Flydubai crash at RVI final report out
Go Around
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.
The first GA might not have been totally unexpected, but still surprising - different levels and duration of mental stress. A Wind-Shear GA is different, how often practiced vs a normal GA.
Aircraft with large thrust-pitch coupling may use reduced thrust for a ‘normal’ GA to reduce pitching tendency and trim effort, but for WSGA the SOP mandates max power, no matter what else - taught and trained by rote.
The second GA, 2 hrs less fuel, light weight aircraft, max thrust, overshoots the potentially misleading pitch target in the HUD. The HUD approved bypassing normal certification and by default accepted by other regulators. Forward stick is maintained until trim catches up; but in this aircraft stick force only reduces with opposite stick movement; it is possible to fly the aircraft with trim.
The HUD format changes with ‘excessive’ attitude to retain a horizon line, but unlike EFIS it compresses the pitch scale with potential for inducing false sense of pitch rate, also ‘upwards’ cues are presented, not related to pitch-roll convention (90deg) and might be misinterpreted as a roll indication.
We are unable - unwilling to consider a graduated response between GA and WSGA, too many variables, complexity - thus KISS (of death), ultimately resorting to the crews judgement, judged after the fact in a mandated SOP culture, with display information based on static format designs - not considering the dynamics of the situation, man, machine, and environment, all assumed (canned in SOPs) for simplicity.
Systems thinking starts by accepting that there is no ‘solution’ - we are challenged by a complex adaptive issue which at best might be contained, and with careful consideration and small interventions, safety might be improved - but we may never know.
In a highly reliable industry we must be careful not to disturbed the fine balance which has enabled this level of safety; don’t jump to conclusions or rush to yet more training; list and check assumptions.
Start with the individual, ourselves; would the issues affect us, if not why not.
There is opportunity in either viewpoint, the key is to think about the issues and form a viewpoint and understand why (you, not others).
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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.
The first GA might not have been totally unexpected, but still surprising - different levels and duration of mental stress. A Wind-Shear GA is different, how often practiced vs a normal GA.
Aircraft with large thrust-pitch coupling may use reduced thrust for a ‘normal’ GA to reduce pitching tendency and trim effort, but for WSGA the SOP mandates max power, no matter what else - taught and trained by rote.
The second GA, 2 hrs less fuel, light weight aircraft, max thrust, overshoots the potentially misleading pitch target in the HUD. The HUD approved bypassing normal certification and by default accepted by other regulators. Forward stick is maintained until trim catches up; but in this aircraft stick force only reduces with opposite stick movement; it is possible to fly the aircraft with trim.
The HUD format changes with ‘excessive’ attitude to retain a horizon line, but unlike EFIS it compresses the pitch scale with potential for inducing false sense of pitch rate, also ‘upwards’ cues are presented, not related to pitch-roll convention (90deg) and might be misinterpreted as a roll indication.
We are unable - unwilling to consider a graduated response between GA and WSGA, too many variables, complexity - thus KISS (of death), ultimately resorting to the crews judgement, judged after the fact in a mandated SOP culture, with display information based on static format designs - not considering the dynamics of the situation, man, machine, and environment, all assumed (canned in SOPs) for simplicity.
Systems thinking starts by accepting that there is no ‘solution’ - we are challenged by a complex adaptive issue which at best might be contained, and with careful consideration and small interventions, safety might be improved - but we may never know.
In a highly reliable industry we must be careful not to disturbed the fine balance which has enabled this level of safety; don’t jump to conclusions or rush to yet more training; list and check assumptions.
Start with the individual, ourselves; would the issues affect us, if not why not.
There is opportunity in either viewpoint, the key is to think about the issues and form a viewpoint and understand why (you, not others).
.
Experience simply isn’t related to hours flown, as was alluded to previously to by misd-agin
I just happened to pick up D.P. Davies his book again, “only” 5000+ hours, but I doubt I’ll ever reach the experience this gentleman had in my whole career.
Flying a widebody in cruise teaches one very little about flying. I now teach how to fly a widebody, and although my hours now number well in to the 5 digits, the hours in cruise didn’t matter all that much..
In my humble opinion exposures and practise is the key, not flight hours. If you get the opportunity to learn how to properly fly your aircraft in varied conditions, you’ll be ever so much better then if you fly 20k hours across the Pacific with the autopilot engaged.
I just happened to pick up D.P. Davies his book again, “only” 5000+ hours, but I doubt I’ll ever reach the experience this gentleman had in my whole career.
Flying a widebody in cruise teaches one very little about flying. I now teach how to fly a widebody, and although my hours now number well in to the 5 digits, the hours in cruise didn’t matter all that much..
In my humble opinion exposures and practise is the key, not flight hours. If you get the opportunity to learn how to properly fly your aircraft in varied conditions, you’ll be ever so much better then if you fly 20k hours across the Pacific with the autopilot engaged.
Only half a speed-brake
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."
"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."
@misd-agin: The present wording on AB, formally interpreted, now instructs the crew to immediately reduce to CLB thrust.
---
The report raises an issue with force-on-yoke vs. trim technique, saying (my wording) to the investigators it was not a new find ... applicable to A/C with movable horizontal stabiliser. Massive truth, and also the note about trim rocker switch being prone to cognitive lock (and alternative technical solutions).
Last edited by FlightDetent; 30th Nov 2019 at 03:31.
[QUOTE=FlightDetent;10629190]Not enough for me. The -3/4/500 had no dual autopilot neither HUD and was CATIIIA. The question stands, what kind of assessment yielded the result, not to use a certified AP/AT for LVP.
Flight detent
I don’t know what type of 300/400 or 500 you flew. I’ve not flown a 400, but all the 737 300s and 500s that I flew certainly had dual autopilot, both of which had to be armed for a dual channel approach and auto-land exactly the same as the 800.
I don’t know what assessment was made by flydubai when they decided to use the HUD, as the decision was made before I joined. However, the following is a direct quote from an email I received from the safety department a year before the accident, when I queried why dual channel approaches weren’t flown, as doing so would allow automatic go arounds to be flown with a reduction in crew workload :
” Dual channel approaches would involve a lot of engineering/ maintenance/ servicing/ paperwork and increase training costs. As yet, the costs probably outweigh the benefits”.
So from that it is evident that at some point prior to the accident, someone in Flydubai had done a cost analysis and decided not to use dual channel approaches and instead to use the HUD. If that still isn’t enough for you there is nothing else I can add.
Flight detent
I don’t know what type of 300/400 or 500 you flew. I’ve not flown a 400, but all the 737 300s and 500s that I flew certainly had dual autopilot, both of which had to be armed for a dual channel approach and auto-land exactly the same as the 800.
I don’t know what assessment was made by flydubai when they decided to use the HUD, as the decision was made before I joined. However, the following is a direct quote from an email I received from the safety department a year before the accident, when I queried why dual channel approaches weren’t flown, as doing so would allow automatic go arounds to be flown with a reduction in crew workload :
” Dual channel approaches would involve a lot of engineering/ maintenance/ servicing/ paperwork and increase training costs. As yet, the costs probably outweigh the benefits”.
So from that it is evident that at some point prior to the accident, someone in Flydubai had done a cost analysis and decided not to use dual channel approaches and instead to use the HUD. If that still isn’t enough for you there is nothing else I can add.
Last edited by excrab; 29th Nov 2019 at 19:32.
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OK, the HUD is designed to allow the pilot to see through the window while superimposing guidance. Why would you need to look out of the window during a go around?
The FO, monitoring the PFD could see exactly why it was going pear shaped, the PF was experiencing a somatogravic upset exacerbated by his view of the landing lights rushing into the overcast.
The FO, monitoring the PFD could see exactly why it was going pear shaped, the PF was experiencing a somatogravic upset exacerbated by his view of the landing lights rushing into the overcast.
Centaurus--
Ahh , TRIM . After 5 years on the Airbus , it was strange having to retrain the left thumb to start blipping the trim switch again on the jumbo .
Reminds me of my training on the 737 back in the dark ages . Favourite trick of the crusty old trainer , somewhere on finals , was to say " take your hands off the stick " just to see if you had the aircraft in trim or not .; you soon learned to make sure you were ...
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.
Reminds me of my training on the 737 back in the dark ages . Favourite trick of the crusty old trainer , somewhere on finals , was to say " take your hands off the stick " just to see if you had the aircraft in trim or not .; you soon learned to make sure you were ...
Only half a speed-brake
Ironically, in the imaginary world where I had a say on how to sketch an airline, purchasing HUDs that would make the approval, trainings and maintenance of autolands obsolete is an idea I'd wish to explore.
I have read most of the official report and about half of this thread, so apologies if I am going over old ground.
Two observations about HUDs, (which I have not used myself):
The one in this report is monochromatic. There s no blue for sky, brown for ground. The user cannot glance at the HUD to see if one is pitching up or down, the actual + or - of the pitch graduations have to be read and interpreted? The barbers pole on the speed scale is not red but the same colour as everything else, (albeit a fuller hashed line), so an impending overspeed does not stand out either.
The HUD presentation is different to the ADI. We all started by flying single engined Cessna’s or equivalent, with the standard “artificial horizon” instrument. The vast majority of our total flying hours have been spent looking at the familiar blue for sky, brown for ground presentation, and bank information to ascertain our attitude. FlyDubai’s SOP was to always use the HUD, but as I understand it, they only flew a small number approaches one day in a SIM to learn the HUD, and that was it? “OK, you’re fully qualified and practised to use the HUD for all flight operations in all weathers from now on”. Really?
Totally agreed, but it is not necessarily a given pilot’s fault. No pilot starts their training wanting to be a bad pilot.
I agree, and have always said that training does need to be vastly improved. I have been amazed to witness some very poor flying in the SIM from experienced Captains of wide-body aircraft. Much of recurrent SIM checks are a tick in the box if you were vaguely within limits and move on to the next exercise. Very tellingly, if the CAA are sitting in during a SIM, one has to absolutely get it right - near enough is not a pass in those situations.
F/O should have yelled out "I HAVE CONTROL! LET GO OF EVERYTHING NOW!", worse case punched the Cap's lights out and immediately taken control. With 40 deg pitch down, speeding towards the ground with engines at full power is not a time to be giving advice and "no, no, no"ing or pulling half halfheartedly on the yoke at the same time the other guy is pushing down. It's time to knock out the dude that's going to kill us all, engines idle and pull out of the freaking dive.
Absolutely, of course he should yes, and it quite obviously should have been an automatic reflex in this particular situation. All I would say is that we are not trained in taking control. We are just told to do it - in text somewhere in the manuals, but during training, F/Os are never actually put into the situation of having to take control from the Captain*. It can be a big deal to take over from a Captain, somebody maybe very senior to oneself, and whom the company has deemed to be good enough to be a Captain, while they’ve decided you’re not.
*The only time we do practise taking control is for an incapacitation, or instrument failure, which is easy because then there is no argument from the Captain - you don’t have to shout at him and wrestle the controls from him and have a disagreement; because he is ‘unconscious’ or willing.
Cabin crew are given actual instruction on how to deal with angry or dangerous passengers - how to deconflict the tension, how to physically act, and how to speak, and they practise it. If the other pilot was going to kill me, I would most certainly take over, (and have done so on two occasions), but what I am saying is; we have never been trained in this, merely told. It is a big deal to become a Captain - many don’t make it - so the image of a Captain is of one who has proved they have got what it takes. Therefore it is also a big deal to take command over the commander, so this should be trained, not merely written somewhere in the manuals.
.
Two observations about HUDs, (which I have not used myself):
The one in this report is monochromatic. There s no blue for sky, brown for ground. The user cannot glance at the HUD to see if one is pitching up or down, the actual + or - of the pitch graduations have to be read and interpreted? The barbers pole on the speed scale is not red but the same colour as everything else, (albeit a fuller hashed line), so an impending overspeed does not stand out either.
The HUD presentation is different to the ADI. We all started by flying single engined Cessna’s or equivalent, with the standard “artificial horizon” instrument. The vast majority of our total flying hours have been spent looking at the familiar blue for sky, brown for ground presentation, and bank information to ascertain our attitude. FlyDubai’s SOP was to always use the HUD, but as I understand it, they only flew a small number approaches one day in a SIM to learn the HUD, and that was it? “OK, you’re fully qualified and practised to use the HUD for all flight operations in all weathers from now on”. Really?
Hell yes, blame the pilots!.....................should not be conceived by anyone that this was in any way an acceptable level of performance from a trained, professional flight crew. Illusions and fatigue are always going to be there - that is not an excuse to smash an airplane nose-first into the ground, along with all its contents.
On the contrary, we need to blame pilots a lot more, training and selection of crew should be a million times more restrictive and intense. It shouldn't be anyone who has money and can pass some ridiculous tests gets to be crew
On the contrary, we need to blame pilots a lot more, training and selection of crew should be a million times more restrictive and intense. It shouldn't be anyone who has money and can pass some ridiculous tests gets to be crew
I agree, and have always said that training does need to be vastly improved. I have been amazed to witness some very poor flying in the SIM from experienced Captains of wide-body aircraft. Much of recurrent SIM checks are a tick in the box if you were vaguely within limits and move on to the next exercise. Very tellingly, if the CAA are sitting in during a SIM, one has to absolutely get it right - near enough is not a pass in those situations.
F/O should have yelled out "I HAVE CONTROL! LET GO OF EVERYTHING NOW!", worse case punched the Cap's lights out and immediately taken control. With 40 deg pitch down, speeding towards the ground with engines at full power is not a time to be giving advice and "no, no, no"ing or pulling half halfheartedly on the yoke at the same time the other guy is pushing down. It's time to knock out the dude that's going to kill us all, engines idle and pull out of the freaking dive.
*The only time we do practise taking control is for an incapacitation, or instrument failure, which is easy because then there is no argument from the Captain - you don’t have to shout at him and wrestle the controls from him and have a disagreement; because he is ‘unconscious’ or willing.
Cabin crew are given actual instruction on how to deal with angry or dangerous passengers - how to deconflict the tension, how to physically act, and how to speak, and they practise it. If the other pilot was going to kill me, I would most certainly take over, (and have done so on two occasions), but what I am saying is; we have never been trained in this, merely told. It is a big deal to become a Captain - many don’t make it - so the image of a Captain is of one who has proved they have got what it takes. Therefore it is also a big deal to take command over the commander, so this should be trained, not merely written somewhere in the manuals.
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Last edited by Uplinker; 30th Nov 2019 at 11:59.
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All I would say is that we are not trained in taking control. We are just told to do it - in text somewhere in the manuals, but during training, F/Os are never actually put into the situation of having to take control from the Captain*. It can be a big deal to take over from a Captain, somebody maybe very senior to oneself, and whom the company has deemed to be good enough to be a Captain, while they’ve decided you’re not.
*The only time we do practise taking control is for an incapacitation, or instrument failure, which is easy because then there is no argument from the Captain - you don’t have to shout at him and wrestle the controls from him and have a disagreement; because he is ‘unconscious’ or willing.
*The only time we do practise taking control is for an incapacitation, or instrument failure, which is easy because then there is no argument from the Captain - you don’t have to shout at him and wrestle the controls from him and have a disagreement; because he is ‘unconscious’ or willing.
It is still trained pretty much every simulator event as part of the upset recovery training, for both the FO and the CPT. Very good training to be had in my view.
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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.
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.
The text below is copied from an HF web forum. There are some important lessons involving certification, and for operators resulting from unforeseen situations perhaps not considered in the SOP: to use HUD at all times. A Windshear GA becoming an upset, the dynamics of equipment and situations vs static evaluation, and erroneous choice of training as a solution.
In normal flight, P1 and P2 use different mental models. When the HUD upset mode appears automatically and unexpected, the Captain is forced to change the mental view and instrument references.
Although a dual HUD installation might alleviate some of the problems, the unconventional format and surprising change during a Windshear GA adds to the surprise and confusion during the GA manoeuvre - controlling pitch and trim.
The overall deficiencies in the HUD format, cf EFIS # 69, and increased workload, suggests that the better, safer option is not to use the HUD all the time.
In normal flight, P1 and P2 use different mental models. When the HUD upset mode appears automatically and unexpected, the Captain is forced to change the mental view and instrument references.
Although a dual HUD installation might alleviate some of the problems, the unconventional format and surprising change during a Windshear GA adds to the surprise and confusion during the GA manoeuvre - controlling pitch and trim.
The overall deficiencies in the HUD format, cf EFIS # 69, and increased workload, suggests that the better, safer option is not to use the HUD all the time.
“The HUD format (certification) and mandated use (operator SOP) would influence awareness.
Normal HUD use is flight director based; a vector display - winged aircraft symbol and circular target, which depicts where the aircraft is going. The ‘command’ task is to match the symbols (video game - skill based) reducing mental workload.
An automatic change to the ‘upset recovery’ format depends on manoeuvre.
This format is attitude based, without the FD, only depicting where the aircraft is pointing. The mental task is ‘interpretive’ - different symbology and format (knowledge based). Mentally demanding, sudden unexpected change, further limits mental resource.
Thus “The F/.O appeared to have a much better grasp of the issue, but was unable to change the outcome,”
… influenced by a better mental model / task, (head down EFIS with FD), but unable to recover due to limiting control - stick forces, trim, conflicting pilot inputs.
HUD approval via STC by-passed formal HF certification and design evaluation, only assessing operations, procedures, and training (OEB).
An opportunity to mask system deficiencies by requiring ‘more training’ (cf 737 Max).
Change the system, not the pilot.”
Normal HUD use is flight director based; a vector display - winged aircraft symbol and circular target, which depicts where the aircraft is going. The ‘command’ task is to match the symbols (video game - skill based) reducing mental workload.
An automatic change to the ‘upset recovery’ format depends on manoeuvre.
This format is attitude based, without the FD, only depicting where the aircraft is pointing. The mental task is ‘interpretive’ - different symbology and format (knowledge based). Mentally demanding, sudden unexpected change, further limits mental resource.
Thus “The F/.O appeared to have a much better grasp of the issue, but was unable to change the outcome,”
… influenced by a better mental model / task, (head down EFIS with FD), but unable to recover due to limiting control - stick forces, trim, conflicting pilot inputs.
HUD approval via STC by-passed formal HF certification and design evaluation, only assessing operations, procedures, and training (OEB).
An opportunity to mask system deficiencies by requiring ‘more training’ (cf 737 Max).
Change the system, not the pilot.”
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.
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.
And no, fully autonomous aircraft are not the answer. Properly trained crews, with sensible rosters and the best tech is.
Undertaking stalls in a large transport adds substantial buffet related loads to the tail of the aircraft, physical maintenance inspections are called for in most types due to theses loads on the structure.
Sim training is a good start, but the crews need to be aware of the limitations in fidelity as to loads experienced in the seat.
Having stalled transports in test, and having used light military jets, heavy pistons and 1 or 2 seat Pitts etc for continuity, I'm not sure that anything more than a decathlon, CAP or RV is needed to maintain a semblance of proficiency in handling. The sim gives benefits but only within the constraints of fidelity.
To achieve -1. 4g recorded at the cg requires a considerable pitch rate.
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I read all of it. Make time.
Some thoughts...
The HUD symbology on both the 737 and 787 is pretty terrible. Predictive and reactive wind shear generate the same “WINDSHEAR” overlay text. In a missed approach you switch from flying flight path guidance to pitch attitude, then back again fairly quickly. Everything is green, the same thickness, and either solid or dashed.
FOs are not trained to take control. Captains are trained to wrestle control from an uncooperative FO. It’s also impossible for another pilot to take control in a Boeing aircraft if the other pilot doesn’t want them too - you can see in this case that it just activated the jammed controls system.
Some thoughts...
The HUD symbology on both the 737 and 787 is pretty terrible. Predictive and reactive wind shear generate the same “WINDSHEAR” overlay text. In a missed approach you switch from flying flight path guidance to pitch attitude, then back again fairly quickly. Everything is green, the same thickness, and either solid or dashed.
FOs are not trained to take control. Captains are trained to wrestle control from an uncooperative FO. It’s also impossible for another pilot to take control in a Boeing aircraft if the other pilot doesn’t want them too - you can see in this case that it just activated the jammed controls system.
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My 2 cents worth having read the report. Yes, its long and detailed but certainly worth reading for any pilot.
Massively disappointed by the lack of info on Fatigue and the Rosters of both pilots in the proceeding weeks. I know that the FO's roster was brutal leading up to the crash.
The number of fatigue reports submitted is eye opening and tells you all you need to know about the safety culture. I left FZ before the crash but if my blurry memory serves me correct, if you were brave enough to call in fatigued there was the threat of been sent to the AME for a "consultation" with the possibility of your medical being suspended while your fatigue was investigated.
The first discontinued approach was a windshear escape, the second was a standard go around procedure. With the first approach still fresh in the mind its so easy for any pilot who is absolutely shattered, dealing with awful weather conditions and staring through a bright HUD to get things wrong. 101% N1 was excessive but there is no N1 indication on the HUD as far as i can remember. You get so fixated on the HUD that your scan can breakdown especially when things start to become "non-normal".
The commercial pressure from ops's to "get in" is also a massive issue that doesn't really get interrogated. For sure they would have left DXB with somewhere close to full tanks of fuel knowing that the weather was marginal. Op's would always say "load it up with fuel and get in when you can", knowing that a divert will leave the operation an aircraft short for the next 12/15 hours. Normally as pilots we like to carry as much fuel as we can, but in this instance a bit of time pressure resulting from less fuel could have meant a divert earlier, maybe even after the first approach resulting in a totally different outcome.
Pretty much every pilot I ever flew with at FZ always feared that something like this might happen one day due to the fatiguing rosters and the nature of the destinations. Tragically in March 2016 all the holes in the cheese lined up.
Massively disappointed by the lack of info on Fatigue and the Rosters of both pilots in the proceeding weeks. I know that the FO's roster was brutal leading up to the crash.
The number of fatigue reports submitted is eye opening and tells you all you need to know about the safety culture. I left FZ before the crash but if my blurry memory serves me correct, if you were brave enough to call in fatigued there was the threat of been sent to the AME for a "consultation" with the possibility of your medical being suspended while your fatigue was investigated.
The first discontinued approach was a windshear escape, the second was a standard go around procedure. With the first approach still fresh in the mind its so easy for any pilot who is absolutely shattered, dealing with awful weather conditions and staring through a bright HUD to get things wrong. 101% N1 was excessive but there is no N1 indication on the HUD as far as i can remember. You get so fixated on the HUD that your scan can breakdown especially when things start to become "non-normal".
The commercial pressure from ops's to "get in" is also a massive issue that doesn't really get interrogated. For sure they would have left DXB with somewhere close to full tanks of fuel knowing that the weather was marginal. Op's would always say "load it up with fuel and get in when you can", knowing that a divert will leave the operation an aircraft short for the next 12/15 hours. Normally as pilots we like to carry as much fuel as we can, but in this instance a bit of time pressure resulting from less fuel could have meant a divert earlier, maybe even after the first approach resulting in a totally different outcome.
Pretty much every pilot I ever flew with at FZ always feared that something like this might happen one day due to the fatiguing rosters and the nature of the destinations. Tragically in March 2016 all the holes in the cheese lined up.
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.
I work at a mob where the approach to fatigue is pretty cavalier, to say the least. Only in the past 2 years has the regulator required FRMS etc. I was involved for a short while is liasing with management about scheduling issues. Despite attempts to promote fatigue reporting, very few reports were submitted, with reasons varying from, "I was too tired" to "I am scared I will be victimised" being given. Many verbal complaints were made, but these are useless. Pilots are their own worst enemies when it comes to this and airlines KNOW it and use it.
I reckon the airlines will very quickly change their strategies when they receive a massive number of legitimate fatigue reports, AND they know copies are being collected by interested parties.
Is it possible that fatigue would have received a far greater emphasis in this report IF there had been a huge number of reports submitted. I am very sure the answer is "YES"
we also need to be alive to do the job! this kind of attitude facilitates the bull**** you refer to. As a professional pilot, you have a responsibility to maintain a certain standard and keep the operation honest!
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?
(I know.......dream on !)
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?
(I know.......dream on !)
Last edited by Uplinker; 2nd Dec 2019 at 11:02.
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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.
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First approach at roughly 230AM body clock after descending through area with severe turbulence reports.
Wind gusting to over 40Kts.
Wind shear Go-Around.
Just on that I'm exhausted and jittery entering my WOCL.
Now, hold for two hours and attempt landing #2 in pretty much identical conditions.
Go around and an accident.
Their contingency plans were well thought out and appropriate and the report backs that up in terms of assessing hold fuel, diversion airports, and potential FDP issues. The one thing the PIC didn't brief at all was their level of fatigue and/or mental state after an extremely taxing evening and the very real possibility that despite a great plan(shoot another approach and divert if necessary), they physically and mentally may not have been able to cope.
So sad.
Wind gusting to over 40Kts.
Wind shear Go-Around.
Just on that I'm exhausted and jittery entering my WOCL.
Now, hold for two hours and attempt landing #2 in pretty much identical conditions.
Go around and an accident.
Their contingency plans were well thought out and appropriate and the report backs that up in terms of assessing hold fuel, diversion airports, and potential FDP issues. The one thing the PIC didn't brief at all was their level of fatigue and/or mental state after an extremely taxing evening and the very real possibility that despite a great plan(shoot another approach and divert if necessary), they physically and mentally may not have been able to cope.
So sad.
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Nevertheless, a couple of intense years longer, and I’ll get the f@#! out of this pointless grind.