Data for the aircraft crew:
aircraft commander - born in 1965, line pilot, total flight time 13,125 hours, as an RRJ-95 aircraft commander - 1,080 hours;
co-pilot - born in 1980, commercial pilot, total flight time 3200 hours, on RRJ-95 aircraft - 1300 hours.
Since May 2018, work has been carried out at the Yakutsk airfield to reconstruct the runway (RWY-05R / 23L), in connection with which the threshold of RWY-05R was moved towards the control point of the aerodrome (KTA) by 1150 meters, and the available landing distance of the runway - 23L is reduced to 2248 meters. Landing aircraft on runway-05R is prohibited. Information on the restrictions imposed has been included in NOTAM A4144/18.
After the aircraft landed on RWY-23L (landing heading magnetic 232°), the aircraft rolled out of its working part at a distance of about 250 meters onto the reconstructed section of the runway. When the aircraft moved along the non-working part of the airfield, the main landing gear was destroyed and the power elements glider. According to preliminary data, medical care 4 passengers applied after the accident.
Landing was carried out in the following weather conditions: wind: 50° 3 m/s, visibility: more than 10 km, cloud cover: significant broken with a height of the lower limit of 600 meters, cumulonimbus, temperature: minus 3°C, dew point: minus 4°C , pressure: QNH 1012 hPa.
Initially, the condition of the runway-23L was estimated with a friction coefficient of 0.45. The same information was transmitted, according to preliminary data, to the crew of the aircraft. However, when assessing the condition of the pavement on RWY-23L after the accident, ice was recorded, the values of the friction coefficient after the measurement were - 0.25 / 0.32 / 0.25, which may indicate improper maintenance of the airfield elements in operational condition airfield service of Yakutsk airport.
The aircraft RRJ-95B RA-89011 was operated with a delayed malfunction - engine reverser deactivated No. 2. According to the limitations of the list of minimum equipment, landing with engine reversers deactivated is allowed with a friction coefficient of at least 0.4.
In March 2018, at a meeting on problematic issues operation of the Yakutsk airfield during the reconstruction of the runway, the Federal Air Transport Agency drew the attention of airlines to the need to develop additional measures aimed at ensuring safe operation aircraft, taking into account the limitations of the takeoff and landing distance.
In 2018, during the inspection of the activities of Yakutia Airlines JSC for compliance with the requirements of federal aviation regulations, the Federal Aviation Administration revealed significant violations of the requirements of air legislation Russian Federation, including:
violation of the maximum duration of flight shifts for flight crews of aircraft;
default Maintenance aircraft on time;
violation of the deadlines for the replacement of aircraft products with a limited resource;
falsification of production and technical documentation.
Based on the results of inspections, the commissions of the Federal Air Transport Agency concluded that the airline's flight safety management system does not fully meet the established requirements, the airline's management is not able to take effective measures to eliminate shortcomings in the airline's activities.
Currently, the Federal Air Transport Agency is considering the issue of introducing restrictions on the validity of the air operator certificate of Yakutia Airlines JSC in accordance with the requirements of federal aviation regulations.
After the accident, work on the evacuation of the aircraft from the runway lasted more than 12 hours, which indicates the lack of the necessary equipment and proper training of personnel at the airport. As a result, the activity of the airport was partially paralyzed - only the departure of aircraft was provided (the airport was closed to receive aircraft).
In March 2017, by letter dated March 13, 2018 No. Vn-2589/04, Rosaviatsia drew the attention of airfield operators to the need for equipment for the evacuation of aircraft that have lost the ability to move for the types of aircraft in operation.
It should also be noted that annually Rosaviatsiya prepares and sends to organizations civil aviation recommendations for taking additional measures aimed at reducing the risks associated with violations that lead to aircraft overrunning the runway. The same issues were emphasized in the directive letter of the Federal Air Transport Agency dated July 30, 2018 No. Ref-18920/02 “On the organization of control over the preparation of civil aviation organizations for the performance and support of flights in the autumn-winter period of 2018-2019”.
I suggest:
1. Managers territorial bodies Rosaviatsia:
1.1. Bring this information to the controlled organizations of civil aviation.
1.2. Conduct an analysis of the procedures for checking the condition of the movement area of the aerodrome contained in Section 4.5 of the Aerodrome Operator's Manual in terms of whether they require an increase in the frequency of checks on the condition of the runway (changes in the friction coefficient, area and thickness of the precipitation layer) in meteorological conditions that contribute to a decrease in braking efficiency.
1.3. At all international airports and airports federal significance until November 10, 2018, organize unscheduled training sessions with personnel and training to practice actions during the evacuation of aircraft (for operated types of aircraft) that have lost the ability to move.
2. Heads of civil aviation organizations:
2.1. Examine the present information with the staff on maintenance aerodrome and air traffic control personnel using information on flight safety previously issued by the Federal Air Transport Agency (No. 26 for 2015; No. 22 for 2016; No. 5 and 19 for 2017), as well as materials posted on the official website of the Federal Air Transport Agency at https: //www.favt.ru/dejatelnost-lms-beopasnost-vpp/ .
2.2. Draw the attention of flight and engineering personnel to the restrictions contained in the minimum equipment list (MEL) associated with the continued operation of the aircraft with malfunctions of reversers, brake flaps (spoilers, spoilers), wheel brakes of the main landing gear, as well as additional restrictions available take-off and landing distances published in aeronautical information documents.
2.3. Conduct additional simulator training for flight crew members to practice the following elements:
landing approach according to the OSB system;
landing in conditions of shortage of the available landing distance, taking into account the actual conditions ( weather conditions; runway pavement condition; MEL (in-flight) and non-MEL (in-flight) failures of aircraft systems that increase flight distance);
failure of reversing devices and braking system on the run;
2.4. For the period of reconstruction of the runway of the Yakutsk airfield, it is forbidden to operate aircraft with malfunctions that preclude the use of engine reversers, brake flaps (spoilers, spoilers) or wheel brakes of the main landing gear specified in the minimum equipment list (MEL) during landing.
3. Head of the Flight Safety Inspectorate of the Federal Air Transport Agency S.S. Masterov to organize control over the execution of this information.
When performing air transportation, in addition to the aircraft, various services are involved that make up the air transport system (ATS) of civil aviation.
The flight safety of an aircraft is determined by the reliable functioning of all components included in the automatic telephone exchange.
Flight safety is understood as the properties of an automatic telephone exchange, consisting in its ability to carry out air transportation without endangering human life and health.
When performing a flight in each of the links of the automatic telephone exchange, along with normal operation, failures and errors are possible. At the same time, it is taken into account that failures of the functional systems of the aircraft are not ruled out in flight, the crew, when piloting the aircraft, under certain circumstances, allows incorrect actions, and, finally, in the activities of ground services for flight preparation and ATC, along with normal actions, errors also occur (Fig. 4).
Rice. 4. Factors determining the safety and airworthiness of vehicles
Thus, flight safety is ensured by a combination of characteristics of the aircraft, crew, ground operations services and ATC. The flight safety provided by the aircraft as an ATS link is assessed by its airworthiness, the level of which is established by the Airworthiness Standards (NLG).
An indicator of aircraft safety is its compliance with airworthiness standards. Under airworthiness understand the ability of an aircraft to operate safely over the full range of its specified expected operating conditions (EOCs) under established operating procedures and provided that the other components of the vehicle are functioning normally.
Flight safety depends on three main factors: the aircraft, the person and environment(Table 4). Each of them is subject to the influence of numerous random factors and their combinations, such as equipment failures, errors of the flight crew and ground services, dangerous atmospheric disturbances (severe turbulence, icing, lightning, etc.).
Table 4
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An analysis of the state of flight safety over the past 10 years shows that in 1998-2003 there was a decrease in the total number of accidents in commercial civil aviation.
However, since 2004 the situation has deteriorated. There is an upward trend in the number of accidents and catastrophes.
In 2008, the state of accidents in commercial aviation was characterized by the following indicators: there were 8 accidents in which 129 people died, 5 accidents, 912 incidents, 5 emergency aviation accidents.
The crash of the B737 aircraft of the Aeroflot-NORD airline at the Perm airport had the most severe consequences last year. It killed 88 people.
The investigation into the crash was completed in May this year. Using the example of this catastrophe, we will consider the shortcomings in the work of the Central Office of the Federal Air Transport Agency, territorial bodies and air carriers.
During the investigation, the causes that led to this accident were established. These include:
- The airline's pilot training programs were developed on the basis of the outdated GA-92 PLS, which did not take into account the specifics of training pilots who had no experience in flying on foreign-made aircraft, with electronic indication, in a two-member crew. This program was developed by the airline and approved by the territorial administration. Thus, the head of the department exceeded his official powers.
- immediate cause accident was the loss of spatial orientation by the pilot, which became the result of the failure of the crew to comply with standard operating procedures, as well as the presence of deferred defects in MEL which were not eliminated by the technical staff. Long-term failure to eliminate defects, failure to use the requirements of the troubleshooting chart and the presence of a significant number of extended deferred defects indicate the unsatisfactory quality of aircraft maintenance in the airline and the poor level of training of VARZ-400 personnel who carried out this maintenance.
- Absence from the airline qualification requirements by knowledge of English language for flight crew members and technical personnel operating foreign-made aircraft with documentation in English.
- The qualifications of the instructors and command-and-flight personnel did not allow to objectively determine the insufficient professional level of pilot training, which affected the formation of the crew.
- Lack of instructional materials regulating the procedure for training crews during retraining and regular training on procedures for actions in case of loss of attitude of the aircraft.
- Immediately before the crash, the airline was checked by the MTU, whose specialists did not have access to the operation of foreign aircraft. They didn't find any shortcomings. However, when checking the organization of flight work in the airline after the disaster, the commission of the Federal Air Transport Agency and Rostransnadzor revealed serious violations.
It should be noted that all these shortcomings are inherent in many airlines and it is necessary to work on their elimination. The remarks noted in the act regarding the Federal Air Transport Agency have been eliminated by the central office. The Pilot Training Program and the Regulations on Examiner Pilots were approved.
In 2009, civil aircraft of commercial aviation of the Russian Federation experienced: 2 crashes, in which 11 people died, 1 accident and 298 incidents.
On January 12, 2009, an Mi-2 helicopter crashed, owned by Converse Avia Airline CJSC, 4 people died;
On January 9, 2009, the Mi-171 helicopter, owned by Gazpromavia Aviation Enterprise LLC, crashed, 7 people died.
In a number of aviation events with helicopters of airlines and GA operators, the negative role of the customer of aviation work can be traced, which force the operators to carry out flights with violations of the requirements normative documents guided only by economic considerations. Such violations become possible in the absence of proper control by the territorial departments over the organization and performance of flights by controlled operators, as well as the lack of proper analysis when coordinating flights in the controlled territory by aircraft and crews of other territorial departments.
A good example of the dishonest performance of their duties and violation of documents regulating flight activities are the actions of the crew of the Tu-154 aircraft of UTair airlines, which on April 24 of this year. flew from Moscow to Samara. From the moment of takeoff and up to an altitude of 7700 meters, the crew did not remove the landing gear. This, together with further illiterate actions of the crew, led to an unauthorized and uncontrolled descent of the aircraft. The causes of a serious aviation incident are due to the illiterate actions of the crew due to violation of the requirements of the Flight Manual and documents regulating the flight rules.
The crew also violated the requirements for mandatory implementation report on the change in flight altitude, and upon arrival at Kurumoch airport (Samara), this aviation event was concealed.
To prevent such events in the future, the Federal Air Transport Agency has taken the following measures:
The crew was suspended from flights;
An unscheduled inspection of the Flight Detachment No. 7 of the Flight Directorate of UTair Aviation OJSC, Samara was carried out;
A decision was made to suspend the flights of an aviation squadron of Tu-154, Tu-134 aircraft;
Another issue that needs to be addressed is the implementation of recommendations resulting from accident investigations. The developed recommendations are being implemented for a long time and often not completely. Feedback on the acceptance (non-acceptance) of the recommendations was absent until recently. Since August 2008, the Federal Air Transport Agency has tightened the requirements in this direction.
In order to prevent situations related to shortcomings in the organization of flight work, in February 2009, the Federal Air Transport Agency held a special meeting with representatives of territorial bodies. At the meeting, shortcomings in the organization and conduct of investigations of aviation events were considered, specific recommendations were given for their exclusion.
In the central office of the Federal Air Transport Agency and in territorial administrations United Coordinating Centers have been set up to provide round-the-clock duty. This made it possible to constantly monitor the situation in civil aviation and quickly respond to emerging problems.
The Federal Air Transport Agency is implementing a number of other measures aimed at improving the level of flight safety:
- by decision of the FAVT, the Regulation on instructors and instructor-examiners of civil aviation enterprises was put into effect, which will improve efficiency state control for the training of aircraft crews;
- re-registration of all certification centers has been organized and is being carried out;
- unscheduled inspections of airlines with an unstable financial and economic condition are carried out;
- by decision of the FAVT, the Model Pilot Training Program was introduced;
- a meeting was organized and held with the leadership of the Aviation Equipment After-sales Service Department Management company JSC "United Aircraft Corporation" on the organization of after-sales support of aviation equipment produced by the industry.
A large role in the activities of the Federal Air Transport Agency is given to inspection checks and inspection control.
In 2009, 841 inspections were carried out in various areas. These checks were carried out by representatives of the central office of the Federal Air Transport Agency, as well as by inspectors of territorial departments.
As a result of inspections, 10 air operator certificates were cancelled. For two operators, the validity of the operator's license was suspended.
Safety management issues are acute in flight educational institutions. In 2006-2007, new initial training aircraft began to enter aviation schools. The period of mastering new technology was complicated by an increase in flight time per cadet up to 150 hours. This is due to the ICAO requirements for obtaining a commercial pilot license.
In solving the problems of flight safety, the Federal Air Transport Agency closely cooperates with the aviation authorities of many states and international organizations.
So in the period from 9 to 11 June 2009, a meeting was held between representatives of the Federal Air Transport Agency and federal agency civil aviation ( FAA ) USA. During the negotiations, the parties got acquainted in detail with the structure and powers of the aviation authorities, discussed the current state of the industry, exchanged experience and decided to resume joint work.
Recently Russian government recommended the leadership of domestic air carriers to do everything possible to ensure flight safety. It was recommended, and, first of all, to pay special attention to countries that are officially considered potentially dangerous in terms of migration. List of countries recognized by the Russian leadership as dangerous for Russian citizens, is quite an impressive list.
In addition to regions where terrorist activity continues today, as well as in countries where fighting, residents of the Russian Federation are not recommended to fly to the following states: Kazakhstan, followed by Albania, followed by Bulgaria, followed by Austria, England and, finally, Montenegro.
Today, the entire planet is in an unstable and unsafe situation. Even such resorts as Turkey and Egypt, Russian authorities recognized as dangerous for the Russians.
Then this list was supplemented by India. Deputies came to the same conclusion. State Duma. In their opinion, the attitude towards Russians has long since changed for the worse. Officials believe that residents of the Indian state of Goa are behaving too aggressively. Many politicians claim that local population of this resort paradise, clearly demonstrates its inadequacy.
What the statistics say
Despite the serious factors affecting flight safety, no one is going to take any significant measures this year. So far, the Russian government is making do with advisory measures. However, harsh statistics have repeatedly confirmed that aircraft do not belong to the category of the most dangerous modes of transport. Turning to the statistics, you can see that on average one person per 110 passenger kilometers dies in air crashes. The main agenda is the safety of flights in civil aviation.
Improving the safety of passenger air travel is always in the focus of attention not only of the Russian leadership, but also of the airline administration.
Choosing a seat on an airliner
Looking through the statistics, you can see that the largest number of air crashes occur during takeoffs and landings. This fact is explained by the complexity of piloting during takeoffs and landings. In addition, the influence of the human factor on flight safety is not excluded. Weather conditions also have a negative impact. The number of surviving passengers depending on their location:
- The front section of the cabin - 49%.
- Economy class, located in front of the wing - 56%.
- Economy class above the wing - 56%.
- The tail section of the cabin - 69%.
Latest data
Confidence in air travel has been undermined by numerous major disasters over the past few years. For example, a large-scale tragedy happened to a flight flying to St. Petersburg. The route began in the Egyptian resort of Sharm el-Sheikh. This happened on the last day of October 2015. The examination revealed that the airliner was attacked by terrorists, taking the lives of two hundred people. A year later, the world shuddered again, hearing about a new terrible catastrophe. The plane flew on a peaceful mission from Sochi to Syria, but crashed into the Black Sea. All 92 people died.
Based on all the statistics, it can be concluded that the definition of flight safety is multifaceted. Recommendations for a tough increase in security measures are relevant for all routes (domestic and international). If we turn to statistics, we can recall that even on domestic flights, terrorists have repeatedly tried and hijacked planes abroad.
According to some reports, safety information received from competent persons, confirms that now specially trained specialists are present on the aircraft. This is not like an armed policeman dressed in civilian clothes. There are now several armed special forces on board the airliner who are able to quickly prevent any terrorist act.
There are also additional recommendations. In particular, employees of all airlines must collect the necessary food supply on board the aircraft. Particular attention is paid to drinking water. In addition, the leaders of domestic air carriers were obliged to conduct a briefing with the flight crew, aimed at strengthening vigilance.
After all, flight safety is not only the neutralization of a terrorist, but also the prevention of his terrorist intentions. In this regard, employees of special services will take part in air travel.
Some safety factors for air travel
The safety factors of air travel include several very important points. Let's consider them in more detail. The safety factors are:
- Environmental influence.
- Material aid. As you know, the availability of benefits also has a positive impact on improving the quality of work of aircraft personnel.
- Micro-level factors. Everything is connected with a favorable climate in the flight team. It is the main safety management system. Each member of the flight crew must be inclined to mutual assistance. There should be no conflict situations on board the aircraft.
- The level of labor motivation. It is no secret that the creation of the necessary conditions has a great influence on the working capacity of the team.
- macro-level factors. The political and economic situation inside the country is connected with this phenomenon.
- status motivation. The ability to move up the career ladder has a certain influence on the work of the crew.
- Factors of the country's policy. Political stability in the state plays a big role in the safety of air travel.
- Moral, ethical and personal factors of the aircraft commander. If he quickly adapts to a variety of situations, does not panic, and is also disciplined, then the percentage of flight safety increases many times over.
Incredible great importance have some principles aviation security. They are conditionally divided into five sections:
- Maintaining maximum security.
- Open reporting of any danger.
- Localization of unnecessary and unforeseen risks.
- Passenger Responsibility.
- Ability to control fear.
What passengers need to know
They should also have information related to the safety of air travel. Flight safety depends on tourists even more than on pilots. Travelers should be understanding when asked to wear seat belts during takeoffs and landings. In addition, passengers must turn off laptops, tablets and other mobile devices during the flight. The proximity of the airstrip and the lack of time sometimes lead to disasters. Aviation safety information states that an aircraft has a better chance of not crashing if it is far from the ground.
It is the duty of all passengers to strictly follow the requirements that the airline management imposes on them.
Theoretically, it is assumed that mobile devices can provide Negative influence to the on-board instruments of the aircraft. In addition, tablets and mobile phones can create significant radio interference. This cannot be allowed, since the pilots communicate with the ground services controllers precisely by radio. In particular, the included mobile phones, network seekers, create certain interference not only in the magnetic field, but everywhere. In this regard, the security measures taken before may be useless. Although such precedents have not yet happened, this does not mean that they will never happen. After all, manufacturers are developing more and more advanced and more powerful mobile devices.
Four main rules
- The seat backs must be in an upright position. If this is not done, then in case of a plane crash, the backrest that is not lowered will definitely block the passage.
- Opening curtains on the portholes. This is due to the need for rapid adaptation of passengers after an accident.
- Timely assembly of tables. This precaution is required in the event of a hard landing.
- Proper use of entertainment. You should not turn on the music too loudly, exceeding all permissible decibels.
Airliner passengers are subject to special requirements when entering the turbulence zone. When entering such a section, everyone must take their seats and fasten their seat belts.
An equally important requirement is the observance of calmness. It is impossible to prevent panic, but you should not worry too much, even if the aircraft is shaking a lot. This happens quite often, however, the planes do not fall apart from this. Turbulence depends on the dimensions of the liner. The more massive and heavier it is, the less its concussion is felt. Too impressionable people should not buy seats near the wings. After all, it seems to passengers who are too suspicious that the wings will certainly fall off. Such experiences lead to severe stress with aggravating consequences. During the existence of aviation, the wings in the turbulence zone have not fallen off from any aircraft.
Level flight
Everyone knows that the requirements for passengers are softened somewhat when the aircraft has gained the required height and flies in a horizontal position. At this time, people can get up from their chairs and go about their business.
Turbulence at a sufficiently high altitude occurs only over the Atlantic. When landing an aircraft, you should be in a chair and be belted security. This is due to some interference. For example, a strong side wind can interfere with an airliner, and the aircraft will behave non-standard. In particular, it may begin to twitch or shake.
Aviation safety in general is a complex concept related to the work of ground services, pilots, flight attendants, passengers, as well as the operational characteristics of aircraft. All this allows you to carry out air travel without a threat to passengers. Air travel safety is no easy task. However, it is solved by the joint forces of the companies involved in the production of aircraft and air carriers.
The level of safety is determined by those factors that during the flight there will be no emergency that could lead to tragedy.
A special situation arises due to the impact of individual factors leading to a slight or significant decrease in the degree of safety of air travel. These factors can be: the influence of unfavorable weather conditions; failure or malfunction of certain elements of systems; unskilled ground support; unprofessional piloting technique, as well as errors in the operation of on-board equipment; manifestation of unsuccessful aerodynamic characteristics of the aircraft.
04/17/2011 at the airport Mineral water There was an incident with the An RA-61706 aircraft, associated with landing on the runway under construction, located 150 meters to the right of runway-30.
The analysis of similar events in the Russian Federation (see annex) indicates that in last years the frequency of use of unscheduled runways has increased.
The problem of erroneous approaches and landings of aircraft on a closed (reconstructed or under construction) runway (or on the MRD) located parallel to the designated runway for landing is one of the most urgent in world aviation practice. Incidents associated with the use of an unspecified runway are usually associated with the errors of crews, ATS personnel, as well as with the features of the elements of the airfield of the aerodrome.
Most often, the above errors are made by crews when landing on non-precision approach systems at airports with several parallel runways and MRDs. Almost all erroneous landing approaches were performed in simple weather conditions by crews with sufficient qualifications and flight experience.
In order to implement additional preventive measures to ensure flight safety, I propose:
1. Heads of the territorial bodies of the Federal Air Transport Agency:
1.1. bring this information with the annex to the heads of controlled civil aviation organizations;
Examine this information with flight commanders, inspectors, instructors and flight crew members, ATS personnel and specialists of airfield services;
To focus the attention of crews on the need for a detailed study (using aerodrome diagrams) of the information contained in NOTAM on changes in the operation of radio equipment and equipment, features of marking runways and taxiways, the location of construction and repair work zones at the aerodrome during pre-flight and pre-landing preparations;
When landing in conditions of limited visibility and / or at night at aerodromes with several parallel runways and taxiways parallel to them, with the possibility of choosing an approach system, recommend that crews give preference to precision approach systems;
For any landing approach system, use navigation aids in a comprehensive manner;
Advise crews to descend below MDA (H) or DA (H) only if the crew can clearly see and identify visual references related to the runway (approach lighting system, runway lights or center line, runway threshold markings or touchdown area markings);
Re-study with the flight crew members the provisions of paragraphs 2.7, 3.34.3, 3.77, 5.13, 5.92.1, 9.5 and 9.6 of the FAR “Preparation and performance of flights in the civil aviation of the Russian Federation”, approved by order of the Ministry of Transport of Russia;
Consider entering additional changes in the RFP and local guidance and technology documents, taking into account the shortcomings affecting the use of unspecified runways ( section III information about incidents involving the use of an unassigned runway).
To provide in the plans for technical training of personnel for additional study of the provisions of standard technologies for the work of air traffic controllers and RPS (order of the Federal Air Navigation Agency), related to the peculiarities of monitoring the trajectory of aircraft on the pre-landing straight (visually and using the available technical means).
FEDERAL AIR TRANSPORT AGENCY
Flight Safety Inspection Office
INFORMATION
ABOUT INCIDENTS RELATED TO
USING A UNDESIGNATED RUNWAY
The information has been prepared by the Office of Flight Safety Inspection of the Federal Air Transport Agency in order to use the information contained in it to implement preventive measures in airlines, ATS units and at aerodromes aimed at preventing cases of mistaken use of an unassigned runway for takeoff or landing.
In preparing this information, information was used on the results of the investigation of incidents received by the Federal Agency air transport until April 22, 2011, as well as analytical and information materials listed in the application.
The use of all or part of the information contained in this information in the materials of public print and online publications without the consent of the Office of the Flight Safety Inspectorate of the Federal Air Transport Agency is prohibited.
I. GENERAL DATA ON INCIDENTS RELATED
USING UNDESIGNED RUNWAY
For the purposes of this information, the term “use of an unassigned runway” refers to events associated with landing/takeoff (short landing/takeoff) on an inactive/closed runway or taxiway.
Since 2000, 17 incidents (including 5 serious ones) involving the use of an unassigned runway have occurred in the Russian Federation or with aircraft of Russian airlines when flying abroad. The distribution of the number of events by years is shown in Figure 1.
Number of incidents involving the use of an unspecified runway
An analysis of the statistical data presented in Figure 1 leads to the conclusion that in recent years the frequency of cases of the use of unspecified runway has increased.
Of the 17 incidents that occurred during the 2nd month of 2011, 4 incidents occurred at foreign airports, 2 incidents occurred with aircraft of foreign airlines when landing at Russian airports, 2 incidents occurred with aircraft of state aviation when landing at a civil airfield.
The effect of the relative position of the runway and taxiway on errors that lead to the use of an unspecified runway is shown in Figure 2. To a greater extent, the considered errors are facilitated by the presence of two, adjacent, parallel runways or runways and taxiways. There were 13 incidents associated with this feature.
The influence of the relative position of the runway and taxiways on errors,
leading to the use of an unspecified runway
II. FACTORS AFFECTING ERRORS
LEADING TO THE USE OF AN UNSPECIFIED RUNWAY
All cases of using an unspecified runway are associated with the errors of crews, ATS personnel, as well as with the features of the airfield elements of the aerodrome.
Crew errors in determining the assigned runway occur at the stage of perception of visual information due to:
The presence of several runways and taxiways located in parallel, having practically the same (or similar) dimensions in length and width, or if the taxiway or runway under construction has a width greater than the working runway;
Better (compared to the assigned runway) contrast of other runways and MRD;
Invisible markings on an active runway or the absence of warning signs on a non-operational runway;
Lack of identification of the active (designated) landing runway using approach lights, edge lights or PAPI;
Termination of the integrated use of navigation aids when establishing visual contact with the airfield.
The factors that influenced the use of unspecified runways are discussed below. At the same time, it should be taken into account that in some events the factors listed below manifested themselves simultaneously.
2.1. Misperception, crew interaction
The majority of flight crew errors occurred during non-precision approaches (OSB, VOR-DME or visual approach) and were associated with an incorrect perception of the appearance of pavements (for example, a taxiway with more contrast than a nearby parallel runway). There were 11 incidents during non-precision approaches.
Taxiing errors and the associated use of an inoperative runway or taxiway for takeoff were due to overconfidence of the crew members in the correctness of the decisions made, in the absence of mutual control, as a result of which no attention was paid to the signs and markings indicating the runway and taxiway.
Examples:
On July 28, 2002, a serious incident occurred with an Il-62M aircraft while landing at the Khabarovsk airport.
Landing was carried out during the day, in simple weather conditions: wind near the ground 260°, 6 m/s, visibility 6500 meters, haze, continuous significant cloudiness with a cloud base height of 210 meters.
The Khabarovsk airfield has two parallel runways, the distance between the axes of the runways is 290 meters. At the same time, runway 23 left was closed for takeoffs and landings of aircraft in connection with a major overhaul.
At the time of the landing approach of the Il-62 aircraft, on the left runway 23, there were two people, two rollers, two asphalt pavers and two technical houses for repair work. Construction equipment and people were located at a distance of meters from the end of runway 23 left.
Landing approach was carried out according to the OSB on the runway 23 right. When the aircraft was at a distance of 11 km from the runway, the controller additionally informed the crew about the permission to land on the right runway 23, to which he received a confirming response.
According to the explanation of the aircraft commander, after switching to visual flight at an altitude of meters, he mistakenly perceived the end of runway 23 protruding forward by 500 meters as the left runway 23, and began to make a turn on this runway with an increase in roll to the left up to 13 °. After performing a turn to the left, the deviation of the aircraft on the course from the established descent trajectory on runway 23 to the right was approximately 400 meters.
At a distance of 2 km from the navigator, the information was received: “The runway along the ku ... a little bit to the right”, and from the landing controller: “535, removal 2, to the left”. At an altitude of about 50 meters, the co-pilot informed: "We are landing on the left." Despite this, the aircraft commander continued to descend.
The dispatcher of the launch control tower, who detected the aircraft in the section between the LBM and the LLB, did not inform the crew about the significant deviation of the aircraft from the course after the flight of the LLB.
At a height of 12 meters, leveling was started, at a height of 3 meters, the engines were switched to idle. At the same time, the launch controller issued an instruction to leave for the second three times. The increase in the engine operation mode to takeoff was started 3 seconds after they were switched to idle at a geometric height of 0 meters (by means of objective control), in the immediate vicinity of the technical facilities located on RWY 23 left. Go-around and re-landing approach were performed without deviations.
02/27/2005, in the afternoon, in simple weather conditions, when landing at Barcelona airport, a serious incident occurred with a Tu-154M aircraft.
During the landing, the crew erroneously landed on the main taxiway "T".
The landing approach was carried out by VOR-DME on runway 25 right. According to the current NOTAM, the landing and approach zone lights were reduced to 360 and 690 meters respectively, PAPI was not used.
When establishing visual contact, the crew mistakenly took the more contrast taxiway "T" (located on the right parallel to the runway) for the working runway 25 right. According to the crew's explanation, during the landing approach, they clearly observed runway 25 left (with approach lights turned on for verification) and taxiway "T", taken by the crew for runway 25 right (on runway 25, the right lights were turned off). In addition, the main taxiway "T" was previously used as a runway and had a large width.
In the process of descending for landing, the crew of the aircraft discovered that another aircraft was on the runway intended for landing (in fact, another aircraft was taxiing on TWY) and decided to go around. When asked by the controller about the reason for go-around, the crew reported that the runway was busy. The controller cleared the re-landing approach on runway 25 right. The second approach was performed similarly to the first one, and as a result of an error in determining the working runway, the landing was made on taxiway "T".
03/14/2006 at the airfield Chelyabinsk (Balandino) an incident occurred with the Yak-40 aircraft: when landing with a magnetic heading of 271°, the aircraft crew approached MRD-1, mistaking it for RWY-27.
The aircraft crew performed a visual landing approach.
During the investigation of the incident, it was found that at the end of the MRD-1 with a magnetic heading of 271 ° a prohibition sign was applied (a yellow cross on the axis of the MRD-1). However, the aircraft crew during the landing approach, due to the pronounced contrast of the MRD-1 in relation to RWY-27, made a landing maneuver based on visual contact with the MRD-1.
The aircraft crew determined their error only at an altitude of 40 meters and a distance of 300 meters from the end of the MRD-1 and decided to go around. In the process of go-around, the crew also received an instruction from the controller about go-around and, after 5 seconds, information about approaching the wrong runway.
On February 25, 2010, a serious incident occurred with an A-320 aircraft at the Oslo airfield (Norway), connected with the takeoff from the taxiway.
A serious incident occurred during the day, in simple weather conditions.
Taxiing was carried out by the aircraft commander, who was in the left pilot's seat. Radio communication was conducted by the co-pilot, who was in the right pilot's seat. The pilot-observer was in an additional seat in the cockpit.
It was planned to take off from runway-01L. According to the explanation of the aircraft commander, during the pre-flight preparation, he decided to take off from taxiway A3. This decision was based on a desire to reduce taxi time due to the fact that the flight was delayed by about 25 minutes. The verification carried out during the investigation showed that the calculations of the required distance for continued and rejected takeoffs for actual conditions (2696 meters) allowed the aircraft crew to perform a safe takeoff from taxiway A3 (runway length from taxiway Ametrov).
The co-pilot informed the controller about the decision to take off from TWY A3 before taxiing and received confirmation of the possibility of takeoff from TWY A3.
Taxiing was to take place on taxiways G, N and A3 (see Figure 3). All taxiway lights were on.
Scheme of the movement of the A-320 aircraft on the airfield
and turning on the lighting equipment at the Oslo airfield on 25.02.2010
During the taxiing of the A-320 aircraft, no other aircraft took off or landed on RWY-1L.
During the interview, the aircraft commander noted that when taxiing along taxiway N, the center line was partially not visible due to the presence of snow on the surface, which caused minor difficulties in maintaining the direction of movement. The co-pilot also noted that taxiway N was partially covered with snow.
Taxiing was carried out at a speed of no more than 20 knots. The takeoff clearance was obtained when the aircraft was taxiing to TWY A3, before crossing TWY M. During the investigation, it was found that the issuance of clearance to take off before taking taxiway A3 (on which the runway stop line is located) did not contradict current procedures Oslo airport. At the same time, the commission noted that the hasty issuance of permission to take off could affect the further development of events. In this regard, the commission recommended the introduction of a practice whereby a take-off clearance should be issued at that point on the taxiway, after which it is no longer possible to continue taxiing in the wrong direction.
After receiving permission to take off, the aircraft commander was not convinced that the aircraft was on the runway. The takeoff was made without stopping at the preliminary and executive start. The Board noted that the airline's SOP did not require crew members to ensure that their seat was correctly determined prior to takeoff. The Commission recommended that SOPs and checklists be amended to require the pilot-in-command and co-pilot to jointly verify that they are on the correct runway prior to takeoff.
According to the explanation of the aircraft commander, when taxiing out on TWY A3, he mistakenly took TWY M for RWY-01L. The aircraft commander explained his mistake by the fact that when occupying taxiway A3, he saw in front of him a dark, snow-cleared surface of the artificial surface of taxiway M, which was more contrasting with respect to the partially snow-covered taxiway A3 and N. As a result, he considered that before him runway-01L. The banners indicating the names of taxiways and runways, as well as the yellow color of the center line of taxiway M and the working lights of taxiway M, were ignored by the aircraft commander and the co-pilot. The pilot-observer, according to his explanation, also had no doubts that the takeoff was made from RWY-01L.
At the junction of the taxiways N-A3-M and taxiway "M" was not installed a banner with the designation of the taxiway "M", which, according to the conclusion of the investigation team, contributed to the error of the aircraft crew (Fig. 4). Figure 4 shows the changes to two signs at the A3-M-N junction that the Oslo Airport Authority made after a serious incident. A new position indicator was installed at a distance of 25 meters north of the holding position (circled in purple dotted line) and the signs on Taxiway N were changed (dotted green).
Taxiway designation changes made after
incident 25.02.2010
TWY M from TWY A3 to TWY A7 (end of TWY M) is approximately 1600 meters long.
The takeoff run along taxiway M was carried out without any special features. The aircraft lifted off at a speed of 143 knots, which corresponds to the calculated speed for actual conditions (take-off weight 61 tons).
During the interrogation, the co-pilot reported that during the climb, during the very first radio communication session, the controller informed the crew that the takeoff was made from taxiway M. The request to repeat this information was already made by the aircraft commander. Only after the controller confirmed the previously transmitted information, the crew of the aircraft realized the mistake made.
The Board of Inquiry concluded that the error during taxi-out and take-off from Taxiway "M" resulted from deficiencies in established procedures and a lack of due diligence on the part of the pilots, combined with insufficient control by the controller, as well as deficiencies in the markings of the aircraft maneuvering area.
2.2. Non-use of airborne positioning aids
Incomplete use of navigation aids was noted during the investigation of most incidents that occurred during the landing. Here, it is also necessary to note the shortcomings in the interaction of crew members: an error in determining the runway for landing was made by the pilot performing active piloting, while the pilot performing control piloting showed passivity or stopped using navigation aids after establishing visual contact with the airfield.
Examples:
04/16/2008, in the afternoon, in simple weather conditions, an incident occurred with the Il-76 aircraft, associated with an attempt to land at the Ulan-Ude "Vostochny" airfield, instead of Ulan-Ude "Mukhino".
The landing approach was carried out according to the ILS system.
The crew of the Il-76 aircraft made a descent to land on runway-26 of the Ulan-Ude Mukhino airfield. Radio equipment at the nearby Ulan-Ude Vostochny airfield was not working at the time of the incident. The airfield of Ulan-Ude "Vostochny" is located at a distance of about 18 km to the east of the airfield of Ulan-Ude "Mukhino".
When the aircraft approached the airfield, the dispatcher at the Ulan-Ude Mukhino airfield allowed the aircraft crew to descend to a height of 800 meters and make an ILS approach to runway-26, and also informed them about the distance of 20 km from the runway.
In the process of descent for landing, while the aircraft was in the area of the fourth turn, the crew of the aircraft saw the runway of the Ulan-Ude airfield "Vostochny" on the right, which they took for the runway of the Ulan-Ude airfield "Mukhino". As a result, the aircraft crew, instead of performing a left turn according to the runway-26 approach scheme, began to perform a right turn in the direction of the runway of the Ulan-Ude airfield "Vostochny".
The landing controller, having found that the aircraft was avoiding the approach pattern, twice instructed the aircraft crew to stop the descent and climb to 1300 meters. The re-landing approach was completed without comment.
The cause of the incident (deviation from the approach procedure) was poor-quality training of the Il-76 aircraft crew for this flight and the failure to use on-board navigation aids to control their location before starting the maneuver.
12/25/2010, in the afternoon, in simple weather conditions, at the Yekaterinburg (Koltsovo) airport, an incident occurred with the An-24RV aircraft, associated with an attempt to land on the main taxiway.
Landing approach was carried out according to the PSP system.
When the aircraft was at a distance of 8 km from the runway, the crew was given permission to land on runway 26 right.
Visually, the aircraft commander observed runway 26 right and to the right of its parallel and comparable in size with the runway main taxiway G. However, the aircraft commander perceived the snow-covered runway 26 right as runway 26 left closed for flights. In addition, after establishing visual contact with the airfield, neither the aircraft commander nor the co-pilot carried out instrument piloting, as a result of which, at the beginning of the visual maneuver for landing on the main taxiway G, they did not see an unacceptable deviation from the landing course on runway 26 right.
The ATS personnel, using the available means and visually detecting the deviation of the aircraft to the right, towards taxiway G, understood the mistake made by the aircraft crew, as a result of which the aircraft crew was instructed to go around.
The re-entry was completed without deviations.
It should be noted that, for similar reasons, during 2010 (January 28 and December 10), when performing approaches for landing under the NSP in simple weather conditions, An-26 aircraft of state aviation landed on TWY G at this airport.
01/25/2011, in the afternoon, in simple weather conditions, when landing at Vladivostok (Knevichi) airport, a serious incident occurred with the Tu aircraft.
The landing approach was carried out according to the OSB system on runway 07 left. Meteorological conditions during landing: visibility 10 km, scattered cumulonimbus clouds 1300 meters high.
To the right of the runway 07 left was located parallel runway 07 right closed for reconstruction. The distance between the axes of the runway is 260 meters.
On the pre-landing straight, to control the course, the flight crew used the data of the aircraft navigation computer system VSS-95, which was not provided for this stage of the flight: the co-pilot read from the VSS-95 the lateral deviation of the aircraft from the track. At the same time, the aircraft crew did not take into account the error of these measurements - according to the VSS-95 data, the deviation of the aircraft from the track to the right was 100 meters, the actual deviation to the right from RWY 07, the left, was meters.
Since the aircraft descended significantly to the right of the extended center line of runway 07 left, during the passage of the LBM and LBM the audible signaling of their passage did not work, which the aircraft crew did not pay attention to.
This serious incident, only by a happy coincidence, did not end with more serious consequences - at the decision-making height, first the co-pilot and then the aircraft commander saw the flashing beacons of a vehicle standing on runway 07 on the right and performed a go-around from a height of 30 meters.
In addition to the errors of the aircraft crew, a serious incident was facilitated by the absence of right markings with prohibitory signs on the reconstructed runway 07 (two mutually perpendicular elements of at least 6.0 * 0.9 meters in size, yellow or white along the runway axis with a minimum interval between signs of no more than 300 meters) .
2.3. Non-use of ground-based positioning aids
International practice shows that the focus of preventive measures to prevent cases of using unintended runways should not be limited only to improving the procedures for interaction between aircraft crew members. The use of modern lighting equipment indicating the working runway, and monitoring the state of runway markings and taxi routes, can also significantly reduce the risk of such incidents.
Example:
On January 26, 2008, an incident occurred with an A-319 aircraft at Chelyabinsk (Balandino) airport, connected with landing on the main taxiway.
Landing was carried out during the day, in simple weather conditions, on runway-09, using the inaccurate VOR-DME system. The landing system was chosen by the aircraft crew in order to perform the training. The condition of the runway during landing: in some places snow up to 2 mm, friction coefficient 0.6.
At the Chelyabinsk (Balandino) airfield, the main taxiway is located parallel to the runway-09/27, the distance between the center lines of the MRD-1 and the runway is approximately 210 meters. The length and width of the runway and MRD-1 are 3200×60 meters and 3000×52 meters, respectively. Previously MRD-1 was used as a runway.
According to the explanation of the aircraft crew, from a distance of 15 + 20 km against the background of a white underlying surface, they observed a characteristic dark spot, which they took for the landing zone of RWY-09. Landing approach to the decision height was performed in automatic mode. After turning off the autopilot, the crew continued to descend to land on the MRD-1, which was mistaken for the runway.
The launch controller detected the crew's error only when the aircraft was approaching the start leveling height. At the same time, the dispatcher's information about approaching the taxiway was superimposed on the commands of the on-board voice informant and was not perceived by the aircraft crew.
In addition to the errors of the aircraft crew, the investigation revealed a serious lack of Russian regulatory documents on the operation of the PAPI type glide path visual indication system (at the Chelyabinsk (Balandino) airfield, installed to the left of the runway-09 threshold).
In accordance with Standard 5.3.5.1 of Annex 14 — Aerodromes (Volume 1 — Aerodromes Design and Operations), visual glide slope indication systems should be installed if pilots may have difficulty in assessing the correctness of their actions during the approach as a result of an insufficient number of visual landmarks when landing over the same terrain in daytime or misconceptions created by the deceptive nature of the surrounding terrain or runway slopes.
According to the requirements of paragraph 7.15.3.2 of the Rules for Air Navigation Services "Air Traffic Management" (Doc 4444/ATM501), the lights of the visual glide path indication system must be switched on during the daytime and at night when the corresponding runway is in use, regardless of visibility conditions.
However, in accordance with the requirements of the GA-85 regulations in force at the time of the incident, when landing in the daytime in simple weather conditions, the runway lighting equipment should have been turned on only at the request of the aircraft crew. As a result, during the landing of the A-319 aircraft, the PAPI visual glide path indicator system with a magnetic heading of 91° was turned off, which contributed to the errors of the aircraft crew in determining their position relative to the center line of the working runway.
Therefore, it is necessary to pay attention to the fact that this moment, in accordance with the requirements of paragraph 8.31 of the FAR "Preparation and performance of flights in the civil aviation of the Russian Federation", approved by order of the Ministry of Transport of Russia, the visual glide slope indication system should include:
For night flights - 15 minutes before sunset or estimated time of aircraft arrival;
In daytime conditions - 15 minutes before the estimated time of arrival of aircraft;
In other cases - at the request of the ATS authority, the crew of the aircraft.
The glide slope visual indication system is turned off when there are interruptions in the arrival of aircraft for more than 15 minutes.
2.4. Lack of control over the movement of the aircraft on the airfield
This factor refers to incidents related to takeoffs (attempts to take off) from an inoperative runway or taxiway, and, as a rule, in addition to the errors of the aircraft crew, it is caused by the passivity of the ATS personnel.
Examples:
On February 29, 2008, a serious incident occurred with an An-2 aircraft during takeoff at the Orenburg airfield.
When taking off from a dirt runway, the aircraft collided with a ski landing gear with a concrete airfield fence and, as a result of the rough landing that followed, received significant structural damage.
Taking into account the direction and speed of the wind near the ground (230° 7 m/s), the aircraft should have taken off with a magnetic heading of 220°. However, the aircraft crew made a mistake - they took a line start and proceeded to take off with a magnetic heading of 40°, opposite to the takeoff heading.
In the process of taxiing and takeoff of the An-2 aircraft in the traffic service, the transfer and acceptance of duty shifts of dispatchers was carried out. Specified work was organized unsatisfactorily, as a result of which air traffic services during this period were carried out formally.
Permission to engage in preliminary and executive starts with a heading of 220 ° was given by the controller of the DPK (with functional responsibilities dispatcher PDSR) shift handing over duty. The permission to take off was issued by the DPK dispatcher of the shift on duty, before the completion of the duty transfer-acceptance procedure. None of the controllers observed the aircraft taxiing to the line start with a heading of 220°.
Despite the issuance of permission to take off, the DPK controller of the incoming shift, in violation of the work technology, did not control the take-off of the An-2 aircraft. As a result, only 2 minutes after the start of takeoff, the dispatcher found the An-2 aircraft lying behind a concrete fence.
On July 22, 2009, during takeoff at Ekaterinburg (Koltsovo) airport, an incident occurred with the Tu aircraft, which was associated with an attempt to take off from an inoperative runway.
The incident occurred at night, in simple weather conditions (visibility 10 km, no precipitation).
During the investigation, it was established that during the pre-flight preparation, the flight crew was informed about the existing prohibitions and restrictions, including the closure of runway-1 (08 left). In addition to runway-1 (08 left) at the Yekaterinburg (Koltsovo) airfield, the Golf taxiway, which runs parallel to runway-1 (08 left), was closed due to repairs.
At the time of the incident, the lighting equipment of the non-working runway-1 (08 left) was turned off.
The Tu-204 aircraft was the only aircraft that was under the leadership of the ATC shift on duty. During the development of the incident, the duties of the flight director were performed by the senior controller.
Subsequently, in violation of the requirements of the work technology, the flight controller did not control the movement of the aircraft along the taxi route until the preliminary start was taken.
As it was established during the analysis of video surveillance records in the ATC hall of KDP-2, the air traffic controller periodically left his workplace(returning only to conduct radio communications with the crew of the aircraft) and was engaged in extraneous matters not related to the performance of his official duties.
At 17:52:01 the air traffic controller instructed the flight crew to switch to communication with the air traffic controller. At the same time, in violation of the requirements of the work technology, the instruction to switch to communication with the air traffic controller was given before the control transfer line (RWY-1 (08 left) preliminary start line), while the aircraft was on the Alpha taxiway, until the aircraft crew reported on pre-start session.
At 17:52:28, the aircraft crew, moving along the Alpha taxiway, before crossing the closed Golf taxiway, got in touch with the traffic controller, requested permission to cross RWY-1 (08 left) and take the line start.
At 17:52:38 the ATC controller cleared the aircraft crew to cross RWY-1 (08 left). In fact, in violation of the work technology, at that moment the air traffic controller was controlling the aircraft in the area of responsibility of the air traffic controller, that is, up to the pre-launch line of RWY-1 (08 left). The scheme of the movement of the Tu-204 aircraft along the Ekaterinburg (Koltsovo) airfield is shown in Figure 5.
To enter RWY-2 (08 right), taxiing had to take place along the apron, the Alpha taxiway and, further, along the Kilo taxiway connecting RWY-1 (08 left) and RWY-2 (08 right). However, full information about the taxi route was not provided to the flight crew.
According to the aircraft crew members, when approaching the closed taxiway "Golf", marked with the corresponding day and night markings, they mistook it for a closed runway-1 (08 left). Neither the aircraft commander nor the co-pilot paid attention to the standard route designations. In addition, as mentioned above, the flight crew did not have information that taxiing on RWY-2 (08 right) should take place along the Kilo taxiway.
The crew of the aircraft, in violation of the requirements of the radio communication rules, did not report to the ATC controller about the release of runway-1 (08 left) and at 17:53:20 requested permission to take the executive start, actually being on the Alpha taxiway.
Scheme of the movement of the Tu-204 aircraft on the airfield of the airfield
Yekaterinburg (Koltsovo) in connection with the incident 07/22/2009
At 17:53:25 the air traffic controller cleared the runway-2 (08 right) runway without receiving the flight crew's report on the crossing of runway-1 (08 left), which is a violation of the work technology requirements.
At 17:54:00 the aircraft crew reported that they were ready for takeoff.
At 17:54:05, the controller of the auxiliary launch control tower of Yekaterinburg (Koltsovo) aerodrome reported to the air traffic controller that the runway was free.
At 17:54:07, the VPS controller cleared the takeoff. The takeoff was made without stopping at the executive start.
Simultaneously with the report on the start of the takeoff, the aircraft crew began to increase the engine operation mode. 18 seconds after that, the engines were put into takeoff mode.
At 17:54:35, the ARFS controller, listening to the radio traffic and controlling the runway-2 (08 right) line-up, found that the aircraft did not take the runway-2 (right-hand 08) runway and, having switched to another ARFS work station, allowing visually observe runway-1 (08 left), found that the aircraft was taking off from runway-1 (08 left), which he immediately reported to the ATC controller.
At 17:54:38, the VCS controller instructed the aircraft crew to stop. At 17:54:39, at a speed of 147+153 km/h, the aircraft crew switched the engine control levers to idle and stopped the takeoff using forced braking. At 17:54:42 a corresponding report was made.
The factors behind the incident were:
insufficient discretion of the crew of the Tu-204 aircraft, which led to the erroneous occupation of the non-working runway-1 (08 left), instead of runway-2 (08 right);
unsatisfactory organization of the work of the ATC duty shift and the lack of control over the work of the air traffic control personnel by the senior air traffic controller, who acted as the flight director during his temporary absence;
lack of control over the movement of the aircraft during taxiing on the part of air traffic controllers and flight controllers.
The investigation also noted that:
the organization of the workplace of the air traffic controller does not allow one air traffic controller to carry out continuous visual observation of all elements of the airfield within the zone of visual detection and control of aircraft movement;
there was no interaction between the control centers on the GHS in the process of aircraft traffic control, all the necessary information on this aircraft was not transmitted and, accordingly, was not confirmed;
ATC duty shift dispatchers ambiguously interpret the requirements of work technologies in terms of ATC handover lines, zones of visual detection and visual control of aircraft movement and the procedure for transmitting taxi route instructions to aircraft crews.
2.5. Influence of lighting conditions and meteorological conditions
Unlike similar events taking place abroad, in Russian practice there is no significant effect of night flight conditions on incidents involving the use of an unassigned runway. Out of 17 incidents, only 2 incidents occurred at night (one during landing and one during takeoff). Both incidents occurred in simple weather conditions and were associated with incorrect perception of light landmarks.
When investigating incidents related to landings on unspecified runways, no significant influence of actual weather conditions on crew decisions was noted. Of the 17 incidents, only 1 occurred during a landing in adverse weather conditions. At the same time, an analysis of the circumstances of the occurrence of errors in determining the runway allows us to conclude that they occurred during the transition from instrument to visual flight in conditions of poor visibility and precipitation.
Despite the small number of incidents caused by the influence of lighting conditions and weather conditions, it is necessary to pay attention to the fact that these two features simultaneously manifested themselves in the crash of the Yak-40 aircraft at the Khanty-Mansiysk airport on 10/26/1996.
Examples:
On October 26, 1996, when landing at night, in difficult weather conditions, a Yak-40 plane crashed at the Khanty-Mansiysk airport.
During the landing approach, the crew was given information about the weather: the lower limit of clouds was 400 meters, visibility was 5300 meters. However, during the investigation it was found that at the time of the landing approach there was a deterioration in visibility associated with precipitation in the form of a snow charge.
At a distance of 3300 meters from the runway, the aircraft crossed the center line of the runway and began to shift to the left.
During the investigation, it was found that the brightness of the helipad lights, located 195 meters to the left and 950 meters in front of the runway threshold, was significantly higher than the runway lights. Under night conditions and reduced visibility due to heavy rainfall in the form of snow, the crew mistook the helipads for a working runway.
At an altitude of about 120 meters (the distance to the runway was 2840 meters, and before the start of the helipads 1800 meters), the aircraft deviated to the left of the landing course line by 60 meters and was 30 meters below the glide path. In further descent, the crew of the aircraft, mistaking the lights of the helicopter stands for the runway, performed an S-shaped maneuver and oriented the aircraft relative to the longitudinal axis of the stands.
The landing was made at a speed of 190 km / h, not reaching the end of 950 meters and to the left of 159 meters from the runway. During the run, the crew saw obstacles and tried to turn the aircraft to the right to prevent a collision, but the short distance and high speed did not allow to avoid a collision. The plane collided with three helicopters in succession and crashed.
The disaster was due to a combination of the following factors:
Lack of information from the aircraft crew about the deterioration of visibility below the aerodrome minimum during the landing approach;
Continuation of the landing approach by the crew in conditions of weather change below the aerodrome visibility minimum;
Turning on the lighting of the heliports, which significantly exceeded the power of the runway lights, in conditions of limited visibility (snow charge), which provoked the crew to erroneously perceive it as the runway lights in the absence of an opportunity effective control for the movement of the aircraft after the flight of the OPRS.
On October 12, 2004, in the afternoon, in adverse weather conditions, an incident occurred with a Yak-40 aircraft during landing at the Bugulma airport (landing on a runway under construction).
The meteorological conditions at the time of the landing approach corresponded to the airfield minimum: wind 340° 6 m/s, visibility 1500 meters, heavy snow, overcast cumulonimbus clouds at 130 meters.
The meteorological channel transmitted a warning to the crews about the unfinished runway: “To the right of the main 190 meters there is an unfinished runway, the end of the runway is on the beam of the BRM. Be careful!". The crew had information about the unfinished runway running parallel to the working runway.
Landing approach was made by drives. The lighting system of the working runway of the aerodrome was turned on at the third level of brightness.
During the landing approach, the controller provided assistance to the aircraft crew, reporting the distance and position of the aircraft relative to the course. After the crew reported that they were ready for landing, the controller additionally warned about the unfinished runway and cleared the landing.
According to the instructor pilot, at an altitude of 100 meters he made visual contact with the runway. Most likely, at an altitude of 100 meters, the pilot-instructor and the aircraft commander (acting as the controlling pilot) were distracted from instrument piloting and, having seen the end of the unfinished runway located more closely, made a turn with an increase in vertical speed and landed.
On August 21, 2007, when landing at the Tyumen airport (Roshchino), an incident occurred with a Boeing-737 associated with an erroneous approach to runway-12 instead of runway-21.
When approaching the KTA beam, at the moment of exit from the clouds, the aircraft commander saw a brightly lit apron and runway-12 lights (radial distance 18 km), turned off the autopilot and manually turned to the lights, mistakenly mistaking them for runway-21 lights. 28 seconds after the start of the maneuver, the controller, observing the change in course (there was only one aircraft at the control in the area of the airfield), requested the current course from the crew and, by vectoring at an altitude of 600 meters, brought the aircraft to the point of the third turn of the runway approach procedure -21.
III. FINAL PROVISIONS
1. The increase in the number of incidents related to the use of an unspecified runway, and the factors causing these events, give grounds for the conclusion that in the context of the growing need to increase the capacity of Russian airfields, their reconstruction and construction of additional runways, Russian civil aviation is beginning to face the same problems as international civil aviation.
At the same time, it is advisable to solve the problem of using unintended runways on a par with the problem of preventing incursions on the runway.
2. The problem of using unintended runways is due to the errors of the aircraft crews, ATS personnel, the features of the elements of the airfield of the airfield and its lighting equipment.
3. To prevent errors by aircraft crews, it is necessary to pay attention to the fact that they are associated with the following shortcomings:
When preparing for taxiing, the restrictions in force at the aerodrome associated with the presence of runways, taxiways or their sections closed for use are not taken into account;
When taxiing, there is no control over the observance of the taxiing route by the pilot (navigator or additional pilot, if any in the crew) who is not involved in aircraft control, no attention is paid to the inscriptions on the banners indicating the runways and taxiways, and the color of the markings on the artificial surface;
The FFR does not describe the procedures before taxiing to the line start, requiring both pilots to verify by the appropriate banners located on the holding line at the runway and the color of the lights of the lighting equipment (lateral, centerline, limiter) that the movement is carried out in the direction of the active runway;
Precision systems landing in visual weather conditions erroneously prioritize visual identification of the runway by the pilot pilot while distracting the controlling pilot from instrument piloting, thereby ignoring unacceptable deviation of the aircraft from the landing course;
When landing on inaccurate systems, the accuracy of the flight of markers on the overturn of the arrow of the ARC and the operation of the corresponding sound alarm are not additionally taken into account;
The landing decision is made only on the basis of visual contact with the underlying surface “like a runway”, without taking into account the runway markings (“zebra” threshold, digital sign of the landing magnetic track angle, signs of a fixed distance zone and touchdown), as well as the colors of the entrance, side and axial lights;
During the preparation for the performance of flights, due importance is not attached to the study and accounting of such individual features aerodrome, such as the low contrast of the runway compared to the underlying surface, the relative position of the runways and taxiways and their dimensions, the presence of runways under construction, the type of lighting equipment and the presence of PAPI;
Aircraft crews do not take into account their right to demand that the runway lighting equipment be turned on when they believe that they will have difficulty in identifying the active runway.
4. To prevent personnel errors, pay attention to the following shortcomings:
Lack of control over the movement of the aircraft on the aerodrome, especially in places where the direction of movement changes, when approaching the runway and occupying (crossing) it;
Hasty issuance of permission to take off, before the aircraft approaches a point on the taxi route, after passing which the crew is guaranteed not to make a mistake in choosing a working runway;
Non-participation or passivity in surveying the aerodrome to identify "problem" places where errors in the definition of a given runway or taxiway may occur and where increased control by ATS personnel is required (for example, places where runways and more than two taxiways intersect; closely spaced ends of non-parallel runways; sections of taxi routes where crews had previously made mistakes in choosing the direction of movement; the presence of “dazzling” lighting on the apron or on the sites in front of the airfield facilities, which makes it difficult to control the movement of aircraft on some sections of the taxi route);
Violation of the rules for conducting radio traffic, including the transmission of instructions or confirmation of receipt of information without the name of the call sign of the aircraft; if there are two parallel runways at the aerodrome, no indication of its location sign (left, right, middle) when issuing permission to continue the approach or make a landing; non-transmission of warnings to crews about the inclusion of lighting equipment on an inoperative runway.
5. In order to prevent the influence of the condition and characteristics of aerodromes on the causes of cases of use of unintended runways, the following shortcomings must be taken into account:
Absence of prohibitory day markings on non-operated runways;
Poor quality of aerodrome surveys to identify places where errors may occur in determining a given runway or taxiway due to changes in the contrast between different sections of pavement, different brightness or placement of lighting equipment, insufficient visibility (absence) of daytime markings or taxiway indicators, and runway;
Non-use or non-use of additional technical means for determining the working runway (for example, visual glide path indication systems);
Clearing snow from a taxiway running parallel to the runway before clearing the active runway, which, due to different contrast, may lead to aircraft crew errors in determining the given runway;
Lack of initiative in determining the need to implement additional measures at the aerodrome to prevent cases of using undesignated runways.