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Publish Investigation Report, EVA Airways Flight BR 189 Veered off the Runway During Landing roll at Songshan Airport


Publication Date 2013-08-27
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Aviation Safety Council (ASC) release the investigation report as following: on September 13, 2012, EVA Airways Corporation (EVA Air) flight 189 scheduled passenger flight, an Airbus A330-300 airplane, registration number B-16331, took off from Tokyo Haneda Airport, Japan to Taipei Songshan Airport. The aircraft encountered heavy shower during landing at 12:43, the flight crew had difficulties to control the aircraft precisely due to visibility was degraded and resulted in the aircraft drift to the right side of the runway. The flight crew did not make rejected landing decision and the aircraft touched down at the right side of the runway centerline. After landing, the aircraft veered off the runway due to the flight crew did not adequately control the direction aircraft.

There were 2 flight crew members, 14 cabin crew members and 218 passengers in total 234 people on board. Before take-off, the flight crew obtained the thunderstorm weather information of the destination airport.  During flight, the flight crew received the information that the visibility at Songshan Airport was 5 kilometers with haze, at 5 nautical miles from the runway threshold, the visibility was 7,000 meters with wet runway condition, and heavy shower before landing. According to the flight crew interview, the runway was in sight at 3 to 4 nautical miles from the runway threshold during approach but can not see the runway end clearly. About 9 seconds before landing the aircraft started to drift to the right side of the runway centerline. The aircraft landed at Runway 10 and the main wheels touched down at the right side of the runway centerline. The visibility was very poor at the time of touchdown. The aircraft right main wheels veered off the runway during landing roll and return to the runway approximately 1,000 ft. after veered off. After landing inspection indicated that the aircraft was not damaged, all people on board were safe. Two runway edge lights were found damaged at Songshan Airport during the field inspection.

The ASC launched investigation according to Aviation Occurrence Investigation Act after the occurrence. Parties to the investigation are the Civil Aeronautics Administration, Ministry of Transportation and Communications (CAA) and EVA Air. Investigation Report was published after approval by the ASC council members on July 30, 2013, at the 13th Council Meeting.

Findings related to probable causes: At the time of final approach, the weather met the CAT I precision approach standard, the visibility decreased and there was heavy shower during landing due to the influence of thermal convection above the airport area. During flare, the flight crew had difficulties to precisely maneuver the aircraft and the aircraft drift to the right side of the runway due to the visibility was limited by heavy rain, the flight crew did not to make rejected landing decision and the aircraft touched down at the right side of the runway centerline. After landing, the flight crew did not correct the direction of the aircraft resulted in the aircraft veered off the runway.

Findings related to risks: The flight crew was acknowledged of rain condition before approach by their activating the ignition switch for the go-around procedure which showed the flight crew had adequate situation awareness, still the flight crew did not make appropriate judgment and action according to the weather change and abrupt visibility variation at landing phase. The aircraft approach process met the stable approach standard; however Pilot Monitoring did not perform standard call-out when the speed range meet the call out criteria and EVA did not have any standard call-out in relevant manuals regarding the aircraft veered off runway centerline after touchdown.

The Aviation Safety Council issued a total of 5 safety recommendations.

Safety Recommendations to EVA Air: Reinforce flight crew’s situation awareness and maneuvering training during flare and after touchdown at landing phase, reinforce maneuvering and handling trainings when visual references are not sufficient; request flight crew to perform standard call-out and review relevant manuals content of standard call-out when aircraft veers off runway centerline after touchdown accordingly. Safety Recommendations to CAA: Supervise EVA Air to execute flight crew’s situation awareness and maneuvering training during flare and after touchdown at landing phase, reinforce maneuvering and handling trainings when visual references are not sufficient; request flight crew to perform standard call-out and review relevant manuals content of standard call-out when aircraft veers off runway centerline after touchdown accordingly; review the feasibility to install runway centerline light at Runway 10 at Songshan Airport.

The complete investigation report is available for download at http://www.asc.gov.tw

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

Last updated 2019-08-08
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