- vor 1 Tag
On 19 March 2016, Flydubai Flight 981 enters a rapid descent and crashes nose-first at Rostov-on-Don Airport in Rostov-on-Don, Russia, after aborting its second landing attempt in poor weather conditions. All 55 passengers and 7 crew members on board are killed.
Kategorie
📚
LernenTranskript
00:00security footage of fly Dubai flight 981 captures its final moments I was diving hard the level of
00:19violence to the impact was catastrophic 62 people are killed in the fatal dive investigators soon
00:26discover the pilots had aborted two landings we're going around I'll go around is done just when
00:33conditions are not perfect did they say why they were going around the second time they just said
00:38going around check your speed the next thing I knew the plane was diving towards the runway
00:44investigators needed to find out how the two go-arounds were different one turns to disaster
00:50why
00:52fly Dubai flight 981 close
01:20is in on Rostov-on-Don International Airport in southwest Russia
01:24Rostov Tower sky Dubai 981 we're at 2600 feet 2300 feet is our next target altitude
01:3411 miles out captain Aristo Sokratus and first officer Alejandro Alva Cruz prepare the Boeing 737-800 for
01:45touchdown both pilots had a pretty good amount of flying hours in the 737 specifically these were
01:53experienced pilots like 981 Rostov tower wind 240 degrees gusts 30 knots you're cleared to land on
02:03runway 222 the controller reports the weather conditions at the airport thick clouds cover Rostov-on-Don high winds are battering the runways the weather in Rostov at that time was pretty low cloud with wind gusts it was typical for that time of year for Rostov if you look at the geography with the sea
02:33and expect some challenges fly Dubai flight 981 departed Dubai International Airport at 1037 p.m.
02:41it's a four-hour flight northwest to Rostov-on-Don it's a bumpy ride for the 55 passengers on board the flight is expected to land in minutes
02:55150 knots eight miles out the pilots reduce speed as they begin the final descent
03:04on approach pilots know exactly what the airplane is doing they know the conditions that they're flying in
03:11flaps 30 flaps 30 they're going to drop the flaps bit by bit when they drop their landing gear
03:18it's a very gradual process it should be a bit bumpy and then later should be calm the pilots expect
03:26turbulence on approach but anticipate a smooth landing the runway is just four miles away but there's a threat
03:36ahead the onboard radar has detected dangerous winds wind shear is a rapid change in direction and speed
03:51of wind if a pilot experience is a strong headwind that suddenly changes to a tailwind the aircraft
03:58might not have enough lift to remain airborne especially at low altitude the wind shear alert is
04:04built into the aircraft's avionics to tell you you're going into wind currents that it could be
04:10problematic just 1,000 feet above the ground landing at Rostov-on-Don becomes too risky
04:22Rostov Tower this is 9 or 8 1 we're conducting a go-around due to wind shear the pilots aboard their
04:29approach every pilot is prepared to make a go-around on every approach it's something that pilots do off the top of their heads there's no manual involved
04:43they have no limit the amount of approaches that they can try as long as they have enough fuel so why not go around and just try it again
04:48flight 9 or 8 1 copy flight 9 8 1 is one of four incoming flights controllers are managing as high winds delay landings
04:59aeroflot 1166 be advised sky by 9 or 8 1 reports wind shear on landing
05:06the air traffic controllers workload was definitely increased in this environment and they have to start juggling all those cards in the air
05:13as flight 9 8 1 climbs aeroflot 1166 you're clear to land on runway 22 an aeroflot flight prepares to land
05:29captain Sokratus pays close attention to its communications i want to see what this guy will do
05:36the crew at this point is hoping that the crews of other flights are able to give them some information
05:40that they might be able to use to make some decisions about what to do next
05:45that flight can't land at rostov-on-don either
05:55the aeroflot pilots also encounter wind shear on final approach they're forced to abort
06:02that kind of seals the deal fly to buy is going to have to either wait or they're going to have to go to
06:06an alternate airport high over rostov-on-don passengers on flight 981 are restless
06:16the pilots are holding at 15 000 feet circling near the airport waiting for a chance to land
06:24the pilots sit in a holding pattern since they had enough fuel to be able to do so
06:27to wait for weather conditions to improve three other planes are also in a holding pattern
06:32the storm-pounding rostov-on-don isn't passing
06:43hello flight 1166 we're down early
06:49guided by 9081 for your information previous truck going to alternate airports all the other flights
06:55decide to divert to alternate airports instead the problem with diverting is that it's expensive and
07:05it's it's inconvenient the passengers don't end up at the destination they have to be put up in hotels and
07:12with a low-cost airline it's the last thing it wants captain sokratus continues monitoring the weather
07:19radar finally he spots a clearing i think i'd like to give it a try i agree let's try it's not unusual for
07:28crews to take advantage if there happens to be a break in the weather pattern that provides safe
07:34conditions to land the aircraft sky nearby 9081 request to send for another approach
07:4115 000 feet over rostov-on-don the pilots again prepare to land
07:45sky Dubai 9081 rostov tower you're clear to land on runway 22
07:56good evening no first officer here we will be landing shortly once again we apologize for the delay
08:0313 miles from runway 22 the pilots line up for a second approach
08:08we advise low altitude headwind 53 knots light icing even though winds are strong controllers aren't
08:18reporting wind shear at the runway
08:24that's 30 flaps 30 but as they approach they soon realize something's not right check your speed
08:38okay go around the pilots execute another go around
08:54keep it at 15 degrees nose up just 2 000 feet in the air captain sokratus is wrestling with the boeing 737
09:00seconds later
09:14flight 981 is diving straight at the runway
09:23oh my god
09:30fire and emergency crews rush to the end of runway 22 the aircraft punched a crater in the runway about a
09:43meter and a half deep with wreckage wreckage thrown everywhere
09:51firefighters battle the flames through the night
09:54but there's no one to be rescued all 62 people on board flight 981 are killed in the crash
10:07grieving families and the world demand answers
10:16hours after fly dubai flight 981 crashes on the runway at rostov-on-don
10:21investigators from the iac the interstate aviation committee arrive on the scene
10:29the iac is the lead air accident investigation agency not just for russia but for several of the
10:36former soviet states the iac must find the cause for the horrific tragedy
10:42okay that's great uh that belongs over here wreckage from flight 981 is laid out in a nearby
10:54hangar for closer inspection a team from the united arab emirates assists in the investigation
10:59so how fast did the plane hit the ground
11:12the size of the debris would tell whether there's a high-speed impact whether there's a low-speed
11:17impact impact there are clues in pieces of wreckage there's not much left of it
11:27it was all small pieces it describes a very high-speed and violent impact with the ground
11:34it makes us question what really happened
11:42let's see it
11:46investigators wonder how the plane could have gathered so much speed during an attempted landing
11:51i was diving hard security footage gives them a look at the last moments of flight 981
12:04flight 981's angle of descent leads investigators to wonder if the pilots were having problems
12:10controlling their plane maybe is there flight controls
12:16i've seen it before boeing 737 flight controls have a problematic history
12:26march the third 1991 united airlines flight 585 banks hard right and crashes while attempting to land
12:35killing all on board three years later it happens again us air flight 427 rolls left and crashes near pittsburgh
12:47investigators were tearing the hair out trying to figure it out
12:51two years pass without incident then while on approach to land the pilots of eastwind airlines flight 517
12:58lose control this time the pilots regain control of their plane and land safely
13:05in richmond virginia
13:09the plane is intact investigators get their best lead yet
13:14after a five-year investigation the national transportation safety board concluded
13:20that a power unit in the rudder had been responsible for what's called a rudder hard over
13:27the rudder had moved to one side and that caused the aircraft
13:32to roll over and then dive into the ground movements of rudder and other control surfaces occur when pilots push
13:40their rudder pedal or pull the yoke power control units turn those commands into actual movements of the
13:47control surfaces it's similar to the power steering on a car
13:51hey there um did you recover the pcus investigators want to know if any of flight 981's control units failed
14:05yep they're here great we need to test them
14:08much of the boeing 737 was destroyed during high-speed impact but two of the power control units have
14:15survived they could provide crucial information pcus are the heart and soul of the flight controls of the
14:22airplane and one of the first questions if you have an airplane that came screaming out of the sky
14:26at a 50 degree angle is did we have a pcu problem in the flight controls
14:33investigators carefully examine the pcus of flight 981
14:37they look for signs of a malfunction
14:49nothing wrong with the pcus
14:50they were extensively examined and found to have had absolutely no connection to what brought this
14:58airplane out of the sky
14:59flight control issues ruled out the team turns to the controller for insight
15:06take me through what you saw they were on final approach
15:13flight 981 rostov tower you're clear to land on runway 22
15:17then they aborted their first attempt to land
15:25they reported windshear
15:28rostov tower this is
15:29981 we're conducting a go-around due to windshear
15:33sky dubai 981 make holding pattern at your convenience
15:38they climbed and began holding how long were they holding
15:42for a long time investigators learned that the pilots held for almost two hours waiting for the
15:49weather to improve
15:52sky dubai 981 request to send for another approach
15:56then they asked to land but something went wrong when the pilots made their second approach
16:02did they say why they were going around the second time no they just said going around that's all
16:16the next thing i knew the plane was diving towards the runway
16:25did they report any problems with the plane no nothing
16:29iac investigators still can't explain why flight 981 suddenly banked and then dived into runway 22
16:39something had gone wrong on the second go around but investigators didn't know what
16:43was there a problem with the airplane did the pilots make a mistake there's no knowing it yet
16:52okay two go-arounds one turns to disaster
16:56why let's take a look at the first one investigators turned to fdr data to better understand why fly
17:05dubai flight 981 performed one successful go around but crashed during the second investigators need
17:12to figure out how the two go-arounds were different from each other zoom in a bit
17:16look they confirmed the pilots reacted to a wind shear alarm during the first approach
17:30and how did they respond thrust jumps up to 102
17:33so he applied max power what about the flaps flaps at 30 and gear and remain down
17:50textbook wind shear go around yeah if a pilot encounters wind shear he'll typically perform a
18:05what's called a wind shear escape maneuver and that involves increasing the engine power to maximum you
18:10leave flaps down you leave the gear down wind shear ahead wind shear go around the first go around was
18:19pretty routine they responded appropriately they did exactly what they should have done
18:27this is the second go around investigators analyzed the second attempt at landing focusing in on the last
18:36moments before the crash now did they get another wind shear warning the second time no nothing
18:50look there's a leap in airspeed from 153 to 176 in seconds
18:5710 seconds before the pilots abort a sudden increase in the plane's airspeed was recorded
19:02investigators saw the airspeed fluctuating for more than 20 knots within a few seconds it's a pretty
19:10strong gust of wind and they can see that on the flight data recorder investigators determined that a
19:16strong gust of wind struck the plane you can feel the wind increase on the nose of the airplane it's
19:23probably also moving the airplane a little bit left or right it's it's not a pleasant position to be in
19:29how did the pilots respond this time let me see
19:36well they added max power okay go around
19:46and what about the flaps landing gear flaps are retracted gear retracted
19:56the data reveals that on the second go around the pilots performed a different procedure
20:05they didn't fly the wind shear escape maneuver during the second go around
20:09well it looks like they were doing a standard go around
20:13on a standard go around the flaps and landing gear are retracted
20:17except they did it at max power given how streamlined the aircraft is with the landing gear up and the
20:25flaps largely retracted the use of maximum power is is very much overkill investigators conclude that on
20:33the second attempt the crew flew a hybrid of two procedures
20:37they used the power of a wind shear escape maneuver with the gear and flap settings of a traditional go around
20:53so what would that do to the plane we'll need to take a look at all the factors at play
20:59they're holding on for nearly two hours that's
21:11four tons of fuel they burned the weight of the boeing 737 is a critical factor in the plane's performance
21:19adding the weight of the plane
21:20total weight that's 54 tons
21:30that's a light plane yeah
21:35at this weight you know the crew would feel a faster acceleration
21:44max power no drag from flaps or landing gear low weight
21:50this plane could have been accelerating dangerously fast
21:56this is really an accelerated situation this is a very powerful airplane doing something that
22:02feels like you just went into afterburner how much quicker did this plane pick up speed
22:07on the second go around
22:13we need to do modeling on this
22:14it was really incumbent upon the investigators to look further into the question of the acceleration
22:24investigators turn to computer modeling to answer a crucial question here's all the data for the
22:30first and second go around yeah how did the rate of acceleration differ at the start of the two attempts
22:37first go around
22:44speed increased by 17 knots and the second
22:57second go around
22:58second go around
23:0125 knot increase that's the difference of eight knots between the two go around
23:05yeah
23:05it was a key part of the findings when they realized that over 40 percent difference existed between the
23:12acceleration from the first go around to the second go around
23:16could the increase in acceleration have affected the pilots themselves
23:20they calculate the impact of the second go around
23:30wow look at the backward force experienced by the pilot
23:35that faster acceleration on the second go around would have pushed him back into the seat
23:39the team also examines the impact of vertical acceleration
23:50the chief force would have lifted the pilots upwards
23:54the pilot would have felt a slight unweighting he would come up out of the seat
23:59so sudden acceleration like this both horizontal and vertical
24:05the pilot would have pushed him back into the seat
24:10were captain socrates's senses his worst enemy
24:14maybe experience a somatographic illusion
24:20check your speed
24:24okay go around
24:25a somatographic illusion is a dangerous form of spatial disorientation
24:30when a plane accelerates quickly with no visual reference of the horizon
24:34the gravitational forces cause a pitch up illusion in the inner ear
24:40the little hairs in the inner ear bend backwards tricking the brain into thinking the head is tilting up
24:48you might be going level but if you cannot see outside that sensation
24:53on your vestibular system is overwhelming and you know you would really feel that you're climbing up
24:59the somatographic illusion is one of the most lethal traps in aviation
25:03keep the nose up 15 degrees it's an extremely convincing illusion
25:13what was the actual pitch of the plane after it accelerated during the second go around
25:19almost 20 seconds after the actual pitch was 8.8 degrees nose up
25:26investigators look for evidence that the pilots of flight 981 became severely disoriented in the dark
25:36if you imagine that this glass of water represents the fluid in your ear
25:41if you accelerated this along a smooth surface the water would be pushed up against the back of the glass
25:46very much like this in other words it's the same effect as if you'd simply tilted the glass
25:55if you take visual information away what tends to happen is that the pilot forgets about the
26:02acceleration and assumes that everything he's feeling is due to the pitch
26:06and what was the pilot's perceived pitch combining the horizontal and vertical acceleration experienced
26:16by the pilot we can calculate the pitch that is perceived by the pilot this is called the illusionary
26:23pitch pilot's perceived pitch was 21.6 degrees they compare the plane's actual pitch to the pilot's
26:32illusionary pitch during the second go around 10 seconds later the plane is pitched up 3.9 degrees
26:46and the pilot perceived it to be 26.7 degrees nose up
26:53wow that's a huge difference
27:08this puts the captain into a situation that he potentially will be experiencing a somatic gravity
27:13collusion the captain is feeling one thing but the aircraft is doing something else
27:18get this near the end of the flight the actual pitch is 7.6 degrees
27:29and the perceived pitch becomes well over 40.
27:35investigators discover three instances where there was a dramatic difference between the plane's actual
27:41and the pilot's perceived pitch keep it at 15 degrees nose up it's evidence that the pilots may
27:49have experienced a somatographic illusion during the second go around
27:54could the feeling of the rapid acceleration have affected how the pilots flew the plane
28:00they dig deeper into the flight data well the captain pushed forward on the yoke
28:05he was trying to pitch the plane downward that's what his senses were telling him to do
28:13the captain responding more to his feelings than to what he was seeing on any instrumentation in
28:17front of him he decides that he needs to push the airplane forward and counteract this massive
28:22pitch up he's trying to save them by pitching down wow check this out he pushed the stabilizer trim down
28:31from the data investigators see the captain didn't just push the yoke be careful
28:40captain applies the stabilizer trim because he's pushing trying to push the nose of the aircraft down
28:46okay for how long yeah he held the trim switch for 12 seconds holding the switch for 12 seconds is unheard of that should never be held for that amount of time
29:05the team discovers that instead of pitching the plane up to climb the captain is pitching the plane towards the ground
29:11no no no no no eventually putting the plane into a fatal dive
29:20the sudden change in direction is jarring at that time you would feel like you're on a roller coaster
29:26you know when you're coming up to the peak as you were diving at speed it's similar to that sensation
29:33the pitch down has another disorienting effect on the pilot's senses
29:37pitching down of the aircraft would have caused both the captain and the first officer to experience
29:43a dramatic change in the g-forces oh my god
29:48that would increase the confusion in the cockpit as to what's going on
29:54investigators conclude that the various g-forces on captain socrates caused his complete spatial
30:00disorientation the captain pushing and pulling on the yoke stomping on the rudder in the dive you know
30:07that shows confusion uh he's probably disorientated oh my god you know he's trying desperately to get out
30:15of that sensation that he's feeling but there's one question that still troubles investigators
30:22was the first officer feeling the illusion as well even though the accelerations experienced by both
30:29pilots was the same the perception of what is happening can differ and that can be due to many different
30:37factors expectation what are they looking at uh their age their experience uh started at the second go
30:45around please the cockpit voice recorder could tell investigators if the first officer was also
30:51under the influence of the somatographic illusion okay go around careful
31:04no no no no no no don't don't do that you see something wrong no pull it pull it pull it
31:15he's telling him to pull back the yoke if he's feeling the same illusion as the captain
31:22it sure doesn't seem like he was affected by it the first officer knew how much trouble the aircraft
31:28was in he knew the captain wasn't responding the way he should oh my god
31:38investigators are left wondering why the first officer didn't intervene
31:46you look at this first officer trying his best and wonder why didn't you just take control i say i've got
31:51the airplane
32:06it's been flying the 737 800 for nearly two years it's fully certified
32:11investigators look into the first officer's background to understand why he didn't take control
32:16of flight 981 when he saw that the captain was making grave mistakes look his trainer wrote notes
32:24on his assessment and this one's telling they find notes left by one of his flight instructors that
32:31alarm them one thing that could have possibly saved this aircraft was discovered in a note that was left
32:38behind by a flight instructor he needs to be a bit more assertive in what is needed from the captain
32:43and it continues tell him what you want done and do not wait for the captain to inquire with you or direct
32:51you in this regard
32:55he's not the type to take control
32:59no bullet bullet bullet bullet the first officer could see that the captain was experiencing enormous
33:08problems trying to control the go around he really should have taken some decisive action and intervened
33:13oh my god
33:20i still don't understand something why did they try to land the plane in the first place
33:26the big mystery was why was this crew so determined to land ever stop and on when every other flight had
33:32already diverted a storm was pummeling rostov-on-don airport as flight 981 circled above
33:38why didn't the pilots divert to another airport investigators look for answers in the cockpit voice recording
33:51guide by 9081 for your information previous traffic going to alternate airports
33:55until their flight's diverted there's no need i'm gonna keep flying
34:04investigators just couldn't understand why they wanted to fly in circles for almost two hours
34:09i'm gonna try this approach and if i can't make it i'll have a go around and i will head to minerale
34:17voody okay okay captain understood who's he talking to oh the dispatcher in dubai
34:22investigators finally get an indication of the captain's rationale for attempting another landing
34:29as the captain decides whether to divert he contacts fly dubai's flight dispatcher in the united arab emirates
34:35we would like to recommend you hold max as possible dispatchers manage the entire fleet's operation for a specific airline
34:46the dispatcher and the captain are co-equally responsible for the safety of the flight
34:50there is a very delicate dance that goes on between and among the dispatchers and the captains
34:57the captain follows with the dispatcher's recommendation
34:59minutes turn to hours as the pilots wait for a chance to land i don't know man if we divert we're
35:06gonna exceed our flying hours
35:12what are you looking at maximum duty hours he's calculating his duty hours regulations limit how
35:21many hours pilots can fly during a duty period in the air for five and a half hours now
35:28the team learns that the pilots were concerned they might exceed their duty hours stop roll the map
35:39they've been flying for at least five hours we'll take another hour to reach their alternate airport
35:45wait out the storm then they start to get back to rostov on dawn before returning to dubai
35:50diverting would put them over their duty hours for the day right
35:52i think it'll be clear by the time we do this approach now and even if we start now i think we'll
36:00be good we'll be good okay is he landing because it's clear or because he wants to get on the ground
36:11the conversation on the flight deck before the second approach clearly showed that they weren't really
36:16thinking so much about the safety of the landing just the fact that they wanted to land
36:22i think i'd like to give it a try i agree let's try stop the recording
36:30so they decide to circle for two hours after a four-hour flight in the middle of the night
36:36did the long flight affect the pilot's ability to land the plane safely two hours a whole six hours
36:48total time aren't we seeing a decline in the decision-making capabilities because of fatigue tired
36:54as investigators break down flight 981's journey from dubai to rostov-on-don they identify a glaring
37:07problem they were actually in the air for more than six hours it's almost 5 a.m their time when they're
37:14landing the circadian rhythm is the body's natural alignment with the day and night cycle the quiet
37:22period is roughly for a four-hour period between two in the morning and six in the morning
37:28that's the point at which your mental ability is pretty much at its lowest
37:35i think i'd like to give it a try i agree let's try
37:40investigators determined the crew was suffering from operational fatigue as they launched their second
37:46approach
37:46the decision to make a second attempt to land at rostov-on-don triggers a chain of events that ends
38:01in catastrophe
38:04check your speed as the aircraft is hit by this sudden wind the crew is forced into executing another go
38:11around okay go around and this time it was all going to go wrong captain sokratus executes a wind
38:18shear go around pushing the throttle to maximum power the first officer performs a standard go around
38:26retracting the flaps and raising the landing gear both pilots were essentially flying two different
38:32airplanes from there this blunder factors heavily into the catastrophe that followed
38:37flight 981 climbs from rostov-on-don at high speed when you lie on field and you put the maximum thrust you will accelerate
38:49it's what happened in the last few seconds that doomed flight 981
38:56keep it at 15 degrees nose up at this moment captain sokratus fights an inner battle
39:01the acceleration of the aircraft makes the captain feel as though the aircraft is pitching up a lot more
39:08than it actually is his spatial orientation deteriorates rapidly
39:15your vestibular senses in your middle ear are all telling you the wrong thing
39:20the captain counters the pitch up feeling of a somatographic illusion by pushing the yoke forward
39:25the captain has lost touch with the reality of what's happening to the airplane then the final blow
39:35the captain holds that stabilizer trim button down for about 12 seconds with the sudden forcing of the
39:42aircraft's nose down and stabilizer trim the aircraft transitions from a climb very suddenly
39:50into a dive the aircraft is now in a very dangerous situation which the captain is unable to overcome
40:00they're accelerating rapidly and the first officer finally gets on the yoke and tries to pull
40:07but the controls on the left side govern where the airplane is
40:12and you get to a certain point and there's no recovery nose diving at full throttle towards the runway
40:19captain sokratus is completely disoriented when he adds rudder at the last moment he's lost all
40:26awareness of how the plane is flying
40:36the pilots in this case were conducting the flight very well right up until those last few moments
40:42and then it all really just fell apart
40:51the iac investigation into the crash of flight 981 is a landmark case of how spatial disorientation
40:59can end in disaster this accident this wake-up call for the industries is one of the accidents that paved the
41:05way into increased training in specialist orientation in their final report investigators blame the captain's
41:15string of errors on his diminished psychological state the iac recommends that fly dubai provide better
41:22training on the manual operation of stabilizer trim so their pilots don't make the same mistake again
41:29research into human factors including situations like this where disorientation likely occurred
41:35is at the forefront of aviation safety research we are training our pilots on simulators
41:42to experience these illusions before they experience them in there so they can recognize those situations
41:47i think the fly goodbye accident shows how quickly uh your senses can overtake you
41:57and one of the key lessons is the pilots to trust in their instruments to take a step back
42:04from what they may think they're experiencing to actually understand what the airplane is doing
42:10you've got to keep the airplane flying