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ASN Wikibase Occurrence # 173592
Last updated: 7 February 2020
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Date:05-FEB-2015
Time:c. 13:15 LT
Type:Silhouette image of generic D228 model; specific model in this crash may look slightly different
Dornier 228-212
Owner/operator:Daily Air Corp.
Registration: B-55563
C/n / msn: 8224
Fatalities:Fatalities: 0 / Occupants: 21
Other fatalities:0
Aircraft damage: Minor
Location:Orchid Island-Lanyu Airport (KYD/RCLY) -   Taiwan
Phase: Landing
Nature:Domestic Scheduled Passenger
Departure airport:Taitung Airport (TTT/RCFN)
Destination airport:Orchid Island-Lanyu Airport (KYD/RCLY)
Narrative:
Daily Air Corp. flight DAC7505, took off at 12:45 Taipei local time from Taitung Airport for schedule passenger flight to Lanyu Airport. The aircraft veered off the runway when the flight crew attempted to maneuver the aircraft back to the runway centerline during landing roll. A go around was performed and the crew discovered that the undercarriage failed to retract (due to severed electrical cables). The flight crew then decided to make an air turn back to Taitung Airport and asked the control tower and related personnel to observe the landing gear prior to landing. The aircraft landed safety at 13:51hrs at Taitung airport without substantial damage but no injuries.

ASC 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.

Nine safety recommendations were raised.

Sources:

https://www.asc.gov.tw/main_en/docDetail.aspx?uid=318&pid=318&docid=663
http://www.asc.gov.tw/upload/acd_att/ASC-AOR-15-12-001.pdf Final report in Chinese
http://www.asc.gov.tw/upload/acd_att/DA7507_Executive%20Summary.pdf English exec summary


Revision history:

Date/timeContributorUpdates
05-Feb-2015 18:50 harro Added
05-Feb-2015 18:51 harro Updated [Time, Aircraft type]
06-Feb-2015 11:02 gerard57 Updated [Total occupants]
28-Jul-2016 11:18 Aerossurance Updated [Time, Source, Narrative]

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