A series of human errors led an Executive Aviation Taiwan Corp aircraft to mistakenly land at the Beigan Airport in Matsu in March last year, an Aviation Safety Council investigation has found.
The Hawker400XP, registration number B-95995, took off on March 25 from Taipei International Airport (Songshan airport) bound for Matsu’s Nangan Airport via Kinmen Airport.
The council’s investigation determined that the flight’s pre-takeoff check sheet did not indicate that pilots could only use visual flight rules when landing at Nangan Airport.
The pilots later told control tower personnel that they had rejected instrument landing procedures on their runway approach, leading the control tower personnel to guide the aircraft to the northern part of the Nangan Airport for an instrument landing, the investigation found.
When the pilots saw Beigan’s runway, they thought it was the Nangan runway, which is why they chose to land there.
“The pilots failed to follow standard operating procedures to inform and call the control tower,” the report said. “The flight crew also failed to use the information presented to them on the aircraft’s dashboard to ascertain the distance between the Nangan and Beigan airports. They also did not apply visual flight rules to confirm sight of the runway.”
“The division of labor between flight crew was not complete either, causing them to continue breaking the rules governing the approach to a runway or aborted landing of an aircraft, and subsequently leading them to land at the wrong airport,” the report said.
The investigation’s other findings include that the B-95995’s flight plan did not mention a backup airport nor the amount of additional fuel that the aircraft would need to reach the backup airport.
The combined weight of the pilot and the copilot also exceeded the pre-estimated value by 36.7kg. When the weight of the flight’s six passengers and their carry-on luggage were added, the weight of the aircraft could have exceeded the maximum limit for a departing flight, the council said.
The council said the pilots also did not sleep well for three consecutive nights prior to the incident, and failure to check their dashboard might have been due to fatigue.
The council has made several recommendations to the Civil Aeronautics Administration about improving flight safety.
Executive Aviation Taiwan Corp and the two pilots were fined a total of NT$3 million (US$97,550).
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