Mandarin E190 at Makung on Aug 17th 2012, overran runway, nose gear collapse

Last Update: September 13, 2013 / 15:46:43 GMT/Zulu time

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Incident Facts

Date of incident
Aug 17, 2012

Classification
Accident

Aircraft Registration
B-16825

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

Taiwan's Aviation Safety Council (ASC) have released their final report in Chinese concluding the probable cause was:

During landing phase, the flight crew early flare the aircraft, did not timely retract the thrust lever to idle position. The flight crew continued holding to the control column and did not initiate a go around or reject landing after the aircraft landed beyond the touchdown zone. After landing, the flight crew did not apply the best deceleration procedures, incorrectly considered the aircraft encountered hydroplaning and intentionally controlled the aircraft out of the runway to the grass field when approaching the end of runway. The aircraft hit the handholds of the taxiway edge lights during landing roll and damaged the nose landing gear.

Findings related to risks:

The ERJ-190 manual recommended the flight crew applied the FLAPS FULL landing configuration during landing when the aircraft was heavy and landing at wet or short runway. However, in this occurrence the flight crew applied the FLAPS 5 configuration during landing. Mandarin Airlines ERJ Flight Operation Manual did not include runway pavement characteristics, runway landing distance calculation, landing skill and touchdown zone judgment specification, nor have landing performance and operation guidance for the wet/slippery runway. Mandarin Airlines relevant manuals did not include the standard call-out when aircraft was deviating from normal operation range therefore the flight crew was unable to enhance situation awareness effectively. Mandarin Airlines ERJ different thrust reducing procedure during landing might caused flight crewfs confusion, and finally, the landing performance information in QRH (Quick Reference Handbook) neither includes landing distance information on wet runways nor the extra 15% safety margin for landing.

Some of the concrete structure within runway strip at Makong Airport was not installed in accordance with eCivil Aerodrome Design and Operation Standardsf recommendedFWithin the general area of the strip adjacent to the runway, measures should be taken to prevent an aeroplanefs wheel when sinking into the ground, from striking a hard vertical face. The uncovered ditch, 85 meters to the runway centerline, parallel to Makong Airport runway 02 was not on graded in accordance to the fCivil Aerodrome Design and Operation Standardsf recommended that the portion of a runway strip should be graded for a precision approach runway.

The ASC reported the aircraft was on the VOR-1 approach to Makung's runway 20 in visibility of 3200 meters and light rain, the weather above minimum conditions permitted for the approach. The crew decided to use flaps 5 and medium automatic brakes for the landing.

The crew got visual with the runway about 12nm out. Descending through 650 feet the first officer (26, ATPL, 403 hours total, 109 hours on type), pilot monitoring, announced "three reds" (referring to the PAPIs) to which the captain (42, ATPL, 9,473 hours total, 2,469 hours on type) replied "correcting" and the pitch attitude increased by about one degree. Descending through 50 feet the flare is being initiated, the aircraft rolls to a right bank angle of 1.5 degrees. At 30 feet the autothrottle still indicated SPD, at 10 feet the autothrottles announced RETARD and the thrust levers move towards idle, the attitude increased further and the aircraft climbed back to 20 feet AGL, autothrottle returned to SPD, before descending again, autothrottle again going into RETARD, and touching down with its main gear about 3150 feet (960 meters) past the runway threshold, 4000 feet (1220 meters) remaining at about 118 KIAS, the captain called out "manual braking", the thrust levers reach idle, the thrust reversers were deployed, the nose gear touched down about 3700 feet down the runway, the brakes pedals travel into their maximum braking position, maximum reverse thrust is being applied. The airspeed decreases through 90 knots, the engines reach their maximum of 70% N1 when the aircraft slowed through 70 knots, the captain applied left rudder, the aircraft turns from 198 degrees to 175 degrees, the thrust reversers are returned to minimum reverse thrust, at 35 knots the first officer calls out "not on runway", at a speed of 23 knots the cockpit voice recorder records "percussive" noises, at 14 knots the landing gear horn starts to sound and continues until stop of cockpit voice recording.

After the aircraft came to a stop the crew worked the relevant checklists, verified there was no fire or leakage, activated the APU, shut down both engines, pulled the circuit breakers for the black boxes, and then helped the passengers to exit the aircraft through the 1R door.

There were no injuries, the aircraft however received substantial damage including nose gear fracture and penetration of the nose. A taxiway light was crushed, a manhole was damaged.

The captain provided testimony that the landing appeared to be normal, they were slightly low on approach which was corrected. After touch down he did not feel deceleration and assumed medium braking wasn't sufficient, hence applied manual braking and applied maximum reverse thrust but still felt he could not stop the aircraft before the runway end and decided to steer the aircraft left.

The ASC analysed that the crew decided to use flaps 5 without considering the increase in landing distance required. Although the approach was stabilized until over the threshold, the aircraft floated more than 1/3 of the runway length and according to standard operating manuals should have aborted the landing and gone around at that point.

During the flare the thrust levers did not reach their idle position causing the long float.

The ASC analyzed that full reverse thrust may be used until full stop of the aircraft, the reversers would be most effective around 80 knots. Performance analysis revealed that had the crew applied maximum braking and maintained maximum reverse thrust until stop the aircraft would have stopped well within the runway boundaries.

The ASC analyzed that the captain suspected the braking system didn't work, with the runway wet he thus believed the aircraft was hydroplaning.
Incident Facts

Date of incident
Aug 17, 2012

Classification
Accident

Aircraft Registration
B-16825

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

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