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Old 27th Nov 2019, 15:18
  #11 (permalink)  
alf5071h
 
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The report is an exceptional example of a thorough investigation and well considered analysis of an accident involving human factors. This should be referenced for all investigators as how it is possible to identify significant contributions to adverse (but as might be expected) human performance, yet not conclude by blaming the human - as we might do.

Although the conclusions focus on the human aspects, which in many circumstances could be labelled ‘error’ and blame, this is skilfully avoided with balanced discussion of many diverse potential contributing factors.

The safety recommendations identify many significant issues, contributing factors, which deserve consideration by all operators and regulators. Particular issues relating experience of other aircraft types and differences in trim systems, depth of training vs information available in manufacturers manuals, both aircraft and HUD, assumption re PM being able to identify rare situations requiring intervention - incapacitation, and the limits and limiting influence of SOPs in rare situations. The HUD observations should concern everyone who uses them, questioning what is taught, display formats over the range operational situations.

Yet again issues of thrust-trim coupling during GA are identified, applicable to many types, but specifically to the 737 in this accident.
Additionally, the reoccurring issues of trim awareness, assumptions about human contribution in abnormal situations, and design philosophy (737).

The regulators involved with the 737 Max recertification should read the last page of this report; paras 5.21, 5.24 and 5.25, and footnote #38.
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