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Releases Final Report of China Airlines Flight CI704 Occurrence Investigation


Publication Date 2018-01-31
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The Aviation Safety Council (ASC) releases final report on investigation of a China Airlines flight CI704, the aircraft experienced a tail strike when performed a reject landing at Taoyuan Airport. 

On October 1, 2016, a China Airlines Airbus A330-300 aircraft, registration number B-18307, took off from Manila International Airport to Taoyuan International Airport to execute a schedule passenger flight. There were 2 flight crews, 11 cabin crews and 124 passengers, total 137 people on board. The aircraft experienced a tail strike when performed a reject landing on the 23R runway of Taoyuan Airport. At 1959 hour, the aircraft safe landed at the Taoyuan Airport with no injury but aircraft belly skin and structure damaged.

According to the Republic of China (ROC) Aviation Occurrence Investigation Act, and the content of Annex 13 to the Convention on International Civil Aviation, the ASC, an independent aviation occurrence investigation agency, was responsible for conducting the investigation. The investigation parties invited to participate in this investigation included: Bureau d'Enquêtes et d'Analyses, France (BEA), Airbus aircraft company, Civil Aeronautical Administration, ROC (CAA) and China Airlines.

Findings related to probable causes:

  1. The attention allocation and situational awareness of the Instructor Pilot were probably affected by the training Captain’s nose-holding tendency after touchdown addressed in the training record, so that he focused too much on the aircraft’s attitude but neglected to monitor critical information during landing as a pilot monitoring should do. For this reason, the Instructor Pilot was neither aware of the “REV” indication on the Engine/Warning Display page nor the position of reverse thrust levers, thus as a result neither held the status of thrust reverser in hand nor used it to make decision on whether to continue or reject the landing while taking over the flight control.
  2. In order to get the aircraft airborne promptly, the Instructor Pilot pulled the side stick full back after taking over the flight control and held that position until the aircraft started to rotate. In the mean time, forward thrust was unable to increase at once since thrust reversers were not in stowed and locked position yet, and the air speed continued to drop while deceleration devices kept functioning. Subsequently under the combination effects of deceleration devices stopped functioning, engine power sharply increased, and the pitch trim position was higher than normal setting, the Instructor Pilot’s full back side stick input caused the aircraft to pitch up rapidly. Though the Instructor Pilot had released the side stick input accordingly, however it didn’t overcome the dramatic pitch up tendency. The excessive rotation rate and high pitch during lift-off then led to the loss of tail section clearance, the tail strike, and the damage to the aircraft.

Findings related to risk:

  1. Although the Instructor Pilot commenced the go-around right after his taking over of the aircraft, the call out was made until the main landing gear had lifted off. This delay resulted in the training Captain’s unawareness of Instructor Pilot’s intention, so that he did not fill the role of pilot monitoring, dispute the nonconforming go-around decision in time, monitor or call out to assist Instructor Pilot in the operation of configuration, power setting, attitude, and speed.
  2. In the occurrence flight, the Instructor Pilot did not take advantage of his professional knowledge and experience to develop an effective situational awareness against the non-normality in the dynamic flight training environment so as to elevate the judging and handling ability for abnormal situation.

Safety Recommendations

To China Airlines:

  1. Reinforce education and training to ensure flight crew familiar with and abide by the standard go-around procedures in company and manufacture’s manuals. Also, ensure flight crew heighten their situational awareness toward air speed, attitude, configuration, deceleration devices, power setting, as well as remaining distance of the runway before making go-around decision, and thoroughly evaluate the adequacy and risk of a go-around prior execution, so that to prevent the tail strike occurrence from happening.
  2. Reinforce education and training of the Instructor Pilots to prevent the inappropriate maneuvers presented in the occurrence, prevent them from overemphasizing trainee’s operation with the result that neglect to fill the role of pilot monitoring. Also, ensure their ability to pose effective situational awareness against the dynamic flight training environment, so as to prepare for abnormal situation throughout the flight.
  3. Take occurrence scenario for example and tailor particular courses in the crew resource management training to strengthen the standardization of flight operations during landing, standard call out, flight crew’s situational awareness, communication and decision making while exchanging the flight duty. Moreover, especially reemphasize the importance to verify the status of thrust reversers after main gear touchdown, and the strict policy of making a full stop as the thrust reversers have been deployed.

To Civil Aeronautics Administration, Ministry of Transportation and Communications:

  1. Supervise and ensure that China Airlines reinforces education and training to ensure flight crew familiar with and abide by the standard go-around procedures in company and manufacture’s manuals. Also, ensure flight crew heighten their situational awareness toward air speed, attitude, configuration, deceleration devices, power setting, as well as remaining distance of the runway before making go-around decision, and thoroughly evaluate the adequacy and risk of a go-around prior execution, so that to prevent the tail strike occurrence from happening.
  2. Supervise and ensure that China Airlines reinforces education and training of their Instructor Pilots to prevent the inappropriate maneuvers presented in the occurrence, prevent them from overemphasizing trainee’s operation with the result that neglect to fill the role of pilot monitoring. Also, ensure their ability to pose effective situational awareness against the dynamic flight training environment, so as to prepare for abnormal situation throughout the flight.
  3. Supervise and ensure that China Airlines takes occurrence scenario for example and tailor particular courses in their crew resource management training to strengthen the standardization of flight operations during landing, standard call out, flight crew’s situational awareness, communication and decision making while exchanging the flight duty. Moreover, especially reemphasize the importance to verify the status of thrust reversers after main gear touchdown, and the strict policy of making a full stop as the thrust reversers have been deployed.

 

Full Final Report is in Chinese only and available for download at www.asc.gov.tw

                               

 

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

 

Last updated 2019-11-07
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