Flydubai 737 crash captain mentally unprepared for go-around

[Ref 3-9 Dec Flight International Magazine,]

Occurrence Date/Time 19 March 2016
Aircraft Type Boeing 737-800 (A6-FDN)
Flight / Operator Flydubai
POB  62 (7 Crew + 55 PAX)
Description Over 1h 40min passed before its crew requested descent for a second landing attempt.

This attempt was also aborted, nearly 2h after the first.

With the lightly-loaded aircraft subjected to maximum thrust, consequently resulting in “substantial excessive nose-up moment” and “significant” pushing on the control column, up to 225N for more than 40s, to counteract it.

The captain did not set and maintain the proper climb profile. Manual stabiliser trim was activated after an unusually long period of time – around 12s – as the aircraft entered low cloud.

“The piloting – especially the precise piloting – of an out-of-trim aircraft is always complicated and implies the increase of the pilot’s workload, including the psycho-emotional component,” says the inquiry.

Excessive application of the stabiliser trim generated negative g-forces as the jet transitioned into a dive. This sudden onset of negative g-force can result in a startle effect, with pilots incapacitated and spatially disoriented and their vision or breathing potentially affected by unsecured objects, mud and dust being thrown up from the cockpit.

The captain’s psychological incapacitation and disorientation, says the inquiry, prevented his responding to prompts from the first officer – who, in turn, did not recognise the signs of the captain’s deteriorating mental state in time to take decisive actions.

The crew had also, by this moment, 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.

Russia’s Interstate Aviation Committee says the captain’s mindset was fixed on conducting a landing at Rostov, following the previous forced go-around and through concern over exceeding duty time for the return flight.

As a result, it says, he had a “lack of psychological readiness” for a second go-around.

After emerging from the cloud, in a steep nose-down attitude, the aircraft struck the ground close to the runway and disintegrated. None of the 62 occupants survived. 

Albeit, analysis of schedules for the crew shows the pilots were sufficiently rested, and the inquiry did not identify any duty-time violation.

Contributory factors
  • psychologically unprepared for the manoeuvre
  • tiredness following a long holding time
  • The captain demonstrated “insufficient knowledge and skill” with the manual stabiliser trim
  • crew’s actions lacked co-ordination
  • the accident occurred at “the worst possible time” in terms of circadian rhythms, when human performance tends to be degraded to its lowest level

However, the investigation ruled out somatogravic illusion as a factor in the crash.

Recommendation Follow SOP, always! (my point of view)



Read More –

What’s Somatogravic illusion?

Somatogravic illusion is the tendency – in the absence of visual references – to incorrectly perceive acceleration as an increase in pitch attitude, a perception that can lead pilots instinctively to make nose-down inputs even if the aircraft is flying level.


Fatigue-Management System (FMS) for Middle Eastern carrier 

The Middle Eastern carrier has a fatigue-management system in effect, the inquiry adds, which “encourages” crews to submit confidential reports relating to fatigue at any stage of flight.

Unfortunately, “For a number of quantitative indicators the system goes beyond the national aviation legislation,” it adds.

Indeed, since Flydubai commenced operations in 2009, it has logged over 1 million hours of flight time. But it has only received 70 fatigue-related confidential reports, says the inquiry, the majority of which were “pro-active”, with crews reporting fatigue and being removed from duty until they felt fit.

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