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B738, Rostov-on-Don Russia, 2016

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Summary
On 19 March 2016, a Boeing 737-800 making a second night ILS approach to Rostov-on-Don commenced a go around from 720 feet aal but soon afterwards crashed at high speed onto the intended landing runway and was completely destroyed by the impact and an explosion. A Preliminary Report on the Investigation states that the descent preceding the crash appears to have been the consequence of an as yet unexplained nose down movement of the control column and a simultaneous and abnormally prolonged nose down stabiliser trim input using the control column switch. Cumulonimbus cloud was present overhead the airport.
Event Details
When March 2016
Actual or Potential
Event Type
Fire Smoke and Fumes, Loss of Control, Weather
Day/Night Night
Flight Conditions IMC
Flight Details
Aircraft BOEING 737-800
Operator Flydubai
Domicile United Arab Emirates
Type of Flight Public Transport (Passenger)
Origin Dubai International Airport
Intended Destination Rostov-on-Don Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Missed Approach
APR
Location - Airport
Airport Rostov-on-Don Airport
General
Tag(s) Approach Unstabilised after Gate-GA
FIRE
Tag(s) Post Crash Fire
LOC
Tag(s) Environmental Factors,
Extreme Pitch
WX
Tag(s) In Flight Airframe Icing,
Low Level Windshear
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Non-aircraft damage Yes
Fatalities Most or all occupants (62)
Safety Recommendation(s)
Group(s) Aircraft Operation
Investigation Type
Type Independent

Description

On 19 March 2016, a Boeing 737-800 (A6-FDN) being operated by Flydubai on a scheduled international passenger flight from Dubai to Rostov-on-Don as FDB 891 failed to complete a night IMC go around initiated at 720 feet aal after possibly encountering wind shear and beginning a go around, then crashed at speed onto the intended landing runway and was destroyed by the high energy impact and the explosion which followed. All 55 passengers and 7 crew members were killed. Damage was caused to the runway surface and to runway lighting and the airport remained closed for two days to allow wreckage recovery and infrastructure repairs.

A general view of the crash site after the removal of larger pieces of wreckage. [Reproduced from the Official Report]

Investigation

An Investigation is being carried out by the Air Accident Investigation Commission of the Interstate Aviation Committee (MAK). Both the FDR and the 2 hour CVR were recovered from the wreckage having sustained "substantial mechanical damage" but the data from both was successfully downloaded. The languages used by the pilots within the flight deck were noted as having been English and Spanish. Recorded ATC radar and communications data were also available.

It has been found that the Captain had 5,961 total flying hours of which 4,905 hours had been on type and 1,056 hours had been in command on all types. The First Officer had 5,767 total flying hours of which 1,100 hours had been on type and some of the rest on the A320, C421 and ATR 42/72. Both pilots held ATPLs issued by the UAE General Civil Aviation Authority.

After flying at FL 360 in the cruise, the aircraft was positioned onto the runway 22 ILS but during the approach, which was conducted with the AP and A/T engaged, the crew advised ATC that they had received an onboard wind shear warning and were going around. The initial climb was to FL 50 and then FL 80 where a holding pattern was commenced. Whilst holding there, the crew advised ATC of "moderate icing" and requested a climb to FL 150, which was approved.

After almost two hours of manoeuvring/holding in the Rostov area, during which there was no marked change in the prevailing weather conditions, a second ILS approach to runway 22 was commenced with the AP and A/T engaged. This was abandoned with about 2½ nm to run and a go around commenced from 720 feet. No reason for this was communicated to ATC but it was noted that "one of the probable causes of the go-around decision could have been the [recorded] 20 knot increase of indicated speed to as much as 176 knots within 3 seconds, which might have been an indication of wind shear”.

This second go around initially commenced normally (TOGA thrust, gear up and flaps to 15°) but FDR data showed that at 1,900 feet, with the pitch attitude at 18°, the PF had "pushed on the control column" which had led to an increase in forward speed and, consequently, to the automatic retraction of the flaps from the initially selected go around setting of 15° to 10° as the airspeed exceeded 200 KCAS. A reduction in engine thrust within "3 seconds" resulted in a speed reduction back below 190 KCAS and the automatic re-extension of the flaps to 15° but TOGA thrust was then almost immediately restored and as the airspeed again exceeded 190 KCAS, the flaps auto-retracted to 10° where they remained until the impact. The PF returned the aircraft to almost the same rate of climb as before - up to 3,150 fpm - but at a height of 2,850 feet, and "there was a simultaneous control column nose down input and stabilizer nose down deflection from -2.5 deg (6.5 units) to +2.5 deg (1.5 units)". FDR data "recorded a nose down stabiliser input from the stabiliser trim switch on the control column lasting 12 seconds" and this trim input was paralleled on the CVR recording by the sound of the trim wheels located on either side of the central pedestal rapidly rotating. As a result of these actions, the aircraft, having reached a little over 3,000 feet, rapidly transitioned into a descent at -1g and thereafter there was no evidence of any crew attempt "to avoid an impact with the ground". Less than 2 minutes after beginning the second go around, the aircraft hit the intended landing runway about 120 metres past the landing threshold with a speed in excess of 320 KCAS and a 50° nose down pitch. An explosion and fire followed the impact totally destroying the aircraft and killing everyone on board. The recorded radar ground track of the aircraft is shown below.

The ground track of the first approach (green), awaiting the second approach (blue) and the second approach to impact(red). [Reproduced from the Official Report]

As the Investigation continues, five "Prompt Safety Recommendations" have been issued as follows:

  1. Inform the flight and maintenance personnel operating Boeing В737-800 aircraft about the accident.
  2. Have additional training on elements of go-arounds in various conditions, in manual control mode with two engines operative from various heights and at low aircraft weights.
  3. Study the possibility of introducing into the FFS training program scenarios which involve go arounds in various conditions, including under manual control with two engines operative from various commencement heights.
  4. Carefully study and analyse the implementation of Safety recommendations issued by investigation teams which investigated the 2013 Boeing 737-500 accident near Kazan Airport and the 2006 A320 accident near Sochi Airport.
  5. Carefully study the potential applicability of the Safety Recommendations to prevent accidents and incidents during go-around developed in the BEA Study on Aeroplane State Awareness during Go-Around (ASAGA) and take any applicable safety measures.


The Interim Report on which this summary is based was released on 20 April 2016.

An Update on the progress of the Investigation issued by the MAK on 20 August 2018 included the following text:

“The preparation of the draft Final Report is now being finalised.....however there remains an open investigative activity that is being pursued before the draft Final Report is completed. That activity relates to the Heads-Up Display (HUD) that is manufactured by Rockwell-Collins, USA which was installed as an optional item at the PIC’s work post and is an approved Supplemental Type Certificate addition to the cockpit instrumentation. This HUD unit is capable of using airplane data to provide visual data such as pitch and roll information to the pilot. An analysis of the Flight Data Recorder (FDR) data indicates that the unit was active during the accident flight.

An attempt to calculate the information displayed on the HUD during the accident flight from the FDR data was performed by Rockwell-Collins. Due to the complexity of reconstructing the HUD displayed information from the FDR data, the initial HUD readings were provided in February 2018. The information was presented on a limited basis constituting of separate snapshots at the specific time instances. As per the claim of the HUD manufacturer, the recovery of the HUD indications as a the stream video is a very challenging and time consuming process that will take considerable time to implement, and would be of a limited time duration.

The HUD visual indications that the PIC had available are potentially relevant to identifying the causes of the accident and possible safety enhancements that could be recommended for implementation. In this regard, the investigation team in collaboration with the participant states is now studying the specifications of the available simulators equipped with HUD in relation to the reproduction of the accident flight profile and HUD data. Subsequent to the respective assessment, the decision will be taken on the feasibility of a simulator experiment carry out to reproduce the HUD indications that would have been displayed during the accident flight.

The Investigation Team is fully committed and makes all efforts to the earliest possible completion of the activities and the Final Report publication.”

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