The Aviation Safety Council （ASC）releases final report on investigation of a Daily Air Corporation （Daily Air） Dornier-228（DO-228） aircraft, the flight crew did not extend the landing gear at Taitung Airport during landing.

On December 21, 2014, a Daily Air  DO-228 airplane, registration number B-55565, took off from Taitung Airport for local flight training nearby the Green Island areas. Both instructor pilot and training captain of this training mission did not follow the standard procedures to conduct the before landing check list, resulted in the airplane belly landed without extended the landing gear.

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 also included: Civil Aeronautics Administration of Ministry of Transportation and Communications （CAA）, German Federal Bureau of Aircraft Accident Investigation and Daily Air Corporation. The Final Report was reviewed and approved by ASC’s 36th Council Meeting on August 25, 2015.

Findings related to probable causes:

1. The instructor pilot and the training captain of this training mission did not follow the standard operation procedures to conduct the before landing check list, resulted in the airplane belly landed without extended the landing gear.
2. The instructor pilot provided massive instructions to the training captain during the flight training process; it impacted the situation awareness in the cockpit. In addition, he did not take over the control after the landing gear warning tone initiated; his airmanship and the proficiency was considered insufficient.

Findings related to the risks

1. The instructor pilot did not comprehend the training contents of this training flight and did not follow the training manual to conduct the briefing.
2. The instructor pilot did not follow the session #1 of the captain training program to conduct the simulated single engine failure controllability exercises in flight area, but conducted the simulated single engine approach and landing exercises which were not in the session #1 of the training program; it impact the flight safety.
3. The Daily Air did not conduct the appropriate training program to the instructor pilot; it may generate the insufficient training and competence of the instructor pilot.
4. Some flight crew in DO-228 fleet did not pay attention to follow the procedures and the safety concept in the manuals during daily operations; it may affect the normal routine operation and flight safety.
5. The manpower shortage of flight operation training department and the employees are depressed by the uncertainty of their job in Daily Air may impact the routine operation and training.
6. The function of flight operation supervision in Daily Air was not fully executed, and the CAA was not reviewing and regulating the related programs and manuals properly as a regulatory of Daily Air.
7. Parts of the manuals of Daily Air were inconsistent with the practical operational conditions; some definition of flight crew training manual was not clearly defined and the right seat captain training program was not defined in training manual, it may affect the training processes.

Safety Recommendations

Recommendations to Daily Air :

1. Develop and conduct the appropriate pilot recruit and training program in accordance with the related company procedures, and enhance the selection, training and assessment of instructor pilot.
2. Demand the flight crew to conduct the preflight briefing by the company procedures.
3. Improve and implement the flight crew to follow the standard operation procedures.
4. Review the manpower requirements and applications in flight operation department.
5. Revise and define the related manuals not in compliance with the practical operational status or not defined.

Recommendations to CAA :

1. Improve the review task of related programs and manuals of Daily Air, and enhance the supervision to the training of the flight crew, the selection, training and assessment of the instructor pilots.
2. Supervise Daily Air to fulfill the preflight briefing by the company procedures.
3. Supervise Daily Air to improve and implement the flight crew to follow the standard operation procedure, and review the manpower requirements and applications in flight operation department.
4. Review and supervise the other similar operators and the operator who plan to supersede the business of Daily Air, whether if they have the issues related to the crew training, manpower utilization and standard operation procedures compliance.

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

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