Boeing 737-800 А6-FDN 19.03.2016

     The fatal accident involving Boeing 737-800 aircraft operated by FlyDubai Airline occurred at Rostov-on-Don Airport (RF) on March 19, 2016. According to the available information, 62 persons on board, 55 passengers and 7 crewmembers were killed.
      In compliance with ICAO Annex 13 and the Regulations on Civil Aircraft Accident and Incident investigation in the Russian Federation the Interstate Aviation Committee as international independent organization has appointed the investigation team, consisting of leading air accident investigators. The team has started the respective activity within accident investigation.
      In the nearest time, experts from the United Arab Emirates will join the investigation team being the representatives of the aircraft State of Registry and Operator and experts from the United States of America representing the aircraft State of Design and Manufacture and the French experts representing the engines State of Design and Manufacture.

On March 20, 2016, flight recorders from Boeing 737-800 A6-FDN aircraft (FlyDubai Airlines – United Arab Emirates) after an accident at Rostov-on-Don Airport occurred on March 19, 2016 were delivered to the Interstate Aviation Committee.

The flight recorders are significantly damaged.

Experts of the Interstate Aviation Committee jointly with the experts from the United Arab Emirates and France have started inspection, opening and extraction of the memory modules from the protected casing in order to continue work on recovery of the interface cables and preparation for the data downloading. The preparation activities are planned to be completed by the end of today.

The Interstate Aviation Committee (IAC) informs that the Investigation team proddeds its activities at the accident site. Today the examination of the fatal acident site is conducted, the wreckage layout mapping is constructed, the aircraft fragments recovery is almost completed. The IAC specialists jointly with UAE representatives analyse the radar surveillance data, the flight crew-ATC communications, and the weather information.

On March 21^st NTSB (USA) experts together with the Boeing experts will join the investigation.

The IAC Laboratory experts jointly with UAE and BEA (France) representatives have performed the preparation activities on the extraction of the memory modules from the Flight Data Recorder (FDR) crash-protected cases, as well as the data readout. The preliminary analysis shows that the recorder was operative, and flight data recording was conducted till the aircraft ground collision. The quality of recording is satisfactory. The experts started the recorded data decoding and analysis.

The Interstate Aviation Committee (IAC) informs that the Investigation team has completed their activities at the accident site and will start the preparation for the accident aircraft fragments layout in Rostov-on-Don.

Airline experts jointly with UAE investigators, and experts from Spain and Cyprus collect and analyze data related to the aircraft airworthiness, flight preparation and flight crew training.

The IAC Laboratory experts jointly with experts from UAE and France have completed activities on the Cockpit Voice Recorder (CVR) data downloading. All data from the CVR is download till the moment of the aircraft ground collision. The quality of data is satisfactory. The experts start data analysis and preparation of the transcript – an extraction of the flight crew speech.

The Investigation team jointly with the experts from the participated states continue work on addressing the possible scenarios of the accident involving Boeing 737-800 A6-FDN (FlyDubai) aircraft.

The meteorological conditions near Rostov Airport are analyzed, as well as Airport aids, ATC and AirMet service actions. ATC data from other aircraft that performed their flights in the same area are used during this analysis.

In the IAC Laboratory the work on the flight recorders and ground aids data is in progress.

With the use of onboard recorders data and all necessary flight and engineering documentation the aircraft systems operability is analyzed, including the aircraft and engines control systems. The flight crew state during the accident flight is also analysed.

The identification of recovered aircraft fragments and the layout is in progress.

The Interstate Aviation Committee (IAC) informs that the investigation team together with UAE and USA experts continues to work on the information collection and analysis. The accident aircraft fragments identification and layout activities are in progress.

According to the onboard recorders data analysis no failures of the aircraft systems or components, and power plant were identified. The aircraft had valid Airworthiness Certificate, received all necessary maintenance and was in normal state before the last departure.

The detailed analysis of all factors related to the aircraft operation is in progress. The investigation team is planning to conduct necessary examinations of the aircraft control system recovered components and elements. The Boeing Company received the request for providing the technical documentation necessary for the evaluation of the aircraft systems performance, and also the information requested related to the Boeing aircraft events with similar scenarios.

At IAC Laboratory activities on the data preparation for the mathematical model analysis and for the aircraft flight trajectory recovering supported by the audio and video reconstruction of the accident flight.

In the context of the media information with some links to the Cockpit Voice Recorder (CVR) data, the Interstate Aviation Committee states that in accordance with International and Russian air accident investigation policy the CVR data is considered as the non-public disclosure information. The IAC has not disclosed and has no intention to disclose this data. The work on the flight crew conversation transcript is in progress. Today we have more than 1 hour of flight crew conversations transcribed, including the final stage conversations. Experts from the UAE, RF, USA, and France are involved in this work in the IAC Laboratory.

The Interstate Aviation Committee is providing upgrade on the progress of the investigation of the accident involving Boeing 737-800 registered A6-FDN operated by FlyDubai.

The Investigation team has completed the two dimensional aircraft mockup and selected assemblies and units to be examined in order to check the longitudinal control system operability. The selected units have been delivered to the Interstate Aviation Committee, where their condition is assessed with examination capabilities. The organizations for conducting appropriate examinations as well as their scope and time frames are being determined.

During the on-site activities the reports on weather, wreckage, Air Traffic Control, avionics, powerplants, structures and systems were prepared and reviewed by investigation teams.

The weather information check revealed that the actual weather at Rostov-on-Don Airport at the time of the accident was consistent with the weather forecast. The weather measuring equipment used for weather observations at Rostov-on-Don Airport was calibrated, in normal state and functional. The meteorological information provided to FlyDubai Boeing 737-800 aicraft registration A6-FDN performing flight FDB981 Dubai - Rostov-on-Don - Dubai crashed during landing at Rostov-on-Don Airport was in compliance with the applicable regulations and manuals.

A preliminary flight data analysis has revealed that the crew was approaching to land manually (autopilot disconnected) in difficult weather conditions (cloud base 630 meters, wind 230 degrees 13 meters per second maximum 18 meters per second, light shower rain, mist, severe turbulence on straight-on and moderate windshear).

During initial approach at 22:42 UTC at a height of 340 meters, after getting a windshear (abrupt change in wind speed and direction) alert, the crew decided to go around and then continued on holding pattern waiting for improved weather conditions.

As the crew were proceeding with another manual approach, it decided to go around again at a height of 220 meters (4 km before the runway) and initiated climb setting the engine to takeoff thrust. At a height of 900 m there was a simultaneous control column nose down input and stabilizer 5-degree nose down deflection, resulting in abrupt descent with negative vertical acceleration of -1g. The following crew actions to recover did not allow to avoid an impact with the ground. The impact occurred with a speed of over 600 km/h over 50 degrees nose down.

Currently in IAC the work is in progress to recover the circumstances of the accident. Both Airlines pilots and test-pilots from the Russian Federation, USA and UAE have been engaged in the investigation to assess the status and actions of the crew. According to the available information, the involved pilots had valid pilot licenses and other necessary papers, had undergone required training and had sufficient flight practice.

Currently the transcript of two-hours cockpit voice recorder data is being completed. The Investigation team is planning to engage investigators from the UAE, USA and Spain for working the IAC laboratory to determine the content of the CVR transcript, translate it from English and Spanish and identify the speakers.

The Interstate Aviation Committee is providing upgraded information on the progress of accident investigation involving Boeing 737-800 aircraft registration A6-FDN operated by Flydubai.

An Interim statement (preliminary reference information) is released and available at the IAC website.

This Interim statement (preliminary reference information) has been issued in compliance with 2.4.12 of the Regulations on Civil Aircraft Accident and Incident investigation in the Russian Federation as well as 7.4 of ICAO Annex 13. The report contains actual information currently available to the Investigation team.

The investigation is in progress, including collection and analysis of information related to crew training, assessment of crew actions and psycho-emotional status during the accident flight as well as evaluation of the aircraft systems and components operability.

The investigation will be completed with a Final Report.

The information provided in the Interim statement is preliminary and can be specified and added based on the appropriate examinations.

The statement is published in the Russian and English languages. If there is a difference in interpretation between the Russian and English versions, the Russian version will prevail.

Прикрепленные документы:

Interim Report A6-FDN (en).pdf (1.15 MB)

Промежуточный отчет A6-FDN (ru).pdf (1.26 MB)

Interstate Aviation Committee (IAC) informs that the investigation of the accident involving Boeing 737-800 A6-FDN (Flydubai) aircraft is in progress.

On April 28 - May 12, 2016, at the IAC headquarters in collaboration with USA and UAE representatives the CVR records listening and transcription (02 hours 03 minutes 49 seconds in total) was completed. A crew voices identification was done with participation of Flydubai airline pilots. The CVR transcript was provided to the Investigation team.

During the meeting the Investigator-in-Charge and the Accredited Representatives provided information regarding the progress of work and determined further focus areas of the investigation.

In accordance with Standard 6.6 of Annex 13, Aircraft Accident and Incident Investigation, to the Convention on International Civil Aviation the Investigator-in-charge of the accident involving Boeing 737-800 A6-FDN aircraft operated by Flydubai Airlines occurred in Rostov-on-Don Airport on March 19, 2016 informs that the Investigation team has conducted respective activities in order to determine causes, circumstances and contributing factors to the accident and develop measures to prevent similar accidents in the future.

Urgent recommendations to prevent accidents were issued by the Investigation team in the Interim statement (preliminary reference) on the investigation progress on April 20, 2016.

In accordance to the ICAO standards the work is carried out in collaboration with accredited representatives of National Transportation Safety Board (NTSB) of the USA as the State of aircraft Design and Manufacture and also Accident Investigation Sector of UAE General Civil Aviation Authority as the State of aircraft Registry and Operator.

The Investigation team has collected all necessary actual information and is currently completing its detailed analysis with participation of experts of the involved States in order to develop a draft Final Report.

The Investigator-in-charge of the fatal accident involving Boeing 737-8KN A6-FDN aircraft operated by Flydubai airline occurred on March 19, 2016 at Rostov-on-Don Airport informs that the preparation of the draft Final Report is now being finalized.

The investigation is conducted in compliance with provisions of Annex 13 “Aircraft Accident and Incident Investigation” to the International Civil Aviation Organization. The accredited representatives of NTSB, USA - as the State of Design and State of Manufacture of the airplane and of AAIS, UAE - as the aircraft State of Registry and the State of the Operator participate in the investigation.

The Investigation team has carried out all the essential activities as follows: the field/on-site stage of the investigation, including the wreckage map patterning together with the full-size layout of the accident aircraft survived fragments; the read-out and analysis of the air traffic control data and flight recorders data; the mathematical simulation of the flight; the analysis of the air navigation and weather support of the flight; specific examinations of the aircraft pitch control components, inclusive of the elevator control system PCUs, the stabilizer jackscrew, the electric stab trim motor et al.; the analysis of the flight crew proficiency and training and the flight operations arrangement at the airline together with the data on the aircraft maintenance and other necessary investigation activities.

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 to its work and is making every effort to complete its activities and publish the final report as soon as possible. 

All areas of concern that are identified in the progress of the investigation, are promptly transferred to the knowledge of the concerned authorities/organizations.