Vliegtuigongeval op 01 SEP 2018 met Boeing 737-8AS (WL) VQ-BJI - Adler/Sochi Airport (AER)
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Status:Accident investigation report completed and information captured
Datum:zaterdag 1 september 2018
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8AS (WL)
Registratie: VQ-BJI
Constructienummer: 29937/1238
Bouwjaar: 2002-10-30 (15 years 10 months)
Aantal vlieguren:45745
Aantal vluchten:23434
Motoren: 2 CFMI CFM56-7B26
Bemanning:slachtoffers: 0 / inzittenden: 6
Passagiers:slachtoffers: 0 / inzittenden: 166
Totaal:slachtoffers: 0 / inzittenden: 172
Schade: Vernield
Gevolgen: Written off (damaged beyond repair)
Plaats:Adler/Sochi Airport (AER) (   Rusland)
Fase: Landing (LDG)
Soort vlucht:Binnenlandse lijnvlucht
Vliegveld van vertrek:Moskva-Vnukovo Airport (VKO/UUWW), Rusland
Vliegveld van aankomst:Adler/Sochi Airport (AER/URSS), Rusland
Utair flight 579, a Boeing 737-800, suffered a runway excursion accident after landing at Adler/Sochi Airport, Russia.
The aircraft departed Moscow's Vnukovo Airport at 00:32 hours local time on a domestic flight to Sochi. The first officer acted as the pilot flying (PF).
Weather at Sochi was poor due to the presence of a thunderstorm in the area. After descending to FL90, the pilot contacted Sochi Radar, waited for the weather that met his minimum and was cleared for landing on runway 06.
At 02:44:11, when the aircraft was at 850 ft (about 260 m) and at distance of 5000 m from the threshold, the Predictive Windshear System Warning sounded: "Go around. Windshear ahead". The crew ignored the wind shear warnings and continued to descend along the glide path. Upon passing the Decision Height of 627 ft (190 m), the PF did not verbalize a decision to continue or go around. The aircraft continued to descend. At 02:45:09, at the altitude of about 170 ft (50 m) and at distance of 850 m from the runway threshold, the "Windshear, Windshear, Windshear" alert sounded in the cockpit.
At an altitude of about 30 m visibility decreased because of heavy showers. The captain took over the controls and performed a go-around. The workload increased and the first officer forgot to raise the flaps from position 1 to fully up, despite stating this to the captain. Half a minute later he realised his mistake and proceeded to raise the flaps. While complaining about the weather, the crew encountered difficulties in engaging the autopilot but eventually succeeded.
Starting 02:49 the aircraft was hastily prepared for the second approach. The captain was now acting as PF for the approach. This time the aircraft was high and fast.
At 02:53:49, the controller informed the flight that a preceding aircraft had gone around. The first officer than contact the Tower controller and reported intercepting the glide slope at 600 m, despite the fact that the aircraft had not reached that altitude yet. Sochi Tower cleared the flight for the approach. At 02:54:48, the flight was cleared to land on runway 06.
At height of 1050 ft (320 m) at a distance of 6100 m from the runway, the aural warning: "Go around. Windshear ahead" sounded, but the approach was continued.
The flight crew failed to verbally confirm that the approach was stabilized, with the captain simply stating: "...to minimum." In fact the approach was not stabilized given the variation in airspeed.
The first officer called out speeds and altitudes continuously in a rather tense voice. During the approach the autopilot and autothrust were engaged.
At 02:56:42, at height of about 470 ft (145 m) and distance of 2650 m to the runway, the chime sound and three-time aural warning "Windshear, Windshear, Windshear" sounded. However, the crew, in spite of these warnings, continued to descend.
At 02:57:13, at height of 75 ft (25 m) and distance of 150 m to the threshold, the captain had disengaged the autopilot and autothrottle, and took manual control. At this time, the aircraft was in the center of the wind shear. Exactly before that, the autothrottle started to reduce the engine rotation speed as the instrument speed to this moment had reached the value of 170 kts. When the autothrottle was disengaged, the throttles remained in this setting. It resulted in the instrument speed increase up to 173 kts. The aircraft passed over the threshold at height of about 54 ft (15 m) and touched down about 1285 m from the threshold at an instrument speed of 160 kts.
Right after the aircraft had landed the spoilers were extended automatically and autobrake was initiated. The first officer reported "Speedbrake up, Reversers maximum", but the reversers were not yet engaged. The captain noticed this 20 seconds after touchdown and immediately ordered them to be deployed. The engines however were already at ground idle, and when the engines reached maximum reverse mode the aircraft had already overrun the runway.
At 02:57:54, 26 seconds after touchdown, the aircraft overran the runway with a ground speed of about 75 kts, broke through the aerodrome fencing and came to rest on a dry and rocky surface in a river bed. Eighteen passengers were injured. The aircraft sustained serious damage.

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 about 200 m from the runway end)

Accident investigation:

Investigating agency: MAK Russia
Status: Investigation completed
Duration: 1 year and 5 months
Accident number: final report
Download report: Final report

METAR Weather report:
00:00 UTC / 03:00 local time:
URSS 010000Z 23004MPS 5000 1800E R02/P3000N TSRA BKN006 OVC030CB 21/21 Q1014 WS ALL RWY R02/250350 R06/250350 NOSIG RMK R06/19004MPS QBB200 MT OBSC QFE759
Winds 230° at 8 kts; Visibility: 5 km; Broken clouds at 600 feet, overcast Cumulonimbus cloud deck at 3000 feet; Temperature and dewpoint 21°C; pressure 1014 mb

22:00 UTC / 01:00 local time:
URSS 312200Z 07004MPS 030V100 4900 1600NW R02/P3000N TSRA SCT013 OVC020CB 22/20 Q1014 WS ALL RWY R02/250350 R06/250350 NOSIG RMK R06/08008G13MPS MT OBSC QFE759

22:30 UTC / 01:30 local time:
URSS 312230Z 07009G16MPS 0400 0250E R06/0900U +TSRA VV013 22/18 Q1014 WS ALL RWY R06/250350 R02/250350 NOSIG RMK R02/04007G12MPS MT OBSC QFE759

23:00 UTC / 02:00 local time:
URSS 312300Z 08009G14MPS 9000 VCTS -SHRA FEW013 OVC033CB 22/19 Q1013 WS ALL RWY R06/220355 R02/250350 NOSIG RMK R02/08007G12MPS MT OBSC QFE759

23:30 UTC / 02:30 local time:
URSS 312330Z 10010G22MPS 030V140 0500 0250NW R02/1200U +TSRA VV013 19/19 Q1014 WS ALL RWY R02/250350 R06/250350 TEMPO VRB10G22MPS 0500 +TSRA


MAK issued 12 Safety Recommendations

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photo of Boeing-737-8AS-VQ-BJI
accident date: 01-09-2018
type: Boeing 737-8AS (WL)
registration: VQ-BJI
photo of Boeing-737-8AS-VQ-BJI
photo of Boeing-737-8AS-VQ-BJI
photo of Boeing-737-8AS-VQ-BJI
accident date: 01-09-2018
type: Boeing 737-8AS (WL)
registration: VQ-BJI

Video, social media

Aircraft history
date registration operator remarks
30 Oct. 2002 EI-CTB Boeing first flight
19 Nov. 2002 EI-CTB Ryanair delivered
14 March 2009 EI-CTB Ryanair stored at Chteauroux
13 May 2010 VQ-BDU Atlant-Soyuz Airlines
1 Nov. 2010 VQ-BDU Moscow Airlines
19 Jan. 2011 VQ-BDU Moscow Airlines stored at Sofia
7 Oct. 2011 VQ-BJI UTAir

Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Moskva-Vnukovo Airport en Adler/Sochi Airport bedraagt 1354 km (846 miles).
Accident location: Exact; deduced from official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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