Flydubai crash at RVI final report out

[bounce'em all]

Every FRMS I’ve seen so far is absolute bull****. We all know how some (all) airlines actually manage it. But hey, most of us need the job, right ?

[Euclideanplane]

Originally Posted by Twiglet1

Euclideanplane I hope you have seen from some of the posts since you posted that your comments with respect show a lack of understanding about FRMS. I'm no sleep scientist (how many Airlines engage such folk) but with the early/late/night FDP's at FZ - there will be a fatigue issue. The FRMS was clearly not functioning.

I posted the quote vertabim because another poster had wondered why the fatigue aspect appears relatively downplayed in the report. It is unusual for a final report on an accident of this character to treat the possible issue with just one short paragraph like this.

[vaneyck]

As to the question of the F/O taking control - A comment from one of his examiners at a training and proficiency check (p 39) says:

Needs to be quite a bit more assertive in
what is needed from the Captain. Tell
him/her what you want done and do not
wait for the Captain to enquire with you or
direct you in this regard. Need to be more
decisive in taking actions when needed.

[OldnGrounded]

Originally Posted by vaneyck

As to the question of the F/O taking control - A comment from one of his examiners at a training and proficiency check (p 39) says:

Needs to be quite a bit more assertive in
what is needed from the Captain. Tell
him/her what you want done and do not
wait for the Captain to enquire with you or
direct you in this regard. Need to be more
decisive in taking actions when needed.

And it was less than one minute between the (second) go-around and the moment the CVR clearly indicates that the FO knew they were in trouble. Indeed, it was about 20 seconds from the exchange: "Go around" -- "Go Around" to the CVR recording the PM saying, "Keep it to fifteen degrees, nose up." 25 seconds after that, we have the PF exclaiming, "Oh sh*t!."

[UltraFan]

Originally Posted by misd-agin

"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.

Yeah, those 50-year-old puddle-jumpers... who the hell do they think they are with their meagre 10k hours! Pfft... amateurs!

However... Let's do some math. A pilot is legally allowed to fly (depending on the country) anywhere between 70 and 90 hours a month. Let's take 80 as an average (because otherwise I'll need a calculator). Even if the pilots gets no vacation or sick leave, 20,000 hours would take 20+ years of legal-limit flying. Some countries limit the minimum age of commercial pilots to 21 or even 23 years old. Therefore, your experienced-title-worthy age doesn't come until at least 40, likely 45. Would you want to call 40+ years old captains with 10-15 years of flying under their belts INexperienced? Or are you just having one of those grass-was-greener-in-my-day moments?

PS And OH, YES, you called yourself experienced! Many, many years later you may have realized that you probably hadn't been, but back then... LIKE HELL YOU DIDN'T!!!

[Phantom Driver]

In the old classic 737 ( I'm talking -200 ) many many years ago ( nothing fancy like AT ) we were taught on GA , after establishing initial 15 degree pitch , next thing you did pronto was pull those thrust levers back a notch or two , otherwise you'd have a ( generally light ) aircraft going like a bat out of hell , with all attendant consequences regarding flap limits / altitude busts .

On my later Boeing types ( 744 / 777 ) , the auto thrust was programmed to do it for you on GA ; brought the power back sufficient to maintain 2000 fpm rate of climb . Always nice to slow things down a bit while brain cells were reorganised .

(p.s. did a spell on A 330/340 ; great aircraft , but one complaint was that , on GA , the system gave full thrust , no matter what . Now this was ok on the 340-300 ( the one with the 4 CFM hairdriers ), but on the 330 (RR donks) it could be a handful ... Our company lost a 320 on GA ; for sure all that thrust contributed to the somatogravic illusion that sadly is still all too common) .

[400guy2]

Originally Posted by UltraFan

Or are you just having one of those grass-was-greener-in-my-day moments?

Yes, it was; thank you for asking. But it is not just the grass: the older I get, the better I used to be.

[CurtainTwitcher]

I find this study quite useful as a review of previous Go-Around incidents & accidents: BEA on Aeroplane State Awareness during Go-Around, Published August 2013.

Phantom Driver, one of the incidents in the BEA study is an A320 Go-Around event in Melbourne in 2007, which the crew tried to manage the anticipated excessive rate of climb by reducing thrust: Go-around event Melbourne Airport, Victoria, 21 July 2007, VH-VQT, Airbus Industrie A320-232.

[misd-agin]

Originally Posted by UltraFan

Yeah, those 50-year-old puddle-jumpers... who the hell do they think they are with their meagre 10k hours! Pfft... amateurs!

However... Let's do some math. A pilot is legally allowed to fly (depending on the country) anywhere between 70 and 90 hours a month. Let's take 80 as an average (because otherwise I'll need a calculator). Even if the pilots gets no vacation or sick leave, 20,000 hours would take 20+ years of legal-limit flying. Some countries limit the minimum age of commercial pilots to 21 or even 23 years old. Therefore, your experienced-title-worthy age doesn't come until at least 40, likely 45. Would you want to call 40+ years old captains with 10-15 years of flying under their belts INexperienced? Or are you just having one of those grass-was-greener-in-my-day moments?

PS And OH, YES, you called yourself experienced! Many, many years later you may have realized that you probably hadn't been, but back then... LIKE HELL YOU DIDN'T!!!

Maybe we use the English language differently on this side of the pond. Where did I call myself "experienced" as an airline pilot with 6,000 hrs TT? When I had that little experience? You might have but I certainly didn't.

This has come up with coworkers and we discussed this privately when a report called a 12,000 hr pilot 'highly experienced.' None of my peers thought that was highly experienced. It might be semantics but we disagree on what experienced, or highly experienced, means. Does a person who only flies into one city get to call himself highly experienced? What about the guy who has limited experience on a lot of aircraft? Does he get to claim 'experienced', or 'highly experienced', when his experience in his new position is relatively limited (500 hrs? 1000 hrs?)?

[misd-agin]

Originally Posted by Phantom Driver

(p.s. did a spell on A 330/340 ; great aircraft , but one complaint was that , on GA , the system gave full thrust , no matter what . Now this was ok on the 340-300 ( the one with the 4 CFM hairdriers ), but on the 330 (RR donks) it could be a handful ... Our company lost a 320 on GA ; for sure all that thrust contributed to the somatogravic illusion that sadly is still all too common) .

There's an option to reduce power to CLB after selecting TOGA on the AB. TOGA gets you the go-around guidance and then reducing to CLB on the Airbus reduces the rate of climb to a rate similar to just pushing the TOGA button once on a Boeing. Full/max power, and a landing weight, can induce vertigo issues, time comparison, high rates of climb, etc. Selecting V/S 1000' FPM is also a way to reduce the rate of climb and make the go-around less hectic.

[JPJP]

Originally Posted by excrab

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.

Your points regarding the HUD are well made. The GA mode is poorly thought out. Apart from a HUD takeoff there is no other mode that uses the same cues. As a result, it’s the least used.

The ‘bore-sight’ and pitch target aren't intuitive, and the transition to the normal symbology shortly afterward is an unnecessary distraction. Especially given the other factors involved (low altitude, high thrust etc.) The GA mode also has a distractingly large perceptual distance between the bore sight and the dotted line. Which adds to any somatographic illusion.

Regarding an FO and there interaction with a CA flying either a GA, or a low vis takeoff on the HUD - they should understand (or be briefed, as you alluded to) the threat associated with the modes. ie. ‘if you see the CA pitching above 15 degrees ANU, be aware that they may be going down a slippery slope’.

[UltraFan]

Flight Global goes Daily Mail on flydubai 981:
https://www.flightglobal.com/news/ar...impact-462590/

[Jwscud]

I can’t help but wonder given that the crew hours were “legal” that there may have been some politics at play in downplaying fatigue. I seem to recall the roster of one of the pilots being posted on here just after the accident and it was pretty bloody awful.

I also found the HUD and guidance cues deeply confusing. It was clear the FO had far better SA throughout, which although was a consequence of his not manually flying the aircraft was also I think because he had traditional instruments in front of him. I suspect with a blue/brown PFD and the traditional crossbar flight directors this would just have been a messy go around.

[CargoOne]

excrab
I am confused with the purpose of HUD on 737NG and performing CATIIIA landing with A/P and A/T disengaged. There are aircraft types with no autoland (like CRJ) where HUD option gives you CATIIIA capability for manual landing, so it is clear. But why would anyone use HUD & manual while 737NG can perform CATIIIA autoland?

[SOPS]

Cargo One.. I have been thinking the same thing after reading the report.

I would also love to see their rosters prior to this flight. Legal does not mean safe. And airlines in this area ( and many others), are well known for making the legal limit, not a limit, but a target.

[wiggy]

Originally Posted by CargoOne

excrab
I am confused with the purpose of HUD on 737NG and performing CATIIIA landing with A/P and A/T disengaged. There are aircraft types with no autoland (like CRJ) where HUD option gives you CATIIIA capability for manual landing, so it is clear. But why would anyone use HUD & manual while 737NG can perform CATIIIA autoland?

excrab made this comment in #38 :

"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."

[Double Back]

Retired 10+ Years ago after having commanded 17 Years on relative "simple" A/C like the 744, I do not envy pilots having to deal with those "stuck or parked" throttles. I could fly an auto GA with the 744 with my eyes closed, NO FMA indications needed at all, all "natural" feedback from pitch movements from the controls, INCLUDING forward A/T driven movement of the throttles to the approximate correct position, G-forces, sound of engines. The position of the throttles in GA or T/O was etched into my stretched arm's muscle memory, NO way I could overlook that.
It took a while though before the company accepted that in a GA it was allowed to leave one hand on the throttles, because officially one had to release them as soon as forward movement was detected. A bit curious as during the approach one was supposed to follow up on the A/T by resting one hand on those throttles.
Muscle memory is way more reliable than inputs obtained by vision, especially in stressful situations when the brains gets saturated with vision inputs.

Studying the presentations of the possible HUD indications make me feel glad I never had to deal with such a system.
The GA procedure should be an extremely simple one, in my career as long hauler I made maybe only 3 actual, so to speak a kind of "emergency". All in good weather. One was F$#*ed up by ATC by requesting us to level off at an altitude we just were zooming through on our way to the published one. Really helpful
MAYBE we are on our way to full pilot less flight and the industry is now coping how to use the developing automatics to "help" the pilots in this era in between. But I am not impressed with the progress that is made because of the arrogance of the automatics.
I just heard the car industry is slowly loosing the idea of ever reaching full automatic control of cars, at least not in the current road infrastructure. Inside concrete tubes, yes, might be possible

[Twiglet1]

Originally Posted by Fox_one

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! .

70 reports in 450,000 flights - wonder what Ryanair had for same amount. Then throw them up against an Airline such as Easyjet who has an FRMS which is up there at the front

[autobrake3]

70 reports in 450,000 flights - wonder what Ryanair had for same amount. Then throw them up against an Airline such as Easyjet who has an FRMS which is up there at the front

The problem at Easyjet, is that thousands of fatigue reports have been submitted and yet nothing has been done about the issues contained in these reports. However, at least you can report fatigued for a duty and then blow off steam by submitting the required report without being invited to a serious grilling and bullying exercise at head office. This is probably one of the reasons why there is not a fatigue issue in Harp land.

As for this particular sad accident, it has fatigue written all over it. Their rosters were generally known to be punishing, they had already been operating for 7 hours in very difficult flying conditions, they had already flown a go around in ice and windshear which the Captain was subsequently fretting about and it was about 4 in the morning for their body clocks. No wonder the Captain ran out of cognitive capacity.

[Centaurus]

Interesting discussion indeed. As a contractor flight simulator instructor for many years I see some quite scary moments while training pilots on the 737 simulator. Low altitude go-arounds on instruments in particular. Automation addicted pilots seem to have the most trouble because of their lack of manually flown no flight director basic raw data instrument flying skills.

One exercise in particular is a reproduction of the Turkish Airlines 737 crash at Amsterdam where the autothrottles closed to idle prematurely while on a coupled ILS approach. Google the accident if more details are required.
For the simulator exercise the autothrottles are set to idle at 1500 feet on final and as the autopilot attempts to maintain the ILS glide slope, eventually the stick shaker actuates. By then the stabiliser trim has wound a long way back under the influence of the autopilot. A go-around is initiated with the IAS in the region of VREF minus 20 knots.

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.

Flown in IMC it takes very careful handling to keep out of the stall regime and on the other hand to prevent a dangerously high nose attitude. A common factor seen is failure by the pilot to stop forward trimming of the stabiliser and this causes the initial pitch up to turn into a dive. In other words the high workload in the few seconds of the go-around results in the pilot forgetting to release the stabiliser thumb switch.

Another factor often noticed is the pilot forgetting to double click the autopilot disconnect button on the control column. In the stress of the go-around he may disconnect the autopilot with one click of the AP disconnect button but then there is the continuous noise of the wailer which is distracting and only adds to the perceived urgency of the situation. Low altitude manually flown go-arounds in IMC without use of the autothrottles and without use of the flight director need to be practiced regularly during simulator training in order to keep instrument flying skills up to scratch. Automatic pilot go-arounds then become a doddle.