Crash of a Boeing 737-524 in Usinsk

Date & Time: Feb 9, 2020 at 1227 LT
Type of aircraft:
Operator:
Registration:
VQ-BPS
Survivors:
Yes
Schedule:
Moscow - Usinsk
MSN:
28909/2960
YOM:
1997
Flight number:
UT595
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
94
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17852
Captain / Total hours on type:
7672.00
Copilot / Total flying hours:
6595
Copilot / Total hours on type:
4989
Aircraft flight hours:
57410
Aircraft flight cycles:
29162
Circumstances:
Following an uneventful flight from Moscow-Vnukovo Airport, the crew initiated the descent to Usinsk Airport Runway 13. On short final, the aircraft hit a snow bank (1,1 metre high) located 32 metres short of runway threshold, still on the concrete zone. Upon impact, both main gears were torn off and the airplane belly landed and slid for few hundred metres before coming to rest. All 100 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The accident with the Boeing 737-500 VQ-BPS aircraft occurred during the landing as a result of a collision of the aircraft with a snow parapet 1.1 m high at a distance of 32 m to the runway threshold (within the paved section of the runway), which resulted in damage to the main landing gear and their subsequent "folding" in the process of moving along the runway.
The accident was caused by a combination of the following factors:
- the presence of contradictions in the Federal Aviation Rules for flights in the airspace of the Russian Federation, the airline's radio control system and the aircraft operational documentation regarding the need and procedure for introducing temperature corrections to the readings of barometric altimeters at low ambient temperatures;
- Failure by the operator of the Usinsk aerodrome to comply with the FAP-262 requirements for the maintenance of the aerodrome, which resulted in the presence of snow parapets on the paved section of the landing strip;
- the operator of the Usinsk aerodrome did not eliminate the shortcomings in the winter maintenance of the aerodrome, noted based on the results of the inspection by the Rosaviatsia commission on January 22, 2020;
- lack of risk assessment in the airline associated with the execution of approaches in the baro-VNAV mode in the presence of factors that impede such approaches (low ambient temperatures, snow-covered underlying surface, drifting snow (snowstorm), significant changes in the relief in front of the runway end, lack of PAPI-type lights), as well as appropriate recommendations to the crews on the specifics of such approaches, including after the transition to visual flight, and crew training;
- insufficient assessment by the crew during the preparation of the existing threats (hazard factors) and making an insufficiently substantiated decision to perform an RNAV (GNSS) approach (under the control of the autopilot in LNAV/VNAV mode) without introducing a correction for low outside air temperature in altitude overflying waypoints, which led to a flight below the established glide path;
- performing a flight along the "extended glide path" after turning off the autopilot and switching to manual piloting without attempting to enter the set glide path;
- the PIC may have had a visual illusion of a "high glide path" due to a snow-covered underlying surface, a snowstorm and the presence of a ravine directly in front of the runway end in the absence of PAPI type lights, which led to an incorrect assessment of the aircraft's flight altitude after switching to manual piloting, lack of reaction to timely and correct warnings of the co-pilot and exit to the runway end at a height significantly less than the established one.
Final Report:

Crash of a Boeing 737-8AS in Sochi

Date & Time: Sep 1, 2018 at 0258 LT
Type of aircraft:
Operator:
Registration:
VQ-BJI
Survivors:
Yes
Schedule:
Moscow - Sochi
MSN:
29937/1238
YOM:
2002
Flight number:
UT579
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13995
Captain / Total hours on type:
6391.00
Copilot / Total flying hours:
12277
Copilot / Total hours on type:
5147
Aircraft flight hours:
45745
Aircraft flight cycles:
23434
Circumstances:
On 31.08.2018 Boeing 737-800 VQ-BJI operated by UTAir Airlines conducted the scheduled flight UT 579 from Moscow (Vnukovo airport) to Sochi (Adler airport). During the preflight briefing (at 19:50) the crew was provided with the necessary weather information. At 20:15, the crew had passed the medical examination at Vnukovo airport mobile RWY medical unit. The Daily Check line maintenance (DY) was done on 30.08.2018 at Vnukovo airport by UTG aviation services, ZAO; job card # 11465742. The A/C takeoff weight was 68680 kg and the MAC was 26.46 %, that was within the AFM limitations for the actual conditions. At 21:33 the takeoff from Vnukovo airport was performed. The flight along he prescribed route was performed on FL350 in auto mode and without any issues. The F/O acted as the pilot flying (PF). When approaching the Sochi aerodrome traffic control area, the flight crew was provided by the aerodrome approach control with the approach and descending conditions, as well as with the weather conditions near the aerodrome. After descending to the height specified by Sochi Approach, the pilot contacted Sochi Radar, waited for the weather that met his minimum and was cleared for landing. In course of the first approach to landing (from the altitude about 30 m) when RVR got down because of heavy showers, the PIC took controls and performed the go-around. In course of the second approach, the crew performed the landing but failed to keep the airplane within the RWY. The airplane had landed at about 1285 m from the RWY threshold, overrun the threshold, broke through the aerodrome fencing, and came to rest in Mzymta river bed. This ended with the fire outbreak of fuel leaking from the damaged LH wing fuel tank. The crew performed the passenger evacuation. The aerodrome alert measures were taken and the fire was brought under control. Eighteen occupants were injured while all other occupants were unhurt. The aircraft was damaged beyond repair.
Probable cause:
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 ≈200 m from the runway end).
Final Report:

Crash of a Dassault Falcon 50EX in Moscow-Vnukovo: 4 killed

Date & Time: Oct 20, 2014 at 2357 LT
Type of aircraft:
Operator:
Registration:
F-GLSA
Flight Phase:
Survivors:
No
Schedule:
Moscow - Paris
MSN:
348
YOM:
2006
Flight number:
LEA074P
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
6624
Captain / Total hours on type:
1266.00
Copilot / Total flying hours:
1478
Copilot / Total hours on type:
246
Aircraft flight hours:
2197
Aircraft flight cycles:
1186
Circumstances:
During the takeoff run on runway 06 at Moscow-Vnukovo Airport, the three engine aircraft hit a snowplow with its left wing. The aircraft went out of control, rolled over and came to rest upside down in flames. All four occupants were killed, three crew members and Mr. Christophe de Margerie, CEO of the French Oil Group Total, who was returning to France following a meeting with the Russian Prime Minister Dmitry Medvedev. At the time of the accident, the RVR on runway 06 was estimated at 350 meters due to foggy conditions. The pilot of the snow-clearing vehicle was slightly injured.
Probable cause:
The accident occurred at nighttime under foggy conditions while it was taking off after cleared by the controller due to collision with the snowplow that executed runway incursion and stopped on the runway. Most probably, the accident was caused by the combination of the following contributing factors:
- lack of guidance on loss of control over an airdrome vehicle and/or situational awareness on the airfield in pertinent documents defining the duties of airdrome service personnel (airdrome shift supervisor and vehicle drivers);
- insufficient efficiency of risk mitigation measures to prevent runway incursions in terms of airdrome peculiarilies that is two intersecling runways;
- lack of proper supervision from the airdrome service shift supervisor, alcohol detected in his organism, over the airfield operations: no report to the ATM or request to the snowplow driver as he lost visual contact with the snowplow;
- violation by the airdrome service shift supervisor of the procedure for airdrome vehicles operations, their entering the runway (RWY 2) out of operation (closed for takeoff and landing operations) without requesting and receiving clearance from the ground controller;
- violations by the medical personnel of Vnukovo AP of vehicle driver medical check requirements by performing formally (only exterior assessment) the mandatory medical check of drivers after the duty, which significantly increased the risk of drivers consuning alcohol during the duty. The measures and controls applied at Vnukovo Airport to mitigate the risk of airdrome drivers doing their duties under the influence of alcohol were not effective enough;
- no possibility for the snowplow drivers engaged in airfield operations (due to lack of pertinent equipment on the airdrome vehicles) to continuously listen to the radio exchange at the Departure Control frequency, which does not comply with the Interaction Procedure of the Airdrome Service with Vnukovo ATC Center.
- loss of situational awareness by the snowplow driver, alcohol detected in his organism, while perfonning airfield operations that led to runway incursion and stop on the runway in use.
His failure to contact the airdrome service shift supervisor or ATC controllers after situational awareness was lost;
- ineffective procedures that resulted in insufficiently trained personnel using the airfield surveillance and control subsystem A3000 of A-SMGCS at the Vnukovo ATC Center, for air traffic management;
- no recommendation in the SOP of ATM personnel of Vnukovo ATC Center on how to set up the airfield surveillance and control subsystem A3000, including activation and deactivation of the Reserved Lines and alerts (as a result, all alerts were de-activated at the departure controller and ground controller's working positions) as well as how to operate the system including attention allocation techniques during aircraft takeoff and actions to deal with the subsystem messages and alerts;
- the porting of the screen second input of the A3000 A-SMGCS at the ATC shift supervisor WP for the display of the weather information that is not envisaged by the operational manual of the airfield surveillance and control subsystem. When weather information is selected to be displayed the radar data and the light alerts (which were present during the accident takeoff) become un available for the specialist that occupies the ATC shift supervisor's working position;
- the ATC shift supervisor's decision to join the sectors at working positions of Ground and Departure Control without considering the actual level of personnel training and possibilities for them to use the information of the airfield surveillance and control system (the criteria for joining of sectors are not defined in the Job Description of ATC shift supervisor, in particular it does not take into account the technical impossibility to change settings of the airfield surveillance and control system);
- failure by the ground controller to comply with the SOPs, by not taking actions to prevent the incursion of RWY 2 that was closed for takeoff and landing operations by the vehicles though having radar information and alert on the screen of the airfield surveillance and control system;
- failure by the out of staff instructor controller and trainee controller (providing ATM under the supervision of the instructor controller) to detect two runway incursions by the snowplow on the runway in use, including after the aircrew had been cleared to take off (as the clearance was given, the runway was clear), provided there was pertinent radar information on the screen of the airfield surveillance and control subsystem and as a result failure to inform the crew about the obstacle on the runway;
- lack of recommendations at the time of the accident in the Operator's (Unijet) FOM for flight crews on actions when external threats appear (e.g. foreign objects on the runway) during the takeoff;
- the crew failing to take measures to reject takeoff as soon as the Captain mentioned «the car crossing the road». No decision to abort takeoff might have been caused by probable nonoptimal psycho-emotional status of the crew (the long wait for the departure at an unfamiliar airport and their desire to fly home as soon as possible), which might have made it difficult for them to assess the actual threat level as they noticed the snowplow after they had started the takeoff run;
- the design peculiarity of the Falcon 50EX aircraft (the nose wheel steering can only be controlled from the LH seat) resulting in necessity to transfer aircraft control at a high workload phase of the takeoff roll when the FO (seated right) performs the takeoff.
Final Report:

Crash of a BAe 125-800B in Moscow

Date & Time: Jul 7, 2014
Type of aircraft:
Operator:
Registration:
RA-02806
Flight Type:
Survivors:
Yes
Schedule:
Moscow – Makhatchkala
MSN:
258106
YOM:
1987
Flight number:
CIG9661
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Moscow-Vnukovo Airport on a positioning flight to Makhatchkala, carrying a crew of three. On approach to Makhatchkala Airport, the crew was unable to lower the gear that remained stuck in their wheel well. Despite several attempts, the crew was unable to lower the gear manually and eventually decided to return to Moscow-Vnukovo for an emergency landing. The aircraft belly landed on a foam covered runway and slid for few dozen metres before coming to rest. All three crew members escaped uninjured and the aircraft was damaged beyond repair.

Crash of a BAe 125-700B in Moscow

Date & Time: Feb 12, 2014 at 1850 LT
Type of aircraft:
Operator:
Registration:
RA-02801
Flight Type:
Survivors:
Yes
Schedule:
Moscow - Moscow
MSN:
257097
YOM:
1980
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Moscow-Sheremetyevo Airport on a positioning flight to Moscow-Vnukovo Airport. On approach by night, the crew configured the aircraft for landed when he realized that the right main gear remained stuck in its wheel well. The crew following a holding pattern and after the runway was covered with foam, he completed an emergency landing. After touchdown, the right wing contacted ground and the aircraft slid for few dozen metres before coming to rest. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Canadair RegionalJet CRJ-200ER in Moscow

Date & Time: Sep 7, 2013 at 2115 LT
Operator:
Registration:
TC-EJA
Survivors:
Yes
Schedule:
Naples - Moscow
MSN:
7763
YOM:
2003
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Naples-Capodichino Airport, the crew started the descent to Moscow. On approach to Vnukovo Airport Runway 09, while completing the approach checklist and configuring the aircraft for landing, the crew noticed that both main landing gears remained stuck in their wheel well while the nose gear was lock down properly. The crew abandoned the approach and initiated a go-around. During a holding circuit, the crew attempted to troubleshoot the system and to deploy both main gears manually without success. The crew eventually decided to complete the landing in such configuration. The aircraft landed on runway 01 with both main gears retracted and the nose gear down, slid for few dozen metres and came to a halt. All 11 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Tupolev TU-204-100V in Moscow: 5 killed

Date & Time: Dec 29, 2012 at 1633 LT
Type of aircraft:
Operator:
Registration:
RA-64047
Flight Type:
Survivors:
Yes
Schedule:
Pardubice - Moscow
MSN:
1450744864047
YOM:
2008
Flight number:
RWZ9268
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
14975
Captain / Total hours on type:
3080.00
Copilot / Total flying hours:
10222
Copilot / Total hours on type:
579
Aircraft flight hours:
8676
Aircraft flight cycles:
2484
Circumstances:
Approach was carried out on the runway 19 at Vnukovo Airport with length of 3060m. Pilot was performed by pilot in command (PIC). Before entering the glide path the aircraft was in landing configuration: with flaps deployed at 37°, slats - at 23 °, and the landing gear down. Decision height was calculated to be 60 m. Landing weight of the aircraft was approximately 67.5 tons, alignment ~26.5%, which did not exceed the limits specified by the flight operation manual (FOM). During flight preparation PIC determined the landing glide path speed as 210 km/h, and specified that the speed at least 230 km/h has to be maintained. Glideslope descent was made in director mode with automatic throttle disabled with an average instrument speed about 255 km/h vertical speed -3…-5 m/s. Descent was performed without significant deviations from the glide path. Flyby of the of the neighboring (to the runway) homing radio beacon was performed at the altitude 65…70 m. Runway threshold was passed at the altitude about 15 m and airspeed of 260 km/h. 5 seconds after the throttle control lever had been switched to the idle mode the aircraft landed at the speed about 230 km/h, distance from the runway threshold of 900-1000 m and left bank of 1... 1.5°, provided that the signal of the signal of left gear strut compression was produced. During aircraft landing the right side wind gust reached up to ~11.5 m/s. The maximum value of the vertical acceleration during touch down was recorded as 1.12g according to flight recorders (hereinafter - magnetic tape recorder). About 10 seconds had passed from the moment of passing 4 m height above ground and touchdown. 3 seconds after landing nose gear strut was compressed. At this stage the right gear strut compression signal had not yet been formed. Almost simultaneously with nose landing gear touchdown the crew moved thrust reverser lever in one motion to the "maximum reverse" position and applied mechanical brakes. Actuation of the reverse valves didn't occur. Air brakes and spoilers were not also activated automatically and the crew didn't make attempt to activate them manually. After thrust levers were moved to the "maximum reverse" position an increase of forward thrust (up to ~90% Nvd) was recorded with both engines. The pressure in the hydraulic system of wheel brakes of the left (compressed) landing gear was up to 50 kgf/сm², whereas there were no pressure in the wheel brakes of the right (not compressed) landing gear. The minimum airspeed to to which the aircraft slowed 7-8 seconds after landing was 200-205 km/h at ~0° pitch and roll of 1° to the left, after that the speed began to increase. 2 seconds after thrust levers were moved to the "maximum reverse" position the flight engineer reported that reversers had not been deployed. Thrust lever had been maintained in the "maximum reverse" position for about 8 seconds and was switched off after that. During this time the airspeed increased to 240 km/h. The increase in airspeed led to further unloading of the main landing gear. With fluctuations in roll (from 4.5° to the left to 2.6° to the right) compression was produced alternately on the left and right landing gear struts. Almost simultaneously sith the reversers being switched off the brake pedal was pushed by left-hand-seat pilot to 60°. As before the breaking was inefficient - hydraulic pressure in the wheel brake in only applied after sufficient compression of the gear strut. 5 seconds after reversers were deactivated, after words of the flight engineer "Turn on reverse! Reverse!" the control was moved to the "maximum reverse" position again. As in the first attempt the deployment of reversers didn't occur, both engines started to produce direct thrust (at Nvd ~ 84%). Aircraft braking didn't occur, airspeed was 230…240 km/h. In 4 seconds the reverse was switched off. At the moment of reverser reactivation the aircraft was at the distance of about 900...1000 m from the exit threshold. 6 seconds after reversers switch off the crew attempted to supply automatic braking as evidenced by the crew conversation and transient appearance of commands: "Automatic braking on" for the primary and backup subsystems. When the aircraft passed the exit threshold thrust levers were in the "small-reverse" position. The aircraft overrun occurred 32 seconds after landing, being almost on the axis of the runway, with an airspeed of about 215 km/h. In the process of overrun flight engineer by PIC command turned off the engines by means of emergency brakes. The aircraft continued to roll outside the runway slowly due to road bumps and snow cover. The compression on both landing gear struts occurred which led to activation of air brakes and spoilers. The aircraft collided with the slope of a ravine at the ground speed of about 190 km/h. Four stewardess were seriously injured while four other crew members were killed. The following day, one of the survivor died from her injuries.
Probable cause:
The accident with Тu-204-100В RA-64047 aircraft was caused by actuator maladjustment and reverse locking of both engines and incorrect crew actions (not complying with FOM provisions) performing landing run during spoilers and thrust reverse control that resulted in lack of efficient aircraft breaking action, RWY overrun, collision with obstacles at a high speed (~190 km/h), aircraft destruction and fatalities. (In accordance with the ICAO Accident and Incident Investigation Manual (DOC 9756 AN/965), causes and factors are in logical order, without the priority assessment).
Contributing factors to the fatal accident were:
- Actual structure stiffness of reverse control and locking mechanism unaccounted in operational documentation determining the engine control system inspection and adjustment procedure during its service replacement. This factor can emerge only in case of the crew thrust reverse control with violation of FOM provisions;
- Incoordination and conflicts in aircraft and engine operational and technical documentation and long-term formalism towards inspections of the engine control system adjustment (including reverse control and locking mechanism) by organisations performing engines replacement that didn't allow to ensure feedback with aircraft and engine designers and timely eliminate identified deficiencies;
- Unstabilized approach and significant (up to 45 km/h) rated overspeed during glide slope phase by the crew that resulted in long holding before landing, significant landing distance extension and aircraft overshoot landing (~950 m);
- Non-extension of spoilers and speed breaks in automatic mode due to the lack of the signal of simultaneous left and right struts compression caused by aircraft anticipatory "soft" landing (plunge acceleration 1.12g) at left main gear at right cross wind saturation (~11.5 м/с);
- Lack of crew monitoring for automatic extension of spoilers and speed brakes after landing and manual non-extension of spoilers;
- Violation of thrust reverse landing procedure be crew specified by FOM resulted in application of maximum thrust reverse by "one motion" without throttle intermediate stop setting (low reverse) and without reverse buckets position (stowage) monitoring that under deficiencies of the reverse control and locking mechanism resulted in immediate thrust increase;
- Lack of simultaneous main landing gear compression during the RWY motion due to design features of limit switches (no failures of limit switches were identified) of main landing gears compressed position (~5.5 tonnes leg load is required for switch actuation) and non compliance with the FOM on spoilers extension in manual mode that resulted in reverser buckets non-stowage into reversal thrust mode;
- Inadequate cockpit resource management by the PIC during flight that resulted in lack of monitoring for stabilized approach at the approach phase and in "fixation" at reverser deployment operation at the lack of monitoring for other systems operation;
- Untimely preventive measures during the investigation of the serious incident with Tu-204-100V RA-64049 aircraft operated by "Red Wings" Airlines occurred in Tolmachevo airport on December 20, 2012;
- Inadequate level of flight operation management and nonoperation of flight safety control system in the airline and formal attitude of the pilot-instructor towards proficiency check of the PIC and the lack of the appropriate supervision over proficiency checks and flight operations using flight recorders that didn't allow to timely identify and eliminate regular deficiencies in PIC's piloting technique regarding increased speed holding during glide-slope flight and the procedure of using reverse thrust application at landing run operation as well. Supervision over proficiency checks specified by FAR-128 (clause 5.7) wasn't held;
- Lack of actions training in situations connected with failure of main landing gears limit switches in line proficiency check programs of crew members followed by non-extension of spoilers and speed breaks in manual mode. Technical abilities of the available simulators don't allow to train this situation.
Final Report: