The Aviation Safety Council （ASC）releases occurrence investigation report of a Far Eastern Air Transport MD-82 airplane, registration number B-28017, overran runway during landing at Kinmen Airport.

On June 16, 2014, a Far Eastern Air Transport MD-82 passenger airplane, flight number FE061, registration number B-28017, flew from Songshan Airport to Kinmen Airport to execute a scheduled passenger transportation mission. The flight departed with 2 flight crew members, 4 cabin crew members and 98 passengers, totally 104 people. During landing at Kinmen Airport, the flight crew could not stop the airplane before the runway end line and the airplane ran into the safety zone of runway.

The ASC is an independent agency responsible for civil aviation, public aircraft and ultra-light vehicle occurrences investigation. According to the Republic of China Aviation Occurrence Investigation Act and referencing to the related content of Annex 13 to the Convention of International Civil Aviation Organization, the ASC launched an occurrence investigation by law. The organizations or agencies been invited to join the investigation team included: Civil Aeronautics Administration of Ministry of Transportation and Communications, Far Eastern Air Transport, National Transportation Safety Board of United States of America and airplane manufacturer, the Boeing company. The occurrences investigation report was reviewed and approved by ASC's 32th Board Meeting on April 28, 2015.

Findings related to probable causes：The airplane approached and landed with 21 knots right cross wind condition. The airplane did not perform firm landing and had phenomenon of delay landing. After airplane touched down, the flight crew did not retard the throttle to flight idle immediately due to the operations of cross wind correction and trying to keep the airplane on runway center line. The flight crew lacked of situational awareness when landed on a wet runway and strong cross wind conditions. The flight crew did not re-extend the spoiler after it was retracted. The flight crew did not apply optimized thrust reversers and maximum brakes in time such that performance of airplane speed reduction was affected after landing. The airplane ran over the end line of runway 06 finally.

Findings related to risks：

In total there are 4 findings:

1.In May 2012, a Far Eastern Air Transport MD-82 passenger airplane had a similar runway overrun occurrence at Magong airport. To prevent runway overrun occurrence from happening again, Far Eastern Air Transport revised its Flight Operation Manual by adding takeoff and landing distance calculation form and the confirmation of landing distance during approach briefing. The flight crew still unfamiliar with the aforementioned landing distance calculation form, referencing to wrong configuration setting and wrong calculation during summing up the landing distance calculations.
2.The airplane touched down at 2,500 feet from the displaced threshold of runway 06 which closed to the touch down zone critical point as specified in the Flight Operation Manual. It might be due to strong cross wind during landing and the flight crew concentrated on the operations kept the airplane on runway centerline. Therefore, the flight crew did not have time to judge whether the airplane landed over touch down zone or not.
3.While the flight crew checked speed reduction related configuration settings before landing, the flight crew did not call out speed and configuration checks. During glide slope interception phase, the flight crew did not call out those of heading, altitude and slope of miss approach settings. When the airplane reached decision altitude, the flight crew did not call out landing or go around. After airplane touched down, the pilot monitor neither called out no spoiler nor carried out thrust reverser standard call-out. The omission of this standard call-out procedure might affect subsequent airplane speed reduction.
4.Current Far Eastern Air Transport Flight Operation Quality Assurance system operational settings about the monitoring of airplane long flare was different from those specified in the document. Current type of monitoring may not be able to monitor the risk of occurrence of airplane long flare during landing.

Safety Recommendations

Recommendations to Far Eastern Air Transport:

1.Follow those flight operation related manuals to enhance flight crew's situational awareness and related trainings about landing on wet and slippery runway.
2.Examine current monitoring functions of Flight Operation Quality Assurance system and reinforce the monitoring of those items related to runway overrun and runway veer off, such as airplane touch down point, long flare, spoiler and the operations of thrust reverser.
3.Review the procedures of Flight Data Analysis Program, reinforce management mechanism of DFDAU Interface Control Document to ensure the correctness and integrity of recorded data.

Recommendations to Civil Aeronautics Administration, Ministry of Transportation and Communications:

1.Supervise Far Eastern Air Transport to follow those flight operation related manuals to enhance flight crew's situational awareness and related trainings about landing on wet and slippery runway.
2.Supervise operators of civil aviation by following current related regulations and referencing to those actions done by US and European countries to enhance monitoring functions of Flight Operation Quality Assurance system; and reinforce the monitoring of those items related to runway overrun and runway veer off.
3.Supervise Far Eastern Air Transport to review the procedures of Flight Data Analysis Program and management mechanism of DFDAU Interface Control Document to ensure the correctness and integrity of recorded data.

Full investigation report is available for download at ASC website: www.asc.gov.tw

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