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| Title: | Runway Overrun During Landing On Taipei Sungshan Airport, Transasia Airways Flight 536, A320-232, B-22310, October 18, 2004 (Recommended) |
| Micro summary: | A320 overruns end of runway. |
| Event Time: | 2004-10-18 at 1959 Taipei local time |
| File Name: | 2004-10-18-TW.pdf |
| Publishing Agency: | Aviation Safety Council (ASC) |
| Publishing Country: | Taiwan |
| Report number: | ASC-AOR-06-03-002 |
| Pages: | 294 |
| Site of event: | Taipei SunghanAirport |
| Departure: | Tainan Airport, Tainan, Taiwan |
| Destination: | Taipei Sungshan Airport, Taipei, Taiwan |
| Airplane Type(s): | Airbus A320-232 |
| Flight Phase: | Landing |
| Registration(s): | B-22310 |
| Operator(s): | Transasia Airway |
| Type of flight: | Revenue |
| Occupants: | 106 |
| Fatalities: | 0 |
| Serious Injuries: | 0 |
| Minor/Non-Injured: | 106 |
| Other Injuries: | 0 |
| Executive Summary: | On October 18, 2004, at 1959 Taipei local time, TransAsia Airways (TNA) flight GE 536, an A320-232 aircraft, registration No.B-22310, departed from Tainan Airport (RCNN), rolling off from the stopway in the end of Runway 10, stopped with its nose gear trapped in a ditch during landing roll on Taipei Sungshan Airport (RCSS). The sliding tube of nose landing gear was broken, number two engine contacted with ground and damaged, none of the 2 pilots (CM-1 and CM-2), 4 cabin crewmembers, and 100 passengers aboard were injured. The flight departed from RCNN at 1924. 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 aircraft employed RCSS Instrument Landing System (ILS) approach Runway 10. At 1958:12, the flight received landing clearance. At 1928, the Automatic Terminal Information service, (ATIS) broadcast for RCSS were “…expect ILS Approach. Runway one zero in use; wind variable at three; visibility four thousand five hundred meters; 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 hactopascals; wind shear on runway one zero; Low Level Wind Shear Advisory in effect, moderate to severe…”. According to the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) data: Total landing weight were 55,140 kilogram, flaps selected “3”, approach speed selected “137 knots”, ground spoilers “ARMED”, autobrake selected “MEDIUM”, antiskid selected “ON” at final approach. At 1959:04, radio altitude 282 feet, auto-pilot disengaged, autothrottle activated. The CVR recorded “RETARD” sound four times between radio altitude 20 feet and the main landing gear touched ground. At 1959:27, the main landing gear touched ground, air speed 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, nose gear touched ground, the number 1/2 throttle level angle positioned at -22.5/22.5 degrees. At 1959:32, the autothrottle disconnected, number one thrust reverser deployed, number two thrust reverser not deployed. At 1959:37 CM-1 called out “no brake”, until 1959:50, CM-1 called “no brake” five times. In the meantime, air speed 112 knots, ground speed 109 knots. At 1959:42, the left/right brake pedal angle positioned at 28/46 degrees. After eight seconds until its full stop, all of the brake pedals angle were positioning between 62 degrees to 80 degrees. The ground spoilers did not extend. The aircraft touch down at 1,750 feet on Runway 10, and rolling off 321 feet from the end of Runway 10. The aircraft stopped in the northern side of the stopway with heading 002 degrees, the distance from stopway to the main landing gear was 72 feet. 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. 3.1 Findings Related to Probable Causes 1. When the aircraft was below 20 ft RA and Retard warnings were sounded, the pilot flying didn’t 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 position’s. 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.?1.11.2?2.3.2?2.3.3?2.4? 2. The pilot monitoring announced “spoiler” automatically when the aircraft touched down without checking the ECAM display first according to SOP before made the announcement, as such the retraction of ground spoilers was ignored. (2.3.3) 3.2 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.?2.5.4? 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.?2.6? |
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