Elitavia Malta Eau52p Final Report

30 December 2020
Elit’Avia Malta Limited Flight EAU52P

Bombardier BD-700-1A10, 9H-OJP
Abnormal Runway Contact during Landing at
Taichung International Airport
Aviation Occurrence Investigation Final Report
January 2022
TTSB-AOR-22-01-001
Intentionally Left Blank
According to the Transportation Occurrences Investigation Act of
the Republic of China and the International Civil Aviation
Organization (ICAO) Annex 13, this report is only for the
improvements of flight safety.
Transportation Occurrences Investigation Act of the Republic of

China, Article 5:
The objective of the TTSB‘s investigation of transportation occurrence is to

prevent recurrence of similar occurrences. It is not the purpose of such
investigation to apportion blame or liability.
ICAO Annex 13, Chapter 3, Section 3.1:
The sole objective of the investigation of an accident or incident shall be the

prevention of accidents and incidents. It is not the purpose of this activity to
apportion blame or liability.
Executive Summary
On 30 December 2020, a Bombardier BD-700-1A10 (Global 6000) aircraft,

Republic of Malta registration 9H-OJP, Elit’Avia Malta Limited flight EAU52P,
with two pilots and one cabin crew, was being operated on an instrument flight
rules (IFR) positioning flight from Korea Incheon International Airport (RKSI),
Republic of Korea, to Taichung International Airport (RCMQ), Taiwan, Republic
of China. The weather conditions at RCMQ were reported good visibility and
strong gusty wind with significant crosswind for the landing runway 36. Just
before touchdown, the flight crew attempted to compensate the disturbances in
the roll and pitch of the aircraft induced by the gusty wind conditions, using
significant control inputs. Both wing tips of the aircraft contacted the runway
surface during landing. The left wing slat and aileron, the right winglet, aileron,
and flap canoes were damaged. No injuries to the persons on board.
According to the Transportation Occurrence Investigation Act of the

Republic of China and the content of Annex 13 to the Convention on International
Civil Aviation Organization, the Taiwan Transportation Safety Board (TTSB), an
independent transportation occurrence investigation agency, was responsible for
conducting the investigation. The investigation team also included members from
the Maltese Bureau of Air Accident Investigation (BAAI), the Transportation
Safety Board of Canada (TSB), Bombardier, and Elit’Avia Malta Limited.
The ‘Final Draft Report’ of the occurrence investigation was completed in

July 2021. In accordance with the procedures, it was reviewed at TTSB’s 31th
Board Meeting on 1st October 2021 and then sent to relevant organizations and
authorities for comments. After comments were collected and integrated, the
English version of the investigation report was reviewed and approved by TTSB’s
34th Board Meeting on 7th January 2022.
i
There are a total of 10 findings from the Final Report. There is no safety
recommendation issued to the related organizations, the safety actions are
presented in the report.
Findings as the result of this investigation
The TTSB presents the findings derived from the factual information
gathered during the investigation and the analysis of the occurrence. The findings
are presented in three categories: findings related to probable causes, findings
related to risk, and other findings.
Findings Related to Probable Cause
1. Taichung International Airport was affected by a strong cold high-pressure

weather system at the time of the occurrence. The meteorological conditions
were reported to be good visibility and strong gusty wind with significant
crosswind for runway 36.
2. Two seconds before the aircraft touched down on the runway, the flight crew
reacted with a significant and rapid control wheel input to compensate for the
disturbances in the roll and pitch of the aircraft caused by the gusty wind
conditions. The right wing down control input resulted in a maximum of 6.76
degrees right wing down roll angle and a 9.31 degrees nose up pitch attitude
at 0 feet radio altitude. The aircraft touched down hard on the right main
landing gear in a right rolling motion. The right wing tip of the aircraft
probably contacted the runway surface at this time.
3. After the right main gear touched the ground and bounced, followed by the
left wing down control input by the pilot flying in an attempt to stop the right
roll motion, the aircraft rolled to the left. The aircraft reached a maximum roll
angle of 9.4 degrees left wing down. With the pitch attitude at 8.26 degrees,
the left wing tip of the aircraft contacted the runway surface.
ii
4. The combination of the strong and gusty wind conditions, insufficient time to
gain complete control of the aircraft due to late disconnection of the autopilot ,
the rapid decrease of the airspeed due to a rapid headwind reduction that was
not compensated for by increasing thrust and the increased pitch angle by the
pitch up control demand of the pilot flying, and the significant and rapid
control input of the flight crew during flare to compensate the disturbance of
roll and pitch by the gusty wind, resulted in a wingtips abnormal runway
contact landing occurrence.
Findings Related to Risk
1. The autopilot was disengaged at 219 feet radio altitude. The pilot flying (PF)
had only 16 seconds to transit from automatic flight to manual flight before
the aircraft reached 30 feet and the PF started the landing flare for touchdown,
which gave the PF insufficient time to gain complete control of the aircraft
before landing in the strong and gusty wind conditions.
2. The difference between the Vref speed adders recommended in different

manuals may create confusion and adversely affect the standardization of
flight operations during approach and landing in strong and gusty wind
conditions.
Other Findings
1. The flight crew were properly certificated and qualified in accordance with
the related regulations and requirements. No evidence indicated any pre-
existing medical conditions, fatigue, medication, or presence of other drugs or
alcohol that might have adversely affected the flight crew’s performance
during the occurrence flight.
2. The occurrence aircraft was properly certified, with no reported technical

issues related to the flight controls system in accordance with the relevant
iii
technical documents.
3. The aircraft’s weight and balance were within the operational limits for the
duration of the occurrence flight.
4. The flight data recorder (FDR) parameters indicated that the autopilot coupled
instrument landing system (ILS) approach of the occurrence flight was a stable
approach in accordance with the company’s stabilized approach criteria.
iv
Contents
Executive Summary .......................................................................................................... i

Contents ............................................................................................................................ v
Tables ............................................................................................................................... ix
Figures .............................................................................................................................. xi
Abbreviation ................................................................................................................... xii
Chapter 1 Factual Information ....................................................................................... 1
1.1 History of Flight ........................................................................................................... 1
1.2 Injuries to Persons ........................................................................................................ 4
1.3 Damage to Aircraft ....................................................................................................... 4
1.4 Other Damage .............................................................................................................. 4
1.5 Personnel Information .................................................................................................. 4
1.5.1 Flight Crew ............................................................................................................. 4
1.5.1.1 Captain ................................................................................................................. 4
1.5.1.2 First Officer ......................................................................................................... 5
1.5.2 Flight Crew Activities within 72 hours Before the Occurrence ............................. 8
1.5.2.1 Captain ................................................................................................................. 8
1.5.2.2 First Officer ......................................................................................................... 8
1.6 Aircraft Information ..................................................................................................... 9
1.6.1 Aircraft and Engine Basic Information ................................................................... 9
1.6.2 Aircraft Maintenance Information ........................................................................ 10
1.6.3 Weight and Balance Information .......................................................................... 10
1.7 Weather Information .................................................................................................. 12
1.8 Aids to Navigation ..................................................................................................... 15
1.9 Communication .......................................................................................................... 15
1.10 Aerodrome................................................................................................................ 15
1.10.1 Airside Basic Information................................................................................... 15
1.10.2 Runway Surface Friction .................................................................................... 16
1.11 Flight Recorders ....................................................................................................... 18
1.11.1 Cockpit Voice Recorder ..................................................................................... 18
1.11.2 Flight Data Recorder........................................................................................... 19
v
1.12 Wreckage and Impact Information ........................................................................... 24
1.12.1 Site Survey .......................................................................................................... 24
1.12.2 Damage ............................................................................................................... 27
1.13 Medical and Pathological Information ..................................................................... 32
1.14 Fire ................................................................................................................... 33
1.15 Survival Aspects....................................................................................................... 33
1.16 Tests and Research ................................................................................................... 33
1.17 Organizational and Management Information ......................................................... 33
1.18 Additional Information ............................................................................................. 33
1.18.1 Aircraft Operating Information ........................................................................... 33
1.18.1.1 Authority, Duties and Responsibilities of the Commander ............................. 33
1.18.1.2 BD-700 Maximum Demonstrated Crosswind Component .............................. 35
1.18.1.3 Automatic Flight Systems ................................................................................ 36
1.18.1.4 Stable Approach............................................................................................... 39
1.18.1.5 Final Approach Speed...................................................................................... 40
1.18.1.6 Standard Callout .............................................................................................. 42
1.18.1.7 Landing Procedures and Technique ................................................................. 44
1.18.1.8 Crosswind Landing Technique ........................................................................ 47
1.18.1.9 Wing Tip Ground Clearance ............................................................................ 50
1.18.1.10 Windshear ...................................................................................................... 51
1.18.2 Interview Summaries .......................................................................................... 53
1.18.2.1 Captain ............................................................................................................. 53
1.18.2.2 First Officer ..................................................................................................... 55
1.18.3 Sequence of Events ............................................................................................. 57
Chapter 2 Analysis ......................................................................................................... 59

2.1 General ................................................................................................................... 59
2.2 Flight Operations ........................................................................................................ 59
2.2.1 Approach and Landing ......................................................................................... 59
2.2.1.1 The Final Approach ........................................................................................... 60
2.2.1.2 The Landing ....................................................................................................... 64
2.2.1.3 Use of Autopilot and Autothrottle ..................................................................... 67
vi
2.2.2 Final Approach Speed........................................................................................... 69
2.2.3 Pilot Flying Duty Assignment .............................................................................. 69
Chapter 3 Conclusions ................................................................................................... 71
3.1 Findings Related to Probable Causes ......................................................................... 71
3.2 Findings Related to Risk ............................................................................................ 72
3.3 Other Findings ............................................................................................................ 73
Chapter 4 Safety Recommendations ............................................................................ 74
4.1 Recommendations ...................................................................................................... 74
4.2 Safety Actions ............................................................................................................ 74
4.2.1 Elit’Avia Malta ..................................................................................................... 74
4.2.1.1 Corrective Actions ............................................................................................. 74
4.2.1.2 Preventative Action - Recommendations .......................................................... 75
4.2.2 Bombardier ........................................................................................................... 80
vii
viii
Tables
Table 1.5-1 Flight crew basic information ......................................................................... 7

Table 1.6-1 Aircraft basic information ............................................................................... 9
Table 1.6-2 Engine basic information .............................................................................. 10
Table 1.6-3 Weight and balance data ............................................................................... 12
Table 1.10-1 The most recent measurement results before the occurrence, 65km/h ....... 17
Table 1.10-2 The most recent measurement results before the occurrence, 95km/h ....... 17
Table 1.10-3 The first measurement results after the occurrence, 65km/h ...................... 18
Table 1.10-4 The first measurement results after the occurrence, 95km/h ...................... 18
Table 1.12-1 Survey item list ........................................................................................... 25
Table 1.18-1 Sequence of events...................................................................................... 57
Table 2.2-1 Flight crew actions and aircraft state during the final approach ................... 62
Table 2.2-2 Flight crew actions and aircraft state during the landing .............................. 65
ix
x
Figures
Figure 1.6-1 BD-700 CG envelope .................................................................................. 11

Figure 1.7-1 AWOS sensor locations ............................................................................... 13
Figure 1.7-2 AWOS S wind speed/direction .................................................................... 14
Figure 1.7-3 AWOS C wind speed/direction ................................................................... 14
Figure 1.10-1 RCMQ Airport chart.................................................................................. 16
Figure 1.11-1 FDR readouts during landing phase (from AP disengaged) ...................... 22
Figure 1.11-2 FDR readouts during landing phase (from RA 50ft) ................................. 22
Figure 1.11-3 FDR recorded flight path of occurrence flight .......................................... 23
Figure 1.12-1 Superimposed site survey item and FDR flight path ................................. 25
Figure 1.12-2 Close-up of site survey item ...................................................................... 26
Figure 1.12-3 First wing mark (R1) ................................................................................. 26
Figure 1.12-4 Second to fourth wing marks (L1~L3) ...................................................... 27
Figure 1.12-5 Right slat.................................................................................................... 27
Figure 1.12-6 Middle bottom of the right winglet............................................................ 28
Figure 1.12-7 Trailing edge of the end of right wing ....................................................... 28
Figure 1.12-8 Right aileron .............................................................................................. 29
Figure 1.12-9 Right outboard flap fairing ........................................................................ 30
Figure 1.12-10 Left slat .................................................................................................... 30
Figure 1.12-11 Trailing edge of the end of left wing ....................................................... 31
Figure 1.12-12 Middle bottom of the left winglet ............................................................ 31
Figure 1.12-13 Left aileron .............................................................................................. 32
Figure 1.12-14 Left outboard flap fairing ........................................................................ 32
xi
Abbreviation
ACAS airborne collision avoidance system

AFM airplane flight manual
ATC air traffic control
ATIS automatic terminal information service
AP autopilot
ATPL air transport pilot license
AWOS automated weather observation system
CFME continuous friction measuring equipment
CG center of gravity
CPL commercial pilot license
CRM crew resource management
CVR cockpit voice recorder
FCOM flight crew operating manual
FDR flight data recorder
FDMP flight data monitoring program
FH flight hour
FSTD flight simulation training devices
GPS global positioning system
ICAO International Civil Aviation Organization
IFR instrument flight rules
ILS instrument landing system
LWD left wing down
MAC mean aerodynamic chord
METAR aerodrome routine meteorological report
NOTAM notice to airmen
PAPI precision approach path indicator
PF pilot flying
PFD primary flight display
PM pilot monitoring
RA radio altitude
RWD right wing down
RESA runway end safety area
ROPAT recommended operational procedures and techniques
SOP standard operating procedure
xii
TCAS traffic alert and collision avoidance system
TLA throttle lever angle
xiii
xiv
Chapter 1 Factual Information
1.1 History of Flight
On 30 December 2020, a Bombardier BD-700-1A10 (Global 6000) aircraft,

Republic of Malta registration 9H-OJP, Elit’Avia Malta Limited flight EAU52P,
with two pilots and one cabin crew, was being operated on an instrument flight
rules (IFR) positioning flight from Korea Incheon International Airport (RKSI),
Republic of Korea, to Taichung International Airport (RCMQ), Taiwan, Republic
of China. At 1038 Taipei Local Time 1, the left and right wings of the aircraft
contacted the runway surface during landing at RCMQ. The left wing slat and
aileron, the right winglet, aileron, and flap canoes of the aircraft were damaged.
No injuries to the persons on board.
The captain occupied the left seat in the cockpit and was the pilot monitoring
(PM) for the occurrence flight. The first officer occupied the right seat and was
the pilot flying (PF). The occurrence flight departed from RKSI at 0809 hours for
RCMQ to pick up passengers and continue to fly to Singapore. At the arrival time
to RCMQ of the occurrence flight, a strong cold high pressure located at
Mongolia drifting southward affected the weather condition in Taiwan. According
to the aerodrome routine meteorological report (METAR) for RCMQ current at
1030 hours, the weather conditions were wind from 030 degrees at 27 knots
gusting to 41 knots with visibility of more than 10 kilometers. The cloud
coverage 2 was few at 500 feet, scattered at 1,500 feet, broken at 2,100 feet,
temperature was 14 degrees Celsius, dew point 8 degrees Celsius, and altimeter
1
Unless otherwise noted, the 24-hour clock is used in this report to describe the local time of day, Taipei Local
Time, as particular events occurred. Taipei Local Time is Universal Coordinated Time (UTC) +8 hours.
2
Cloud amounts are reported in oktas. An okta is a unit of sky area equal to one-eighth of total sky visible to the
celestial horizon. Few = 1 to 2 oktas, scattered = 3 to 4 oktas, broken = 5 to 7 oktas and overcast = 8 oktas. The
METAR reports the height of the cloud base in hundreds of feet above aerodrome elevation.
1
setting (QNH) was 1020 hPa.
According to the flight data recorder (FDR), cockpit voice recorder (CVR),
and the interview notes of the flight crew, the flight was normal for takeoff, climb,
and cruise. The initial cruising altitude was FL3803 and the final cruising altitude
was FL400. Before descent, the PF conducted the approach briefing after
obtaining the latest RCMQ automatic terminal information service (ATIS)
information Lima. The briefing included the arrival routes and the weather
conditions. During approach, the captain advised the PF to keep the airspeed a
little bit higher and plan to disconnect the autothrottle if the winds were gusty.
The approach reference speed (Vref) was 127 knots according to the weight of
the aircraft and the final approach speed was set to 132 knots, Vref + 5 knots, by
the flight crew.
The approach in use at RCMQ was the ILS4 (instrument landing system)
runway 36 for the occurrence flight in windy and gusty conditions. The FDR,
CVR, and interview data indicated that, when the aircraft was below 1,000 feet
radio altitude (RA), the approach was normal and stable. The autopilot was
disengaged by the PF at 1037:56 hours, radio altitude 219 feet; the autothrottle
remained engaged. At 1038:05.4 hours, the radio altitude of the aircraft was about
70 feet, the PM called out “you are below glides” to remind the PF that the aircraft
was below the glideslope. The PF responded “correct(ing)” and raised the nose
of the aircraft about one degree to get back onto the glide path.
At 1038:08 hours, the radio altitude of the aircraft was 50 feet, indicated
airspeed was 137 knots, pitch angle was about 5.3 degrees and roll angle was
3
Flight level 380, equal to 38,000 feet.
4
An ILS is a standard ground aid to landing, comprising two directional radio transmitters: the localizer, which
provides direction in the horizontal plane or lateral flightpath tracking guidance; and the glideslope for vertical
plane direction or vertical flightpath tracking guidance usually at an inclination of 3°. Distance measuring
equipment (DME) or marker beacons along the approach provide distance information.
2
about 0.5 degrees right wing down (RWD), the altitude auto callout announced
“fifty” in the cockpit. One second later, the throttle levers moved to idle. At
1038:11 hours, the aircraft passed over the runway 36 threshold at radio altitude
of 34 feet, airspeed was 123.75 knots, groundspeed was 89 knots, the aircraft
pitch angle was 5.6 degrees and roll angle was 2.4 degrees RWD. At 1038:12
hours, the altitude auto callout announced “thirty” at the aircraft radio altitude of
24 feet, airspeed was 125.5 knots, and pitch angle was about 6 degrees. At
1038:14 hours, the altitude auto callout announced “ten” at the aircraft radio
altitude of 5.6 feet, airspeed was 113 knots, and pitch angle increased to about 8.5
degrees. One second later, at 1038:15 hours, the aircraft touched down on runway
36 with the airspeed 113 knots, pitch angle 10.2 degrees, and roll angle 5.88 RWD
with the control wheel position about 62 degrees RWD5. The vertical acceleration
of the aircraft at touched down was 2.12 g.
Right after touch down, at 1038:16 hours, the PF introduced a large amount
of left wing down (LWD) control wheel input. The control wheel position
changed from 62 degrees RWD to 81 degrees LWD, the aircraft roll angle
changed from the maximum RWD bank angle 6.76 degrees to 9.4 degrees LWD,
and the right main gear air/ground switch changed from ground to air. At 1038:17
hours, the autothrottle was disengaged and the right main gear air/ground switch
changed to ground again. The aircraft started to decelerate without further
incident.
During post-landing walk-around, the flight crew discovered damage on

both wingtip areas.
5
At 1038:14.75 hours, the maximum RWD bank angle of the aircraft immediately before touch down were 6.76
degrees with a pitch angle of 9.31 degrees.
3
1.2 Injuries to Persons
No injuries to the persons on board.
1.3 Damage to Aircraft
Abrasions of outboard corner of the left outboard leading edge slat, the
outboard trailing edge of the left aileron, the bottom of the right winglet, the
outboard trailing edge of the right aileron, the tip of the right outboard flap canoe,
and the tip of the right center flap canoe, see 1.12 for details.
1.4 Other Damage
None.
1.5 Personnel Information
1.5.1 Flight Crew
1.5.1.1 Captain
The captain was a Republic of Slovenia national. He joined Elit'Avia Malta

on 16 May 2018. The captain was a Bombardier Canadair Regional Jet (CRJ)
pilot for about 10 years. In 2017, the captain started to fly Bombardier BD-700
aircraft. At the time of the occurrence flight, the captain had total flying time of
about 6,143 hours with about 1,710 hours on the BD-700.
The captain held an air transport pilot license (ATPL) issued by the Civil
Aviation Agency of the Republic of Slovenia with single-engine piston land,
multi-engine, instrument, and type rating on CRJ CL-65 and BD-700, endorsed
with privileges for operation of radiotelephone on board an aircraft and a current
Slovenian level 6 and English Level 5 language proficiency.
The captain passed his most recent annual line check on 3 July 2020.
The captain completed a one-day annual recurrent ground school training on

20 September 2020. The subjects of the ground school training included aircraft
4
systems, performance, and weight & balance. The recurrent simulator training
was conducted on 23 and 24 September 2020. The simulator training comprised
upset prevention and recovery training, including windshear, stalls, approach,
landing, and airborne collision avoidance system (ACAS) and traffic alert and
collision avoidance system (TCAS) events, and normal/abnormal procedures
including go around, hydraulic system, landing gear and brake system, smoke
control and removal. The captain’s performance of the training was assessed as
“well done”. The captain passed the proficiency check on 25 September 2020.
The captain received his most recent crew resource management (CRM)
training on 6 May 2020 and fatigue management training on 2 September 2020.
The captain’s Class 1 medical certificate was issued by the Civil Aviation
Agency Republic of Slovenia on 15 May 2020 with no limitations.
The result of the captain’s alcohol test performed by the RCMQ operation
officer after the occurrence indicated the alcohol value was zero
1.5.1.2 First Officer
The first officer was a Netherlands national. He had his initial flight training
in 2005 and was a single-engine piston aircraft flight instructor for 7 years. At the
time of the occurrence flight, he had 3 years BD-700 flight experience, having
flown for a private owner for 2 years and then joining Elit’Avia Malta in 2020.
His total flying time was about 3,841 hours with 484 hours on BD-700.
The first officer held a commercial pilot license (CPL) issued by Civil
Aviation Authority Netherlands with single-engine piston land, multi-engine
piston land, instrument, night, flight instructor, and type rating on BD-700,
endorsed with privileges for operation of radiotelephone on board an aircraft and
a current English Level 6 language proficiency.
The first officer passed his most recent annual line check on 3 July 2020.
5
The first officer completed a one-day annual recurrent ground school
training on 18 June 2020. The subjects of the ground school training included
aircraft systems, performance, and weight & balance. The recurrent simulator
training was conducted on 24 and 25 June 2020. The simulator training comprised
upset prevention and recovery training, including windshear, stalls, approach,
landing, and ACAS and TCAS events, and normal/abnormal procedures
including go around, hydraulic system, landing gear and brake system, smoke
control and removal. The first officer’s performance of the training was assessed
as “very high standard”. The first officer passed the proficiency check on 26 June
2020.
The first officer received his most recent CRM training on 14 December
2020 and fatigue management training on 7 September 2020.
The first officer’s Class 1 medical certificate was issued by the Civil
Aviation Authority Netherlands on 14 May 2020 with limitations of
“CORRECTION FOR DEFECTIVE DISTANT VISION”.
The result of the first officer’s alcohol test performed by the RCMQ
operation officer after the occurrence indicated the alcohol value was zero.
Basic information of the occurrence flight crew is in Table 1.5-1.
6
Table 1.5-1 Flight crew basic information
Item Captain First Officer

Gender Male Male
Age as of occurrence 35 35
Commenced employment with
16 May 2018 20 Jan 2020
Elit’Avia Malta
License issued ATPL – Aeroplanes CPL – Aeroplanes
Type rating BD-700 BD-700
date of expiry 30 November 2021 31 July 2021
Medical certificate Class 1 Class 1
date of expiry 15 May 2021 11 June 2021
Total flying time 6,143 hrs and 20 mins 3,841 hrs and 30 mins
Total flying time on BD-700 1,710 hrs and 55 mins 484 hrs and 05 mins
Total flying time last 12
432 hrs and 44 mins 306 hrs and 30 mins
months
Total flying time last 90 days 61 hrs and 26 mins 91 hrs and 30 mins
Total flying time last 24 hours 2 hrs and 50 mins 2 hrs and 50 mins
Rest period before occurrence 16 hrs 25 mins 16 hrs 25mins
7
1.5.2 Flight Crew Activities within 72 hours Before the Occurrence
1.5.2.1 Captain
The captain stayed at home without flight duty for more than 10 days.
28 December 2020 Slovenia time (UTC+1)
0700L woke up
1300L departed from home
1445L positioning flight from Slovenia to Frankfurt as a passenger
1805L positioning flight from Frankfurt to Seoul as a passenger
29 December 2020 Seoul time (UTC+9)
1200L landed at Seoul
1315L checked in to Seoul Incheon airport transit hotel
2100L went to bed
0315L woke up
0700L checked out from hotel
0853L departed RKSI on the occurrence flight as the captain
The first officer stayed at home without flight duty for more than 10 days.
28 December 2020 Netherlands time (UTC+1)
1000L woke up
1800L departed from home to airport
8
2100L positioning flight from Amsterdam to RKSI as a passenger
1600L landed at Seoul
2230L went to bed at the transit hotel
0100L awakened, stayed in bed slept/snoozed on and off until 0600L6
0700L checked out from hotel
0853L departed RKSI on the occurrence flight as the first officer
1.6 Aircraft Information
1.6.1 Aircraft and Engine Basic Information

Basic information of the occurrence aircraft is shown in Table 1.6-1.
Table 1.6-1 Aircraft basic information
Aircraft basic information (statistics date: 30 December 2020)

Nationality 9H (Malta)
Aircraft registration number 9H-OJP
Aircraft model BD-700-1A-10
Manufacturer Bombardier Inc.
Aircraft serial number 9764
Date of manufactured 2016
30-Apr-2019 (date registered with
Date of received
Elit’Avia Malta)
Owner Bombardier G6000-9764 Ltd.
Operator Elit’Avia Malta Ltd.
Number of certificate of
653/1
registration
Certificate of airworthiness
653
number
6
The PF stated that he was feeling well rested and fit to fly.
9
Certificate of airworthiness, due
07-May-2021
date
Total flight time (hours:minutes) 2873:05
Total flight cycles 703
Last periodic check/ 250 FH Check/
Perform date 21-Dec-2020 (2844:53 FH / 696 CYC)
Basic information for the two Rolls-Royce engines is shown in Table 1.6-2.
Table 1.6-2 Engine basic information
Engine basic information
Number/position No. 1/ Left No. 2/ Right

Rolls-Royce Rolls-Royce
Manufacturer
Deutschland Ltd Deutschland Ltd
Model BD700-710A2-20 BD700-710A2-20
Serial number 22707 22706
Manufacture date 13-Oct-2016 12-Oct-2016
Time since last maintenance 258:43 258:43
Cycle since last maintenance 64 64
Time since new 2857:53 2857:53
Cycle since new 697 697
1.6.2 Aircraft Maintenance Information
A review of the last 3 months maintenance records, found no reported

technical issues related to the flight control system in accordance with the
technical logbooks, minimum equipment list, configuration deviation list and
deferred defect log. A review of applicable airworthiness directives and service
bulletins found no anomalies. No anomalies were noted during the most recent
250 flight hour (FH) check before the occurrence.
1.6.3 Weight and Balance Information
The actual takeoff weight of the occurrence aircraft was 86,207 lbs. The
aircraft’s center of gravity (CG) for takeoff was located at 31.0% mean
aerodynamic chord (MAC). The CG for landing was located at 30.4% MAC. The
10
center of gravity envelope of the BD-700 is depicted in Figure 1.6-1. Table 1.6-3
shows the occurrence aircraft’s weight and balance data. The aircraft’s weight
and balance were within the operational limits for the duration of the occurrence
flight.
Figure 1.6-1 BD-700 CG envelope
11
Table 1.6-3 Weight and balance data
Max. zero fuel weight 58,000 lbs.

Actual zero fuel weight 52,607 lbs.
Max. takeoff weight 99,500 lbs.
Actual takeoff weight 86,207 lbs.
Takeoff fuel 33,600 lbs.
Estimated trip fuel 8,650 lbs.
Max. landing weight 78,600 lbs.
Estimated landing weight 77,557 lbs.
Takeoff/landing CG +31.0/+30.4 MAC
1.7 Weather Information
The high-pressure of 1088 hPa was located and almost stationary in

Mongolia. Taiwan was affected by the strong cold high-pressure system drifting
southward. The northeasterly wind on the ground had increased significantly,
with wind speeds ranging from 10 to 28 knots.
The aerodrome routine meteorological reports (METAR) for RCMQ around

the time of the occurrence were:
METAR at 1000 hours, wind from 030 degrees at 28 knots gusting to 41

knots, visibility greater than 10 kilometers, few clouds at 500 feet, scattered
clouds at 1,200 feet, broken at 2,100 feet, temperature 14°C; dew point
temperature 8°C, altimeter setting 1020 hPa , trend forecast-no significant change,
remarks: altimeter setting 30.14 in-Hg, runway 36 wind not available7. (ATIS L)
METAR at 1030 hours, wind from 030 degrees at 27 knots gusting to 41

knots, visibility greater than 10 kilometers, few clouds at 500 feet, scattered
7
The runway 36 anemometer (one of automated weather observation system (AWOS) S sensors) operated
normally but the data transformation was malfunction from 1420 on 29 December to 1520 on 30 December 2020.
The wind information of ATIS was acquired from AWOS C at the time of the occurrence.
12
clouds at 1,200 feet, broken at 2,100 feet, temperature 14°C; dew point
temperature 8°C, altimeter setting 1020 hPa , trend forecast-no significant change,
remarks: altimeter setting 30.13 in-Hg, runway 36 wind not available. (ATIS M)
The sensors of the automated weather observation system (AWOS) were

located at the approach ends and midpoint of the runway, as shown in Figure 1.7-
1, providing real-time weather information to the displays of the weather center
and the tower. The wind information from 1035 to 1041 hours was shown in
Figure 1.7-2 and 1.7-3. From 1037:56 hours (the radio altitude of the aircraft was
220 feet) to 1040:10 hours (the aircraft taxied into taxiway), the wind variations
were from 010 to 050 degrees and from 14 to 31 knots for AWOS S, the wind
variations were from 020 to 050 degrees and from 23 to 45 knots for AWOS C.
Figure 1.7-1 AWOS sensor locations
13
Wind Direction (Degree) Wind Direction (Degree)
0
10
20
30
40
50
60
0
10
20
30
40
50
60
1035:00 1035:00
1035:10 1035:10
1035:20 1035:20
1035:30 1035:30
1035:40 1035:40
1035:50 1035:50
1036:00 1036:00
1036:10 1036:10
1036:20 1036:20
1036:30 1036:30
WD
1036:40 1036:40
1036:50 1036:50
WD
1037:00 1037:00
1037:10 1037:10
WS
1037:20 1037:20
1037:30 1037:30
1037:40 1037:40
1037:50 1037:50
WS
1038:00 1038:00
14
Time
Time
1038:10 1038:10
1038:20 1038:20
1038:30 1038:30
1038:40 1038:40
1038:50 1038:50
1039:00 1039:00
1039:10 1039:10
1039:20 1039:20
1039:30 1039:30
1039:40 1039:40
1039:50 1039:50
1040:00 1040:00
Figure 1.7-2 AWOS S wind speed/direction
Figure 1.7-3 AWOS C wind speed/direction

1040:10 1040:10
1040:20 1040:20
1040:30 1040:30
1040:40 1040:40
1040:50 1040:50
1041:00 1041:00
0
0
10
20
30
40
50
60
10
20
30
40
50
60
Wind Speed (Knots) Wind Speed (Knots)

1.8 Aids to Navigation
Not applicable.
1.9 Communication
Not applicable.
1.10 Aerodrome
1.10.1 Airside Basic Information
Taichung/Cingcyuangang (RCMQ) Airport is located 10 km northwest of

Taichung City. There is only one runway, oriented north and south, and designated
as runway 18/36 with declared dimensions of 3,659 meters long, 61 meters wide.
Runway 18’s true bearing is 176.69°, and the threshold elevation is 653 feet. It
has neither clearway nor stopway. Runway 36’s true bearing is 356.69°, and the
threshold elevation is 663 feet. It also has neither clearway nor stopway, but a
runway end safety area (RESA) with 90 meters square provided. (See Figure
1.10-1). The mean profile slope of runway 36 is about -0.09%, and the mean
cross-section slope is about 0.53%.
15
Figure 1.10-1 RCMQ Airport chart
Runway edge lights installed on both sides of runway 18/36 are high
intensity and with 60 meters spacing. Both centerline lights and touchdown zone
lights are not available. Runway 36 is a precision approach runway equipped with
a category I approach lighting system consisting of 900-meter-long sequenced
flashers (ALSF-1) and a high intensity precision approach path indicator (PAPI).
1.10.2 Runway Surface Friction
Surface friction measurements of runway 18/36 are carried out by a

commissioned contractor using Grip-Tester, a continuous friction measuring
equipment (CFME) conforming to ICAO8 standards and recommended practices.
With 1 mm depth of water sprayed on the dry runway surface, the measurement
8
International Civil Aviation Organization.
16
conducts with 65km/h and 95km/h along a line approximately 3 meters on each
side of the runway centerline. Whenever a one-third segment’s friction value of
the runway is lower than 0.53 at 65km/h, or 0.36 at 95km/h, the airport authority
should plan to take corrective actions. Whenever a one-third segment’s friction
value of the runway is lower than 0.43 at 65km/h, or 0.24 at 95km/h, the airport
authority should take corrective actions immediately and issue a notice to airmen
(NOTAM) to warn that the runway might be slippery until the work has been
completed.
Measurement results before the occurrence
The most recent measurement before the occurrence was conducted on 8

December 2020. Results are listed in tables 1.10-1 and 1.10-2.
Table 1.10-1 The most recent measurement results before the occurrence,
65km/h
1st 1/3 2nd 1/3 3rd 1/3

Runway Runway
Segment Segment Segment
0.63 0.65 0.70

18 36
0.67 0.63 0.69
Table 1.10-2 The most recent measurement results before the occurrence,
95km/h
1st 1/3 2nd 1/3 3rd 1/3

Runway Runway
0.66 0.64 0.65

18 36
0.65 0.62 0.67
Measurement results right after the occurrence
The first measurements after the occurrence were conducted on 5 January

2021. Results are listed in tables 1.10-3 and 1.10-4.
17
Table 1.10-3 The first measurement results after the occurrence, 65km/h
1st 1/3 2nd 1/3 3rd 1/3

Runway Runway
0.68 0.69 0.74

18 36
0.72 0.68 0.73
Table 1.10-4 The first measurement results after the occurrence, 95km/h
1st 1/3 2nd 1/3 3rd 1/3

Runway Runway
0.66 0.64 0.68

18 36
0.68 0.63 0.66
There was no rubber removal work carried out in the interval between the
measurements before and after the occurrence.
1.11 Flight Recorders
1.11.1 Cockpit Voice Recorder
The aircraft was equipped with a solid-state cockpit voice recorder (CVR)
made by L3Harris Avionics Systems, part number 2100-1225-24, serial number
001089488. The CVR is capable of 2 hours of 4-channel high-quality recording.
It records the flight crew conversations, radio communications, cockpit area
sound, and digital data (data link and GMT). An examination of the downloaded
CVR data indicated that 124 minutes and 14.5 seconds of 4 channels were
recorded, which included the descent phase from an altitude of FL200, approach
and landing at RCMQ, taxing, parking, and engine shutdown. The CVR audio
quality of each channel was either good or excellent. The investigation team made
a transcript of 11 minutes of the CVR recording related to the occurrence.
Timings for the CVR recording were established by correlating the CVR
18
events to common events on the flight data recorder (FDR) and then
synchronizing those events with the air traffic control (ATC) timing system.
1.11.2 Flight Data Recorder
The aircraft was equipped with a solid-state FDR made by L3Harris

Avionics Systems, part number 2100-2245-22, serial number 001094442. The
FDR readout was performed based on the interpretation document9 provided by
the manufacturer of the aircraft. The FDR recording contained about 85 hours 12
minutes and 44 seconds of data with approximately 1,207 parameters.
After downloading, parsing and confirming the mandatory FDR parameters,

the flight data related to the occurrence are summarized as follows:
1. At 1037:56 hours, autopilot (AP) was disengaged, with autothrottle

remaining engaged, radio altimeter 219 feet, airspeed 132 knots,
groundspeed 87 knots, pitch attitude 2.46 degrees nose-up, roll attitude 1.49
degrees RWD, magnetic heading 10.2 degrees, windspeed 49 knots, wind
direction 23.2 degrees, throttle lever angle (TLA)10 5.4 degrees (left) and 5.8
degrees (right).
2. At 1038:11 hours, the aircraft flew over the threshold of runway 36, radio
altimeter 34.3 feet, airspeed 123.75 knots, groundspeed 89 knots, pitch
attitude 5.0 degrees nose-up, roll attitude 2.46 degrees RWD, magnetic
heading 9.9 degrees, windspeed 41 knots, wind direction 29.5 degrees, angle
of attack (AOA11) 10.2 degree (left) and 8.96 degree (right), TLA 1.5 degrees
9
SSFDR DATA INTERPRETATION – FLIGHT DATA RECORDER CONFIGURATION STANDARD (FRCS)
REPORT, RAE-C700-441, Revision: B.
10
According to FDR readouts, the TLA was about 38 degrees maximum during takeoff phase, about 2 degrees
during flight idle, about 0 degrees during ground idle and about -23 degrees minimum during thrust reverser in
use.
11
The angle of attack parameter recorded on the FDR is the angle of attack as measured by the vanes; it is not
the aircraft (body or fuselage) angle of attack.
19
(left) and 1.5 degrees (right).
3. At 1038:14.75 hours, the aircraft radio altimeter was 0 feet, airspeed 111
knots, groundspeed 87 knots, pitch attitude 9.31 degrees nose-up, roll attitude
reached the maximum RWD angle of 6.76 degrees.
4. At 1038:15 hours, the aircraft radio altimeter was -2.5 feet, airspeed 113
knots, groundspeed 87 knots, pitch attitude 9.8 degrees nose-up, roll attitude
5.88 degrees RWD, magnetic heading 8.8 degrees, windspeed 30 knots, wind
direction 34.4 degrees, vertical acceleration with 1.44g value, AOA 23.81
degree (left) and 19.68 degree (right), TLA 1.14 degrees (left) and 1.58
degrees (right).
5. At 1038:15.25 hours, the 「air/ground」parameter of right landing gear

changed from air to ground, radio altimeter -2.5 feet, airspeed 112.5 knots,
groundspeed 87 knots, pitch attitude 10.19 degrees nose-up, roll attitude 0.87
degrees LWD, vertical acceleration with 2.12g and lateral acceleration of
0.26 maximum value were recorded .
6. From 1038:15 to 1038:17 hours, the 「air/ground」 parameter of both main

landing gear changed 4 times with roll attitude and magnetic heading changes
as follows:
Left landing Right landing Magnetic
Roll attitude
Time gear gear heading
（degree）
(air/ground) (air/ground) （degree）
1038:14.75 air air 6.76 RWD -
1038:15.00 air air 5.88 RWD 8.9
1038:15.25 air air → ground 0.87 LWD -
1038:15.50 air → ground ground 5.53 LWD -
1038:15.75 ground ground 9.31 LWD -
1038:16.00 ground ground → air 9.4 LWD 5.6
1038:16.25 ground air 6.15 LWD -
1038:16.50 ground air 2.19 LWD -
20
1038:16.75 ground air → ground 2.54 RWD -
1038:17.00 ground ground 2.1 RWD 2.5
7. At 1038:17 hours, autothrottle was disengaged, the airspeed was 114 knots,
groundspeed 85 knots, magnetic heading 2.5 degrees, TLA 1.05 degrees (left)
and 1.75 degrees (right).
8. At 1038:19 hours, the 「air/ground」parameter of nose landing gear changed

from air to ground, airspeed 102.75 knots, groundspeed 82 knots, pitch
attitude 0.79 degrees nose-up, TLA -0.35 degrees (left) and -0.17 degrees
(right).
9. At 1040:10 hours, the aircraft vacated runway 36.
10. The FDR stopped recording at 1253 hours.
Figure 1.11-1 and 1.11-2 shows the occurrence related FDR parameters
during the landing phase of the aircraft, and Figure 1.11-3 shows the FDR flight
path of the occurrence flight.
21
Figure 1.11-1 FDR readouts during landing phase (from AP disengaged)
Figure 1.11-2 FDR readouts during landing phase (from RA 50ft)
22
RKSI
RCMQ
Figure 1.11-3 FDR recorded flight path of occurrence flight
23
1.12 Wreckage and Impact Information
1.12.1 Site Survey
The investigation team arrived at RCMQ around 1515 hours on the

occurrence day, and then searched for significant wing contact marks on the
runway 36 surface around 1537 hours. The team utilized global positioning
system (GPS) equipment and a camera to conduct a ground survey of the
occurrence site. The team found the first (right) wing mark (R1) at about 503 feet
from the runway threshold, then the three parallel (left) wing marks (L1 to L3)
were found about 636 feet from the runway threshold.
The first wing mark (R1) starts about 503 feet from the runway threshold
and 19 feet to the right of the centerline, and stops about 515 feet from the runway
threshold and 20 feet to the right of the centerline, with a total length of 12 feet.
The mark points 5 degrees away from the runway centerline direction.
The second wing mark (L1) starts about 636 feet from the runway threshold
and 53 feet to the left of the centerline, and stops about 652 feet from the runway
threshold and 52 feet to the left of the centerline, with a total length of 15 feet.
The mark points 3 degrees towards the runway centerline direction.
The third wing mark (L2) starts about 618 feet from the runway threshold
The fourth wing mark (L3) starts about 633 feet from the runway threshold
The survey item list is shown as table 1.12-1. Figure 1.12-1 shows the
24
superimposed site survey items and FDR recorded flight path. Figure 1.12-2 is a
close-up of the site survey items. Figure 1.12-3 shows the first wing mark. Figure
1.12-4 shows the second to fourth wing marks.
Table 1.12-1 Survey item list
Distance from runway 36

No. Survey item Length (ft)
threshold (ft)
1 First wing mark(R1) 503~515 12

2 Second wing mark(L1) 636~652 15
3 Third wing mark(L2) 618~658 42
4 Fourth wing mark(L3) 633~650 17
Figure 1.12-1 Superimposed site survey item and FDR flight path
25
Figure 1.12-2 Close-up of site survey item
Figure 1.12-3 First wing mark (R1)
26
Figure 1.12-4 Second to fourth wing marks (L1~L3)
1.12.2 Damage
The aircraft sustained abrasive damage during the occurrence, most of the
damage was located at the bottom and trailing edge of the outboard end on both
wing areas, the details are shown as follows.
An abrasion was detected on the right end bottom of the most outboard slat
on the right wing; the abrasion area was about 0.75 sq.cm.
Figure 1.12-5 Right slat
An abrasion was detected on the middle bottom of the right winglet; the
27
abrasion area was about 18 sq.cm.
Figure 1.12-6 Middle bottom of the right winglet
An abrasion was detected on the very end of right wing and split into 2
delaminations at the trailing edge. The damage area abraded on the trailing edge
connects with the winglet trailing edge, the length of separation at the trailing
edge was about 40 cm long, and the abrasion area was about 100 sq.cm.
Figure 1.12-7 Trailing edge of the end of right wing
An abrasion was detected on the right end of the aileron and split into two
28
delaminations at the trailing edge, the aileron had severe damage at the right end
trailing edge corner. The abrasion damage extended into the honeycomb in the
aileron trailing edge corner, the abrasion area was about 158 sq.cm. The length of
separation at the right end of the aileron was about 48 cm long.
The outboard two static wicks on the aileron were lost, one of the detached
static wicks was found at the right wing touchdown zone. The most outboard
static wick location was worn down to the aileron surface by abrasive contact.
Figure 1.12-8 Right aileron
Severe abrasive wearing was detected on the aft end of the most outboard
flap fairing on the right wing; the area of wear was about 13 cm long and 3 cm
wide.
29
Figure 1.12-9 Right outboard flap fairing
An abrasion was detected on the right end bottom of the most outboard slat
on the left wing; the abrasion area was about 13 sq.cm.
Figure 1.12-10 Left slat
An abrasion was detected on the very end of the left wing, abraded on the
trailing edge at the connection with winglet trailing edge, the length of separation
at the trailing edge was about 25 cm long, and the abrasion area was about 25
sq.cm.
30
Figure 1.12-11 Trailing edge of the end of left wing
An abrasion was detected on the middle bottom of the left winglet; the
abrasion area was about 78 sq.cm.
Figure 1.12-12 Middle bottom of the left winglet
An abrasion was detected on the right end of the aileron and split into two
delaminations at the trailing edge, the aileron had severe damage at the left end
trailing edge corner. The abrasion damage extended into the honeycomb in the
aileron trailing edge corner, the abrasion area was about 245 sq.cm. The length of
separation at the left end of the aileron was about 48 cm long.
The outboard two static wicks on the aileron were lost. The most outboard
static wick location was worn down to the aileron surface level by abrasive
contact, the upper structure of the static wick was detached.
31
Figure 1.12-13 Left aileron
Severe abrasive wearing was detected on the most outboard flap fairing at
the end tail on the left wing; the size of the abraded area was about 7 cm long and
1.5 cm wide.
Figure 1.12-14 Left outboard flap fairing

1.13 Medical and Pathological Information
Not applicable.
32
1.14 Fire
Not applicable.
1.15 Survival Aspects
Not applicable.
1.16 Tests and Research
Not applicable.
1.17 Organizational and Management Information
Elit'Avia Malta is a private jet company, founded in 2006, with Air Operator
Certificates (AOC) in Slovenia and Malta. Elit’Avia Malta provides aviation
services to Europe, Middle East, Africa, Russia & CIS (Commonwealth of
Independent States), and North America. At the time of the occurrence, Elit'Avia
Malta operated a jet fleet consisting of one Challenger 604, two Challenger 650,
one Gulfstream G450, one Falcon 7X, one Global 5000, and four Global 6000 for
private aircraft charter service.
1.18 Additional Information
1.18.1 Aircraft Operating Information
1.18.1.1 Authority, Duties and Responsibilities of the Commander
According to Elit’Avia Malta Operations Manual Part A (OM-A, issued 08

REV 00-Dec 15/2020), Section 1.4, the commander has authority to decide on
who will be PF and PNF12 after taking into account of co-pilot’s experience and
operational conditions specified in OM-A 8.3.1.7 (e).
8.3.1.7. Assignment of PF duties
a) For most routine flight operations, commanders are encouraged to
12
Pilot not flying. PNF is the same as PM.
33
share PF duties equally between the pilots whenever the circumstances allow.
b) In order to maintain and improve his skill in handling the airplane,
the copilot shall carry out part of the flying and part of the total number of
landings. As a commonly adopted rule, the copilot should be given the
opportunity to fly at the controls around 50% of the total flight time and carry
out such takeoffs, climb-outs, approaches and landings which fall within his
flying time.
c) When a copilot is flying the airplane, the commander shall perform
the PM duties and should not interfere with the PF dispositions and flying
unless these are considered to be contrary to safety, regulations or SOPs.
d) For the more demanding circumstances or the less frequently
encountered circumstances, the commander should take into account the
copilot’s experience level versus the circumstances before assigning PF
duties to the copilot.
e) Conditions when the Left Pilot should act as PF include, but are not
limited to, the following circumstances:
1) Ground operations up to initiation of the takeoff-roll and from
after completion of the landing roll;
2) When the copilot has less than 1 year experience on the airplane
type and the crosswind component exceeds 15 kts or crosswind
component is close to maximum authorised regardless of copilot’s
experience;
3) Operations under adverse weather conditions, including
operations on slippery or contaminated runways;
4) Windshear is reported in the vicinity of the airport;
5) Takeoff from or landing at an aerodrome categorized as C;
6) Short field operations (SFOPS) are conducted;
34
7) Approaches at night without glidepath guidance by means of
visual or electronic glidepath guidance or glidepath indications on
flight deck instruments;
8) System malfunctions affecting the airplane flight characteristics;
9) Rapid depressurization/emergency descent;
10) On ground emergency/passenger evacuation;
11) When otherwise prescribed, for example, for low visibility
operations or per Aerodrome Information NOTAM; or
12) Any other condition in which the pilot in command determines it
to be prudent to exercise the pilot in command's authority.
After the occurrence, Elit’Avia Malta issued a temporary revision of 8.3.1.7

(e)(2) in January 2021 as below:
2) When the total steady crosswind is 20 kts or more (15 kts for co-
pilots under 1 year experience) and/or the gusting is 10 kts or more;
1.18.1.2 BD-700 Maximum Demonstrated Crosswind Component
According to the Global 6000 Airplane Model BD 700-1A10 Airplane Flight

Manual (AFM), revision 36 Nov. 2020, the maximum demonstrated crosswind
component for takeoff and landing [at 33 feet (10 meters) tower height] is 29
knots and is not considered limiting for takeoff and landing. Landings have been
performed at an approach speed of Vref +1/2 of the gust.
The company maximum crosswind limitations are listed in Operations

Manual Part B (OM-B, issued 04 REV 00-Oct 16/2020), section 1.32:
1.32. WIND LIMITATIONS
Tailwind and Maximum Crosswind Limitations
The maximum tailwind component approved for takeoff and landing is
35
10 Knots.
Satisfactory controllability during takeoff and landing has been

demonstrate with 90-degree crosswind component during aircraft
certification process. The AFM maximum demonstrated crosswind
component was demonstrated on a dry runway by manufacturer’s test pilots
and is not considered to be limiting.
Elit’Avia Malta limits its 6000 crewmembers to the following crosswind

(steady or gust) depending on reported runway condition.
When braking action or friction coefficient is reported or considered

unreliable, use RWY Equivalent Condition for maximum crosswind
determination:
1. Dry, damp or wet runway (less than 3 mm water depth) or

compacted dry snow
2. Runway covered with slush or wet snow
3. Runway covered with dry snow
4. Runway covered with standing water
5. Runway covered with ice
Operation in strong gusty crosswinds is not recommended.
1.18.1.3 Automatic Flight Systems
According to Elit’Avia Malta OM-A, issued 08 REV 00-Dec 15/2020, the

use of autopilot and autothrottle is described in section 8.3.1.12. :
36
8.3.1.12. Automatic Flight Systems (AFS)
a) General
1) Automatic flight systems may be used to their maximum extent

within the limitations of the applicable OM-B.
2) When the autoflight system does not operate as anticipated, the
first action shall be to disengage the autoflight system and control
the flight path manually. Establishing the reason for the observed
system behavior always takes second place.
3) Below 2500 feet AGL, the Pilot Flying (PF) shall be ready to
immediately take manual control, if required. For this purpose he
shall have one hand on the control wheel and, during approach only,
the other hand on the throttles.
4) In selecting the level of automation to be used the PF should take
account of the following considerations:
(i) PM workload,
(ii) Weather,
(iii) Crew alertness,
(iv) Traffic density,
(v) Airplane serviceability status.
As a general policy during normal line operations (scheduled line or
base training flights are exempted) the highest available level of automation
should be used.
5) …..
b) Autopilot
1) The autopilot should be engaged if one pilot is controlling the
flight path unmonitored by another pilot, for example during non-
normal operation or passenger address.
37
2) Pilots should remain current with manual flight. For this purpose
it is recommended to regularly practice manual flight below
approximately 10.000 feet AGL. Conditions taken into account when
practising manual flight include, but are not limited to:
(i) Phase of flight;
(ii) Workload conditions;
(iii) Altitude/Flight Level (non-Reduced Vertical Separation
Minima (RVSM));
(iv) Meteorological conditions;
(v) Traffic density;
(vi) Air Traffic Control (ATC) and Air Traffic Management
(ATM) procedures;
(vii) Pilot and crew experience; and
(viii) Elit’Avia Malta operational experience with the aircraft
type.
Pilots should use automated systems e.g. during high workload
conditions, while operating in traffic congested airspaces, or when following
airspace procedures that require the use of autopilot for precise operations.
3) Except for autoland operations, the autopilot(s) should be
disengaged:
(i) For operations below (M)DA, and;
(ii) When the reported crosswind exceeds 15 knots, when
descending through 500 ft RA.
c) Autothrottle/Autothrust
Except as provided for, and within the limitations of the respective OM-
B, the autothrottle should be operated as follows:
1) During automatic flight the autothrottle should be engaged.
38
2) During manual flight the autothrottle should be disengaged.
d) ….
1.18.1.4 Stable Approach
Stable approach criteria is described in Elit’Avia Malta OM-A (issue 08

REV 00-Dec 15/2020), section 8.3.2.11.15.:
8.3.2.11.15. Stabilized approach (CAT.OP.MPA.115)
a) Each approach procedure shall be planned and executed in a manner

to achieve stabilization criteria latest at the target height (stabilized
approach window). Lowest target height is:
1) 1000 feet AGL for precision approaches;
2) Height corresponding FAF for non-precision approaches; and
3) 500 feet AGL for visual approach and 300 feet AGL for circle-to-
land approach.
b) An approach is stabilized when all of the following criteria are met:
1) The airplane is on the correct flight path;
2) Bank angle is equal to or less than 15 degrees;
3) Only minor changes in heading and pitch are required to
maintain the correct flight path, except in circle-to-land approach
where heading stabilization shall be achieved latest at 300 ft AGL;
4) Indicated airspeed shall not be less than VREF and not greater
than VREF + 20 kts;
5) The airplane is in the correct landing configuration;
6) Vertical speed is not greater than 1000 fpm (except for steep
approach); and the ROD deviations should not exceed ± 300 fpm,
except under exceptional circumstances which have been
anticipated and briefed prior to commencing the approach; ,for
39
example, a strong tailwind;
7) The thrust is stabilized above idle to maintain the target speed on
the desired glide path;
8) Position allows a landing within the touch down zone of the
runway, using normal maneuvers; and
9) All briefings and checklists have been completed.
1.18.1.5 Final Approach Speed
The final approach speed calculation is described in several sections in

Global 6000 Model BD 700-1A10 Flight Crew Operating Manual (GL 6000
FCOM), and Elit’Avia Malta OM-A and OM-B:
According to the GL 6000 FCOM Volume 1, revision 36: Nov 11/2020,

Chapter 10 NORMAL AND NON-NORMAL PROCEDURES, Section 10-01 H.
Landing (2) SPEED ADDER FOR APPROACH AND LANDING IN GUSTY
WIND CONDITIONS:
The VREF speed adder should be used for approach and landing when
turbulence or gusty wind conditions are anticipated during the approach and
landing.
When gusty conditions are reported, it is recommended to add half of the gust,
to a maximum of 10 KIAS.13 (e.g. for winds of 15 kts gusting to 40 kts, half of the
25 kt gust is 12.5 kts, so in this case the correction applied to VREF is 10 KIAS.)
Final approach speed calculation in OM-A, issued 08 REV 00-Dec 15/2020,

section 8.3.2.12:
8.3.2.12. Touchdown
13
The Bombardier has revised this guidance. The "maximum of 10 KIAS" was removed in the May 2021 revision
of the FCOM.
40
To accomplish a safe landing the height of the airplane over the landing
runway threshold should be approximately 50 feet. This height may vary
according to information provided on the approach chart (TCH). Final
approach shall be adjusted so as to achieve touchdown in the Touch Down
Zone (TDZ) area, paying due regard to obstructions in the final approach
area, runway length, runway conditions etc. If the touchdown cannot be
accomplished within the TDZ a missed approach shall be initiated. For the
purposes of this section, the TDZ is defined as the area extending from 150
m to 1000 m from the landing threshold, or the first one third of the landing
runway (whichever is less).
Wind speeds including gust are to be compensated at the commander's

discretion and according to the circumstances (expected or reported wind
shear, available runway, specific wind phenomena at some aerodromes,
possible malfunction, etc.).
Final Approach Speed = VREF + 1/2 steady wind + full gust (max.
VREF + 20 KIAS)
Pilot shall start braking after touchdown of the nose gear but latest at
80 KTS. Aircraft shall reach safe taxi speed well before turning off the runway.
Brake for safety, not for comfort.
The final approach speed calculation is also mentioned in OM-B, issued 04

REV 00-Oct 16/2020, section 2.8.15:
2.8.15. Landing
For General information refer to OM-A 8.3.2.12.Touchdown.
Wind speeds including gust are to be compensated at the Commander's

discretion and according to the circumstances (expected or reported wind
shear, available runway, specific wind phenomena at some aerodromes,
41
possible malfunction, etc.). Below 500 feet above TDZE thrust shall be above
idle and maximum 1000 fpm ROD must be maintained.
Final Approach Speed = VREF + 1/2 gust (max. VREF + 10 KIAS)
Reduce thrust by 50 ft.
The PM shall supervise the correct operation of the ground lift dumpers
and call out "SPOILERS OUT and THRUST REVERSERS OUT" when
extended.
Avoid high flare. Lower the nose wheel without delay. Use rudder pedals
for directional control (do not use nose wheel steering tiller).
Pilot shall start braking after touchdown of the nose gear but latest at
80 KTS. Aircraft shall reach safe taxi speed well before turning off the runway.
Brake for safety, not for comfort!
LP shall call "MY CONTROLS" and take controls during landing roll
when he deems necessary.
1.18.1.6 Standard Callout
The callout for deviations is described in Elit’Avia Malta OM-A, issued 08

REV 00-Dec 15/2020, section 8.3.1.21. PNF monitoring duties and associated
terminology:
8.3.1.21. PNF monitoring duties and associated terminology
In addition to other specific monitoring duties and calls described in this

Operations Manual, PNF shall monitor the flight execution and inform PF
immediately of observed deviations using the terminology described below.
In addition and where applicable PNF shall verify that corrective action is
taken.
42
a) Airspeed
When the airspeed deviates more than 5 kts from the desired or
selected value or exceeds or tends to exceed a limit value, PNF shall
call: ”SPEED HIGH” or “SPEED LOW”, as appropriate.
b) Vertical speed
When the vertical speed during descent deviates more than 500 ft/min
from a predetermined value or exceeds or tends to exceed a limit
value, PNF shall call: “SINK RATE”.
c) Bank angle
When the bank angle exceeds or tends to exceed 30 degrees or any
lower applicable bank angle limit, PNF shall call: “BANK ANGLE”.
d) Altitude
When the aeroplane deviates more than 150 ft from the cleared
altitude/flight level or exceeds or tends to exceed an altitude limit
PNF shall call: “CHECK ALTITUDE”.
e) Proximity to terrain
When undue proximity to terrain has been detected, such as during
GPWS or windshear recovery, PNF shall call out each 100 ft Radio
Altitude and the vertical trend at or below 500 ft, e.g. “TWO
HUNDRED FEET CLIMBING, THREE HUNDRED FEET LEVEL,
FIVE HUNDRED FEET DESCENDING”.
f) Windshear
When windshear is detected or suspected on take-off or final
approach and no windshear detection system is available, PNF shall
call: “WINDSHEAR”.
g) Attitude
When the attitude deviates significantly from the normal target
43
attitude for the phase of flight, the PNF shall call: “PITCH”.
Also, OM-A section 8.3.2.11.15 Stabilized approach:
PM call-outs during final approach:
"SPEED" when speed becomes lower than VREF – 5 kt or higher

than VREF + 10 kt;
"PITCH" when pitch att. becomes lower than 5° nose down or

higher than 5° nose up;
"BANK" when bank angle becomes steeper than 7°;
"SINK RATE" when descent rate exceeds 1000 ft/min;
"LOCALIZER" when LOC deviation becomes ≥ ½ dot LOC;
"GLIDE SLOPE" when GS deviation becomes ≥ ± ½ dot GS;
"RWY/APP LIGHTS IN SIGHT" as soon as approach lights and/or

runway (lights) are in sight.
1.18.1.7 Landing Procedures and Technique
BD-700 aircraft landing thrust and pitch control procedures are described in
GL 6000 FCOM Volume 1, revision 36: Nov 11/2020, Chapter 4 NORMAL
PROCEDURES, Section 04-08 APPROACH AND LANDING:
FULL STOP LANDING
The procedures outlined below are done simultaneously or in quick

succession, as the situation requires.
Approach through 50 feet height point at VREF (Refer to the Airplane Flight
Manual; Chapter 6; PERFORMANCE − LANDING PERFORMANCE) on
stabilized glide slope of 3 degrees, with landing gear down, slats out and flaps at
30 degrees.
44
Thrust reversers may be used after touchdown to supplement the use of wheel
brakes.
With the thrust reversers deployed, a nose-up pitching tendency will occur at
high reverse thrust settings, particularly at aft c.g. light weights. This tendency is
controllable with elevator and may be minimized by ensuring that nose wheel
touchdown is achieved, and nose-down elevator applied, before selecting reverse
thrust.
At or below 50 feet AGL:
1. Thrust levers ............................................................IDLE
2. Airplane attitude......................... Maintain until close to the runway.
• Perform partial flare, and touchdown without holding off.
3. Ground lift dumping ................................Check deployed
4. Brakes......................................................................Apply
• Apply brakes as appropriate for landing and runway conditions.
5. Thrust reversers................................................. Deploy
CAUTION
If maximum reverse thrust is required, MAX reverse may be deployed to

a full stop. If Max reverse is not required, reverse thrust should be manually
reduced to Reverse Idle by 50 KIAS to prevent re−ingestion of engine gases,
ingestion of Foreign Object Debris (FOD) and prevent dust, sand, water or
other contaminants from being blown onto airplane surfaces. If Max reverse
is used below 50 KIAS a maintenance inspection will be required on the
Compressor stage within the next 15 engine cycles.
6. Directional control ............................................ Maintain
45
• Use aileron and rudder as required.
7. Engine instruments and Airspeed ........................Monitor
• PM will advise PF of any engine limitations about to be reached or of

any discrepancy.
8. Thrust reversers......................................IDLE / STOW
• Confirm reversers are stowed.
NOTE:
Inadvertent positioning of the thrust levers between the IDLE and the
REV detents will result in propulsion system anomalies, such as L (R)
REVERSER FAIL indications.
9. Nose wheel steering ....................................... As required
The landing technique of BD-700 airplane is described in the GL 6000

FCOM Volume 1, revision 36: Nov 11/2020, Chapter 10 NORMAL AND NON-
NORMAL PROCEDURES, Section 10-01 H. Landing (5) LANDING
TECHNIQUE:
(5) LANDING TECHNIQUE
At 50 ft AGL autothrottles retard to idle − based on Rad Alt. If

autothrottles are not engaged, manually reduce thrust to idle at 50 ft AGL.
As soon as thrust is reduced to idle, the airplane will decelerate.

Touchdown at approximately VREF −4 kts is reasonable. For a normal 3
degree glidepath, induce a flare at approximately 30 ft AGL, slightly earlier
for steeper approach angles.
At touchdown, the GLD system extends all spoilers automatically.

Maintain the pitch input initially and ease the nosewheel touchdown.
46
Continue to apply appropriate crosswind input, with increasing aileron
deflection as speed decreases during the roll−out.
Autobrakes, if selected, activate at touchdown after GLD deployment;

and, weight on wheels for 5 seconds or wheel spin−up to greater than 50 kts.
Deceleration will occur at the preselected rate.
If autobraking is not selected for landing, smoothly apply wheel brakes

and select thrust reversers as required. Apply brakes by steadily increasing
pedal pressure, adjusting for runway condition and length available. Do not
pump the brakes. Maintain deceleration rate until stopped or desired taxi
speed is reached.
After main wheel touchdown, continue to “fly” the nosewheel down to

the ground by adjusting aft yoke pressure as required. As speed decreases
more aft yoke movement is usually required. This is more pronounced with
greater forward CG balance. Do not hold the nose wheel off the surface or
delay de−rotation excessively to avoid the nosewheel slamming onto the
runway as speed and elevator effectiveness decay. Autobrake engagement
prior to nosewheel touchdown will also accelerate de−rotation and will
require timely aft yoke input to mitigate hard nosewheel touchdown. If thrust
reversers are deployed prior to nosewheel touchdown, there may be a
requirement to slightly reduce the control yoke aft pressure to avoid a pitch
increase as reverse thrust is applied.
1.18.1.8 Crosswind Landing Technique
BD-700 airplane crosswind landing technique is described in GL 6000

FCOM Volume 1, revision 36: Nov 11/2020, Chapter 4 NORMAL
PROCEDURES, Section 04-08 APPROACH AND LANDING:
11. CROSSWIND LANDING
47
The recommended technique for approach is the wings level crab
technique where the aircraft is pointed into the wind to control direction.
If a crosswind is present, as the flare is commenced, application of

rudder is used to align the fuselage parallel with the runway centerline.
As rudder is applied the aircraft will tend to roll in the direction of the
rudder input. To counter this, simultaneous input of rudder and opposite
aileron is required to keep the wings level. In this wings level condition there
will be some sideways drift. A slight, into wind, wing down should control
this sideways motion.
Excessive wing down can cause the wing tip to contact the runway. In
order to minimize this possibility, the bank should be limited to less than 3
degrees and the touchdown should occur as soon as the aircraft is aligned
with the runway. Prolonging the flare would increase the pitch attitude which
brings the wing tip closer to the ground.
The aileron input is required throughout the landing roll and the input
should be increased as the airspeed decreases.
Any lateral motion on final approach should be controlled using aileron

inputs. The rudder should not be used to control lateral motion and should
only be used in the flare to align the aircraft with the runway.
The use of autobrake is recommended for strong crosswinds.
In addition, crosswind landing technique is also described in Chapter 10

NORMAL AND NON-NORMAL PROCEDURES, Section 10-01 H. Landing (7)
CROSSWIND LANDING TECHNIQUE:
(7) CROSSWIND LANDING TECHNIQUE
The recommended technique for approach in crosswinds is a
48
wings−level crab technique; the airplane is pointed into wind while tracking
the extended runway centerline. Tracking correction should be made with
aileron. Do not use rudder to control lateral tracking on final approach.
If a crosswind is present, as the flare is commenced at approximately 30

ft, apply downwind rudder to align the fuselage parallel with the runway
centerline.
As rudder is applied, the airplane will tend to roll in the direction of

rudder input. To counter this, simultaneous input of rudder and opposite
aileron is required to keep the wings level. Touchdown should occur as soon
as the airplane is aligned with the runway. The action of removing into−wind
crab and aligning with the runway may also be known as de−crab.
Do not prolong the flare or significantly delay touchdown. The airplane

will start to drift, accelerating downwind as soon as de−crab occurs.
Although a very slight into−wind wing−down may be tolerated after de−crab,
the focus should remain on a wings level touchdown with minimum delay.
Delaying touchdown or extending flare usually requires increased pitch.

With pitch increase, the tolerance for bank and wing tip ground clearance is
reduced. Excessive wing−down can cause the wingtip to contact the runway.
For gusty crosswinds, a deliberate positive touchdown is recommended.
Otherwise, extending the flare in strong crosswinds may jeopardize a safe
landing within the lateral confines of the runway.
If the final approach or landing phase becomes unstable, an immediate

go−around is recommended.
After placing the nosewheel onto the ground, rudder input can be
modulated to rely more on nosewheel friction to control airplane direction.
The aerodynamic effect of rudder will rapidly diminish during the
49
after−landing deceleration. Nosewheel steering via rudder pedal input will
become increasingly relied upon during the transition to taxi speed.
Effectively the transition from predominant aerodynamic rudder control to
nosewheel steering via rudder pedal input will be transparent to passengers.
Into−wind aileron input is required throughout the landing roll, with

input increasing as the speed decreases to taxi speed. This technique is
especially important for wet/contaminated runways.
CAUTION
Nosewheel tiller steering should only be used at taxi speeds and below.
Sensitivity of the tiller steering may contribute to over−controlling and pilot
induced oscillations if used at higher speeds.
Division of flight control duties between the two pilots is not

recommended. The PF should not use the tiller during the landing roll until
the airplane has reached taxi speed.
The use of autobrake in crosswinds is recommended.
A VREF speed adder should be used for gusty conditions. The correct
addition is “half the gust”, to a maximum of 10 kts. Adding more speed on
top of the appropriate gust adder may present additional challenges during
the landing phase. Extra energy in the landing phase combined with ground
effect may contribute to a tendency to float prior to touchdown. The stability
of the landing will be significantly aggravated as crosswinds and drift
tendency increase. Adding extra speed beyond the necessary adders is not
recommended.
1.18.1.9 Wing Tip Ground Clearance
BD-700 wingtip ground clearance during landing is described in GL 6000

FCOM Volume 1, revision 36: Nov 11/2020, Chapter 10 NORMAL AND NON-
50
NORMAL PROCEDURES, Section 10-01 H. Landing (8) AIRPLANE
GEOMETRY CONSIDERATIONS FOR LANDING:
(8) AIRPLANE GEOMETRY CONSIDERATIONS FOR LANDING
The wing sweep (34 degrees at the leading edge) and wing span
contribute to reduced wing tip ground clearance as pitch increases during
touchdown. This is exacerbated with increase in bank angles. It is therefore
highly recommended to target wings level for landing.
Recommended pitch at touchdown is 7 to 8 degrees. The following table

represents the worst case scenario for a touchdown with wings not creating
lift.
 It is highly unlikely that the airplane will ever encounter a tail strike.
Pitch attitude required for tail strike is as follows:
− 15.3 degrees for fully compressed gear
Eye reference height at touchdown in the landing attitude is 4.75 m

(15.60 ft).
1.18.1.10 Windshear
A guideline of windshear encounter operations are listed in Elit’Avia Malta

OM-A, issued 08 REV 00-Dec 15/2020, section 8.3.11.5. Windshear:
8.3.11.5. Windshear
a) If windshear is suspected, maximum takeoff thrust should be used for

51
takeoff. The longest suitable runway should be used taking into consideration
crosswind and tailwind limitations, and obstacles in the takeoff path.
b) Pilots shall remain alert to the possibility of windshear, and be

prepared to make relatively harsh control movements and thrust changes to
offset its effects. Immediately after takeoff, the pilot’s choices of action will
be limited, since he will normally have full thrust applied, and be at the
recommended climb speed for the configuration. If the presence of windshear
is indicated by rapidly fluctuating airspeed or rate of climb/descent, or by a
Windshear Alert and Guidance System (WAGS), ensure that full thrust is
applied and aim to achieve maximum lift and maximum distance from the
ground or follow WAGS guidance.
Similarly, if the windshear is encountered during the approach, positive

application of the thrust and flight controls should be used to keep the speed
and rate of descent within the normal limits. If there is any doubt, the
approach should be abandoned and action taken as in the after takeoff case
above. Whenever windshear is encountered, its existence should be notified
to Air Traffic Control as soon as possible.
c) The following guidelines may be used to indicate uncontrolled

changes from the normal steady state conditions. Changes in excess of:
1) 15 kts IAS;
2) 500 ft/min vertical speed;
3) 5 degrees pitch attitude;
4) 1 dot displacement from the glide path; and
5) Unusual throttle position for a significant period of time.
52
1.18.2 Interview Summaries
1.18.2.1 Captain
The occurrence flight departed from RKSI at 0009 UTC. Stop at RCMQ to
pick up the passengers and then fly to Singapore.
The approach at RCMQ was ILS 36 with very windy and gusty condition.
The captain was the PM of the occurrence flight.
The initial cruising altitude was FL380 and then climbed to FL400. There
was jet stream en route for about wind speed of 180 knots. The descent was fine,
the primary flight display (PFD) did not show any wind before the airplane
turning base. During final approach, the head wind was about 50 knots.
The flight crew obtained RCMQ METAR and ATIS L before the approach.
The approach briefing was conducted by the PF at 10 to 15 minutes before top of
descend. The Vref speed for the approach was 129 knots 14 . Due to the wind
conditions, approach speed was Vref + 5knots. The captain stated that he advised
the PF to keep more energy for windy conditions for landing.
About 500 feet 15 , the PF disconnected the autopilot. The approach was
normal until about 100 feet, the airplane dropped and banked to the left. The PF
pitched up further and the left landing gear touched the ground. The captain did
not hear anything abnormal that indicated the wings of the airplane touched the
ground.
When the airplane sank, the captain called out glide slope because the
airplane was below the glide path. The captain put his hands on the control but
did not give any input. When the airplane banked to the left, the captain helped
to bank the airplane to wings level by right bank control input. The captain stated
14
The Vref was 127 knots for the occurrence flight.
15
Appears to be referencing pressure altitude.
53
that he considered to go around at the time but it was too late.
The captain remembered that the PF increased the thrust during sinking, but
could not remember the pitch angle during flare. He did not look at the PFD
because he was looking outside at the time.
The captain felt the left main gear touch the ground, did not remember
feeling the right main gear touch the ground. It was a firm landing.
The captain thought the wingtips touched the runway surface because the
airplane was pitched up too much and banked at the same time during the landing
flare.
The maximum demonstrated crosswind for Global 6000 is 29 knots. The

company limit is 25 knots. By calculation, the max crosswind encountered during
approach was about 24 knots. It was within the limitation.
This was the first time the captain landed at RCMQ. The captain had flown
with the first officer 2 times in the past, one in May, one in the summer to Taipei
(RCTP). The captain stated that he always encouraged the first officer to fly the
airplane to gain experience.
The approach was stable all the way, following the glideslope, everything
was within limits, therefore the captain never thought about a go around. The PF
was doing OK so there was no reason to consider taking over the controls.
However, go around was still always an option for all flights.
The captain stated that if in the same weather conditions next time, he would
be the PF.
In the manual, there is information about how much pitch angle versus bank
angle are allowed during flare. The more pitch angle of the airplane, the less bank
angle is allowed.
54
The captain felt normal physically and mentally for the flight. Did not take
any medication before the flight.
The captain has never had an aviation incident before.

Crew was reporting for duty at RKSI at 0700 local time and takeoff at 0900.
First officer was the PF for the occurrence flight and everything was normal for
climb and cruise. The flight crew received RCMQ ATIS L indicated wind was
030 degrees at 28knots, gusting to 41knots, visibility more than 10 kilometers,
scatter or few cloud at 2,000 feet, altitude setting (QNH) was 1027. When
switched to the approach frequency, controller provided the QNH was 1020. The
PF conducted the approach briefing after obtaining the latest ATIS information.
The briefing included the approach routes and the weather conditions. The captain
advised the PF to keep speed a little bit higher, consider turning off the
autothrottle and fly manually if wind is gusty. The Vref was 127 knots for the
approach; the approach speed was Vref + 5 knots, 132 knots.
After crew inserted weather information into the flight management system
(FMS), it gave cross wind component 14 knots and the number was within aircraft
and first officer limit. The maximum demonstrated crosswind limit of Global
6000 is 29 knots; it was the same as the company limitations16. For the first officer
with experience less than 1 year on Global, the crosswind limitation was 15 knots.
The PF stated that the 1-year requirement for 15 knots crosswind limitation is not
relative to time in the company, but for time on the Global type. Since he has 3
years experiences on Global, he is not restricted by the 15 knots crosswind limit.
The PF stated that the wind gust was 40 knots and the crosswind component was
16
The company limitation was 25 knots.
55
20 knots, it was within the limitation. The approach was quite stable, he did not
consider the wind was challenging at that time.
At about 250 feet17, the autopilot was disengaged and the PF was flying
manually. Around 100 feet, wind became more gusty and the airplane sank below
the glide slope. The PF raised the nose of the airplane to get back to the glide path.
About a little bit below 30 feet, the left wing dropped to the left and the PF
gave full aileron input to the right. He expressed that it might be too late for the
correcting action. The PF felt the wing drop like the wind had just gone, like a
wind dip. The PF had full input on the control wheel but that just did not do
anything.
Before touchdown, the left wing was still low. The PF recalled that the left
main gear touched the ground first then the right main gear touched the runway.
During the flare, the captain had his hands on the control wheel to help on the
flight control. The PF cannot remember whether the PM made any call out during
that time. He did not feel the wing touch the ground. The damage on both wing
tips was discovered during post-landing walk around.
There was no windshear report from air traffic control (ATC). The wind
condition was updated by ATC at 1,000 feet and the number was similar to what
was in the ATIS. Auto call out for 100 feet and 50 feet were normal. The PF stated
that normally at 50 feet, the autothrottle will reduce the thrust to idle and the
airplane will pitch 1 degree up automatically. Around 30 feet, the pilot will pitch
up 0.5 degree and at 10 feet pitch up 0.5 degree for normal landing.
For the occurrence flight, the PF stated that the drift angle was about 7 to 8
degrees for the approach. At about 100 feet, because the airplane was below the
17
Appears to be referencing radio altitude. According to the FDR, the actual height above ground when the
autopilot was disengaged was 219 feet.
56
glide slope, PF pitched up about 1 degree. The PF stated that the pitch angle of
the occurrence flight below 30 feet was about 1 to 2 degrees higher than normal
flights.
Below 30 feet, when the left wing dropped, the PF put in the right aileron
input and gave the left rudder input at the same time. His focus was on the roll
control to level the wing. He thought that was the most important thing to do. The
PF did not add any thrust after the aircraft descended below 50 feet. He had not
considered a go around because the airplane was stable above 30 feet and
everything was happening too fast below 30 feet. He was focused on keeping
wings level, did not think about go around.
It was the first time that the PF had landed at RCMQ. The PF was a little bit
tired due to jet lag but he felt it did not affect his performance for the occurrence
flight. The PF had stayed home for 3 weeks before going on duty, he was happy
to go do the flight. He felt good physically and mentally for this flight. He did not
take any medication before the flight.
1.18.3 Sequence of Events
The sequence of events of the occurrence flight is listed in Table 1.18-1.
Table 1.18-1 Sequence of events

Taipei
Event Source
Time
0809 Takeoff from RKSI airport FDR
1006:31 CVR recording started CVR
The flight was during its descent toward waypoint ANPU, then FATAN
1007 -
with altitude around FL200. The crew received RCMQ ATIS information CVR
1021
Lima.
The captain advised the first officer to consider disconnect the autothrottle
1021 CVR
for final approach in gusty weather condition
1034:28 The captain advised the first officer “I will keep a little bit higher speed…” CVR
1034:54 Contacted RCMQ tower control, established ILS runway 36 approach CVR
RCMQ tower control provided wind 030 degrees at 27 knots gusty 41 knots
1035 CVR
for runway 36, clear to land
57
1036:08 Before landing checklist completed CVR
1036:59 PM called “one thousand passed and stabilized” CVR
1037:24 PM called “five hundred” CVR
1037:47 Auto callout “minimum minimum minimum” CVR
CVR,
1037:56 PF disconnected autopilot
FDR
1038:04 Auto altitude callout “one hundred” CVR
1038:05 PM advised “you are below glides”, PF responded “correct(ing)” CVR
1038:08 Auto altitude callout “fifty” CVR
1038:12 Auto altitude callout “thirty” CVR
1038:14 Auto altitude callout “ten” CVR
The occurrence aircraft touched down at the airspeed 113 knots, pitch
CVR,
1038:15 attitude 10.2 degrees up, roll attitude 5.8 degrees right, vertical acceleration
FDR
with 2.12g
CVR,
1038:17 Autothrottle disengaged, auto callout “autothrust”
FDR
1040:10 The occurrence aircraft vacated runway 36 FDR
58
Chapter 2 Analysis
2.1 General
The captain and the first officer of Elit’Avia Malta flight EAU52P were
properly certificated under Civil Aviation Agency of the Republic of Slovenia and
Civil Aviation Authority Netherlands respectively. No evidence indicated any
pre-existing medical conditions, fatigue, medication, or presence of other drugs
or alcohol that might have adversely affected the flight crew’s performance
during the occurrence flight.
The occurrence aircraft was properly certified, no reported technical issues

related to the flight controls system in accordance with the relevant technical
documents. The aircraft’s weight and balance were within the operational limits
for the duration of the occurrence flight.
Taiwan was affected by a strong cold high-pressure system around the time
of the occurrence flight. The weather conditions at RCMQ were reported good
visibility and strong gusty wind with significant crosswind for runway 36.
Windshear was not reported.
The analysis will focus primarily on the conduct of the flight in relation to
the wind conditions during the approach and landing, followed by an analysis of
the use of the autopilot and the autothrottle system by the flight crew.
2.2 Flight Operations
2.2.1 Approach and Landing
The CVR and interview records indicated that the flight crew completed the
approach briefing before the top of descent. At around 1020 hours, when the
aircraft altitude was FL200, the flight crew received ATIS information Lima,
which indicated the wind at RCMQ was from 030 degrees at 28 knots, gusting to
41 knots. The captain advised the first officer to consider disconnecting the
59
autothrottle for final approach in gusty weather conditions.
For the weight of the aircraft and a flap 30 landing, the Vref for the approach
was 127 knots. The flight crew added a 5 knots adder to the Vref speed for the
gusty wind conditions. The final approach speed was 132 knots.
2.2.1.1 The Final Approach
According to the CVR and FDR data, at 1036:08 hours, the aircraft
descended through 1,370 feet radio altitude on the ILS approach to RCMQ
runway 36 with flap 30 (slat 20), gear down and locked, airspeed was 135 knots,
with autopilot and autothrottle engaged. At 1036:58 hours, the aircraft descended
through 813 feet radio altitude, airspeed was 133 knots, the PM called “one
thousand passed and stabilized”. At 1037:40 hours, the PM called “approaching
minimum”, the PF responded “landing”. At 1037:46 hours, the aircraft radio
altitude was 302 feet, airspeed was 127 knots, the auto callout announced
“minimum minimum minimum”. The FDR parameters indicated that the
autopilot coupled ILS approach of the occurrence flight was a stable approach in
accordance with the company’s stabilized approach criteria.
At 1037:56 hours, the autopilot was disengaged by the PF at 219 feet radio
altitude, the autothrottle remained engaged. From this point on in the descent,
there was a significant clockwise shift in wind vector. The aircraft was manually
controlled by the PF, the airspeed varied between 127 knots and 133 knots, except
for 1 to 2 seconds when the airspeed dropped to a minimum of 121.25 knots due
to the gusty wind. The ground speed remained approximately constant between
85 knots to 89 knots. For further details, see table 2.2-1.
At 1038:08 hours, the aircraft was descending through 50 feet radio altitude,
airspeed was 137 knots, the auto callout announced “fifty” in the cockpit. One
second later, at 1038:09 hours, the autothrottle changed to “position throttle retard”
mode, the fan speed of both engines was reduced from around 62% N1 to in-
60
flight idle (around 34% N1) by the autothrottle system18. The indicated airspeed
started to decrease from 132.5 knots at 47 feet radio altitude to 123.75 knots at
34 feet radio altitude, and further decreased to 113 knots at 5 feet and touchdown.
During this time, the groundspeed went from approximately 90 knots to 87 knots;
the difference between the delta airspeed (19.5 knots) and the delta groundspeed
(3 knots) indicates a significant reduction in headwind. The vertical speed of the
aircraft increased from -248 ft/min at 47 feet radio altitude to the maximum
descent rate of -600 ft/min at 24 feet radio altitude; the aircraft touched down at
a vertical speed of -341 ft/min.
18
The engine N1 reduced from 62% at 50 feet to 42% at 24 feet, and to 34% at 5.6 feet, one second before
touchdown.
61
Table 2.2-1 Flight crew actions and aircraft state during the final approach
Radio Ground Vertical Pitch Roll Wind Wind

CVR Airspeed Angle
Time Altitude Speed Speed19 Angle Direction20 Speed
Transcript (kts)
(ft.) (kts) (ft/min) (deg) (deg) (deg) (kts)
1037:5621 219 132.25 87 2.46 1.49 8 27
1037:57 200 132.25 86 2.98 1.66 6 29
1037:57.4 PF : disconnect autopilot
1037:58 192 128.75 86 2.63 -0.17 13 29
1037:59 177 127 85 3.16 -2.72 18 27
1038:00 156 127 85 4.65 -1.58 23 25
1038:01 136 121.25 86 4.30 -2.28 28 22
1038:02 121 124.5 87 3.51 1.31 31 21
1038:03 106 130.5 87 5.27 0.26 34 19
1038:03.8 Auto callout : one hundred
1038:04 91 128 87 7.38 -2.8 28 19
1038:05 69 122.25 87 7.03 -0.08 24 20
1038:05.4 PM : you are below glides
1038:06 63 133.5 89 4.57 -3.77 26 21
19
Derived from FDR radio height parameter.
20
AWOS S wind direction and speed.
21
Autopilot disengaged by the PF.
62
Radio Ground Vertical Pitch Roll Wind Wind
CVR Airspeed Angle
Time Altitude Speed Speed19 Angle Direction20 Speed
Transcript (kts)
(ft.) (kts) (ft/min) (deg) (deg) (deg) (kts)
1038:07 57 131 89 5.27 -3.25 30 20
1038:07.0 PF : correct(ing)
1038:08 51 137 90 -319 5.36 0.52 40 17
1038:08.2 Auto callout : fifty
1038:09 47 132.5 90 -248 4.48 2.54 45 16
1038:10 42 131.25 90 -368 4.48 4.48 47 17
1038:11 34 123.75 89 -503 5.00 2.46 44 18
1038:12 24 125.5 89 -600 6.15 1.84 41 20
1038:12.0 Auto callout : thirty
1038:13 15 120.25 88 -559 6.24 -1.58 42 21
1038:14 5.6 113 87 -525 8.08 0.96 42 23
1038:14.2 Auto callout : ten
1038:15 -2.5 113 87 -341 9.84 5.88 38 24
1038:15.0 Sound similar to landing gear touchdown
1038:16 -0.5 112.75 86 124 8.26 -9.40 33 24
1038:16.8 Auto callout : autothrust
1038:17 -1.9 114 85 -26 4.47 2.10 36 25
63
2.2.1.2 The Landing
When the aircraft reached the flare altitude of 30 feet, the pitch up control
column input by the PF resulted in an increase of the pitch angle of the aircraft
from about 5 degrees nose up to 10 degrees nose up at touchdown. The flight
crew recalled experiencing a wing dip to the left when the aircraft altitude was
below 30 feet. The PF stated that he gave full aileron input to the right when the
aircraft rolled to the left. The PM stated that he helped to bank the aircraft to
wings level by right bank control input.
Just before touchdown, the flight crew attempted to compensate the

disturbances in the roll and pitch of the aircraft induced by the gusty wind
conditions, using significant control inputs. These conditions and the limited time
available before landing after autopilot disengagement made it difficult to
maintain the required wings level attitude of the aircraft. The numbers in table
2.2-2 indicate that two seconds before the aircraft touched down on the runway,
the flight crew reacted with a significant and rapid control wheel input to
counteract the left wing drop. The right wing down control input resulted in a
maximum of 6.76 degrees RWD roll angle and a 9.31 degrees nose up pitch
attitude at 0 feet radio altitude. The aircraft touched down hard on the right main
landing gear in a right rolling motion. The right wing tip of the aircraft probably
contacted the runway surface at this time. After the right main gear touched the
ground and bounced, followed by the left wing down control input by the PF in
an attempt to stop the right roll motion, the aircraft rolled to the left. The aircraft
reached a maximum roll angle of 9.4 degrees LWD and the right main gear
transitioned back to “air” mode. With the pitch attitude at 8.26 degrees, the left
wing tip of the aircraft contacted the runway surface.
At touchdown, a peak normal acceleration of +2.12g and a peak lateral

acceleration of +0.26g were recorded.
64
Table 2.2-2 Flight crew actions and aircraft state during the landing
PF Control PM Control
Radio Pitch Angle Roll Angle Gear (L) on Gear (R) on
Time Wheel FTU22 Wheel FTU
Altitude (ft.) (deg) (deg)24 Ground Ground
(lbs)23 (lbs)
1038:12 24 -29.25 -2 6.15 1.84 Air Air
1038:12.25 22.37 -0.75 4.75 5.97 0.87 Air Air
1038:12.50 19.25 19.75 2 6.06 -0.08 Air Air
1038:12.75 17.5 27.25 -2.25 6.06 -1.23 Air Air
1038:13 15.12 33 1.5 6.24 -1.58 Air Air
1038:13.25 13.25 32.25 -6.25 6.76 -2.10 Air Air
1038:13.50 9.62 20 -27.5 7.11 -2.10 Air Air
1038:13.75 7.87 -17.75 -40.75 7.73 -0.70 Air Air
1038:14 5.62 -9 -13 8.08 0.96 Air Air
1038:14.25 4 -12.75 18 8.52 3.69 Air Air
1038:14.50 1.25 -21 14.25 8.78 5.27 Air Air
1038:14.75 0 -25 14.5 9.31 6.76 Air Air
1038:15 -2.5 -66.25 -5.5 9.84 5.88 Air Air
1038:15.25 -3.75 0.75 20.25 10.19 -0.87 Air Air
22
Force transducer unit.
23
Negative value: left wing down control input. Positive value: right wing down control input.
24
Negative value: left wing down. Positive value: right wing down.
65
PF Control PM Control
Radio Pitch Angle Roll Angle Gear (L) on Gear (R) on
Time Wheel FTU22 Wheel FTU
Altitude (ft.) (deg) (deg)24 Ground Ground
(lbs)23 (lbs)
1038:15.50 -3.25 12 -34.5 9.93 -5.53 Air Ground
1038:15.75 -2.37 11.75 -65 8.96 -9.31 Ground Ground
1038:16 -0.5 56 -75.75 8.26 -9.40 Ground Ground
1038:16.25 -0.37 92 -35 7.20 -6.15 Ground Air
1038:16.50 -1 71.75 9 6.50 -2.19 Ground Air
1038:16.75 -1.75 6.75 -3.25 5.36 2.54 Ground Air
1038:17 -1.87 2.75 16.75 4.74 2.10 Ground Ground
66
2.2.1.3 Use of Autopilot and Autothrottle
The CVR and FDR data indicated that the autopilot was disengaged by the
PF at 219 feet radio altitude. The autothrottle remained engaged for the approach
and landing and was disengaged25 2 seconds after the aircraft touched down on
runway 36.
According to the operator’s OM-A, see 1.18.1.3, except for autoland

operations, the autopilot should be disengaged for operations below MDA. In
addition, when the reported crosswind exceeds 15 knots, the autopilot should be
disengaged when the aircraft descends through 500 feet radio altitude. The
reported crosswind components for RCMQ runway 36 for the occurrence flight
was 14 knots steady wind gusting to 20.5 knots. Therefore, the autopilot should
have been disengaged at either 500 feet radio altitude or no lower than the MDA
for the occurrence flight.
There was no windshear reported for the approach of the occurrence flight.
However, the existing wind conditions may have included small-scale up drafts
and/or downdrafts, and local vortices close to the ground. Although use of the
autoflight system has the advantage of an accurately flown flightpath at a selected
speed and will reduce the workload of the pilots, it is essential to disconnect the
autopilot at an altitude that allows the pilot to have ample time to adapt to the
highly dynamic situations during landing. The autopilot was disengaged at 219
feet radio altitude. The PF had only 16 seconds to transition from automatic flight
to manual flight before the aircraft reached 30 feet, where the PF started the
landing flare for touchdown, which may have given the PF, especially in strong
gusting wind conditions, insufficient time to gain complete control of the aircraft,
and could have contributed to an over-controlled hard landing.
25
According to the FCOM, the autothrottle will disengage automatically on landing (weight on wheels).
67
In addition, according to the operator’s OM-A, the autothrottle should be
disengaged during manual flight. When the PF disengaged the autopilot, the
autothrottle was not disengaged. The autothrottle of the aircraft remained in
control of the thrust for the approach, flare, and landing. In accordance with the
FCOM, the autothrottle retard mode activates when the aircraft is in a landing
configuration and a radio altitude of 50 feet is reached. The retard mode
commands both thrust levers to automatically retard to idle at a fixed rate during
the landing flare. The FDR data indicated that the throttle lever positions for both
engines were reduced from about 10 degrees to 1.5 degrees at the aircraft radio
altitude reached 50 feet. A 20 knots decrease in airspeed occurred from 50 feet to
touchdown, an excessive decrease as compared to a normal landing where a
decrease of only 4 to 5 knots in the flare would be expected. Although the
reduction in thrust and pitch up control input commanded by the PF contributed
to this loss of airspeed, the majority of the decrease was most likely due to a rapid
headwind reduction that was not compensated for by increasing thrust. Although
the aircraft was still fully controllable, the aerodynamic effect of rudder and
aileron was diminished during the rapid deceleration and made the flight control
tasks more demanding.
The above analysis indicates that the combination of the strong and gusty
wind conditions, insufficient time to gain complete control of the aircraft due to
late disconnection of the autopilot, the rapid decrease of the airspeed due to a
rapid headwind reduction that was not compensated for by increasing thrust and
the increased pitch angle by the pitch up control demand of the PF, and the
significant and rapid control input of the flight crew during flare to compensate
for the disturbance of roll and pitch by the gusty wind, resulted in a wingtips
abnormal runway contact landing occurrence.
68
2.2.2 Final Approach Speed
Interview records indicated that the Vref speed of the occurrence aircraft for
the approach was 127 knots. The flight crew added a 5 knots adder to the Vref to
compensate for the gusty wind conditions. The final approach speed was 132
knots.
According to the operator’s FCOM and OM-B, see 1.18.1.5, the Vref speed
adder should be used for approach and landing when turbulence or gusty wind
conditions are anticipated during the approach and landing. It is recommended to
add half of the gust, to a maximum of 10 knots to the Vref for the final approach
speed.
Final Approach Speed = Vref + 1/2 gust (max. Vref + 10 knots)
However, the Vref speed adder recommended in the OM-A was to add half
of the steady wind and full gust, to a maximum of 20 knots.
Final Approach Speed = Vref + 1/2 steady wind + full gust (max. Vref + 20
knots)
For the occurrence flight, the reported wind was 030 degrees at 28 knots,
gusting to 41 knots. The final approach speed could be 133.5 knots in accordance
with the recommended adder in FCOM or OM-B, or 147 knots in accordance
with the OM-A. The difference between the Vref speed adders recommended in
different manuals may create confusion and adversely affect the standardization
of flight operations during approach and landing in strong and gusty wind
conditions.
2.2.3 Pilot Flying Duty Assignment
According to the operator’s OM-A, see 1.18.1.1, the commander of the flight
decides who will be PF and PM after taking into account the first officer’s
experience and operational conditions. When the first officer has less than one
69
year experience on the aircraft type and the crosswind component exceeds 15
knots or the crosswind component is close to the maximum authorized regardless
of first officer’s experience, the captain should act as PF.
The occurrence first officer had three years BD-700 flight experience. The
reported crosswind component during approach for the occurrence flight was 14
knots steady wind gusting to 20.5 knots. Therefore, the first officer was qualified
to be assigned as the PF for the flight. However, it is noteworthy that the PF did
not take the captain’s advice to disengage the autothrottle and keep the airspeed
higher to compensate for the strong and gusty wind conditions. In addition, the
PF reacted with too much control on the roll and pitch of the aircraft to recover
from the wing drop during the flare. The operational conditions of the occurrence
flight during final approach and landing appeared to be challenging considering
the PF’s flight experience.
After the occurrence, the operator issued a temporary revision of PF’s

requirement for wind conditions. When the total steady crosswind is 20 knots or
more (15 knots for first officer under one year experience) and/or the gust
component is 10 knots or more, the captain should act as PF.
70
Chapter 3 Conclusions
In this Chapter, the Taiwan Transportation Safety Board presents the findings
derived from the information gathered during the investigation and the analysis
of the occurrence. The findings are presented in three categories: findings related
to probable causes, findings related to risk, and other findings.
The findings related to probable causes identify elements that have been
shown to be directly causal to the occurrence, or almost certainly contributed to
the occurrence. These findings are associated with unsafe acts, unsafe conditions,
or safety deficiencies associated with safety significant events that played a major
role in the circumstances leading to the occurrence.
The findings related to risk identify elements of risk that have the potential
to degrade aviation safety. Some of the findings in this category identify unsafe
acts, unsafe conditions, and safety deficiencies including organizational and
systemic risks, that made this occurrence more likely; however, they cannot be
clearly shown to have operated in the occurrence alone. Furthermore, some of the
findings in this category identify risks that are unlikely to be related to the
occurrence but, nonetheless, were safety deficiencies that may warrant future
safety actions.
Other findings identify elements that have the potential to enhance aviation
safety, resolve a controversial issue, or clarify an ambiguity point which remains
to be resolved. Some of these findings are of general interests that are often
included in the ICAO format accident reports for informational, safety awareness,
education, and improvement purposes.
3.1 Findings Related to Probable Causes
1. Taichung International Airport was affected by a strong cold high-pressure

weather system at the time of the occurrence. The meteorological conditions
71
were reported to be good visibility and strong gusty wind with significant
crosswind for runway 36. (1.7, 2.1)
2. Two seconds before the aircraft touched down on the runway, the flight crew
reacted with a significant and rapid control wheel input to compensate for the
disturbances in the roll and pitch of the aircraft caused by the gusty wind
conditions. The right wing down control input resulted in a maximum of 6.76
degrees right wing down roll angle and a 9.31 degrees nose up pitch attitude
at 0 feet radio altitude. The aircraft touched down hard on the right main
landing gear in a right rolling motion. The right wing tip of the aircraft
probably contacted the runway surface at this time. (1.11.2, 2.2.1.2)
3. After the right main gear touched the ground and bounced, followed by the
left wing down control input by the pilot flying in an attempt to stop the right
roll motion, the aircraft rolled to the left. The aircraft reached a maximum
roll angle of 9.4 degrees left wing down. With the pitch attitude at 8.26
degrees, the left wing tip of the aircraft contacted the runway surface. (1.11.2,
2.2.1.2)
4. The combination of the strong and gusty wind conditions, insufficient time
to gain complete control of the aircraft due to late disconnection of the
autopilot, the rapid decrease of the airspeed due to a rapid headwind
reduction that was not compensated for by increasing thrust and the increased
pitch angle by the pitch up control demand of the pilot flying, and the
significant and rapid control input of the flight crew during flare to
compensate the disturbance of roll and pitch by the gusty wind, resulted in a
wingtips abnormal runway contact landing occurrence. (1.7, 1.11, 1.12,
2.2.1.1, 2.2.1.2)
3.2 Findings Related to Risk
1. The autopilot was disengaged at 219 feet radio altitude. The pilot flying (PF)
72
had only 16 seconds to transit from automatic flight to manual flight before
the aircraft reached 30 feet and the PF started the landing flare for touchdown,
which gave the PF insufficient time to gain complete control of the aircraft
before landing in the strong and gusty wind conditions. (1.11.2, 2.2.1.1)
2. The difference between the Vref speed adders recommended in different

manuals may create confusion and adversely affect the standardization of
flight operations during approach and landing in strong and gusty wind
conditions. (1.18.1.5, 2.2.2)
3.3 Other Findings
1. The flight crew were properly certificated and qualified in accordance with
the related regulations and requirements. No evidence indicated any pre-
existing medical conditions, fatigue, medication, or presence of other drugs
or alcohol that might have adversely affected the flight crew’s performance
during the occurrence flight. (1.5, 2.1)
2. The occurrence aircraft was properly certified, with no reported technical

issues related to the flight controls system in accordance with the relevant
technical documents. (1.6.2, 2.1)
3. The aircraft’s weight and balance were within the operational limits for the
duration of the occurrence flight. (1.6.3, 2.1)
4. The flight data recorder (FDR) parameters indicated that the autopilot
coupled instrument landing system (ILS) approach of the occurrence flight
was a stable approach in accordance with the company’s stabilized approach
criteria. (1.11.2, 2.2.1.1)
73
Chapter 4 Safety Recommendations
4.1 Recommendations
There is no safety recommendation in this report. The safety actions of

Elit’Avia Malta and Bombardier are presented in 4.2.
4.2 Safety Actions
Elit’Avia Malta and Bombardier provided the safety actions accomplished

or being accomplished after the EAU52P occurrence. Those actions are presented
as follows:
4.2.1 Elit’Avia Malta
4.2.1.1 Corrective Actions
Immediate - complete
1. Notice to crew (NTC) issued – crew to review Bombardier crosswind landing

e-learning module;
2. Flight simulation training devices (FSTD) – satisfactorily completed for

subject crew;
3. OM-A / B temporary revision (TR) and amendment with clarification of:
 Nomination of the first officer as PF;
 Advice with regards to use of Vref + 10 in strong / gusty winds.
Follow Up – in progress
1. Request with flight data monitoring program (FDMP) provider re event: Roll
angle below 7 ft RA. Currently event roll angle below 20 ft RA;
2. FDM active monitoring of pitch and roll angles on landing;
3. Discussion with Bombardier company pilot – issue of Vref+10 limit as Vapp
74
raised26;
4. Consider advice / training on:
 use of auto thrust. Practice auto thrust override in the flare;
 use of manual thrust – FSTD / aircraft practice.
5. Consider pilot monitoring function below 100ft:
 Call outs / speed trend vector;
 Bank / Pitch callouts;
 Go-Around.
4.2.1.2 Preventative Action

Crew education and training
1. in landing in strong winds and strong crosswinds and effects of gust variation.
2. the role of the pilot monitoring in the last 100 ft of the approach should be
examined.
Use of autopilot in strong and gusty wind conditions
The autopilot and autothrottle reduce pilot workload thereby increasing the
monitoring capacity for the PF as well as the PM. However, the downside is that
late disconnection of the autopilot and / or the autothrottle creates a ‘window of
disconnect’ – it takes a finite time for a pilot to ‘get in sync’ with the aircraft in
the transition from auto to manual control. In this incident autopilot disconnect to
26
According to Bombardier, the "maximum of 10 KIAS" was removed in the May 2021 revision of the FCOM.
The revised guidance (Global 6000 FCOM vol.1, rev. 38, page 10-01-113) now states the following: "(2) SPEED
ADDER FOR APPROACH AND LANDING IN GUSTY WIND CONDITIONS The VREF speed adder should be
used for approach and landing when turbulence or gusty wind conditions are anticipated during the approach
and landing. When gusty conditions are reported, it is recommended to add half of the gust, (e.g. for winds of 15
kts gusting to 40 kts, half of the 25 kt gust is 12.5 kts, so in this case the correction applied to VREF is 13 KIAS.)"
75
landing was 16 seconds and disconnect occurred just before the most critical
phase of flight.
It is therefore recommended that in conditions of strong and gusty wind

conditions autopilot disconnection is effected no later than 500 ft RA to allow a
period of familiarization and synchronization in manual aircraft control before
reaching the flare.
Use of autothrottle system be considered
The autothrottle system is certified for use during the landing phase. In this
incident the autothrottle system performed in accordance with its design
philosophy. Thrust had increased from a nominal approach thrust setting of 55%
NI to 62 % NI when the speed reduced to Vref and slightly below just above 50
ft RA.
However at 50 ft RA the autothrottle mode changes from speed to landing

flare and thrust is progressively reduced to idle thrust for landing irrespective of
airspeed and airspeed trend vector. This is not a criticism but a fact and is not
challenged in this report.
Crew need to be aware of this design philosophy and need to be trained in

options to intervene in the situation that the crew found themselves in during this
incident.
The crew reported ‘sink’ below 100 ft RA which is confirmed by flight data.
To counteract the sink, (increased rate of descent) given that the speed was correct
required:
a. Pitch attitude nose up change to increase lift;
b. Thrust increase to counteract increased lift dependent drag and also contribute
to total lift due vertical component of thrust. This action was achieved by the
autothrottle between 100 ft and 50 ft RA prior to retard mode.
76
At 50 ft RA the autothrottle entered the retard mode and thrust was correctly
commanded to idle by the autothrottle system. Speed was correct at 136 kts at
this point. By 30ft RA speed had decreased to Vref -3 kts decreasing to Vref - 15
kts on landing and thrust was therefore required to stabilize speed and rate of
descent. The PF had three options at this late stage:
c. Move thrust levers with autothrottle engaged, or
d. Disconnect the autothrottle system and control thrust manually, or
e. Go-Around.
Given that time is critical in this situation, and increase of thrust is the
required operational solution, it is considered that movement / override of thrust
levers to command more thrust is the preferred option. This option and skill
requires briefing and training in the FSTD.
An alternative option is to manually control thrust and disconnect the auto

thrust system in strong and gusty wind conditions. This requires training and
regular practice.
Finally, a Go-Around in the flare is always an option and should also be

practiced in the FSTD.
Options discussed introduce increased risk and should be risk assessed by

Flight Operations and Crew Training managers.
Flight Data Monitoring
The Safety Manager of the occurrence operator believes that FDMP is second
only to training standards, self discipline and professional standards in applied
aircraft operational safety.
The Elit’Avia G6000 Fleet is enrolled into the FDMP.
77
There is a direct correlation between pitch angle and roll angle with regards
to risk of wing ground contact on landing. The following schematic is provided
by Bombardier and is part of the e-learning module with regards to crosswind
landings.
The FDM relevant events available and monitored prior to the occurrence are:
e. Pitch angle 50 ft to touchdown: Event Code LPA002 with Level 1 set at 7 deg
NU, Level 2 set at 8 deg NU and Level 3 at 9 deg NU.
78
f. Roll angle 20 ft to touchdown: Event Code LRA002 with Level 1 set at 6 deg
roll, Level 2 at 7 deg roll and Level 3 at 8 deg roll.
The FDMP provider has been requested to introduce an additional event for
roll below 10 ft RA to monitor roll angle close to the ground set at:
Level 1: Roll +/- of 3 deg or more
Level 2 Roll of +/- 4 deg or more
Level 3 Roll of +/- 5 deg or more
In the longer term an event that monitors Pitch / Roll combination at

touchdown has been requested.
79
Finally, airspeed at touchdown is monitored by Event LSA 202. The trigger
parameters and data spread is shown in schematic below:
It is proposed that the LSA202 parameters be changed to reflect that airspeed

on landing is approximately 5% less than Vapp / Vref. The proposed Event
Parameters:
Level 1 < Vref - 5 kts, Level 2 < Vref – 7 kts and Level 3 < Vref – 10 kts
4.2.2 Bombardier
Bombardier has implemented the following safety actions:
1. Introduction of a new chapter in the Global 6000 FCOM called ROPAT

(recommended operational procedures and techniques). The purpose of the
ROPAT is to provide recommendations and procedural guidance for
operation of the Global 6000 airplane. The guidance presented is intended to
facilitate safe and efficient operation of the Global 6000. The material in the
ROPAT is not intended to be used as standard operation procedures (SOP),
but may be used to facilitate the development of SOPs. With the introduction
of the ROPAT, the FCOM can be used as a single reference manual for both
training and operations. In particular, the ROPAT expands on the guidance
available to the flight crew for wingtip strike avoidance. The ROPAT was
80
introduced in November 2020 and therefore would most likely not yet have
been reviewed by the occurrence flight crew.
2. The free on-line crosswind operations training module, originally developed

by Bombardier Training Services but now hosted by CAE, was repatriated to
Bombardier's customer website in March 2021, in order to facilitate access
for all Global customers. An Advisory Wire (AW700-00-0479 Rev 2) was
issued on March 29th, 2021, instructing customers on how to access the
repatriated training module. The AW states that the training module, " [...]
discusses takeoff techniques, and approach and landing considerations. For
landing, the geometry of the Global wing and the decreasing margin between
wing and runway on flare and touchdown with the interrelationship of bank
and pitch angle is presented in detail. The recommended technique can be
summarized here as 'crab to flare, rudder to straighten and ailerons to keep
wings level.' Other considerations are presented to provide an excellent
opportunity for discussion by flight crews." and highly recommends that all
Global series pilots review the material as well as their standard operations
procedures.
3. The on-line training module was further improved and updated. The updated
version was made available on Bombardier's customer website in June 2021.
In addition to the above, Bombardier is working on the following:
4. Bombardier has requested that crosswind landing and wingtip strike

avoidance be added as a training area of special emphasis in Transport
Canada's Operational Evaluation Board (OEB) Report, the FAA's Flight
Standardization Board (FSB) report, and EASA's Operational Suitability
Data (OSD) for the aircraft type.
5. Bombardier is working on adding expanded guidance to the ROPAT with
81
regards to the following aspects of landings in crosswinds with strong gusty
or turbulent conditions: the use of automation, thrust management in the final
phase of the approach and landing, and the go-around decision.
6. Bombardier is working on expanding the on-line training module to include

recommended guidance on division of Pilot Flying and Pilot Monitoring
responsibilities.
7. Bombardier will recommend that training providers review and update

crosswind landing training and, where necessary, include gusty or turbulent
conditions within the maximum crosswind landing event, with additional
emphasis on the following aspects: applying correct Vref adders, use of
automation, Pilot Flying and Pilot Monitoring responsibilities during the
approach and landing phase, speed and thrust management in the flare, and
the go-around decision.
82

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30 December 2020

Elit’Avia Malta Limited Flight EAU52P

Transportation Occurrences Investigation Act of the Republic of

The objective of the TTSB‘s investigation of transportation occurrence is to

ICAO Annex 13, Chapter 3, Section 3.1:

The sole objective of the investigation of an accident or incident shall be the

On 30 December 2020, a Bombardier BD-700-1A10 (Global 6000) aircraft,

According to the Transportation Occurrence Investigation Act of the

The ‘Final Draft Report’ of the occurrence investigation was completed in

Findings as the result of this investigation

1. Taichung International Airport was affected by a strong cold high-pressure

2. The difference between the Vref speed adders recommended in different

2. The occurrence aircraft was properly certified, with no reported technical

Executive Summary .......................................................................................................... i

Chapter 2 Analysis ......................................................................................................... 59

Table 1.5-1 Flight crew basic information ......................................................................... 7

Figure 1.6-1 BD-700 CG envelope .................................................................................. 11

ACAS airborne collision avoidance system

On 30 December 2020, a Bombardier BD-700-1A10 (Global 6000) aircraft,

During post-landing walk-around, the flight crew discovered damage on

No injuries to the persons on board.

1.3 Damage to Aircraft

1.4 Other Damage

1.5 Personnel Information

1.5.1 Flight Crew

The captain was a Republic of Slovenia national. He joined Elit'Avia Malta

The captain completed a one-day annual recurrent ground school training on

1.5.1.2 First Officer

Basic information of the occurrence flight crew is in Table 1.5-1.

Item Captain First Officer

28 December 2020 Slovenia time (UTC+1)

1300L departed from home

1445L positioning flight from Slovenia to Frankfurt as a passenger

1805L positioning flight from Frankfurt to Seoul as a passenger

29 December 2020 Seoul time (UTC+9)

1200L landed at Seoul

1315L checked in to Seoul Incheon airport transit hotel

2100L went to bed

30 December 2020 Seoul time (UTC+9)

0700L checked out from hotel

0853L departed RKSI on the occurrence flight as the captain

1.5.2.2 First Officer

28 December 2020 Netherlands time (UTC+1)

1800L departed from home to airport

29 December 2020 Seoul time (UTC+9)

1600L landed at Seoul

2230L went to bed at the transit hotel

30 December 2020 Seoul time (UTC+9)

0100L awakened, stayed in bed slept/snoozed on and off until 0600L6

0700L checked out from hotel

0853L departed RKSI on the occurrence flight as the first officer

1.6 Aircraft Information

1.6.1 Aircraft and Engine Basic Information

Table 1.6-1 Aircraft basic information

Aircraft basic information (statistics date: 30 December 2020)

Table 1.6-2 Engine basic information

Engine basic information

Number/position No. 1/ Left No. 2/ Right

1.6.2 Aircraft Maintenance Information

A review of the last 3 months maintenance records, found no reported