Caspian MD83 at Mahshahr on Jan 27th 2020, overran runway on landing
Last Update: September 1, 2020 / 18:21:47 GMT/Zulu time
Incident Facts
Date of incident
Jan 27, 2020
Classification
Accident
Flight number
IV-6936
Departure
Tehran Mehrabad, Iran
Destination
Mahshahr, Iran
Aircraft Registration
EP-CPZ
Aircraft Type
McDonnell Douglas MD-83
ICAO Type Designator
MD83
On Jan 27th 2020 in the evening (Tehran time) Iran's AIB released their preliminary report in Persian stating the captain was pilot flying. The aircraft had departed Mehrabad's runway 29L, had flown about 50 minutes and landed on Mahshahr's runway 13, but overran the end of the runway. There have been no injuries.
The aircraft had performed a VOR/DME runway 13 approach. According to ground observers at the airport the aircraft landed long, went through the airport perimeter fence and came to a stop at the Expressway. Tower activated emergency services who arrived at the aircraft within 4 minutes.
The AIB is conducting the investigation into the accident (editorial note: in the report there is no mention of any emergency prior to touch down).
On Sep 1st 2020 Iran's AIB released their final report (editorial note: first 3 pages in Persian, then the English report follows) concluding the probable causes of the accident were:
The Aircraft Accident Investigation Board determines that the probable causes of this accident were the pilots’ failures below, resulting in a runway overrun:
- Poor decision-making for acceptance of the risk of high-speed landing;
- Un-stabilized approach against the normal flight profile;
- Poor CRM in the cockpit; and
- Poor judgment and not accomplishing go-around while performing an unstabilized approach.
Contributing Factors:
- Loading of 5 tons of extra fuel, which increased the landing distance required.
- Decision to make a landing on RWY 13 with tailwind.
- Inability of the copilot (PM) to take control of the aircraft and proper action to execute goaround.
The AIB reported the captain (64, ATPL, 18,430 hours total, 7,759 hours on type) was pilot flying, the first officer (28, CPL, 300 hours total, 124 hours on type) was pilot monitoring. The crew requested a VOR/DME approach to runway 13.
The flight was normal until the approach. The descent/approach checklist was carried out, however, only partially. The landing checklist was missed by the crew.
The transcript quoted in the report shows eight "Sink Rate" GPWS callouts between 1000 feet AGL and 500 feet AGL (automated GPWS callouts), following the automated 400 feet AGL GPWS call out the GPWS sounded "Sink Rate!", "Pull up!", "Pull up!", "Pull Up!", "Sink Rate!", "Sink Rate!", "Sink Rate!", "Fourty", "Sink Rate!", "Twenty", "Ten".
Radar data showed the aircraft at 2700 feet MSL (aerodrome elevation 18 feet) at 249 knots over ground about 3nm before the runway threshold.
The aircraft touched down nose gear first at 171 KIAS (Vapp 135 KIAS, Vref 131 KIAS) 1695 meters past the runway threshold (LDA 2695 meters) at about +1.22G after having descended through the last 1000 feet AGL within 38 seconds (average rate of descent about 1580 feet per minute). The gear proximity switch went into ground mode, briefly into airborne mode before returning to ground mode, a bounce thus was likely.
No injuries occurred, the aircraft however received so substantial damage that the AIB assessed the aircraft as destroyed.
The AIB computed the landing distance in the circumstances:
MAHSHAHR RWY 13 length: 8842 ft. (2695m)
- Normal landing distance with this weight: 3865 ft.(1178m)
- tailwind correction: +508 ft. (155m)
- speed above Vref: +2438 ft. (743m)
- 5 tons extra fuel (at least):+250 ft.(76)
Based on the analysis, the minimum required distance for the flight in normal condition was calculated at 2152 m.
The AIB analysed:
At 03:49:34 UTC, CPN 6936 requested descent clearance, so the flight was cleared to FL100.
At 03:50:03 UTC, the pilots performed the Descent/ Approach checklist, but landing data & briefing were not completely done.
At 03:52:30 UTC, the pilot called Mahshahr AFISO and reported position 50 nm inbounds GODMO and estimated time over GODMO at 03:59 UTC.
At 03:52:51 UTC, Mahshahr AFISO reported necessary information as below:
"RWY active is 31; wind is now 280/08kts, CAVOK, temperature +06, DP 04 and QNH 1023, expected VOR approach RWY 31 via GODMO 1E ARRIVAL"
At 03:53:33 UTC, the pilot requested RWY 13 to save time and Mahshahr AFISO approved it to perform VOR/DME Approach RWY13, via GODMO 1F arrival. The pilot made a poor decision to land on RWY 13 with the risk of extra fuel onboard and tailwind condition.
At 03:59: 39 UTC, the pilot reported, "We are approaching position GODMO" and the TRN ACC controller asked; "Would you confirm in contact with destination Mahshahr” The pilot told him "Affirm". After that, the controller released the flight CPN 6936 to destination Mahshahr as below:
"Frequency change approved, Radar service terminated and no reported traffic below"
The minimum safe level of the route on “GODMO” was FL40, but the ACC controller transferred the flight at FL100 to Mahshahr AFISO, which was against L o C. The flight was not informed to the Ahwaz Airport either.
At 04:00:41 UTC, the pilot reported his position "GODMO" to Mahshahr AFISO. In accordance with radar data and FDR, the flight was then reaching FL100. Afterwards, the flight received the information below:
“CPN 6936 yes sir; descend as profile to MNM 2000 ft. for VOR/DME APP RWY 13, report when leaving IAF and cleared APP”
At 04:02:46 UTC, the pilot reported leaving of IAF (FDR data shows the altitude at 6647ft. and computed airspeed 243 kt.) and received landing clearance for RWY13. Meanwhile, the crew prepared the cabin for landing.
At 04:04:35 UTC, the autopilot was disengaged and the aircraft passed 2500 ft. (radio altimeter) with high actual speed 219 kt. Then the captain decided to control altitude & speed by executing “S” turn maneuver several times and continued in visual reference with the ground.
At 04:05:29 UTC, at altitude 934 ft. the captain asked the copilot to set speed and the copilot called out airspeed 135 knots (target speed) when the FDR was showing IAS 196 kt. After a moment upon receiving EGPWS Sink Rate warning, the copilot warned the pilot to read the landing checklist, but the captain did not accept and accomplished an unstabilized high-speed approach for the purpose of landing. In this situation, the captain as pilot flying should commence go-around, but yet again he continued for landing. Meanwhile, the copilot should advise un-stabilized approach and call out go-around.
The copilot claimed in his statement after the accident that:
“I wanted to take control of the aircraft and follow missed approach procedure but due to pilot over-confidence to overcome present situation and age gap, I disregarded it.”
From 1000ft until 10 ft. altitude, sink rate and pull up warnings were recorded in the CVR successively which were heard by the crew (cockpit and senior cabin crew).
Finally, at 04:06:11 UTC, the aircraft landed with high speed (171 kt.); however, the landing speed in landing BUG card was considered at 131 kt. and after passing two-thirds of RWY touched the RWY with the nose landing gear. Full auto thrust reversers and brakes were applied. The aircraft overran the runway, rolled through a non-paved area and airport perimeter fence, passed a shallow canal then onto an adjacent roadway, where it struck a concrete median strip and a lamp post before coming to a stop.
Metars:
OIAM 270600Z 30008KT 7000 NSC 08/06 Q1023=
OIAM 270500Z 29006KT 7000 NSC 07/05 Q1023=
OIAM 270400Z 28006KT CAVOK 06/04 Q1023=
OIAM 270300Z 29008KT 8000 NSC 06/04 Q1022=
OIAM 270200Z 29004KT CAVOK 06/04 Q1022=
OIAM 270100Z 00000KT CAVOK 06/04 Q1022=
OIAM 270000Z 00000KT CAVOK 07/01 Q1022=
Incident Facts
Date of incident
Jan 27, 2020
Classification
Accident
Flight number
IV-6936
Departure
Tehran Mehrabad, Iran
Destination
Mahshahr, Iran
Aircraft Registration
EP-CPZ
Aircraft Type
McDonnell Douglas MD-83
ICAO Type Designator
MD83
This article is published under license from Avherald.com. © of text by Avherald.com.
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