"Because of the wrong configuration and errors in piloting": IAC named the reasons for the crash of Boeing in Rostov-on-Don

The Interstate Aviation Committee completed an investigation into the crash of a Boeing 737-800 aircraft near Rostov-on-Don, which occurred on March 19, 2016. The cause of the disaster, experts called the erroneous actions of the crew. This is stated in the final report of the IAC.

“The crash of a Boeing 737-8KN A6-FDN aircraft occurred while re-entering the second circle due to an incorrect configuration and errors in piloting, followed by the loss of FAC (aircraft commander. - RT ) situational awareness at night in instrumental weather conditions, which led to loss of control for flight parameters and the plane’s collision with the ground, ”the document says.

Recall that the Boeing 737-800 of Flydubai flying from Dubai crashed while landing on the night of March 19, 2016 at the Rostov-on-Don airport. 62 people became victims of the crash: 55 passengers and 7 crew members. In addition to the Russians, on board were citizens of India, Spain, Cyprus, Colombia, Kyrgyzstan, Seychelles, Ukraine and Uzbekistan. In 2017, a monument to the dead opened in front of the airport building.

The commission, which investigated the causes of the tragedy, was attended by representatives of the aircraft development company (Boeing Company, USA), Flydubai, specialists from Rostov-on-Don Airport, the Federal Air Transport Agency, Rostransnadzor, Roshydromet, FSUE State ATM Corporation, and Rodina NPO ”, JSC“ LII named after M. Gromov ”, as well as pilots of some Russian airlines. In addition to the delegates from the United States and the United Arab Emirates, French experts also participated in the commission, as the aircraft engines were developed in France.

Human factor

The pilot error version began to appear in the media almost immediately after the crash. So, for example, in April 2016, Russian media reported that, in the wake of the disaster, the Rosaviatsia ordered to additionally train pilots to go to the second round in manual mode after an interrupted landing.

• Appearance of a voice recorder of a destroyed aircraft

The IAC interim report, which was published in April 2016, ruled out the technical cause of the crash. Experts concluded that all the aircraft's onboard systems were operating normally and were operational at the time of the crash. Then the IAC did not blame the pilots. However, the recommendations stated the need to strengthen the training of pilots, especially with regard to approaches to the second round.

As noted in the IAC's final report, according to information received from Flydubai, the crew was quite rested before the flight.

At least the time spent in the air and the total working time for the last 28 days did not exceed the standards of the company itself - 100 and 190 hours, respectively. The aircraft commander (FAC) had the opportunity to rest before the flight for 15 hours, and the co-pilot for 20 hours. At the same time, representatives of UAE airlines previously complained about an irregular schedule and overwork.

Both pilots periodically trained on the simulator to enter the second circle during landing, including in difficult weather conditions. However, they had never flown together before. It was also their first flight to Rostov-on-Don Airport. The co-pilot had never landed on Russian airfields before.

As noted in the final report of the IAC, “the commission of inquiry did not reveal signs of the use of PIC and the co-pilot of alcohol and other psychoactive substances”. Both had no health problems.

When the aircraft landed at the Rostov airport, the aircraft was forced to enter the second round due to the automatic warning “wind shear”.

“At the same time, in fact, the crew faced one of the most unfavorable scenarios: the need to go to the second circle due to the alarm about the possibility of wind getting into the shear from a sufficiently high altitude (with a small margin to the established height of departure to the second circle) on“ light “By plane,” the IAC final report notes.

For a long time the plane was in the waiting area and even negotiated with the Volgograd airport about the possibility of landing there. At the same time, the crew had difficulty communicating with the manager of the Rostov airport due to the lack of English proficiency in the latter.

As a result, when re-approaching, the crew noticed an excess of flight speed and at 00:40 decided to leave again for the second round.

The reason is in psychology

According to the IAC, at this moment, most likely, the crew lost the ability to predict the reaction of the aircraft to their actions, which may be associated with an increase in the workload of the pilots, including psychological. As a result, all the actions of the pilots were belated.

• General panorama of the scene of the incident with traces of the first touch of the Boeing 737

At 00:41 the situation began to take on a critical character, and the crew, according to experts, was in a state of extreme stress. The recorded actions of the crew allow us to judge that at that moment the commander lost the ability to adequately assess the situation and was very nervous. The co-pilot tried to save the situation and prompt the PIC to take the right action - deviating the helm “by itself”, but in vain. By that time, the PIC did not hear the co-pilot and did not respond to his words.

“As a result of the inadequate actions of the PIC,” according to the IAC report, the aircraft was “in a difficult spatial position.” It could have been saved if, at the right moment in time, the helm column had been completely tilted towards itself. However, this was not done and the plane entered at a peak.

“The situation corresponded to the loss of ability (psychologically) of the pilot pilot to fly the aircraft (pilot incapacitation),” the IAC report said.

According to experts of the International Aviation Committee, the psychological unwillingness to go to the second round and the desire to land the plane at the Rostov airport at all costs affected it.

Overloads - at the last stage of the flight - and crew fatigue also played a role: at that time he had been in the air for 6 hours, including “2 hours in a tense working environment”.

Based on the results of the investigation, the IAC recommends that the Russian authorities bring its results to the entire civilian aviation flight staff and assess the risks of pilot admission to the Boeing 737-800 if it is the first multi-engine aircraft in their career. Among the recommendations for Flydubai is “to consider the feasibility of supplementing the RPP (flight operations manual. - RT ) of the airline with psychological performance criteria and recommendations for action in such cases.”

The ICAO International Civil Aviation Organization is encouraged to “consider the advisability of creating a working group to study the issues of loss of working capacity by crew members psychologically and develop appropriate recommendations to provide methodological assistance to states and airlines.”