the aircraft. Before landing the left wing was lower than normal condition, which could lead the aircraft to skid off the left side of the runway center line during landing. Although the flight crew attempted to rectify the left deviation at touch-down, but has been unable to stop the aircraft. Flight crews was loss of situation awareness before landing, did not assess and properly handle the change of weather, which was known as a threat to the flight.
 
Findings related to Risks: During approach, the aircraft was affected by low-level fog and increased the risk in performing approach and landing.

The Aviation Safety Council issued a total of 9 Safety Recommendations

Safety Recommendations to EVA Airways：reinforce trainings to flight crew’s acknowledgement, situation awareness, operation and handling to unstable visibility and request flight crew to conduct immediate go-around when unable to see the runway during final approach. Recommendations to Taoyuan International Airport Company include：conduct a feasibility study to set up the runway centre line lights on Runway 06/24 to reinforce visual reference for flight crew to aim at the runway during landing; set up runway approach lighting systems specified in ICAO Annex 14 to meet the international standards; reinforce instant monitoring, defect warning and recording function to runway approach lighting systems, runway edge lights, runway threshold lights, and runway end lights at Taoyuan Airport. Recommendations to CAA： supervise EVA Air to reinforce trainings to flight crew’s acknowledgement, situation awareness, operation and handling to unstable visibility and request flight crew to conduct go-around immediately when unable to see the runway during final approach; supervise Taoyuan International Airport Company to conduct a feasibility study to set up the runway centre line lights on Runway 06/24 to reinforce visual reference for flight crew to aim at the runway during landing; to set up runway approach lighting systems specified in ICAO Annex 14 to meet the international standards; to reinforce instant monitoring, defect warning and recording function to runway approach lighting systems, runway edge lights, runway threshold lights, and runway end lights at Taoyuan Airport; review the necessity of the 9 nautical-mile tailwind landing limitation at airports in Taiwan.

The full investigation report is available for download at http://www.asc.gov.tw (Chinese version only)

Sherry Liu, Engineer
Tel: 89127388-330 
Email:sherry@asc.gov.tw