• editor@avoidingcatastrophe.com

Flydubai 981 - how CRM could have made the difference


The MAK's Final Report into the Flydubai crash at Rostov-on-Don offers a useful insight into how the effective application of CRM/NTS could have assisted during the final critical moments when control over the aircraft was lost and it entered a fatal nosedive, and quite possibly averted the disaster.




The Report is quite clear in its conclusion as to what went wrong. It states,


"Most probably, psychologically, the PIC had never got over the impossibility to perform landing at the destination aerodrome and accepted the need to divert to an alternate aerodrome. Particularly given that after the first go-around he had been sure in mind that he would have managed landing. The confidence in question at certain time kept haunting his mind and he spoke it out even in conversation with the cabin attendant.


As the result, probably, the PIC had been stuck in “a clinch” of two opposite goals (motives): to proceed approach for landing or initiate go-around. Even though the PIC, in compliance with SOP, took the immediate decision to perform go-around, “the clinch” resulted in the disruption of the previous flight mental mode (the approach with landing), whereas the new one (the go-around) had not been formed yet." (p. 157)


For a fuller discussion of how this assessment was reached, and how this state of affairs came into being, see our previous articles on the crash (here and here). Here we will simply take the MAK's statement at face value and proceed from there.


For reasons we have discussed earlier, and in line with the MAK's evaluation, on his second approach the PIC was fully absorbed by the task at hand. Initiation of a go around followed an over-speed on descent, and as the Report states, called for a shift in 'mental mode' in order to meet this new challenge. This the PIC proved unable to carry out.


Nevertheless, this need not have been fatal. Why not ? CRM, or put another way, the presence of the first officer. There is no reason why the F/O could not have stepped in at this point and taken over, having mentally prepared for such a contingency and in a good position to perform the climb out correctly and safely. The two pilots could have planned for such a turn of events, given the strong probability that a go around would be required, and in this way shared the elevated cognitive load between them. This is how CRM is designed to work.


If we follow this logic, then the key question becomes - what is needed for CRM to function as intended, for a pilot and first officer to be able to arrive at such a solution ? The short answer is - TRUST. Trust is one of the five dimensions in the HCD Team Processes Framework which is based both on classic CRM principles, and the US Navy's Tactical Decision Making Under Stress (TADMUS) research, as well as the literature on High Reliability Organisations (HROs).


In this case, the trust dimension manifested itself in the following ways

  • the PIC needed to have confidence in the F/O's ability to perform the go around

  • the F/O needed to have the confidence to raise with the PIC the latter's clearly degraded mental state following the first failed attempt at landing, so that they could find a way around this

  • the PIC needed a level of personal trust in the F/O to admit he was 'thrown' off balance by the earlier attempt and was not at his best

  • both pilots needed to be comfortable with discussing the reality that the F/O was better placed to conduct the go around, based on what had occurred the first time around

Russian Federation regulations stipulated that the PIC had to conduct the approach on landing, so there was no possibility of the F/O taking over this segment of the flight. The go around, on the other hand, could be conducted by either. The presence of two pilots meant that the 'resource' of a division of labour, and therefore of a sharing of the cognitive demands involved, WAS available. The guiding idea behind CRM is precisely to take advantage of such a resource and put it to the best possible use.


Building trust takes both time and effort. Unfortunately, as is common, the two pilots had never flown together before and did not know one another. They were of different nationalities for who English was a second language, which is also normal. This is simply the starting point most crews have to begin from. On the positive side, once in the air several hours existed during which to build a good rapport on the flight deck, to get acquainted with one another, to evaluate each other's strengths and weaknesses, temperament, mental state and so on (Mutual awareness, or 'how well we know one another' is the first dimension in the HCD TP Framework). In this case, there is strong evidence that the pilots DID take advantage of this opportunity. This was especially so during the holding period following the first go around, where they conducted a debrief over what had just taken place, talked through their options at length, and prepared contingency plans should a second landing attempt fail. All of this would have gone some way to build a level of trust between the two.


Unfortunately it was not enough to arrive at the solution suggested here. The Report does shed some light as to why this was how it went (p. 158), suggesting the F/O struggled with being assertive enough when interacting with his captain. This, however, is an all too common situation, CRM training and other efforts to shape cockpit culture are specifically aimed at addressing this problem, in other words it is an ORGANISATIONAL rather than a personal challenge. Any number of other PIC and F/O combinations, from this airline or any other, could well have ended up in the same position.


This allows us to recognise the reality of where we are at. CRM/NTS has much to offer, and can even make all the difference in avoiding catastrophe under the right circumstances, but it has to be worked at, it requires a conscious effort, above all at an organisational level.





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