Mandarin E190 at Taichung on Sep 20th 2014, temporary runway excursion on landing
Last Update: November 3, 2015 / 14:43:08 GMT/Zulu time
Incident Facts
Date of incident
Sep 20, 2014
Classification
Incident
Airline
Mandarin Airlines
Flight number
AE-864
Departure
Zhengzhou, China
Destination
Taichung, Taiwan
Aircraft Registration
B-16821
Aircraft Type
Embraer ERJ-190
ICAO Type Designator
E190
Airport ICAO Code
RCMQ
Taiwan's Aviation Safety Council (ASC) have opened an investigation into the occurrence.
On Sep 23rd 2014 the ASC reported that the aircraft hit runway edge lights and signs and received damage to right main gear tyres as well as the right hand engine's cowling. The ASC dispatched investigators on site, who secured the cockpit voice and flight data recorders, performed interviews with the crew and air traffic control, examined the runway runway taking measurements and doing flight testing. The occurrence has been rated an accident.
Taichung Airport features a runway 18/36 of 3659 meters/12000 feet length with ILS approaches for both directions.
ON Nov 3rd 2015 the ASC released their executive summary of the final report into the incident releasing following findings:
Findings related to probable causes:
- Under the circumstance of heavy rain, low visibility, no runway center line light and standing water along runway edges, the flight crew might be unable to identify runway visual cues and cross reference the aircraft normal approach profile with the runway. The flight crew should have initiated a go-around.
- The flight crew did not disengage the autopilot until radio altitude 50 feet. The late autopilot disengagement was not in favor of cross wind maneuver while the aircraft was flaring to the right downwind side.
- The flight crew used improper cross wind correction during flare to the right downwind side, the aircraft landed on the right side of the runway center line, and continued to drift to the downwind side of the runway.
- While the aircraft landed at the right side of the runway 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.
Findings related to risks
- The flight crew neither discussed weather change, nor the correspondent procedures during approach briefing or final approach checklist, did not request tower for further weather information. The flight crew was in lack of situation awareness especially to weather change.
- If the flight crew was not able to identify the runway center line within initial 3000 ft. runway touchdown zone, the flight crew should have initiated a go-around prior to or during touchdown.
- The company Flight Operation Manual operating policy regarding flight crew encountering adverse factors during approach was that they may use the autopilot until the minimum usage height, which was different from the recommended Embraer SOPM procedure of autopilot disengagement at MDA/DA/DH.
- The average transverse slope of Runway 36 is about 0.5% lower than the regulation requirement (1.0-1.5 % ). Therefore the poor drainage performance of runway pavement may lead to runway standing water and increased hydroplaning possibility.
- The occurrence aircraft ran over a manhole. The iron cover of the manhole was not firmly attached, and hence was lifted off by the aircraft. There were a total of 118 similar manholes aside the runway at Taichung Airport.
- 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.
- The copy record of meteorological reports of tower showed the SPECIs of 2045, 2105 and 2116 were not copied.(1.18.2.5, 2.3.1)
- The meteorological report disseminating procedure adopted by CAA meteorological unit was to send reports to towers via automation system and compile ATIS automatically. However, the Air Force disseminating procedure was to furnish reports to towers by phone, and then the towers would copy the reports and record ATIS manually. The procedure is not only time-consuming but increasing the workload. Errors may occur during the process.
Other findings
- Flight crew qualifications complied with current civil aviation regulations. No evidence shows that the flight crew had any influences from drugs during the flight.
- The AWOS per minute wind records maintained by Air Force were unable to provide detailed wind component information when there were runway excursion events.
- No evidence showed the aircraft encountered hydroplaning during landing operation.
- The fragile material within the runway area and the grid test result was in compliance with the regulations.
- The runway 36 width at Taichung International Airport is 60 meters. The existing runway edge lights were only suitable for a runway width of 45 meters, and was not in compliance with the requirements of “Civil Aerodrome Design and Operation Guidance” and ICAO Annex 14.
- Runway center line lights should be provided on a precision approach runway category I, particularly when the runway is used by aircraft with high landing speeds or where the width between the runway edge lights is greater than 50 meters, which is true for Taichung International Airport runway 36. According to the recommendations from “Civil Aerodrome Design and Operation Guidance” and ICAO Annex 14, the installation of runway center line lights may enhance pilots visual reference during landing operation.
- No abnormal log entries were found after reviewing maintenance records for the last 6 months, including all scheduled check items after engine one installation and the last scheduled check.
- System function test, brake system function test, and reverser function test results were normal. Landing gear tire depth treads, brake lining and tire pressure were within the tolerance.
- Engine on wings test of the ESM 72-00-00-810-324 Engine flameout,and ESM 72-00-00-810-321 Compressor stall results were normal.
- According to GE engine investigation report, number 1 engine (including FADEC) function was normal and could have been returned to service. Mandarin sent number 1 engine to IHI engine overhaul shop at Japan for test and result was normal.
- Based on the DVDR data, GE reviewed the probable causes of number 1 engine flame out. The engine investigation report concluded: most probable cause for the left hand engine (LHE) flame-out was water ingestion from the aircraft nose gear when the aircraft had a -20 deg heading.
- There was an incorrect aileron parameter definition in the DVDR readout document. The positive should be surface down. The incorrect information was fixed in Embraer’s latest DVDR document revision.
The ASC reported the captain was pilot flying and the first officer pilot monitoring. RVR was 550 meters, the runway was wet, however, the information was not relayed to the crew by tower. The aircraft performed an eventless approach on autopilot until the autopilot was disconnected one second after the automated call "Fifty". At the time the autopilot was disconnected the aircraft was at 46.2 feet AGL, nose up 6.3 degrees and right bank of 4 degrees on a magnetic heading of 358.4 degrees, the course deflection indication was +0.073 dots. Following the disconnection of the autopilot the course deflection indication increased to +0.315 dots. The aircraft touched down 1290 feet past the runway threshold, bounced and touched down a second time 1620 feet past the runway threshold. Autothrust was disconnected at that point, the nose was lowered and the nose gear touched down 2120 feet past the runway threshold, at the same time the right hand main gear departed the runway surface. 3 seconds after the nose gear touched down a master caution occurred that the pilot monitoring identified to be related to the left hand engine (CF34) the EGT of which had dropped to below idle. About 6-7 seconds after nose gear touchdown the right main gear returned onto the runway 3230 feet past the runway threshold.
The crew taxied the aircraft to the apron on single engine and requested tower to check whether they had contacted any runway edge light. Ground personnel found one damage runway edge light and one damaged runway sign.
Ground staff subsequently detected that a right hand main tyre as well as the right hand engine cowling had been damaged.
Metars:
RCMQ 201500Z 04001KT 7000 BKN002 FEW014CB OVC025 25/24 Q1001 NOSIG RMK A2957 RETS RERA CB SW MOV NW QFF1002.0HPA
RCMQ 201410Z 29007KT 4000 -SHRA VCTS BKN002 FEW010CB OVC020 24/23 Q1002 RMK A2960 RETS TS SW MOV N
RCMQ 201454Z 02001KT 7000 BKN002 FEW014CB OVC025 25/24 Q1001 RMK A2957 CB SW MOV NW
RCMQ 201418Z 29005KT 5000 -RA VCTS BR BKN002 FEW014CB OVC025 24/23 Q1002 RMK A2959 TS SW MOV N
RCMQ 201406Z 29008KT 2400 -TSRA BKN002 FEW010CB OVC014 24/23 Q1002 RMK A2960 RERA TS SW MOV N
RCMQ 201400Z 27007KT 0600 R36/1000U +TSRA BKN002 FEW010CB OVC014 24/23 Q1002 NOSIG RMK A2960 TS OVHD MOV N QFF1003.3HPA
RCMQ 201336Z 28008KT 0600 R36/0800D +TSRA BKN002 FEW010CB OVC014 25/24 Q1002 RMK A2961 TS OVHD MOV N
RCMQ 201330Z 26008KT 1200 R36/1000N +TSRA SCT002 BKN006 FEW014CB OVC020 25/24 Q1002 NOSIG RMK A2961 TS OVHD MOV N
RCMQ 201310Z 33006KT 4000 -TSRA SCT004 BKN008 FEW014CB BKN030 27/25 Q1002 RMK A2960 TS OVHD MOV N
RCMQ 201305Z 34007KT 4000 -TSRA SCT004 BKN008 FEW014CB BKN030 27/25 Q1002 RMK A2960 TS S MOV N
RCMQ 201300Z 34007KT 6000 -SHRA VCTS SCT004 BKN008 FEW014CB BKN030 27/25 Q1002 NOSIG RMK A2959 TS S MOV N QFF1002.7HPA
RCMQ 201230Z 36010KT 9000 SCT004 BKN008 BKN030 27/25 Q1001 NOSIG RMK A2957
RCMQ 201252Z 35005KT 9000 -SHRA VCTS SCT004 BKN008 FEW014CB BKN030 27/25 Q1002 RMK A2959 TS S MOV N
RCMQ 201245Z 36005KT 9000 VCTS VCSH SCT004 BKN008 FEW014CB BKN030 27/25 Q1002 RMK A2959 TS S MOV N VCSH S
RCMQ 201208Z 36009KT 9000 SCT004 BKN008 BKN030 27/25 Q1001 RMK A2957
RCMQ 201200Z 36010KT 9000 -RA SCT004 BKN008 BKN030 27/25 Q1000 NOSIG RMK A2955 QFF1000.7HPA
RCMQ 201137Z 36013KT 9000 -RA SCT004 BKN008 BKN030 27/25 Q1000 RMK A2954
RCMQ 201130Z 36014KT 9000 SCT004 BKN008 OVC030 27/25 Q1000 NOSIG RMK A2954
RCMQ 201100Z 36013KT 9000 SCT004 BKN008 OVC030 27/25 Q1000 NOSIG RMK A2954 QFF1000.3HPA
RCMQ 201030Z 36016KT 9000 SCT004 BKN008 OVC030 27/25 Q1000 NOSIG RMK A2953
RCMQ 201010Z 36014KT 9000 VCSH SCT004 BKN008 OVC030 28/25 Q0999 RMK A2952 VCSH SW
RCMQ 201000Z 01014KT 9999 VCSH FEW004 BKN010 BKN050 28/25 Q0999 NOSIG RMK A2952 QFF999.7HPA VCSH SW
Incident Facts
Date of incident
Sep 20, 2014
Classification
Incident
Airline
Mandarin Airlines
Flight number
AE-864
Departure
Zhengzhou, China
Destination
Taichung, Taiwan
Aircraft Registration
B-16821
Aircraft Type
Embraer ERJ-190
ICAO Type Designator
E190
Airport ICAO Code
RCMQ
This article is published under license from Avherald.com. © of text by Avherald.com.
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