Three years after the fatal FlyDubai flight FS981 went down in Rostov-on-Don (Russia), the accident investigators have finally concluded their work. Publishing the final report in November 2019, they found pilot’s mistake as the main cause of the tragedy.
FlyDubai Boeing 737-800 (registration number A6-FDN) took off from Dubai (the United Arab Emirates) on March 19, 2016. Arriving in Rostov-on-Don (Russia), the aircraft was unable to land due to harsh weather conditions. After the second attempt to land, also not successful, the plane was expected to head to another airport. However, during the second go-around it hit the ground, killing all seven crew and 55 passengers on board.
Russia’s Interstate Aviation Committee (IAC) was in charge of the accident investigation. Releasing the preliminary findings in April 2016, it has published the final report only on November 26, 2019. The main conclusion: incorrect aircraft configuration and crew piloting resulted in the pilot in command losing situational awareness and running the aircraft to the ground.
What could FlyDubai have done better?
As investigation found pilot’s mistake to be the main cause of the accident, the majority of contributing factors, identified in the final report, revolve around psychological aspects that determine decision-making in critical situations. Nevertheless, according to the IAC, two contributing factors that led to the crash were related to FlyDubai’s own operating manual.
In particular, the manual lacked instructions of the maneuver type specification at the go-around call-out. The first officer also did not recognize the captain’s psychological incapacitation in time ‒ the criteria of which were absent in the airline’s operations manual, according to the IAC.
Eight of the 26 safety improvement recommendations, outlined in the final report, are actually addressed to the airline. They include suggested training on the specific aspects of the stabilizer trim manual operation (the forces trim); improving training on upset conditions, such as pilots’ practical familiarization with zero and negative G state conditions; amending operations manual with criteria of psychological incapacitation and recommended actions in such cases.
FlyDubai reacts to FS981 crash final report
Reacting to the final report’s release, FlyDubai released a statement in which it acknowledges IAC’s conclusions and recommendations. Claiming it was fully compliant with all regulatory requirements at the time of the accident, the airline states it took its obligations “seriously” and implemented “a number” of precautionary measures since 2016.
“The airline made proactive operational enhancements to both simulator and classroom training to reinforce awareness and enhance understanding of spatial disorientation,” the statement reads. “Furthermore, flydubai made additions to the manufacturer’s standard operating procedures and manuals. All pilots have been trained on these enhancements which exceed regulatory requirements.”
FlyDubai: majority of compensations settled
Following the tragedy, the victims’ families filed millions-reaching lawsuits against the budget airline. FlyDubai says the majority of claims are now settled, while the rest of the “process” remains a priority for the airline. “FlyDubai’s aim has always been to fairly compensate those who have been impacted by the loss of loved ones following the accident involving FZ 981,” the airline’s statement reads. “We recognise this is a poignant moment for the families and our long term care team remains available for as long as they need.”
Delayed closure of three years-long investigation
In August 2018, the IAC announced that preparation of the final report was being finalized, as investigators had carried out all the essential activities. However, as they also wanted to pursue additional examination of the Heads-Up Display (HUD), manufactured by Rockwell Collins, visual indications, which were deemed relevant to identifying the causes of the accident and possible safety enhancements, the actual release of the findings took place over one year later ‒ December 2019.
The aircraft was equipped with a Head-Up Display (HUD) ‒ a transparent display that presents data without requiring users to look away from their usual viewpoints. In this way, pilots are able to view information with the head positioned “up” and looking forward, eliminating the need to angle down for looking at lower instruments. FlyDubai’s Boeing 737-800 was the first crashed aircraft with the HUD system installed on board.
The IAC was weighing the feasibility of a simulator experiment to reproduce the HUD indications that would have been displayed during the accident flight. However, despite the prolonged effort to gain more insight on a HUD’s possible impact on the flight outcome, the final report concludes stating that objective information is insufficient to make said conclusion.