Original subtitles

we're beginning our descent towards

Amsterdam

Turkish Airlines flight 1951 is

preparing to land in Amsterdam

Amsterdam

turkish1951 descending to 7000 speed

250

the crew is flying a state-of-the-art

Boeing 737.

flaps 15

localizer alive

localizer capture

in the final moments of the flight The

Landing turns into a catastrophe

the plane Falls like a rock

the crash of Turkish Airlines flight

1951 involves the most popular plane on

Earth with nearly one and a half million

passengers boarding 737s every day

investigators need to figure out if the

problem was with the plane or with the

pilots flying it

amazing

foreign

[Music]

on the morning of February the 25th 2009

Turkish Airlines flight 1951 becomes the

first plane to crash at Amsterdam's

skibble airport in more than 10 years

smashed into the ground really hard and

made a tremendous noise

the plane hits the ground in a muddy

field just north of Runway 18 right

since the crash was so close to the

airport rescue workers arrived quickly

[Music]

survivors are taken straight to local

hospitals

[Music]

images of the Amsterdam accident quickly

spread around the world

this is the third crash of a passenger

jet in the past six weeks

the sudden nature of this accident adds

to the mystery

it doesn't take long for the Dutch

safety board to arrive at the scene

they will be investigating this accident

but they won't be alone

the crash involved an American-made

plane so the U.S national Transportation

safety board sends Joe sadore one of its

most experienced investigators to

Amsterdam when it's a non-us registered

aircraft that crashes overseas such as

this Turkish Airlines we are the state

of of manufacture and design of the

airframe and also in this case the

engines

fuselage in three large pieces engines

forward of the main wreck site

flight 1951 was one of the most advanced

aircraft in the skies

the Boeing

737-800 series it's designed to travel

longer routes at higher altitudes

the new generation 737 is still the best

airplane boy never built

we developed an airplane that had an

improved Wing improved avionics simpler

systems that required less maintenance

investigators know this isn't just any

plane

the 737 is the world's best-selling

commercial jet

finding out why this one crashed is

imperative there are more than 5 000 of

them in the skies they carry about one

and a half million passengers a day

investigators must quickly determine if

there's a floor with the plane that

could cause another accident

what they know so far is that flight

1951 had been traveling from Istanbul

Turkey to Amsterdam

there were 128 passengers on board the

early morning flight including four

Engineers from Boeing

Airport please raise your seat backs to

the upright position and stow away your

tray tables

there was no mention on board of any

kind of trouble in the cockpit

the crash has killed nine people

including three members of the Boeing

team and the pilots in the cockpit

see if you can get me some Aerials of

the crashing there are Eerie

similarities to another recent accident

involving a Boeing aircraft British

Airways flight 38. approximately a year

before this there had been a triple

seven short landing at Heathrow which

had a dual engine flame art in that

accident a Boeing triple seven fell to

the ground short of the runway

the British Airways Pilots reported that

both their engines stopped delivering

power just before landing

at the time of the Turkish airways crash

the cause of that accident hasn't been

found

like in that case investigators have

plenty of Clues to work with

the plane and its engines are largely

intact

the flight data recorder and cockpit

voice recorder are found in good

condition there are also plenty of

survivors to describe what happened

according to the passengers The Landing

had been routine but then suddenly the

plane simply dropped out of the sky and

hit the ground

but perhaps the biggest clue comes from

the crash site itself the wreckage is

not spread out

it tells investigators that the plane

could not have been traveling forward at

high speed when it hit the ground

the way the aircraft had crashed it did

appear to be some sort of a landing

accident in which there was moderate

control of some sort

the pattern of debris and the passenger

reports Point investigators to an

immediate suspect the engines

the engine's issue was a very big issue

in my thought process at the time

initially

there's no evidence of fire on the

fuselage in many crashes fuel in the

plane's tanks ignites on impact the lack

of fire raises an obvious question did

the engine stop running because flight

1951 had simply run out of gas

that was one of the first thoughts that

I had was does this airplane have fuel

aboard because otherwise how does a 737

literally fall out of the sky on

approach to an airport

but the location and condition of the

plane's engines suggests that perhaps

they didn't quit in Flight sure looks

like it was running when we first looked

at where the engines ended up

the initial impression was that they

probably were producing thrust at impact

given that they were so far forward of

the main wreckage that was just a very

general uh conclusion

only the flight data recorder can tell

investigators how much power the engines

were generating in the seconds before

the crash

lots of fuel rules that out it doesn't

take long to discover that there was

plenty of fuel in the plane's tanks

flight 1951 definitely did not run out

of gas

engers report that in the final seconds

before the crash the plane hit what felt

like turbulence

it points investigators to a well-known

culprit a microburst a microburst is a

powerful column of air that shoots out

of storm clouds it can literally slam a

low-flying plane to the ground

if an airplane flies into that at

approach speeds you're not going to be

flying anymore you're going to come out

of the sky certainly it was one of the

things that all of us took a look at at

the beginning was there a microburst

in 1985 a Delta Airlines flight was

caught in a microburst while landing at

Dallas-Fort Worth Airport

the plane hit the ground short of the

runway

137 people were killed

[Music]

investigators learned that there were

heavy clouds above the airport at the

time of the accident

powerful gust of wind May well have

accompanied them

the flight data recorder will have

recorded wind speeds outside the plane

investigators will need to analyze the

flight data to prove the microburst

Theory

in the meantime the rescue has led to an

unusual discovery

there was three pilots in the cockpit

which is unusual this is a two crew

cockpit

so why was that third pilot there

since none of the three Pilots survived

the accident it's all the more urgent

for investigators to retrieve the data

from the cockpit voice recorder

it records conversations in the cockpit

they're in luck because of the way that

the aircraft crashed accessed the

recorders and the condition of the

recorders was excellent the reason for

the third pilot is soon uncovered flying

stand of the Rival route

visibility 3500 meters expected to

decrease to 2500 meters for first

officer Murat cesare this had been a

training flight of sorts he was new to

the airline and was being shown the

intricacies of landing at Amsterdam's

Airport

in the Jepsen charts which is what all

Pilots use to navigate to and from

skiphold there's 102 pages of

information on skiff hold alone so

there's dozens of approaches Runway 18

right has three high-speed exits to the

left the captain Hassan arasan was doing

double duty

he was training his first officer make

small corrections as we get close to the

runway and was in command of flight

1951. it's because Captain arasan was

teaching that there was the third pilot

in the cockpit

was a safety pilot he was there to keep

an eye on the flight's progress during

this training mission

the purpose of that second set of eyes

is to make sure that that the captain

and the first officer if they are in a

situation where it's a little bit of a

training portion of the flight that they

don't miss something

we've got a clean recording

the voice recorder reveals that the

three crew members began preparations

for landing when still above 8 500 feet

Amsterdam

turkish1951 descending to 7000 speed

250

but the voice recorder has picked up an

unusual sound a warning that makes no

sense at this stage of the flight

one of the investigators from Boeing was

a engineering

pilot that came and helped with the CDR

and he's listening to see when or are

there any unusual sounds that can be

heard that would not be normal

our ils-182 8 right

the same 4000 ILS 18 right

the alarm keeps sounding it's the

landing gear configuration warning horn

Captain arasan continually dismisses it

1951 descent 4000 ILS 18 right

landing gear

is that the landing gear warning they're

8 300 feet here

the warning is a solid clue but

investigators can't yet see how it could

possibly have caused a crash

the crew of Turkish Airlines flight 1951

got warnings to extend their landing

gear while still thousands of feet in

the air

and the initial listen we heard a gear

warning horn occur as the aircraft was

approaching when it was still up and it

was coming in about 10 000 feet and

below

investigators now turn to the flight

data recorder to help solve some of the

Mysteries surrounding this flight the

analysis of wind speeds outside the

aircraft is completed it's clear none

are drastic enough to have brought down

the planes evidence of a microburst

[Music]

but the flight data recorder does

provide some valuable insight into the

cause of the landing gear warning

[Music]

one of the instruments that measures

altitude had the plane already on the

ground

when we looked and saw the radio Altima

data

and the recorder it showed about 8 000

feet and then immediately it went down

to about -8

minus eight feet is an indication that

the aircraft's on the ground but of

course it's still at two thousand feet

the Boeing 737 is equipped with two

separate altimeters one measures air

pressure to determine the plane's height

above sea level

that reading is displayed prominently in

the cockpit on both Pilots flight

display

the plane is also equipped with a radio

altimeter

it's made up of four antennas

two transmit signals to the ground and

two others read the signal that bounces

back to determine the plane's height

it's precise

it's very very precise pressure

altimeters can sometimes

be not as accurate and

radar altimeters are 100 accurate if

they're working properly

one antenna feeds the reading to the

first officer's display

the other feeds the captain's

instruments

in the case of flight 1951 the captain's

side was wrong most of the flight

investigators go back over the CVR and

make a puzzling discovery

Amsterdam turkish1951

5-0

[Music]

ultimate Captain arasan seems to have

known that the landing gear warning was

being caused by a faulty radio altimeter

the airplane thought that it was low to

the ground and the gear was not down and

the captain recognized that the problem

was really in the radio altimeter

showing him that they should be on the

ground and he goes it's just the radio

altimeter

throughout much of the approach the

captain's radio altimeter had been

displaying a reading of -8 feet

triggering the warning to lower the gear

they treated it like it was a nuisance

1951

investigators dig for any other

abnormalities

they learned that with flight 1951 still

about 17 kilometers from the airport

controllers directed the pilots to begin

their final turn to line up with the

runway Turkish 1951 left heading 2-1-0

cleared approach one eight right

left to one zero cleared ILS Turkish

1951

[Music]

210 sensor

this turn puts flight 1951 in line with

Runway 18 right

it's equipped with an instrument Landing

system which sends out a signal

outlining the ideal descent path to the

foot of the runway

the autopilot follows that Glide path

until the plane is a few hundred feet

from the ground then the pilot takes

over

it makes Landing almost effortless the

ILS is pretty easy to file it's a video

game my daughter has flown in a

simulator and and can land a 737

using the ILS

the crew begins configuring their plane

for landing unfazed by the warning horn

that's repeatedly triggered by the

malfunctioning radio altimeter

flaps 15

kilometers out flight 1951 picks up the

ILS signal that will guide the plane to

the runway

localize our life

localizer capture the safety pilot Olga

now reminds Captain arasan about the

failed altimeter we have radio automator

failure sir

okay

Runway one eight right clear to land

clear the land thank you

investigators are stumped the crew knew

about the malfunction and continued

their approach how had it then caused

them to crash clearly there was more to

this accident than a faulty altimeter

the whole premise of Airline safety uh

the way we build the airplanes the way

we fly them is based on the idea that we

can have any number of failures and we

should still be able to arrive safely

the radio altimeter is just one

instrument there's no way in the world

that that one instrument if it fails

should uh be a major cause of worry that

we're going to have a crash

investigators wonder if the crew had

been given proper guidance for their

approach

they turned to exchanges between the

pilots and the controller who guided

them in

they carefully review every instruction

[Music]

Turkish 1951 left heading 2-1-0 cleared

approach one eight rights

by following the controller's

instructions

the crew made their final turn much too

close to the runway

so they intercept properly they should

be here

International guidelines call for

approaching planes to intercept a signal

that guides them to the runway From

Below it's so Pilots don't have to make

any drastic last-minute course

corrections to get to it

The Intercept here

they had to descend but flight 1951 was

given instructions that brought it to

the threshold of the Glide slope while

still way above it it's a common

practice at skipol because it gets

planes to the runway faster

they were so close they had to capture

the Glide slope from above although it

is an unusual situation it is one that

that can be handled by a flight crew if

it is managed properly

approaching a Glide slope from above is

more difficult mostly because the crew

has to suddenly slow the plane and

descend rapidly to intercept the signal

we also call this a slam dunk approach

and some Pilots like it some Pilots

don't it's a little bit harder and

things happen quicker when you're above

the Glide path trying to intercept from

from above and it's just a challenge for

a lot of Pilots the approach from above

increased the crew's workload but its

standard practice at skipol airport I've

flown in to skip old dozens of times and

I expect it

if the controller's instructions had

somehow over taxed This Crew

their conversations would indicate it

they're just five kilometers from the

runway thousand Jack

flaps 40.

you break

[Music]

armed green light one thing at a time

landing gear

Gear down three green

flaps flaps 40 green light

500. all lights on

please warn the cabin crew Okay

Kevin crew take your seats

then real trouble a stall warning

speeds up I have control

100 knots of speed

arasan fought to save his plane but just

400 feet above the ground at only one

and a half kilometers from the runway

the Boeing 737 suddenly fell straight

down

it only took a few seconds for it to hit

the ground

Turkish 1951 the recording sheds light

on the final minutes of the flight

the crew was configuring their plane for

landing well after it should have been

done

have regulations that call for a flight

to be stabilized to have all checklists

completed by the time the plane hits one

thousand feet in instrument conditions

uh you required a thousand feet to have

basically everything done the airplane

is configured you have slowed you have

run your before landing check and you've

received your Landing clearance and from

a thousand feet on in you just monitor

the instruments and we're looking for

the runway

please warn the cabin crew

in fact this crew was still running

their checklist after the moment the

crisis hit 460 feet above the ground

this approach was not stabilized

because the aircraft was unstable the

flight crew was in a very high workload

environment in the last thousand feet of

flight

the radio altimeter was malfunctioning

the aircraft was giving off warnings the

crew was assigned a challenging approach

and they were executing a checklist late

but none of this explains why flight

1951 crashed in these type of accidents

you can never get inside the head of the

pilots and that's a very frustrating

type of accident

but the flight data recorder does

provide another intriguing clue moments

before flight 1951 hit the ground the

plane's engines were at idle hardly

providing any power

perhaps this accident is a repeat of the

Heathrow incident the engines it was

interesting to note were at idle

approximately the last two minutes of

flight until the very end when the

thrust was increased again

that was a big red flag right there

the question is why was that the case

but then they spot something that's very

different from the accident at Heathrow

[ __ ] flare mode

for some reason while still more than a

thousand feet above the ground

the plane's computer began preparing to

touch down

in retired Flair mode engine power is

reduced to idle by the flight computer

and the plane's nose automatically

pitches up to the flare position

planes should only be in this

configuration just before they touch the

ground

the autopilot raises the nose to break

the Descent the auto throttles brings

the power back to flight idle and you

touch down with the power either all the

way in idle are just about to be an idol

but fly to 1951 went into a slow nose up

position well before touchdown causing

the plane to fly slower and slower

throughout its descent

so why was flight 1951 in landing mode

and why hadn't any of the three crew

members noticed how slowly they were

flying

[Music]

so what else is going on when the

engines went to idle the trouble seems

to start with the malfunctioning

altimeter we had to look at the system

as a whole and see how that minus eight

affected the other systems on the

aircraft

and that was a very big portion of this

investigation we had to say how did the

autopilot use that data more importantly

how did the auto throttle use that data

the computer that flies the plane

consists of two main systems the

autopilot and the auto throttle the auto

throttle determines how much power to

ask the engines for while the autopilot

controls the plane's altitude and

direction

the two systems work independently of

each other and only one of the radio

altimeters provides information to the

auto throttle

in this case I had to learn everything

there was about radio altimeters and

auto throttle systems which I didn't

know before

the pieces of the puzzle begin coming

together when they find the connection

between the faulty radio altimeter and

engine power

the radio alternator provides

information to the auto throttle from

the captain side

[Music]

the only altimeter feeding information

to the auto throttle was the captains

and it was wrong

it showed minus eight feet throughout

most of flight 1951's approach

it's beginning to look like the faulty

radio altimeter triggered the events

that led to the crash investigators need

to know what went wrong with it

on a 737 the transmitting and receiving

antennas for both radio altimeters are

lined up underneath the cockpit

three of the antennas were all but

destroyed in the crash they can't be

tested

but one antenna from the captain's side

is undamaged

investigators consider two possibilities

a failure of one of the components or

some sort of interference that caused

the faulty reading

the only component that survived the

crash checks out

the computers that control the system

also work

but investigators do make a curious

discovery about them they aren't the

same ones that were installed on the

plane when it was delivered to Turkish

Airlines seven years ago

this find changes the focus of the

investigation

the maintenance aspect of this accident

aircraft was one that we looked at as

deeply as we could

when the plane's maintenance log is

studied investigators find that the

radio altimeter on this plane had a

problematic history we got additional

data from Turkish Airlines

and that data showed that on this one

aircraft of the past I believe over a

thousand flights there was about 150

flights that had faulty radio altimeter

systems

the documents show that a little more

than a year before the crash both

computers were replaced because of

complaints they were causing faulty

readings one of the incidents involved a

radio altimeter reading of -8 feet

so that was telling us that there was a

an issue that had been there the issue

did not just occur on this flight

the faulty readings persisted

mechanics repeatedly swapped the

computers and replaced the antennas to

try to solve the problem

it's determined that Turkish Airlines

tried several ways to fix the altimeter

but they couldn't find a repair that

worked

at the time of the accident Turkish

Airlines had a fleet of 52 Boeing

737-800 series airplanes

[Music]

it's on page 93 when we reviewed the

maintenance data we found that radio

altimeter problems had been written up

several times on both the axon airplane

and the fleet

investigators discover that in the year

before the crash Turkish Airlines dealt

with

235 system faults with the radio

altimeters on their 737s

fixes ranged from replacing and

exchanging antennas cleaning of the

systems exchanging and replacing the

computers

and installing gaskets to Shield the

system from possible water damage

it's not like they weren't doing

anything about it

the Turkish Airlines maintenance

Personnel knew that the radio altimeter

problem

was one of their highest issues with

regard to maintenance

16 of those altimeter repairs were made

to the plane that crashed in February

2009. if the problem was so widespread

investigators wonder why it hadn't

caused serious problems before this

accident

they don't have to dig too far back to

find out that in fact it had on this

very same plane

two recent flights they had the exact

same problem

twice in the 48 Hours leading up to the

accident

the radio altimeter showed a negative

reading

putting the plane into [ __ ] flare mode

both times the crew noticed the problem

disengage the auto throttles and brought

the plane in for a safe landing

[Music]

you just disconnect and fly the airplane

in the months after the crash other

operators come forward with similar

stories in Australia

in the Netherlands in Canada in Austria

Pilots report their 737s going into

[ __ ] flare mode when the left radio

altimeter showed a faulty reading

each of those Crews reacted the same way

they disengaged the auto throttle and

pushed the power back up manually

they all landed safely

things are going to break on an airplane

and usually you're able to to identify

that and take that out of make it so

that it's not a threat for the landing

in 2008 Boeing received a whopping

2569 reports of faulty radio altimeters

on their latest 737s but very few of

those cases involved the plane going

into [ __ ] flare mode hardly any

reports at all

Boeing also tried but couldn't find the

cause of the failures

They concluded that the radio altimeter

problem was not a threat to safety

because the 737 gives off enough

warnings so that Crews can intervene and

land safely

in fact in every instance where the

radio altimeter failed Crews were able

to recover

Kish Airlines flight 1951 seems to be

the one exception

investigators still don't know why

it really got us wondering of what

happened and that's when we started to

look really closely at the

at the actions of the flight Crews while

it was on that Final Approach in less

than a thousand feet

finally as investigators again revisit

the last minutes of flight 1951.

the circumstances of the tragedy become

clear

they see a remarkable sequence of events

that transpire to bring down this plane

so

what was happening when the plane went

into retired flare mode they discovered

that the plane went into landing mode

and pulled back power at the worst

possible moment exactly as the crew was

descending to meet the Glide slope it

masked what was actually happened

[Music]

as the crew configured their plane to

drop down to meet the Glide slope they

expected the plane to slow down as part

of that maneuver

but the plane was actually slowing down

because the computer was in landing mode

that's why none of the three Pilots said

anything about the throttles moving to

idle it was Insidious where it first

captured in the [ __ ] mode it didn't

hurt them at all because they were

actually high and they were a little bit

fast and the pilots actually wanted the

power back anyway in fact the throttles

may have already been in the flight idle

mode as they were trying to get down and

slow down

the treble starts here at 8 300 feet 13

miles out from the airport minutes

before the crash

Turkish 1951 descending 7000 speed 250.

speed okay for ILS

right

radio ultimate

but would the crew have known that

because of that radio altimeter they

would have gone to a [ __ ] flare mode

in the throttles no

it was a common problem at the airline

but the crew couldn't see the risk it

posed this flight

we have an airplane that was

malfunctioning in a very minor way but

in a way that if not caught could and

did metastasize into something much more

virulent

2000 1951

Turkish 1951 left heading two one zero

cleared approach one eight right left

two on zero clear ILS Turkish 1951 the

left the 210 degrees maintaining two

thousand feet brings the plate in right

here

5.5 miles out we now have to intercept

the Glide slope from above

at two thousand feet with the Glide

slope below them the pilots have to

reduce their speed while descending

steeply

speed one four zero they believe the

throttles are moving back for The

Descent to the Glide slope

in fact the auto throttle is slowing the

plane down because it's gone into

landing mode

it will continue to slow the plane until

it stalls what we found is that when the

flight crew was doing their before

landing checklist

each one of them was doing something

while they should have been monitoring

their airspeed for the next 100 seconds

no one notices what's happening

until it's too late

established altitude set thousand check

flaps 40 speed set the experienced pilot

recognized that the first officer is

probably a little bit behind on the

approach so he calls for Flash 40 and

moves the lever informing the first

officer that he has done so he's trying

to help the first officer catch up to

the position of the aircraft speed brake

green light one thing at a time landing

gear

the plane is now 700 feet from the

ground gear down three green flaps flaps

40 green light

in their haste to complete their

checklist none of the three crew members

noticed the warnings that their speed is

dropping Dangerously

first a red bar appeared on their flight

display

then when the airspeed continued to drop

a flashing box appeared around their

actual AirSpeed to draw the Pilot's

attention to it

at this point no one sees either cabin

report confirmed the aircraft is now 600

feet from Landing when things start

changing colors it's a warning to you

it's a caution to you that you're

approaching the limits of the aircraft

missed approach altitude set 500 so all

these indications the crew has in front

of them saying that the aircraft is

slowing down during that time they were

still completing their checklist of

course the aircraft is getting closer to

the ground in fact it's less than 500

feet from touchdown and right before

the stick Shaker started the captain

told the safety pilot group

Kevin crew take your seats

speed zone I have control by the time

they Advance the travels to full power

it was unrecoverable they were too low

for the engines to catch up

and that's it it's now too late to save

this plane

they all knew about the altimeter

problem but knowing didn't help

Boeing also didn't foresee the

potentially deadly effect of a faulty

altimeter

but on February 25th 2009 it triggered

an unusual sequence of events that

brought down a jetliner and killed nine

people

the official report into the accident

blames it on a convergence of

circumstances

there is never ever just one cause to an

airline accident it simply doesn't exist

maybe someday God will swap one out of

the sky but until then there's never one

cause the Dutch report also points out

that Boeing could have realized the

problem with the radio altimeter system

could have had an impact on safety given

that no one foresaw how that failure

might cause a crash

the Turkish Airlines accident raises a

big question

are airplanes becoming too complex

[Music]

investigators have determined that

Turkish Airlines flight 1951 crashed

mainly because the pilots didn't

recognize the consequences of the

warnings they were getting

turkish1951 descent to four thousand

this is not the first plane to crash

because the crew didn't understand what

their plane was telling them our problem

is not the automation our problem is the

depth of the training and the ability of

the human beings to recover from

mistakes made in interfacing with the

automation

Mika Ensley studies the relationship

between pilots and Technology

we haven't really designed the

automation to take best advantage of

what people do well and take them take

away the parts that people don't do well

in 1996 the crew of an aero Peru 757

crashed when the pilots couldn't

decipher contradictory warnings about

their altitude and airspeed

the plane flew into the Pacific Ocean 61

passengers and nine crew members were

killed

in 1995 the flight management system on

a Boeing 757 could and should have

steered the plane to a safe landing in

Kali Colombia

but a last-minute change to the flight

plan meant the crew had to reprogram

their computer they mistakenly entered a

course that took them headlong into a 9

000 foot Mountain

159 people died in the crash

the cautionary tale here is that we can

get this equipment we can get these

silicon-based units if you will So

Sophisticated that we can't talk to them

effectively and when they go berserk or

they have a problem or we misprogram

them we end up putting ourselves and our

passengers in danger while we're trying

to figure it out

NASA is working on something called the

integrated intelligent Flight Deck

it's a project aimed at helping humans

better use the technology that surrounds

them in the cockpit they're looking at

automated flight manual systems voice

recognition systems they've developed

new kinds of microphones that are bone

conducting chips they're developing new

displays for understanding the ground

environment for being able to detect

where other aircraft are in the

environment what some researchers are

finding is that the best technology

shouldn't replace Pilots but work with

them

really integrating people with

technology more effectively has to do

with designing the displays so that you

can really understand what it's doing

and you can make it simpler to

understand how to make it do what it is

you want it to do you shouldn't have to

push 16 buttons through eight levels of

menus to figure out what's going on with

the system it should be integrated and

presented effectively it should be as

easy to communicate with as the person

next to you Boeing and Airbus the two

largest manufacturers of passenger

planes take very different approaches to

the relationship between humans and

Technology

Airbus gives the flight computer much of

the decision-making power in the cockpit

in their view this is a way to prevent a

lot of human Errors By by making sure

the airplane doesn't do something that's

going to cause a crash even if the

humans wanted to but Boeing has a

different view its philosophy is to

provide information to pilots and have

them make decisions

having more information is better for

the pilot than having the pilot in the

loop in the equation so to speak

I kind of like that Airbus will argue

vociferously and and in continuous

fashion that that view is archaic and

incorrect I think the jury is still out

the final report into the Turkish

Airlines tragedy blames the crash of

Flight 1951 partly on a failure of

Technology the erroneous radio altimeter

data caused the auto throttle to go to a

improper mode that is of course not a

good situation the cause of the radio

altimeter failure was never uncovered

the Dutch investigation asks Boeing to

improve the reliability of the system we

learned a lot about the radio altimeter

system and how it affects the auto

throttle system Boeing is currently

working on on system improvements to

to prevent this type of

Auto throttle event from occurring again

but the report also faults the crew for

not noticing that their AirSpeed was

dropping dangerously low in spite of the

fact that there were three pilots on

board forget that you got an auto

throttle

you look at the airspeed and you look at

the altitude you look out the damn

window if you want to but AirSpeed is a

crucial component of staying in alive in

an airplane and you always need to know

what your AirSpeed is

but Tamika Ensley the crew's failure to

monitor instruments is entirely

understandable and may be more the fault

of the instruments than the crew

it's actually very difficult for people

to be monitors of automation one of the

things that people don't do a good job

of actually is monitoring we're very

good on the spot decision makers we're

very good at coming up with Creative

Solutions to problems but repetitive

monitoring is the kind of thing that

actually people aren't very good at at

all so what we have to do is design

automation to work with people in a way

that keeps them more actively

cognitively involved and in the loop and

not just monitoring a piece of

automation to say is it doing what it's

supposed to be doing

who's the ultimate computer the pilot

the individual who should be able to say

I don't know what this thing is doing to

me but I'm punching it off and flying

the airplane fly the jet probably the

smartest thing we ever learned to say in

our training in the airlines fly the jet

do that first or nothing else counts

that's what they forgot to do