Incident Overview

Date: Saturday 1 September 2018
Aircraft Type: Boeing 737-8AS (WL)
Owner/operator: Utair
Registration Number: VQ-BJI
Location: Adler/Sochi Airport (AER) – ÿ Russia
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 0 / Occupants: 172
Investigating Agency: MAKMAK
Category: Accident
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Description

Utair flight 579, a Boeing 737-800, suffered a runway excursion accident after landing at Adler/Sochi Airport, Russia. The aircraft departed Moscow’s Vnukovo Airport at 00:32 hours local time on a domestic flight to Sochi. The first officer acted as the pilot flying (PF). Weather at Sochi was poor due to the presence of a thunderstorm in the area. After descending to FL90, the pilot contacted Sochi Radar, waited for the weather that met his minimum and was cleared for landing on runway 06. At 02:44:11, when the aircraft was at 850 ft (about 260 m) and at distance of 5000 m from the threshold, the Predictive Windshear System Warning sounded: “Go around. Windshear ahead”. The crew ignored the wind shear warnings and continued to descend along the glide path. Upon passing the Decision Height of 627 ft (190 m), the PF did not verbalize a decision to continue or go around. The aircraft continued to descend. At 02:45:09, at the altitude of about 170 ft (50 m) and at distance of 850 m from the runway threshold, the “Windshear, Windshear, Windshear” alert sounded in the cockpit. At an altitude of about 30 m visibility decreased because of heavy showers. The captain took over the controls and performed a go-around. The workload increased and the first officer forgot to raise the flaps from position 1 to fully up, despite stating this to the captain. Half a minute later he realised his mistake and proceeded to raise the flaps. While complaining about the weather, the crew encountered difficulties in engaging the autopilot but eventually succeeded. Starting 02:49 the aircraft was hastily prepared for the second approach. The captain was now acting as PF for the approach. This time the aircraft was high and fast. At 02:53:49, the controller informed the flight that a preceding aircraft had gone around. The first officer than contact the Tower controller and reported intercepting the glide slope at 600 m, despite the fact that the aircraft had not reached that altitude yet. Sochi Tower cleared the flight for the approach. At 02:54:48, the flight was cleared to land on runway 06. At height of 1050 ft (320 m) at a distance of 6100 m from the runway, the aural warning: “Go around. Windshear ahead” sounded, but the approach was continued. The flight crew failed to verbally confirm that the approach was stabilized, with the captain simply stating: “…to minimum.” In fact the approach was not stabilized given the variation in airspeed. The first officer called out speeds and altitudes continuously in a rather tense voice. During the approach the autopilot and autothrust were engaged. At 02:56:42, at height of about 470 ft (145 m) and distance of 2650 m to the runway, the chime sound and three-time aural warning “Windshear, Windshear, Windshear” sounded. However, the crew, in spite of these warnings, continued to descend. At 02:57:13, at height of 75 ft (25 m) and distance of 150 m to the threshold, the captain had disengaged the autopilot and autothrottle, and took manual control. At this time, the aircraft was in the center of the wind shear. Exactly before that, the autothrottle started to reduce the engine rotation speed as the instrument speed to this moment had reached the value of 170 kts. When the autothrottle was disengaged, the throttles remained in this setting. It resulted in the instrument speed increase up to 173 kts. The aircraft passed over the threshold at height of about 54 ft (15 m) and touched down about 1285 m from the threshold at an instrument speed of 160 kts. Right after the aircraft had landed the spoilers were extended automatically and autobrake was initiated. The first officer reported “Speedbrake up, Reversers maximum”, but the reversers were not yet engaged. The captain noticed this 20 seconds after touchdown and immediately ordered them to be deployed. The engines however were already at ground idle, and when the engines reached maximum reverse mode the aircraft had already overrun the runway. At 02:57:54, 26 seconds after touchdown, the aircraft overran the runway with a ground speed of about 75 kts, broke through the aerodrome fencing and came to rest on a dry and rocky surface in a river bed. Eighteen passengers were injured. The aircraft sustained serious damage. The aircraft overrun, destroying and damage by fire were caused by the following factors: – repeated disregarding of the windshear warnings which when entered a horizontal windshear (changing from the head wind to tail one) at low altitude resulted in landing at distance of 1285 m from the RWY threshold (overrunning the landing zone by 385 m) with the increased IAS and tail wind; – landing to the runway, when its normative friction coefficient was less than 0.3 that according to the regulations in force, did not allow to land. The factors contributed the accident: – the crew violation of the AFM and Operator’s OM requirements in regards to the actions required a forecasted or actual wind shear warning; – use of the automatic flight mode (autopilot, autothrottle) in the flight under the windshear conditions which resulted in the aircraft being unstable (excess thrust) when turning to the manual control; – lack of prevention measures taken by the Operator when the previous cases of poor crew response to windshear warning were found; – insufficient crew training in regards to CRM and TEM that did not allow to identify committed mistakes and/or violations in good time; – the crew members’ high psychoemotional state caused by inconsistency between the actual landing conditions and the received training as well as the psychological limit which was determined by the individual psychological constitution of each member; – insufficient braking both in auto and manual mode during the aircraft rollout caused by the insufficient tyre-to-ground friction aiming to achieve the specified rate of braking. Most probably the insufficient tyre-to-ground friction was caused by the significant amount of water on the RWY surface; – the aerodrome services’ noncompliance of Sochi International Aerodrome Manual requirements related to the RWY after heavy showers inspection which resulted in the crew provision of wrong normative friction coefficients. In obtaining of the increased overrun speed of about 75 kt (140 km/h) the later setting of engines into reverse mode was contributed (the engines were set into reverse mode 16 s later than the aircraft landed at distance of about about 200 m from the runway end)

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