Wind Rose E145 at Zaporozhye on Mar 3rd 2018, runway excursion on landing

Last Update: May 16, 2018 / 18:26:12 GMT/Zulu time

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Incident Facts

Date of incident
Mar 3, 2018

Classification
Incident

Cause
Runway excursion

Airline
Windrose Aviation

Flight number
PS-87

Departure
Kiev Borispol, Ukraine

Destination
Zaporozhye, Ukraine

Aircraft Registration
UR-DPB

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-DPB performing flight PS-87 from Kiev Borispol to Zaporozhye (Ukraine) with 37 passengers and 4 crew, landed on Zaporozhye's runway 02 at about 14:06L (12:06Z) but suffered a runway excursion. There were no injuries.

Ukraine's NBAAI rated the occurrence a serious incident and opened an investigation.

A similiar runway excursion had occurred in September 2017, see Incident: Wind Rose E145 at Zaporozhye on Sep 1st 2017, runway excursion on landing.

On Apr 17th 2018 Ukraine's NBAAI reported the Wind Rose aircraft veered left off the runway, exited the left runway edge about 1745 meters past the runway threshold and came to a stop about 99 meters to the left of the runway center line.

On May 16th 2018 the NBAAI released their final report in Ukrainian concluding the probable cause of the incident was:

untimely and insufficient actions by the crew to maintain directional control while landing on a contaminated runway in crosswinds.

Contributing factors were:

- a crosswind of 16 knots on a contaminated runway
- incorrect pre-flight data provided to the crew and insufficient preflight preparation by the crew

The NBAAI reported the crew performed an ILS approach to runway 02 in instrument meteorological conditions. About 1745 meters down the runway the aircraft veered to the left and came to a stop about 99 meters to the left of the center line at a heading of 220 degrees. The aircraft sustained minor damage to the right main gear (auxiliary door, wheels) and the #4 tyre (cut, outboard right tyre).

The NBAAI analysed that there was no technical issue with the aircraft. Prior to the flight dispatch provided the crew with a number of NOTAMs and SNOWTAMs including UKDE, planned alternate airfields as well as 14 other aerodromes unrelated to the flight. The flight was delayed two times, according to the delay notice to Eurocontrol due to weather conditions at the departure aerodrome, which however does not match objective information, the runway condition at the destination however were below requirements. When the last set of information was obtained, the weather at destination had sufficiently improved, so that the flight could be conducted. However, the SNOWTAM did not correspond to the journal at Zaporozhye airport. The SNOWTAM reported the runway was covered with wet snow of 93mm thickness, estimated braking action was good, the measured braking coefficient was 0.4. However, the journal stated, the runway was wet, covered with wet snow of 15cm thickness at 80% of the runway surface. The NBAAI analysed that the SNOWTAM information issued at 01:00Z of snow cover and braking action good did not raise any doubt with the flight crew about the reliability of such data showing the crew's superficial analysis of weather conditions. The Met office also made a mistake by putting the value of the snow layer's thickness 93mm into the SNOWTAM, which according to SNOWTAM encoding indicates 150mm thickness. Other later SNOWTAM messages were not provided to the crew. Snow removal at the destination was completed at about 06:00L after which the runway was covered with 5mm slush, braking coefficients were 0.35/0.35/0.35 and braking action was medium. Snow removal took place again around 10:00, after which the runway was described as contaminated 30% with slush of 5mm and spots of incinerated snow, braking action good with braking coefficients of 0.48 along the entire runway. The airport made another encoding error suggesting the runway was contaminated between 51 and 100%.

Such inaccuracies may have a negative impact on flight safety, the NBAAI concluded the weather data analysis.

While the aircraft was descending towards Zaporozhye ATC provided the crew with runway information indicating 30% of the runway were covered with slush 5mm deep, there were spots tucked with snow. Braking action was good, coefficients 0.48. Tower informed the crew visibility was 1900 meters, cloud base at 180 meters, winds from 110 degrees at 7m/s (approx 14 knots) maximum 8m/s (approx 16 knots) and cleared the flight to land. 3 minutes later the controller raised alarm after seeing the aircraft veer off the runway.

A runway inspection was conducted including measurement of the braking action, braking coefficients of 0.4 along the entire runway were measured identifying braking action good, 30% of the runway were covered with slush 5mm and spots of rolled snow, the runway was wet.

The NBAAI analysed the crew applied the "crab" methode for landing, at touchdown the aircraft showed a heading of 23 degrees, the pilot flying (the first officer) however did not reduce the crab angle, the rudder pedal positions remained near neutral for more than 2.5 seconds suggesting that neither pilot took action to prevent the aircraft turning into the wind (weather cocking), consequently the heading changed to 27 degrees, only at that point the rudder pedals were moved to correct the aircraft drift and the aircraft first went towards the right edge of the runway, then towards the left edge, drifted again to the right side and finally went off the left side of the runway.

The NBAAI analysed that according to the FCOM the lateral component of reverse thrust adds to the lateral component of the wind, which may cause a tendency for aircraft to drift off runways as has happened in this case.

Metars:
UKDE 031330Z 10004MPS 060V130 2300 -RA BR OVC004 01/01 Q0994 R02/290548 BECMG 0500 -SHRA FG BKN003 BKN013CB=
UKDE 031300Z 11004MPS 060V150 4000 -DZ BR OVC004 01/01 Q0994 R02/290548 BECMG 0500 -SHRA FG BKN003 BKN013CB=
UKDE 031256Z 11004MPS 3800 -RA BR OVC005 01/01 Q0994 R02/290548 BECMG 0500 -SHRA FG BKN003 BKN013CB=
UKDE 031239Z 11004MPS 080V150 2900 -RA BR OVC005 01/01 Q0995 R02/290548 BECMG 0500 -SHRA FG BKN003 BKN013CB=
UKDE 031230Z 11005MPS 080V150 3300 -RA BR OVC006 01/01 Q0995 R02/290548 BECMG 0500 -SHRA FG BKN003 BKN013CB=
UKDE 031200Z 11007MPS 080V140 2100 -RA BR OVC006 01/01 Q0995 R02/290548 BECMG 1000 SHRA BR BKN003 BKN013CB=
UKDE 031130Z 11007MPS 080V140 2100 -RA BR OVC006 01/01 Q0995 R02/290548 BECMG 1000 SHRA BR BKN003 BKN013CB=
UKDE 031107Z 11008MPS 080V150 2500 -RA BR OVC008 02/01 Q0996 R02/650540 BECMG 1000 SHRA BKN003 BKN013CB=
UKDE 031100Z 12008MPS 080V150 3100 -RA BR BKN009 02/01 Q0996 R02/650540 BECMG 1000 SHRA BKN003 BKN013CB=
UKDE 031050Z 12008MPS 080V150 2900 -RA BR OVC006 02/01 Q0996 R02/650540 NOSIG=
UKDE 031030Z 12007MPS 080V140 4000 -RA BKN009 02/01 Q0996 R02/650540 NOSIG=
UKDE 031017Z 11008MPS 080V150 6000 -RA BKN009 02/01 Q0996 R02/650540 NOSIG=
UKDE 031000Z 11007MPS 070V170 8000 -RA BKN011 02/02 Q0997 R02/650540 NOSIG=
UKDE 030930Z 11007MPS 080V140 6000 -RA OVC007 02/02 Q0997 R02/650540 NOSIG=
UKDE 030900Z 11006MPS 080V150 5000 -RA OVC006 02/01 Q0998 R02/650540 NOSIG=

Related NOTAMs:
A0399/18 NOTAMN
Q) UKDV/QMRLC/IV/NBO/A /000/999/4752N03519E005
A) UKDE B) 1803031435 C) 1803031800
E) RWY 02/20 CLOSED DUE TO TECHNICAL REASON.

A0400/18 NOTAMR A0399/18
Q) UKDV/QMRLC/IV/NBO/A /000/999/4752N03519E005
A) UKDE B) 1803031750 C) 1803032000
E) RWY 02/20 CLOSED DUE TO TECHNICAL REASON.