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1
00:00:00,965 --> 00:00:03,843
(automation): Pull up.
- Go around, Captain! Go around!
2
00:00:03,843 --> 00:00:05,970
(narrator):
With the runway in sight,
3
00:00:05,970 --> 00:00:09,723
a passenger jet smashes down
at catastrophic speed.
4
00:00:10,808 --> 00:00:13,310
- Why did the crew go off
the end of the runway?
5
00:00:13,310 --> 00:00:15,813
Was there a problem
with the airplane?
6
00:00:16,230 --> 00:00:17,648
- Hang on to the sonofabitch!
7
00:00:17,648 --> 00:00:20,526
(narrator): A Delta flight crew
battle a deadly storm
8
00:00:20,526 --> 00:00:22,778
during their final approach
in Dallas.
9
00:00:22,778 --> 00:00:27,616
- They didn't have any idea
of the severity
of what they were about to face.
10
00:00:28,450 --> 00:00:31,495
- Speed! Oh, God! Go around!
11
00:00:31,579 --> 00:00:34,999
(narrator): And tragedy strikes
in San Francisco
12
00:00:35,040 --> 00:00:37,793
when a Boeing 777 lands short.
13
00:00:37,793 --> 00:00:38,794
- Hang on!
14
00:00:38,836 --> 00:00:41,297
- How could a couple
of highly trained,
experienced pilots
15
00:00:41,297 --> 00:00:45,050
simply fly an airplane
into the ground
short of the runway?
16
00:00:45,467 --> 00:00:47,928
(narrator):
Landing is a routine operation,
17
00:00:47,928 --> 00:00:51,473
but also one of the most
dangerous stages of flight.
18
00:00:51,891 --> 00:00:54,643
Investigators have to determine
what went wrong
19
00:00:54,685 --> 00:00:57,271
when the safety of the runway
was in sight.
20
00:00:57,313 --> 00:01:00,774
- If you're not prepared
to land the plane,
you shouldn't do it.
21
00:01:03,611 --> 00:01:05,571
- Mayday, mayday!
22
00:01:07,907 --> 00:01:09,825
- It's going up!
23
00:01:10,618 --> 00:01:13,120
(indistinct radio chatter)
24
00:01:27,718 --> 00:01:31,972
(narrator): It's early morning
on the Indonesian island
of Java.
25
00:01:33,807 --> 00:01:37,937
A Boeing 737 flies
high overhead.
26
00:01:38,979 --> 00:01:41,941
- Visibility: 8 kilometres.
27
00:01:42,608 --> 00:01:44,860
27,000 feet.
28
00:01:44,902 --> 00:01:46,195
- 27,000.
29
00:01:46,570 --> 00:01:51,408
(narrator):
The crew of Garuda Flight 200
is preparing to land.
30
00:01:51,450 --> 00:01:53,202
(chiming)
31
00:01:53,744 --> 00:01:57,915
There are 133 passengers
on board this morning.
32
00:01:58,707 --> 00:02:00,626
They're nearing the end
of a short flight
33
00:02:00,668 --> 00:02:02,920
from the Indonesian capital
of Jakarta,
34
00:02:02,920 --> 00:02:07,883
265 miles southeast
to the city of Yogyakarta.
35
00:02:10,970 --> 00:02:14,348
The plane is 15 minutes
from touchdown.
36
00:02:14,348 --> 00:02:17,601
- Okay, when we're cleared,
we approach runway 9,
37
00:02:17,643 --> 00:02:19,645
course 088.
38
00:02:21,021 --> 00:02:24,942
(narrator):
Captain Muhammad Marwoto Komar
has been with Garuda
39
00:02:24,984 --> 00:02:27,111
for 21 years.
40
00:02:27,778 --> 00:02:31,448
- Approach flaps: 40,
auto-brake: 2.
41
00:02:31,991 --> 00:02:34,535
(narrator):
As they near the airport,
42
00:02:34,576 --> 00:02:36,328
he briefs First Officer
Gagam Rachman
43
00:02:36,370 --> 00:02:40,374
on the final steps needed
to get their plane
on the ground.
44
00:02:41,417 --> 00:02:43,085
- Understood.
45
00:02:43,127 --> 00:02:45,754
Approach briefing complete.
46
00:02:53,554 --> 00:02:57,016
- Garuda 200,
you're cleared to approach
runway zero-niner.
47
00:02:57,057 --> 00:02:59,768
Let me know when you have
the runway in sight.
48
00:03:01,979 --> 00:03:03,731
- Gear down.
49
00:03:05,024 --> 00:03:06,775
- Gear down.
50
00:03:08,777 --> 00:03:12,865
(narrator): They are now
less than 3,000 feet
above the ground.
51
00:03:12,906 --> 00:03:15,034
The runway is in sight.
52
00:03:15,659 --> 00:03:17,578
- Flaps: 15.
53
00:03:21,749 --> 00:03:24,209
(narrator):
But as the plane descends,
54
00:03:24,251 --> 00:03:26,962
passengers notice
something isn't right.
55
00:03:28,255 --> 00:03:32,926
The plane is going very fast
and is very low to the ground.
56
00:03:34,678 --> 00:03:37,306
- Cleared to land.
Two miles out.
57
00:03:45,689 --> 00:03:48,817
(automation): Pull up.
Too low. Terrain.
58
00:03:48,817 --> 00:03:50,694
- Whoa. Go around, Captain!
Go around!
59
00:03:50,736 --> 00:03:54,323
(automation): Too low.
Terrain. Terrain.
60
00:03:54,365 --> 00:03:55,949
Pull up.
61
00:04:00,162 --> 00:04:01,830
(screaming and grunting)
62
00:04:01,872 --> 00:04:03,832
(narrator):
Passengers are thrown violently
63
00:04:03,832 --> 00:04:06,251
as the plane bounces
a second time.
64
00:04:13,967 --> 00:04:17,805
Even after a third impact,
the plane isn't stopping.
65
00:04:21,475 --> 00:04:24,103
(screaming)
(alarm sounding)
66
00:04:29,274 --> 00:04:31,110
(sirens wailing)
67
00:04:31,151 --> 00:04:37,908
The 737 has come to a stop
in a swampy rice field
off the end of the runway.
68
00:04:41,578 --> 00:04:43,914
But the disaster isn't over.
69
00:04:43,956 --> 00:04:45,499
(screaming)
70
00:04:45,541 --> 00:04:49,420
Inside the burning fuselage,
passengers struggle to get out.
71
00:04:50,129 --> 00:04:54,716
And outside,
firefighters battle to reach
the swampy crash site.
72
00:04:54,758 --> 00:04:58,679
If the fuel tanks ignite,
the plane could explode.
73
00:04:58,679 --> 00:05:01,223
- Anytime you've got
the possibility of fuel,
74
00:05:01,265 --> 00:05:03,934
you need fire suppression
right there, right now,
75
00:05:03,934 --> 00:05:06,979
because you've got
massive flames at 1800°.
76
00:05:06,979 --> 00:05:09,690
You've got a lethal situation.
(groaning)
(coughing)
77
00:05:09,731 --> 00:05:12,151
- Give me a hand with this!
78
00:05:13,777 --> 00:05:15,529
(grunting)
79
00:05:19,575 --> 00:05:20,742
(coughing)
80
00:05:21,034 --> 00:05:25,831
(narrator):
With an exit door finally open,
passengers make their escape.
81
00:05:28,959 --> 00:05:32,504
Of the 140 passengers
and crew on board...
82
00:05:33,005 --> 00:05:35,174
...21 people are dead.
83
00:05:35,799 --> 00:05:40,012
- Clearly, you knew that people
were not gonna survive this.
84
00:05:40,220 --> 00:05:43,724
It's almost a miracle
that so many did survive.
85
00:05:44,975 --> 00:05:47,394
- There's a variety
of different scenarios
86
00:05:47,394 --> 00:05:49,938
that go with any kind
of landing accident.
87
00:05:49,980 --> 00:05:52,441
So from the challenges
of an investigator
88
00:05:52,483 --> 00:05:56,862
with regard to trying to piece
these elements back together.
89
00:05:56,904 --> 00:05:59,531
Why did the crew
go off the end of the runway?
90
00:05:59,573 --> 00:06:01,909
Were they flying
the approach properly?
91
00:06:01,909 --> 00:06:04,495
Was there a problem
with the airplane?
92
00:06:08,540 --> 00:06:09,958
(narrator): At the crash site,
93
00:06:10,000 --> 00:06:14,296
investigators from Indonesia's
National Transportation
Safety Committee,
94
00:06:14,338 --> 00:06:16,006
or NTSC...
95
00:06:16,507 --> 00:06:20,469
...face the enormous task
of determining what went wrong.
96
00:06:21,762 --> 00:06:26,725
They're joined by members
of the Australian
Transport Safety Bureau,
97
00:06:26,725 --> 00:06:28,685
including investigator
Alan Stray.
98
00:06:28,727 --> 00:06:30,103
- What've you got so far?
99
00:06:30,145 --> 00:06:33,065
We have to establish:
Where did it touch down?
100
00:06:33,106 --> 00:06:37,778
Were there any runway marks?
Did it bounce? Did it skid?
101
00:06:41,114 --> 00:06:42,908
Looks like they hit pretty hard.
102
00:06:42,950 --> 00:06:46,036
(narrator): Investigators
quickly discover gouges
103
00:06:46,036 --> 00:06:49,122
and shattered pieces
of landing gear on the runway,
104
00:06:49,122 --> 00:06:53,210
clear signs that the plane
slammed down with unusual force.
105
00:06:53,210 --> 00:06:56,088
The nose wheel digging in
and fracturing
106
00:06:56,129 --> 00:07:01,718
was indicative
of a very hard G-force
on that impact.
107
00:07:02,177 --> 00:07:03,595
More skid marks here.
108
00:07:03,595 --> 00:07:08,183
(narrator): It's also clear
that the plane hit the runway
more than once.
109
00:07:09,184 --> 00:07:13,397
- So one... two... three,
110
00:07:13,438 --> 00:07:16,233
then off the end of the runway.
111
00:07:17,651 --> 00:07:21,822
(narrator): What caused
the pilots to perform
such a dangerous landing?
112
00:07:23,782 --> 00:07:28,036
Investigators need to know
what happened
on board the aircraft.
113
00:07:28,453 --> 00:07:32,040
Thankfully,
the plane's flight recorders
are quickly recovered
114
00:07:32,040 --> 00:07:33,917
from the scorched wreckage.
115
00:07:33,959 --> 00:07:37,087
- Alright.
Let's get these into the lab.
116
00:07:37,546 --> 00:07:40,424
Without that data,
we're screwed.
117
00:07:43,093 --> 00:07:44,803
(narrator): While they wait
for the flight data,
118
00:07:44,845 --> 00:07:49,516
investigators look
into the mechanical systems
of the 737.
119
00:07:51,310 --> 00:07:53,228
- Was there a mechanical
failure?
120
00:07:53,270 --> 00:07:55,939
Looking at the performance
of the aircraft,
121
00:07:55,939 --> 00:07:59,610
was it physically possible
for the aircraft to stop?
122
00:08:00,027 --> 00:08:04,072
(narrator): The team focuses in
on the systems used
during landing,
123
00:08:04,114 --> 00:08:06,283
including the wing flaps.
124
00:08:07,159 --> 00:08:09,995
- The flap system
on a modern jetliner like a 737
125
00:08:10,037 --> 00:08:11,580
create greater lift,
126
00:08:11,580 --> 00:08:15,542
and that means
that we can approach an airport
or take off from an airport
127
00:08:15,584 --> 00:08:18,253
with a much lower
and safer airspeed.
128
00:08:19,046 --> 00:08:22,966
(narrator): They inspect
the mechanical rods,
or jackscrews,
129
00:08:22,966 --> 00:08:24,885
that move the flaps.
130
00:08:24,885 --> 00:08:28,639
- We measured
the screw-jack extension...
131
00:08:28,639 --> 00:08:31,308
to establish
what the flap setting was.
132
00:08:32,392 --> 00:08:34,978
(narrator):
What they find is astonishing.
133
00:08:35,228 --> 00:08:38,774
- It doesn't look like the flaps
were all the way out.
134
00:08:40,984 --> 00:08:43,445
(narrator): To provide
enough lift on landing,
135
00:08:43,487 --> 00:08:48,200
the flaps of a 737 are usually
extended step by step,
136
00:08:48,241 --> 00:08:51,286
from zero all the way
to 40 degrees
137
00:08:51,286 --> 00:08:54,956
as the plane slows
and descends towards the runway.
138
00:08:56,041 --> 00:09:00,712
However, the jackscrews show
a flap setting
of just five degrees,
139
00:09:00,712 --> 00:09:02,923
not nearly enough
for a safe landing.
140
00:09:02,964 --> 00:09:08,637
- We just could not believe
that the aircraft would've
landed with only five degrees.
141
00:09:10,013 --> 00:09:13,266
(narrator):
Was there a malfunction
within the flap system
142
00:09:13,266 --> 00:09:16,603
that caused
the terrifying landing?
(screaming)
143
00:09:17,854 --> 00:09:22,693
Investigators hope the data
from the flight recorder
will shed some light
144
00:09:22,734 --> 00:09:25,821
on how the plane was operating
before the crash.
145
00:09:26,321 --> 00:09:29,700
- We were able
to get information
about the flap settings,
146
00:09:29,700 --> 00:09:32,452
the speed on the approach,
the thrust-reverser deployment,
147
00:09:32,494 --> 00:09:36,373
the dynamics of the approach
and landing itself.
148
00:09:36,873 --> 00:09:39,918
Pull up the data for the flaps,
would you, please?
149
00:09:41,878 --> 00:09:43,338
There.
150
00:09:44,256 --> 00:09:47,259
The flaps were set
for five degrees.
151
00:09:48,301 --> 00:09:50,846
Never more than five degrees.
152
00:09:51,847 --> 00:09:57,185
(narrator): The data confirms
the flaps were not configured
properly for landing.
153
00:09:57,644 --> 00:10:00,522
- To hear an airplane
that has been in an accident
154
00:10:00,564 --> 00:10:02,107
because of overrunning
the runway
155
00:10:02,149 --> 00:10:06,611
had a flap setting
of only five in a 737
is very disturbing.
156
00:10:07,946 --> 00:10:10,449
(narrator): As they continue
to review the data,
157
00:10:10,490 --> 00:10:16,538
investigators discover the 737
was coming in for landing
blazingly fast.
158
00:10:16,955 --> 00:10:21,793
Flight 200 hit the ground
at over 250 miles an hour,
159
00:10:21,835 --> 00:10:25,547
more than 100 miles an hour
faster than normal.
160
00:10:25,547 --> 00:10:27,382
- We're not stopping!
161
00:10:27,924 --> 00:10:33,263
- The speed of the aircraft
on short final and on touchdown
162
00:10:33,305 --> 00:10:37,684
was so excessive...
there was no way
it was gonna stop.
163
00:10:38,310 --> 00:10:40,854
(narrator): But why
did the pilots touch down
164
00:10:40,854 --> 00:10:44,107
at such a catastrophically
high speed?
165
00:10:51,406 --> 00:10:55,619
(narrator): After a painstaking
data-recovery process...
- Finally.
166
00:10:55,952 --> 00:11:00,540
- ...investigators in Indonesia
are able to listen
to the cockpit voice recorder
167
00:11:00,582 --> 00:11:02,459
from Garuda Flight 200.
168
00:11:02,501 --> 00:11:05,462
- Fortunately,
the recorder specialists
at the laboratories,
169
00:11:05,504 --> 00:11:10,091
uh, are a tenacious breed
and they do not give up easily.
170
00:11:10,675 --> 00:11:12,803
(narrator): They hope
the recording will help explain
171
00:11:12,844 --> 00:11:17,849
why the pilots failed
to configure the aircraft
properly for landing.
172
00:11:17,849 --> 00:11:20,435
- Okay, let's hear it.
173
00:11:21,436 --> 00:11:25,899
- Okay, when we're cleared,
we approach runway 9,
course 088.
174
00:11:26,316 --> 00:11:30,487
- What you're doing is listening
for the atmosphere and the tone,
175
00:11:30,529 --> 00:11:33,073
the ambiance if you like,
in the cockpit.
176
00:11:33,490 --> 00:11:37,285
- Approach flaps: 40,
auto-brake: 2.
177
00:11:38,119 --> 00:11:40,288
- Approach briefing complete.
178
00:11:45,335 --> 00:11:48,088
- The captain certainly
doesn't sound stressed.
179
00:11:49,548 --> 00:11:52,801
(narrator): Then the first hint
that something's wrong.
180
00:11:52,843 --> 00:11:54,636
- Looks like we're not gonna hit
the glide slope.
181
00:11:54,678 --> 00:11:59,140
(narrator): The plane is higher
than it should be
for this stage of the approach.
182
00:11:59,140 --> 00:12:01,393
- Better get down
a little faster.
183
00:12:03,728 --> 00:12:05,605
(narrator): To land smoothly,
184
00:12:05,647 --> 00:12:08,149
planes need to lose enough speed
and altitude
185
00:12:08,191 --> 00:12:12,988
to descend gradually and meet
the runway at a shallow angle.
186
00:12:13,989 --> 00:12:17,659
But Flight 200 is too high
for a steady landing.
187
00:12:17,993 --> 00:12:22,622
- He definitely has some work
to do if he hopes
to get on track.
188
00:12:22,664 --> 00:12:24,958
- Check speed. Flaps: 15.
189
00:12:26,042 --> 00:12:27,752
- Flaps: 5.
190
00:12:29,671 --> 00:12:32,632
- The captain is calling
for flaps 15.
191
00:12:33,174 --> 00:12:34,926
Why is he saying flaps 5?
192
00:12:34,968 --> 00:12:36,344
- Flaps: 15.
193
00:12:36,553 --> 00:12:39,681
(narrator):
The captain repeatedly tells
the first officer...
194
00:12:39,723 --> 00:12:41,057
- Check speed. Flaps: 15!
195
00:12:41,057 --> 00:12:44,895
- ...to increase the flaps.
- Check speed. Flaps: 15!
196
00:12:45,103 --> 00:12:49,399
(narrator):
But the first officer never
moves them past five degrees.
197
00:12:53,194 --> 00:12:54,863
- Okay.
198
00:12:54,905 --> 00:12:56,197
First things first.
199
00:12:56,197 --> 00:13:00,827
Why did the first officer
ignore the captain
and leave the plane at flaps 5?
200
00:13:00,827 --> 00:13:05,040
- It's very perplexing.
If you got professional pilots,
we can make mistakes,
201
00:13:05,040 --> 00:13:09,169
but usually that's why we've got
two people up there,
so one catches the other.
202
00:13:09,210 --> 00:13:11,796
(automation): Pull up.
(alarm sounding)
(exclamations)
203
00:13:11,796 --> 00:13:15,133
(narrator):
When investigators revisit
the speed of the landing,
204
00:13:15,175 --> 00:13:20,555
they understand why
the first officer was reluctant
to increase the flap setting.
205
00:13:20,597 --> 00:13:23,808
- Way too fast... for flaps 15.
206
00:13:24,184 --> 00:13:27,145
(narrator): The plane
is travelling 35 knots faster
207
00:13:27,187 --> 00:13:30,273
than is designed
for flaps at 15 degrees.
208
00:13:32,525 --> 00:13:35,654
Wind drag could tear the flaps
right off the wings
209
00:13:35,695 --> 00:13:38,573
if the flaps are extended
past five degrees.
210
00:13:38,615 --> 00:13:42,285
- The first officer
was exactly right
in not putting them down.
211
00:13:42,744 --> 00:13:46,081
- But why didn't
the first officer say something?
212
00:13:46,081 --> 00:13:48,625
Tell the captain to slow down?
213
00:13:49,167 --> 00:13:53,463
(Nance): It's very clear
the co-pilot should've said,
"Captain, I got the airplane."
214
00:13:53,463 --> 00:13:56,257
But what it tells me here
is that this co-pilot
215
00:13:56,257 --> 00:13:59,177
did not feel he could speak up
one way or another.
216
00:13:59,177 --> 00:14:00,887
(automation): Pull up.
(alarm sounding)
217
00:14:00,929 --> 00:14:04,766
(narrator):
The captain's behaviour
continues to stun investigators.
218
00:14:04,808 --> 00:14:07,352
- Landing checklist completed,
right?
219
00:14:07,394 --> 00:14:09,854
- Landing checklist?
220
00:14:10,438 --> 00:14:14,526
- There were 15 ground-proximity
alerts and warnings
221
00:14:14,526 --> 00:14:17,112
during that final stage
of the approach.
222
00:14:17,112 --> 00:14:21,825
When a crew member hears that,
there should be instant action.
223
00:14:23,034 --> 00:14:24,577
(narrator):
But instead of reacting,
224
00:14:24,577 --> 00:14:27,831
the captain becomes fixated
on the landing checklist.
225
00:14:27,872 --> 00:14:32,877
Stray and his team begin
to question the quality
of the crew's training.
226
00:14:33,253 --> 00:14:35,422
- Fixation is when we are...
227
00:14:35,463 --> 00:14:38,049
focused on, uh,
228
00:14:38,091 --> 00:14:39,426
completing a task...
229
00:14:39,426 --> 00:14:44,180
to the exclusion of other things
that may be going on around us.
230
00:14:44,848 --> 00:14:47,267
(narrator):
Investigators theorize
that the captain
231
00:14:47,308 --> 00:14:50,311
is completely fixated
on descending
to the proper altitude.
232
00:14:50,353 --> 00:14:53,940
(automation): Pull up.
- Landing checklist completed,
right?
233
00:14:53,982 --> 00:14:57,485
(automation): Pull up.
- In the case of a pilot
fixating on a runway,
234
00:14:57,527 --> 00:15:00,071
he or she can blank out
the rest of the advice,
235
00:15:00,113 --> 00:15:02,282
the ground-proximity warning
system, everything.
236
00:15:02,657 --> 00:15:06,286
(narrator): Pilot training
is designed to combat fixation,
237
00:15:06,286 --> 00:15:08,163
ensuring that pilots
in a crisis situation
238
00:15:08,163 --> 00:15:13,334
can break the spell and take in
the information they need.
239
00:15:15,170 --> 00:15:17,505
Better training might have
helped the first officer
240
00:15:17,547 --> 00:15:20,842
overcome his reluctance
to correct
the captain's mistake.
241
00:15:20,842 --> 00:15:26,139
(automation): Pull up.
- Go around, Captain. Go around!
(automation): Pull up.
242
00:15:29,350 --> 00:15:31,019
- Go around!
(automation): Pull up.
243
00:15:31,061 --> 00:15:33,480
- Landing checklist completed,
right?
(automation): Pull up.
244
00:15:33,521 --> 00:15:36,900
- Without question,
if the captain wasn't going
to respond by going around,
245
00:15:36,941 --> 00:15:40,612
which is what he should've done
instantly on hearing
"whoop-whoop, pull up,"
246
00:15:40,653 --> 00:15:44,449
the co-pilot should've said,
"I've got it,"
and done the same thing.
247
00:15:45,116 --> 00:15:47,410
(alarm sounding)
248
00:15:52,415 --> 00:15:56,753
(narrator): In 2008,
Captain Marwoto Komar
faced charges,
249
00:15:56,753 --> 00:15:59,464
and was found guilty
of negligence,
250
00:15:59,506 --> 00:16:02,592
but the conviction
was overturned on appeal.
251
00:16:04,302 --> 00:16:05,762
In their final report,
252
00:16:05,762 --> 00:16:08,807
investigators call
for improved pilot training
253
00:16:08,807 --> 00:16:12,435
with added focus on approach
and landing procedures.
254
00:16:13,812 --> 00:16:16,481
In the aftermath
of the Garuda 200 disaster,
255
00:16:16,481 --> 00:16:20,902
the airline overhauls
its training
and safety protocols,
256
00:16:20,944 --> 00:16:24,989
and today it is a safer airline
than it's ever been.
257
00:16:26,074 --> 00:16:30,161
- The takeaway
is that the organization
has a responsibility
258
00:16:30,161 --> 00:16:32,831
to provide the pilots with
the best-available training,
259
00:16:32,831 --> 00:16:35,125
flying the best-available
equipment,
260
00:16:35,166 --> 00:16:37,377
and then having a process
to ensure...
261
00:16:37,418 --> 00:16:41,631
that even when no one's looking,
they're doing the right thing.
262
00:16:43,341 --> 00:16:44,717
(narrator): But sometimes,
263
00:16:44,717 --> 00:16:48,972
even the best-trained pilots
can be taken by surprise
on landing
264
00:16:48,972 --> 00:16:53,476
when faced with an unpredictable
force of nature.
265
00:17:01,317 --> 00:17:02,986
(narrator):
It's a scorching-hot day
266
00:17:02,986 --> 00:17:05,613
at Dallas-Fort Worth
International Airport,
267
00:17:05,613 --> 00:17:09,534
with the temperature reaching
101° Fahrenheit.
268
00:17:13,037 --> 00:17:17,292
The intense heat
triggers thunderstorms
that surround the airport.
269
00:17:22,297 --> 00:17:27,760
Delta Airlines Flight 191
heads in for landing at DFW.
270
00:17:28,636 --> 00:17:31,848
- Weather's 6,000 scattered,
21,000 scattered.
271
00:17:31,890 --> 00:17:35,143
Visibility: 10,
temperature: 101.
272
00:17:35,143 --> 00:17:36,311
Wind calm.
273
00:17:36,352 --> 00:17:40,607
- A hundred and one?
- A hundred-and-one degrees.
Yes, sir.
274
00:17:41,149 --> 00:17:45,195
(narrator): Captain Ed Connors
and First Officer Rudy Price
275
00:17:45,236 --> 00:17:48,781
are two of Delta Airlines'
most experienced pilots.
276
00:17:49,407 --> 00:17:55,330
Second Officer Nick Nassick
is one of Delta's most highly
regarded flight engineers.
277
00:17:56,956 --> 00:18:00,919
They're flying
a six-year-old L-1011 Tristar.
278
00:18:04,380 --> 00:18:09,427
There are 152 passengers
and 11 crew members on board.
279
00:18:10,929 --> 00:18:15,350
- Ladies and gentlemen,
we are starting our approach
to DFW.
280
00:18:16,851 --> 00:18:21,564
(narrator): The crew begins
their final descent into
the Dallas-Fort Worth area.
281
00:18:21,856 --> 00:18:23,775
(ATC): Attention,
all aircraft listening,
282
00:18:23,775 --> 00:18:27,445
there's a little rain shower
just north of the airport.
283
00:18:28,947 --> 00:18:31,574
(narrator): While continuing
with their approach procedures,
284
00:18:31,616 --> 00:18:35,036
First Officer Price notices
the upcoming storm.
285
00:18:35,495 --> 00:18:37,997
- We're gonna get
our airplane washed.
286
00:18:40,416 --> 00:18:42,210
(narrator): Less than six miles
from the runway,
287
00:18:42,252 --> 00:18:48,800
the controller tells the crew
to expect a stiff but manageable
crosswind of up to 15 knots.
288
00:18:48,800 --> 00:18:50,927
(ATC): ...at 5. Gusts: 15.
- Tower.
289
00:18:50,969 --> 00:18:54,639
Delta 191 heavy,
out here in the rain.
Feels good.
290
00:18:58,726 --> 00:19:01,521
(narrator): First Officer Price
is at the controls.
291
00:19:02,021 --> 00:19:05,358
He realizes the storm is more
than just a little rain.
292
00:19:05,400 --> 00:19:08,236
- There's lightning
coming out of that one.
293
00:19:08,236 --> 00:19:10,697
- Where?
- Right ahead of us.
294
00:19:12,448 --> 00:19:16,286
- A thousand feet.
I'll call 'em out to you.
- Alright.
295
00:19:19,122 --> 00:19:20,748
(narrator):
One minute away from landing,
296
00:19:20,748 --> 00:19:25,253
Price carefully guides
the aircraft towards the runway.
297
00:19:27,922 --> 00:19:32,176
Without warning, the intensity
of the storm increases.
298
00:19:34,846 --> 00:19:37,515
Driving rain pounds the L-1011.
299
00:19:40,059 --> 00:19:43,271
All of a sudden,
their airspeed picks up.
300
00:19:44,897 --> 00:19:46,649
- Watch your speed.
301
00:19:47,066 --> 00:19:49,736
(narrator): Price needs
to slow the plane down
302
00:19:49,736 --> 00:19:52,196
so they don't overshoot
the runway.
303
00:19:52,989 --> 00:19:55,742
They're only 600 feet
off the ground.
304
00:19:58,745 --> 00:20:00,163
- There it is!
305
00:20:00,455 --> 00:20:03,833
(narrator): Suddenly,
the plane drops sharply.
306
00:20:03,875 --> 00:20:05,418
(screaming)
307
00:20:06,044 --> 00:20:09,714
It's as though
an invisible force
is pushing it to the ground.
308
00:20:09,714 --> 00:20:13,676
- Push it up! Push it way up!
Way up!
309
00:20:13,718 --> 00:20:15,678
- Way up!
- Way up!
310
00:20:24,771 --> 00:20:28,232
(narrator):
The pilots' efforts are futile.
311
00:20:31,819 --> 00:20:35,990
One mile short of the runway,
the plane plows into a field,
312
00:20:36,032 --> 00:20:39,577
travelling more than 200 miles
an hour.
313
00:20:41,162 --> 00:20:46,125
At that moment, the controller
catches sight of Delta 191.
314
00:20:46,167 --> 00:20:49,128
- He's gonna crash!
Delta, go around!
315
00:20:58,596 --> 00:21:02,558
- He cartwheeled into the tank
in just an instant,
and then, of course,
316
00:21:02,558 --> 00:21:05,728
there was a wall of fire.
(sirens wailing)
317
00:21:09,690 --> 00:21:12,318
In the tower, it's just quiet,
318
00:21:12,318 --> 00:21:15,738
and you just sit there...
stunned,
319
00:21:15,780 --> 00:21:19,242
wishing you could do anything
to take it back.
320
00:21:31,671 --> 00:21:34,882
(narrator): When firefighters
and rescue workers arrive,
321
00:21:34,924 --> 00:21:38,344
they discover
27 people have survived.
322
00:21:40,721 --> 00:21:41,931
But Captain Connors,
323
00:21:41,973 --> 00:21:45,768
First Officer Price
and Second Officer Nassick
are killed,
324
00:21:45,810 --> 00:21:48,771
along with five
other crew members
325
00:21:48,813 --> 00:21:52,733
and a devastating
128 passengers.
326
00:21:58,239 --> 00:22:01,492
- I was on a Delta flight
behind that flight.
327
00:22:01,742 --> 00:22:06,873
You could see this horrific fire
and burning wreckage
just out the plane window.
328
00:22:06,914 --> 00:22:12,253
And we came into the gate
where that plane
was supposed to have come.
329
00:22:12,712 --> 00:22:16,632
And at that time,
families could go to the gates.
330
00:22:17,758 --> 00:22:20,803
It was a sight
I will never forget.
331
00:22:21,888 --> 00:22:24,682
(narrator):
Investigators from the National
Transportation Safety Board,
332
00:22:24,682 --> 00:22:29,896
or NTSB,
arrive at Dallas-Fort Worth,
determined to find the cause.
333
00:22:29,896 --> 00:22:33,316
- One of our field investigators
would've been on scene,
334
00:22:33,357 --> 00:22:37,612
trying to locate
the flight-data recorder
and the cockpit voice recorder,
335
00:22:37,653 --> 00:22:39,280
which is, you know,
336
00:22:39,322 --> 00:22:42,867
a very important part
of the investigation.
337
00:22:43,576 --> 00:22:46,954
(narrator): Thankfully,
both flight recorders
are recovered quickly,
338
00:22:46,954 --> 00:22:50,041
and immediately sent
for analysis.
339
00:22:51,375 --> 00:22:57,006
Investigators hope the data
will reveal what caused
Flight 191 to crash
340
00:22:57,048 --> 00:23:00,718
into a water tank
off the end of the runway.
341
00:23:03,763 --> 00:23:08,392
- This flight-data recorder
gave us several parameters
we didn't have before -
342
00:23:08,392 --> 00:23:12,313
engine power,
longitudinal acceleration -
343
00:23:12,355 --> 00:23:16,609
and those parameters
really enabled us to do
344
00:23:16,651 --> 00:23:18,694
a more in-depth analysis.
345
00:23:19,362 --> 00:23:22,532
(narrator):
The device also records
external elements,
346
00:23:22,573 --> 00:23:26,702
like temperature, wind speed,
altitude and air pressure.
347
00:23:28,162 --> 00:23:29,580
When they review the data,
348
00:23:29,580 --> 00:23:34,710
investigators discover
an alarming weather pattern
logged on the recorder.
349
00:23:34,919 --> 00:23:37,046
- Then it shifts to a downdraft.
350
00:23:37,046 --> 00:23:38,506
(narrator):
In a matter of seconds,
351
00:23:38,548 --> 00:23:41,842
the plane is hit
with three strong winds
from the front,
352
00:23:41,884 --> 00:23:43,928
above and then behind.
353
00:23:44,720 --> 00:23:46,013
- There you have it.
354
00:23:46,055 --> 00:23:49,850
(narrator):
Bud Laynor immediately
recognizes the weather pattern.
355
00:23:50,142 --> 00:23:53,479
The plane flew
through a microburst.
356
00:23:56,023 --> 00:24:00,987
A microburst is a violent shaft
of air falling
from a storm cloud.
357
00:24:01,862 --> 00:24:06,826
On the day of the crash,
it had been extremely hot,
and hot air rises.
358
00:24:07,201 --> 00:24:11,163
When that hot air
meets the cold, moist air
in the storm clouds,
359
00:24:11,205 --> 00:24:15,668
it cools instantly and rushes
violently back to Earth.
360
00:24:16,752 --> 00:24:20,298
- If you're at the kitchen sink
and you turn on the water,
361
00:24:20,298 --> 00:24:24,010
and it goes straight down
and it splashes out
in all directions.
362
00:24:24,010 --> 00:24:26,846
And that's kind of what
a microburst is,
363
00:24:26,887 --> 00:24:29,849
except that it is extremely...
bad news
364
00:24:29,890 --> 00:24:34,186
if you're an airplane
flying through it
at low altitude.
365
00:24:34,937 --> 00:24:37,773
(narrator):
The plane first faces
a strong headwind,
366
00:24:37,815 --> 00:24:39,817
which lifts the plane skyward.
367
00:24:40,234 --> 00:24:44,280
Then it's hit by a downdraft,
slamming it toward the ground.
368
00:24:44,822 --> 00:24:50,202
Finally, the microburst delivers
its most dangerous punch:
the tailwind.
369
00:24:50,578 --> 00:24:53,539
- And you would get
a rapid descent,
370
00:24:53,539 --> 00:24:56,417
a loss of lift and a rapid
descent towards the ground,
371
00:24:56,417 --> 00:24:59,211
and easily crash the airplane.
372
00:25:00,504 --> 00:25:04,091
(narrator):
It's clear that the 136 people
on Flight 191
373
00:25:04,091 --> 00:25:08,095
are the latest victims of
the intense weather phenomenon.
374
00:25:09,055 --> 00:25:10,973
- Unbelievable.
375
00:25:12,725 --> 00:25:14,518
(narrator):
But one mystery still remains.
376
00:25:14,518 --> 00:25:19,857
- Altimeters?
- How did such an experienced
crew fall victim to a storm...
377
00:25:19,899 --> 00:25:21,317
- You're in good shape.
378
00:25:21,317 --> 00:25:24,278
- ...they were all trained
to overcome?
379
00:25:30,159 --> 00:25:32,870
(narrator):
When NTSB investigators
compare the actions
380
00:25:32,912 --> 00:25:37,333
of Flight 191's pilots
to the force
of the microburst...
381
00:25:37,375 --> 00:25:38,834
- A thousand feet.
382
00:25:38,834 --> 00:25:42,380
- ...they uncover details
of a fight to the death.
- I'll call 'em out to you.
383
00:25:42,421 --> 00:25:47,009
- A fight that the Delta pilots
almost won.
- Watch your speed.
384
00:25:49,136 --> 00:25:51,389
(narrator): The increase
in airspeed from the headwind
385
00:25:51,430 --> 00:25:55,893
prompts First Officer Price
to reduce power to his engines.
386
00:25:56,394 --> 00:25:58,979
Power he'll desperately need
in just a few seconds.
387
00:25:59,021 --> 00:26:02,900
- You're gonna lose it
all of a sudden.
There it is.
388
00:26:03,567 --> 00:26:06,779
- The captain knew
the characteristics
of a microburst.
389
00:26:06,821 --> 00:26:10,533
He'd obviously been given
an introduction to windshear
390
00:26:10,533 --> 00:26:14,495
and microburst characteristics
in his flight training.
391
00:26:15,121 --> 00:26:18,666
(narrator):
But when Connors and Price
are hit with the tailwind,
392
00:26:18,708 --> 00:26:21,168
there is very little
they can do.
393
00:26:21,961 --> 00:26:23,629
Only 500 feet off the ground,
394
00:26:23,671 --> 00:26:28,134
they have insufficient speed
and altitude
with which to manoeuvre.
395
00:26:28,134 --> 00:26:30,636
- Push it up! Way up!
396
00:26:32,471 --> 00:26:35,433
(narrator): Then suddenly,
the microburst delivers
another blow:
397
00:26:35,433 --> 00:26:39,937
a fierce crosswind that forces
their plane to bank dangerously
to the right.
398
00:26:39,979 --> 00:26:42,398
(automation): Pull up.
- Hang onto the sonofabitch!
399
00:26:42,398 --> 00:26:46,736
(narrator):
Combined with the other winds,
the crew is defenseless.
400
00:26:46,777 --> 00:26:48,821
- TOGA!
401
00:26:49,029 --> 00:26:50,614
TOGA!
402
00:26:50,614 --> 00:26:52,366
- TOGA is Take-Off
Go-Around mode.
403
00:26:52,366 --> 00:26:57,079
Let's abandon the approach.
We're no longer gonna try
to land this airplane.
404
00:26:57,621 --> 00:27:01,500
(narrator):
The skill and experience
of the pilots are no match
405
00:27:01,500 --> 00:27:03,419
for this fierce microburst.
406
00:27:03,461 --> 00:27:07,882
It's too big,
its winds too powerful
and unpredictable.
407
00:27:11,218 --> 00:27:13,012
Making matters worse,
408
00:27:13,012 --> 00:27:19,185
investigators discover the storm
at the foot of the runway
arrives virtually unannounced.
409
00:27:20,227 --> 00:27:23,689
Once trained weather observers
see it on the radar,
410
00:27:23,731 --> 00:27:27,818
it's too late to warn the crew
of Delta 191.
411
00:27:28,736 --> 00:27:32,865
- It's small,
it's the length of a runway,
roughly,
412
00:27:32,907 --> 00:27:35,743
and it doesn't last very long,
so...
413
00:27:35,785 --> 00:27:38,245
it's something
that can happen so quickly
414
00:27:38,245 --> 00:27:42,666
that many accidents
have occurred because nobody
knew it was there.
415
00:27:45,044 --> 00:27:48,088
(narrator):
Investigators conclude
that the Delta crash was caused
416
00:27:48,130 --> 00:27:52,551
by the pilots' decision
to continue their approach
into the storm.
417
00:27:53,135 --> 00:27:58,057
A decision that was made
because the crew wasn't warned
about the hazard.
418
00:28:00,601 --> 00:28:03,103
After the crash of Delta 191,
419
00:28:03,145 --> 00:28:09,109
the Federal Aviation Authority
install Terminal Doppler Weather
Radar at high-risk airports,
420
00:28:09,109 --> 00:28:11,278
including Dallas-Fort Worth.
421
00:28:11,779 --> 00:28:17,451
Doppler Radar detects
the direction and speed
of precipitation and wind flow.
422
00:28:17,451 --> 00:28:19,870
- Doppler Radar,
which is on the ground,
423
00:28:19,912 --> 00:28:23,415
is incredibly effective
in detecting microbursts.
424
00:28:23,457 --> 00:28:27,795
And in fact, it can detect
about 98% of a microburst.
425
00:28:29,171 --> 00:28:31,715
- Even though we've learned
a lot of information
426
00:28:31,757 --> 00:28:33,676
from accidents
involving thunderstorms,
427
00:28:33,717 --> 00:28:37,388
things can still go wrong
on a clear and sunny day,
428
00:28:37,388 --> 00:28:39,640
only feet from the runway.
429
00:28:42,059 --> 00:28:46,146
- Ladies and gentlemen,
this is your captain speaking.
Hope you had a pleasant flight.
430
00:28:46,146 --> 00:28:48,858
We'll be on the ground
in about 30 minutes.
431
00:28:49,859 --> 00:28:54,238
(narrator): Asiana Flight 214
is nearing the end
of an overnight flight
432
00:28:54,280 --> 00:28:57,408
from Seoul, Korea,
to San Francisco.
433
00:29:00,452 --> 00:29:06,667
The Boeing 777 is carrying
291 passengers
and 16 crew members.
434
00:29:07,877 --> 00:29:09,879
- Is that the Golden Gate?
435
00:29:09,920 --> 00:29:12,548
(narrator): Captain Lee Kang Kuk
takes in the sights
436
00:29:12,548 --> 00:29:15,092
as he guides the plane
towards the airport.
437
00:29:15,134 --> 00:29:18,971
- The Golden Gate's over there.
That bridge goes to Oakland.
438
00:29:19,013 --> 00:29:21,265
- Ah. Okay.
439
00:29:21,515 --> 00:29:23,726
(narrator): Lee Jung Min,
also a captain,
440
00:29:23,767 --> 00:29:26,478
is serving
as First Officer today.
441
00:29:27,479 --> 00:29:29,440
- Runway in sight.
442
00:29:31,442 --> 00:29:33,819
- Okay. Gear down, sir.
443
00:29:36,906 --> 00:29:38,949
- Gear down.
444
00:29:41,285 --> 00:29:46,749
(narrator): In the cabin,
the flight attendants prepare
passengers for landing.
445
00:29:49,418 --> 00:29:54,214
- Asiana 214 heavy,
runway 28 left, cleared to land.
446
00:29:54,882 --> 00:29:57,259
- Landing checklist complete.
447
00:29:57,384 --> 00:30:00,220
Clear to land. On glidepath.
448
00:30:01,013 --> 00:30:02,723
- Check.
449
00:30:03,766 --> 00:30:06,769
(narrator): The plane is less
than a minute from the runway
450
00:30:06,769 --> 00:30:09,939
when a passenger notices
something alarming.
451
00:30:10,856 --> 00:30:14,568
- There's a small pier
that extends out of the runway,
452
00:30:14,568 --> 00:30:17,154
and I'm, like:
Wow, we're very low.
453
00:30:22,785 --> 00:30:26,288
(narrator): In the cockpit...
- Speed!
- ...a crisis hits.
454
00:30:26,288 --> 00:30:28,958
(automation): Terrain. Pull up.
- I've got control!
455
00:30:28,999 --> 00:30:33,087
(automation): Pull up. Pull up.
- Oh, God!
456
00:30:33,087 --> 00:30:34,630
Go around!
457
00:30:35,547 --> 00:30:40,678
(narrator):
The captain pulls up the nose
and tries to climb.
458
00:30:40,719 --> 00:30:42,805
(screaming)
459
00:30:44,890 --> 00:30:47,518
(automation): Terrain.
Terrain. Pull up.
- Ah!
460
00:30:54,358 --> 00:30:55,943
- Ah!
461
00:30:56,318 --> 00:30:59,446
Just wondering
how it's gonna end,
how it's gonna stop,
462
00:30:59,488 --> 00:31:01,991
and when it's gonna stop.
(all screaming)
463
00:31:02,366 --> 00:31:04,910
- Hang on! Hang on!
464
00:31:08,497 --> 00:31:10,916
(screaming and exclamations)
465
00:31:17,673 --> 00:31:20,384
(narrator): In the cockpit,
the pilots have survived,
466
00:31:20,384 --> 00:31:23,804
but they have no idea
of the extent of the damage.
467
00:31:25,472 --> 00:31:29,601
The brutal impact
has torn the tail
off the body of the plane.
468
00:31:29,643 --> 00:31:31,979
- Control, come in.
469
00:31:31,979 --> 00:31:33,897
It's Asiana 214.
470
00:31:33,897 --> 00:31:36,859
Initiating evacuation checklist.
471
00:31:37,401 --> 00:31:38,652
We need help out here.
472
00:31:38,652 --> 00:31:42,781
- Asiana 214 heavy,
emergency vehicles
are responding.
473
00:31:46,577 --> 00:31:49,121
(woman): Oh, my God,
that's scary.
474
00:31:49,705 --> 00:31:52,207
(narrator): Eyewitness video
captures the dramatic scene
475
00:31:52,207 --> 00:31:56,086
as hundreds of people flee
the cabin from only a few exits.
476
00:31:56,128 --> 00:31:58,881
- Come on. Get out.
477
00:31:59,757 --> 00:32:06,221
(narrator): Asiana Flight 214
has crashed on one of
the airport's busiest runways.
478
00:32:09,975 --> 00:32:13,020
Nearly 50 people
are seriously injured.
479
00:32:14,021 --> 00:32:18,150
Six were thrown out
of the back of the plane
when the tail broke off.
480
00:32:19,359 --> 00:32:21,070
Two of them are dead.
481
00:32:21,278 --> 00:32:27,076
- The challenges
in the Asiana 214 investigation
were... myriad.
482
00:32:27,284 --> 00:32:30,079
You would think: Oh, okay,
most everyone survived.
483
00:32:30,120 --> 00:32:33,707
This shouldn't be
a problematic investigation.
484
00:32:33,749 --> 00:32:35,501
But it was.
485
00:32:40,506 --> 00:32:44,218
(narrator): Investigators
at the National Transportation
Safety Board
486
00:32:44,259 --> 00:32:46,804
quickly pull together a team.
487
00:32:50,641 --> 00:32:55,979
Senior investigator Bill English
leads the high-profile
investigation.
488
00:32:56,522 --> 00:32:58,565
- Everyone's on standby
as of right now.
489
00:32:58,565 --> 00:33:01,985
So the 777 had been in service
for about 20 years
at the time of this accident,
490
00:33:01,985 --> 00:33:07,324
and this was the first
fatal accident of a 777
in that entire time.
491
00:33:10,911 --> 00:33:14,498
(narrator):
The investigators arrive
at the horrific crash site
492
00:33:14,540 --> 00:33:16,667
the following morning.
493
00:33:16,708 --> 00:33:19,086
Before searching
the scorched wreckage,
494
00:33:19,128 --> 00:33:24,007
they equip themselves
with protective gear to shield
them from the toxic fumes.
495
00:33:24,049 --> 00:33:26,009
- Okay, here we go.
496
00:33:26,552 --> 00:33:30,097
(narrator):
For NTSB investigator Roger Cox,
497
00:33:30,139 --> 00:33:33,267
the hunt for evidence
is worth the risk.
498
00:33:33,892 --> 00:33:36,645
- It was a tricky accident site.
499
00:33:36,645 --> 00:33:40,023
Uh, we had to be properly
garbed up to make sure
500
00:33:40,065 --> 00:33:41,775
that we weren't affected
too much
501
00:33:41,817 --> 00:33:44,570
by the dangerous wreckage
that was there.
502
00:33:45,529 --> 00:33:50,701
(narrator):
Cox gathers the pilots' charts
and personal effects,
503
00:33:50,742 --> 00:33:53,537
hoping to find clues
about what the pilots were doing
504
00:33:53,537 --> 00:33:55,581
in the final stages
of the flight.
505
00:33:55,581 --> 00:33:58,000
- That's everything
I could find.
506
00:33:58,709 --> 00:34:00,878
(narrator):
Many of the documents
are in Korean.
507
00:34:00,919 --> 00:34:05,090
They'll need to be translated
before they can be
fully analyzed.
508
00:34:10,637 --> 00:34:13,640
Meanwhile, at NTSB headquarters,
509
00:34:13,640 --> 00:34:18,353
photos of the crash zone
provide investigators
with a crucial lead.
510
00:34:18,395 --> 00:34:21,273
- Where it impacted on the rocks
of the seawall
511
00:34:21,315 --> 00:34:23,233
pretty much tells us
it was too low.
512
00:34:23,233 --> 00:34:26,278
It landed well short
of where it should have.
513
00:34:26,987 --> 00:34:29,198
(narrator): The team hopes
the data recovered
514
00:34:29,198 --> 00:34:30,657
from the 777's flight recorders
515
00:34:30,657 --> 00:34:35,287
will help explain why the plane
crashed into the seawall.
516
00:34:36,413 --> 00:34:38,165
(screaming)
517
00:34:39,541 --> 00:34:43,420
- We were able to see
all the basic things,
like airspeed, altitude,
518
00:34:43,420 --> 00:34:45,923
the configuration
of the airplane.
519
00:34:46,423 --> 00:34:50,427
We were also able to see
all the inputs
that the crew made.
520
00:34:50,969 --> 00:34:53,764
(narrator): English carefully
plots the data.
521
00:34:53,805 --> 00:34:56,099
Most of it looks
completely normal.
522
00:34:56,350 --> 00:34:59,144
But then he spots
something unexpected.
523
00:34:59,394 --> 00:35:01,438
- This is where
they bring it back to idle.
524
00:35:01,480 --> 00:35:06,735
(narrator): One minute
before the crash, engine power
suddenly drops to idle.
525
00:35:07,486 --> 00:35:09,655
- Right here.
- Ahem.
526
00:35:09,696 --> 00:35:13,450
(narrator): The sudden change
in power settings
makes no sense.
527
00:35:15,035 --> 00:35:18,872
Normally, the last moments
of flight are when pilots
need more power
528
00:35:18,914 --> 00:35:23,085
to overcome drag
from the landing gear
and wing flaps.
529
00:35:24,711 --> 00:35:26,338
And data from earlier
in the flight
530
00:35:26,380 --> 00:35:29,258
shows the engines
were functioning properly.
531
00:35:30,133 --> 00:35:32,886
- We could see that the engines
were making proper power
532
00:35:32,886 --> 00:35:35,180
all the way
through the approach.
533
00:35:35,222 --> 00:35:36,723
(narrator): The question now:
534
00:35:36,765 --> 00:35:39,393
What was the crew doing
to control engine power
535
00:35:39,434 --> 00:35:42,688
in the critical final moments
of flight?
536
00:35:43,313 --> 00:35:44,773
- Speed.
537
00:35:44,815 --> 00:35:47,526
- How did the pilots operate
the airplane?
(alarm sounding)
538
00:35:47,526 --> 00:35:52,364
Why did they do what they did
that got the airplane too low?
(automation): Terrain. Terrain.
539
00:35:58,245 --> 00:36:03,792
(narrator): Investigators turn
their focus squarely
on the actions of the pilots.
540
00:36:03,834 --> 00:36:05,252
- "Gear down, sir."
541
00:36:05,294 --> 00:36:09,798
(narrator): Understanding
every nuance of the cockpit
voice recording is crucial.
542
00:36:11,508 --> 00:36:16,555
They listen as the pilots
prepare for a visual approach
and landing.
543
00:36:16,555 --> 00:36:18,932
- Missed approach 3,000 feet.
544
00:36:19,433 --> 00:36:21,893
- Landing checklist complete.
545
00:36:21,935 --> 00:36:24,646
Clear to land. On glidepath.
546
00:36:25,188 --> 00:36:28,859
(narrator): They combine
what they hear with the data
from the flight recorder
547
00:36:28,859 --> 00:36:32,446
that shows how the pilots
were manipulating the controls.
548
00:36:32,446 --> 00:36:34,531
- This seems a little high.
549
00:36:34,531 --> 00:36:36,908
(narrator):
As the crew nears the runway,
550
00:36:36,908 --> 00:36:40,537
the recording hints
at the first sign of trouble.
551
00:36:41,788 --> 00:36:43,874
The rate of descent is too slow.
552
00:36:43,874 --> 00:36:46,877
They risk overshooting
the runway.
553
00:36:47,294 --> 00:36:49,296
- I will descend more.
554
00:36:50,547 --> 00:36:54,051
(narrator): What the recording
reveals next is stunning.
555
00:36:55,719 --> 00:36:57,512
To speed up the rate of descent,
556
00:36:57,512 --> 00:36:59,806
the captain switches
the autopilot
557
00:36:59,806 --> 00:37:01,600
to Flight Level Change Mode.
558
00:37:01,641 --> 00:37:04,061
But he makes
a dangerous mistake.
559
00:37:04,603 --> 00:37:08,231
- He made an entry
to the autopilot that, at first,
560
00:37:08,231 --> 00:37:11,276
actually made
the airplane climb.
561
00:37:11,735 --> 00:37:14,237
Obviously,
he didn't want to do that.
562
00:37:14,446 --> 00:37:16,531
(narrator):
Instead of descending,
563
00:37:16,531 --> 00:37:19,034
the new mode instructs the plane
to climb
564
00:37:19,034 --> 00:37:23,038
to its preset go-around altitude
of 3,000 feet.
565
00:37:24,706 --> 00:37:28,543
- The autopilot mode
switches here,
starts all the confusion.
566
00:37:28,585 --> 00:37:32,339
The pilot flying is supposed
to actually select things
567
00:37:32,339 --> 00:37:34,966
with the auto-flight system
and call out what he's doing.
568
00:37:35,008 --> 00:37:37,469
And the pilot monitoring
is supposed to verify
569
00:37:37,469 --> 00:37:40,013
that the change
has actually occurred.
570
00:37:40,514 --> 00:37:44,726
No callouts.
How's anyone supposed to know
what he's doing?
571
00:37:46,895 --> 00:37:48,688
(narrator):
To bring his plane back down,
572
00:37:48,730 --> 00:37:53,110
the captain immediately pulls
the throttles back to idle...
573
00:37:53,902 --> 00:37:58,281
...stripping the plane
of crucial airspeed
they need for landing.
574
00:38:00,742 --> 00:38:02,119
- It's low.
575
00:38:02,119 --> 00:38:06,415
(narrator):
Investigators now understand
how the engines got to idle.
576
00:38:06,456 --> 00:38:07,791
- Yeah.
577
00:38:07,791 --> 00:38:12,254
(narrator): But why would
an experienced captain make the
mistake of leaving them there?
578
00:38:12,295 --> 00:38:15,340
(automation): Pull up.
- Oh, God! Go around!
(alarm sounding)
579
00:38:15,632 --> 00:38:21,430
(narrator): And why did the crew
not notice they were dangerously
low until it was too late?
580
00:38:21,430 --> 00:38:24,015
(automation): Terrain. Pull up.
581
00:38:27,144 --> 00:38:30,939
(narrator): NTSB investigators
are anxious to interview
the pilot
582
00:38:30,939 --> 00:38:32,899
who was flying Asiana Flight 214
583
00:38:32,899 --> 00:38:36,987
when it crashed
onto a San Francisco runway.
584
00:38:37,279 --> 00:38:39,156
- I'll try to help if I can.
585
00:38:39,739 --> 00:38:44,494
(narrator): The captain explains
he was worried about landing
in San Francisco.
586
00:38:44,703 --> 00:38:46,705
- I was a bit nervous.
587
00:38:47,456 --> 00:38:49,124
(narrator):
On the day of the crash,
588
00:38:49,124 --> 00:38:54,671
the electronic runway equipment
designed to help guide pilots
in for landing was down.
589
00:38:55,881 --> 00:38:59,092
- I thought
that was very unusual coming
from an experienced pilot,
590
00:38:59,092 --> 00:39:02,971
because no one really needs
an electronic glide slope
on a clear day
591
00:39:03,013 --> 00:39:06,766
to be able to land an airplane.
It's a fundamental skill.
592
00:39:07,476 --> 00:39:09,895
- Other pilots were making
that landing.
593
00:39:11,980 --> 00:39:15,025
I thought I should be able
to make it too.
594
00:39:16,151 --> 00:39:18,862
- Why did he not ask
the other guy for help?
595
00:39:18,862 --> 00:39:21,698
I think he just didn't want
to admit the weakness.
596
00:39:21,740 --> 00:39:23,366
- It's low.
597
00:39:23,909 --> 00:39:27,037
(narrator):
The captain tells investigators
he doesn't understand
598
00:39:27,078 --> 00:39:30,707
why the plane didn't have
enough power on landing.
599
00:39:30,707 --> 00:39:32,042
- I know I made some mistakes,
600
00:39:32,083 --> 00:39:36,171
but I was certain
that the auto-throttle
would control the speed.
601
00:39:37,255 --> 00:39:39,174
(narrator):
Like other modern jets,
602
00:39:39,216 --> 00:39:42,469
the 777 can automatically
increase or decrease
engine power
603
00:39:42,469 --> 00:39:46,139
through a system
known as the auto-throttle.
604
00:39:46,806 --> 00:39:48,391
- He was confident
the auto-throttle
605
00:39:48,433 --> 00:39:51,811
was actually gonna take care
of speed for him...
606
00:39:52,062 --> 00:39:54,231
...that the auto-throttles
would wake up,
607
00:39:54,231 --> 00:39:57,275
advance the thrust
and keep them safe.
(automation): Up. Up.
608
00:39:57,317 --> 00:40:02,405
(narrator): But investigators
discover the auto-throttle
never corrected the speed.
609
00:40:02,447 --> 00:40:04,658
- Oh! Go around!
(automation): Terrain. Pull up.
610
00:40:04,699 --> 00:40:08,995
(narrator): Did the critical
automated system fail in flight?
611
00:40:14,626 --> 00:40:17,504
When they conduct
an exhaustive search
612
00:40:17,546 --> 00:40:20,298
of the plane's
computerized functions...
613
00:40:20,924 --> 00:40:23,468
...the team makes
a surprising discovery.
614
00:40:23,677 --> 00:40:27,806
- We could see
some strange things happening
with automation inputs
615
00:40:27,847 --> 00:40:30,809
while that airplane
was on short final.
616
00:40:33,520 --> 00:40:37,899
(narrator): When they replicate
the sequence of inputs
made by the captain,
617
00:40:37,941 --> 00:40:40,819
including changing
the autopilot mode...
618
00:40:41,152 --> 00:40:44,114
...and then reducing
the thrust...
619
00:40:46,658 --> 00:40:49,411
(beep)
- Bingo! That does it.
620
00:40:49,452 --> 00:40:51,788
- ...the unusual combination
of commands
621
00:40:51,830 --> 00:40:55,417
switches off
the 777's auto-throttle system,
622
00:40:55,417 --> 00:40:57,586
leaving the engines at idle.
623
00:40:58,044 --> 00:41:02,173
- By doing that,
that sent the signal
to the auto-throttle system
624
00:41:02,215 --> 00:41:03,633
that he wanted control
of the power.
625
00:41:03,675 --> 00:41:08,847
So at that point, in effect,
the airplane was basically
just gliding.
626
00:41:11,558 --> 00:41:14,352
(narrator): Investigators
finally understand
627
00:41:14,394 --> 00:41:16,938
why the auto-throttle
did not re-engage
628
00:41:16,938 --> 00:41:18,940
and boost engine thrust
on landing.
629
00:41:18,940 --> 00:41:21,985
- Oh, God!
(automation): Pull up.
- Go around!
630
00:41:22,402 --> 00:41:25,488
(narrator):
But it doesn't explain why
the captain was so uncertain
631
00:41:25,530 --> 00:41:31,036
about autopilot function
and why the crew
were so slow to react.
632
00:41:31,620 --> 00:41:35,165
- Twenty-two-thousand hours
between them.
633
00:41:36,041 --> 00:41:38,752
You'd think
they'd notice the speed.
634
00:41:39,377 --> 00:41:42,797
(narrator):
The translated documents
retrieved from the cockpit
635
00:41:42,839 --> 00:41:45,133
provide some crucial answers.
636
00:41:46,760 --> 00:41:48,803
They reveal
that Captain Lee Kang Kuk
637
00:41:48,845 --> 00:41:51,640
was training
on the Boeing 777...
638
00:41:51,640 --> 00:41:53,308
- Is that the Golden Gate?
639
00:41:53,350 --> 00:41:55,935
- ...after flying
the Airbus A320,
640
00:41:55,977 --> 00:42:00,231
an aircraft
with a very different style
of automation.
641
00:42:00,732 --> 00:42:03,860
- Check.
- He was a little bit stressed,
642
00:42:03,902 --> 00:42:05,195
because it was...
643
00:42:05,236 --> 00:42:10,533
a training flight
and he was being monitored
by this more senior pilot.
644
00:42:11,117 --> 00:42:15,997
(narrator): But why did
the experienced first officer
wait until it was too late
645
00:42:16,039 --> 00:42:18,583
before taking control
of the plane?
646
00:42:18,833 --> 00:42:21,002
(automation): Pull up.
- I've got control!
647
00:42:21,002 --> 00:42:22,837
(narrator):
If he had intervened sooner...
648
00:42:22,879 --> 00:42:28,051
- Positive rate.
- ...he would almost certainly
have prevented the accident.
649
00:42:29,719 --> 00:42:33,306
When they continue looking
through company records,
650
00:42:33,348 --> 00:42:35,058
investigators discover
the first officer
651
00:42:35,100 --> 00:42:38,561
had never before supervised
a training flight like this one.
652
00:42:38,603 --> 00:42:39,854
- It's low.
653
00:42:39,854 --> 00:42:44,526
(narrator):
His inexperience most likely
led him to wait too long...
654
00:42:44,567 --> 00:42:45,860
(alarm sounding)
- Speed!
655
00:42:45,902 --> 00:42:49,072
- ...before taking over
the controls.
656
00:42:55,370 --> 00:42:59,499
In their final report
on the crash of Asiana 214,
657
00:42:59,541 --> 00:43:03,461
investigators list pilot error
as the probable cause,
658
00:43:03,503 --> 00:43:08,341
but they also cite
the complexities
of the automation system
659
00:43:08,383 --> 00:43:09,718
as a contributing factor.
660
00:43:09,759 --> 00:43:12,846
- I am not confident
that the majority of pilots,
777 pilots at the time,
661
00:43:12,887 --> 00:43:18,560
would've been able to predict
the modes that the airplane
would end up in.
662
00:43:19,519 --> 00:43:22,689
(narrator): The report calls
for better pilot training,
663
00:43:22,731 --> 00:43:25,316
more intuitive designs
of aircraft automation,
664
00:43:25,358 --> 00:43:31,364
and better cockpit alarms
to warn pilots if their speed
gets too low.
665
00:43:34,951 --> 00:43:38,663
- Modern jets are very,
very, very efficient,
666
00:43:38,705 --> 00:43:41,082
which means that they're hard
to slow down.
667
00:43:41,124 --> 00:43:44,043
So getting the airplane
on the proper speed
668
00:43:44,085 --> 00:43:47,547
is one of the biggest challenges
that jet pilots face.
669
00:43:47,589 --> 00:43:51,259
(narrator):
If pilots aren't prepared
when the runway is in sight,
670
00:43:51,301 --> 00:43:54,846
a routine landing
can quickly become a tragedy.
671
00:43:54,888 --> 00:43:57,682
- A stabilized approach says:
I know we can make it.
672
00:43:57,682 --> 00:44:02,270
If you're a pilot and ever say,
"I think we can make it,"
you better be doing a go-around,
673
00:44:02,312 --> 00:44:07,567
because those are the last words
I've heard on so many cockpit
voice recordings.
674
00:44:36,429 --> 00:44:38,640
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