Back to home pageVQ-BPS 737-500 Landed short of runway

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16 Mar 2021 - The final report has been published into VP-BPS (28909/2960), 737-500 operated by UT Air that landed short of the runway at Usinsk (UUYS) on 9 Feb 2020.

The report is in Russian so there may be translation errors.

UUYS 090910Z 17006G11MPS 1500 SN BLSN BKN015 M21/M23 Q0999 R13/390238 TEMPO 1000 SN BLSN RMK QFE741/0989=

The Captain was PF. The crew conducted an RNAV(GNSS) approach, although the aircraft was not approved for such an approach. The OAT was -21C but no temperature correction was made. As a result the altimeters indicated up to 280ft higher than the actual altitude.

The Captain disconnected the automatics at 660ft indicated altitude. On short finals the aircraft was 50ft below the vertical profile and PAPIs were not available.

The aircraft hit a 1.1m high snow bank located 32m before the runway threshold. The impact damaged the main landing gear which collapsed on landing.The aircraft came to rest across the side of the runway.

Causal factors are given below

The full report can be read here.

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*** Updated 23 Nov 2020 ***

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VQ-BPS 737-500 accident

VQ-BPS after the accident (photo final report)

Causal Factors

  • The existance of contradictions in Federal Aviation Regulations in Airspace of the Russian Federation, the airline's standard operating procedures and the operations manual of the aircraft with respect to temperature corrections to barometric altimeter readings at low temperatures of ambient air
  • The Usinsk aerodrome operator's failure to comply with FAP-262 for aerodromes required a paved safety area free of snow banks
  • The Usinsk aerodrome operator's failure to eliminate shortcomings in the winter operations of the aerodrome that were noted in a Rosaviatsia commission inspection on Jan 22nd 2020
  • Lack of risk assessment by the airline of conducting baro-VNAV approaches in the presence of factors hampering such approaches (low ambient air temperatures, presence of snow cover on surfaces, drifting snow/snowstorm, significant changes in terrain profile before the runway, no approach guidance lights like PAPI) as well as lack of according recommendations to crews of how to conduct such approaches including the transition to visual approach, and lack of training of crews
  • Insufficient assessment of present hazards and threats during pre-landing preparations by the crew reaching an insufficiently substantiated decision to perform a RNAV (GNSS) approach under control of the autopilot in LNAV/VNAV without introduction of correction for the low ambient temperature which led to the approach flown below the glidepath
  • Performing a flight below extended glidepath after the autopilot was disconnected and transition to manual control without attempting to acquire the correct glide path
  • The PIC is likely to have a visual illusion of being high on the glide path due to the snow covered surface, blowing snow and the presence of a ravine directly in front of the runway's paved surface in absence of PAPI lights, which led to incorrect estimation of the aircraft's height, lack of timely call outs by the first officer leading to crossing the begin of paved surface of the runway significantly below the required height.

Other inadequacies found

  • Failure by the aerodrome service to clear snow from the timing zone leads to interference in the critical area of ​​the antenna, as a result of which the timing belt does not suitable for use.
  • Insufficient performance of the runway safety team in terms of accounting climatic features of the Usinsk aerodrome area (loss of significant precipitation in winter) and their impact on aviation operations.
  • The crew performed an approach in accordance with the RNP APCH specification (RNAV (GNSS)) intended for use at initial, intermediate and final approach segments, however on this aircraft the use of the specified approach system at the final stage is not allowed due to the lack of the necessary equipment on board, defined by Boeing SERVICE LETTER 737-SL-02-025D from 06.06.2018.
  • The evacuation of passengers after stopping the aircraft on the runway began with a delay, which was about 2 minutes. Delay was caused by delayed recognition the crew folding the main landing gear on the run, which indicates shortcomings in working out the actions of the crew in non-standard situations in the process carrying out training on simulators.
  • During the investigation, the airline did not provide documents on the mandatory psychological testing of flight crew members, which excluded analysis of the possible influence of the personal characteristics of the crew members and their psycho-emotional state on the outcome of the flight.
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