B-738 Crash in Russia Rostov-on-Don

[Capn Bloggs]

I bet Boeing will modify the trim logic so that the trim can only be run for a maximum of a few seconds at a time.
"Stabiliser Motion, Stabiliser Motion". :ok:

[Centaurus]

I bet Boeing will modify the trim logic so that the trim can only be run for a maximum of a few seconds at a time.

I would be most surprised if Boeing introduce a mod like that. In the end it boils down to individual pilot flying skills. Like everyday car drivers, there are very safe pilots and others so awful that you wonder how they have got away with it over the years without an accident. They may pass regular simulator checks and get the boxes ticked for years.

But then one night for them when by sheer chance and coincidence, the wrong combination of circumstances all come together - and it might happen only once in their career - then the end is nigh for them. It has always been such.

[Jwscud]

Boeing don't introduce mods like that as it would hint at liability.

Hence why the takeoff config and cabin altitude horns are still identical a decade after the Helios accident...

[RAT 5]

So now they will install a flashing light in front of both pilots that alerts you to the trim switch being pressed: just like they did (steady lights) with the takeoff config & cabin alt. An added warning with no liability/admission issues.

Note: there is already a light for autopilot trim issues.

[737er]

Boeing don't introduce mods like that as it would hint at liability.

Hence why the takeoff config and cabin altitude horns are still identical a decade after the Helios accident...




Jwscud,

Well except for the tiny detail that Boeing added both a Cabin Altitude Warning light and a Takeoff Configuration Warning light in the 737 after the Helios accident.

http://www.b737.org.uk/images/cabinaltitudelights.jpg

[Aluminium shuffler]

TOGA arms at 2500RA, so if you press TOGA, whichever parts of the AFDS are on will engage in that mode, regardless of MCP altitude. The MCP altitude will, if above the alt at which TOGA was pressed, be the commanded level-off alt, but if below the alt at which TOGA engaged, you will have an unrestricted climb away from the MCP window. This can be over-ridden by engaging LVL CHG, V/S, manual intervention or by winding the MCP alt up to an altitude higher than the passing alt.

[Jwscud]

737er - I'm aware of those lights.

That they were added was not an admission of liability in the same way altering the cabin alt warning horn would have been.

[Old King Coal]

Aluminium shuffler: Almost correct.

Nb. I’ve only shown the text for the 'F/D Go-Around', as flydubai are not approved to use ‘A/P Go-Around’, i.e. they are not approved to utilise a dual-autopilot based approach mode, and so its likely that they were either flying the approach utilising just a single autopilot (which will have disengaged the moment a TOGA button was pressed) or else they were flying manually and, in either case, the following then applies.

F/D Go–Around

If both A/Ps are not engaged, a manual F/D only go–around is available under the following conditions:• inflight below 2000 feet RA
• inflight above 2000 feet RA with flaps not up or G/S captured
• not in takeoff mode.

With the first push of either TO/GA switch:
• A/T (if armed) engages in GA and advances thrust toward the reduced go–around N1 to produce 1000 to 2000 fpm rate of climb. The A/T Engaged Mode annunciation on the FMA indicates GA
• autopilot (if engaged) disengages
• pitch mode engages in TO/GA and the Pitch Engaged Mode annunciation on the FMA indicates TO/GA
• F/D pitch commands 15 degrees nose up until reaching programmed rate of climb. F/D pitch then commands target airspeed for each flap setting based on maximum takeoff weight calculations
• F/D roll commands approach ground track at time of engagement. The Roll Engaged Mode annunciation on the FMA is blank
• the IAS/Mach display blanks
• the command airspeed cursor automatically moves to a target airspeed for the existing flap position based on maximum takeoff weight calculations.
With the second push of either TO/GA switch (if A/T engaged and after A/T reaches reduced go–around thrust):
• the A/T advances to the full go–around N1 limit

TO/GA mode termination from F/D go–around:
• below 400 feet RA, both F/D switches must be turned off.
• above 400 feet RA, select a different pitch or roll mode.
• if the roll mode is changed first:- F/D roll engages in the selected mode
- F/D pitch mode remains in TO/GA.
• if the pitch mode is changed first:- F/D pitch engages in the selected mode.
- F/D roll mode automatically changes to HDG SEL
• the A/T GA mode (if engaged) is terminated when:- another pitch mode is selected
- ALT ACQ annunciates engaged.
Note: Engaging an A/P in CMD automatically engages the A/P and F/Ds in LVL CHG for pitch and HDG SEL for roll.

Nb. The above system description was cut / paste straight out of the Boeing B737-800 / FCOM / Volume 2 / Section 4 - Automatic Flight / Go Around, and which it seems that some of you could well do with reading!

[Almostfamous]

At least as far as courts in the United States are concerned, a subsequent remedial measure is inadmissible to prove liability. Otherwise, nobody would fix anything if it opened the door to successful suit.

[Aluminium shuffler]

Coal, my response was in response to the question at the top of the same (last) page, and contained the information pertinent to the question. What you have quoted is correct but irrelevant and omits the information specifically sought, ie. the bit about MCP altitude settings. I was trying to give a simple answer to a simple question, and my answer is entirely correct regardless of whether the MAP is flown manually or by autopilot, as it is relevant to the engagement logic of ALT AQUIRE, which is the same for FD as for A/P.

[16024]

What Shuffler said.
Coal's post is correct but he is answering a different question.

[Aluminium shuffler]

Thank you, 16024.

For what it's worth, I'm pretty sure all aircraft with AFDS are designed to behave this way to ensure an immediate MAP even if the pilots forgot to wind the MCP ALT up (eg for a non-precision app, where the ALT was set to app minima). As serious as a level bust is, and as badly as they can be managed, it is preferable to TOGA not engaging because you forgot to set the MCP ALT higher.

[striker26]

Flydubai pilot to be laid to rest - Cyprus Mail Cyprus Mail (http://cyprus-mail.com/2016/06/24/flydubai-pilot-laid-rest/)

Sad...may they all RIP


I hope the official report outlines specifically who/what was at fault. There will be many causes leading up to this crash, not just one!

[pax britanica]

Looking at OKCs post with the extract from the Boeing Manual , I am tempted very naively with a lot of tongue in cheek to say that far from helping the pilot a long list of 'If this do that ' alternative options, some of which could have dire consequences if misunderstood seem to be less rather than more help to a pilot going around than pull back a bit, push thrust leavers a good way forward and adjust both till you see say ten degrees nose up and positive climb.

Not belittling anyone as I have the greatest respect for all FD crew and to be in a situation like this, tired, in dead of night and poor weather must be horrible. However reading this thread and others , Asiana T7 , Turkish 738 it seems that the number of mods and options and conditional actions on the automatics seem to be making these situations worse rather than better

[Chronus]

pax britanica on this thread every conceivable speculation has been debated and discussed to complete exhaustion. Any suggestion that automatics may be exacerbating the incidence of aviation accidents is not supported by those cited. There is very little communality in the majority of air accidents, each and every one involves a unique and lengthy chain of complex events. That is the sole communality to all air accidents. Never one that can be reduced to a single factor.
The outstanding feature in this instance is the large pitch down moment applied to a large aircraft at low level, at high energy and inertia. That seems to be the sum total of the facts known so far.

[Kulverstukas]

We get another "leak" today. Some "source" inside investigation body suggested that Cpt. deliberately moved HS to dive position and "he was completely aware about a/c position and his intentions and speak in calm and self confident voice".

interfax (http://www.interfax.ru/russia/522868)

No new information on IAC page yet since May.

[unworry]

Kulverstukas, due to my poor translation of the article, would you clarify: is the inference that these action were due to fatigue and loss of situational awareness by the captain or is it implying he deliberately flew her into the ground.

[pax britanica]

Chronus

I am not suggesting automatic flight control features are a cause of more accidents what iwas trying to say is that it seems that recently most of the accidents that have happened ( and I fully accept that autoflight systems have probably prevented very many more) may be due to nuances/subtlties, call them what you will where some element of autoflight behaviour previously unknown or an ambiguity has been a causal factor in those incidents that have taken place.
Posts on this forum regulary highlight differences in undertanding with what the aircraft will do when button x is pushed pulled or turned in different circumstances. SoI am not criticising the concept or its applciation but it does seem to me that perhaps training lags a little behind reality in developing procedures to ensure that what is supposed to happen really does and how crews can develop motor memory skills and actions that ensure that things like pressing TOGA buttons means the engines spool up and not that they spool up except when condition x is present and in that case they immediately spool down again.

And I would repeat that i am not criticising anyone here especially flight crews who I have the utmost respect for working under pressurised and mentally and physically tiring conditions

[Kulverstukas]

unworry,
is the inference that these action were due to fatigue and loss of situational awareness by the captain or is it implying he deliberately flew her into the ground.
in the article it implies the second, with reference to fatigue problems and Cpt decision to leave FD as sidenote.

UPD: IAC dismissed this. "IAC is not the source of this information, investigation is carried on".

[Super VC-10]

Interim report published.

http://mak-iac.org/upload/iblock/ecd/Interim%20Report%20A6-FDN%20(en).pdf

[Skyjob]

Didn't know this was possible:
Page 6: "automatic retraction of flaps from 15° to 10° at a speed of over 200 knots" ... "decrease in engine thrust within 3 seconds resulted in decreasing speed and flaps extension to 15°".. "crew inputs to regain maximum takeoff/go- around thrust led to speed increase and reiterated automatic flaps retraction to 10°"

[megan]

Flap overspeed protection at work?

[unworry]

Thanks for you response in August, Kulverstukas

From the report:

http://i.imgur.com/piBfrad.png

[Avenger]

Skijob, SP versions have flap load relief from Flap 10 to 40..

[Kulverstukas]

Interim report published.

http://mak-iac.org/upload/iblock/ecd/Interim%20Report%20A6-FDN%20(en).pdf

Wasn't it published in 2016?

[flyingchanges]

12 seconds of trim with the flaps extended takes you to full nose down, or very close to it.

[donotdespisethesnake]

Wasn't it published in 2016?

Yes, little has changed since April 2016, but someone has to give the hamster wheel a push :)

MAK are still working on final report ...

The Interstate Aviation Committee (IAC) - official website (http://mak-iac.org/en/rassledovaniya/boeing-737-800-a6-fdn-19-03-2016)
20 march 2017

...
The Investigation team has collected all necessary factual information and is currently completing its detailed analysis with participation of experts of the involved States in order to develop a draft Final Report.

[Skyjob]

Skijob, SP versions have flap load relief from Flap 10 to 40..

Unaware of that, thanks for info!

[captplaystation]

So, 2 possibilities. Total & utter crew incompetence, which we can mitigate by introducing illusions involving the inner ear/fatigue/whatever . . . or, Boeing are very glad to adopt that , thanks very much. Frankly, no matter how tired/disorientated, I find it difficult to imagine any reasonably experienced crew member holding forward Stab-trim input for 12 sec, but, I haven't flown a FlyDubai roster. . . . . . .

[Judd]

which we can mitigate by introducing illusions involving the inner ear/fatigue/whatever Personal opinion only; but I wish I had a dollar for every time I see speculation that sensory illusions cannot be counted out as a contributory cause of IMC crashes. In most of the IMC/night accidents one reads about in accident reports, it seems a good bet that questionable basic instrument flying skills has a lot to do with these sort of prangs.

Re the Fly Dubai accident, I have seen pilots occasionally "freeze" on the 737 stab trim button during simulator training where a low altitude stall recovery was attempted while replicating the Turkish Airlines Amsterdam crash.

That was where the autothrottles went to idle during an auto-coupled ILS and the autopilot tried to fly the ILS glide slope and the stab trim had automatically wound slowly back to almost full aft by the time the aircraft stalled.

In this case, on the application of GA thrust and subsequent very strong pitch up (combination of high thrust and lots of back stab trim) strong forward elevator accompanied by forward stab trim action is required by the pilot to avoid an unusual attitude problem.

It is then we occasionally observe the pilot inadvertently keeping his thumb pressed hard on the stab trim button and in the heat of the moment forget to stop trimming. The usual result is the climb turns into a bunt and steep dive with no hope of recovery at that low altitude.

[G SXTY]

but, I haven't flown a FlyDubai roster. . . . . . .

I have.

I have had rosters very similar to the poor FO who died at Rostov, and on one flight was so tired I managed to forget the phonetic alphabet and even struggled to read our callsign back to ATC. Until you have experienced that level of fatigue, you cannot appreciate just how much it drains your capacity - and how reliant you are on the person sat next to you.

Many of us felt it was only a matter of time. Just put two equally fatigued pilots together in the middle of the night, throw in some bad weather and/or non normals and you're rolling the dice. It could have been me on that flight, or any of my mates. My only surprise was that it happened at Rostov - I can think of at least half a dozen places on the FZ network more likely to witness a smoking hole.

There but for the grace of God.

[RAT 5]

G60: Am I forgetting, but were they rostered for an out & back? Your suggesting they so were knackered for this approach, perhaps, but they still had the return sector to complete? Is that correct?

[framer]

I have been fatigued and it actually doesn't matter what stage of an individual duty you are at, it could be on the taxi out of the first sector at 8am and you can still be mentally ill equiped for operating. A duty can appear to be a good one on paper and you are not even capable of recovering well enough to do it. Eg you can have a day off with 10 hours sleep and not be sharp enough to operate a 10am sign on sector.
In my case it built up over a twelve month period and was due to a combination of household circumstances ( new baby, two bedroom apartment, no sound proofing) and poor rostering ( lates into earlies and back again every week perpetually). One night sleep didn't even put a dent in it. It took at least six months of getting proper uninterrupted sleep before my usual mental processing capabilities returned. As an aside, so did my positive outlook and ability to remember not only what day of the week it was but what we had planned on that day.
For me it was the circadian disruption that got me more than the lack of total sleep hours, but everyone is different.
The rosters that you flew GSXTY should be illegal and the head of FlyD should have to defend his/her oversite of the rosters produced leading up to the crash ( I won't say accident).

[G SXTY]

Rat 5

It was an out and back 2 sector duty.

framer

An excellent description of fatigue. It can be insidious and creep up on you without you even realizing. Regarding accountability, fatiguing rostering practices have been a fact of life at FZ for years. In my experience, with the honourable exception of the safety department, management were utterly indifferent to the problem. In the months leading up to the crash, there were around 20 fatigue-related ASR's per month, and the response was usually along the lines of "it's legal captain" or "that's how it is, if you don't like it you can leave." Many did.

Bearing in mind that Flydubai's chairman is also president of the Dubai CAA, and given the local culture where bad / embarrassing / inconvenient news is - how can I put it - 'discouraged,' I seriously doubt that anyone senior in the company will ever be held accountable.

A final report blaming pilot error would suit certain people very nicely.

[Vortex Thing]

The rosters that you flew GSXTY should be illegal and the head of FlyD should have to defend his/her oversite of the rosters produced leading up to the crash ( I won't say accident).

The flaw in the cunning plan there is that the then Chief Pilot at FZ now unbelievably promoted to DFO. Gave more of a flying monkeys as to the contents of his hankie the last time he blew his nose than about fatigue, hull losses and you or anyone else.

To aid that there is no effective or real oversight, he is literally a law unto himself and the people allegedly accountable for oversight of him and the whole shebang own the airline!

The only thing that can happen is that pilots simply do what he says in his daily mantra. "if you don't like it, leave!" When they have no pilots or no pax the problem ends. Until then the dice are rolled at least 54 times a day and often two or three times that! Sadly the only inevitability here is when the next one will be.

So unnecessary and so sad. The blind being led by the blind being overseen by the greedy and uncaring for the aloof. What a receipe!

[RAT 5]

So when are the pilots who have gajones (there must be enough of them to affect the roster) going to make a very public block protest and leave a/c on the ground? Are you suggesting that all the pilots are willing to Ko-tow. I know it's easier said than done, but why risk your health when there is a solution via resistance on safety grounds. Even in Dubai they can't ignore that argument if the voice is full & loud. Or is that all too wishful thinking?

[framer]

I think it will be within the next couple of years. Many pilots are making a fuss about it right now. My outfit just hired an office person full time to deal with the reporting and management of fatigue, we have ten aircraft.

[SMT Member]

There are several good reasons, why a large number of people chose to fly a 737 in the Sandpit rather than in their home countries/continents. Combine that with the fact organised labour and strikes are illegal in the UAE, and you've handed management a set of powerful tools with which to keep the workers in check.

Asking the crew to collectively stand up against the practices in e.g. FZ is therefore not only unreasonable, it would also be illegal and could have dire consequences for those involved.

Pilots, when not strongly organised in a union, have an exceedingly poor track record of forming ranks to improve their collective situation. To put it bluntly, a group of pilots are not a team; they are a collection of individual PLCs, acting only in what they believe is in their own self interest.

[BusAirDriver]

So Fatigue has not been mentioned in the report, wonder why?

Convenient for airlines, the dead can't defend themselves, and the companies can continue their normal operations, as their operations are legal, when will somebody stand up for fatigue in the business, or do we need many more "Pilot Error" crashes before somebody will finally wake up. :ugh:

[TriStar_drvr]

Final report released today.

https://www.reuters.com/article/us-russia-crash-flydubai/report-cites-pilot-error-in-2016-russia-flydubai-plane-crash-idUSKBN1Y01QD

I can’t find a link to the report though.

[Lena.Kiev]

https://mak-iac.org/upload/iblock/3d1/report_a6-fdn_eng.pdf