FZ 981 – final report

 


The final report on the 2016 crash of flydubai flight 981, a Boeing 737-800 at Rostov-on-Don, Russia, was issued last week by Russia’s Interstate Aviation Committee (IAC). In summary the report said the primary cause was the incorrect aircraft configuration as a result of the captain losing situational awareness in night-time instrument meteorological conditions.

The report is here: FZ981 – Final Report

The aircraft had flown from Dubai to Rostov. All 62 on board died when the aircraft dove into the ground in the early hours of March 19, 2016.

Weather conditions in the area at the time were poor, with what the IAC accident report described as “moderate-to-strong windshear.”

The aircraft had been arriving from Dubai late at night on 19 March 2016 and had aborted one approach – despite being stable with the runway in sight – owing to a windshear warning. Over 1h 40min passed before its crew requested descent for a second landing attempt.

This attempt was also aborted – at 03:40, nearly 2h after the first – when a wind gust on the approach at about 1,000ft caused a sharp increase in airspeed from 153kt to 176kt.

The report noted that neither the captain, who was flying the aircraft, nor the first officer had ever previously flown to Rostov-on-Don Airport.

The IAC said contributing factors to the accident probably included the captain not being in a go-around mindset, as he was focused on landing at the destination airport after the initial go-around amid possible concerns that the crew could run out of flight duty-time to perform the return flight to Dubai.

IAC cited “the crew’s uncoordinated actions during the second go-around: on the low-weight aircraft the crew was performing the standard go-around procedure (with the retraction of landing gear and flaps), but with the maximum available thrust, consistent with the windshear escape maneuver procedure that led to the generation of substantial excessive nose-up movement and significant ‘pushing’ forces on the control column to counteract it.”

The IAC cited the captain’s likely “total spatial disorientation that did not allow him to respond to the correct prompts of the first officer.”

It is worth noting here that at no time did the first officer take command of the aircraft.

It has been widely held that fatique much have played a role in this accident. By the time a second approach was made the crew had been operating the aircraft for 6h of which 2h had been under intense workload, with the added pressure of having to make non-standard decisions.

The IAC report says that the pilots were sufficiently rested, and the inquiry did not identify any duty-time violation. The report does not reveal the roster patterns that these pilots flew prior to the accident. That would be instructive.

The report also added that flydubai has a fatigue-management system in effect that “encouraged crews to submit confidential reports relating to fatigue at any stage of flight.

Indeed this section of the report feels as though it was written by flydubai or their lawyers:

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.”

There is some debate about this on PPRUNE. Was there a culture at flydubai where pilots did not feel able to report fatigue. Given the number of overnight flights and east and west flight patterns cumulative and/or chronic fatique must become an issue for some.

A pilot may technically be legal to fly and within flight time limitations but that does not account for the effects of fatigue and tiredness.

The captain was reported to have had 15 hours of crew rest at home before this flight – was that from the end of his last duty until this duty so including travel and preparation time. Since Rostov was a night flight then his previous flight must have been a night flight back into Dubai – so 15 hours of mainly daytime rest. Just how much sleep did he have?

And that is where I am troubled by this report. It is thorough. Very thorough. But it feels as though too many parties have done their very best to ensure that they carry no responsibility for the accident – after all it was the deceased pilots who were in error.

Make no mistake about what I am trying to say here – this crew flew a near new 737-800 into the ground – their flying was not that of a trained, professional flight crew. But it still happened; and I do not think that the report is able to tell us ‘why’ as it is primarily focused on ‘how.’

As with most accidents there is a swiss cheese of factors that all come into alignment at the wrong time. Poor weather; a crew that had never flown to this destination; pressure to stay in the holding pattern and not divert; fatigue, wind-sheer; inadequate go-around and stall/upset training in the simulator or better still in a real airliner; a first officer who was known to be non-assertive.

flydubai, in its response to the report, said that following safety recommendations in an interim report published the month after the crash and after its own internal review, the airline had initiated spatial disorientation training for all pilots and enhanced its go-around training.

This on PPRUNE is revealing – the author should remain anonymous:

…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.

Among training issues cited at the airline the same author notes that “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.”

As with most airliner crashes there are many lessons to be learned. Pilots should be demanding upset/stall training and go around training in different and stressful situations. This really applies to everyone from a private pilot to an experienced commercial crew.

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