B-738 Crash in Russia Rostov-on-Don

[bsieker]

Preliminary ATC transcript

I have tried to make a transcript of the ATC communications from the posted youtube video and made it available here:
http://nuxi.homenet.org/misc/FlyDuba...t-20160319.txt

I'd be grateful for any feedback and corrections, and maybe someone can fill in a translation of the Russian parts if they seem pertinent to this case.

Nothing quite out of the ordinary as far as I can see.

In the opinion of line pilots, is there anything especially unusual about announcing to climb to FL80 after a go-around rather than the normal 2250 (or 3240) ft?

Could that be an indication that they intended to divert after this second attempt?


Kind regards,
Bernd

[ManaAdaSystem]

Fl 080 was probably to get above the turbulence.
Does the Misap procedure for Rostov contain a hard altitude in the FMC? Or maybe they set the MCP altitude to a lower altitude than FL 080.
A manual go around followed by a flight director level off, thrust cutback to reduce to speed at altitude capture, pitch down, confusion and ...

[bsieker]

ManaAdaSystem,

Thanks.

According to the chart posted here, missed approach procedure is

218º - at 940 LT
intercept QDM 080 KS to KS
climb 2250

or by ATC:
218º - at 940 LT 038º -
climb 3240

No idea about altitude in the FMC.


Bernd

[MrSnuggles]

Here is some kind of transcript along with a supposed flight path, even in 3D.

https://www.youtube.com/watch?v=CRUVDZjBAAs

[Vc10Tail]

Transport Jock "last time i checked when i did 2 cat3a approaches in a week in December in a 737, the autopilot was NOT engaged as it has to be manually flown and disconnected by 1000ft AGL.."

Did you mean AP disconnected at 1000 ft and manually flown

[Alice025]

Originally Posted by transilvana

Rostov is quite a tricky airport on bad weather, all the area is. On 2 ocassions I couldn´t land there and GA to Anapa and Krasnodar which is quite close for pax. Also runway is sleepery due to tyre residues on touchdown and rwy 22 is upslope giving you false approach sensations

But if locals don´t land there neither do I, even if you have enormous amounts of fuel on board. This pushing crews to the limit is getting nosense.

(In the Russian blogs) Norilsk city pilots say their airport, like a handful of others, in the Russian Far North, tends to. how to say. be partial to old Soviet safety rules rather than modern international when it comes to bad weather. Namely - diverts them all 1500 km away :o, leaving pilots no choice to attempt landing or not in bad weather, and never mind fuel cost, feeding pasengers, accomodating them in the hotels, all the additional costs incurred. They say that's why they are all still alive in the Far North, as safety interests are authoritatively ranked higher than any commercial or financial ones. There are no roads nor railroads in the Far North, safety of aviation is paramount to keep northerners in place. Norilsk Nickel company is tsar and God in those quarters and it wants people. It is also able to stand law suits in case of local airports being overly careful with weather.

[5 APUs captain]

2. Alice025:

They've crashed during Go-around... So, there is no reason to talk about Norilsk and Rostov RW and so on.
Looks like the GA altitude had been set on MCP instead of 8000 ft with in manual flight.

[airsound]

bsiekr

Thanks for your good work on the ATC transcript, Bernd. Very helpful.

Of course, as I've said before, we don't know if the audio was edited, and we don't know what might be missing - for instance, did they actually call on 121.2 at the end?

But.... the conversation does sound normal, so whatever went wrong after "121.2 bye bye" must have happened pretty quickly.

airsound

PS It would be helpful to have some translation of the Russian speech - anyone? I presume the exchanges in Russian were with other aircraft.

[singleacting]

I might be wrong here, but listening to the transcript, was there confusion between QFE and QNH? ( 998 & 988 )

[FlyingOfficerKite]

... just out of interest, what's that white 'stuff' on the external parts of the aircraft shown on the Wikipedia photographs? snow, ice, foam? It seems to be on the exterior parts but not on the (remains) on the internal components ...


FOK

[furbpilot]

Just wondering if engine anti ice might have been left off..

[Airbubba]

If they had a lower altitude set in the window, e.g. the published miss of 2260 feet, as they climbed to FL80, would the autothrottles come alive and pull the power back to idle as they zoomed upward in manual flight past the window altitude? This is what happens in some of the so called EFIS Boeings.

Does the Misap procedure for Rostov contain a hard altitude in the FMC? Or maybe they set the MCP altitude to a lower altitude than FL 080. A manual go around followed by a flight director level off, thrust cutback to reduce to speed at altitude capture, pitch down, confusion and ...

Looks like the GA altitude had been set on MCP instead of 8000 ft with in manual flight.

Yep, a very real possibility that the published missed approach altitude (2250 feet or 2260 feet depending on the chart maker) was somehow set in the window even though ATC said 'roger' to the climb to FL80.

And, ManaAdaSystem's question about the hard missed approach altitude in the FMS sure sounds pertinent. Even with 8000 feet in the window the autothrottles and flight director would still see the altitude constraint in the box if they were engaged in a vertical navigation mode.

In the opinion of line pilots, is there anything especially unusual about announcing to climb to FL80 after a go-around rather than the normal 2250 (or 3240) ft?

Great transcript, thanks for doing it. About the only thing I would normally do differently is phrase the climb to FL80 as a request. And a climb to FL80 in a light airliner would normally be more comfortable than leveling 2000 feet off the ground as long as things went well.

I overfly Russia but don't land there so I'm not sure what would be customary. Some places in South America you are pretty much on your own as far as ATC and you are expected to tell the controller what you are going to do next.

I might be wrong here, but listening to the transcript, was there confusion between QFE and QNH? ( 998 & 988 )

I don't think so, the crew explicitly read back only the QNH numbers. There is a gotcha that I've experienced on other Boeings where you are in an altitude capture mode and make a large altimeter setting change, say going from QNH to QNE as you would in this case on the missed approach to FL80. Twisting the altimeter knob as you start to level off can induce a noticeable pitch excursion.

Another update on the analysis of the flight and voice recorders:

The Interstate Aviation Committee (IAC) informs that the investigation team keeps working at the accident site. Today the examination of the site of the aircraft air collision is conducted, the wreckage map is constructed, the aircraft fragments' recovering is almost completed. The IAC specialists together with UAE representatives analyze the radar surveillance data, the flight crew-ATC communications, and the weather information.

On March 21st NTSB (USA) experts together with the Boeing experts will join the investigation.

The IAC Laboratory experts together with UAE and BEA (France) representatives have performed the preparation works on the extraction of the memory modules from the Flight Data Recorder (FDR) crash-protected cases, as well as the data readout. The preliminary analysis shows that the recorder was operational in flight, and was recording the flight data till the aircraft ground collision. The quality of recording is satisfactory. The experts start the recording data decoding and analyzing.

The Cockpit Data Recorder (CVR) shows the mechanical damages. In course of these damages the data cable was destroyed. The X-ray radiographic examination of memory module and interface cable was performed. The interface cable recovering, as well as the module non-volatile memory state examination are continued.

[Aluminium shuffler]

For those speculating about autoflight ILS approaches and go arounds on the 737, they are normally flown single channel autopilot for Cat I and most companies only allow dual channel for Cat II/III or practice autolands. On disconnection of the single channel on Cat I, the autothrottle is also disconnected - manual control, manual thrust; Boeing insist on an all or nothing method on the 737, unlike their other types.

However, pressing TOGA while on a single channel app will give TOGA autothrottle while instantly disengaging the autopilot, putting the pilots in an unfamiliar position of having manual control but autothrottle. This is a big set up for one nasty mode reversion habit of the 737 (Classic and NG alike) - when the aircraft approaches its level off altitude, the AFDS goes from its current pitch mode (in this case TOGA) to Alt Aquire. As it does so, the MCP speed window opens at the current speed, not the FMC speed or previously set MCP airspeed. So, with the autothrottles engaged, it is very easy on the level off, especially if ROC was high, to have the engines throttle back to a commanded speed much, much less than the one previously set, possibly much less than the minimum speed for the flap setting (which may be being retracted post GA). This nasty mode reversion really sets you up for a stall just as workload is very high in a way that is not as easy to spot as it should be. This is compounded by the target airspeed airspeed being commanded in a two engine go around by the flap lever, the only time it is ever controlled by anything other than the MCP window or FMC, often causing a level of confusion. So, on each stage of flap retraction, the target speed jumps up a bit higher than the minimum speed for the selected flap, and eventually you see a target faster than clean speed. This flap lever speed selection is overridden by that Alt Aqu reversion, so unless you are watching the mode annunciations or see the speed bug jump, you probably won't know it happened. So, you have seen a safe speed selected, and then, all by it self, it drops by up to 40kts. Not good, especially in shear. It is a quirk that should be emphasised during training, but it doesn't seem to be.

[furbpilot]

I listened to ATC and there is confusion between QFE/ QNH indeed.They seem to be descending to 600 on QNH while cleared to 600m on QFE. They are obviously starting to show symptoms of fatigue. Fact is that many operator using FDP/FTL limits as the norm..this was just waiting to happen..and it will happen again...

[Rananim]

I dont post on this site much since new management but I'll try again as this accident may well prove to be critical in highlighting yet again what is seriously wrong in our industry.We are all speculating with whats available.That's a given.Certainly speculation is no reason to actually ban a post.Its a rumors network supposedly for pro pilots,for Chrissakes.Investigators start with speculation...
I recognize some old names here like Centaurus and what they're saying is what we've all been saying for a long time now;there's an endemic problem in how a pilot is being trained today.Simply put,they're not being trained to "fly the plane" but rather manage the flight via the AFDS.Pilot vs flight manager.This is why we're getting the AF447,the Asiana,the THY at Schiphol,the pull not push when faced with something as basic as a stall etc...
Then you have the apologists who throw in things like fatigue and somatogravic illusion as a blanket to explain away and camouflage the real issue;pilots cant fly the plane anymore.Automation complacency and reliance have been eroding piloting skills for decades.Aided and abetted by focus on SOP as opposed to airmanship(the wrong people becoming trainers),and compounded by new management styles(beancounter focus on bottom line and not much else..tell these idiots there is nothing more costly in aviation than a crash).
I hope for the sake of the 62 souls that perished that it was an unsurmountable environmental encounter that would have defeated any line "pilot" with moderate stick and rudder skills and a scan.Because if it was more evidence of destitute flying skills(chasing a FD as someone suggested,not being able to fly a simple GA without AFDS,overtrimming your HS-a great big flt ctl surface that demands respect,likewise rudder-or not diverting when even the hardy locals are doing so which relates to judgment/airmanship)).then we need to sit down and rethink things.
The right people need to become trainers again,pilots need to be back on the decision-making board level,defocus SOP and rote push-button mentality,and start training pilots again not flt managers.

[Aluminium shuffler]

Distrust of automation is a healthy thing, and old school mentality is why things didn't get far out of shape whenever the above was done to me, Rananim, but we also have to accept that culture and mentality have changed over the past few decades. People trust computers now more than the older generations did. Whatever we think of it, that is the world we live in.

However, my post was not a hypothesis of what happened or why, or any kind of supposition about the pilots in this sad event. It was to clarify the autoflight system operation for the sake of the discussion as many on here are making assumptions about how it is used that are not right for the 737.

[furbpilot]

I might agree..but after 8 hours duty in them middle of the night what makes flying possible is automation. So train the pilot to fly but give'em the the intellectual capabilities to do it...cause some times..we are all counting on good luck and you know it.

[too_much]

Anyone have an updated QNH for time of approach? And how much it differ from
The QNE in terms of real altitude?

Maybe it could explain why the GA was not at minimums but an incorrect QNH setting called minimums early??

[JammedStab]

Concerning the fatigue issue, perhaps they were fatigued and perhaps they were not. Based on personal experience, even if tired, it tends to go away for me during an approach, especially when the weather is poor or challenging. And if a missed approach is thrown in, one wakes up quite quickly. So while I can see fatigue being an issue for forgetting to reset an MCP altitude or some other similar thing, I find it difficult to believe that it will be a major issue in terms of flying a missed approach manually unless one is grossly fatigued. As someone mentioned, mistakes happen to non-fatigued crews as well. Fatigue tends to be thrown around as an automatic excuse for a mistake. Many of us are starting our flights in the evening, so fatigue is just part of the job.

Concerning the weather, it appears that the weather is little different than is frequently encountered by crews around the world every day in which approaches are made. It was windy but nearly down the runway and there were reports of turbulence. An approach was made as is done in similar conditions around the world. Possibly, it got turbulent and they went around. Nothing out of the ordinary although one should expect that some of the passengers would not be happy with the expected turbulence. That being said, the statement that one pilot made of not attempting an approach if the locals are not making it in seems like a wise thought.

Concerning the holding and people asking why would the pilot hold for two hours, there is nothing unsafe about that at all as long as you have the fuel to do so. Perhaps the forecast was for improving weather.

Concerning the CB's, I just checked the Petropavlovsk weather as we use it as an alternate every time we fly by it. Once again, CB's in the Metar and forcast. It is 0 degrees C and snowing. Every time I check the weather at this airport there are CB's including throughout the cold weather which is ridiculous weather forecasting and observations. Seeing as this appears to be something that happens all across Russia, I say that their weather reporti g lacks credibility, at least when it comes to CB's, meaning that I don't believe that there was a thunderstorm at Rostov that night as it was still winter there as well.

[Airbubba]

This nasty mode reversion really sets you up for a stall just as workload is very high in a way that is not as easy to spot as it should be.

So, you have seen a safe speed selected, and then, all by it self, it drops by up to 40kts. Not good, especially in shear. It is a quirk that should be emphasised during training, but it doesn't seem to be.

However, my post was not a hypothesis of what happened or why, or any kind of supposition about the pilots in this sad event. It was to clarify the autoflight system operation for the sake of the discussion as many on here are making assumptions about how it is used that are not right for the 737.

Wow, thanks for the detailed explanation.