Flydubai crash at RVI final report out
 

Still reading it but overall I'm fairly impressed by the quality of the report. Lots of efforts went into it.

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?

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.

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

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.

I'm connected. :cool: 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/

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.

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.

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."

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.

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.

Dreadful accident. Magnificent report.

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.

He who wants to learn and do better...

With respect, I would say that quite a number of people should make time.

Yes and yes.

Alf, and others, thanks for the heads up. Saved it and will read it when I have some more time available. This really makes pprune worth it!

He/she who is crossing the pacific at night on a flight deck.

F/O should have taken control? He seemed to know what was happening. CPT should have admitted to himself he had no idea what was happening.

CORRECT limited time though.

Been long enough in the RH seat to know that to physically take over control is maybe the most difficult decision to take as a F/O . However in this case... he saw death approaching, In my view there was some kind of "blurry" steep authority gradient, caused by different cultures/backgrounds/languages.

(pax) I read the report and found it apparently thorough but a bit ' discursive'. It is as if they wanted to make the report a ' home' for everything they considered or photographed. The -1.4g excursion got my attention, as did the observation that uncontrolled leg movements are considered a typical sign of loss of personal control, which I assume means what a layman may call ' panic'. I think it harsh to blame the F/O given the timeline and collapsing situation with the PF hands locked on the column, pressing the trim switch and pumping the pedals. The fact that the PF kept harping on about the speed excursion, including engaging with cabin crew on this, perhaps indicates his mental calm was fragile before the long hold which was indicative of his anxiety to avoid a diversion. A dreadful read and a very great pity. The F/O was getting there but there wasn't time for him to recover the situation given the dynamics.

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.

Me. A newly-qualified PPL (Piper Warrior) who just wants to know.

‘F/O should have taken control.’
 

The investigation did consider this aspect; there were indications that the PM had the better understanding of the rapidly developing situation. However, whilst he could ‘see’ what the aircraft was doing, not knowing why might have delayed the choice of ‘drastic’ intervention after repeatedly alerting the PF to the abnormal condition (CVR).

The report discusses control force from the FDR which suggests that there was dual control input, even to the point of left / right control breakout - PF pushing, PM pulling, but the situation at that time was significant nose down attitude, speed increasing, and the trim moving fully forward.
The above indicates that the concept of monitoring and crew intervention cannot be assured in all situations.

The difficulty in identifying trim operation and position (as in the Max accidents) is explained, as is the mechanics of control forces and impossibility of effecting a recovery at low altitude, again as in the Max accidents. This point should be noted by regulators / operators if the 737 Max post MCAS mod, were to revert to a ‘near NG’ configuration, in that any assumption requiring quick identification and pilot action to intervene for a trim malfunction is misjudged given the findings in this accident.
Also see footnote #38 page 175.

Fox_one perfectly highlights the problem with flydubai's fatigue reporting system. If you reported fatigued you would be taken off flying whilst the company decided, in consultation with an AME, if fatigue was an issue. This could take a considerable time, and if they decided that it was not then the time you spent not flying was recorded as sick leave. Bearing in mind that you were only allowed paid sick leave for fifteen days per year, if they decided that there was nothing wrong with your roster and you were therefore not fatigued you could potentially spend a long period not being paid until you returned to flying, and living in Dubai is expensive, especially if you have a family. To be fair to the company they did go through the motions of improving things, but even two years after the accident one of the second officers was called into a meeting with the chief pilot after he had not felt fit to fly due to lack of sleep having been kept awake by his newly born baby, to be told by the chief pilot that in his (the chief pilot's) opinion, if he could not manage his sleep with a new baby in the house he was not only unfit to be a professional pilot, but unfit to be a parent. That, by the way, was the new chief pilot who was put in place when the previous one was promoted out of the way following the accident. With that sort of thing to contend with it is hardly surprising that people didn't report fatigued, instead it was not uncommon for occupants of both seats to be taking controlled rest of one or two hours on long night flights.

There were also issues with training. I joined the company as a type rated DEC two years before the accident happened and left two years afterwards. For my OCC I was paired up with a type rated F/O, and despite what was quoted in the report regarding the training to use the HUD we never swapped seats, so that was at least one F/O who didn't get to use the HUD during his training. Also, despite the syllabus quoted in the report, shortly after the accident I asked an F/O who I knew had joined non type rated how many standard two engine go-arounds he had done in training and the answer was one, flown by the captain during LVO training. He had done a couple of others due to systems failures, also in the LVO training, but had never done one himself. He had also never flown using the HUD as his training had been done with two F/Os and a stand in captain, so also no seat swapping, although he had seen the hud repeater image in the back of the sim whilst observing. Also, up until the accident there was no SOP to brief how a go around was to be flown, indeed when I did this on my first day of line training I was told by the LTC not to do so, as it wasn't SOP and might confuse F/Os who did not have English as their first language.

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.

As a caveat to all this, I left two years ago. Maybe things have changed, but I'm surprised that this isn't being discussed on the ME forum or that there don't seem to be more posts from flydubai pilots. Having said that I am lucky not to have to access pprune through a VPN anymore, and wonder if it is still blocked in the UAE?

Apologies if I'm being thick, probably am, but I'm a non HUD user and that comment has confused me. Are you saying the SOP in CAT 3a was autopilot out at 1000' and then a hand flown approach to (?) a hand flown landing ("through" the HUD??)...

Other than that question I thought the whole report was a very sobering read and provides a classic example of how quickly things can deteriorate in aviation from being essentially "Ops normal though a bit challenging", to coming completely undone..

Different type (E195) and airline but that's exactly what we did for CAT3A approaches.

It doesn't require reading every single line on every single page. Thirty minutes should provide enough time to review the portions most interesting to a pilot.

"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.

Ah OK many thanks to you and Chesty for the explanation and also the extra info.

We're (T7) very much automatics in in poor wx, and the full use of the automatics are very much recommended for as long as possible if there's prospect of windshear. As a result I had a :confused: the first time I read about the autopilot disconnect in the report, but can now see why perhaps the crew were "spring loaded" to knocking the automatics out....

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.