Boeing 737-800 А6-FDN 19.03.2016

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

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

The flight recorders are significantly damaged.

The Interstate Aviation Committee experts jointly with the experts from the United Arab Emiratesand 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 keeps working at the accident site. Today the examination of the site of the aircraft air collision is conducted, the wreckage map is constructed, the aircraft fragments' recovering is almost completed. The IAC specialists together with UAE representatives analyze 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 together 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 operational in flight, and was recording the flight data 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 the works at the accident site and will start the preparation for the accident aircraft fragments layout in Rostov-on-Don.

Together with the airline experts, UAE investigators, and with participation of experts from Spain and Cyprus, the collection and analysis of the information related to the aircraft airworthiness, flight preparation and flight crew training is conducted.

The IAC Laboratory experts together with experts from UAE and France have completed the works 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 the data analysis and the preparation of the transcript – an extraction of the flight crew speech.

The Air Accident Investigation Commission jointly with the experts from the participated States continue work on addressing the possible scenarios of Boeing 737-800 A6-FDN (FlyDubai) aircraft accident.

The meteorological conditions near Rostov aerodrome are analyzed, as well as aerodrome aids, ATC and AirMet service actions. ATC data from other aircrafts that conducted their flight in the same area are used during this analysis.

In the IAC Laboratory, the work on the flight recorders' and ground aids' data is continued.

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

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 on at Rostov Civil Aviation Factory N412 facilities.

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 going on. 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 a Boeing 737-800 registered A6-FDN operated by FlyDubai.

The investigative 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, wherein their condition is assessed along with examination capabilities. The organizations to conduct pertinent examinations as well as their scope and terms are being determined.

During the on-site operations reports of the Weather, Wreckage, Air Traffic Control, Avionics, Powerplants, Structures and Systems investigative groups were prepared and reviewed.

The weather information examination has 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, operable and functional. The weather information service provided to the FlyDubai Boeing 737-800 registered A6-FDN conducting Flight FDB981 Dubai - Rostov-on-Don - Dubai that crashed while 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).

In the course of the 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, they 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 works are underway at the IAC facilities to reproduce the circumstances of the accident. Both airline pilots and test-pilots from the Russian Federation, the USA and the UAE have been engaged in the investigation to assess the status and actions of the crew. According to the available information the involved pilots were holding valid pilot licenses and other pertinent papers, had undergone required training and had sufficient flight experience.

Right now the transcript of two hours of cockpit voice recorder data is being completed. The investigative team is planning to engage investigators from the UAE, the USA and Spain to proceed at the IAC laboratory with clarifying the content of the CVR transcript, translating it from English and Spanish and identifying the speakers.

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

An interim report (preliminary reference information) is released and available at the IAC website.

This interim report (preliminary reference information) has been issued in compliance with 2.4.12 of the Rules of Investigation of Accident and Incidents Involving Civil Aircraft in the Russian Federation as well as 7.4 of ICAO Annex 13. The report contains factual information currently available to the investigation team.

The investigation is underway, including collection and analysis of information related to crew training, assessment of crew actions and psycho-emotional status in the course of 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 presented in the Interim Report is preliminary and can be subject to clarification and amendment based on the pertinent examinations.

The Report 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)

The Interstate Aviation Committee (IAC) informs that the Investigation team continues Boeing 737-800 A6-FDN (Flydubai) accident investigation.

Between April 28 and May 12, 2016 in 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 the 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 for the accident involving Boeing 737-800 A6-FDN aircraft operated by Flydubai Airlines that 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 report (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 factual 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 to the Flydubai airline Boeing 737-8KN A6-FDN aircraft that occurred on 19.03.2016 at the 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 and makes all efforts to the earliest possible completion of the activities and the Final Report publication.   

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