Whenever an aircraft goes down, pilots immediately want to know “what went wrong?”
If the aircraft involved is similar to the type you happen to fly, the interest in possible causes takes on an even more personal imperative. The recent crash of the FlyDubai B738 at Rostov-on Don, Russia lead to much speculation – and as I fly the B738, I obviously took a personal interest in the crash.
The recent interim report by the Russian Authorities provides some insights into the situation leading up to the crash. This preliminary report clearly states that, in accordance with ICAO standards and practices its sole objective is to prevent aviation accidents and no blame or liability is apportioned. The Flight Data Recorder and Cockpit Voice Recorder are still being interpreted and that information will undoubtedly provide further insights into the factors involved.
What is insightful is the final paragraph, which reads:
“For the purpose of preventive measures the investigative team recommends to:”
And then adds 5 recommendations, all relating to the same issue – here summarised in their para.2: “Have additional training on elements of go-arounds in various conditions, in manual control mode with two engines operative from various heights and with insignificant flight weights”.
They also refer to the 2013 B735 crash at Kazan and the 2006 A320 crash near Sochi, stating that the safety recommendations issued by the investigation teams should be “repeatedly studied and analyzed”.
It would thus appear that, at this early stage no malfunctions are reported and that the second go-around ended in a loss of control situation. This led the investigative team to feel that they needed to publish immediate recommendations regarding training.
Just looking at the facts presented: There were 7 crew members and 55 passengers on board, which makes for a very light aircraft. Take-off weight is given as 68 tons. Just doing the simple maths, I would reckon that they had a zero-fuel weight of anywhere between 50 – 55 tons, depending on whether any freight was carried. That would mean that they could have carried anywhere between 13 to 18 tons of fuel. The report does not indicate how much they had, but they flew for just over four hours, made an approach and went around, then held for just over 1 hour and 40 minutes before requesting a second approach. Just using raw numbers, calculating conservatively they had probably used around 12 tons of fuel by then.
So on the second go-around the aircraft would have been very light and at TOGA thrust it would have climbed very rapidly – as indeed indicated in the report.
Both approaches were manually flown using the HUD system. FlyDubai’s B738 airframes are apparently not certified for dual channel approaches and auto-lands, so this would have been according to their SOP’s. (A number of operators prefer this option, probably because of the lower costs associated – pure speculation on my part).
Importantly though, the report states that both approaches were flown “without significant heading or altitude deviations” – in other words, these were well flown approaches.
So it appears to be the go-around that went wrong – and from a Human Factors perspective I would await the final report and CVR analysis with great interest.
I have no idea how long the crew had been on duty, but they had clearly flown for more than 5.5 hours at that stage and were conducting the second approach well after midnight. The report uses Z time, but the local time was just before 04h00. Needless to say, as we know from dire experience – humans are diurnal beings and we do not perform well nocturnally.
Neither do we perform well when tired or fatigued. I have just recently presented a CRM workshop at ICEM 2016 and the emergency medical fraternity were extremely aware of the dangers when humans are tasked to perform in demanding situations while fatigued.
While the preliminary report suggests that training for go-around manoeuvres is required, I sincerely hope that the CRM aspects will be thoroughly investigated when the final report is published.
My own experience in airline operations is that what may be completely legal may not necessarily be safe – nor wise.