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Publish Investigation Report, China Airlines Flight CI 6416 Veered Off Runway During Landing at Taoyuan Airport


Publication Date 2015-03-23
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The Aviation Safety Council (ASC) released the investigation report of China Airlines Flight 6416, a Boeing B747-400F aircraft, conducted cargo flight departed from Abu Dhabi International Airport for Taoyuan International Airport. On March 31, 2014 about 2000 local time the flight crew selected autoland under good weather condition. There was another airplane takeoff and passed over the ILS sensitive area while the CI 6416 was on final landing phase in the same runway, resulting in ILS signal interference. Flight crew did not maintain adequate aircraft control when it behaved unexpectedly. As a result, the aircraft veered off the runway.

In accordance with the Aviation Occurrence Investigation Act, Republic of China (R.O.C) and the content of Annex 13 to the Convention on International Civil Aviation (Chicago Convention), which is administered by the International Civil Aviation Organization (ICAO), the Aviation Safety Council (ASC), an independent agency of the ROC government responsible for civil aviation occurrences investigation, after confirmation of this occurrence, organized a team to conduct the investigation. The investigation team also included members from China Airlines, Civil Aeronautics Administration (CAA) R.O.C, Taoyuan International Airport Corporation and the state of manufacture, represented by NTSB (National Transport Safety Board, USA) including technical advisor from Boeing. The Investigation report was approval in the ASC 30th Board meeting on January 27, 2015.

Findings related to probable causes

In total there are 2 findings:

  • The flight crew selected autoland under good weather condition, and did not notify ATC to confirm if the ILS sensitive area was protected. There was another airplane takeoff and passed over the ILS sensitive area while the CI 6416 was on final landing phase in the same runway, resulting in ILS signal interference.
  • When touch-down, the autopilot and navigation system were affected by the interfered ILS signals, making the aircraft deviate from runway centerline.  Flight crew did not maintain situational awareness, and manually control the aircraft by disengaging the autopilot when it behaved unexpectedly.  As a result, the aircraft veered off the runway.

Findings related to risk

In total there are 2 findings:

  • The standard callout procedure training and Evidence Based Training (EBT) of China Airlines that simulated line operation scenario did not review the effectiveness of the training results according to current training system, and develop a specific scenario that reflects actual line operation risks to enhance the training effectiveness.
  • The relevant manuals at China Airlines did not regulate specifically if it is allowed to manually override autopilot and a standard regarding deviation from runway centerline during landing, making prevention of runway veer-off events more difficult.

Safety Recommendation to CAA:

In total there are 2 recommendations:

  • Supervise China Airlines on training regarding autoland, its standard callouts, and the effectiveness of Evidence Based Training.
  • Supervise national carriers on training and alertness over aircraft anomalies, and implement relevant staff on their duties of daily checks and pre-flight checks.

Safety Recommendation to Taoyuan International Airport Corporation:

In total there are 2 recommendations:

  • Enhance runway foreign object detection and prevention mechanism.
  • Implement the changing management procedures as regulated in airport safety management system.  When activation condition is met, re-identify risk factors to confirm if they generate new hazards so that follow-on safety risk management actions can be taken.

China Airlines has been improving or already improved the deficiencies that the investigation finding has been found by ASC. ASC proposed safety recommendations to China Airlines are no longer needed.

 

Further information including the factual data, analysis and safety action taken or being planned; please refer to the Final Report. The Final Report in Chinese and courtesy translation Executive Summary in English of this investigation are available for download at http://www.asc.gov.tw

 

Sherry Liu, Engineer

Tel: 89127388-330

Email:sherry@asc.gov.tw

Last updated 2015-03-19
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