Mandarin AT72 at Taichung on Aug 22nd 2018, runway excursion

Last Update: August 21, 2019 / 15:39:30 GMT/Zulu time

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Incident Facts

Date of incident
Aug 22, 2018

Classification
Accident

Cause
Runway excursion

Airline
Mandarin Airlines

Flight number
AE-788

Departure
Magong, Taiwan

Destination
Taichung, Taiwan

Aircraft Registration
B-16852

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

Airport
Taichung Ching Chuang Kang Airport, Taichung City

Airport ICAO Code
RCMQ

A Mandarin Airlines Avions de Transport Regional ATR-72-212A, registration B-16852 performing flight AE-788 from Magong to Taichung (Taiwan) with 70 passengers and 4 crew, landed on Taichung's runway 36 at 19:29L (11:29Z) but contacted a number of runway edge lights. There were no injuries, the aircraft sustained substantial damage however.

Taiwan's ASC rated the occurrence an accident and opened an investigation.

On Aug 21st 2019 the ASC, now renamed to Taiwan Transportation Safety Board TTSB (per Aug 1st 2019), released their final report in Chinese only as well as an executive summary in English (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Chinese only release - even with a brief executive summary in English - does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).
.

The report concludes the probable causes of the accident were:

Findings Related to Probable Causes

1. The occurrence flight crew did not comply with Mandarin Airlines Flight Operations Manual, the first officer acted as the pilot flying for the approach and landing while the visibility during approach did not meet the first officer takeoff and landing minimums.

2. During the time the pilot flying disengaged the autopilot and controlled the aircraft manually, the aircraft continued to deviate from the runway center line to the left. The pilot flying was unable to manage the lateral control of the aircraft and correct the aircraft back to the runway center line.

3. The captain allowed the aircraft to deviate from the runway center line to a large extent, reducing the fault tolerance range of safety margin, and did not recognize the possible risk of aircraft slow and continuous left deviation. The rain affected the visibility right before the aircraft touched down. After the aircraft landed near the runway edge line and continuously deviated to the left, the captain then took over the control. It was too late for the correction and caused the aircraft to veer off the runway.

Findings Related to Risk

1. Before the occurrence aircraft descent, the contents of the approach briefing by the pilot flying included only approach procedure related information. The briefing did not follow the company's CFIT/ALAR/RWY EXCURSION AVOIDANCE checklist and threat and error management content, examining possible risk increasing to approach landing due to threats of heavy rain, thunderstorms and low visibility.

2. The ground base of the runway edge lights within the runway strip of Taichung Airport existed potholes and hard vertical cement concrete structures. It may increase the possibility of aircraft damage during runway veer-off occurrence.

Other Findings

1. The Taichung Airport runway 36 was classified as a category I precision approach runway. Without the setting of runway centerline lights was in compliance with the Civil Aerodrome Design and Operation Standards. However, considering that the distance between the runway edge lights was greater than 50 meters, the compliance of the proposed setting of runway centerline lights would assist pilots to align the runway.

2. The runway average transverse slope of Taichung Airport is 0.53%, which is lower than the recommended 1% to 1.5% slope of the Civil Aerodrome Design and Operation Standards.

3. The results of the latest runway surface friction coefficient measurements of Taichung Airport before and after the occurrence were all in compliance with the relevant standards.

4. The flight crew of the occurrence aircraft held valid Air Transport Pilot License and medical certificate issued by the Civil Aeronautics Administration, Ministry of Transportation and Communications. The rest and activities of flight crew 72 hours before the occurrence were
all normal. No evidence indicated any pre-existed medical conditions, alcohol or fatigue that might have adversely affected the flight crew’s performance during the occurrence flight.

5. The control and implementation of the airworthiness directive and technical notice of the occurrence aircraft complied with relevant regulations. The aircraft’s aircraft and engine maintenance records 3 months before the occurrence flight revealed that there was no abnormal entry that related to the aircraft’s directional control systems.

The TTSB reported the aircraft received substantial damage to the belly (a large hole), the right main gear, the nose gear, the right hand propeller (cracks in the blades).

Metars:
RCMQ 221300Z 17002KT 1600 -RA BR SCT004 SCT008CB BKN016 OVC030 26/25 Q0999 RETS NOSIG RMK A2952 RA AMT 7.2MM CB NW=
RCMQ 221250Z 15002KT 1600 -RA BR SCT004 SCT008CB BKN016 OVC030 26/25 Q0999 NOSIG RMK A2952 CB NW=
RCMQ 221230Z 00000KT 1600 -TSRA SCT004 SCT008CB BKN016 OVC030 26/25 Q0999 NOSIG RMK A2950 TS NW STNRY=
RCMQ 221220Z 23002KT 1600 -TSRA SCT004 SCT008CB BKN016 OVC030 26/25 Q0999 NOSIG RMK A2950 TS NW STNRY=
RCMQ 221208Z 22006KT 1600 TSRA SCT004 SCT008CB BKN016 OVC030 26/25 Q0999 NOSIG RMK A2950 TS W MOV NW=
RCMQ 221200Z 22006KT 1600 TSRA SCT004 SCT008CB BKN016 OVC030 26/25 Q0999 NOSIG RMK A2950 TS W MOV NW=
RCMQ 221200Z 23006KT 0600 R36/1600U +TSRA SCT004 SCT008CB BKN016 OVC030 26/25 Q0999 NOSIG RMK A2950 RA AMT 25.5MM TS W MOV NW=
RCMQ 221144Z 21005KT 0600 R36/1000N +TSRA SCT004 SCT008CB BKN016 OVC030 26/25 Q0999 NOSIG RMK A2950 TS W MOV NW=
RCMQ 221130Z 19006KT 0600 R36/1000U +TSRA SCT004 SCT008CB BKN016 OVC030 26/25 Q0998 NOSIG RMK A2949 TS OVHD MOV W=
RCMQ 221100Z 16008KT 0600 R36/0800N +TSRA SCT004 SCT008CB BKN016 OVC030 28/27 Q0998 NOSIG RMK A2949 RA AMT 21.5MM TS OVHD MOV N=
RCMQ 221053Z 15008KT 0600 R36/0800D +TSRA SCT004 SCT008CB BKN016 OVC030 28/27 Q0998 NOSIG RMK A2949 TS SE MOV N=
RCMQ 221030Z 25001KT 0800 R36/1200U TSRA SCT004 SCT008CB BKN016 OVC030 28/27 Q0998 NOSIG RMK A2947 TS SE MOV VRBL=
RCMQ 221024Z 25001KT 0800 R36/1100N TSRA SCT004 SCT008CB BKN016 OVC030 28/27 Q0998 NOSIG RMK A2947 TS SE MOV VRBL=
RCMQ 221016Z 28002KT 0800 R36/1100 TSRA SCT004 SCT008CB BKN016 OVC030 28/27 Q0998 NOSIG RMK A2947 TS OVHD MOV NW=
RCMQ 221003Z 30002KT 1600 TSRA SCT004 SCT008CB BKN025 BKN040 28/27 Q0998 NOSIG RMK A2947 TS OVHD MOV NW=
RCMQ 221000Z 27002KT 3200 -TSRA SCT008CB BKN025 BKN040 28/27 Q0998 NOSIG RMK A2947 RA AMT 1.5MM TS OVHD MOV NW=
RCMQ 220953Z 27001KT 3200 -TSRA SCT008CB BKN025 BKN040 28/27 Q0998 NOSIG RMK A2947 TS OVHD MOV NW=
RCMQ 220947Z 29003KT 4000 -TSRA SCT008CB BKN025 BKN040 28/27 Q0998 NOSIG RMK A2947 TS OVHD MOV NW=
RCMQ 220930Z 32003KT 4800 -TSRA SCT008CB BKN025 BKN040 28/26 Q0997 NOSIG RMK A2946 TS OVHD MOV NW=
RCMQ 220923Z 33005KT 4800 -TSRA FEW008CB BKN025 BKN040 28/26 Q0997 NOSIG RMK A2946 TS OVHD MOV NW=
RCMQ 220915Z 32004KT 6000 -TSRA FEW010CB BKN025 BKN040 28/26 Q0997 NOSIG RMK A2946 TS SE MOV NW=
RCMQ 220908Z 35005KT 7000 TS VCSH FEW010CB BKN025 BKN040 29/25 Q0997 NOSIG RMK A2946 TS SE MOV NW VCSH SE=
RCMQ 220900Z 34005KT 8000 VCTS VCSH FEW010CB BKN025 BKN040 29/25 Q0997 NOSIG RMK A2946 TS SE STNRY VCSH SE=
RCMQ 220842Z 33006KT 8000 VCTS VCSH FEW010CB BKN025 BKN040 29/25 Q0997 NOSIG RMK A2946 TS SE STNRY VCSH SE=
RCMQ 220830Z 35005KT 9999 VCSH FEW010 BKN025 BKN050 29/25 Q0997 NOSIG RMK A2946 VCSH SE=
RCMQ 220800Z 33006KT 9999 VCSH FEW010 BKN025 BKN050 30/25 Q0998 NOSIG RMK A2947 VCSH E=