Original subtitles

security footage of fly dubai flight 981 captures its final moments i was diving

hard the level of violence to the impact was catastrophic 62 people are killed in

the fatal dive investigators soon discover the pilots had aborted two

landings

We're going around.

A go-around is done just when conditions are not perfect.

Did they say why they were going around a second time? They just said going

around. Check your speed.

The next thing I knew, the plane was diving towards the runway.

Investigators needed to find out how the two go-arounds were different.

One turns to disaster.

Why?

Fly Dubai, Flight 981 closes in on Rostov-on-Don International Airport in

southwest Russia.

Rostov Tower, Sky Dubai, 9081, we're at 2,600 feet.

2,300 feet is our next target altitude.

Eleven miles out, Captain Aristos Sokratos and First Officer Alejandro

Alva Cruz prepare the Boeing 737-800 for touchdown.

Both pilots had a pretty good amount of flying hours in the 737 specifically.

These were experienced pilots.

Flight 9081, Rostov Tower.

Wind 240 degrees, gusts 30 knots.

You're cleared to land on runway 22.

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 and the hills around it, then yes, you can expect some

challenges.

FlyDubai Flight 981 departed Dubai International Airport at 10.37pm.

It'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.

150 knots.

Eight miles out, the pilots reduce speed as they begin the final descent.

On approach.

Pilots know exactly what the airplane is doing. They know the conditions that

they're flying in.

Flaps 30.

Flaps 30.

They're going to drop the flaps bit by bit when they drop their landing gear.

It's a very gradual process.

It should be a bit bumpy, and then later it should be calm.

The pilots expect turbulence on approach, but anticipate a smooth

landing.

The runway is just four miles away.

But there's a threat ahead.

Go around.

Wind shear ahead.

The onboard radar has detected dangerous winds.

Wind shear ahead.

Wind shear ahead.

Wind shear is a rapid change in direction and speed of wind.

If a pilot experiences a strong headwind that suddenly changes to a tailwind, the

aircraft might not have enough lift to remain airborne, especially at low

altitude.

The wind shear alert is built into the aircraft's avionics to tell you you're

going into wind currents that could be problematic.

Wind shear ahead.

Wind shear go around.

Just 1,000 feet above the ground, landing at Rostov-on-Don becomes too

risky.

Rostov Tower, this is 9081.

We're conducting a go around due to wind shear.

The pilots abort their approach.

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.

They have no limit to 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?

Flight 981, copy.

Flight 981 is one of four incoming flights controllers are managing as high

winds delay landings.

Aeroflot 1166, be advised, Sky Dubai 981 reports wind shear on landing.

The air traffic controller's workload was definitely increased in this

environment and they have to start juggling all those cards in the air.

As flight 981 climbs.

Aeroflot 1166, you're cleared to land on runway 22.

An Aeroflot flight prepares to land.

Captain Sokratos pays close attention to its communications.

I want to see what this guy will do.

The crew at this point is hoping that the crews of other flights are able to

give them some information that they might be able to use to make some

decisions about what to do next.

That flight can't land at Rostov-on-Don either.

The Aeroflot pilots also encounter wind shear on final approach.

They're forced to abort.

That kind of seals the deal. Fly-to-binds are going to have to either

wait or they're going to have to go to an alternate airport.

High over Rostov-on-Don, passengers on flight 981 are restless.

The pilots are holding at 15,000 feet, circling near the airport, waiting for a

chance to land.

The pilots sit in a holding pattern since they had enough fuel to be able to

do so, to wait for weather conditions to improve.

Three other planes are also in a holding pattern.

The storm-pounding Rostov-on-Don isn't passing.

All the other flights decide to divert to alternate airports instead.

The problem with diverting is that it's expensive and it's inconvenient.

The passengers don't end up at the destination.

They have to be put up in hotels.

And with a low-cost airline, it's the last thing it wants.

Captain Sokratos continues monitoring the weather radar.

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 crews to take advantage if there happens to be a break

in the weather pattern that provides safe conditions to land the aircraft.

Skyton by 9081, request descent for another approach.

15,000 feet over Rostov-on-Don, the pilots again prepare to land.

Sky Dubai 9 or 8-1, Rostov Tower, you're cleared to land on runway 22.

Good evening, Air Force officer here.

We will be landing shortly.

Once again, we apologize for the delay.

13 miles from runway 22, the pilots line up for a second approach.

Headwind 53 knots, light icing.

Even though winds are strong, controllers aren't reporting wind shear

at the runway.

Flaps 30. Flaps 30.

But as they approach, they soon realize something's not right.

Check your speed.

Okay, go around.

The pilots execute another go around.

Keep it at 15 degrees, nose up.

Just 2,000 feet in the air, Captain Socrates is wrestling with the Boeing

737.

Seconds later

Flight

981 is diving straight at the runway Oh

my god

Fire and emergency crews rush to the end of runway 22.

The aircraft punched a crater in the runway about a metre and a half deep

with wreckage thrown everywhere.

Firefighters battle the flames through the night.

But there's no one to be rescued.

All 62 people on board flight 981 are killed in the crash.

Grieving families and the world demand answers.

Hours after FlyDubai Flight 981 crashes on the runway at Rostov-on-Don,

investigators from the IAC, the Interstate Aviation Committee, arrive on

the scene.

The IAC is the lead air accident investigation agency.

not just for russia but for several of the former soviet states the iac must

find the cause for the horrific tragedy okay that's great

uh that belongs over here wreckage from flight 981 is laid out

in a nearby hangar for closer inspection a team from the united arab emirates

assists in the investigation

So how fast did the plane hit the ground?

The size of the debris would tell whether there's a high-speed impact,

whether there's a low-speed impact.

There are clues in pieces of wreckage.

There's not much left of it.

It was all small pieces.

It describes a very high speed and violent impact with the ground.

It makes us question what really happened.

Let's see it.

Investigators wonder how the plane could have gathered so much speed during an

attempted landing.

I was diving hard.

Security footage gives them a look at the last moments of flight 981.

Flight 981's angle of descent leads investigators to wonder if the pilots

were having problems controlling their plane.

Maybe it's their flight controls?

No, I've seen it before.

Boeing 737 flight controls have a problematic history.

March the 3rd, 1991.

United Airlines Flight 585 banks hard right and crashes while attempting to

land, killing all on board.

Three years later, it happens again.

US Air Flight 427 rolls left and crashes near Pittsburgh.

Investigators were tearing their hair out trying to figure it out.

Two years pass without incident.

Then, while on approach to land, the pilots of East Wind Airlines Flight 517

lose control.

This time, the pilots regain control of their plane and land safely in Richmond,

Virginia.

The plane is intact.

Investigators get their best lead yet.

After a five-year investigation, the National Transportation Safety Board

concluded that a power unit in the rudder had been responsible for what's

called a rudder hardover. The rudder had moved to one side, and that caused the

aircraft to roll over and then dive into the ground.

Movements of rudder and other control surfaces occur when pilots push their

rudder pedal or pull the yoke.

Power control units turn those commands into actual movements of the control

surfaces.

It's similar to the power steering on a car.

Hey there.

Did you recover the PCUs?

Investigators want to know if any of Flight 981's control units failed.

Yep, they're here. Great. We need to test them.

Much of the Boeing 737 was destroyed during high-speed impact, but two of the

power control units have survived.

They could provide crucial information.

PCUs are the heart and soul of the flight controls of the airplane, and one

of the first questions if you have an airplane that came screaming out of the

sky at a 50-degree angle is, did we have a PCU problem in the flight controls?

Investigators carefully examine the PCUs of flight 981.

They look for signs of a malfunction.

Nothing wrong with the PCUs.

They were extensively examined and found to have had absolutely no connection to

what brought this airplane out of the sky.

With flight control issues ruled out, the team turns to the controller for

insight.

Take me through what you saw.

They were on final approach.

Flight 9081, Rostov Tower. You're cleared to land on runway 22.

Then they aborted their first attempt to land.

They reported wind shear.

Sky Dubai 9 or 8-1, make holding pattern at your convenience.

They climbed and began holding.

How long were they holding?

For a long time.

Investigators learned that the pilots held for almost two hours, waiting for

the weather to improve.

Sky Dubai 9 or 8-1, request descent for another approach.

Then they asked to land.

But something went wrong when the pilots made their second approach

Did

they say why they were going around the second time no, they just

said going around that's all The next thing I knew the plane was diving

towards the runway

Did they report any problems with the plane?

No. Nothing.

IAC investigators still can't explain why Flight 981 suddenly banked and then

dived into Runway 22.

Something had gone wrong on the second go-around, but investigators didn't know

what. Was there a problem with the airplane?

Did the pilots make a mistake?

There was no knowing it yet.

Okay.

Two go-arounds.

One turns to disaster.

Why? Let's take a look at the first one.

Investigators turn to FDR data to better understand why FlyDubaiFlight981

performed one successful go-around, but crashed during the second.

Investigators need to figure out how the two go-arounds were different from each

other.

Zoom in a bit.

Look.

They confirm the pilots reacted to a wind shear alarm during the first

approach.

And how did they respond?

Thrust jumps up to 102.

So he applied max power.

What about the flaps?

Flaps at 30.

And gear will remain down.

Textbook windshear go-around. Yeah.

If a pilot encounters windshear, he'll typically perform what's called a

windshear escape maneuver.

And that involves increasing the engine power to a maximum. You leave the flaps

down. You leave the gear down.

Windshear ahead.

Windshear go-around.

The first go-around was pretty routine.

They responded appropriately.

They did exactly what they should have done.

This is the second go-around.

Investigators analyze the second attempt at landing, focusing in on the last

moments before the crash.

Now, did they get another windshield warning the second time?

No, nothing.

Look, there's a leap in airspeed from 153 to 176 in seconds.

Ten seconds before the pilots aboard, a sudden increase in the plane's airspeed

was recorded.

Investigators saw the airspeed fluctuating for more than 20 knots

within a few seconds.

It's a pretty strong gust of wind, and they can see that on the flight note

recorder.

Investigators determined that a strong gust of wind struck the plane.

You can feel the wind increase on the nose of the airplane. It's probably also

moving the airplane a little bit left or right. It's not a pleasant position to

be in.

How did the pilots respond this time? Let me see.

Well, they added max power.

Okay, go around.

And what about the flaps and landing gear?

Flaps are retracted.

Gear retracted.

The data reveals that on the second go-around, the pilots performed a

different procedure.

They didn't fly the wind shear escape maneuver during the second go-around.

Well, it looks like they were doing a standard go-around.

On a standard go-around, the flaps and landing gear are retracted.

Except they did it at max power.

Given how streamlined the aircraft is with the landing gear up and the flaps

largely retracted, the use of maximum power is very much overkill.

Investigators conclude that on the second attempt, the crew flew a hybrid

of two procedures.

They used the power of a windshear escape maneuver with the gear and flap

settings of a traditional go-around.

So, what would that do to the plane?

We'll need to take a look at all the factors at play.

They were holding on for nearly two hours.

That's...

Four tons of fuel they burned.

The weight of the Boeing 737 is a critical factor in the plane's

performance.

Adding the weight of the plane.

Total weight, that's 54 tons.

That's a light plane.

Yeah.

At this weight, the crew would feel a faster acceleration.

Max power, no drag from flaps or landing gear, low weight.

This plane could have been accelerating dangerously fast.

This is really an accelerated situation.

This is a very powerful airplane doing something that feels like you just went

into afterburner.

How much quicker did this plane pick up speed on the second go around?

We need to do modeling on this.

It was really incumbent upon the investigators to look further into the

question of the acceleration.

Investigators turned to computer modeling to answer a crucial question.

Here's all the data for the first and second go-around.

How did the rate of acceleration differ at the start of the two attempts?

First go-around, speed increased by 17 knots.

And the second?

Second go-around, 25 knot increase.

That's a difference of 8 knots between the two go-arounds. Yeah.

It was a key part of the findings when they realized that over 40% difference

existed between the acceleration from the first go-around to the second go

-around.

Could the increase in acceleration have affected the pilots themselves?

They calculate the impact of the second go-around.

Wow.

Look at the backward force experienced by the pilot.

That faster acceleration on the second go-around would have pushed him back

into the seat.

The team also examines the impact of vertical acceleration.

The Jeep first would have lifted the pilots upwards.

The pilot would have felt a slight unweighting. He would come up out of the

seat. So, sudden acceleration like this, both...

Horizontal and vertical.

I'll play tricks on your mind.

Were Captain Socrates' senses his worst enemy?

Maybe he experienced a somatographic illusion.

Check your speed.

Okay, go around. A somatographic illusion is a dangerous form of spatial

disorientation.

When a plane accelerates quickly with no visual reference of the horizon, the

gravitational forces cause a pitch-up illusion in the inner ear.

The little hairs in the inner ear bend backwards, tricking the brain into

thinking the head is tilting up.

You might be going level, but if you cannot see outside, that sensation on

your vestibular system is overwhelming, and you would really feel that you're

climbing up.

The somatographic illusion is one of the most lethal traps in aviation.

Keep the nose up. 15 degrees.

It's an extremely convincing illusion.

What was the actual pitch of the plane after it accelerated during the second

go-around?

Almost 20 seconds after the actual pitch was 8.8 degrees

nose up.

Investigators look for evidence that the pilots of Flight 981 became severely

disoriented in the dark.

If you imagine that this glass of water represents the fluid in your ear, if you

accelerated this along a smooth surface, the water would be pushed up against the

back of the glass, very much like this.

In other words, it's the same effect as if you'd simply tilted the glass.

If you take visual information away, what tends to happen is that the pilot

forgets about the acceleration and assumes that everything he's feeling is

due to the pitch.

And what was the pilot's perceived pitch?

Combining the horizontal and vertical acceleration experienced by the pilot,

we can calculate the pitch that is perceived by the pilot.

This is called the illusionary pitch.

Pilot's perceived pitch was 21.6 degrees.

They compare the plane's actual pitch to the pilot's illusionary pitch during the

second go-around.

Ten seconds later, the plane is pitched up 3.9 degrees.

And the pilot perceived it to be...

26.7 degrees nose up.

Wow, that's a huge difference.

This puts the captain into a situation that he potentially will be experiencing

a somatographic illusion.

The captain is feeling one thing, but the aircraft is doing something else.

Get this near the end of the flight the actual pitch is 7.6 degrees

And the perceived pitch

becomes well over 40 Investigators discover three

instances where there was a dramatic difference between the planes actual and

the pilots perceived pitch

It's evidence that the pilots may have experienced a somatographic illusion

during the second go-around.

Could the feeling of the rapid acceleration have affected how the

pilots flew the plane?

They dig deeper into the flight data.

Well, the captain pushed forward on the yoke.

He was trying to pitch the plane downward.

That's what his senses were telling him to do.

The captain, responding more to his feelings than to what he was seeing on

any instrumentation in front of him, he decides that he needs to push the

airplane forward and counteract this massive pitch-up. He's trying to save

them by pitching down.

Wow. Check this out.

He pushed the stabilizer trim down.

From the data, investigators see the captain didn't just push the yoke. Be

careful!

Captain applies the stabilizer trim because he's pushing, trying to push the

nose of the aircraft down.

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.

The team discovers that instead of pitching the plane up to climb, the

captain is pitching the plane towards the ground.

Eventually putting the plane into a fatal dive.

The sudden change in direction is jarring.

At that time you would feel like you're on a roller coaster.

You know, when you're coming up to the peak as you're diving at speed, it's

similar to that sensation.

The pitch down has another disorienting effect on the pilot senses Pitching down

of the aircraft would have caused both the captain and the first officer to

experience a dramatic change in the g-force That would increase the

confusion in the cockpit as to what's going on

Investigators conclude that the various G-forces on Captain Sokratos caused his

complete spatial disorientation.

The captain pushing and pulling on the yoke, stomping on the rudder. In the

dive, you know, that shows confusion.

He's probably disorientated.

Oh, my God!

You know, he's trying desperately to get out of that sensation that he's feeling.

But there's one question that still troubles investigators.

Was the first officer feeling the illusion as well?

Even though the accelerations experienced by both pilots was the same,

the perception of what is happening can differ, and that can be due to many

different factors, expectation, what are they looking at, their age, their

experience.

Start it at the second go-around, please.

The cockpit voice recorder could tell investigators if the first officer was

also under the influence of the somatographic illusion.

Okay, go around.

Careful.

No, no, no, no, no, no.

Don't. Don't do that.

You see something wrong.

No. Pull it. Pull it, pull it.

He's telling him to pull back the yoke. If he's feeling the same illusion as the

captain, it sure doesn't seem like he was affected by it.

The first officer knew how much trouble the aircraft was in. He knew the captain

wasn't responding the way he should.

Oh, my God!

Investigators are left wondering why the first officer didn't intervene.

You look at this first officer trying his best and wonder, why didn't you just

take control? I say, I've got the airplane.

It's been flying the 737-800 for nearly two years. It's fully certified.

Investigators look into the first officer's background to understand why

he didn't take control of flight 981 when he saw that the captain was making

grave mistakes.

Look, his trainer wrote notes on his assessment, and this one's telling.

They find notes left by one of his flight instructors that alarm them.

One thing that could have possibly saved this aircraft was discovered in a note

that was left behind by a flight instructor.

He needs to be a bit more assertive in what is needed from the captain and it

continues Tell him what you want done and do not wait for the captain to

inquire with you or direct you in this regard He's not the

type to take control The

first officer could see that the captain was experiencing

enormous problems trying to control the go-around.

He really should have taken some decisive action and intervened. Oh, my

God!

I still don't understand something.

Why did they try to land the plane in the first place?

The big mystery was, why was this crew so determined to land at Rostov-on-Don

when every other flight had already diverted?

A storm was pummeling Rostov-on-Don Airport as flight 981 circled above.

Why didn't the pilots divert to another airport?

Investigators look for answers in the cockpit voice recording.

Guided by 981, for your information, previous traffic going to alternate

airports.

Two other flights diverted?

There's no need.

I'm going to keep flying.

Investigators just couldn't understand why they wanted to fly in circles for

almost two hours.

I'm going to try this approach, and if I can't make it, I'll have a go around,

and I will head to Minerali Voiti, okay?

Okay, Captain. Understood.

Who's he talking to? The dispatcher in Dubai.

Investigators finally get an indication of the captain's rationale for

attempting another landing.

As the captain decides whether to divert, he contacts FlyDubai's flight

dispatcher in the United Arab Emirates.

We would like to recommend you hold max as possible.

Dispatchers manage the entire fleet's operation for a specific airline.

The dispatcher and the captain are co-equally responsible for the safety of

the flight. There is a very delicate dance that goes on between and among the

dispatchers and the captains.

The captain follows with the dispatcher's recommendation.

Minutes turn to hours as the pilots wait for a chance to land.

I don't know, man. If we divert, we're going to exceed our flying hours.

What are you looking at?

Maximum duty hours.

He's calculating his duty hours.

Regulations limit how many hours pilots can fly during a duty period.

I've been in the air for five and a half hours now.

The team learns that the pilots were concerned they might exceed their duty

hours.

Stop.

Roll the map.

They've been flying for at least five hours.

It will take another hour to reach their alternate airport, wait out the storm.

Then they still have to get back to Rostov-on-Don before returning to Dubai.

Diverting would put them over their duty hours for the day. Right.

I think it'll be clear by the time we do this approach now.

And even if we start now, I think we'll be good.

We'll be good.

Okay.

Is he landing because it's clear or because he wants to get on the ground?

The conversation on the flight deck before the second approach clearly

showed that they weren't really thinking so much about the safety of the landing,

just the fact that they wanted to land.

I think I'd like to give it a try.

I agree. Let's try.

Stop the recording.

So they decide to circle for two hours after a four-hour flight in the middle

of the night.

Did the long flight affect the pilot's ability to land the plane safely?

Two hours a whole, six hours total time. Aren't we seeing a decline in the

decision-making capabilities because of fatigue?

No.

As investigators break down Flight 981's journey from Dubai to Rostov-on-Don,

they identify a glaring problem.

They were actually in the air for more than six hours.

It's almost 5 a.m. their time when they're landing.

The circadian rhythm is the body's natural alignment with the day and night

cycle. The quiet period is roughly for a four-hour period between two in the

morning and six in the morning.

That's the point at which your mental ability is pretty much at its lowest.

I think I'd like to give it a try.

I agree. Let's try.

Investigators determined the crew was suffering from operational fatigue as

they launched their second approach.

The decision

to make a second attempt to land at Rostov-on-Don triggers a chain of events

that ends in catastrophe.

As the aircraft is hit by this sudden wind, the crew is forced into executing

another go-around.

Okay, go around.

And this time, it was all going to go wrong.

Captain Sokratis executes a windshear go-around, pushing the throttle to

maximum power.

The first officer performs a standard go-around, retracting the flaps and

raising the landing gear.

Both pilots were essentially flying two different airplanes from there.

This blunder factors heavily into the catastrophe that followed.

Flight 981 climbs from Rostov-on-Don at high speed.

When you're light on field and you put the maximum thrust, you will accelerate.

It's what happened in the last few seconds that doomed flight 981.

Keep it at 15 degrees, nose up.

At this moment, Captain Sokratos fights an inner battle.

The acceleration of the aircraft makes the captain feel as though the aircraft

is pitching up a lot more than it actually is.

His spatial orientation deteriorates rapidly.

Your vestibular senses and your middle ear are all telling you the wrong thing.

The captain counters the pitch-up feeling of a somatographic illusion by

pushing the yoke forward.

The captain has lost touch with the reality of what's happening to the

airplane. Then the final blow.

The captain holds that stabilizer trim button down for about 12 seconds.

With the sudden forcing of the aircraft's nose down and stabilizer

trim, the aircraft transitions from a climb very suddenly into a dive.

The aircraft is now in a very dangerous situation, which the captain is unable

to overcome.

They're accelerating rapidly, and the first officer finally gets on the yoke

and tries to pull, but the controls on the left side govern where the airplane

is.

And you get to a certain point.

And there's no recovery.

Nosediving at full throttle towards the runway, Captain Sokratos is completely

disoriented. When he adds rudder at the last moment, he's lost all awareness of

how the plane is flying.

The pilots in this case were conducting the

flight very well, right up until those last few moments.

And then it all really just fell apart.

The IAC investigation into the crash of Flight 981 is a landmark case of how

spatial disorientation can end in disaster.

This accident is a wake-up call for the industry. This is one of the accidents

that paved the way into increased training in spatial disorientation.

In their final report, investigators blame the captain's string of errors on

his diminished psychological state.

The IAC recommends that FlyDubai provide better training on the manual operation

of stabilizer trim, so their pilots don't make the same mistake again.

Research into human factors, including situations like this where

disorientation likely occurred, is at the forefront of aviation safety

research.

We are training our pilots on simulators to experience these illusions before

they experience them in there so they can recognize those situations.

I think the fly-by-by accident shows how quickly your senses can overtake you.

And one of the key lessons is for pilots to trust in their instruments, to take a

step back from what they may think they're experiencing.

to actually understand what the aeroplane is doing you've got to keep

the aeroplane flying.