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| Date: | Monday 15 January 2001 |
| Time: | c. 11:13 LT |
| Type: |  de Havilland Canada DHC-8-311Q Dash 8 |
| Owner/operator: | UNI Air |
| Registration: | B-15235 |
| MSN: | 443 |
| Year of manufacture: | 1997 |
| Engine model: | P&W Canada PW123 |
| Fatalities: | Fatalities: 0 / Occupants: 27 |
| Other fatalities: | 0 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Kinmen-Shang-Yi Airport (KNH/RCBS) -
 Taiwan
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Tainan Airport (TNN/RCNN) |
| Kinmen-Shang-Yi Airport (KNH/RCBS) | |
| Investigating agency: | ASC |
| Confidence Rating: |  Accident investigation report completed and information captured |
UNI Air flight B7695, a de Havilland DHC-8-300, B-15235, suffered an extremely heavy landing at Kinmen Airport. The aircraft suffered very substantial damage to the underside, tail, wingtip, engines, frame, and landing gear components. Nobody was injured. The accident was attributed to poor crew handling of unstable airflow on final approach.
On January 15, 2001, Uni Air flight B7695, a DASH-8-300 aircraft with national markings and registration number B-15235, took off from Tainan Airport at 10:35 AM, carrying passengers. It landed at 11:13 AM on Runway 06 at Kinmen Shangyi Airport. Upon landing, the aircraft suffered damage to its left and right landing gear, and the rear section of the belly panel was worn through on the runway. It came to rest approximately 3,380 feet from the runway threshold. On board were two pilots, two cabin crew members, and 23 passengers.
According to the company's dispatch schedule, the pilots were scheduled to fly a total of six missions that day. The accident occurred on their second flight of the day. On the previous day, they had flown four round-trip missions between Kaohsiung and Magong.
At 10:35, the pilots took off from Tainan Airport for Kinmen, with the first pilot in command. The first pilot explained that they had also been in command of the first flight of the day, from Kaohsiung to Kinmen. While approaching for landing, they experienced unstable airflow, but the landing went smoothly, indicating they were familiar with Kinmen's weather conditions.
At 11:02, the aircraft began descending on route W-6. At 11:07, the area control center cleared the aircraft for a "NDB/DME Bravo approach to Runway 06 at Kinmen Shangyi Airport." At 11:09, the pilot reported a visual airport and requested a visual approach, which was subsequently cleared by the area control center.
At 11:09, Kinmen Shangyi Airport Control Tower (hereinafter referred to as the control tower) took over the aircraft. At that time, the aircraft reported a position of 8 nautical miles southeast of the airport. The control tower issued a landing clearance and provided the following information: "Use runway 06, altimeter setting 1030 hPa, wind direction 040 degrees, wind speed 15 knots per hour, maximum wind speed 21 knots per hour, clearance to land."
The Flight Data Recorder (FDR) data showed that the aircraft's final approach speed averaged approximately 114 knots with flaps 15 degrees. The aircraft was at an altitude of 310 feet and a heading of 060 degrees when turning onto the final leg of the airport's route. The FDR stopped recording at 11:13:55.
The pilot stated that the aircraft was at an altitude of approximately 50 feet as it passed the runway clearance area. When it dropped to approximately 30 to 20 feet, it suddenly began to sink rapidly. Just as he was about to raise the stick and apply throttle, he felt the aircraft touch down.
The cabin crew reported that as the aircraft taxied on the runway, smoke billowed from the rear cabin floor. The C3 cabin crew and passengers left their seats and moved forward before the aircraft stopped. The L1 cabin crew pressed the intercom button to call the pilot, but received no response. After the aircraft stopped, the cabin filled with smoke, and most passengers moved toward the L1 passenger door. After opening the L1 passenger door and the R2 central emergency exit door, passengers began evacuating the cabin.
According to the tower recording, at 11:14, the aircraft reported to the tower, "I'm shutting down on the runway now, thank you." When the tower controller asked if there was any problem, the aircraft replied, "My tire might be punctured." The tower controller immediately notified Kinmen Airport's flight crew to investigate. Following the notification from the flight crew, the airport fire department dispatched a fire truck to the scene.
Measurements of ground marks, detached components, and video footage from the accident indicate that the aircraft, along with its nose wheel, two main wheels, and belly, struck the ground approximately 200 feet from the runway threshold on Runway 06. The aircraft bounced off, with the right wheel door falling off. The aircraft touched down again at 1,300 feet, then dragged its rear fuselage belly-on to a stop at 3,380 feet.
Probable Cause:
The most likely cause of the Accident involving UNI Air flight B7695 was determined to be the crew’s inability to prevent the aircraft from contacting the runway in an unsafe manor by not being able to correct the effect of unstable airflow on final.
Investigation Results Related to Possible Causes
1. After descending through an altitude of 250 feet, B7695 encountered unstable airflow three times, causing the descent rate to vary by more than 500 feet per minute. Five seconds before landing, it encountered downdraft again. Approximately two seconds before landing, the pilot applied elevator control, but due to insufficient altitude to correct the error, the aircraft landed at a descent rate of 28 feet per second, resulting in a hard landing that damaged both the left and right landing gear and caused the aircraft to drag on its belly.
2. The B7 695 pilot was insufficiently alert to the situation and failed to respond promptly when encountering unstable airflow.
Risk-Related Findings
1. UNI Air had no records of wind shear training for pilots other than simulator training. Low-altitude gust training for Runway 06 at Kinmen Airport was not included in special airport training, resulting in pilots not being familiar with handling unstable airflow.
2. During approach, the pilot failed to inform the non-pilot pilots of the procedures and precautions for encountering unstable airflow, failing to effectively utilize all available resources.
3. The original DASH8 manufacturer's (de HAVILLAND) Operating Data Manual and Flight Manual do not include operating procedures and techniques for wind shear.
4. UNI Air's flight operations manual did not specify a "standard call" procedure for handling wind shear, resulting in the pilot not using the standard call procedure for wind shear.
5. The pilot and cabin crew were insufficiently alert to the presence of smoke in the cabin and failed to declare and execute emergency evacuation procedures. The pilot also failed to notify the control tower of the presence of heavy smoke in the cabin, hindering the airport's emergency response timeline.
6. The co-pilot failed to use emergency means to open the cockpit door when it became stuck, thus delaying the time limit for emergency exit from the cockpit.
7. When heavy smoke formed in the cabin, the cabin crew failed to press the "Emergency Call" button to call the flight crew as required. The flight crew also failed to respond to the cabin crew's call, preventing them from promptly identifying the cabin emergency and addressing the situation.
8. The DASH 8-300 aircraft cabin is not equipped with smoke masks, and civil aviation regulations do not specify the number and placement of smoke masks, which affects the cabin crew's ability to respond to smoke in the cabin.
9. The cabin crew failed to follow procedures to locate the source of the smoke and failed to obtain a fire extinguisher. This was not in compliance with the company's "Service Department Work Instructions," resulting in a lapse in safety measures.
10. UNI Air failed to conduct coordinated emergency evacuation training for pilots and cabin crew. The communication and cooperation between the pilots and cabin crew during this incident were not at a familiar level.
11. The competent authority lacks dedicated cabin safety inspectors to conduct cabin safety audits, and flight operations inspectors are tasked with doing so concurrently, resulting in inadequate cabin safety supervision.
12. The operating procedures for the closed-circuit television (CCTV) monitors at Kinmen Airport Control Station are not included in the station's "Operations Manual," making it easy for errors to occur.
13. Kinmen Airport's control tower controllers were unable to see the Runway 06 landing zone from their workstations, and were using closed-circuit television to monitor aircraft movements in the area. However, this information was not announced in the Taipei Flight Information Region Flight Guide, leaving operators unaware of the situation.
14. Within the control area of Kinmen Shangyi Airport, 13 obstacles exceeded the restricted height, and three structures were located within the restricted construction zone. Uncovered trenches existed within the runway and taxiway areas, which did not comply with the "Civil Aviation Airport Civil Facilities Design Standard Specifications." The Civil Aviation Administration's relevant business units failed to communicate and coordinate effectively, resulting in the failure to disclose flight-related information in accordance with relevant regulations, posing a potential threat to flight safety.
15. The Civil Aeronautics Administration failed to identify certain information in the "Taipei Flight Information Region Flight Guide," such as information on loading and unloading services at Kinmen Shangyi Airport, which was inconsistent with current conditions. This suggests a lack of effective oversight mechanisms.
16. Kinmen Shangyi Airport's perimeter and barrier facilities are incomplete, allowing for repeated intrusions by people and animals, posing a threat to flight safety.
17. The height of the obstacle surrounding the wind direction and anemometer at the runway head of Kinmen Shangyi Airport (Shangyi Airport) 06 does not meet ICAO clearance standards, resulting in measurement errors. The failure to establish an effective mechanism for communication and feedback from weather data users prevented early detection of the measurement errors.
Other Survey Findings
1. The pilot held a valid license in accordance with current civil aviation regulations.
2. Pilots must complete relevant training in accordance with current civil aviation regulations.
3. The driver's work and rest were normal within 72 hours prior to the accident; there is no evidence that he was under the influence of physical, psychological, drugs, or alcohol at the time of the accident.
4. The aircraft has implemented all airworthiness directives and is in airworthy condition.
5. The aircraft's load and balance are within the limits.
6. All damage to the aircraft structure was caused by external forces and overload.
7. The pilot's response and flight operations from the moment the aircraft encountered downdraft again 5 seconds before landing to the moment of landing were normal.
8. The competent authority, in approving a maintenance plan based on the aircraft manufacturer's maintenance requirements, failed to identify that the flight recorder system's periodic inspections did not comply with ICAO standards.
9. The aircraft's flight recorder's power supply was cut off by the acceleration inertia switch during the accident, preventing the recording of important data required for the investigation and hampering the investigation.
10. The DASH8 flight recorder does not record time parameters. While Coordinated Universal Time (UTC) can be inferred from parameters such as the synchronization character, VHF key, and radar time, the power outage in the "Frame Counter" caused some parameters to become distorted, resulting in errors in the recorded time parameters and affecting the investigation. This does not comply with Article 104 of the Civil Aviation Law and the standards of ICAO Annex 6.
Recommendations:
To UNI Air
1. Strengthen pilot training on wind shear alertness and handling procedures, including wind shear recognition, judgment, standard calls, operating procedures, crew coordination, and task allocation.
(ASR-02-02-001)
2. Establish standard call-out procedures for wind shear conditions encountered during approach and landing.
(ASR-02-02-002)
3. Require pilots to strictly follow instructions; include special precautions when issuing approach/landing instructions in adverse weather conditions. (ASR-02-02-003)
4. Strengthen pilot and cabin crew training on cabin smoke alertness and procedures. (ASR-02-02-004)
5. Review emergency protocols, procedures, and training, including emergency communication between the cockpit and cabin, the use of cockpit emergency equipment, emergency exit procedures, pilot and cabin crew understanding of emergency evacuation, decision-making, timing of announcements, and execution procedures. (ASR-02-02-005)
6. Develop procedures and standard call instructions to ensure pilots promptly provide relevant information to air traffic control personnel when encountering abnormal conditions such as tire blowouts, landing gear failure (or possible landing gear issues resulting in steering or braking difficulties), and cabin smoke, to facilitate subsequent handling. (ASR-02-02-006)
To the Civil Aviation Administration of China, Ministry of Transportation and Communications
1. Correct any non-compliant structures within Kinmen Shangyi Airport, including prohibited or restricted structures, super-high obstacles, uncovered trenches within runway and taxiway zones, and airport perimeter and barrier structures. Situations that cannot be corrected or have not yet been completed, as well as visual obstructions between the airport control tower and the runway, should be listed in the Taipei Flight Information Region Flight Guide.
(ASR-02-02-007)
2. Revise the inconsistencies in the Taipei Flight Information Region Flight Guide and establish effective mechanisms to prevent similar incidents. (ASR-02-02-008)
3. Eliminate visual barriers between the control tower and the runway at Kinmen Shangyi Airport and develop standard operating procedures for the closed-circuit television surveillance system. (ASR-02-02-009)
4. Re-examine the relevant operational procedures and protocols for the activation of the "crash alarm" by relevant units within Kinmen Shangyi Airport. (ASR-02-02-010)
5. Re-examine the relevant laws and regulations and inspection procedures for cabin safety in the civil aviation industry and hire dedicated inspectors to conduct cabin safety inspections. (ASR-02-02-011)
6. Improve the installation environment for the wind direction and anemometer at the runway head 06, in accordance with ICAO Document 8896. (ASR-02-02-012)
7. Establish a maintenance plan review basis for periodic inspections of recorder systems, in accordance with Section 6.3 of Annex VI of the International Civil Aviation Organization and U.S. FAA Advisory Circular No. 20-141. (ASR-02-02-013)
8. Evaluate the removal of regulations related to acceleration inertia switches. (ASR-02-02-014)
9. Re-evaluate organization and management to enhance the capabilities and performance of relevant departments (units) in internal coordination and communication, oversight mechanisms, and the development and management of civil aviation regulations. (ASR-02-02-015)
To aircraft manufacturers (de Havilland Canada)
1. The DASH-8 aircraft operating manual specifies the aircraft's performance, characteristics, operating procedures, techniques, and optimal configuration settings when encountering or potentially encountering wind shear, as a guide for pilots to follow when encountering or potentially encountering wind shear. (ASR-02-02-016)
Accident investigation:
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Sources:
https://www.ttsb.gov.tw/media/3398/asc-aar-02-02-001.pdf
https://www.jetphotos.com/photo/88541 (Photo)
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 03-Sep-2025 21:22 | Justanormalperson | Added |
| 03-Sep-2025 21:23 | Justanormalperson | Updated [Accident report, ] |
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