The fatal crash of a flydubai Boeing 737-800 at Rostov-on-Don, Russia, in 2016 occurred because of incorrect aircraft configuration and crew piloting, according to the final report by Russia’s Interstate Aviation Committee (IAC).

The IAC report said that those errors led the loss of the captian’s loss of situational awareness in night-time instrument meteorological conditions.

The aircraft had flown from Dubai to Rostov. All 62 on board died when the aircraft dove into the ground in the early hours of March 19, 2016.

Weather conditions in the area at the time were poor, with what the IAC accident report described as “moderate-to-strong windshear” resulting in two go-arounds as the aircraft attempted to land.  

The report noted that neither the captain, who was flying the aircraft, nor the first officer had ever previously flown to Rostov-on-Don Airport.

Contributing factors to the accident probably included the captain not being in a go-around mindset, as he was focused on landing at the destination airport after the initial go-around amid possible concerns that the crew could run out of flight duty-time to perform the return flight to Dubai.

IAC cited “the crew’s uncoordinated actions during the second go-around: on the low-weight aircraft the crew was performing the standard go-around procedure (with the retraction of landing gear and flaps), but with the maximum available thrust, consistent with the windshear escape maneuver procedure that led to the generation of substantial excessive nose-up movement and significant ‘pushing’ forces on the control column to counteract it.”

The IAC cited the captain’s likely “total spatial disorientation that did not allow him to respond to the correct prompts of the first officer.”

Flydubai, in its response to the report, said that following safety recommendations in an interim report published the month after the crash and after its own internal review, the airline had initiated spatial disorientation training for all pilots and enhanced its go-around training.

Flydubai’s own internal review noted that the crew had held over Rostov-on-Don for two hours because of the weather reports and that after receiving an incomplete weather report from air traffic control without an active windshear warning, the crew made the decision to fly the second approach.

“It is possible that the captain and first officer were experiencing operational tiredness at the time of the second go-around, which was conducted under intense workload and in turbulent weather,” the airline said.

Alan Dron alandron@adepteditorial.com