These are the safety recommendations made by the final report into the fatal accident of FlyDubai flight 981.
It is recommended that FATA
1. Inform the flight personnel, the air training centers staff and the ATC officers on the results of the investigation in question at the subject-oriented debriefing meetings.
2. Consider the possibility of expediting of the Russian Federation transition to the flight operations on QNH.
3. Draw the attention of organizations, engaged in the aviation personnel testing for their compliance with the ICAO Language Proficiency Requirements, to the need for enhanced monitoring of the raters-examiners’ activities, as well as further develop the measures to exclude the assignment of the ICAO language proficiency level to persons, whose level in question does not meet the subject requirements.
4. Draw the attention of the air navigation service providers to the need for enhanced monitoring and responsibility of the instructor personnel, engaged in the officers’ simulator training, inter alia of the adherence to the R/T rules in English.
5. In association with Roshydromet and the State ATM Corporation, FSUE organize training with the ATC and meteorological services officers on the procedure of the information communication on windshear to the flight crews.
6. In view of the position of the aircraft manufacturer that the Boeing 737-800 operational documentation implies the presence of the pilots’ previous experience of operating the jet multi-engine aircraft, familiarization with the basic systems and basic airmanship, assess the risks of the pilots’ approval for the type in case it is the first jet multi-engine airplane in the pilot’s career. If required, amend the current regulations. Assess the applicability of this safety recommendation as for the other aircraft types.
It is recommended that the Flydubai airline
7. Conduct the flight personnel training on the specific aspects of the stabilizer trim manual operation (the forces trim).
8. Consider the practicability of the HUD Model 4000 changing to Model 6000 (STC ST02522SE) to equip both pilots’ duty stations.
9. In association with the aircraft and HGS manufacturers, consider the practicability of the development of the additional instructional guidelines on the HUD use at the different stages of flight.
10. Consider the practicability of the elaboration of the flight personnel training programs, allowing for the incorporation of the practical familiarization (training) of the pilots with the upset conditions, including zero and negative G state.
11. Consider the practicability to amend the airline OM with the criteria of the psychological incapacitation and the respective recommended actions.
12. Consider the practicability of the elaboration of SOP in terms of specifying the type of the next maneuver (for example Go-Around, Windshear Escape Maneuver) as far as the callout by the PF is concerned.
13. Consider the practicability to elaborate SOP in terms of monitoring of the trim duration and the current stabilizer position.
14. Evaluate the possible risks, associated with the partial blocking of the PFD at the significant forward deflection of the control column and take measures on the risks mitigation (if required).
It is recommended that FAA, Rockwell-Collins
15. Consider the practicability of the conduct of the additional flight tests of HGS into all the anticipated operating conditions and the entire range of G of the aircraft with these systems installed.
16. Taking into account the views of the experts in ergonomics and aviation psychology, consider the practicability of the improvement of the HUD information presentation in order to mitigate the risk of its erroneous interpretation.
17. In association with the designers and manufacturers of the aircraft, equipped with the HGS, consider the practicability of development of the additional guidance on the use of HUD at different stages of flight.
It is recommended that FAA, the other certification authorities (EASA, IAC Aviation Register, FATA etc.)
18. Consider the practicability of the amendment of the aviation regulations with the provisions on the mandatory flight assessment of the flight parameters indication systems to pilots into the entire operating range of the aircraft with such systems installed.
19. Consider the practicability of the amendment of the aviation regulations that determine the procedure of the STC issue for the indication systems to pilots, with the requirement to the manufacturer of the equipment in question to have the hardware/software package available to reproduce the indication as per the FDR data in real time and in the scope, sufficient for the investigation of the aircraft accidents and incidents.
It is recommended that the Boeing Company
20. Consider the practicability of the amendment of the FCT 737 NG (ТМ) Low Altitude Level Off – Low Gross Weight section with more detailed information on the criteria that the pilots should follow to determine the point, when the maximum thrust should be reduced, including go-around performance in windshear.
21. Consider the practicability to implement the design changes of the stabilizer control system to reduce the risk for the pilot to set stabilizer in-flight into out of trim position.
22. Consider the practicability of the elaboration of SOP in terms of specifying the type of the Go-Around maneuver (for example Go-Around, Windshear Escape Maneuver) as far as the callout by the PF is concerned.
23. In association with FAA assess the possible risks, arising due to the partial blockage of PFD at considerable forward deflection of the control column and take measures on their mitigation (if necessary).
24. Taking into consideration the information, stated in Section 1.18.2, consider the practicability of introduction of additions and amendments to FCOM and/or FCTM, explaining the stabilizer control sequence on the Boeing 737 aircraft under different conditions. Consider the applicability of this safety recommendation for the other aircraft families.
25. Consider the practicability of the introduction of additions and amendments to FCOM and/or FCTM, explaining general principles of the stabilizer use and forces trim, as well as the monitoring of the current stabilizer setting.
It is recommended that ICAO
26. Consider the practicability of establishing a working group to study the issues of the psychological incapacitation of the flight crewmembers and elaboration of the relevant recommendations to provide guidance to the operators and States in the OM draw up and approval.
For the full final report, click HERE