Flydubai crash could have been pilot error – investigators

[rooster59]

Flydubai crash could have been pilot error – investigators



Russian investigators have said pilot error could be to blame for the crash of a Flydubai passenger flight in March, but added the conditions and their actions were still being evaluated.

They said the flight entered a steep dive due to crew action before it came down in Rostov-on-Don killing all 62 people on board.

The Moscow-based Interstate Aviation Committee (IAC), said the plane had been flown in a “contradictory manner” in the minutes leading up the crash.

The crew had decided to abort landing and circle round again. They had begun to gain altitude when the controls of the plane were abruptly pushed away, pushing its nose lower.

That, combined with the angle of the tail fin, sent the plane into a steep dive which the pilots were unable to pull out of, the IAC said.

-- (c) Copyright Euronews 2019-04-09

[NeverSure]

I don't know what happened but there is one thing that comes to mind...

"The crew had decided to abort landing and circle round again. They had begun to gain altitude when the controls of the plane were abruptly pushed away, pushing its nose lower.

That, combined with the angle of the tail fin, sent the plane into a steep dive which the pilots were unable to pull out of, the IAC said."

In laymens' terms, if the plane is nosed up too steeply, it will obviously lose speed. At the extreme, the wings will stall meaning they don't have enough airflow over them to maintain lift.* At the moment of stall the nose will drop as the wings stop flying. Planes are always somewhat nose-heavy to make them more stable. To recover from this stall, the pilots must push the controls forward which pushes the nose down and puts the plane into a dive so that it can regain flying speed. When sufficient airspeed is regained the nose is pulled back up to level or climb. There has to be enough altitude available to do that, and the reaction of the pilot has to be correct.

Knowing all of that and reading the article makes me wonder if it stalled and the pilots couldn't or didn't recover for some reason.

*That is a rough description of what a stall is and good enough for this discussion but not good enough to pass a pilot's exam.

[rosst]

Yes, that could very well explain it but with the added complication of some failsafe devices which complicates matters.

Added to this the probability of wind shear in the stated conditions and the loss of confidence after a couple of failed attempts, a recipe for disaster.

The other consideration is the lack of hands on manual flying now being done is reducing the skill level of airline pilots.

[F430murci]

I don't know what happened but there is one thing that comes to mind...

"The crew had decided to abort landing and circle round again. They had begun to gain altitude when the controls of the plane were abruptly pushed away, pushing its nose lower.

That, combined with the angle of the tail fin, sent the plane into a steep dive which the pilots were unable to pull out of, the IAC said."

In laymens' terms, if the plane is nosed up too steeply, it will obviously lose speed. At the extreme, the wings will stall meaning they don't have enough airflow over them to maintain lift.* At the moment of stall the nose will drop as the wings stop flying. Planes are always somewhat nose-heavy to make them more stable. To recover from this stall, the pilots must push the controls forward which pushes the nose down and puts the plane into a dive so that it can regain flying speed. When sufficient airspeed is regained the nose is pulled back up to level or climb. There has to be enough altitude available to do that, and the reaction of the pilot has to be correct.

Knowing all of that and reading the article makes me wonder if it stalled and the pilots couldn't or didn't recover for some reason.

*That is a rough description of what a stall is and good enough for this discussion but not good enough to pass a pilot's exam.

Stall should be readily apparent on CVR and BB.

[Chicog]

Presumably the FDR will tell unequivocally whether or not the plane was improperly configured at the time of the crash.

They've leaked enough of this already to point the finger unflinchingly at the flight deck.

[Tywais]

Flydubai plane piloted into ground at 600kph, flight records show

Flydubai flight FZ981 was on manual control when the cockpit crew apparently sent it into a nosedive, resulting in a fatal crash in Russia, investigators have reported, citing flight recorder data. The plane hit the ground at 600kph and was at an angle of 50 degrees.

The flight records have been transcribed and provisionally analyzed, the Interstate Aviation Committee reported on Friday. The data showed that flight FZ981 made two landing approaches to Rostov-on-Don Airport, but on both attempts decided to cut short the process and perform a go-around maneuver. In both attempts the crew piloted the aircraft in manual mode.

The second approach was discontinued when the Boeing 737-800 was at 220 meters altitude, 4km from the runway. The crew switched engines into take-off mode and started ascending. They then apparently took a maneuver that resulted in the crash.

“At the altitude of 900 meters the crew pushed the yoke and at the same time a stabilizer was moved five degrees into nosedive position, which resulted in a rapid descent and a vertical acceleration of up to -1g,” the report said. “The consequent actions of the crew failed to prevent the aircraft’s collision with the ground. The collision happened at a speed of over 600 kmh and pitch angle of over 50 degrees.”

Full article here - rt.com

[Tywais]

Flydubai Flight Crash: Russian TV Airs Final Words Of Pilots

Suspicions of pilot error were aroused after Russian state television aired the final words of the pilots of the Flydubai passenger jet that crashed in Rostov-on-Don last week, killing 62 people. The report suggests that the pilot may have lost control of the plane immediately after switching off the autopilot.

“Don’t worry,” the pilot was heard saying repeatedly before saying seconds later, “Don't do that!” The last words are repeated calls to “Pull up!” a transcript of the words exchanged between the pilot and his crew obtained by Russia’s Rossiya-1 channel said.

More here - International Business Times

[Tywais]

Flydubai Flight FZ981 Crash Update: Airliner Worked Crew To Death, Ignored ‘Pilot Fatigue’ Complaints, Report Says

The crash of Flydubai flight FZ981 Saturday was inevitable as the pilot was “worked to death” by the airliner, a former Flydubai captain told RT News. All 62 people on board were killed after the plane went down in southern Russian city of Rostov-on-Don.

The former pilot reportedly said that Flydubai’s top management was aware that pilots were being overworked as several complaints were made to the authorities. As the new report emerged about Flydubai's crew being overworked, Russian investigators said Monday that they had been able to retrieve data from a damaged cockpit voice recorder recovered from the scene of a plane crash.

More here - International Business Times

[F4UCorsair]

In a missed approach, with power applied, the 737 pitches nose up. That can require a fair bit of forward pressure and trim to overcome.

I see a couple of possibilities......

The speed was already a little slow, full power was applied, the aircraft pitched up violently and stalled. That would cause a steep nose down attitude that the pilots may not have been able to overcome, but doesn't explain the control column being pushed forward, if that in fact happened, and it's not just press confusion.

The second is that when power was applied and the aircraft pitched up, the pilot forward control pressure and trim input was way too great, and caused the violent pitch down from which they were not able to recover. That fits with what has been reported.

Due to the property of inertia, applying full power to a jet aircraft doesn't result in an immediate increase in speed; it takes time to overcome the inertia and get the mass moving.

Time will tell.

A former colleague with knowledge of Fly Dubai, and has friends there, was telling me this morning that the Captain had resigned, and this was one of his last flights before moving on.

Edited April 9, 2016 by F4UCorsair

[sanukjim]

87 percent of all airplane crashes are from crew error.To gain enough flight hours many pilots resort to "flying the Parker Pen" to show qualifications for a flight job.With the need for more pilots and the number of growing minor airlines with dubious training methods for their pilots these incidences of crashes will only increase. Saving money flying the smaller airlines .is taking a big risk

[Rancid]

I know noting about flying but saw a report on RT (free streaming app on my smart TV) where numerous FlyDubai pilots had claimed they were overworked to the point of chronic fatigue, and some were saying that they had advised the company that an accident would occur unless things were rectified.

So it may be pilot error but not really the fault of the pilots, guess time will tell.

[PETERTHEEATER]

....and the angle of the tail fin.....

Is this referring to the vertical stabiliser? If so how does 'the angle' contribute to an input nose down attitude?

Better that they did not release anything but conclusions.

[Srikcir]

The erratic flight behavior moments before the crash almost sounds like there was a physical fight within the cockpit.

In such a chaos aircraft controls would be vulnerable to inadvertant activation.

[NeverSure]

It still seems that the plane may have stalled. Maybe not. Adding power, going into a climb and stalling leaves the correct recovery method of pushing the nose down to regain speed and fly out of it. The articles seem to agree that the controls were used to push the nose down but I don't see a clue as to why they didn't pull it back up when they regained sufficient speed (if it stalled.)

Everything I read there while proving nothing, is consistent with a stall, and a recovery attempt gone awry. I'm not saying it was, but right now it's the only thing I can think of that checks all of the boxes with what information they are giving.

If it did stall at an altitude of just 900 meters, it might not have had enough altitude to recover from and fly out of a stall, but the high rate of speed at which they hit the ground combined with pilot disagreement on the tapes makes it sound like a screw up of some kind.

Cheers.

[NeverSure]

....and the angle of the tail fin.....

Is this referring to the vertical stabiliser? If so how does 'the angle' contribute to an input nose down attitude?

Better that they did not release anything but conclusions.

I think they are talking about the horizontal stabilizer on the tail. It is the "small wing on the tail" and It controls the pitch of the plane (nose up, down, level). When you push forward on the controls that lifts the tail and lowers the nose. Remember, the plane, in laymen's terms, is balanced by the lift on the wings but is designed to be slightly nose-heavy at all times for stability.

The article says that the plane was pitched down which would be a matter of lifting the tail via the horizontal stabilizer which they seem to be calling the "tail fin".

Cheers.

[AGLV0121]

I don't know what happened but there is one thing that comes to mind...

"The crew had decided to abort landing and circle round again. They had begun to gain altitude when the controls of the plane were abruptly pushed away, pushing its nose lower.

That, combined with the angle of the tail fin, sent the plane into a steep dive which the pilots were unable to pull out of, the IAC said."

In laymens' terms, if the plane is nosed up too steeply, it will obviously lose speed. At the extreme, the wings will stall meaning they don't have enough airflow over them to maintain lift.* At the moment of stall the nose will drop as the wings stop flying. Planes are always somewhat nose-heavy to make them more stable. To recover from this stall, the pilots must push the controls forward which pushes the nose down and puts the plane into a dive so that it can regain flying speed. When sufficient airspeed is regained the nose is pulled back up to level or climb. There has to be enough altitude available to do that, and the reaction of the pilot has to be correct.

Knowing all of that and reading the article makes me wonder if it stalled and the pilots couldn't or didn't recover for some reason.

*That is a rough description of what a stall is and good enough for this discussion but not good enough to pass a pilot's exam.

Exactly same as China Airlines Flight 140

[F4UCorsair]

87 percent of all airplane crashes are from crew error.To gain enough flight hours many pilots resort to "flying the Parker Pen" to show qualifications for a flight job.With the need for more pilots and the number of growing minor airlines with dubious training methods for their pilots these incidences of crashes will only increase. Saving money flying the smaller airlines .is taking a big risk

No stats kept on the number of aircraft saved by pilots actions though.

Absolute garbage statement contending that pilots pen in hours. The penalties are severe, and lack of real experience shows in performance.

Edited April 9, 2016 by F4UCorsair

[F4UCorsair]

I know noting about flying but saw a report on RT (free streaming app on my smart TV) where numerous FlyDubai pilots had claimed they were overworked to the point of chronic fatigue, and some were saying that they had advised the company that an accident would occur unless things were rectified.

So it may be pilot error but not really the fault of the pilots, guess time will tell.

Agreed Rancid, a crash that occurs as a result of pilot fatigue is not solely pilot error. Keeping records of flight times is a joint company/pilot responsibility, and that is enshrined in aviation law.

An incident/crash is seldom, or possibly NEVER, a result of a single factor. Human Factors studies show that a crash is the culmination of usually multiple factors, an example of which may be (not every one of these, incidentally)........Crying baby kept the pilot awake, insufficient sleep as a consequence, argument with the wife before leaving for work, caught in traffic so late signing on, aircraft late arriving from a previous flight, taxying out and a mechanical fault is revealed so return to the gate, change of aircraft, trek across the terminal to start the day again, late refuelling of the new aircraft, vile weather for departure, enroute or arrival, ground crew rushing to board pax and dispatch the aircraft, time pressures now on, etc.

These may seem insignificant to a non aviation type, but they take on a whole new importance for crews.

James Reason, a British psychologist who has specialized in organizational processes and human error, established the Swiss Cheese hypothesis, diagram below, that all the holes in different layers of cheese must 'line up' before an accident can happen. If the path is blocked because a hole is not in place, the accident will be averted. Human factors training in aviation seeks to educate ALL levels of staff/crew in airline companies to identify and block potential factors that could contribute to an incident, not just the pilots themselves, but right across the spectrum of staff, from check in staff to senior management and company policies.

Check this link for an example of systemic failures https://en.wikipedia.org/wiki/Gimli_Glider

I once briefly worked for an airline that had a couple of aircraft with fuel gauges calibrated in pounds, but we worked in kilograms for all other purposes. The rest of the fleet had gauges calibrated in kgs!! It was a recipe for disaster, and extreme diligence was required by crews to avoid a similar mishap to that of the Gimli glider, until the gauges were replaced with those calibrated in Kgs months later, and that brings into play a factor way beyond the pilots' control, a cash strapped airline that didn't want to shell out thousands of $$ to replace components, whatever the associated risk. The aircraft had been bought from a company in a country that still used pounds rather than kgs. Just managing the fuel loading, checking and rechecking ACTUAL fuel requirements, introduced an unwelcome level of stress, just another layer in the Swiss Cheese Hypothesis.

Quoting Tywais, post # 6,

“At the altitude of 900 meters the crew pushed the yoke and at the same time a stabilizer was moved five degrees into nosedive position, which resulted in a rapid descent and a vertical acceleration of up to -1g,” the report said. “The consequent actions of the crew failed to prevent the aircraft’s collision with the ground. The collision happened at a speed of over 600 kmh and pitch angle of over 50 degrees.”

A second or two after introducing 5 degrees nose down on the stabilizer, and the aircraft would not have been recoverable. Why that input was made will be the subject of much deliberation.

Of course, the management will be ducking and weaving, trying their best to tin plate their ar$es, and appear blameless. Some things never change, and in a place like Dubai, they may just get away with it. Hopefully, Boeing will be involved in the investigation, and I expect they will be.

Edited April 9, 2016 by F4UCorsair