Flydubai crash at RVI final report out
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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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.
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.
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.
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
#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
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
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
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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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.
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
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 ?
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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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.
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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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.
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 16:05. Reason: missed word
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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?
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?
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.
15kt/sec represents a gust, whereas aircraft are more sedate, approx max 3kt/sec, depending on type.
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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.
15kt/sec represents a gust, whereas aircraft are more sedate, approx max 3kt/sec, depending on type.
This is a desperately sad story.
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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?
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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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 ?
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 ?
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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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.
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.
Am absolutely certain fatigue played a huge part in this crash.
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.
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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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.
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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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.
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.
Cheers