Wind shear on the runway and pilot errors likely caused a Daily Air airplane to veer off the runway when it tried to land at Lanyu Airport on Orchid Island (Lanyu, 蘭嶼) last year, a report published yesterday by the Aviation Safety Council said.
On April 13, Daily Air’s Flight 55571 left Taitung Airport for Orchid Island with 19 people onboard: the captain, copilot, one maintenance crew member and 16 passengers
The airplane — a Viking DHC-6-400 — overran the runway and crashed into guard rails at Lanyu Airport.
The passengers were safely evacuated after the incident.
The council said it has also invited officials from the Transport Safety Board of Canada and Transport Canada — a department within the Canadian government in charge of developing transportation regulations, policies and services — to help investigate the causes of the accident.
Aircraft manufacturer Viking Air, aircraft engine manufacturer Pratt & Whitney Canada, the Civil Aeronautics Administration (CAA) and Daily Air have also sent representatives to help in the investigation.
The report showed that when the airplane tried to land on Lanyu, a crosswind caused the plane’s nose to deviate to the left.
The aircraft began drifting to the left after landing, possibly due to influence from a wind shear and pilot error, the report said.
The council said the captain had used the right rudder to stop the aircraft from further deviating to the left and also pulled the power levers into reverse.
However, the engine data record showed that the captain inadvertently pulled back the left power lever while he was intending to apply the right-turning power to assist him in correcting the direction of the aircraft.
The error resulted in an increase in the left reverse power and caused the plane to turn further to the left, the council said in the report.
“The captain attempted to get directional control of the aircraft by increasing the right rudder input and the right wheel brake pressure, but he continued to increase the left engine’s reverse power to the maximum, not knowing he was taking the wrong side. Consequently, the aircraft veered off the runway, hit the fence and caused substantial damage to the plane,” the report said.
The report also identified safety risks in Daily Air’s flight operation and management.
The captain and the copilot had not accumulated enough experience to fly the DHC-6-400, and their experience and familiarity in applying differential power for directional control during landing were very limited, the report said, adding that the two disagreed on how and when this particular procedure should be performed.
Daily Air failed to provide flight crew members detailed guidance on using differential power during landing or instruct them about the technique and timing for using it during their transition training, the report said.
Although Daily Air’s safety management committee and flight operations safety action group followed the requirements of the Safety Management Manual to convene meetings regularly, they failed to effectively review the internal and external safety data related to flight operation, the council said.
The airline’s principal instructor of safety management system (SMS) did not receive formal SMS training, as specified in the safety management manual, it said.
“Daily Air’s flight operations department not only failed to follow up on some of the findings of an internal evaluation program [IEP], but it also failed to conduct a trend analysis of IEP,” the council said, adding that this compromised the overall effectiveness of the program.
Although the CAA had conducted regular inspections of Daily Air’s flight operations’ internal evaluation program, several deficiencies identified during the investigation should have been addressed by thoroughly reviewing the airline’s IEP, the council said.
This indicates that the methods, frequency and focuses of IEP inspection performed by the CAA should be enhanced, it said.
The CAA should assess the priorities of airport runway improvement projects after the accident, such as giving priority to the hazards caused by non-fragile objects and open ditches on runway strips so as to enhance runway safety in a timely manner, it said.
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