Russian investigators believe the captain of a Flydubai Boeing 737-800 that crashed during a second go-around at Rostov-on-Don was psychologically unprepared for the manoeuvre and possibly suffering fatigue following a long hold.
Russian investigators believe the captain of a Flydubai Boeing 737-800 that crashed during a second go-around at Rostov-on-Don was psychologically unprepared for the manoeuvre and possibly suffering tiredness following a long holding time in the early hours of the morning.
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.
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.
This led to a delay in the captain’s mental state adapting from carrying out a landing to carrying out a go-around.
The inquiry adds that the crew’s actions lacked co-ordination, 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.
As the aircraft climbed away the captain did not set and maintain the proper climb profile and demonstrated “insufficient knowledge and skill” with the manual stabiliser trim, activating it for 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.
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.
Investigators point out that the accident occurred at “the worst possible time” in terms of circadian rhythms, when human performance tends to be degraded to its lowest level.
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.
But analysis of schedules for the crew shows the pilots were sufficiently rested, and the inquiry did not identify any duty-time violation.
The Middle Eastern carrier has a fatigue-management system in effect, the inquiry adds, and that this “encourages” crews to submit confidential reports relating to fatigue at any stage of flight.
“For a number of quantitative indicators the system goes beyond the national aviation legislation,” it adds.
It states that, since the airline commenced operations in 2009, it has logged over 1 million hours’ 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.
