Flydubai crash at RVI final report out
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How many back side of the clock flights did they do in the preceding weeks? One may be legal with regards to rest and still be suffering from the affects of cumulative or chronic fatigue. Those who have done back to back to back overnight flights know what one feels like after two or three in a row. I don't see this detailed in the report.
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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.
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Been long enough in the RH seat to know that to physically take over control is maybe the most difficult decision to take as a F/O . However in this case... he saw death approaching, In my view there was some kind of "blurry" steep authority gradient, caused by different cultures/backgrounds/languages.
(pax) I read the report and found it apparently thorough but a bit ' discursive'. It is as if they wanted to make the report a ' home' for everything they considered or photographed. The -1.4g excursion got my attention, as did the observation that uncontrolled leg movements are considered a typical sign of loss of personal control, which I assume means what a layman may call ' panic'. I think it harsh to blame the F/O given the timeline and collapsing situation with the PF hands locked on the column, pressing the trim switch and pumping the pedals. The fact that the PF kept harping on about the speed excursion, including engaging with cabin crew on this, perhaps indicates his mental calm was fragile before the long hold which was indicative of his anxiety to avoid a diversion. A dreadful read and a very great pity. The F/O was getting there but there wasn't time for him to recover the situation given the dynamics.
A really tragic accident. Lots of lessons to be learned though. A couple of things that stood out for me:
Fatigue
If it’s not reported then there is no problem.
Between 2009 and 2016, flydubai performed 450,000 flights and had 70 fatigue reports. Seriously, 70 reports, that’s a report rate of 0.015 %. There’s your problem right there, clearly a culture where people do not feel able to report fatigue.
It really highlights why FTLs are not fit for purpose and offer no protection against the effects of fatigue and tiredness. How can a safety critical industry just ignore scientific and medical studies? Oh yeah, because if you are tired, or fatigued you just say so. Well that doesn’t work in all airlines (or any airlines IMO) does it? See above!
Pilot Training
I still find it unbelievable that professional airline pilots do not need to do stall training in a jet or upset training (in an aircraft) or be subjected to G force. We could all be faced with a situation like this. At the end of a long duty, on a dark, crappy night either our control inputs or some upset expose us to confusing and previously unknown psychological effects such as G force and within seconds we are completely disoriented. Already tried and under high stress and now we subjected forces and feelings we’ve never experienced, and guess what we probably won’t do such a great job.
This was an experienced crew who had been making decent decisions and within a few seconds, the PIC lost all spacial awareness and flew a perfectly good aircraft into the ground. But oh yeah, training like that would be pretty expensive so let’s just tick the box in the simulator and pray.
It’s a bit like training soldiers at laser quest and then sending them to war. “Don’t worry guys, there’s a little bit more noise and the odd explosion but your training will kick in, good luck!”.
And no, fully autonomous aircraft are not the answer. Properly trained crews, with sensible rosters and the best tech is.
Fatigue
If it’s not reported then there is no problem.
Between 2009 and 2016, flydubai performed 450,000 flights and had 70 fatigue reports. Seriously, 70 reports, that’s a report rate of 0.015 %. There’s your problem right there, clearly a culture where people do not feel able to report fatigue.
It really highlights why FTLs are not fit for purpose and offer no protection against the effects of fatigue and tiredness. How can a safety critical industry just ignore scientific and medical studies? Oh yeah, because if you are tired, or fatigued you just say so. Well that doesn’t work in all airlines (or any airlines IMO) does it? See above!
Pilot Training
I still find it unbelievable that professional airline pilots do not need to do stall training in a jet or upset training (in an aircraft) or be subjected to G force. We could all be faced with a situation like this. At the end of a long duty, on a dark, crappy night either our control inputs or some upset expose us to confusing and previously unknown psychological effects such as G force and within seconds we are completely disoriented. Already tried and under high stress and now we subjected forces and feelings we’ve never experienced, and guess what we probably won’t do such a great job.
This was an experienced crew who had been making decent decisions and within a few seconds, the PIC lost all spacial awareness and flew a perfectly good aircraft into the ground. But oh yeah, training like that would be pretty expensive so let’s just tick the box in the simulator and pray.
It’s a bit like training soldiers at laser quest and then sending them to war. “Don’t worry guys, there’s a little bit more noise and the odd explosion but your training will kick in, good luck!”.
And no, fully autonomous aircraft are not the answer. Properly trained crews, with sensible rosters and the best tech is.
‘F/O should have taken control.’
The investigation did consider this aspect; there were indications that the PM had the better understanding of the rapidly developing situation. However, whilst he could ‘see’ what the aircraft was doing, not knowing why might have delayed the choice of ‘drastic’ intervention after repeatedly alerting the PF to the abnormal condition (CVR).
The report discusses control force from the FDR which suggests that there was dual control input, even to the point of left / right control breakout - PF pushing, PM pulling, but the situation at that time was significant nose down attitude, speed increasing, and the trim moving fully forward.
The above indicates that the concept of monitoring and crew intervention cannot be assured in all situations.
The difficulty in identifying trim operation and position (as in the Max accidents) is explained, as is the mechanics of control forces and impossibility of effecting a recovery at low altitude, again as in the Max accidents. This point should be noted by regulators / operators if the 737 Max post MCAS mod, were to revert to a ‘near NG’ configuration, in that any assumption requiring quick identification and pilot action to intervene for a trim malfunction is misjudged given the findings in this accident.
Also see footnote #38 page 175.
The report discusses control force from the FDR which suggests that there was dual control input, even to the point of left / right control breakout - PF pushing, PM pulling, but the situation at that time was significant nose down attitude, speed increasing, and the trim moving fully forward.
The above indicates that the concept of monitoring and crew intervention cannot be assured in all situations.
The difficulty in identifying trim operation and position (as in the Max accidents) is explained, as is the mechanics of control forces and impossibility of effecting a recovery at low altitude, again as in the Max accidents. This point should be noted by regulators / operators if the 737 Max post MCAS mod, were to revert to a ‘near NG’ configuration, in that any assumption requiring quick identification and pilot action to intervene for a trim malfunction is misjudged given the findings in this accident.
Also see footnote #38 page 175.
Fox_one perfectly highlights the problem with flydubai's fatigue reporting system. If you reported fatigued you would be taken off flying whilst the company decided, in consultation with an AME, if fatigue was an issue. This could take a considerable time, and if they decided that it was not then the time you spent not flying was recorded as sick leave. Bearing in mind that you were only allowed paid sick leave for fifteen days per year, if they decided that there was nothing wrong with your roster and you were therefore not fatigued you could potentially spend a long period not being paid until you returned to flying, and living in Dubai is expensive, especially if you have a family. To be fair to the company they did go through the motions of improving things, but even two years after the accident one of the second officers was called into a meeting with the chief pilot after he had not felt fit to fly due to lack of sleep having been kept awake by his newly born baby, to be told by the chief pilot that in his (the chief pilot's) opinion, if he could not manage his sleep with a new baby in the house he was not only unfit to be a professional pilot, but unfit to be a parent. That, by the way, was the new chief pilot who was put in place when the previous one was promoted out of the way following the accident. With that sort of thing to contend with it is hardly surprising that people didn't report fatigued, instead it was not uncommon for occupants of both seats to be taking controlled rest of one or two hours on long night flights.
There were also issues with training. I joined the company as a type rated DEC two years before the accident happened and left two years afterwards. For my OCC I was paired up with a type rated F/O, and despite what was quoted in the report regarding the training to use the HUD we never swapped seats, so that was at least one F/O who didn't get to use the HUD during his training. Also, despite the syllabus quoted in the report, shortly after the accident I asked an F/O who I knew had joined non type rated how many standard two engine go-arounds he had done in training and the answer was one, flown by the captain during LVO training. He had done a couple of others due to systems failures, also in the LVO training, but had never done one himself. He had also never flown using the HUD as his training had been done with two F/Os and a stand in captain, so also no seat swapping, although he had seen the hud repeater image in the back of the sim whilst observing. Also, up until the accident there was no SOP to brief how a go around was to be flown, indeed when I did this on my first day of line training I was told by the LTC not to do so, as it wasn't SOP and might confuse F/Os who did not have English as their first language.
On the subject of the HUD, I can't help thinking that flydubai did the accident crew, and indeed all the crew members who went through the type rating training with them, a great miss service. The SOP, as high lighted in the accident report, was for the HUD to be used for all stages of flight, and as mentioned in the report their are many stages of flight where this is not an advantage. Flying the HUD, for those who haven't done it, is just like being in a giant computer game, and takes away a lot of situational awareness, as you don't have the map display to look at. Also, flydubai got everyone into a mind set of flying all approaches manually from 1000ft, as that was what was required for a cat3a approach. With the weather conditions these pilots experienced at Rostov I9and this is just personal) would have left the automatics engaged for as long as possible, right down to cat1 minimas if I felt it neccessary. There was no reason for the captain to disengage the autopilot and auto-throttle except that it was what he was used to doing. Many of the captains who joined the company from other airlines would ignore the SOP and only use the HUD for cat2 or 3 approaches. Unfortunately flydubais training in bad weather ops was limited, as most line training flights were done on short sectors around the Gulf to make it easier for the line trainers.
As a caveat to all this, I left two years ago. Maybe things have changed, but I'm surprised that this isn't being discussed on the ME forum or that there don't seem to be more posts from flydubai pilots. Having said that I am lucky not to have to access pprune through a VPN anymore, and wonder if it is still blocked in the UAE?
There were also issues with training. I joined the company as a type rated DEC two years before the accident happened and left two years afterwards. For my OCC I was paired up with a type rated F/O, and despite what was quoted in the report regarding the training to use the HUD we never swapped seats, so that was at least one F/O who didn't get to use the HUD during his training. Also, despite the syllabus quoted in the report, shortly after the accident I asked an F/O who I knew had joined non type rated how many standard two engine go-arounds he had done in training and the answer was one, flown by the captain during LVO training. He had done a couple of others due to systems failures, also in the LVO training, but had never done one himself. He had also never flown using the HUD as his training had been done with two F/Os and a stand in captain, so also no seat swapping, although he had seen the hud repeater image in the back of the sim whilst observing. Also, up until the accident there was no SOP to brief how a go around was to be flown, indeed when I did this on my first day of line training I was told by the LTC not to do so, as it wasn't SOP and might confuse F/Os who did not have English as their first language.
On the subject of the HUD, I can't help thinking that flydubai did the accident crew, and indeed all the crew members who went through the type rating training with them, a great miss service. The SOP, as high lighted in the accident report, was for the HUD to be used for all stages of flight, and as mentioned in the report their are many stages of flight where this is not an advantage. Flying the HUD, for those who haven't done it, is just like being in a giant computer game, and takes away a lot of situational awareness, as you don't have the map display to look at. Also, flydubai got everyone into a mind set of flying all approaches manually from 1000ft, as that was what was required for a cat3a approach. With the weather conditions these pilots experienced at Rostov I9and this is just personal) would have left the automatics engaged for as long as possible, right down to cat1 minimas if I felt it neccessary. There was no reason for the captain to disengage the autopilot and auto-throttle except that it was what he was used to doing. Many of the captains who joined the company from other airlines would ignore the SOP and only use the HUD for cat2 or 3 approaches. Unfortunately flydubais training in bad weather ops was limited, as most line training flights were done on short sectors around the Gulf to make it easier for the line trainers.
As a caveat to all this, I left two years ago. Maybe things have changed, but I'm surprised that this isn't being discussed on the ME forum or that there don't seem to be more posts from flydubai pilots. Having said that I am lucky not to have to access pprune through a VPN anymore, and wonder if it is still blocked in the UAE?
Other than that question I thought the whole report was a very sobering read and provides a classic example of how quickly things can deteriorate in aviation from being essentially "Ops normal though a bit challenging", to coming completely undone..
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Different type (E195) and airline but that's exactly what we did for CAT3A approaches.
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wiggy - yes that’s exactly what I’m saying, for a cat3a approach A/T and A/P disengaged by 1000 ft Rad alt, and hand flown to a manual landing following the HUD cues for RETARD and flaring by following the steering cue (target circle in the doughnut). It works well, but not the best thing to do when you’re knackered after a 12 hr night duty; and because of this the normal teaching of leaving the automatics in until you get low down beneath the cloud base with increased peripheral vision of the runway environment of flying a cat 1 or non-precision approach was not taught.
And let’s not be mistaken here, there was one reason for flydubai having the HUD. It wasn’t to
make the operation safer or give the captain increased situational awareness, it was because it was cheaper than keeping the autopilots certified for dual channel
approaches and auto land.
And let’s not be mistaken here, there was one reason for flydubai having the HUD. It wasn’t to
make the operation safer or give the captain increased situational awareness, it was because it was cheaper than keeping the autopilots certified for dual channel
approaches and auto land.
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"Experienced pilots". Both pilots had roughly 6,000 hrs TT. I upgraded with about 6,000 hrs and wouldn't have called myself "experienced." 15,000 hrs? 20,000 hrs? Yes. 6,000? No.
We're (T7) very much automatics in in poor wx, and the full use of the automatics are very much recommended for as long as possible if there's prospect of windshear. As a result I had a
the first time I read about the autopilot disconnect in the report, but can now see why perhaps the crew were "spring loaded" to knocking the automatics out....
Last edited by wiggy; 28th Nov 2019 at 14:19.
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Based on this quote from page 105 of the report it may not have been deemed necessary:
"The analysis of compliance of the work and rest schedule within a record period (28 consecutive days) did not identify any violations. The crew had a sufficient amount of the preflight rest. As per the submitted data, the Fatigue Management System is implemented in the airline. The system encourages the fatigue-related confidential reports by the crewmembers for any stage of the flight operations (the preflight, in-flight, post-flight one). For a number of quantitative indicators the system goes beyond the national aviation legislation (that is it ensures the improved conditions for the crewmembers). Since 2009, the airline has accumulated 450 000 flights with a total flight time of more than 1 million hours. Within the period, 70 fatigue-related confidential reports were submitted. The majority of them were proactive by nature – as the crewmembers reported the fatigue presence and were removed from duty until they felt fit for flight operations."
"The analysis of compliance of the work and rest schedule within a record period (28 consecutive days) did not identify any violations. The crew had a sufficient amount of the preflight rest. As per the submitted data, the Fatigue Management System is implemented in the airline. The system encourages the fatigue-related confidential reports by the crewmembers for any stage of the flight operations (the preflight, in-flight, post-flight one). For a number of quantitative indicators the system goes beyond the national aviation legislation (that is it ensures the improved conditions for the crewmembers). Since 2009, the airline has accumulated 450 000 flights with a total flight time of more than 1 million hours. Within the period, 70 fatigue-related confidential reports were submitted. The majority of them were proactive by nature – as the crewmembers reported the fatigue presence and were removed from duty until they felt fit for flight operations."