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Flydubai crash at RVI final report out

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Flydubai crash at RVI final report out

Old 26th Nov 2019, 19:32
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Flydubai crash at RVI final report out

https://www.mak-iac.org/upload/ibloc...a6-fdn_eng.pdf
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Old 26th Nov 2019, 20:05
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Still reading it but overall I'm fairly impressed by the quality of the report. Lots of efforts went into it.

Last edited by atakacs; 27th Nov 2019 at 00:05.
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Old 26th Nov 2019, 22:22
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That makes sobering reading!
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Old 27th Nov 2019, 01:12
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Is this official? The report has not been linked to from any of the investigation pages, the news or any other page, and the link can not be found via search? How did you get this link?
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Old 27th Nov 2019, 01:50
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A very well written report. As detailed as I have ever seen. The one thing I would have liked to have seen was the roster patterns that these pilots flew prior to the accident. As the report touched on fatigue was a factor and I believe the rostering patterns played a big part in cumulative fatigue.
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Old 27th Nov 2019, 08:10
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A very disturbing report for me. Educational for those coming up through the.ranks.
Seems more of a coroner’s inquest vs A plane crash report. Very disturbing

Last edited by Bravo Delta; 27th Nov 2019 at 08:55. Reason: Added the word report
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Old 27th Nov 2019, 08:17
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What amazes me is that they even checked (or at least tried to check) what the pilots could see on their HUDs when the plane was in negative Gs. They tried to get Rockwell-Collins to emulate it and make a video recording of what happens when the pilots are displaced from their seats by the negative G-forces, but the company said it was impossible. SPOILER ALERT: One of the recommendations to Flydubai is to replace the HUDs.
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Old 27th Nov 2019, 08:25
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Originally Posted by Austrian Simon View Post
Is this official? The report has not been linked to from any of the investigation pages, the news or any other page, and the link can not be found via search? How did you get this link?
I'm connected. To the Internet. If you reduce the link to just the .org part, you will find yourself on the official website of the investigating authority. This is the link to the whole investigation:
https://www.mak-iac.org/en/rassledov...dn-19-03-2016/
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Old 27th Nov 2019, 09:33
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Personally I think that Somotagravic probably played a significant role in the crash. I don’t agree with the conclusion that it wouldn’t have been a factor just because they were VMC.When you set 100% N1 in a light NG at night there’s not always much of a horizon being sensed from the outside world. I’ve had it once and all I wanted to do was push forward and when the instruments told me the pitch was low I found it very difficult to believe.
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Old 27th Nov 2019, 09:55
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Originally Posted by UltraFan View Post
I'm connected. To the Internet. If you reduce the link to just the .org part, you will find yourself on the official website of the investigating authority. This is the link to the whole investigation:
https://www.mak-iac.org/en/rassledov...dn-19-03-2016/
It's also included in the chronological listing at https://www.mak-iac.org/en/rassledovaniya/
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Old 27th Nov 2019, 16:18
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The report is an exceptional example of a thorough investigation and well considered analysis of an accident involving human factors. This should be referenced for all investigators as how it is possible to identify significant contributions to adverse (but as might be expected) human performance, yet not conclude by blaming the human - as we might do.

Although the conclusions focus on the human aspects, which in many circumstances could be labelled ‘error’ and blame, this is skilfully avoided with balanced discussion of many diverse potential contributing factors.

The safety recommendations identify many significant issues, contributing factors, which deserve consideration by all operators and regulators. Particular issues relating experience of other aircraft types and differences in trim systems, depth of training vs information available in manufacturers manuals, both aircraft and HUD, assumption re PM being able to identify rare situations requiring intervention - incapacitation, and the limits and limiting influence of SOPs in rare situations. The HUD observations should concern everyone who uses them, questioning what is taught, display formats over the range operational situations.

Yet again issues of thrust-trim coupling during GA are identified, applicable to many types, but specifically to the 737 in this accident.
Additionally, the reoccurring issues of trim awareness, assumptions about human contribution in abnormal situations, and design philosophy (737).

The regulators involved with the 737 Max recertification should read the last page of this report; paras 5.21, 5.24 and 5.25, and footnote #38.
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Old 27th Nov 2019, 16:56
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I have to agree. I am not a pilot, but with an interest in these things I have read many reports from the USA, UK and other authorities, and this for me is the most through analysis leading to useful conclusions that I have read. Kudos are due to the team producing it.
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Old 27th Nov 2019, 17:16
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Originally Posted by Hogger60 View Post
A very well written report. As detailed as I have ever seen. The one thing I would have liked to have seen was the roster patterns that these pilots flew prior to the accident. As the report touched on fatigue was a factor and I believe the rostering patterns played a big part in cumulative fatigue.
Agreed, a scientific evaluation of the rosters attached to the report would have given an insight. It seems strange that this has been missed.
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Old 27th Nov 2019, 18:06
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Originally Posted by Twiglet1 View Post
Agreed, a scientific evaluation of the rosters attached to the report would have given an insight. It seems strange that this has been missed.
Based on this quote from page 105 of the report it may not have been deemed necessary:

"The analysis of compliance of the work and rest schedule within a record period (28
consecutive days) did not identify any violations. The crew had a sufficient amount of the preflight
rest. As per the submitted data, the Fatigue Management System is implemented in the airline. The
system encourages the fatigue-related confidential reports by the crewmembers for any stage of
the flight operations (the preflight, in-flight, post-flight one). For a number of quantitative
indicators the system goes beyond the national aviation legislation (that is it ensures the improved
conditions for the crewmembers). Since 2009, the airline has accumulated 450 000 flights with a
total flight time of more than 1 million hours. Within the period, 70 fatigue-related confidential
reports were submitted. The majority of them were proactive by nature – as the crewmembers
reported the fatigue presence and were removed from duty until they felt fit for flight operations."
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Old 27th Nov 2019, 18:30
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Originally Posted by alf5071h View Post
The report is an exceptional example of a thorough investigation and well considered analysis of an accident involving human factors. This should be referenced for all investigators as how it is possible to identify significant contributions to adverse (but as might be expected) human performance, yet not conclude by blaming the human - as we might do.

Although the conclusions focus on the human aspects, which in many circumstances could be labelled ‘error’ and blame, this is skilfully avoided with balanced discussion of many diverse potential contributing factors.

The safety recommendations identify many significant issues, contributing factors, which deserve consideration by all operators and regulators. Particular issues relating experience of other aircraft types and differences in trim systems, depth of training vs information available in manufacturers manuals, both aircraft and HUD, assumption re PM being able to identify rare situations requiring intervention - incapacitation, and the limits and limiting influence of SOPs in rare situations. The HUD observations should concern everyone who uses them, questioning what is taught, display formats over the range operational situations.

Yet again issues of thrust-trim coupling during GA are identified, applicable to many types, but specifically to the 737 in this accident.
Additionally, the reoccurring issues of trim awareness, assumptions about human contribution in abnormal situations, and design philosophy (737).

The regulators involved with the 737 Max recertification should read the last page of this report; paras 5.21, 5.24 and 5.25, and footnote #38.
And we're back to the 737!

What's with the obsession on this forum about "not blaming the pilots"? Hell yes, blame the pilots! Did you read the autopsy section? Did you read about what happened to those passengers? They found the highly fragmented remains of 63 people. Only 62 were on the manifest, they eventually identified the 63d as a foetus - one of the women on board was pregnant. 63 beautiful lives turned into mince meat.

The dead pilots are not with us anymore, and it doesn't matter what we say about them. They were the first to die. But it sure as hell 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. Flying an airplane is not a joke.
The heavy burden of responsibility from flying living beings around at speeds generating energies massive enough to disintegrate their bodies cannot be overstated.

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.
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Old 27th Nov 2019, 18:32
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Who actually has the time to read 175 pages?
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Old 27th Nov 2019, 18:43
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Based on this quote from page 105 of the report it may not have been deemed necessary:
I haven’t read the report but on the basis of these comments I am reminded of the oft-quoted and valid aphorism, absence of evidence is not evidence of absence.
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Old 27th Nov 2019, 18:56
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LookingForAJob, ‘absence’ - equally you will find what ever you look for.
‘Operational’ fatigue was discussed in the report.

Contact Approach, ‘who has time’ - those with an appropriate safety culture, a willingness to learn, prepared to consider this report and other viewpoints, to debate and argue as required.

This report has a lot to learn from; if only we, the industry, is willing, able to learn.
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Old 27th Nov 2019, 19:17
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Dreadful accident. Magnificent report.
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Old 27th Nov 2019, 20:02
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Originally Posted by Euclideanplane View Post
Based on this quote from page 105 of the report it may not have been deemed necessary:

"The analysis of compliance of the work and rest schedule within a record period (28
consecutive days) did not identify any violations. The crew had a sufficient amount of the preflight
rest. As per the submitted data, the Fatigue Management System is implemented in the airline. The
system encourages the fatigue-related confidential reports by the crewmembers for any stage of
the flight operations (the preflight, in-flight, post-flight one). For a number of quantitative
indicators the system goes beyond the national aviation legislation (that is it ensures the improved
conditions for the crewmembers). Since 2009, the airline has accumulated 450 000 flights with a
total flight time of more than 1 million hours. Within the period, 70 fatigue-related confidential
reports were submitted. The majority of them were proactive by nature – as the crewmembers
reported the fatigue presence and were removed from duty until they felt fit for flight operations."
What it doesn't say is that the board reviewed the actual FRMS data for the rosters of the two pilots in the weeks before the crash. How many back side of the clock flights did they do in the preceding weeks? One may be legal with regards to rest and still be suffering from the affects of cumulative or chronic fatigue. Those who have done back to back to back overnight flights know what one feels like after two or three in a row. I don't see this detailed in the report.
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