Flydubai B738 at Dubai on Dec 11th 2019, serious upset during go around

Last Update: February 24, 2020 / 15:48:02 GMT/Zulu time

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Incident Facts

Date of incident
Dec 11, 2019

Classification
Incident

Airline
Flydubai

Flight number
FZ-1736

Departure
Almaty, Kazakhstan

Destination
Dubai, United Arab Emirates

Aircraft Registration
A6-FEX

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport
Dubai International Airport, Dubai

Airport ICAO Code
OMDB

A Flydubai Boeing 737-800, registration A6-FEX performing flight FZ-1736 from Almaty (Kazakhstan) to Dubai (United Arab Emirates), was on final approach to Dubai's runway 30L when the crew initiated a go around due to weather and runway conditions. The aircraft joined a left downwind turning onto the downwind well ahead of the runway threshold, positioned for another approach and was on final approach to runway 30L again, when the crew needed to go around a second time well ahead of the runway threshold. This time ATC issued an instruction to turn right, the crew accepted the turn while about overhead Mirdif (United Arab Emirates) about 3nm short of runway 30L threshold and began to turn, the aircraft however entered a steep descent at about 4000 fpm instead of a climb, which was recovered at about 1300 feet MSL, the aircraft was pulled up and now climbed at about 9500 fpm, overshot the cleared altitude of 4000 feet MSL and descended back levelling off at 4000 feet, entered a hold and subsequently positioned for another approach this time to runway 12L and landed safely about 50 minutes after the first go around.

Sources claimed the incident crew had been deadheading in economy class on the flight to Almaty with another crew flying that sector for about 4.5 hours, then took over the aircraft without having had some rest during the flight to Almaty, then operated the flight back to Dubai. As result of the incident the night deadheading was stopped, crews are now taking layovers in such destinations. According to insiders the occurrence is compared to the crash of another Flydubai B738 in Rostov, see Crash: Flydubai B738 at Rostov on Don on Mar 19th 2016, lost height on go around after stabilizer moved nose down following holding for 2 hours.

Flydubai confirmed the occurrence sending following statement to The Aviation Herald: "There was an incident on 11 December 2019 involving flydubai flight FZ 1736 from Almaty to Dubai. Following a second missed approach an upset condition occurred which was corrected by our flight crew. The aircraft made a third approach and landed safely. A full investigation is being undertaken and is led by our regulator, the General Civil Aviation Authority (GCAA). As part of our transparent reporting environment we made our crews aware of the incident through an Aircrew Notification (ACN) issued in December 2019. We will investigate this incident to conclusion and we will implement any and all recommendations. We will continue to communicate to our crews with any further findings and share any learnings for the enhancement of safety in the industry."

On Feb 18th 2020 United Arab Emirates GCAA released a safety alert stating:

The GCAA would like to bring to the attention of the industry the lessons learned rising from a recent incident. “During the second missed approach, immediately after selecting TOGA at 1900 feet, the aircraft entered into a descent of 9 degrees nose down with a right bank reaching a maximum descent rate of 4000 fpm. According to the FDR reading, the descent was arrested by 1300 feet AGL. The aircraft subsequently entered into a climb of approximatively 30 degrees nose up recording 9500 fpm climb rate. It then levelled off at the assigned altitude after breaching by 400 feet.” The event occurred at the final destination airport where severe weather conditions were reported.

The preliminary investigation disclosed several findings as probable causes/factors that degraded the crew performance. These probable causes/factors, not in the order of priority, are:

a) inadequate workload management.

b) ATC instructions during a critical flight stage.

c) multiple night flight sectors involving operation during the night Window of Circadian Low (WOCL).

d) night standby duty combined with inappropriate in-flight crew rest facility and environment.

This Safety Alert is issued to:

a) draw the attention of UAE Operators towards some of the probable causes/factors involving crew reduced performance;

b) alert operators regarding the possibility of the occurrence of similar incidents involving long duty periods inclusive of night operations, weather conditions and maneuvers.

The GCAA released following recommendations:

a) UAE operators should review their current system to ensure that crewmembers’ performance is not impaired by fatigue.

b) during the review, verify their compliance with CAR-OPS 1 Subpart Q provisions and in particular , verify that:

1) their Flight Time Limitation scheme including any Variation (if granted) can prevent or avoid degraded flight crew performance due to fatigue;

2) the established maximum FDP and minimum rest periods are based on the nature of operations undertaken. The limits should be measurable and can be evaluated;

3) crewmembers are appropriately rested and free from fatigue so that they can operate efficiently and safely during normal and abnormal situations; and

4) they are proactively considering fatigue as a hazard in all safety activities conducted within their system.

c) UAE operators should, when deciding the rest periods and rest conditions, correlate all available information to address any emerging risk posed by fatigue such as the frequency and pattern of scheduled FDPs, rest periods, time off, and accumulated effects of long working hours interspersed with minimum rest, rest facilities and environment and complexity of physical or mental work to be conducted.

d) UAE operators should also acknowledge that, despite their commitment and actions for reduction of fatigue in their operational safety environment, fatigue will remain a permanent hazard to safety. Consequently, UAE operators should:

1) develop clear operational policies to assist the flight crew on decision making when inflight taking into account risks such as fatigue, weather conditions, technical issues, aircraft capabilities, ATC environment, etc.

2) enable and promote reporting of fatigue and safety promotion activities to provide crew with means to understand and manage their own fatigue; and

3) encourage their crew to maximize the use of automation in-flight to reduce their exposure to increased physical or mental work where and when appropriate. When deciding to increase use of automation, a Management of Change process should be initiated to address potential induced hazards.

Metars:
OMDB 110700Z 16006KT 130V190 9999 FEW045 22/20 Q1015 NOSIG=
OMDB 110600Z 12007G17KT 020V160 7000 -RA FEW015 20/19 Q1016 WS ALL RWY TEMPO VRB15G25KT=
OMDB 110500Z VRB03KT 4500 -RA SCT008 BKN035 20/19 Q1016 RESHRA WS ALL RWY TEMPO VRB15G25KT=
OMDB 110414Z 07011G21KT 030V090 3000 RA SCT010 BKN035 20/19 Q1015 RESHRA WS ALL RWY TEMPO VRB20G40KT 1500 TSRA SCT030CB=
OMDB 110400Z 35014G27KT 280V080 2000 SHRA SCT010 SCT030 20/19 Q1016 WS ALL RWY TEMPO VRB20G40KT 1500 TSRA SCT030CB=
OMDB 110349Z 35015KT 320V040 7000 SCT010 SCT030 21/18 Q1016 WS ALL RWY TEMPO VRB20G40KT 1500 TSRA SCT030CB=
OMDB 110300Z 05016KT 9999 -RA SCT009 21/19 Q1014 WS ALL RWY TEMPO 36020KT 3000 SHRA FEW040TCU=
OMDB 110200Z 02011KT 350V080 9999 -RA FEW013 21/19 Q1014 NOSIG=
OMDB 110100Z 05010KT 030V090 9999 -RA FEW027 22/19 Q1013 NOSIG=
OMDB 110000Z 03014KT 340V040 9999 -RA SCT026 23/19 Q1013 NOSIG=