Pilot error in bad weather led to fatal flydubai crash, Russian investigation concludes

Accident in 2016 at Rostov-on-Don resulted in the deaths of all 62 on board

Emergencies Ministry members work at the crash site of a Boeing 737-800 operated by flydubai, at the airport of Rostov-On-Don, Russia, March 20, 2016. Reuters

Russian emergency rescuers and forensic investigators work on the wreckage of the flydubai passenger jet which crashed, killing all 62 people on board as it tried to land in bad weather in the city of Rostov-on-Don on March 19, 2016. AFP

Russian rescuers working at the crash site of a passenger plane in Rostov-on-Don on March 19, 2016. AFP / Russian Emergencies Ministry

The final report from Russian investigators concluded that pilot error in bad weather and an incorrect aircraft configuration were the main factors behind a fatal flydubai crash more than three years ago.

The Boeing 737-800 from Dubai crashed in the early hours of March 19, 2016, at Rostov-on-Don airport in southern Russia on its second attempt to land. All 62 - 55 passengers and 7 crew - on board were killed.

The conclusion of the report, released by the Interstate Aviation Committee, said the accident occurred "due to an incorrect aircraft configuration and crew piloting, the subsequent loss of the pilot in command's situational awareness in nighttime ...This resulted in a loss of control of the aircraft and its impact with the ground".

The passenger jet circled the south Russia airport for two hours after an initial landing attempt was aborted because of high winds.

On its second landing attempt, the plane plunged to the ground and burst into flames about 250 metres short of the runway.

Among the probable contributing factors were "turbulence and gusty wind", the pilot's confusion and "lack of psychological readiness" for a second go-around and "the possible operational tiredness of the crew ... at the worst possible time in terms of the circadian rhythms, when the human performance is severely degraded and is at its lower level along with the increase of the risk of errors".

On the first approach to Rostov, the crew conducted a go-around following a windshear warning from air traffic control.

Following an incomplete weather report, the crew decided to make a second approach, which was changed by the pilot to a go-around based on a spike in air speed, according to a statement about the report's findings on Tuesday from flydubai.

However, on the second go-around the pilot was focused on landing, in line with his original plan, and in spite of changing conditions.

"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," flydubai said.

Ambiguity in the manufacturer's operating manuals over the procedures for such a go-around also led to confusion. The crew subsequently lost control of the aircraft leading to the impact with the ground.

"The accident is classified as Loss of Control In-Flight occurrence," the report from the investigators said.

Flydubai acknowledged the report's conclusions and recommendations and said "today, our first thoughts are with the passengers and crew who lost their lives on board flight FZ 981 and those who continue to grieve".

The airline said that since the crash it has "made proactive operational enhancements to both simulator and classroom training to reinforce awareness and enhance understanding of spatial disorientation".

Go-around training has also been improved, including bad weather scenarios, it said. Standards and procedures for go-arounds have also been changed.

Up to 30 people worked for the airline's team to support the investigation. It said it intends "to share its additional learnings and insights with the industry”.

Flydubai said it has settled the majority of compensation claims by families of the victims and it is working to complete the process.

Its aim "has always been to fairly compensate those who have been impacted by the loss of loved ones".

In August of 2018, Dubai Civil Court awarded Russian siblings Dh800,000 in compensation for the death of their parents in the flight.

"We recognise this is a poignant moment for the families and our long-term care team remains available for as long as they need,” flydubai said.