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Publish Final Report, Mandarin Airlines flight AE 964 runway veer off during landing at Taichung International Airport occurrence final report.


Publication Date 2015-11-03
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Aviation Safety Council (ASC) releases investigation Final Report of Mandarin Airlines flight AE 964 runway veer off during landing at Taichung International Airport.

On September 20th, 2014, Mandarin Airlines flight AE 964, a scheduled revenue service passenger flight, an ERJ-190, with aircraft registration number B-16821, took off from Zheng Zhou International Airport, Henan Province, China at 1852 Taipei time for Taichung International Airport. There were 2 flight crew members, 1 on board mechanic, 3 cabin crew members and 73 passengers, total 79 people on board.

The airplane was touching down at the right side of the runway center line with a light bounce landing. The aileron and rudder were not in the correct positions in accordance with cross wind correction; the aircraft continued veering to the right and off the 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 (ICAO), the ASC launched an occurrence investigation by law. The organization or agency been invited to join the investigation team included: Civil Aeronautics Administration of Ministry of Transportation and Communications, Air Force Command Headquarters, Ministry of National Defense, R.O.C., Mandarin Airlines, (AERONAUTICAL ACCIDENT INVESTIGATION AND PREVENTION CENTER, CENIPA) and Embraer S.A. (ERJ aerospace company),(National Transportation Safety Board, NTSB) and Engine manufacturer, the GE Company. The Final Report was reviewed and approved by ASC's 37th Council Meeting on October 13th, 2015.

Findings related to probable causes: the flight crew might be unable to identify runway visual cues and cross reference the aircraft normal approach profile with the runway ,did not initiated a go-around; The late autopilot disengagement was not in favor of cross wind maneuver while the aircraft was flaring to the right downwind side, the aircraft landed on the right side of the runway center line with light bouncing, the aileron and rudder were not in the correct positions in accordance with cross wind correction, the aircraft continued veering to the right and off the runway after 2 seconds.

There are three risk findings related to “flight operations”: the flight crew was in lack of situation awareness especially to weather change; the flight crew did not initiated a go-around when unable to identify the runway center line within initial 3000 ft.; the company Flight Operation Manual autopilot operating policy was different from the recommended Embraer SOPM procedure. Four risk findings related to “Air Traffic Control”: the tower did not advise the RVR values to AE 964 flight crew after the aircraft was transferred from Taipei Approach; the tower did not relay “runway condition wet” to AE 964 flight crew after receiving information from the Flight Operation Office; Meteorological reports at 2105 and 2116 were not copied and the way that Air Force disseminating meteorological report procedure was only time-consuming but increasing the workload. There are two risk findings related to “airport”: the average transverse slope of Runway 36 is about 0.5% which was lower than the regulation requirement (1.0-1.5%); The poor drainage performance of runway pavement may lead to runway standing water and increased hydroplaning possibility and the iron cover of the manhole was not firmly attached.  

 

A total of seventeen recommendations are issued. Three recommendations are issued to Mandarin Airlines:

  • Enhance flight crew on go around (reject landing) training and incorporate sudden loss of visual cues scenario into the training syllabus.
  • Enhance flight crew on weather change situation awareness and weather information monitoring.
  • Review the policies and current operations of automation usage during approach and insure their compliance with manufacturer guidance. Provide flight crew with detailed automation operation guidance.

Recommendations issued to CAA except required CAA to supervise Mandarin Airlines implementation of above recommendations, four other recommendations are issued to CAA and Air Force Command Headquarters, Ministry of National Defense:

  • Advised CAA to cooperate with Air Force Command Headquarters, Ministry of National Defense, to inspect and improve the drainage performance of Taichung Airport runway pavement.
  • Advised CAA to cooperate with Air Force Command Headquarters, Ministry of National Defense to inspect the manhole design aside the runway  of all common used airports, and mitigate the risk of lifted manhole covers when aircraft running over.
  • Advised CAA to cooperation with Air Force Command Headquarters, Ministry of National Defense, to inspect and improve the runway edge lights at Taichung Airport Runway 36.
  • Advised CAA to cooperation with Air Force Command Headquarters, Ministry of National Defense, to evaluate the feasibility to install runway center line lights at Taichung International Airport.

 

There are three other recommendations issued to Air Force Command Headquarters, Ministry of National Defense:

  • Supervise the Communications, ATC and Information Wing to implement ATMP regulations regarding tower advising weather and runway conditions to flight crew.
  • Refer to CAA operation, set up the automation system for meteorological report dissemination and ATIS recording.
  • Refer to CAA operation; provide second by second AWOS wind records.

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

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

Last updated 2019-11-07
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