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Flydubai crash at RVI final report out

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Flydubai crash at RVI final report out

Old 2nd Dec 2019, 21:58
  #81 (permalink)  
 
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Originally Posted by gtseraf View Post
we also need to be alive to do the job! this kind of attitude facilitates the bullshit you refer to. As a professional pilot, you have a responsibility to maintain a certain standard and keep the operation honest!
exactly right. That’s why, when I realized that in order to keep it honest I’d have had to call “fatigued” every other week (at best), I decided to take my services elsewhere. Where, for one, I fly no nights. Huge difference. I feel honest again.
Nevertheless, a couple of intense years longer, and I’ll get the [email protected]#! out of this pointless grind.
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Old 3rd Dec 2019, 14:07
  #82 (permalink)  
 
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Originally Posted by Denti View Post
Is that not the case in the UK? I thought it was actually a requirement under EASA rules.....
You might be right, but all the fatigue reports I have ever completed were required to be sent to the company, not the CAA.
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Old 3rd Dec 2019, 17:30
  #83 (permalink)  
 
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And don't forget, as this thread is specifically about flydubai, that you are surmising that fatigue reports should be sent to the GCAA, the chairman of which is also the chairman of the Emirates group of which flydubai is a part. Don't expect the regulator in this case to take significant action over anything which may harm the profitability of the Emirates group. Like many things in Dubai saying something is being done and it actually being done is not always the same thing, the truth is not necessarily at the top of their list of priorities.
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Old 3rd Dec 2019, 23:21
  #84 (permalink)  

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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.
In the latter half of 2015, flight crew fatigue ASRs at Flydubai were running at around 20 per month. Some of them submitted by me. There were 21 reports in December 2015 alone. I believed then (and still do) that there was a corporate indifference to fatigue at FZ, and that the holes were starting to line up. It was one of the main reasons I left.

When the crash happened, the only thing that surprised me was the location - I could name many FZ destinations that were far more challenging and/or hazardous than Rostov. But that's the thing about fatigue - keep on sending tired crews up night after night, and the destination doesn't make much difference. Sooner or later, two equally fatigued pilots will encounter nasty weather and/or an emergency, and run out of capacity.

What an utter waste of 62 lives.
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Old 4th Dec 2019, 08:52
  #85 (permalink)  
 
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Focus

The discussion drifts back to fatigue, a single focus. Although important, it isn’t the dominant or overriding issue in this accident; that is about how it is possible for all of the factors to come together at that time.

#62 titled GA, could equally be titled fatigue, or system design, or SOPs, etc; the quote below still applies. Perhaps this viewpoint is the better item to debate.

Humans are simple creatures in a complex world. We crave understanding, we simplify issues and discuss them in isolation (we are lazy - cognitive misers), and detesting uncertainty conclude ‘black or white’, not wishing to accept the reality of a grey world.
The report is ‘grey’ - a very good shade, without ‘definitive conclusion’, yet able to identify and discuss contributing factors which could have resulted in the observed behaviour (hindsight).
Factors were reviewed in isolation, enabling each to be examined for their potential to improve safety, but not excluding more realistic or unidentifiable combinations - a subjective task requiring skills of critical thought and acceptance that there is no single solution - systems thinking - foresight
Consider how each of the agencies cited in the reports recommendations might act:- the airline, the regulator, the manufacturer, ICAO. At best, individually, they might “consider” the issues.
And anything that they or we might consider would be ineffective without action; thus the prime questions are what to act on, and who, and how is this to be actioned, what do we change - joined up thinking.

Thinking … https://ta-tutor.com/sites/ta-tutor....ts/thinkng.pdf
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Old 4th Dec 2019, 09:10
  #86 (permalink)  
 
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Originally Posted by G SXTY View Post
What an utter waste of 62 lives.
Not nitpicking, but, 63. RIP little unborn one.
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Old 4th Dec 2019, 10:30
  #87 (permalink)  
 
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Very sad event and a classic example of the Swiss cheese holes lining up. I was there for a while and there were many challenges. Not least a toxic and bully boy management culture backed up by minimal or no human rights as is typical in the ME. Pilots were understandably afraid to be fatigued or even sick. Chief pilot at the time embraced the toxic culture until being moved sideways to another management job in a training organisation having no previous training experience. You could not have made it up. Very tragic and RIP to all involved.
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Old 4th Dec 2019, 12:03
  #88 (permalink)  
 
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Centaurus

The thrust levers are manually positioned to max thrust for the go-around and the ensuing severe pitch up is further exacerbated by the aft position of the stabiliser trim. The pilot can only contain the pitch up that occurs by forward control column and holding constant forward stabiliser trim for approximately six seconds which permits fairing of the stabiliser and elevator thus allowing normal elevator control to keep the pitch attitude within reasonable limits.
With all due respect ( and I do mean that sincerely as we are apparently both in the same field) but depending upon when you were teaching this, I would take issue with your statement (bolded by me) as the pilot does in fact have another tool with which to contain the pitch up and that is the reduction of thrust in conjunction with pitch inputs. Certainly not intuitive in such conditions but probably vital. If there is insufficient pitch control or authority thrust reduction to the point of restoring that authority MUST be considered at least.

It was exactly this type of event, as well as the likes of the Thomsonfly B737 GA at Bournemouth (UK 2007)
in very similar circumstances which led to a complete review of the stall and approach to stall procedures globally, which changed the priorities of pitch (AoA) over thrust.


Thomsonfly B737 2007
https://assets.digital.cabinet-offic...009_G-THOF.pdf
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Old 4th Dec 2019, 13:53
  #89 (permalink)  
 
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Starbear, “- the pilot does in fact have another tool with which to contain the pitch up and that is the reduction of thrust in conjunction with pitch inputs.”

You appear to overlook that the GA was in response to a Windshear alert, which in general (overwhelmingly) requires maximum thrust.
At some point there may be a conflict between reducing thrust as judged by the crew in the actual conditions, and the operators SOP, - cognitive dissonance - mental effort, confusion, distraction.

What do operators teach and mandate by SOP ?
What advice do operators provide for reducing thrust after a Windshear GA ?
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Old 4th Dec 2019, 16:04
  #90 (permalink)  
 
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Originally Posted by safetypee View Post
You appear to overlook that the GA was in response to a Windshear alert . . .
That's true for the first go-around, but the second appears to have been initiated because of overspeed.

At the point of One thousand advisory callout activation (00:40:37) the aircraft was nearly stabilized for the approach (the flaps at a landing position 30), landing gear down, the deviations off the beam on localizer and glideslope within tolerance), with that the PIC uttered: «Stabilizing now», most probably, speaking about speed that was equal to 163kt (and trended to reduce), which was 10kt higher than the approach speed, determined by the crew.

The aircraft was flown a little bit higher of glideslope (0.3...0.2 dots), and the PIC was applying the corrective “pushing” movements on the control column to maintain the glide path descent more precisely, along with that the thrust (N1) was increased from 65% to 70%. Over the same moment the aircraft encountered wind gust. The combination of these three factors resulted in the IAS, after decreasing to the target value of 153kt, increase within a second for15kt (from 153 to 168kt), in 2 next seconds it additionally increased up to 176kt. In such a way the actual speed exceeded the target one (153kt) for more than 20kt.

This overspeed was responded by the F/O at 00:40:49: «Check the speed». It is the overspeed for a considerable value that, most probably, was the reason for the PIC to make decision on go-around. The PIC took the decision right away, called it out to the F/O and similarly was responded immediately:

00:40:49,7 00:40:50,4 CPT (Ok), go around.
00:40:50,500:40:51,1 F/O Go around.

At 00:40:50 the TO/GA mode was activated with the power levers advanced to full thrust.

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Old 4th Dec 2019, 17:04
  #91 (permalink)  
 
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Originally Posted by Denti View Post
Is that not the case in the UK? I thought it was actually a requirement under EASA rules (which of course do not apply to FlyDubai). At least when working in a FRMS Safety Action Group in a previous airline all actual fatigue reports were sent on to the authority, however there was a dispute if pre-emptive fatigue reports ("I am concerned this roster will induce fatigue") had to be send on. Reports were actively encouraged, calling in fatigued for a duty then required a report, so there was plenty to work through.
Hi Denti - not in the UK don't forget a fatigue report is a confidential report normally so SMS protocols kick in - the biggest test of FRMS however is the balls of the Chief Pilot to ensure his crew are not "named and shamed" to the DFO and MD - sometimes difficult if a flight is cancelled. CAA get top level stats and invites to FSAG.
In my experience of a mature AOC with FRMS fatigue issues are split down the middle between AOC and crew. AOC are the usual roster issues, stability of changes, Hotels etc and crews poor sleeping habits and lack of education and the C word (and that's not Christmas)
There is something missing though in that whilst the likes of Easyjet can provide loads of data on early and late combo's and DHL UK can provide loads of data on nights the ME airlines operate a mix of early, late and nights (and particularly long nights) and with 70 fatigue reports - sadly no data.

Last edited by Twiglet1; 4th Dec 2019 at 17:05. Reason: missed word
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Old 4th Dec 2019, 17:16
  #92 (permalink)  
 
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Originally Posted by Uplinker View Post
Not being an expert, it seems to me that factors contributing to this accident were attempting a go-around using the unfamiliar, different, monochromatic symbology and presentation of an HUD, instead of the normal ADI, IAS, V/S and N1 gauges - leading to disorientation? Operation with one pilot on a HUD and the other on conventional instruments had not been sufficiently trained, nor allowed to be sufficiently practised - particularly in the case of an F/O taking control from a Captain - both using different instruments - during a high workload situation, such as a go-around, which is going pear shaped.

Add to this, a possibly fatigued crew during their WOCL, and a horrible weather situation. The Captain clearly felt pressure that he had to land at the destination, and also not go out of hours, whereas from one’s armchair it would seem reasonable to divert after the first two landing attempts.
I think I have experienced good company FRMS systems, but allowing airlines to monitor their own fatigue reporting and deal with it in-house could potentially be a case of the foxes looking after the hen house?
If fatigue reports had to be sent to and dealt with by the equivalent CAA, then fatigue would be officially examined and might actually have to change?
Fatigue reports are the same as confidential reports - managed within the SMS. If names get leaked then the Pilots lose trust in the SMS and stop reporting. Again some AOC's have sleep scientists that assess the rosters individually. However an aweful lot of Airlines also have (commercial) bio-mathematical modelling systems latched onto their scheduling systems which they use to convince their CAA's they are managing fatigue e.g. system says green so good to go. Are they validated, do they have data on that particular AOC - you know the answer.
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Old 4th Dec 2019, 17:57
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Oldn, my interpretation of the report was that windshear caused the speed change. The Captain reported that the approach was stable, higher speed than normal, but then “increase within a second for 15kt (from 153 to 168kt)” a change most unlikely to be a commanded change in the thrust setting or vertical speed.

15kt/sec represents a gust, whereas aircraft are more sedate, approx max 3kt/sec, depending on type.
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Old 4th Dec 2019, 18:23
  #94 (permalink)  
 
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Originally Posted by safetypee View Post
Oldn, my interpretation of the report was that windshear caused the speed change. The Captain reported that the approach was stable, higher speed than normal, but then “increase within a second for 15kt (from 153 to 168kt)” a change most unlikely to be a commanded change in the thrust setting or vertical speed.

15kt/sec represents a gust, whereas aircraft are more sedate, approx max 3kt/sec, depending on type.
I understand, Safety, and the report does speculate that the PF may have interpreted the reported gust to be evidence of windshear. On the other hand, there was no windshear warning on that second attempt; PF was pushing the nose down a bit and thrust was increased a bit in the moments leading up to the overspeed; the CVR recording doesn't include any evidence that PF told PM they were executing a windshear escape GA; and the PM's offer to retract flaps back to 15 suggests that he didn't think they were flying a windshear escape. I guess we're all guessing.

This is a desperately sad story.
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Old 4th Dec 2019, 19:28
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In "my" days it was promoted to specify the type of wind shear. If during the APP a "negative" shear or performance decreasing shear, was reported, a drop in speed (IAS) could be expected. The confusing about it that the same (TWR) controller had to report this same shear as a "positive" shear to departing A/C.
In this case the arriving A/C should have been told to expect a "positive" shear.
Is this still needed to/practiced?
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Old 5th Dec 2019, 04:28
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Originally Posted by safetypee View Post
Starbear, “- the pilot does in fact have another tool with which to contain the pitch up and that is the reduction of thrust in conjunction with pitch inputs.”

You appear to overlook that the GA was in response to a Windshear alert, which in general (overwhelmingly) requires maximum thrust.
At some point there may be a conflict between reducing thrust as judged by the crew in the actual conditions, and the operators SOP, - cognitive dissonance - mental effort, confusion, distraction.

What do operators teach and mandate by SOP ?
What advice do operators provide for reducing thrust after a Windshear GA ?
No, I don't believe that I did but perhaps did not make myself clear enough. Perhaps I should have included the full quote from his post but I was specifically referencing Centaurus' tale of teaching recovery from a severely out of trim/low speed situation such as the Turkish B737 at Amsterdam and offered the Thomsonfly B737 incident as a parallel to the Turkish one.I was not or not intending to link to the Flydubai incident. There have been quite a few others but am a little hazy on precise details now, without research but a couple of A310s, I think Tarom (?) but again severely out of trim for a variety of reasons. And the modifcations to a stall/approach to stall recovery were changed long before the FlyDubai case.

With regard to reactive windshear recovery and your posed questions, I would suggest that sadly the answer is "not very much" and is often as much use as the manufacturer's instruction to "smoothly adjust the pitch to follow the guidance". However what I can confirm from observation that many pilots continue to maintian an inapproriate high pitch attitude even when well clear of the windshear and/or terrain. Often as high as 20 deg (and more)for a sustained period with 2 or even 3,000 feet terrain clearance and reducing IAS.
They do not appear to have a reference for confiming they are now in a safe situation and able to revert to a normal GA type scenario. They always get there in the end, (so who can knock that?) but it is often very "untidy".

I would not comment on the pilots' reactions in the Dubai case, as I believe the report has already covered that very well.
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Old 5th Dec 2019, 04:39
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Originally Posted by Twiglet1 View Post
Fatigue reports are the same as confidential reports - managed within the SMS. If names get leaked then the Pilots lose trust in the SMS and stop reporting. Again some AOC's have sleep scientists that assess the rosters individually. However an aweful lot of Airlines also have (commercial) bio-mathematical modelling systems latched onto their scheduling systems which they use to convince their CAA's they are managing fatigue e.g. system says green so good to go. Are they validated, do they have data on that particular AOC - you know the answer.

I agree wholeheartedly. The FRMS software systems that I have experience with are pretty easy to manipulate. The company can make almost any roster appear to be in compliance with their regulator's standards. At most companies only lip service is paid to fatigue. I believe this is the case in the Rostov crash, with brutal rosters playing a huge part in the Captain's mistakes.
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Old 5th Dec 2019, 11:44
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I used to fly for a very well respected UK airline. They wrote a “propaganda” pamphlet to the crews on how wonderful their FRMS system was on making the rosters. Interesting in that I wrote to the author pointing out on release the rosters were fine, but they were never flown as the rosters were always completely changed by day to day crewing. ( to knackering patterns). Funny old thing I never got a response. But bet the pamphlet looked great to the CAA.
Am absolutely certain fatigue played a huge part in this crash.
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Old 5th Dec 2019, 14:20
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Starbear, our interpretations of this report differ, as might be expected by the human condition.

Similarly with other examples; accidents involving human-automation interaction, indications, alerting, and physical interaction with aircraft trim or autopilot. I recall that one of the examples and possibly two others (A310, Avro RJ) involved overpowering the autopilot causing the trim to run. The latter two resulted in aircraft modification, but other manufacturers argued, as you might, that the human should manage systems, where others would see them as weak / flawed designs.

Certification regulations now require improved human - autos interaction, but not retrospectively. [for info, see the AMS 737 report - annex of comments, manufacturer / FAA / investigator. Chilling similarities with recent events.]

A problem with this line of thought is that it might exclude the wider picture, to consider other factors and interactions, which will also differ according to viewpoint, within or after the fact.

Your views on WS GA are useful, thanks. However, with the advent of sophisticated detection systems, differentiating predictive or reactive WS, and possibly excess energy, result in more, and case sensitive alerts and procedures; general or specific SOPs. This adds complexity to operations and training, increasing demands on situation awareness an interpretation. So claimed technical safety improvement, may be diminished by more dependence on stretched human ability in rare and surprising situations.
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Old 6th Dec 2019, 07:32
  #100 (permalink)  
 
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If not represented by a strong union, "fatigue reports" are treated by the management as nails into pilot's own coffin!
Try calling fatigued or writing SMS reports, twice in a row at an airline like Fly Dubai. Heck, even at Emirates or Ryanair!
Although this very well prepared crash investigation report paints a perfect picture of a total incapacitation due to pilot pushing and chronic fatigue.
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