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17 Feb 2017 - On 17 February 2017, Boeing 737-524, VP-BVS, operated by Vim Airlines of Russia was taking off from Runway 18 at Riga International Airport deviated sharply to the right, traveled along the grass to the side of the runway for approximately 600m and collided with the RVR installation and power boxes before regaining the runway, therefore both engines were full of mud, dirt and grass.

EVRA 170950Z 23007KT 210V270 8000 -RA OVC004 03/03 Q1011 R18/290195 NOSIG

The Latvian TAAIB published their final report here
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*** Updated 20 Nov 2018 ***

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VP-BVS Vim Airlines 737-500 RTO and runway excursion

VP-BVS on soft ground (Photo Aleksandrs Cubikins)

Findings

  • The engine thrust on the both engines was stabilized before the Take-Off/Go-Around (TO/GA) button was pressed.
  • At the initial stage of the aircraft takeoff the flight crew attention was focusing on the aligning of the aircraft to the runway centerline.
  • The FO (Pilot Monitoring) hadn't monitored the engine parameters during of takeoff roll and didn’t announce timely when the difference of engines’ thrust increased.
  • After the TO/GA had been engaged, the thrust levers (TLA) had moved not synchronically within 2.5 seconds.
  • The aircraft engines’ thrust difference during the early stages of the takeoff roll initiated the torque about the aircraft’s normal axis that led to the loss of directional control.
  • The nose wheel steering had been turned to the left with full left rudder pedal and was not released before thrust increased.
  • The rejected takeoff (RTO) wasn’t initiated with the application of maximum wheel braking.
  • The nose wheel steering below Vmcg was ineffective; the asymmetric thrust of the led to the nose wheel skidding.
  • The pilot (PIC) didn’t attempt to stop the aircraft and continued the moving after run off the runway without regard to Flight Operation Manual requirements.
  • The aircraft flight crew didn't accomplish the Non-standard Operational Procedures requirements in the runway excursion.
  • The aircraft flight crew didn’t inform the airport Riga Maintenance Company about the similar problem with the aircraft in the previous flight.

Proximate Cause

The flight crew operation was not coordinated in accordance with the take-off procedure.

Root Cause

  • The FO (copilot) didn’t act upon the aircraft Flight Manual requirements in the takeoff procedure.
  • Insufficient training skills of the flight crew in the Standard Operational Procedures.
  • The flight crew didn’t report of any technical failures in the previous flight.

Contributing causes

  • Short-term technical failure of the thrust control system.
  • The rejected takeoff (RTO) procedure wasn’t initiated immediately after the technical abnormality.
  • Erroneous decision to continue the moving after the run off from the runway surface.

Primary cause

Human Factor in an abnormal flight situation.

SAFETY RECOMENDATIONS

The Transport Accident and Incident Investigation Bureau (TAIIB) following Safety Recommendations were addressed to the Federal Air Transport Agency (Rosaviatsia):

Recommendation – LV 2018-001 Due to the flight crew operations and disagreements in the Takeoff Procedure according with the Flight Crew Manual, the TAIIB recommended to Rosavacia to consider the necessity to make possible some amendments in the Pilot Training programs for recurrent and the induction training included briefing and assessment on the correct procedure for start of the takeoff roll, including the runway alignment prior to thrust application, the engine stabilization with symmetrical thrust after thrust levers to takeoff thrust (to switch TO/GA) and the use of the nose-wheel steering wheel during the takeoff.

Recommendation LV 2018-002 Due to the flight crew’s erroneous actions in a non-standard situation (Runway excursion), TAIIB recommended to the Rosaviatsia to review the Pilot Training programs of aircraft operators and consider the necessity to include in the training syllabus for recurrent the analyses of occurred aviation incidents to train the flight crews in abnormal flight situations.
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