The Far Eastern Air Transport FE 025 Occurrence Investigation Report
The Aviation Safety Council (ASC) released the investigation report of Far Eastern Air Transport FE 025 occurrence. The flight crew did not pay attention to the wind related information provided by the air traffic control (ATC). As a result, they did not assess the influence of the tailwind on the safe landing and caused the aircraft overran the runway.
On May 16, 2012, Far Eastern Air Transport passengers flight 025, a MD-82 aircraft registration number B-28037 took off from Songshan Airport for Magong Airport. There were 172 people on board. At 1022:41, when the aircraft was at 49 nautical miles from Magong Airport, the aircraft began to descend. At 1034:15, the aircraft was at altitude 2,000 feet and obtained approach clearance from ATC to land on runway 02. Approximately 2 minutes later, Magong control tower notified that the southwest weather system was approaching, and flight crew should pay attention to the turbulent wind field. At 1037:17 and 1037:20, the Pilot Monitoring (PM) called out, ‘the tailwind is too strong’, and ‘we should go around’. At 1037:22, the flight crew notified Magong control tower that due to strong tailwind, they would go around and requested to re-join the approach.
At 1038:31, the aircraft reported to Kaohsiung approach. At 1043:18 Kaohsiung approach notified the aircraft weather information provided by Magong control tower, the wind direction was 190 degrees, wind speed was 19 nautical miles/hour, and the wind direction was changing. At 1043:26, the aircraft requested for ILS approach on runway 02. At 1048:52, the aircraft reported to Magong control tower again. The Magong control tower notified that the wind direction was 190 degrees and the wind speed was 11 nautical miles/hour on runway 02, while the aircraft was at 5 miles away and the altitude was 1,700 feet. At 1050:52, the main landing gears of the aircraft touched down on runway 02, and the brake pressure built up to about 2,700 PSI. After that, the flight crew called out that they were unable to stop the aircraft. Subsequently, the aircraft overran the temporary end lights of the runway and stopped around 328 feet (100 meters) beyond the end lights.
According to the Aviation Occurrence investigation Act, the ASC launched investigation after the occurrence. Investigation report was published after the approval by the ASC council members on May 28, 2013, at the 11th Council Meeting.
Findings related to probable causes: During the first approach, the flight crew evaluated that the tailwind was too strong to landing safely. Therefore, they decided to go around. During the second approach, flight crew did not pay attention to the wind related information provided by the air traffic control. As a result, they did not assess the influence of tailwind on safe landing and kept approach continually, caused the aircraft overran the runway. It showed that the flight crew lacked of situational awareness to perform a tailwind landing. Both flight crews realized that during ILS landing the aircraft was at downwind side. If the control tower suggested the flight crew to adopt a VOR approach, the best way is to go miss approach and requested for another approach. But the flight crew did not request to continue the issue ILS approach. It showed that while encountering a suggestion to change the approach from the control tower, the flight crew did not act and adopt correct response immediately, Flight Data Recorder (FDR) data showed that the tailwind speed was around 21 nautical miles/hour while the autopilot of the aircraft was disengaged; and the tailwind speed was about 14 nautical miles/ hour while the main landing gears were touch-down. It showed that during the second approach and landing, the tailwind speed exceeded the 10 nautical miles/ hour tailwind limitation as specified in the Flight Operation Manual.
Findings related to Risks: The AWOS (Automated Weather Observing System) of control tower showed that since 1041, the tailwind speed was 10 knots or above on runway 02, the gust wind speed was up to 19 knots, and the control tower did not change the runway in use. According to Far Eastern Air Transport Flight Operation Manual, ’if the first go around is due to weather condition, flight crew should request holding and request approach clearance after the weather condition is stabilized, but only one re-try is allowed. While at the same time, the flight crew should always check fuel quantity and following the rule turning back to the original departure airport or diverting to an alternate airport as early as possible’. If it was not resulted from the influence of weather condition, the re-try for another approach is not limited to only once. Flight crew’s incorrect recognition increased their mental pressure on aircraft turn back if the landing could not be completed. While at the same time as the aircraft performed ILS approach, the evacuation of those persons and aircrafts near the critical area of localizer were on-going. If the accuracy of ILS approach was affected by human workers and equipments, it might cause the risk of inaccurate flight path track and deviation of glide slope. As for the transition of aircraft control while the occurrence occurred, the PM did not follow the rules as specified in the Far Eastern Air Transport Flight Operation Manual, ‘during the transition of flight control, both pilots should use the standard called out, ‘You have control’ and ‘I have control’, and verified by each other to complete the transition’, which resulted in cognitive error of the Pilot Flight (PF). The PF was still performing aircraft directional control while the PM took over aircraft control. Due to the ceiling was 200 feet at that time, the approach controller asked whether the flight crew accepted VOR approach or not, flight crew did not use standard communication terminology to communicate with the ATC approach, which resulted in the perception that the controller thought the aircraft was conducting a VOR approach. As a result, non-standard terms were likely to cause misunderstanding. Reference to the landing distance chart in MD-80 Aircraft Flight Manual and the ‘Good Reported Braking Action’ chart for slippery runway, under the conditions of the landing position of FE025 and the strong tailwind at that time, the estimated landing distance was greater than the usable length of runway 02 at Magong Airport.
Safety Recommendation to Far Eastern Air Transport include: Enhance flight crew’s training on situation awareness during approach, the standard operation procedures of the transition of flight control, and the tailwind landing and go around speed limitation. Enhance flight crew’s training on using correct terms to communicate with air traffic controllers to avoid misunderstanding. Review the employment status of flight operation staff to meet the requirements as specified in those flight operation related manuals. Safety Recommendation to CAA (Civil Aeronautics Administration, Ministry of Transportation and Communications) include: Supervise the training of Far Eastern Air Transport on the enhancement of flight crew’s situation awareness during approach, the standard operation procedures of the transition of flight control, and the tailwind landing and go around speed limitation. When changing the type of approach, air traffic controller should consider the safety of different types of approach, required procedures and time for the flight crew. The choice of runway in use should comply with those procedures as specified in the air traffic management procedures.
The full investigation report is available for download at http://www.asc.gov.tw (Chinese version only)
Sherry Liu, Engineer