4 Years ago today: On 19 March 2016 a flydubai Boeing 737-800 crashed during a go around at Rostov Airport, Russia; all 62 on board were killed.
|Date:||Saturday 19 March 2016|
Boeing 737-8KN (WL)
|C/n / msn:||40241/3517|
|First flight:||2010-12-21 (5 years 3 months)|
|Total airframe hrs:||21257|
|Engines:||2 CFMI CFM56-7B27|
|Crew:||Fatalities: 7 / Occupants: 7|
|Passengers:||Fatalities: 55 / Occupants: 55|
|Total:||Fatalities: 62 / Occupants: 62|
|Aircraft fate:||Written off (damaged beyond repair)|
|Location:||Rostov Airport (ROV) ( Russia)|
|Nature:||International Scheduled Passenger|
|Departure airport:||Dubai Airport (DXB/OMDB), United Arab Emirates|
|Destination airport:||Rostov Airport (ROV/URRR), Russia|
A Boeing 737-800 aircraft, operated by flydubai as Flight FZ981 from Dubai, impacted airport terrain during a second approach attempt in bad weather to Rostov-On-Don Airport in Southern Russia. The airplane was destroyed and the 55 passengers and 7 crew fatally injured.
Flight 981 departed Dubai at 18:37 hours UTC on March 18. The en route part of the flight was normal. The flight arrived near Rostov and the crew performed a manual approach to runway 22 with the autopilot disconnected. Weather conditions were poor with a cloud base at 630 meters, wind 230 degrees at 13 meters per second, maximum 18 meters per second, light rain shower, mist, severe turbulence and moderate windshear.
At 22:42 UTC (01:42 local time) in the course of the initial approach at a height of 340 meters (1115 feet), the flight received a windshear alert. The flight crew decided to go around and then continued to a holding pattern waiting for improved weather conditions.
The flight left the holding pattern at 00:28 UTC (03:28 LT) and descended towards Rostov for another approach to runway 22.
As the crew were proceeding with another manual approach, they decided to go around again at a height of 220 meters (721 feet), 4,5 km before the runway after receiving another windshear alert. They initiated a climb with a vertical speed of up to 20 m/s and setting the engines to maximum takeoff/go-around (TOGA) thrust.
In the course of the go-around the crew set flaps to 15° and retracted the landing gear.
At the height of 1900 ft (approx. 600 m) after reaching the pitch angle of 18° the pilot flying pushed on the control column, which led to a decrease in vertical acceleration of up to 0.5, increase in forward speed and, consequently, automatic retraction of flaps from 15° to 10° at a speed of over 200 knots.
The short-term decrease in engine thrust within 3 seconds resulted in decreasing speed and flaps extension to 15°, although the following crew inputs to regain maximum takeoff/go-around thrust led to speed increase and reiterated automatic flaps retraction to 10°. The flaps remained in the latter configuration until the impact.
The pilot flying, by pulling up the control column, continued climbing with a vertical speed of as much as 16 m/s.
At a height of 900 m there was a simultaneous control column nose down input and stabilizer nose down deflection from -2,5 deg (6,5 units) to +2,5 deg (1,5 units). The FDR recorded a nose down stabilizer input from the stabilizer trim switch of the control wheel lasting 12 seconds, while the CVR record contains a specific noise of rotation of the trim wheels located on both sides of the central pedestal. As a result the aircraft, having climbed to about 1000 m, turned into descent with a negative vertical acceleration of -1g. The following crew recovery actions did not allow to avoid an impact with the ground.
The aircraft hit the runway about 120 m from the threshold with a speed of over 600 km/h and over 50 degrees nose down pitch.
Timeline of events (times in UTC)
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 its first approach to runway 22
22:28 U62758 (an Airbus A320 from Khudzhand) lands after its 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.
The fatal air accident to the Boeing 737-8KN A6-FDN aircraft occurred during the second go around, due to an incorrect aircraft configuration and crew piloting, the subsequent loss of PIC’s situational awareness in nighttime in IMC. This resulted in a loss of control of the aircraft and its impact with the ground. The accident is classified as Loss of Control In-Flight (LOC-I) occurrence.
Most probably, the contributing factors to the accident were:
– the presence of turbulence and gusty wind with the parameters, classified as a moderate to-strong “windshear” that resulted in the need to perform two go-arounds;
– the lack of psychological readiness (not go-around minded) of the PIC to perform the second go-around as he had the dominant mindset on the landing performance exactly at the destination aerodrome, having formed out of the “emotional distress” after the first unsuccessful approach (despite the RWY had been in sight and the aircraft stabilized on the glide path, the PIC had been forced to initiate go-around due to the windshear warning activation), concern on the potential exceedance of the duty time to perform the return flight and the recommendation of the airline on the priority of landing at the destination aerodrome;
– the loss of the PIC’s leadership in the crew after the initiation of go-around and his “confusion” that led to the impossibility of the on-time transition of the flight mental mode from “approach with landing” into “go-around”;
– the absence of the instructions of the maneuver type specification at the go-around callout in the aircraft manufacturer documentation and the airline OM;
– 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 the substantial excessive nose-up moment and significant (up to 50 lb/23 kg) “pushing” forces on the control column to counteract it;
– the failure of the PIC within a long time to create the pitch, required to perform go around and maintain the required climb profile while piloting aircraft unbalanced in forces;
– the PIC’s insufficient knowledge and skills on the stabilizer manual trim operation, which led to the long-time (for 12 sec) continuous stabilizer nose-down trim with the subsequent substantial imbalance of the aircraft and its upset encounter with the generation of the negative G, which the crew had not been prepared to. The potential impact of the somatogravic “pitch-up illusion” on the PIC might have contributed to the long keeping the stabilizer trim switches pressed;
– the psychological incapacitation of the PIC that resulted in his total spatial disorientation, did not allow him to respond to the correct prompts of the F/O;
– the absence of the criteria of the psychological incapacitation in the airline OM, which prevented the F/O from the in-time recognition of the situation and undertaking more decisive actions;
– the possible operational tiredness of the crew: by the time of the accident the crew had been proceeding the flight for 6 hours, of which 2 hours under intense workload that implied the need to make non-standard decisions; in this context the fatal accident occurred at the worst possible time in terms of the circadian rhythms, when the human performance is severely degraded and is at its lower level along with the increase of the risk of errors.
The lack of the objective information on the HUD operation (there were no flight tests of the unit carried out into the entire range of the operational G, including the negative ones; the impossibility to reproduce the real HUD readings in the progress of the accident flight, that is the image the pilot was watching with the consideration of his posture in the seat trough the stream video or at the FFS) did not allow making conclusion on its possible impact on the flight outcome.
At the same time the investigation team is of the opinion that the specific features of the HUD indication and display in conditions existed during final phase of the accident flight (severe turbulence, the aircraft upset encounter with the resulting negative G, the significant difference between the actual and the target flight path) that generally do not occur under conditions of the standard simulator sessions, could have affected the situational awareness of the PIC, having been in the highly stressed state.