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UT Air 737-800 VQ-BJI Runway excursion after landing at Sochi 01 Sep 2018

On 01 Sep 2018 UT Air 737-800, VQ-BJI (29937/1238 delivered Nov 2002), departed the far end of runway 06 at Sochi (URSS) whilst landing in a thunderstorm at 23:57z (02:57L).

The aircraft went through the perimeter fence and down an embankment into a river bed. The aircraft was written off. The aircraft was carrying 164 passengers and 6 crew. There were no fatalities but 18 injuries including 8 taken to hospital.

URSS 010000Z 23004MPS 5000 1800E R02/P3000N TSRA BKN006 OVC030CB 21/21 Q1014 WS ALL RWY R02/250350 R06/250350 NOSIG RMK R06/19004MPS QBB200 MT OBSC QFE759=

The final report was issued in Dec 2019. It concluded that:

Conclusion

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 tailwind;
  • 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.

Contributory factors:

  • 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 ≈200 m from the runway end).
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*** Updated 18 Apr 2020 ***

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The preliminary report describes how the crew held before making an approach due to bad weather. When the weather improved to RVR 3500/1500/3500m 090/14G37 they commenced an approach. During this approach they received "monitor radar display" at 1100RA and "Go Around! Wind Shear ahead!" at 850RA. The continued the approach and went around from 50RA after losing visual references in heavy rain.

The crew received a weather check of RVR 2500/2600/2400m and 200/8G16 and commenced a second approach. At 1100RA they received a "Monitor radar display!"; at 1050RA they received a "Go Around! Windshear ahead!"; at 460RA "Windshear! Windshear! Windshear!". The autothrust was commanding N1 changes of between 30-90% N1. The crew continued the approach. The automatics were disconnected at 75RA, the wind was 170/8. The aircraft touched down 1300m beyond the 06 threshold with a groundspeed of 170Kts. Reverse thrust was not deployed until 20.5 seconds after touchdown. 13 secs after autobrake engaged, the Captain applied manual braking. 13 seconds later the aircraft went off the runway.

VQ-BJI FDR

VQ-BJI in its final resting position

VQ-BJI in its final resting position Photo: Southern Transport Prosecution Office

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