Daily D228 at Lanyu on Feb 5th 2015, runway excursion on landing

Last Update: December 14, 2015 / 14:11:54 GMT/Zulu time

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Incident Facts

Date of incident
Feb 5, 2015

Classification
Accident

Cause
Runway excursion

Airline
Daily Air

Flight number
DA-7507

Departure
Taitung, Taiwan

Destination
Lanyu, Taiwan

Aircraft Registration
B-55563

Aircraft Type
DORNIER 228

ICAO Type Designator
D228

A Daily Air Dornier Do-228, registration B-55563 performing flight DA-7507 from Taitung to Lanyu (Taiwan) with 19 passengers and 2 crew, landed on Lanyu's runway 31 but touched down to the right of the runway center line with the right hand main gear outside the runway edge, the crew aborted the landing and went around. When attempting to retract the gear the crew found the gear lever did not operate normally into the up position and decided to return to Taitung where the aircraft performed a low approach to verify from the ground that the landing gear was down and landed without further incident about 66 minutes after departure from Taitung. There were no injuries, the aircraft sustained substantial damage however.

Taiwan's ASC reported the occurrence was rated an accident, flight data and cockpit voice recorders were secured, an investigation has been opened and investigators are expected on site on Feb 6th.

The airline reported the crew encountered a gust of crosswind and balked the landing, the gear however received damage and could not be retracted. The crew decided to return to Taitung and performed three low approaches for a visual inspection from the ground, the landing gear appeared normal and the aircraft landed safely afterwards. The aircraft sustained damage.

No Metars are available, the local weather station reported northerly winds at 14 knots, visbility of 15km, partly cloudy about 1.5 hours prior to the occurrence and northerly winds at 12 knots, visibility of 12km and partly cloudy about 1.5 hours after the occurrence.

On Dec 10th 2015 the ASC released their executive summary of the final report and the final report in Chinese concluding the probable causes of the accident were:

Findings related to probable cause

- On the date of the occurrence, it was the first time for the Captain been paired with non-instructor pilots to conduct the flight duties to Lanyu Airport. While wind conditions were within limitations, the Captain’s crosswind landing technique and deviation correcting maneuver were inadequate for the landing operation, and leaded the aircraft to veer off the runway after touchdown.

- Daily Air neither provided proper initial route training required by its training manual to the Captain, nor dispatched him to carry out flight duties on the west-shore routes first after checkout for familiarization purpose according to the company’s customary practices, which has caused the un-proficiency of Captain’s landing technique. The instructor pilot’s qualification check could not ensure that the pilots were competent to conduct flight duties to Lanyu Airport.

Findings related to risk

- Daily Air did not incorporate its safety ensuring measures such as the customary practice of “newly checkout Captain should be dispatched to carry out flight duties on the west-shore routes first for familiarization purpose” into related procedures with the aim of easier to manage and abide by.

- Daily Air has no clear evaluation standards and procedures for instructor pilots to verify the competency of newly checkout Captains before dispatching them to conduct flight duties to special airports.

- Due to shortage of manpower in the Flight Operations Division, the training procedures, standards, flight crew qualification, and risk management in Daily Air were not in place.

- Daily Air did not conduct self-audit in accordance with its own procedures after it experienced the occurrence of landing without lowering the landing gears in December 2014.

- When conducting the self-audit toward system safety of the flight operations, Daily Air did not certainly review the training that newly hired flight crew received conformed to company’s requirements.

- The pre-set values of risk indexes on Daily Air’s “flight crew dispatch risk evaluation checklist” might not effectively reflect, identify and manage the duty risk.

- Due to high workload, the CAA inspector did not conduct the on-scene inspections toward Daily Air. Several deficiencies like the noncompliance of Captain’s route training, the insufficient manpower in training department of Flight Operations Division, and the improper risk assessment were not identified during the routine oversights.

- Due to geographical restraint, Lanyu Airport is unable to conform to the recommendation in the “Civil Aerodrome Design and Operation Standards”addressing that the width of runway strips for a 1B non-instrument runway should be 60 meters. The declared width of runway strips in Lanyu Airport is 40 meters only, thus it was categorized as a special airport.

- There are uncovered ditches, reinforced concrete fences and cliffs within the recommended runway strips and grading area in Lanyu Airport, thus it does not conform to the recommendation in the “Civil Aerodrome Design and Operation Standards”addressing that the width of runway strips for a 1B non-instrument runway should be 60 meters.

Other findings

- The qualifications of flight crew complied with current civil aviation regulations. No evidence showed that the flight crew were influenced by any drugs and alcohol during the flight.

- No abnormal log entries were found after reviewing maintenance records for the previous month. All certifications and airworthiness complied with current regulations, and the weight and balance was within limitations. All systems were functioning normally prior to the occurrence. The damages to the landing gears were caused during the occurrence.

- Though the absence of flight data recorder on Daily Air’s Dornier-228 was approved by the CAA and therefore it conformed to the Aircraft Flight Operation Regulations, it deprived the operator of collecting routine operations data, and consequently caused the difficulty in ensuring safety management. It is also unfavorable for occurrence investigation if there is any.

The ASC reported that the captain was pilot flying and was informed about runway 31 in use while checking in with Lanyu Control Tower, winds were at 13 knots from 070 degrees gusting up to 22 knots. Following touchdown on the runway the aircraft veered right leaving the right runway edge 1900 feet down the runway and rolled on soft ground for 338 feet before returning onto the paved surface. The crew then decided to reject the landing and went around, during climb the crew discovered that the landing gear handle could no longer be normally retracted and decided to return to Taitung. The aircraft sustained minor damage (editorial note: however, the Chinese report makes clear the accident rating was sustained).

Nine safety recommendations were released as result of the investigation.

On Dec 14th 2015 a native Chinese reader recommended to add one detail mentioned in the Chinese report (but not mentioned in the executive summary): a number of electrical cables connecting to the left main gear solenoid had been severed resulting in the inability to retract the landing gear.
Incident Facts

Date of incident
Feb 5, 2015

Classification
Accident

Cause
Runway excursion

Airline
Daily Air

Flight number
DA-7507

Departure
Taitung, Taiwan

Destination
Lanyu, Taiwan

Aircraft Registration
B-55563

Aircraft Type
DORNIER 228

ICAO Type Designator
D228

This article is published under license from Avherald.com. © of text by Avherald.com.
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