Wind Rose E145 at Zaporozhye on Sep 1st 2017, runway excursion on landing

Last Update: January 12, 2018 / 19:21:06 GMT/Zulu time

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Photo of Windrose Aviation UR-DNF, Embraer ERJ-145 — Windrose Aviation UR-DNF, Embraer ERJ-145 (Photo credit: Anna Zvereva / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Sep 1, 2017

Classification
Incident

Cause
Runway excursion

Airline
Windrose Aviation

Flight number
PS-87

Departure
Kiev, Ukraine

Destination
Zaporozhye, Ukraine

Aircraft Registration
UR-DNF

Aircraft Type
Embraer ERJ-145

ICAO Type Designator
E145

Airport
Zaporizhzhia International Airport, Zaporizhia

Airport ICAO Code
UKDE

A Wind Rose Aviation Embraer ERJ-145 on behalf of Ukraine International Airlines, registration UR-DNF performing flight PS-87 from Kiev to Zaporozhye (Ukraine) with 39 passengers and 4 crew, landed on Zaporozhye runway 02 at 11:15L (08:15Z) but overran the end of the runway, veered left off the runway and came to a stop with all gear on soft ground about 8 meters past the runway end and about 40 meters to the left of the runway center line. There were no injuries, the aircraft did receive minor damage.

On Sep 4th 2017 Ukraine's NBAAI reported the occurrence was rated a serious incident and is being investigated by the NBAAI.

On Jan 11th 2018 Ukraine's NBAAI released their final report in Ukrainian concluding the probable causes of the serious incident were:

- the professionally baseless decision by the captain to use flaps 22 instead of flaps 45 for landing
- ineffective braking (especially during the last 700 meters of runway remaining)
- the application of emergency brakes and the release of the flaps to 45 degrees during the roll out
- Dnepropetrovsk and Zaporizhia Control Centers did not forward information about the runway condition to the crew although present and available in METARs
- The crew did not request information about the runway conditions (runway was contaminated) and did not use such information for computing the landing distance required with flaps 22, which was 2647 meters with a landing distance of 2500 meters being available, for flaps 45 the landing distance required would have been 2355 meters.
- the tower controller did not include the operationally important information about the runway condition
- deficiencies in the airline's operating procedures with respect to landing preparations and determination of runway condition and landing distance computations

Contributing factors:

- landing with a tail wind component of 10 knots
- incomplete and low quality preflight preparation and landing briefing

Other factors:

- The investigation determined the runway lighting did not match requirements having been built in 1989 with different regulations in place, current regulations require the runway edge lights to be located within 3 meters of the runway edge, the airport however had installed the edge lights 11.5 meters from the runway edge.

The NBAII reported there were no injuries, the aircraft received minor damage to an auxiliary door at the right main gear support and damage to three main tyres.

The NBAII reported that during pre-flight preparations the crew reviewed the available METARs of 06:00Z and TAF weather information. The weather information did not preclude the decision to depart however required increased attention by the crew. While in flight the crew received verbal information from Dnepropetrovsk ATC: "wind from 240 degrees at 3m/s (6 knots), winds signficantly varying from 210 to 280 degrees, visibility 1800 meters, light rain, haze, broken clouds ceiling 180 meters, temperature +14 degrees, QNH 1013 hPa, active runway 02, braking coefficient 0.57, temporary meteorological visibility of 1000 meters, storm rain, broken clouds in height 180 meters." While on approach to runway 02 about 2 minutes prior to touchdown the crew received weather information stating: "Wind from 230 degrees at 4 m / s (8 knots), a maximum of 6 m / s (12 knots), wind direction varying from 190 to 260 degrees, in the area of the runway there are individual flights of birds".

The NBAII analysed that there were no technical deficiencies with the aircraft even though the tyres were worn close to the limits.

The NBAII analysed that prior to takeoff, despite reviewing available weather information, the crew did not receive information about the actual condition of the runway. The crew performed an ILS approach to runway 02, the captain decided to use flaps 22 for landing without taking the actual condition of the runway into account.

The NBAII made a lengthy analysis using various computation methods to determine ground roll scenarios, landing distances etc. (editorial note: most of which appears to be lost in translation, hence we won't summarize that extensive part of the analysis).

Metars:
UKDE 011000Z 24004MPS 2900 -SHRA BR BKN014 BKN020CB 15/14 Q1012 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010930Z 25004MPS 210V280 3300 -SHRA BR BKN010 BKN020CB 15/14 Q1012 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010900Z 24005MPS 4700 -SHRA BR BKN010 BKN020CB 14/14 Q1012 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010830Z 24004MPS 210V290 3100 -SHRA BR BKN009 BKN020CB 14/14 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010800Z 23004MPS 180V280 2700 -SHRA BR BKN009 BKN020CB 14/14 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010730Z 24003MPS 210V280 1800 -SHRA BR BKN009 BKN020CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010720Z 23003MPS 1200 R02/P2000N -SHRA BR BKN008 BKN015CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010703Z 24003MPS 210V270 1200 R02/P2000N -SHRA BR BKN006 BKN015CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010700Z 25004MPS 2000 -SHRA BR BKN007 BKN020CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010650Z 25003MPS 1200 R02/1900N SHRA BR BKN007 BKN020CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010630Z 25003MPS 2100 SHRA BR BKN007 BKN020CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010600Z 26003MPS 230V300 1200 R02/1100V1400D SHRA BR BKN013 BKN020CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010549Z 27003MPS 230V300 1200 R02/P2000N SHRA BR BKN013 BKN033CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010542Z 27003MPS 240V310 1800 SHRA BR BKN013 BKN033CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010533Z 27003MPS 1400 R02/P2000N SHRA BR BKN013 BKN033CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010530Z 27003MPS 250V310 3200 -SHRA BR BKN013 BKN033CB 14/13 Q1013 R02/290457 TEMPO 1000 SHRA BKN006 BKN013CB=
UKDE 010500Z 27003MPS 2200 -SHRA BR BKN013 BKN033CB 14/13 Q1013 R02/210367 NOSIG=