At the scene of the crash in Rostov-on-Don, Russia in 2016.
PHOTO BY ARCHIVE
DUBAI – A final report on the tragic flydubai FZ981 crash that killed all 62 onboard has been released, three years after the March 19, 2016 incident.
According to the report, turbulent weather conditions, “ambiguity in operating manuals” and pilot tiredness contributed to the crash at Rostov-on-Don in Russia.
The report also said that the captain is thought to have experienced a pitch-up illusion before becoming “incapacitated” during the last phase of the flight.
According to the report, the aircraft was “airworthy” when it left the Dubai International Airport, and that the crew were “fully rested” prior to the flight, however, the captain later experienced “operational tiredness”. Russian media reports at the time claimed that pilot fatigue led to the crash.
The newly released report also stated that the crew conducted a go-around “in line with standard operating procedures following an audible wind shear warning” and held for two hours at Rostov-on-Don based on the weather reports.
The crew then decided to fly a second approach after receiving an “incomplete weather report” from Air Traffic Control without an active wind shear warning. According to the report, the captain initiated a second go-around after observing a spike in air speed.
“During the second go-around, the final report concludes that the captain’s mindset was focused on landing. This was an unconscious cognitive bias to continue with an original plan in spite of changing conditions. This behaviour is widely understood in human factors,” the report further said.
“Ambiguity in the manufacturer’s operating manuals led to confusion in the type of go-around being flown. One call-out led to two distinct procedures each with a different aircraft configuration and thrust setting. It is possible that the captain and the first officer were experiencing operational tiredness at the time of the second go-around which was conducted under intense workload and in turbulent weather.”
Later in the flight, the captain ran the stabiliser trim for 12 seconds in what is thought to be a “pitch-up illusion”, called somatogravic that may have caused the captain to continually press the trim switch. Pilots use the trim switch to pitch the aircraft up or down during flight.
According to the report, the captain “became incapacitated” during the last phase of the flight.
Meanwhile, Flydubai said it will “fairly compensate” the families of victims of flight FZ 981. The airline previously announced that it would pay $1.4 million to the families of the victims, plus a “hardship payment” of $20,000 each. ICA/Expat Media
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