Last updated: 23 January 2017
Narrative:The flight departed Tainan at 19:24. The pilot-in-commend (CM-1) was on the left seat as the pilot monitor (PM), the first officer (CM-2) was on the right seat as the pilot flying (PF). The crew executed an ILS approach to runway 10 at Taipei-Sung Shan. At 19:58:12, the flight received landing clearance. At 19:28, the ATIS broadcast for RCSS read "...expect ILS Approach. Runway one zero in use; wind variable at three; visibility four thousand five hundred meters;
|Date:||Monday 18 October 2004|
|C/n / msn:|| 791|
|First flight:|| 1998|
|Total airframe hrs:||12124|
|Engines:|| 2 IAE V2527-A5|
|Crew:||Fatalities: 0 / Occupants: 6|
|Passengers:||Fatalities: 0 / Occupants: 100|
|Total:||Fatalities: 0 / Occupants: 106 |
|Airplane damage:|| Substantial|
|Airplane fate:|| Repaired|
|Location:||Taipei-Sung Shan Airport (TSA) ( Taiwan)
|Phase:|| Landing (LDG)|
|Nature:||Domestic Scheduled Passenger|
|Departure airport:||Tainan Airport (TNN/RCNN), Taiwan|
|Destination airport:||Taipei-Sung Shan Airport (TSA/RCSS), Taiwan|
light rain; cloud scattered eight hundred feet, broken one thousand eight hundred feet, overcast three thousand five hundred feet; temperature two three; dew point two two; QNH one zero zero eight hectopascals; wind shear on runway one zero; Low Level Wind Shear Advisory in effect, moderate to severe...".
The total landing weight was 55,140 kilogram, flaps were selected at 3 and the approach speed was 137 knots, ground spoilers were ARMED, autobrake selected MEDIUM, and antiskid selected ON at final approach.
At 19:59:04, radio altitude 282 feet, auto-pilot disengaged, autothrottle activated. The "RETARD" sound was heard four times between radio altitude 20 feet and the moment when the main landing gear touched the ground.
At 19:59:27, the main landing gear touched ground, airspeed 138 knots, ground speed 146 knots, heading 093 degrees, wind direction 297 degrees, wind speed 11 knots, the number 1/2 throttle level angle positioned at 19.7/22.5 degrees. Three seconds later the nose gear touched ground, the number 1/2 throttle level angle positioned at -22.5/22.5 degrees.
At 19:59:32, the autothrottle disconnected, number one thrust reverser deployed, but number two thrust reverser did not deploy. At 19:59:37 CM-1 called out "no brake", until 19:59:50, CM-1 called "no brake" five times. In the meantime, air speed 112 knots, ground speed 109 knots. The ground spoilers did not extend.
The aircraft touched down at 1,750 feet on runway 10, and rolled off the runway 321 feet from the end of runway 10, ending up with the nosegear in a ditch. According to the records in the Technical Log Book of the aircraft: The number 2 engine thrust reverser system was malfunctioned and was transferred to deferred defect (DD) item and the thrust reverser was deactivated in accordance with the procedures in the Minimum Equipment List.
Probable Cause:FINDINGS RELATED TO PROBABLE CAUSES:
1. When the aircraft was below 20 ft RA and Retard warnings were sounded, the pilot flying didnít pull thrust lever 2 to Idle detent which caused the ground spoilers were not deployed after touchdown though they were at Armed position, therefore the auto braking system was not triggered. Moreover, when the auto thrust was changed to manual operation mode automatically after touchdown, the thrust lever 2 was remained at 22.5 degrees which caused the Engine 2 still had an larger thrust output (EPR1.08) than idle positionís. Thereupon, the aircraft was not able to complete deceleration within the residual length of the runway, and deviated from the runway before came to a full stop, even though the manual braking was actuated by the pilot 13 seconds after touchdown.
2. The pilot monitoring announced "spoiler" automatically when the aircraft touched down without checking the ECAM display first according to SOPbefore made the announcement, as such the retraction of ground spoilers was ignored.
FINDINGS RELATED TO RISK:
1. After touchdown, when the thrust lever 2 was not pulled back to Idle position and the Retard warning sounds have ceased, there were no other ways to remind pilots to pull back the thrust lever.
2. The diminution of Runway Safety Zone proclaimed by Sungshan airport, and the fixed objects of non auxiliary aviation facilities and uncovered drainage ditch within the area do not meet the requirements of Civil Airports Designing and Operating Regulations.
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not
display the exact flight path.
Distance from Tainan Airport to Taipei-Sung Shan Airport as the crow flies is 271 km (169 miles).