Bravo MD83 at Kiev on Jun 14th 2018, runway excursion on landing

Last Update: October 19, 2020 / 22:16:22 GMT/Zulu time

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Incident Facts

Date of incident
Jun 14, 2018

Classification
Accident

Cause
Runway excursion

Flight number
BAY-4406

Departure
Antalya, Turkey

Destination
Kiev Igor Sikorsky/Zhuliyani, Ukraine

Aircraft Registration
UR-CPR

Aircraft Type
McDonnell Douglas MD-83

ICAO Type Designator
MD83

Airport
Kiev Zhuliany International Airport, Kiev

Airport ICAO Code
UKKK

A Bravo Air McDonnell Douglas MD-83, registration UR-CPR performing flight BAY-4406 from Antalya (Turkey) to Kiev Igor Sikorsky/Zhuliyani (Ukraine) with 169 passengers and 6 crew, landed on Igor Sikorsky (formerly known as Zhulyani) Airport's runway 08 at 20:40L (17:40Z) but veered left off the runway and came to a stop on soft ground. The aircraft was evacuated via slides. There were no injuries, the aircraft sustained substantial damage.

Passengers reported the aircraft came to a stop with the right wing on the grass, a number of passengers seats inside the cabin had been torn off, the smell of smoke appeared in the cabin prompting the passengers to run off the aircraft.

The airport reported the aircraft suffered a runway excursion while landing at Zhuliyani. The airport was closed for 3 hours as result of the ocurrence. All 169 passengers of the aircraft were safely evacuated and taken to the terminal.

Ukraine's NBAAI reported the aircraft ran beyond the limits of the runway while landing at Zhulyani/Igor Sikorsky Airport. There were no injuries. The NBAAI have opened an investigation.

There is no clear information so far as to whether the right main gear collapsed or sunk into the ground.

Ukraine's State Aviation Service reported one of the thrust reversers of the aircraft failed to deploy.

Photos showing the recovery works released by Kiev's Sikorsky Airport on Jul 5th 2018 make clear that the right hand gear had collapsed (see below).

On Sep 22nd 2020 Ukraine's NBAAI released their final report in Ukrainian promising an English version would be soon released. We thus refrain from translating and summarizing the Ukrainian version and wait for the English release. The Ukrainian report concludes the probable causes of the accident were:

The cause of the runway excursion was the captain's decision to continue the landing at Kiev Zhuliany in conditions of thunderstorms at the airfield with following factors:

- unstabilized landing event starting at 1000 feet
- non-release of spoilers by the crew
- incorrect actions by the crew with respect to the use of thrust reversers on a wet runway (EPR exceeding 1.3).

Contributing factors were:

- ATC service was not fully provided to the crew as required by the Order of the Ministry of Transport of Ukraine from 16.04.2003 No 293
- winds variable in strength and direction
- probably the crew had not listened to current ATIS at Zhuliany
- The operators Operating Manual lacks procedures for landing
- poorly conducted pre-flight and approach briefings as well as reading and carrying out the checklists at all stages of the flight

On Oct 19th 2020 the NBAAI published the English version of the final report following a major rework of their website (and breaking all old links to investigation reports) concluding the probable causes of the accident were:

The cause of the accident, i.e. runway excursion of MD-83 UR-CPR aircraft operated by Bravo Airways, which took place on June 14, 2018 at the Kyiv (Zhulyany) Aerodrome at performance of flight BAY 4406 en-route Antalya-Kyiv (Zhulyany) – was the PIC’s decision to continue the landing at the Kyiv (Zhulyany) Aerodrome in the thunderstorm conditions with the following main factors:

- non-stabilized approach for landing, starting from the height of 1,000 feet;

- spoiler non-deployment by the crew;

- incorrect crew actions in application of the reverse thrust on a wet runway (EPR>1.3).

Contributing Factors:

- Air traffic control service in the classified airspace of Ukraine, which is required by the Order of the Ministry of Transport of Ukraine dated April 16, 2003, No. 293, was not provided to the crew in full;

- Wind variable in strength and direction;

- Probably, the crew’s failure to listen to the latest ATIS reports for the Kyiv (Zhulyany) Aerodrome;

- Bravo Airways Operator's Manual does not contain landing approach procedures;

- Low-quality pre-flight preparation, pre-landing preparation, checklist reading and completion at all flight stages.

The NBAAI analysed that the captain of the flight did not provide the flight information package received prior to the departure in Antalya, the investigation therefore was not able to determine whether the preflight preparation had been done. The NBAAI stated the captain indicated no significant weather was forecast for Kiev and wrote: "The PIC's statement is not true that the weather forecast for the Kyiv (Zhulyany) Aerodrome did not indicate the presence of dangerous weather phenomena."

The NBAAI however stated that the weather data available at the time did not interfere with the decision to depart for Kiev.

During the descent towards Kiev the crew received weather information the weather at Kiev Zhuliyani indicated CAVOK. The NBAAI commented: "METAR reports for 03:30 pm, 04:00 pm, 04:30 pm and 05:00 pm for Kyiv (Zhulyany) Aerodrome contained the good weather information (CAVOK), and 2-hour landing forecast (TREND) did not forecast any deterioration of the meteorological conditions or onset of hazardous conditions (NOSIG.) In this part, the forecast did not come true."

During the approach the aircraft needed to deviate around a number of thunderstorm cells about 20nm from the airport.

The NBAAI wrote:

At the time of communication of the MD-83 UR-CPR aircraft crew with the BV1 sector controller, there were significant changes in weather conditions at the Kyiv (Zhulyany) Aerodrome. According to ATIS at 05:21:31 pm for 05:20 pm at Kyiv (Zhulyany) Aerodrome, there was a thunderstorm, which was accompanied by significant changes in wind direction in the sector from 080 to 140º. According to the TREND forecast for landing, an unstable wind with gusts up to 17 m/s was expected at the aerodrome. This information was not transmitted to the crew.

Due to the fact that the controllers did not receive confirmation from the crew of receipt of the ATIS radio transmission and they did not know if the crew listened to it (and if it did, then for which time), the controllers should have provided the crew with the up-to-date meteorological information and runway status information.

ATIS broadcast the following:

Aerodrome weather: Wind magnetic: landing area: 080º 7 m/s. Changing from 060 to 120º. Runway threshold: 080º 6 m/s, gusts max 9, min 4 m/s. Changing: from 070 to 130º. Visibility 10 km, thunderstorm with light rain. Cloudiness scattered cumulonimbus, 630 m, significant 1290 m. Temperature: 23, dew point 19. QNH 1007 hPa, QFE 986 hPa.

Landing forecast: occasionally, wind is unstable 10 m/s, gusts maximum 17 m/s. Visibility 1000 m, thunderstorm, with moderate rain, storm. Cloudiness: significant cumulonimbus 750 m.

Ground-based meteorological radar data: thunderstorm, with a squall line. Sector 0 to 360º. Distance 0 to 101 km, moving to the North at the speed of 20 km/h, weakening. After take-off, work immediately with Kyiv Radar 125.3. Confirm receipt of Hotel information. For arrival: Kyiv Radar 127.72 or 124.67. For departure: Zhulyany-Taxiing 119.0 .

The NBAAI analysed:

At 05:37:40 pm, at the distance of 6 nm to the landing point, the BV5 sector controller informed the crew that the aircraft was positioned to the left of the landing heading and asked, if it would continue to approach for landing in this configuration. To that, the crew replied that the runway is observed, and it continues the approach for landing.

According to the onboard recorders, the aircraft was at the altitude of 680 m, had a speed of 159 knots, magnetic heading was 93º, the distance to the runway threshold was 11 km, the lateral deviation to the left was 476 m, which allowed the crew to stabilize the aircraft for landing.

According to ground-based recorders data, the crew of MD-83 UR-CPR aircraft did not confirm the receipt of ATIS radio information to any of controllers on the descent route. At the same time, according to the information provided by the PIC, the crew had information from ATIS "Bravo" for 5:00 pm and information about the thunderstorm activity provided by controllers. Information about the thunderstorm at the aerodrome was provided by ATIS channel, starting from 05:21:31 pm.

At 05:38:02 pm, the crew switched to communication with the Kyiv (Zhulyany) Tower controller. According to the recorder, the aircraft was at the altitude of 510 m, had a speed of 160 knots, magnetic heading of 91º, distance to the runway threshold was 9 km, lateral deviation 276 m, which allowed the crew to stabilize the aircraft for landing.

After the crew contacted him, the Tower controller informed the crew of the wind at the runway touchdown point, QNH value, runway-in-use “wind 80°, 5 gusts 8 m/s, QNH 1007, RW 08”) and gave clearance to landing. A few seconds later, at 05:38:30 pm, the controller informed the crew of the runway status: "Runway is wet, water up to 3 mm, friction Mu-factor 0.54, braking action is “Good." The crew confirmed receipt of all information provided by the controller.

According to subparagraph (a) of paragraph 5.3.8.2 of the Operating Instruction of the Kyiv (Zhulyany) Airport Control Tower, the information on significant changes in the mean direction and speed of the surface wind must be transmitted at the beginning of the final approach segment. The Tower controller did not provide such information to the aircraft.

Note: Meteorological and aeronautical information was transmitted in full as part of ATIS radio reports: "D" for 17:22, "G" for 17:26 and "H" for 17:30. At 05:39:17 pm, the pilot asked for the actual value of the wind and received the answer: "wind 080º, 7 gusts 11 m/s."

In accordance with paragraph 5.1.4.2 of the Operating Instruction of the Kyiv (Zhulyany) Airport Control Tower, the controller shall, at the request of the pilot, provide the information contained in the relevant radio broadcast or instruct to listen to an appropriate frequency. At the time of the crew's inquiry about the actual value of the wind, the ATIS broadcast contained the following information about the wind at the aerodrome (at 05:36:39 pm for 05:30 pm): "wind magnetic, landing zone 080º 7 m/s, varies from 060 to 120º, runway threshold 080º 6 m/s, gusts maximum 9 minimum 4 m/s, varies from 070 to 130º." In accordance with paragraph 5.1.4.3 of the Operating Instruction of the Airport Control Tower of the Kyiv (Zhulyany) Airport, upon receipt of the information not yet included into the relevant radio broadcast, but which may affect flight operations, the controller shall transmit this information to the respective aircraft.

...

The aircraft touchdown was performed at 05:39:53.

Note: According to SPECIAL Local Special Report for 05:40 pm, the weather
conditions were as follows:

«Wind in the landing zone 090º 9 m/s, maximum wind speed 13 m/s, minimum wind speed 6 m/s, varies from 060º to 170º, at the end of the runway 130º, 5 m/s, varies from 060º to 200º, landing zone visibility 10 km, weather phenomenon - thunderstorm, light rain, scattered cumulonimbus at 630 m, broken cloudiness at 1230 m, air temperature 22ºС, dew point temperature 19ºС, QNH: 1006 hPa, atmospheric pressure at the level of the runway threshold: 0986 hPa, forecast for landing: occasionally, surface wind direction variable, wind speed 10 m/s with gusts up to 17 m/s, visibility 1000 m, thunderstorm, moderate rain, squall, broken cumulonimbus at 750 m, wind at altitude of 500 m 120º, 13 m/s, thunderstorm, squalls line with azimuth from 071º to 270º, distance 12/96 km, moving to the northeast with 30 km/h, weakening."

The Tower Flight Director was watching the aircraft run on the runway. Having seen that the aircraft suffered the runway excursion, the Flight Director instantly, at 05:40:17 pm, announced Alarm to rescue teams.

According to the SPECIAL Local Special Report for 05:40:50 pm (upon the
Alarm), the actual meteorological conditions at the aerodrome were as follows:

“landing zone wind 140º, 9 m/s, maximum wind speed 13 m/s, minimum wind speed 4 m/s, changes from 060º to 250º, at the end of runway 150º, 6 m/s, maximum wind speed 12 m/s, minimum wind speed 3 m/s, varies from 060º to 210º, landing zone visibility 10 km, weather phenomenon - thunderstorm, light rain, scattered cumulonimbus at 630 m, broken clouds at 1230 m, air temperature 22º, dew point temperature 19º, QNH: 1006 hPa, atmospheric pressure at the level of the runway threshold: 986 hPa, landing forecast: occasionally, variable wind direction, wind speed 10 m/s with gusts up to 17 m/s, visibility of 1000 meters, thunderstorm, moderate rain, squall, broken cumulonimbus at 750 m, wind at 500 m altitude: 120º 13 m/s, thunderstorm, line of squalls azimuth sector from 071º to 270º, distance of 12/96 km, moving to the northeast with 30 km/h, weakening.”

In accordance with the requirements of subparagraph d) paragraph 4.1. of the Regulations on Aircraft Flights and Air Traffic Services in Ukraine's Classified Airspace, one of the main tasks of the ATM, namely, provision of advice and information to ensure the safe and efficient operation of flights, was not fully implemented by BVO, BVL, BV1 and BV5 controllers. In the course of the investigation, it was established that the ATS working shift of the Kyiv ACC was fully prepared in accordance with the current legislation.

The NBAAI analysed that descending through 1000 feet AGL, the GPWS sounding "One Thousand", the aircraft speed was 168 KIAS (Vapp=133 KIAS, which was Vref+20 knots) and the aircraft was descending at 1150 fpm, both values being outside the stabilized criteria. The captain should have initiated a go around at this point.

Descending through 500 feet AGL the aircraft was doing 168 KIAS, was 2 dots below glide slope, both values being outside the stabilized criteria, which should have prompted a go around.

The NBAAI concluded that part of the analysis:

Height 200 feet, speed 168 knots, heading 79 degrees, distance from the runway threshold 1150 m, deviation to the left from the runway center line 14 m. On the CVR record, the voice alert system gives the Minimums signal. From height 200 to 100 feet, the pitch gradually increases from -5 to -3, and the instrument speed drops from 168 to 160 knots. Upon crossing the height of 100 feet, the engine mode increases from 1.1 to 1.3-1.35 EPR. The instrument speed stabilizes at a value of 151 knots. The PIC's report on continuation of the landing approach was not found in CVR recordings. There was no action also on the part of the co-pilot to perform go-around.

Note: According to paragraph 1.5.1 (Duties and Responsibilities of Co-Pilot) of the Operation Manual of Bravo Airlines LLC, Part A, the co-pilot should perform goaround according to FCOM from the decision altitude, if till that moment the PIC failed to take a decision and failed to notify the crew of landing or go-around.

The NBAAI analysed the landing:

After touchdown, the crew deploys a thrust reverser and begins to increase the engine thrust level. Spoilers were not deployed in the automatic mode after touchdown, and the crew did not deploy them in the manual mode.

Lowering of the nose landing gear took place for one second after touchdown.

During the run, the PIC must immediately apply the brake system according to the manuals. The PIC's braking actions were correct.

After the main gear touchdown and after start of the nose gear lowering, the thrust reversers must be switched to the throttle reverse idle gate system. After the nose wheel is compressed, and ENG REVERSE UNLOCK and ENG REVERSE THRUST lights are on, the reverse thrust should be increased as needed. The Pilot Non-flying must monitor the engine's operating limits and report of any approaching or exceeding engine operation limits, any thrust reverse failures or other deviations. It is necessary to apply the required value of the reverse thrust up to the maximum – to reach the speed of 80 knots, but, at the actual runway condition – no more than 1.3 EPR, as recommended in the Flight Operations Bulletin and Letter to All MD-80 Aircraft Operators.

However, the crew actions to use the reverse were incorrect. The engine operation mode on the reverse thrust was increased to 1.9-2.1 EPR.

05:39:57.5 pm: EPR = 1.3 In 4 seconds after the runway touchdown by the main landing gear, at 715 m from the runway threshold (365 m from the touchdown point), the engine reverse thrust reaches 1.3 EPR and continues to increase. Simultaneously with achievement of EPR = 1.3 in the reverse thrust mode, the aircraft had a tendency to turn by heading and deviate to the left due to the previous deviation of the rudder to the left (Figure 10.) Differential braking of the right landing gear wheels up to the pressure of 2000 psi and then – to the maximum pressure of 3000 psi was applied to compensate the turning moment to the left and maintain the aircraft heading along the runway center line. The rudder was deflected to the right to the maximum values.

However, the differential braking by the right wheels and handwheel control deflection (simultaneously with the rudder) to maintain the movement direction parallel to the runway center line during the aircraft run were ineffective due to spoilers nondeployment, and the rudder deflection control at the expense of aerodynamic forces "was ineffective" due to shadowing of the rudder. "The aircraft continues to turn to the left of the heading and continues to move uncontrollably with drift to the left along the runway center line.

In order to correct the aircraft back to the center line, the brakes must be released, and the reverse thrust should be reduced to idle. The brakes release increases the tire rotation and contributes to maintaining or restoring the directional control. Switching the reverse thrust to idle reduces the lateral component of the thrust force with no need to go through a complete reverse cycle. Pedal steering and differential braking must be used to prevent an excessive correction with crossing the runway centerline. When heading control is restored and the aircraft is aligned along the runway center line, the maximum braking and symmetrical reverse thrust should be applied to fully stop the aircraft.

...

Failure to maintain the specified parameters for using the reverse thrust during the landing run, namely, maintaining the value of the degree of increase in engine pressure above 1.3 EPR, has led to the loss of the aircraft controllability due to a rudder shading and did not allow the crew keeping the aircraft within the runway, and caused its runway excursion to the left.

05:40:07 pm: Runway Excursion. In 13.5-14 seconds after touchdown, at the
distance of 1260 m from the threshold, the aircraft is suffering the runway excursion.

The recorded instrument speed was 48 knots (taking into account the drift angle and air pressure probe shading, it was approximately 60 knots). The aircraft continued its movement on the soil beyond the runway and stopped at the distance of 1690 m from the runway threshold, 145 m to the left of the runway center line (counting to the aircraft center-of-gravity position.) 2 to 3 seconds prior to the runway excursion, the engines were slowed down, and the left wheel brakes were applied (up to 2000 psi.) The right and left wheels braking continued to be applied until the aircraft came to rest.

The further movement of the aircraft is marked with the tire footprints.

After the runway excursion, the PIC re-increased the power rating in the reverse thrust mode.

In the process of movement outside the runway, the right main landing gear retracted to the undercarriage bay, and the left main landing gear was broken, which damaged the left wing and spoiler mechanism on the left side (Figure 11), resulting in deflection of the left spoilers, which was recorded by the FDR.

2 to 3 seconds before the aircraft came to rest, the flaps were retracted to 28 degrees. According to the PIC, the flaps were retracted for convenience of passenger evacuation.

The FDR did not contain a record of engine shut down (probably, according to the instructions, the recorders were turned off after the aircraft stop with circuit breakers pulling.)

The aircraft suffered damage, which is depicted in section 1.3 of this report, as a result of movement on the soil.

As a result of the accident, none of the crew and passengers sustained serious injuries.

The aircraft was recovered from the aerodrome in a week after the accident, following which, the airport operation was restored with no limitations.

Metars:
UKKK 141900Z VRB01MPS 8000 -TSRA SCT028CB 19/18 Q1008 R08/290354 TEMPO VRB10G17MPS 1000 TSRA SQ BKN025CB=
UKKK 141830Z 34002MPS 300V010 9000 -TSRA SCT028CB 19/17 Q1008 R08/290354 TEMPO VRB10G17MPS 1000 TSRA SQ BKN025CB=
UKKK 141800Z 25008G13MPS 180V280 7000 1900E TSRA SCT014 BKN026CB 19/17 Q1008 R08/290354 TEMPO VRB10G17MPS 1000 TSRA SQ BKN025CB=
UKKK 141741Z 10007G16MPS 9999 -TSRA SCT021CB BKN041 22/19 Q1007 R08/290354 TEMPO VRB10G17MPS 1000 TSRA SQ BKN025CB=
UKKK 141730Z 10006MPS 070V130 7000 -TSRA SCT021CB BKN043 23/19 Q1007 R08/290354 TEMPO VRB10G17MPS 1000 TSRA SQ BKN025CB=
UKKK 141721Z 11006MPS 9000 -TSRA SCT026CB 25/18 Q1007 R08/CLRD70 TEMPO VRB10G17MPS 2100 -TSRA BKN025CB=
UKKK 141700Z 11004MPS CAVOK 25/17 Q1007 R08/CLRD70 NOSIG=
UKKK 141630Z 11005MPS 080V150 CAVOK 25/17 Q1007 R08/CLRD70 NOSIG=
UKKK 141600Z 11006MPS CAVOK 26/17 Q1006 R08/CLRD70 NOSIG=
UKKK 141530Z 11005MPS CAVOK 27/17 Q1006 R08/CLRD70 NOSIG=
UKKK 141500Z 11004MPS CAVOK 27/16 Q1007 R08/CLRD70 NOSIG=
UKKK 141430Z 10005MPS CAVOK 27/15 Q1007 R08/190060 NOSIG=
UKKK 141400Z 12004MPS CAVOK 27/15 Q1007 R08/190060 NOSIG=