Flydubai accident update

Fly-dubai (4)

Photo (C) Pavel. All rights reserved

From the blogger: Please note this article was posted on April, 5th, 2016, previous to the publication of the Interim Report by the investigation authority on April 20th, 2016 which was published on this blog on April 23rd, 2016. You only have to follow the link Flydubai accident Interim Report  

“On Apr 5th, 2016 Russia’s Ministry of Transport reported that on first approach to runway 22 the aircraft went around, the crew reported a wind shear on final approach, climbed to FL050 then FL080 and entered a hold to wait for the improvement of weather. The crew subsequently requested and was cleared to FL150 in the hold. When air traffic control provided information that the visibility was 5000 meters, cloud ceiling at 630 meters/2000 feet, winds from 230 degrees at 13m/s gusting 18m/s (25 knots gusting 35 knots), no wind shear, the crew requested another approach clearance. On final approach at about 220 meters/720 feet the crew went around again and climbed, at 900 meters/3000 feet the stabilizer moved nose down causing the aircraft to stop climbing at about 1000 meters/3330 feet and entering a descent. The aircraft impacted ground about 120 meters from the runway threshold. Preliminary examination results of flight data and cockpit voice recorder do not reveal any evidence of a technical malfunction of engines or aircraft systems or any evidence of an explosion. The investigation is focussing on how the pitch control system works and crew actions during the go around. The captain (ATPL, 5,965 hours total, 2,597 hours on type) was certified for CATIIIa approaches.” Excerpted from http://avherald.com/h?article=495997e2&opt=0.

April 8th, 2016 

The Interstate Aviation Committee is providing the upgrade on the progress of the investigation of the accident involving a Boeing 737-800 registered A6-FDN operated by FlyDubai.

The investigative team has completed the two-dimensional aircraft mockup and selected assemblies and units to be examined in order to check the longitudinal control system operability. The selected units have been delivered to the Interstate Aviation Committee, wherein their condition is assessed along with examination capabilities. The organizations to conduct pertinent examinations, as well as their scope and terms, are being determined.

During the on-site operations, reports of the Weather, Wreckage, Air Traffic Control, Avionics, Powerplants, Structures and Systems investigative groups were prepared and reviewed.

The weather information examination has revealed that the actual weather at Rostov-on-Don Airport at the time of the accident was consistent with the weather forecast. The weather measuring equipment used for weather observations at Rostov-on-Don Airport was calibrated, operable and functional. The weather information service provided to the FlyDubai Boeing 737-800 registered A6-FDN conducting Flight FDB981 Dubai – Rostov-on-Don – Dubai that crashed while landing at Rostov-on-Don Airport was in compliance with the applicable regulations and manuals.

A preliminary flight data analysis has revealed that the crew was approaching to land manually (autopilot disconnected) in difficult weather conditions (cloud base 630 meters, wind 230 degrees 13 meters per second maximum 18 meters per second, light shower rain, mist, severe turbulence on straight-on and moderate windshear).

In the course of the initial approach at 22:42 UTC at a height of 340 meters, after getting a windshear (abrupt change in wind speed and direction) alert, the crew decided to go around and then continued on holding pattern waiting for improved weather conditions.

As the crew was proceeding with another manual approach, they decided to go around again at a height of 220 meters (4 km before the runway) and initiated climb setting the engine to takeoff thrust. At a height of 900 m, there was a simultaneous control column nose down input and stabilizer 5-degree nose down deflection, resulting in abrupt descent with a negative vertical acceleration of -1g. The following crew actions to recover did not allow to avoid an impact with the ground. The impact occurred with a speed of over 600 km/h over 50 degrees nose down.

Currently, works are underway at the IAC facilities to reproduce the circumstances of the accident. Both airline pilots and test pilots from the Russian Federation, the USA, and the UAE have been engaged in the investigation to assess the status and actions of the crew. According to the available information, the involved pilots were holding valid pilot licenses and other pertinent papers, had undergone required training and had sufficient flight experience.

Right now the transcript of two hours of cockpit voice recorder data is being completed. The investigative team is planning to engage investigators from the UAE, the USA, and Spain to proceed at the IAC laboratory with clarifying the content of the CVR transcript, translating it from English and Spanish and identifying the speakers.

Timeline of events (times in UTC): (From Flight Safety Foundation’s Aviation Safety Network: Aircraft accident Boeing 737-8KN (WL) A6-FDN Rostov Airport (ROV) https://aviation-safety.net/database/record.php?id=20160319-0.)
17:45 FZ981 scheduled time of departure
18:22 FZ981 pushed back from Stand E18 at Dubai Airport
18:37 FZ981 commences takeoff from runway 30R at Dubai Airport
19:14 FZ981 reaches cruising altitude of FL360
22:16 FZ981 commences descent from FL360
22:20 FZ981 scheduled time of arrival
22:23 S71159 (an Airbus A319 from Moscow-Domodedovo) lands after it’s first approach to runway 22
22:28 U62758 (an Airbus A320 from Khudzhand) lands after it’s first approach to runway 22
22:39 FZ981 commences final approach to runway 22 at Rostov Airport
22:42 FZ981 aborts first approach at 1725 ft, 6.7 km short of the runway
22:49 FZ981 reaches 8000 feet and heads towards the northeast of the airport
22:54 SU1166 (a Sukhoi Superjet 100-95B from Moscow-Sheremetyevo) aborts the first approach to runway 22
23:07 SU1166 aborts the second approach to runway 22
23:17 SU1166 aborts the third approach to runway 22
23:20 SU1166 diverts towards Krasnodar
23:20 FZ982 scheduled time of return flight back to Dubai
23:27 FZ981 enters holding pattern at 15000 feet to the southeast of the airport
00:28 FZ981 leaves the holding pattern and descends for a second approach
00:36 FZ981 intercepts the runway 22 localizer at 10 NM from the runway
00:40 FZ981 aborts second approach at 721 ft, 4 km short of the runway
00:41 FZ981 impacts airport terrain after a steep descent from 900 m

METAR Weather report:
00:00 UTC / 03:00 local time:
URRR 190000Z 24010MPS 8000 -SHRA SCT017 BKN040CB OVC100 06/03 Q0998 WS R22 R22/290046 TEMPO 25015G20MPS 1000 SHRA BR SCT003 BKN020CB RMK QFE741/0988
00:30 UTC / 03:30 local time:
URRR 190030Z 24012G19MPS 6000 -SHRA SCT018 BKN036CB OVC100 06/04 Q0998 R22/290046 TEMPO 25017G25MPS 1000 SHRA BR SCT003 BKN020CB RMK QFE741/0988
Wind 240 degrees, 12 m/s gusting to 19 m/s; Visibility 6000m; light rain showers; Scattered couds at 1800 feet, broken Cumulonimbus clouds at 3600 feet, overcast at 10000 feet; Temperature 6°C; Dew point 4°C

22:30 UTC / 01:30 local time:
URRR 182230Z 25011G17MPS 4200 -SHRA SCT016 BKN033CB OVC100 06/03 Q1000 R22/290046 TEMPO 25015G20MPS 1000 SHRA BR SCT003 BKN020CB RMK QFE742/0990
Wind 250 degrees, 11 m/s gusting to 17 m/s; Visibility 4200m; light rain showers; Scattered clouds at 1600 feet, broken Cumulonimbus clouds at 3300 feet, overcast at 10000 feet; Temperature 6°C; dewpoint 3°C

23:00 UTC / 02:00 local time:
URRR 182300Z 24009G15MPS 4500 -SHRA SCT017 BKN036CB OVC100 05/03 Q0999 WS R22 R22/290046 TEMPO 25015G20MPS 1000 SHRA BR SCT003 BKN020CB RMK QFE742/0989

23:30 UTC / 02:30 local time:
URRR 182330Z 24012MPS 3900 -SHRA SCT019 BKN036CB OVC100 06/03 Q0999 WS R22 R22/290046 TEMPO 25015G20MPS 1000 SHRA BR SCT003 BKN020CB RMK QFE741/0989

Sources

  1. The Aviation Herald http://avherald.com/h?article=495997e2&opt=0
  2. Aviation Safety Network https://aviation-safety.net/database/record.php?id=20160319-0
  3. Межгосударственный авиационный комитет (МАК) – Interstate Aviation Committee  http://mak-iac.org/en/rassledovaniya/boeing-737-800-a6-fdn-19-03-2016. MAK-IAC is the investigation authority for Flydubai accident.

*********

No wind shear or other meteorological issues that could induce the loss of control, no technical malfunction. It seems the Human Factors issues are going to be of high importance. The Human Factors, of which very little is spoken in the basic flight schools, airline ground schools, in the design of training programs and material, training of instructors, service time and rest schedules…

Right now they are looking for the Whats and the How. The Whys are the most difficult part of the investigation and will take much more time. As soon as I have new information, I’ll share it with you.

minime2By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@dralaurita. Human Factors information almost every day 

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