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Mayday, mayday,
engine flameout.
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Mayday, mayday,
engine flameout.
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00:00:12,712 --> 00:00:15,348
A dash cam video
captures the last moments
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00:00:15,415 --> 00:00:16,716
of a horrific plane crash.
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00:00:19,386 --> 00:00:20,620
A minor flight issue...
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00:00:22,222 --> 00:00:23,590
Right engine oil pressure.
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...turns into a crisis.
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...turns into a crisis.
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Gerrit, Gerrit.
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There was several
places where the airplane
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There was several
places where the airplane
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could have been saved.
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Fire.
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00:00:35,635 --> 00:00:38,071
A revolutionary
new aircraft breaks
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A revolutionary
new aircraft breaks
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up during a critical flight.
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Three tragedies caused
by fateful decisions
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made in the heat of the moment.
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The tendency
is always, let's solve
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The tendency
is always, let's solve
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the problem right this minute.
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And we've lost a lot
of airplanes that way.
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Ladies and gentlemen,
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Ladies and gentlemen,
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we are starting our approach.
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We lost both engines.
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The last...
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emergency descend.
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Brace for impact.
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Brace for impact.
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It's going to crush.
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Taipei, capital city of Taiwan.
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Taipei, capital city of Taiwan.
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Near its center lies
Songshan Airport.
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Near its center lies
Songshan Airport.
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The next plane scheduled
for departure this morning
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The next plane scheduled
for departure this morning
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is TransAsia Flight 235.
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is TransAsia Flight 235.
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The first officer
is Liu Tze-chung.
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He has almost 7,000
hours of flying time.
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He has almost 7,000
hours of flying time.
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Oil pressure.
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Check.
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The captain,
Liao Chien-tsung,
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is a former military pilot.
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is a former military pilot.
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A third pilot is
observing today's flight.
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A third pilot is
observing today's flight.
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TransAsia 235 is a one hour
commuter flight from Taipei
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TransAsia 235 is a one hour
commuter flight from Taipei
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to the Taiwanese
island of Kinmen,
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just off the coast
of mainland China.
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just off the coast
of mainland China.
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TransAsia 235, runway 10,
wind 100 degree, nine are not,
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TransAsia 235, runway 10,
wind 100 degree, nine are not,
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cleared for takeoff.
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OK, cleared for takeoff.
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OK, cleared for takeoff.
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Immediately after takeoff, the captain
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Immediately after takeoff, the captain
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engages the autopilot.
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Gear up.
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Gear up.
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Flight 235 climbs
over metropolitan Taipei,
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Flight 235 climbs
over metropolitan Taipei,
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home to more than
seven million people.
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Seconds later, the
Master Warning sounds.
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Seconds later, the
Master Warning sounds.
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The Master Warning is
indicative of an emergency
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situation requiring
an immediate response.
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situation requiring
an immediate response.
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TransAsia 235 has lost an engine.
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TransAsia 235 has lost an engine.
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The captain disengages
the autopilot.
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I have control.
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You have control.
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You have control.
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Heading mode?
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He needs a
heading back to the airport.
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Below 2,500 feet.
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Below 2,500 feet.
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Turn to heading, it's...
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Come on!
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Zero, zero niner five.
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Zero, zero niner five.
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Check.
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When you lose
an engine in a twin engine
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aircraft, you need to
be able to maintain
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00:03:33,913 --> 00:03:36,549
aircraft, you need to
be able to maintain
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00:03:36,616 --> 00:03:38,651
your client performance.
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OK, engine flameout check.
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00:03:44,457 --> 00:03:46,259
Check.
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The speed and
climb rate are dropping fast.
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00:03:46,326 --> 00:03:49,395
The speed and
climb rate are dropping fast.
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00:03:49,462 --> 00:03:52,432
Watch the speed.
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00:03:52,498 --> 00:03:55,001
Stall, stall, stall.
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00:03:52,498 --> 00:03:55,001
Stall, stall, stall.
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00:03:55,068 --> 00:03:57,570
The Stall Warning
indicates the plane is flying
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00:03:57,637 --> 00:04:00,006
too slowly to maintain lift.
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00:03:57,637 --> 00:04:00,006
too slowly to maintain lift.
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00:04:00,073 --> 00:04:02,008
The Stall
Warning at low altitudes,
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00:04:02,075 --> 00:04:05,878
a critical situation that no
pilot ever wants to end up in.
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00:04:05,945 --> 00:04:07,246
Terrain ahead.
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00:04:05,945 --> 00:04:07,246
Terrain ahead.
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00:04:07,313 --> 00:04:08,715
Tower, TransAsia 235.
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00:04:08,781 --> 00:04:11,985
Mayday, mayday, engine flameout.
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Engine flameout, both sides.
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00:04:20,593 --> 00:04:22,795
How is this possible?
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The crew was
surrounded by high density
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00:04:22,862 --> 00:04:25,765
The crew was
surrounded by high density
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housing, high rise
apartment blocks,
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a heavily populated area.
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a heavily populated area.
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Impact, brace for impact!
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00:04:34,374 --> 00:04:37,010
Impact, brace for impact!
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00:04:37,076 --> 00:04:37,510
Oh, no!
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Oh.
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Oh no!
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Pull up.
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TransAsia flight 235 has
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gone down in the Keelung River.
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00:04:58,831 --> 00:05:01,000
gone down in the Keelung River.
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00:05:04,737 --> 00:05:06,806
Suspend all takeoff
and landing operations.
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00:05:04,737 --> 00:05:06,806
Suspend all takeoff
and landing operations.
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00:05:06,873 --> 00:05:11,010
Begin emergency procedures.
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Rescuers rushed to the scene.
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00:05:11,077 --> 00:05:12,578
Rescuers rushed to the scene.
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00:05:17,150 --> 00:05:23,890
Of the 58 people on board,
only 15 make it out alive.
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00:05:17,150 --> 00:05:23,890
Of the 58 people on board,
only 15 make it out alive.
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00:05:23,956 --> 00:05:25,725
All three pilots are dead.
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00:05:23,956 --> 00:05:25,725
All three pilots are dead.
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00:05:32,565 --> 00:05:35,702
Investigators from Taiwan's
Aviation Safety Council
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00:05:35,768 --> 00:05:38,071
need to start collecting
evidence at the scene.
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00:05:35,768 --> 00:05:38,071
need to start collecting
evidence at the scene.
136
00:05:41,774 --> 00:05:44,711
But even before they
leave headquarters...
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00:05:41,774 --> 00:05:44,711
But even before they
leave headquarters...
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00:05:44,777 --> 00:05:46,412
Take a look at this.
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00:05:46,479 --> 00:05:48,481
...a stunning piece
of evidence from a dashboard
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00:05:46,479 --> 00:05:48,481
...a stunning piece
of evidence from a dashboard
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00:05:48,548 --> 00:05:49,749
camera surfaces.
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00:05:56,589 --> 00:05:57,623
What?
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00:06:01,794 --> 00:06:04,964
What was happening
on that plane?
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00:06:05,031 --> 00:06:06,566
What do you think?
145
00:06:05,031 --> 00:06:06,566
What do you think?
146
00:06:06,632 --> 00:06:08,868
Left engine?
147
00:06:08,935 --> 00:06:10,470
When we watched
the video clip,
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00:06:10,536 --> 00:06:13,372
we know there's something
wrong about the engine.
149
00:06:10,536 --> 00:06:13,372
we know there's something
wrong about the engine.
150
00:06:13,439 --> 00:06:15,074
The prop seems very slow.
151
00:06:18,778 --> 00:06:20,880
Is this the left engine?
152
00:06:20,947 --> 00:06:22,048
Uh, yes.
153
00:06:24,650 --> 00:06:27,553
Investigators can
see in the dash cam video
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00:06:27,620 --> 00:06:32,158
that the plane was banked
steeply to the left.
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00:06:27,620 --> 00:06:32,158
that the plane was banked
steeply to the left.
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00:06:32,225 --> 00:06:35,128
A faulty left engine is
the most likely suspect.
157
00:06:39,599 --> 00:06:43,770
But the recovered engine
shows no sign of a fault.
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00:06:39,599 --> 00:06:43,770
But the recovered engine
shows no sign of a fault.
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00:06:43,836 --> 00:06:45,905
Left engine
completely operational.
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00:06:48,508 --> 00:06:48,975
Ah, strange.
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00:06:53,679 --> 00:06:56,616
When they study the
right engine, what they find
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00:06:53,679 --> 00:06:56,616
When they study the
right engine, what they find
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00:06:56,682 --> 00:06:58,050
is equally mystifying.
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00:07:01,621 --> 00:07:04,624
Look at the blades.
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They're feathered.
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00:07:09,529 --> 00:07:13,533
Feathered is a
propeller's fail safe position.
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00:07:09,529 --> 00:07:13,533
Feathered is a
propeller's fail safe position.
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00:07:13,599 --> 00:07:16,469
When a propeller engine
loses power in flight,
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00:07:16,536 --> 00:07:20,072
the blades automatically rotate
parallel to the airstream
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00:07:16,536 --> 00:07:20,072
the blades automatically rotate
parallel to the airstream
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to reduce drag and
allow the plane
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to operate with one engine.
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to operate with one engine.
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00:07:24,977 --> 00:07:27,046
Why would the right
engine be feathered
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00:07:27,113 --> 00:07:28,948
when the dash cam
video clearly shows
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the plane banking to the left?
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00:07:29,015 --> 00:07:30,917
the plane banking to the left?
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00:07:30,983 --> 00:07:33,186
It doesn't make any sense.
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00:07:33,252 --> 00:07:35,988
Let's have a look.
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00:07:36,055 --> 00:07:39,792
When we discover a
feathered of the propeller,
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00:07:39,859 --> 00:07:41,961
we know there
should be something
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00:07:42,028 --> 00:07:44,230
wrong about the engine.
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00:07:44,297 --> 00:07:46,833
But their inspection
shows the right engine
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is also in working condition.
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00:07:46,899 --> 00:07:48,935
is also in working condition.
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00:07:49,001 --> 00:07:51,804
If both engines
were operational,
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00:07:51,871 --> 00:07:53,739
why did this plane crash?
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00:07:57,577 --> 00:08:00,546
Investigators hope the
plane's flight data recorder,
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00:07:57,577 --> 00:08:00,546
Investigators hope the
plane's flight data recorder,
190
00:08:00,613 --> 00:08:03,749
which records dozens of flight
parameters, can tell them more.
191
00:08:06,552 --> 00:08:09,589
But all data points indicate
the plane was operating
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00:08:09,655 --> 00:08:11,924
normally, except for one.
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00:08:11,991 --> 00:08:15,027
Take a look at this.
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00:08:11,991 --> 00:08:15,027
Take a look at this.
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00:08:15,094 --> 00:08:16,295
The torque is all
over the place.
196
00:08:21,033 --> 00:08:22,902
Torque is
the twisting rotational
197
00:08:22,969 --> 00:08:25,671
force created by the engine.
198
00:08:22,969 --> 00:08:25,671
force created by the engine.
199
00:08:25,738 --> 00:08:28,975
It increases and decreases
during specific phases
200
00:08:29,041 --> 00:08:32,245
of flight, but it's not
supposed to fluctuate
201
00:08:29,041 --> 00:08:32,245
of flight, but it's not
supposed to fluctuate
202
00:08:32,311 --> 00:08:33,880
in such rapid bursts.
203
00:08:33,946 --> 00:08:35,781
Why is it doing that?
204
00:08:35,848 --> 00:08:37,183
They dig
deeper, studying
205
00:08:35,848 --> 00:08:37,183
They dig
deeper, studying
206
00:08:37,250 --> 00:08:40,253
how the Pratt & Whitney
engine measures torque.
207
00:08:40,319 --> 00:08:42,989
So we try
to find out the design
208
00:08:40,319 --> 00:08:42,989
So we try
to find out the design
209
00:08:43,055 --> 00:08:45,191
logic for the system.
210
00:08:45,258 --> 00:08:47,793
What's the connection
between the torque
211
00:08:47,860 --> 00:08:49,095
and the feather propellers?
212
00:08:47,860 --> 00:08:49,095
and the feather propellers?
213
00:08:51,964 --> 00:08:53,666
They learned
that the engine's
214
00:08:53,733 --> 00:08:57,236
auto feathering system includes
an electronic torque sensor.
215
00:08:53,733 --> 00:08:57,236
auto feathering system includes
an electronic torque sensor.
216
00:08:57,303 --> 00:09:01,908
It measures how much rotational
force the engine is producing.
217
00:08:57,303 --> 00:09:01,908
It measures how much rotational
force the engine is producing.
218
00:09:01,974 --> 00:09:04,310
An extremely low torque
reading indicates
219
00:09:04,377 --> 00:09:08,047
that the engine has failed and
triggers automatic feathering.
220
00:09:04,377 --> 00:09:08,047
that the engine has failed and
triggers automatic feathering.
221
00:09:12,051 --> 00:09:13,853
But investigators
have already concluded
222
00:09:13,920 --> 00:09:16,255
the engine was operational.
223
00:09:16,322 --> 00:09:18,991
They need to find the
reason incorrect torque
224
00:09:16,322 --> 00:09:18,991
They need to find the
reason incorrect torque
225
00:09:19,058 --> 00:09:21,594
readings would cause the
right engine to feather.
226
00:09:21,661 --> 00:09:25,765
Maybe the sensor is sending
a faulty reading, triggering
227
00:09:21,661 --> 00:09:25,765
Maybe the sensor is sending
a faulty reading, triggering
228
00:09:25,831 --> 00:09:27,099
the auto feathering unit.
229
00:09:30,102 --> 00:09:31,771
Investigators find the circuit
230
00:09:31,837 --> 00:09:32,972
board from the right engine.
231
00:09:33,039 --> 00:09:35,207
Took a look underneath.
232
00:09:35,274 --> 00:09:37,109
And look
for any defects
233
00:09:35,274 --> 00:09:37,109
And look
for any defects
234
00:09:37,176 --> 00:09:40,346
that could have caused the
propeller to feather in flight.
235
00:09:40,413 --> 00:09:43,149
It's
a broken solder.
236
00:09:40,413 --> 00:09:43,149
It's
a broken solder.
237
00:09:43,215 --> 00:09:45,751
They discover
microscopic faults
238
00:09:45,818 --> 00:09:46,619
in the circuit board.
239
00:09:52,291 --> 00:09:54,627
With a broken circuit
board, the sensor
240
00:09:52,291 --> 00:09:54,627
With a broken circuit
board, the sensor
241
00:09:54,694 --> 00:09:57,763
couldn't detect torque
even though the engine
242
00:09:57,830 --> 00:09:59,699
was functioning perfectly.
243
00:09:59,765 --> 00:10:02,868
So the system automatically
feathered the propeller.
244
00:09:59,765 --> 00:10:02,868
So the system automatically
feathered the propeller.
245
00:10:04,937 --> 00:10:05,972
OK.
246
00:10:06,038 --> 00:10:07,606
Engine flameout check.
247
00:10:07,673 --> 00:10:08,841
Check.
248
00:10:08,908 --> 00:10:11,377
They now understand
why the right-side propeller
249
00:10:11,444 --> 00:10:12,345
feathered.
250
00:10:11,444 --> 00:10:12,345
feathered.
251
00:10:12,411 --> 00:10:16,182
Investigators now face
an even bigger mystery.
252
00:10:16,248 --> 00:10:18,250
Losing thrust in
the right engine
253
00:10:16,248 --> 00:10:18,250
Losing thrust in
the right engine
254
00:10:18,317 --> 00:10:23,756
should cause a right bank,
but the dash cam video clearly
255
00:10:23,823 --> 00:10:27,059
shows the plane banking left.
256
00:10:23,823 --> 00:10:27,059
shows the plane banking left.
257
00:10:27,126 --> 00:10:29,762
The power lever angle.
258
00:10:29,829 --> 00:10:31,964
When investigators
check the throttle settings
259
00:10:29,829 --> 00:10:31,964
When investigators
check the throttle settings
260
00:10:32,031 --> 00:10:34,800
on the left or
number one engine,
261
00:10:34,867 --> 00:10:37,303
they make a stunning discovery.
262
00:10:34,867 --> 00:10:37,303
they make a stunning discovery.
263
00:10:37,370 --> 00:10:39,205
Unbelievable.
264
00:10:39,271 --> 00:10:43,009
The power of the
number one engine
265
00:10:39,271 --> 00:10:43,009
The power of the
number one engine
266
00:10:43,075 --> 00:10:46,145
was gradually being
reduced, reduced,
267
00:10:46,212 --> 00:10:48,314
and eventually being shut off.
268
00:10:46,212 --> 00:10:48,314
and eventually being shut off.
269
00:10:52,051 --> 00:10:54,820
On this
ATR 72, the throttles
270
00:10:52,051 --> 00:10:54,820
On this
ATR 72, the throttles
271
00:10:54,887 --> 00:10:56,288
can only be moved by hand.
272
00:11:01,160 --> 00:11:04,196
It had to have been shut
down by one of the pilots.
273
00:11:04,263 --> 00:11:05,664
So we
start to wondering,
274
00:11:05,731 --> 00:11:09,001
why the pilot was shut
down the good engine.
275
00:11:05,731 --> 00:11:09,001
why the pilot was shut
down the good engine.
276
00:11:09,068 --> 00:11:10,236
That's crazy.
277
00:11:17,276 --> 00:11:19,812
How is this possible?
278
00:11:19,879 --> 00:11:22,715
Investigators turned
to the cockpit voice recording
279
00:11:19,879 --> 00:11:22,715
Investigators turned
to the cockpit voice recording
280
00:11:22,782 --> 00:11:26,919
to help explain why
TransAsia flight 235 crashed
281
00:11:26,986 --> 00:11:29,288
in Taipei's Keelung River.
282
00:11:26,986 --> 00:11:29,288
in Taipei's Keelung River.
283
00:11:29,355 --> 00:11:31,424
TransAsia 235,
284
00:11:31,490 --> 00:11:35,928
contact approach a one, one,
niner decimal seven, good day.
285
00:11:31,490 --> 00:11:35,928
contact approach a one, one,
niner decimal seven, good day.
286
00:11:35,995 --> 00:11:40,433
We still have number one
engine produce power normally,
287
00:11:35,995 --> 00:11:40,433
We still have number one
engine produce power normally,
288
00:11:40,499 --> 00:11:42,935
but for some reason
the pilot decided
289
00:11:43,002 --> 00:11:45,004
to shut down the good engine.
290
00:11:45,071 --> 00:11:47,339
We have to find out why.
291
00:11:45,071 --> 00:11:47,339
We have to find out why.
292
00:11:48,841 --> 00:11:50,009
What's that sound?
293
00:11:50,076 --> 00:11:53,112
It must be the
engine Default Warning.
294
00:11:50,076 --> 00:11:53,112
It must be the
engine Default Warning.
295
00:11:53,179 --> 00:11:54,413
Investigators already know
296
00:11:54,480 --> 00:11:57,216
a faulty torque sensor
caused the right engine
297
00:11:54,480 --> 00:11:57,216
a faulty torque sensor
caused the right engine
298
00:11:57,283 --> 00:12:01,053
to feather and lose thrust.
299
00:12:01,120 --> 00:12:03,122
This is a crucial moment.
300
00:12:01,120 --> 00:12:03,122
This is a crucial moment.
301
00:12:03,189 --> 00:12:05,357
Let's hear what they're
going to do next.
302
00:12:05,424 --> 00:12:06,759
I have control.
303
00:12:06,826 --> 00:12:08,160
Investigators hear the sound
304
00:12:08,227 --> 00:12:10,229
of the autopilot turning off.
305
00:12:08,227 --> 00:12:10,229
of the autopilot turning off.
306
00:12:10,296 --> 00:12:12,098
He's disengaging
the autopilot.
307
00:12:12,164 --> 00:12:13,299
He shouldn't be doing that.
308
00:12:17,603 --> 00:12:22,541
He just made a
difficult situation worse.
309
00:12:17,603 --> 00:12:22,541
He just made a
difficult situation worse.
310
00:12:22,608 --> 00:12:24,777
OK, engine flameout check.
311
00:12:24,844 --> 00:12:26,278
Check.
312
00:12:26,345 --> 00:12:30,316
There's a checklist
procedure on the screen.
313
00:12:26,345 --> 00:12:30,316
There's a checklist
procedure on the screen.
314
00:12:30,382 --> 00:12:34,153
If they follow the procedure,
do everything correctly,
315
00:12:30,382 --> 00:12:34,153
If they follow the procedure,
do everything correctly,
316
00:12:34,220 --> 00:12:39,258
they should be able to fly back
to land without any problem.
317
00:12:34,220 --> 00:12:39,258
they should be able to fly back
to land without any problem.
318
00:12:39,325 --> 00:12:40,793
But instead of following
319
00:12:40,860 --> 00:12:42,828
the emergency checklist...
320
00:12:42,895 --> 00:12:44,563
Watch the speed.
321
00:12:44,630 --> 00:12:47,032
...the captain
does something inexplicable.
322
00:12:44,630 --> 00:12:47,032
...the captain
does something inexplicable.
323
00:12:47,099 --> 00:12:48,400
Pull back number one.
324
00:12:51,570 --> 00:12:54,507
Both engines are
capable of producing power,
325
00:12:54,573 --> 00:12:56,842
but because the right
engine has feathered,
326
00:12:56,909 --> 00:13:01,881
it has lost thrust behaving
like a car in neutral gear.
327
00:12:56,909 --> 00:13:01,881
it has lost thrust behaving
like a car in neutral gear.
328
00:13:01,947 --> 00:13:05,451
When the captain then pulls
back the left engine throttle,
329
00:13:01,947 --> 00:13:05,451
When the captain then pulls
back the left engine throttle,
330
00:13:05,518 --> 00:13:09,455
he leaves himself
with no thrust at all.
331
00:13:05,518 --> 00:13:09,455
he leaves himself
with no thrust at all.
332
00:13:09,522 --> 00:13:11,457
How could he do such a thing?
333
00:13:11,524 --> 00:13:14,260
The captain of Flight 235
334
00:13:14,326 --> 00:13:18,964
has shut down the plane's
only working engine.
335
00:13:14,326 --> 00:13:18,964
has shut down the plane's
only working engine.
336
00:13:19,031 --> 00:13:21,300
No, wait a
second, cross-check.
337
00:13:19,031 --> 00:13:21,300
No, wait a
second, cross-check.
338
00:13:21,367 --> 00:13:23,202
The pilot
monitoring, to his credit,
339
00:13:23,269 --> 00:13:26,839
did try to stop the pilot flying
from manipulating the engine
340
00:13:26,906 --> 00:13:29,875
number one power
lever and he announced
341
00:13:26,906 --> 00:13:29,875
number one power
lever and he announced
342
00:13:29,942 --> 00:13:30,543
he wanted to cross check.
343
00:13:33,179 --> 00:13:35,047
Heading mode.
344
00:13:35,114 --> 00:13:36,882
But the captain
interrupted the first officer
345
00:13:36,949 --> 00:13:38,951
to ask for a new heading.
346
00:13:39,018 --> 00:13:40,319
Come on!
347
00:13:39,018 --> 00:13:40,319
Come on!
348
00:13:40,386 --> 00:13:42,588
Zero, zero niner five.
349
00:13:42,655 --> 00:13:43,789
Check.
350
00:13:43,856 --> 00:13:46,325
All of a sudden
they've got a dual engine
351
00:13:43,856 --> 00:13:46,325
All of a sudden
they've got a dual engine
352
00:13:46,392 --> 00:13:49,195
failure and the pilot
monitoring I think
353
00:13:49,261 --> 00:13:51,363
has been caught off guard.
354
00:13:49,261 --> 00:13:51,363
has been caught off guard.
355
00:13:51,430 --> 00:13:54,099
And he's not really
sure what's going on.
356
00:13:54,166 --> 00:13:55,301
Restart the engine.
357
00:13:55,367 --> 00:13:56,936
I can't restart the engine!
358
00:13:57,002 --> 00:13:59,238
When the captain
realizes his mistake...
359
00:13:57,002 --> 00:13:59,238
When the captain
realizes his mistake...
360
00:13:59,305 --> 00:14:03,075
Oh, well, I shut
off the wrong engine.
361
00:14:03,142 --> 00:14:05,311
...there's no
time to restart the engine.
362
00:14:09,481 --> 00:14:11,450
Impact, brace for impact!
363
00:14:11,517 --> 00:14:13,152
Oh, no!
364
00:14:17,590 --> 00:14:19,291
Investigators now have an even more
365
00:14:19,358 --> 00:14:22,027
puzzling question to answer.
366
00:14:19,358 --> 00:14:22,027
puzzling question to answer.
367
00:14:22,094 --> 00:14:25,231
Why didn't the captain
understand what he was doing?
368
00:14:27,967 --> 00:14:30,436
Did taking
manual control of the plane
369
00:14:30,502 --> 00:14:35,574
distract the pilot from
verifying which engine failed?
370
00:14:30,502 --> 00:14:35,574
distract the pilot from
verifying which engine failed?
371
00:14:37,476 --> 00:14:38,510
Watch the speed.
372
00:14:43,148 --> 00:14:46,919
He could have been suffering
from change blindness.
373
00:14:43,148 --> 00:14:46,919
He could have been suffering
from change blindness.
374
00:14:46,986 --> 00:14:49,588
Change blindness,
people are focused or fixated
375
00:14:49,655 --> 00:14:52,391
on another item or
area of interest
376
00:14:49,655 --> 00:14:52,391
on another item or
area of interest
377
00:14:52,458 --> 00:14:54,960
and so they miss what
would be considered
378
00:14:55,027 --> 00:14:57,396
a very distinguishable
change in the environment,
379
00:14:55,027 --> 00:14:57,396
a very distinguishable
change in the environment,
380
00:14:57,463 --> 00:14:59,198
but they don't perceive it.
381
00:15:02,368 --> 00:15:03,302
I will pull back
engine one throttle.
382
00:15:02,368 --> 00:15:03,302
I will pull back
engine one throttle.
383
00:15:06,338 --> 00:15:10,142
Even when all the systems were
telling him it was engine two,
384
00:15:06,338 --> 00:15:10,142
Even when all the systems were
telling him it was engine two,
385
00:15:10,209 --> 00:15:15,247
his perception told him he
was doing the right thing.
386
00:15:10,209 --> 00:15:15,247
his perception told him he
was doing the right thing.
387
00:15:15,314 --> 00:15:16,348
Change blindness.
388
00:15:20,152 --> 00:15:23,222
Investigators finally
understand what went wrong
389
00:15:20,152 --> 00:15:23,222
Investigators finally
understand what went wrong
390
00:15:23,289 --> 00:15:27,726
aboard TransAsia Flight 235.
391
00:15:23,289 --> 00:15:27,726
aboard TransAsia Flight 235.
392
00:15:27,793 --> 00:15:30,429
A microscopic crack
in a circuit board
393
00:15:30,496 --> 00:15:32,598
disabled a sensor
in the right engine,
394
00:15:32,665 --> 00:15:35,434
causing the system to
incorrectly determine
395
00:15:32,665 --> 00:15:35,434
causing the system to
incorrectly determine
396
00:15:35,501 --> 00:15:36,669
that the engine had failed.
397
00:15:39,071 --> 00:15:42,508
This was a series of mistakes
on the part of the captain.
398
00:15:39,071 --> 00:15:42,508
This was a series of mistakes
on the part of the captain.
399
00:15:42,574 --> 00:15:44,677
When engine two
feathered, the captain
400
00:15:44,743 --> 00:15:47,546
reacted before he had properly
assessed the situation.
401
00:15:44,743 --> 00:15:47,546
reacted before he had properly
assessed the situation.
402
00:15:53,319 --> 00:15:57,122
The captain should
have followed a checklist.
403
00:15:53,319 --> 00:15:57,122
The captain should
have followed a checklist.
404
00:15:57,189 --> 00:15:58,357
I have control.
405
00:15:58,424 --> 00:15:59,558
But in the
heat of the moment,
406
00:15:59,625 --> 00:16:02,027
he turned off the
autopilot and reduced
407
00:16:02,094 --> 00:16:04,463
power in the wrong engine.
408
00:16:02,094 --> 00:16:04,463
power in the wrong engine.
409
00:16:04,530 --> 00:16:05,731
I will pull back
engine one throttle.
410
00:16:09,401 --> 00:16:12,504
He shut down their
only working engine.
411
00:16:12,571 --> 00:16:18,277
By the time he
realizes, it's too late.
412
00:16:12,571 --> 00:16:18,277
By the time he
realizes, it's too late.
413
00:16:18,344 --> 00:16:19,478
Restart the engine!
414
00:16:19,545 --> 00:16:22,114
I can't restart the engine.
415
00:16:19,545 --> 00:16:22,114
I can't restart the engine.
416
00:16:22,181 --> 00:16:24,283
Wow, I shut off the engine.
417
00:16:27,653 --> 00:16:29,788
The crash of Flight 235
418
00:16:29,855 --> 00:16:34,660
would be the last accident
for TransAsia Airways.
419
00:16:29,855 --> 00:16:34,660
would be the last accident
for TransAsia Airways.
420
00:16:34,727 --> 00:16:37,696
In November 2016, the
company went out of business.
421
00:16:41,233 --> 00:16:44,236
When you talk about the
TransAsia situation in Taipei,
422
00:16:44,303 --> 00:16:46,805
we've got a situation there
where if they had just delayed
423
00:16:44,303 --> 00:16:46,805
we've got a situation there
where if they had just delayed
424
00:16:46,872 --> 00:16:50,075
until they had enough altitude
and air speed doing anything,
425
00:16:50,142 --> 00:16:51,477
they would have probably lived.
426
00:16:50,142 --> 00:16:51,477
they would have probably lived.
427
00:16:57,783 --> 00:16:58,951
Runway in sight.
428
00:16:59,017 --> 00:17:02,388
But sometimes when a
split second decision is made...
429
00:17:02,454 --> 00:17:03,722
Steer, steer!
430
00:17:02,454 --> 00:17:03,722
Steer, steer!
431
00:17:03,789 --> 00:17:08,427
...even a minor
issue can turn deadly.
432
00:17:08,494 --> 00:17:10,295
Gerrit!
433
00:17:08,494 --> 00:17:10,295
Gerrit!
434
00:17:17,836 --> 00:17:20,539
It's
Easter Monday, 1994,
435
00:17:20,606 --> 00:17:23,175
at Amsterdam Schiphol Airport.
436
00:17:20,606 --> 00:17:23,175
at Amsterdam Schiphol Airport.
437
00:17:23,242 --> 00:17:25,844
Set torque.
438
00:17:25,911 --> 00:17:27,413
My controls.
439
00:17:27,479 --> 00:17:29,815
KLM Cityhopper Flight 433
440
00:17:27,479 --> 00:17:29,815
KLM Cityhopper Flight 433
441
00:17:29,882 --> 00:17:34,153
is preparing to fly from
Amsterdam to Cardiff, Wales.
442
00:17:34,219 --> 00:17:37,156
Torque set.
443
00:17:34,219 --> 00:17:37,156
Torque set.
444
00:17:37,222 --> 00:17:39,825
Flying time is
an hour and 20 minutes.
445
00:17:43,695 --> 00:17:48,367
V1, rotate.
446
00:17:43,695 --> 00:17:48,367
V1, rotate.
447
00:17:48,434 --> 00:17:52,604
The plane is a Saab
340B, a dual turboprop designed
448
00:17:48,434 --> 00:17:52,604
The plane is a Saab
340B, a dual turboprop designed
449
00:17:52,671 --> 00:17:54,173
for short regional flights.
450
00:17:57,309 --> 00:18:02,714
The captain on Flight 433 is
37-year-old Gerrit Lievaart.
451
00:17:57,309 --> 00:18:02,714
The captain on Flight 433 is
37-year-old Gerrit Lievaart.
452
00:18:02,781 --> 00:18:05,551
The first Officer
Paul Stassen is 34.
453
00:18:02,781 --> 00:18:05,551
The first Officer
Paul Stassen is 34.
454
00:18:08,887 --> 00:18:10,889
There are 21
passengers on board.
455
00:18:08,887 --> 00:18:10,889
There are 21
passengers on board.
456
00:18:18,397 --> 00:18:21,667
Amsterdam KLM 433.
457
00:18:21,733 --> 00:18:23,635
Go ahead, 433.
458
00:18:21,733 --> 00:18:23,635
Go ahead, 433.
459
00:18:23,702 --> 00:18:25,504
Is flight level 200 available?
460
00:18:28,407 --> 00:18:29,708
Climb to 200.
461
00:18:28,407 --> 00:18:29,708
Climb to 200.
462
00:18:29,775 --> 00:18:32,511
You are recleared
flight level 200.
463
00:18:32,578 --> 00:18:33,679
Thank you, sir.
464
00:18:33,745 --> 00:18:40,853
Climbing flight
level 200, KLM 433.
465
00:18:33,745 --> 00:18:40,853
Climbing flight
level 200, KLM 433.
466
00:18:33,745 --> 00:18:40,853
Climbing flight
level 200, KLM 433.
467
00:18:40,919 --> 00:18:43,322
But on the
way up to 20,000 feet.
468
00:18:47,826 --> 00:18:49,461
Right engine oil pressure.
469
00:18:49,528 --> 00:18:50,295
Check.
470
00:18:50,362 --> 00:18:50,929
Take action.
471
00:18:50,996 --> 00:18:53,265
Copy, taking action.
472
00:18:50,996 --> 00:18:53,265
Copy, taking action.
473
00:18:53,332 --> 00:18:55,701
First Officer
Stassen consults the Engine
474
00:18:55,767 --> 00:18:57,903
Oil Pressure Warning checklist.
475
00:18:57,970 --> 00:18:59,471
There are several
reasons where oil pressure
476
00:18:57,970 --> 00:18:59,471
There are several
reasons where oil pressure
477
00:18:59,538 --> 00:19:01,373
could drop in an engine.
478
00:19:01,440 --> 00:19:04,676
Primarily due to leaks or
some sort of damaging event
479
00:19:01,440 --> 00:19:04,676
Primarily due to leaks or
some sort of damaging event
480
00:19:04,743 --> 00:19:06,478
in the engine system.
481
00:19:06,545 --> 00:19:11,416
Emergency checklist for engine
and propeller oil pressure low.
482
00:19:06,545 --> 00:19:11,416
Emergency checklist for engine
and propeller oil pressure low.
483
00:19:11,483 --> 00:19:12,985
The checklist tells him
484
00:19:13,051 --> 00:19:16,922
to monitor the Warning Light
and the oil pressure gauges.
485
00:19:13,051 --> 00:19:16,922
to monitor the Warning Light
and the oil pressure gauges.
486
00:19:16,989 --> 00:19:21,727
If the Warning Light is
on or the gauge is below 30,
487
00:19:21,793 --> 00:19:23,862
then you can continue.
488
00:19:21,793 --> 00:19:23,862
then you can continue.
489
00:19:23,929 --> 00:19:27,432
But if you have both,
then shut down the engine.
490
00:19:27,499 --> 00:19:30,302
That's not the case.
491
00:19:27,499 --> 00:19:30,302
That's not the case.
492
00:19:30,369 --> 00:19:34,406
The crew decides
it's safe to keep flying.
493
00:19:34,473 --> 00:19:36,275
But then.
494
00:19:34,473 --> 00:19:36,275
But then.
495
00:19:36,341 --> 00:19:41,446
OK, we're
not climbing anymore.
496
00:19:36,341 --> 00:19:41,446
OK, we're
not climbing anymore.
497
00:19:41,513 --> 00:19:43,348
Approaching 17,000 feet
498
00:19:43,415 --> 00:19:45,851
captain Lievaart notices
the plane is not climbing
499
00:19:45,918 --> 00:19:48,320
as quickly as it should be.
500
00:19:45,918 --> 00:19:48,320
as quickly as it should be.
501
00:19:48,387 --> 00:19:49,054
No.
502
00:19:52,491 --> 00:19:55,694
We need to return to
Amsterdam, make a pan call,
503
00:19:52,491 --> 00:19:55,694
We need to return to
Amsterdam, make a pan call,
504
00:19:55,761 --> 00:19:58,797
request to maintain
flight level 160.
505
00:19:55,761 --> 00:19:58,797
request to maintain
flight level 160.
506
00:19:58,864 --> 00:20:00,966
Tell them we have
a technical issue.
507
00:20:01,033 --> 00:20:03,902
A pan call means
there is an unusual situation.
508
00:20:03,969 --> 00:20:06,638
Please pay attention to
us, we need extra help.
509
00:20:03,969 --> 00:20:06,638
Please pay attention to
us, we need extra help.
510
00:20:06,705 --> 00:20:11,310
Amsterdam KLM 433,
pan-pan, pan-pan, pan-pan.
511
00:20:06,705 --> 00:20:11,310
Amsterdam KLM 433,
pan-pan, pan-pan, pan-pan.
512
00:20:11,376 --> 00:20:13,779
We have an engine problem
and we'd like to maintain
513
00:20:13,845 --> 00:20:17,316
160 for return to Schiphol.
514
00:20:13,845 --> 00:20:17,316
160 for return to Schiphol.
515
00:20:17,382 --> 00:20:18,550
That's copy sir.
516
00:20:18,617 --> 00:20:19,851
You may turn right
heading to Schiphol.
517
00:20:25,857 --> 00:20:28,460
KLM 433, 3 can you
give me any details?
518
00:20:28,527 --> 00:20:31,630
KLM 433,
situation's under control.
519
00:20:28,527 --> 00:20:31,630
KLM 433,
situation's under control.
520
00:20:31,697 --> 00:20:35,367
We have an engine oil pressure
problem in engine number two.
521
00:20:31,697 --> 00:20:35,367
We have an engine oil pressure
problem in engine number two.
522
00:20:35,434 --> 00:20:40,639
Yes, OK, we can bring you
in 406, you're our number one.
523
00:20:35,434 --> 00:20:40,639
Yes, OK, we can bring you
in 406, you're our number one.
524
00:20:40,706 --> 00:20:42,507
Five minutes
later, the plane
525
00:20:42,574 --> 00:20:44,476
lines up with a runway.
526
00:20:44,543 --> 00:20:46,411
Runway in sight.
527
00:20:46,478 --> 00:20:48,647
Flaps 20.
528
00:20:46,478 --> 00:20:48,647
Flaps 20.
529
00:20:48,714 --> 00:20:52,084
Flaps 20, out of marker.
530
00:20:52,150 --> 00:20:53,952
Check.
531
00:20:52,150 --> 00:20:53,952
Check.
532
00:20:54,019 --> 00:20:59,458
KLM 433 is just
500 feet above the ground.
533
00:20:54,019 --> 00:20:59,458
KLM 433 is just
500 feet above the ground.
534
00:20:59,524 --> 00:21:01,360
Watch your speed.
535
00:21:01,426 --> 00:21:02,794
The plane
has slowed to the point
536
00:21:02,861 --> 00:21:05,364
that it could stall.
537
00:21:02,861 --> 00:21:05,364
that it could stall.
538
00:21:05,430 --> 00:21:07,432
I'm on it.
539
00:21:07,499 --> 00:21:11,436
Suddenly the
plane banks to the right.
540
00:21:07,499 --> 00:21:11,436
Suddenly the
plane banks to the right.
541
00:21:11,503 --> 00:21:12,537
Going around.
542
00:21:12,604 --> 00:21:15,540
Set torque, flaps
seven, gear up.
543
00:21:15,607 --> 00:21:17,676
Captain Lievaart
attempts to go around.
544
00:21:15,607 --> 00:21:17,676
Captain Lievaart
attempts to go around.
545
00:21:19,911 --> 00:21:22,014
But the plane keeps
banking right.
546
00:21:26,918 --> 00:21:28,920
Steer, steer, steer.
547
00:21:26,918 --> 00:21:28,920
Steer, steer, steer.
548
00:21:28,987 --> 00:21:31,023
Gerrit, Gerrit, Gerrit!
549
00:21:42,501 --> 00:21:45,804
Crash, crash, crash, runway
06, emergency, runway 06.
550
00:21:53,211 --> 00:21:56,515
KLM Flight 433
has crashed in a field next
551
00:21:56,581 --> 00:21:57,082
to the runway.
552
00:22:00,485 --> 00:22:03,522
Of the 24 people on board,
two passengers and the captain
553
00:22:03,588 --> 00:22:04,656
are dead.
554
00:22:03,588 --> 00:22:04,656
are dead.
555
00:22:07,125 --> 00:22:10,095
Eight passengers and the first
officer are seriously injured.
556
00:22:13,498 --> 00:22:16,068
Investigators from the
Netherlands Aviation Safety
557
00:22:16,134 --> 00:22:18,570
Board recover the
plane's black boxes
558
00:22:16,134 --> 00:22:18,570
Board recover the
plane's black boxes
559
00:22:18,637 --> 00:22:20,138
and send them off
for processing.
560
00:22:27,679 --> 00:22:30,682
Meanwhile, lead investigator Ben
Groenendijk is eager to speak
561
00:22:27,679 --> 00:22:30,682
Meanwhile, lead investigator Ben
Groenendijk is eager to speak
562
00:22:30,749 --> 00:22:32,184
with air traffic control.
563
00:22:32,250 --> 00:22:35,787
We go
to the tower and approach
564
00:22:32,250 --> 00:22:35,787
We go
to the tower and approach
565
00:22:35,854 --> 00:22:40,592
and we get the
first information.
566
00:22:35,854 --> 00:22:40,592
and we get the
first information.
567
00:22:40,659 --> 00:22:42,961
They issued a pan call, we're
coming back to the airport.
568
00:22:43,028 --> 00:22:47,966
Amsterdam KLM 433,
pan-pan, pan-pan, pan-pan.
569
00:22:43,028 --> 00:22:47,966
Amsterdam KLM 433,
pan-pan, pan-pan, pan-pan.
570
00:22:48,033 --> 00:22:50,469
We have an engine problem
and we'd like to maintain
571
00:22:50,535 --> 00:22:52,003
160 for return to Schiphol.
572
00:22:56,208 --> 00:22:58,076
Did they tell you
what the problem was?
573
00:22:58,143 --> 00:23:01,913
Yeah, they said it had to
do with the oil pressure.
574
00:22:58,143 --> 00:23:01,913
Yeah, they said it had to
do with the oil pressure.
575
00:23:01,980 --> 00:23:04,783
KLM 433, situation's
under control.
576
00:23:01,980 --> 00:23:04,783
KLM 433, situation's
under control.
577
00:23:04,850 --> 00:23:10,155
We have an engine oil pressure
problem in engine number two.
578
00:23:10,222 --> 00:23:11,857
Next thing I knew
they were going around.
579
00:23:10,222 --> 00:23:11,857
Next thing I knew
they were going around.
580
00:23:15,727 --> 00:23:17,028
Going around.
581
00:23:15,727 --> 00:23:17,028
Going around.
582
00:23:17,095 --> 00:23:20,632
Set torque, flap seven, gear up.
583
00:23:20,699 --> 00:23:22,801
Pilots conduct a
go around if their landing
584
00:23:20,699 --> 00:23:22,801
Pilots conduct a
go around if their landing
585
00:23:22,868 --> 00:23:25,670
becomes unstable.
586
00:23:25,737 --> 00:23:28,173
They increase
the power, they gain altitude.
587
00:23:28,240 --> 00:23:33,044
They circle around and they try
a second time for that landing.
588
00:23:28,240 --> 00:23:33,044
They circle around and they try
a second time for that landing.
589
00:23:33,111 --> 00:23:35,647
Right before the aircraft
is about to touch down...
590
00:23:33,111 --> 00:23:35,647
Right before the aircraft
is about to touch down...
591
00:23:35,714 --> 00:23:37,048
Steer, steer.
592
00:23:37,115 --> 00:23:38,850
...the
potential for danger
593
00:23:38,917 --> 00:23:40,819
is much much higher
than if the same problem
594
00:23:38,917 --> 00:23:40,819
is much much higher
than if the same problem
595
00:23:40,886 --> 00:23:44,556
happened at altitude.
596
00:23:52,230 --> 00:23:54,199
In a hangar
at Schiphol Airport
597
00:23:52,230 --> 00:23:54,199
In a hangar
at Schiphol Airport
598
00:23:54,266 --> 00:23:56,234
the investigators
try to determine
599
00:23:56,301 --> 00:23:58,203
the nature of the
oil pressure problem
600
00:23:58,270 --> 00:24:00,205
and if it contributed
to the crash.
601
00:23:58,270 --> 00:24:00,205
and if it contributed
to the crash.
602
00:24:03,241 --> 00:24:07,746
He could have the seizure
of an engine or overheating
603
00:24:03,241 --> 00:24:07,746
He could have the seizure
of an engine or overheating
604
00:24:07,813 --> 00:24:11,850
because the oil is not there.
605
00:24:07,813 --> 00:24:11,850
because the oil is not there.
606
00:24:11,917 --> 00:24:15,020
Hm, turbines are moving.
607
00:24:15,086 --> 00:24:17,756
But curiously,
they find no evidence
608
00:24:15,086 --> 00:24:17,756
But curiously,
they find no evidence
609
00:24:17,823 --> 00:24:20,058
of any oil pressure issues.
610
00:24:20,125 --> 00:24:26,331
Any damages from the
impact, not from oil pressure.
611
00:24:20,125 --> 00:24:26,331
Any damages from the
impact, not from oil pressure.
612
00:24:26,398 --> 00:24:28,166
It seems
the pilots reported
613
00:24:28,233 --> 00:24:30,268
a problem that didn't exist.
614
00:24:28,233 --> 00:24:30,268
a problem that didn't exist.
615
00:24:34,806 --> 00:24:35,907
Why would they
report a problem
616
00:24:35,974 --> 00:24:37,976
if they didn't have one?
617
00:24:38,043 --> 00:24:39,644
What were they looking at?
618
00:24:39,711 --> 00:24:42,647
Investigators now wonder, did the cockpit
619
00:24:42,714 --> 00:24:46,885
instruments on KLM Flight
433 somehow malfunction
620
00:24:42,714 --> 00:24:46,885
instruments on KLM Flight
433 somehow malfunction
621
00:24:46,952 --> 00:24:48,353
and mislead the pilots?
622
00:24:50,188 --> 00:24:52,090
Right engine oil pressure.
623
00:24:52,157 --> 00:24:54,025
Check, take action.
624
00:24:54,092 --> 00:24:55,260
Copy, taking action.
625
00:24:58,396 --> 00:25:03,034
When investigators
test the oil pressure system
626
00:24:58,396 --> 00:25:03,034
When investigators
test the oil pressure system
627
00:25:03,101 --> 00:25:04,202
one thing jumps out.
628
00:25:07,739 --> 00:25:13,945
Ah, OK, there's a short
circuit in the switch.
629
00:25:07,739 --> 00:25:13,945
Ah, OK, there's a short
circuit in the switch.
630
00:25:14,012 --> 00:25:17,249
Now they understand
what the pilots were seeing,
631
00:25:17,315 --> 00:25:18,717
a false warning.
632
00:25:22,954 --> 00:25:25,190
Right engine oil pressure.
633
00:25:25,257 --> 00:25:26,791
But a
false warning alone
634
00:25:25,257 --> 00:25:26,791
But a
false warning alone
635
00:25:26,858 --> 00:25:28,326
is not enough to cause a crash.
636
00:25:32,197 --> 00:25:34,399
Investigators turned to
the cockpit voice recorder.
637
00:25:37,502 --> 00:25:38,370
OK, let's hear it.
638
00:25:37,502 --> 00:25:38,370
OK, let's hear it.
639
00:25:40,939 --> 00:25:43,408
They hope it will tell
them how a false warning, which
640
00:25:43,475 --> 00:25:46,978
required no action, still
led the pilots to turn
641
00:25:43,475 --> 00:25:46,978
required no action, still
led the pilots to turn
642
00:25:47,045 --> 00:25:49,347
back to Schiphol Airport.
643
00:25:49,948 --> 00:25:51,316
There's the warning.
644
00:25:49,948 --> 00:25:51,316
There's the warning.
645
00:25:51,383 --> 00:25:54,019
Right engine oil pressure.
646
00:25:54,085 --> 00:25:57,155
Let's see how they handle it.
647
00:25:54,085 --> 00:25:57,155
Let's see how they handle it.
648
00:25:57,222 --> 00:25:58,957
Check, take action.
649
00:25:59,024 --> 00:26:02,761
Copy, taking action.
650
00:25:59,024 --> 00:26:02,761
Copy, taking action.
651
00:26:02,827 --> 00:26:05,297
The pilots consult an
emergency checklist that should
652
00:26:05,363 --> 00:26:08,400
help them solve the problem.
653
00:26:05,363 --> 00:26:08,400
help them solve the problem.
654
00:26:08,466 --> 00:26:10,368
If the
Warning Light is on
655
00:26:10,435 --> 00:26:16,374
or the gauge is below 30,
then you can continue.
656
00:26:10,435 --> 00:26:16,374
or the gauge is below 30,
then you can continue.
657
00:26:16,441 --> 00:26:18,209
On Saab
340, the Warning
658
00:26:18,276 --> 00:26:20,812
System and the Oil
Measuring System
659
00:26:18,276 --> 00:26:20,812
System and the Oil
Measuring System
660
00:26:20,879 --> 00:26:22,414
are two separate systems.
661
00:26:22,480 --> 00:26:24,316
And if there is a
confusion between the two,
662
00:26:24,382 --> 00:26:26,184
the guidance on the
emergency checklist
663
00:26:24,382 --> 00:26:26,184
the guidance on the
emergency checklist
664
00:26:26,251 --> 00:26:28,186
is to continue
normal operations.
665
00:26:28,253 --> 00:26:31,222
So the light is on,
but we're above 30 PSI.
666
00:26:31,289 --> 00:26:31,856
So...
667
00:26:31,923 --> 00:26:33,758
Continue normal operation.
668
00:26:31,923 --> 00:26:33,758
Continue normal operation.
669
00:26:36,428 --> 00:26:39,064
The recording reveals
that the pilots knew it was
670
00:26:36,428 --> 00:26:39,064
The recording reveals
that the pilots knew it was
671
00:26:39,130 --> 00:26:40,765
safe to continue their flight.
672
00:26:45,837 --> 00:26:47,439
Why the heck did they
decide to turn back?
673
00:26:52,911 --> 00:26:55,213
OK, we're
not climbing anymore.
674
00:26:55,280 --> 00:26:56,047
Ah.
675
00:26:55,280 --> 00:26:56,047
Ah.
676
00:26:56,114 --> 00:26:57,182
No.
677
00:26:57,248 --> 00:26:59,417
That must be why
they turned back.
678
00:26:59,484 --> 00:27:02,087
Engines are fine.
679
00:26:59,484 --> 00:27:02,087
Engines are fine.
680
00:27:02,153 --> 00:27:03,321
Why are they not climbing?
681
00:27:07,459 --> 00:27:10,128
Investigators now turn
to the flight data recorder.
682
00:27:07,459 --> 00:27:10,128
Investigators now turn
to the flight data recorder.
683
00:27:14,099 --> 00:27:15,333
What's going on here?
684
00:27:19,437 --> 00:27:24,342
Right-side engine
thrust, it's dropping.
685
00:27:19,437 --> 00:27:24,342
Right-side engine
thrust, it's dropping.
686
00:27:24,409 --> 00:27:26,845
It's a
major discovery.
687
00:27:24,409 --> 00:27:26,845
It's a
major discovery.
688
00:27:26,911 --> 00:27:30,348
It suggests pilot error may
have caused the deadly disaster.
689
00:27:33,551 --> 00:27:36,388
Right here, right
after the alarm goes off,
690
00:27:36,454 --> 00:27:38,223
he actually pulls
the power back.
691
00:27:36,454 --> 00:27:38,223
he actually pulls
the power back.
692
00:27:41,192 --> 00:27:42,394
All the way to idle.
693
00:27:46,464 --> 00:27:48,133
The captain
may have been trying not
694
00:27:48,199 --> 00:27:51,069
to further damage what he
thought was a crippled engine
695
00:27:48,199 --> 00:27:51,069
to further damage what he
thought was a crippled engine
696
00:27:51,136 --> 00:27:52,137
when he powered back.
697
00:27:55,507 --> 00:27:57,976
And look, he keeps sitting
idle for the remainder
698
00:27:55,507 --> 00:27:57,976
And look, he keeps sitting
idle for the remainder
699
00:27:58,043 --> 00:28:00,111
of the flight.
700
00:28:00,178 --> 00:28:01,346
Well, no wonder
they couldn't climb.
701
00:28:05,550 --> 00:28:10,188
Did having an idle engine
cause this accident?
702
00:28:05,550 --> 00:28:10,188
Did having an idle engine
cause this accident?
703
00:28:10,255 --> 00:28:13,958
Let's see the data from
the final approach.
704
00:28:14,025 --> 00:28:16,161
The data shows
how the right engine being
705
00:28:16,227 --> 00:28:19,297
at idle affected the landing.
706
00:28:19,364 --> 00:28:22,100
At this point,
they are too slow.
707
00:28:19,364 --> 00:28:22,100
At this point,
they are too slow.
708
00:28:26,071 --> 00:28:28,440
Watch your speed.
709
00:28:28,506 --> 00:28:29,374
I'm on it.
710
00:28:36,114 --> 00:28:39,217
The captain advances
power to the left engine,
711
00:28:36,114 --> 00:28:39,217
The captain advances
power to the left engine,
712
00:28:39,284 --> 00:28:40,518
pushing the aircraft
to the right
713
00:28:40,585 --> 00:28:43,388
because the right engine
isn't producing thrust.
714
00:28:51,496 --> 00:28:53,198
Now at this point
there's no way they're
715
00:28:53,264 --> 00:28:54,566
going to make the landing.
716
00:28:54,632 --> 00:28:57,469
So they have no choice but
to attempt to go around.
717
00:28:54,632 --> 00:28:57,469
So they have no choice but
to attempt to go around.
718
00:28:57,535 --> 00:28:58,169
Going around.
719
00:28:58,236 --> 00:29:02,373
Set torque, flap seven, gear up.
720
00:28:58,236 --> 00:29:02,373
Set torque, flap seven, gear up.
721
00:29:02,440 --> 00:29:05,009
To climb, the
captain pushes the left engine
722
00:29:05,076 --> 00:29:08,880
to maximum power, but that only
sends the plane into an even
723
00:29:05,076 --> 00:29:08,880
to maximum power, but that only
sends the plane into an even
724
00:29:08,947 --> 00:29:11,616
steeper right bank.
725
00:29:11,683 --> 00:29:14,185
Oh, steer, steer.
726
00:29:11,683 --> 00:29:14,185
Oh, steer, steer.
727
00:29:14,252 --> 00:29:18,156
Gerrit, Gerrit, Gerrit.
728
00:29:27,232 --> 00:29:28,299
What a blunder.
729
00:29:31,603 --> 00:29:33,438
Investigators finally understand
730
00:29:31,603 --> 00:29:33,438
Investigators finally understand
731
00:29:33,505 --> 00:29:35,273
the sequence of
events that brought
732
00:29:35,340 --> 00:29:38,943
down KLM Cityhopper Flight 433.
733
00:29:35,340 --> 00:29:38,943
down KLM Cityhopper Flight 433.
734
00:29:43,348 --> 00:29:44,415
Right engine oil pressure.
735
00:29:43,348 --> 00:29:44,415
Right engine oil pressure.
736
00:29:44,482 --> 00:29:46,117
Check, take action.
737
00:29:46,184 --> 00:29:47,652
Taking action.
738
00:29:47,719 --> 00:29:49,420
In the
heat of the moment,
739
00:29:49,487 --> 00:29:51,956
the captain reduces
right engine power
740
00:29:49,487 --> 00:29:51,956
the captain reduces
right engine power
741
00:29:52,023 --> 00:29:55,126
before his first officer has a
chance to read the checklist.
742
00:29:55,193 --> 00:29:58,296
This fools them both into
thinking they have an engine
743
00:29:55,193 --> 00:29:58,296
This fools them both into
thinking they have an engine
744
00:29:58,363 --> 00:30:00,031
problem when they don't.
745
00:30:00,098 --> 00:30:03,301
The right power
lever remained in the position
746
00:30:00,098 --> 00:30:03,301
The right power
lever remained in the position
747
00:30:03,368 --> 00:30:06,070
of flight idle, and
I didn't discuss
748
00:30:06,137 --> 00:30:07,605
the consequences of that.
749
00:30:11,643 --> 00:30:13,244
Going around.
750
00:30:13,311 --> 00:30:16,548
Set torque, flaps
seven, gear up.
751
00:30:13,311 --> 00:30:16,548
Set torque, flaps
seven, gear up.
752
00:30:16,614 --> 00:30:19,284
Attempting a go
around using just one engine
753
00:30:19,350 --> 00:30:21,286
is the final mistake.
754
00:30:19,350 --> 00:30:21,286
is the final mistake.
755
00:30:21,352 --> 00:30:23,988
Steer, steer, steer.
756
00:30:24,055 --> 00:30:28,626
Gerrit, Gerrit, Gerrit!
757
00:30:24,055 --> 00:30:28,626
Gerrit, Gerrit, Gerrit!
758
00:30:38,503 --> 00:30:40,405
The Netherlands
Aviation Safety Board
759
00:30:40,471 --> 00:30:42,440
determines that the
cause of those errors
760
00:30:42,507 --> 00:30:43,675
goes beyond the cockpit.
761
00:30:47,779 --> 00:30:51,516
The final report recommends
KLM review pilot testing
762
00:30:47,779 --> 00:30:51,516
The final report recommends
KLM review pilot testing
763
00:30:51,583 --> 00:30:55,520
techniques, establish
cockpit management training,
764
00:30:55,587 --> 00:30:59,657
and improve guidance on
flying with an idle engine.
765
00:30:55,587 --> 00:30:59,657
and improve guidance on
flying with an idle engine.
766
00:30:59,724 --> 00:31:03,094
There's an old adage in
aviation about the level
767
00:30:59,724 --> 00:31:03,094
There's an old adage in
aviation about the level
768
00:31:03,161 --> 00:31:06,030
of forgiveness of an airplane,
but one of the things it's not
769
00:31:06,097 --> 00:31:09,334
going to forgive is failing
to do the things that are
770
00:31:06,097 --> 00:31:09,334
going to forgive is failing
to do the things that are
771
00:31:09,400 --> 00:31:10,668
in the checklist appropriately.
772
00:31:10,735 --> 00:31:14,772
Checklists are
there for a reason.
773
00:31:10,735 --> 00:31:14,772
Checklists are
there for a reason.
774
00:31:14,839 --> 00:31:17,442
It's an adage that
holds for even the best pilots
775
00:31:17,508 --> 00:31:19,611
in the most advanced planes.
776
00:31:24,682 --> 00:31:28,486
At the Mojave Air & Space
Port in Southern California,
777
00:31:24,682 --> 00:31:28,486
At the Mojave Air & Space
Port in Southern California,
778
00:31:28,553 --> 00:31:31,189
a revolutionary new aircraft
is about to undertake
779
00:31:31,256 --> 00:31:31,723
a test flight.
780
00:31:35,426 --> 00:31:37,295
It's called SpaceshipTwo.
781
00:31:43,768 --> 00:31:45,603
System booting.
782
00:31:43,768 --> 00:31:45,603
System booting.
783
00:31:45,670 --> 00:31:47,238
The spaceship is designed
784
00:31:47,305 --> 00:31:49,507
by American Aerospace
company Scaled
785
00:31:49,574 --> 00:31:53,311
Composites for Virgin Galactic.
786
00:31:49,574 --> 00:31:53,311
Composites for Virgin Galactic.
787
00:31:53,378 --> 00:31:55,813
Showing green
across the board.
788
00:31:55,880 --> 00:31:56,748
Copy that.
789
00:31:55,880 --> 00:31:56,748
Copy that.
790
00:32:04,756 --> 00:32:06,824
Virgin Galactic's
owner, Sir Richard Branson,
791
00:32:06,891 --> 00:32:09,694
hopes this unique craft will
soon carry paying customers
792
00:32:06,891 --> 00:32:09,694
hopes this unique craft will
soon carry paying customers
793
00:32:09,761 --> 00:32:12,830
to the edge of space and back.
794
00:32:12,897 --> 00:32:17,435
Together we can make space
accessible in a way that
795
00:32:12,897 --> 00:32:17,435
Together we can make space
accessible in a way that
796
00:32:17,502 --> 00:32:20,805
has only been dreamed
of before now.
797
00:32:17,502 --> 00:32:20,805
has only been dreamed
of before now.
798
00:32:20,872 --> 00:32:23,107
The success of
this stage of the program
799
00:32:23,174 --> 00:32:25,643
rests on the shoulders
of these two test pilots.
800
00:32:28,313 --> 00:32:32,750
43-year-old Peter Siebold is
an award-winning engineer.
801
00:32:28,313 --> 00:32:32,750
43-year-old Peter Siebold is
an award-winning engineer.
802
00:32:32,817 --> 00:32:36,421
He's piloted 11 different
types of experimental aircraft.
803
00:32:39,624 --> 00:32:42,393
His co-pilot,
39-year-old Mike Alsbury,
804
00:32:42,460 --> 00:32:46,431
is also a seasoned test pilot
and an aeronautical engineer.
805
00:32:42,460 --> 00:32:46,431
is also a seasoned test pilot
and an aeronautical engineer.
806
00:32:50,201 --> 00:32:54,472
They've spent almost nine months
training for this mission.
807
00:32:54,539 --> 00:32:56,274
These guys are test pilots,
808
00:32:54,539 --> 00:32:56,274
These guys are test pilots,
809
00:32:56,341 --> 00:32:57,608
very, very experienced pilots.
810
00:32:57,675 --> 00:32:58,776
These are the best of
the best of the best.
811
00:33:01,779 --> 00:33:03,481
The rocket
powered spaceship
812
00:33:01,779 --> 00:33:03,481
The rocket
powered spaceship
813
00:33:03,548 --> 00:33:09,487
is suspended from a jet powered
plane with a 140-foot wingspan.
814
00:33:03,548 --> 00:33:09,487
is suspended from a jet powered
plane with a 140-foot wingspan.
815
00:33:09,554 --> 00:33:11,689
The launch plane is
called White Knight 2.
816
00:33:14,392 --> 00:33:20,498
White Knight 2 will carry the
spaceship up to 46,000 feet.
817
00:33:14,392 --> 00:33:20,498
White Knight 2 will carry the
spaceship up to 46,000 feet.
818
00:33:20,565 --> 00:33:24,836
At that altitude, SpaceShipTwo
will detach from the airplane,
819
00:33:24,902 --> 00:33:28,773
fire its rocket motor, and
climb another 100,000 feet
820
00:33:24,902 --> 00:33:28,773
fire its rocket motor, and
climb another 100,000 feet
821
00:33:28,840 --> 00:33:31,909
up into the Earth's atmosphere.
822
00:33:31,976 --> 00:33:35,580
Flying four times higher than
a typical commercial aircraft,
823
00:33:31,976 --> 00:33:35,580
Flying four times higher than
a typical commercial aircraft,
824
00:33:35,646 --> 00:33:37,815
it will then glide
back to Earth.
825
00:33:41,686 --> 00:33:44,622
Monitoring today's flight
is a flight director.
826
00:33:41,686 --> 00:33:44,622
Monitoring today's flight
is a flight director.
827
00:33:44,689 --> 00:33:46,524
He communicates with
a team of flight
828
00:33:46,591 --> 00:33:48,426
engineers and the four pilots.
829
00:33:50,995 --> 00:33:52,497
At 9:20 AM.
830
00:33:52,563 --> 00:33:57,902
White Knight 2, you are go.
831
00:33:52,563 --> 00:33:57,902
White Knight 2, you are go.
832
00:34:01,873 --> 00:34:04,542
Takeoff speed is 150 knots.
833
00:34:01,873 --> 00:34:04,542
Takeoff speed is 150 knots.
834
00:34:12,917 --> 00:34:16,320
Once SpaceShipTwo is
released, Captain Siebold
835
00:34:12,917 --> 00:34:16,320
Once SpaceShipTwo is
released, Captain Siebold
836
00:34:16,387 --> 00:34:19,524
will take the control column,
while co-pilot Alsbury
837
00:34:19,590 --> 00:34:21,559
monitors the instruments
and configures
838
00:34:19,590 --> 00:34:21,559
monitors the instruments
and configures
839
00:34:21,626 --> 00:34:22,794
the craft for its descent.
840
00:34:27,765 --> 00:34:29,967
You are clear to
arm a time-on release.
841
00:34:30,034 --> 00:34:32,503
I'll call fire.
842
00:34:30,034 --> 00:34:32,503
I'll call fire.
843
00:34:32,570 --> 00:34:33,805
In the
minutes before launch,
844
00:34:33,871 --> 00:34:35,840
the pilots review
the flight checklists
845
00:34:35,907 --> 00:34:40,344
they've been training
for months to memorize.
846
00:34:35,907 --> 00:34:40,344
they've been training
for months to memorize.
847
00:34:40,411 --> 00:34:47,885
Can't pitch up, pitch down,
trim feather unlock 1.4.
848
00:34:40,411 --> 00:34:47,885
Can't pitch up, pitch down,
trim feather unlock 1.4.
849
00:34:47,952 --> 00:34:49,554
Things happen
very, very, very quickly.
850
00:34:49,620 --> 00:34:52,590
They do not have the time
physically to go and pull out
851
00:34:49,620 --> 00:34:52,590
They do not have the time
physically to go and pull out
852
00:34:52,657 --> 00:34:54,926
the checklist and
read the checklist
853
00:34:54,992 --> 00:34:56,861
because these things are
happening second after second
854
00:34:54,992 --> 00:34:56,861
because these things are
happening second after second
855
00:34:56,928 --> 00:34:57,795
after second.
856
00:34:59,931 --> 00:35:04,402
Glide trim's good,
green for release.
857
00:34:59,931 --> 00:35:04,402
Glide trim's good,
green for release.
858
00:35:04,469 --> 00:35:05,369
OK.
859
00:35:05,436 --> 00:35:07,271
Here we go.
860
00:35:07,338 --> 00:35:09,540
Stick.
861
00:35:07,338 --> 00:35:09,540
Stick.
862
00:35:09,607 --> 00:35:11,509
Let's take us forward.
863
00:35:11,576 --> 00:35:19,450
And 5, 4,
3, 2, 1, release.
864
00:35:11,576 --> 00:35:19,450
And 5, 4,
3, 2, 1, release.
865
00:35:19,517 --> 00:35:22,420
As SpaceShipTwo
drops from its carry plane...
866
00:35:19,517 --> 00:35:22,420
As SpaceShipTwo
drops from its carry plane...
867
00:35:22,487 --> 00:35:24,455
Clean release.
868
00:35:24,522 --> 00:35:27,291
...Mike Alsbury engages
the experimental rocket motor.
869
00:35:24,522 --> 00:35:27,291
...Mike Alsbury engages
the experimental rocket motor.
870
00:35:27,358 --> 00:35:28,926
Arm.
871
00:35:28,993 --> 00:35:29,727
Fire.
872
00:35:29,794 --> 00:35:30,862
Fire.
873
00:35:34,765 --> 00:35:36,767
6,000 pounds
of thrust propel them
874
00:35:36,834 --> 00:35:38,069
towards the speed of sound.
875
00:35:36,834 --> 00:35:38,069
towards the speed of sound.
876
00:35:41,372 --> 00:35:43,374
Good light.
877
00:35:43,441 --> 00:35:46,611
SpaceShipTwo,
its top speed as close to three
878
00:35:43,441 --> 00:35:46,611
SpaceShipTwo,
its top speed as close to three
879
00:35:46,677 --> 00:35:48,579
Mach, so three times
a speed of sound,
880
00:35:48,646 --> 00:35:50,448
over 2,000 miles per hour.
881
00:35:48,646 --> 00:35:50,448
over 2,000 miles per hour.
882
00:35:50,515 --> 00:35:51,649
Yeehaw.
883
00:35:54,018 --> 00:35:55,887
It's a
very, very rough ride.
884
00:35:55,953 --> 00:35:57,121
So you think about
the worst turbulence
885
00:35:55,953 --> 00:35:57,121
So you think about
the worst turbulence
886
00:35:57,188 --> 00:36:01,959
you've been in an aircraft liner
and then magnify that by 10.
887
00:36:02,026 --> 00:36:04,862
It was supposed to be a 38
second burn of the engine.
888
00:36:07,899 --> 00:36:12,670
But just 14
seconds after ignition
889
00:36:07,899 --> 00:36:12,670
But just 14
seconds after ignition
890
00:36:12,737 --> 00:36:16,374
something goes terribly wrong.
891
00:36:12,737 --> 00:36:16,374
something goes terribly wrong.
892
00:36:23,481 --> 00:36:26,751
SpaceShipTwo lies in
pieces after breaking up
893
00:36:26,817 --> 00:36:29,820
over California's Mojave desert.
894
00:36:26,817 --> 00:36:29,820
over California's Mojave desert.
895
00:36:29,887 --> 00:36:32,123
Co-pilot Mike Alsbury
was killed in the crash.
896
00:36:37,461 --> 00:36:40,731
Amazingly, Captain Pete
Siebold parachuted to safety.
897
00:36:37,461 --> 00:36:40,731
Amazingly, Captain Pete
Siebold parachuted to safety.
898
00:36:43,901 --> 00:36:46,070
He's badly injured, but alive.
899
00:36:50,174 --> 00:36:54,545
Emergency responders
rushed him to the hospital,
900
00:36:50,174 --> 00:36:54,545
Emergency responders
rushed him to the hospital,
901
00:36:54,612 --> 00:36:57,615
while a team from the NTSB
Combs through the wreckage
902
00:36:57,682 --> 00:36:58,950
spread over the Mojave Desert.
903
00:36:57,682 --> 00:36:58,950
spread over the Mojave Desert.
904
00:37:02,653 --> 00:37:04,455
One of the things
that we were able to tell
905
00:37:02,653 --> 00:37:04,455
One of the things
that we were able to tell
906
00:37:04,522 --> 00:37:07,959
by being on scene was that
the motor was not an issue
907
00:37:08,025 --> 00:37:09,860
as to why the vehicle broke up.
908
00:37:13,598 --> 00:37:16,534
Investigators hope
the craft's external cameras
909
00:37:13,598 --> 00:37:16,534
Investigators hope
the craft's external cameras
910
00:37:16,601 --> 00:37:18,669
will provide vital information.
911
00:37:18,736 --> 00:37:20,471
See here?
912
00:37:20,538 --> 00:37:23,207
The tailbone folded in on
the aircraft along the hinge
913
00:37:20,538 --> 00:37:23,207
The tailbone folded in on
the aircraft along the hinge
914
00:37:23,274 --> 00:37:24,942
of the feather system.
915
00:37:25,009 --> 00:37:26,711
It went into feather mode?
916
00:37:29,113 --> 00:37:31,649
Feather mode refers
to the defining feature
917
00:37:31,716 --> 00:37:34,485
of SpaceShipTwo's design.
918
00:37:31,716 --> 00:37:34,485
of SpaceShipTwo's design.
919
00:37:34,552 --> 00:37:38,823
The spaceship actually
changes shape during flight.
920
00:37:38,889 --> 00:37:43,127
After reaching maximum altitude
the pilots rotate twin rudders
921
00:37:38,889 --> 00:37:43,127
After reaching maximum altitude
the pilots rotate twin rudders
922
00:37:43,194 --> 00:37:45,796
into the feather
position to increase drag
923
00:37:45,863 --> 00:37:47,064
and slow their descent.
924
00:37:45,863 --> 00:37:47,064
and slow their descent.
925
00:37:49,800 --> 00:37:53,070
The craft can then drop safely
back into Earth's atmosphere
926
00:37:49,800 --> 00:37:53,070
The craft can then drop safely
back into Earth's atmosphere
927
00:37:53,137 --> 00:37:55,072
before gliding to a runway.
928
00:38:01,545 --> 00:38:05,950
Lorenda Ward reviews the
video from a cockpit camera.
929
00:38:01,545 --> 00:38:05,950
Lorenda Ward reviews the
video from a cockpit camera.
930
00:38:06,017 --> 00:38:08,219
So he unlocked
the feather system?
931
00:38:08,285 --> 00:38:10,988
Correct.
932
00:38:08,285 --> 00:38:10,988
Correct.
933
00:38:11,055 --> 00:38:13,658
But did he actually deploy it?
934
00:38:13,724 --> 00:38:14,925
No.
935
00:38:14,992 --> 00:38:15,893
That's a weird thing.
936
00:38:15,960 --> 00:38:19,196
No one touched the handle.
937
00:38:15,960 --> 00:38:19,196
No one touched the handle.
938
00:38:19,263 --> 00:38:23,100
There are two steps
to feathering the spaceship.
939
00:38:19,263 --> 00:38:23,100
There are two steps
to feathering the spaceship.
940
00:38:23,167 --> 00:38:26,170
First, the pilots unlock
the feather system.
941
00:38:26,237 --> 00:38:30,107
So the tail boom can
pivot when commanded.
942
00:38:26,237 --> 00:38:30,107
So the tail boom can
pivot when commanded.
943
00:38:30,174 --> 00:38:33,544
Second, the pilots must pull
the feather handle to actually
944
00:38:33,611 --> 00:38:36,647
deploy the tail boom.
945
00:38:33,611 --> 00:38:36,647
deploy the tail boom.
946
00:38:36,714 --> 00:38:40,051
So we have the
video of the copilot unlocking,
947
00:38:40,117 --> 00:38:44,221
but we never see him actually
operate the feathers.
948
00:38:40,117 --> 00:38:44,221
but we never see him actually
operate the feathers.
949
00:38:44,288 --> 00:38:49,593
But we know from external
video that the feathers moved.
950
00:38:44,288 --> 00:38:49,593
But we know from external
video that the feathers moved.
951
00:38:49,660 --> 00:38:55,132
So we knew that we had a
performance or a dynamic issue.
952
00:38:49,660 --> 00:38:55,132
So we knew that we had a
performance or a dynamic issue.
953
00:38:55,199 --> 00:38:58,069
Somehow the system
designed to slow the craft
954
00:38:58,135 --> 00:39:01,038
on descent deployed while
the crew was accelerating
955
00:38:58,135 --> 00:39:01,038
on descent deployed while
the crew was accelerating
956
00:39:01,105 --> 00:39:02,239
toward the speed of sound.
957
00:39:05,276 --> 00:39:07,778
To learn more about
the feather system,
958
00:39:07,845 --> 00:39:11,882
investigators consult engineers
at Scaled Composites, the firm
959
00:39:07,845 --> 00:39:11,882
investigators consult engineers
at Scaled Composites, the firm
960
00:39:11,949 --> 00:39:14,085
that designs SpaceShipTwo.
961
00:39:14,151 --> 00:39:16,187
So when is supposed to
unlock the feather system?
962
00:39:19,090 --> 00:39:23,894
Between Mach 1.4 and 1.8.
963
00:39:19,090 --> 00:39:23,894
Between Mach 1.4 and 1.8.
964
00:39:23,961 --> 00:39:24,929
You want to play that?
965
00:39:28,833 --> 00:39:30,201
48, unlocking.
966
00:39:34,105 --> 00:39:37,742
The co-pilot had
actually unlocked
967
00:39:34,105 --> 00:39:37,742
The co-pilot had
actually unlocked
968
00:39:37,808 --> 00:39:41,345
the feather system early.
969
00:39:37,808 --> 00:39:41,345
the feather system early.
970
00:39:41,412 --> 00:39:44,815
Isn't it safer to unlock
it at lower speeds?
971
00:39:44,882 --> 00:39:45,916
No, ma'am.
972
00:39:45,983 --> 00:39:48,119
It can be catastrophic.
973
00:39:45,983 --> 00:39:48,119
It can be catastrophic.
974
00:39:48,185 --> 00:39:49,286
In the transonic phase,
975
00:39:49,353 --> 00:39:53,624
you get a huge amount of
upward force on the tail boom,
976
00:39:49,353 --> 00:39:53,624
you get a huge amount of
upward force on the tail boom,
977
00:39:53,691 --> 00:39:56,594
on the tail of the
spacecraft, and the feather
978
00:39:56,660 --> 00:40:00,264
system was not designed to
deal with that sort of load.
979
00:39:56,660 --> 00:40:00,264
system was not designed to
deal with that sort of load.
980
00:40:02,933 --> 00:40:04,201
It's a
devastating discovery
981
00:40:04,268 --> 00:40:06,270
that points to pilot error.
982
00:40:04,268 --> 00:40:06,270
that points to pilot error.
983
00:40:06,337 --> 00:40:07,471
Unlocking.
984
00:40:07,538 --> 00:40:10,608
When co-pilot Mike
Alsbury unlocked the feather
985
00:40:07,538 --> 00:40:10,608
When co-pilot Mike
Alsbury unlocked the feather
986
00:40:10,674 --> 00:40:14,979
system 16 seconds early,
aerodynamic forces
987
00:40:15,045 --> 00:40:17,148
were so strong they
pulled the tail
988
00:40:15,045 --> 00:40:17,148
were so strong they
pulled the tail
989
00:40:17,214 --> 00:40:20,284
into the feathered position
and tore the aircraft apart.
990
00:40:25,156 --> 00:40:27,658
But why would a highly
experienced test pilot
991
00:40:27,725 --> 00:40:31,162
like Mike Alsbury, who had
already carried out eight
992
00:40:27,725 --> 00:40:31,162
like Mike Alsbury, who had
already carried out eight
993
00:40:31,228 --> 00:40:33,631
previous flights
on SpaceShipTwo,
994
00:40:33,697 --> 00:40:38,269
unlock the tail boom at the
deadliest possible moment?
995
00:40:33,697 --> 00:40:38,269
unlock the tail boom at the
deadliest possible moment?
996
00:40:38,335 --> 00:40:43,274
The team pores over
training materials.
997
00:40:38,335 --> 00:40:43,274
The team pores over
training materials.
998
00:40:43,340 --> 00:40:45,676
We need to figure out what
they were told about unlocking
999
00:40:45,743 --> 00:40:46,677
the feather system early.
1000
00:40:45,743 --> 00:40:46,677
the feather system early.
1001
00:40:51,215 --> 00:40:52,683
Record show that co-pilot
1002
00:40:51,215 --> 00:40:52,683
Record show that co-pilot
1003
00:40:52,750 --> 00:40:56,387
Alsbury flew 112 simulator
runs for this mission.
1004
00:40:59,256 --> 00:41:02,092
Never once did the co-pilot
unlock the feather early.
1005
00:41:05,396 --> 00:41:06,330
Hold on now.
1006
00:41:09,366 --> 00:41:12,102
But the records do
reveal that on one occasion
1007
00:41:09,366 --> 00:41:12,102
But the records do
reveal that on one occasion
1008
00:41:12,169 --> 00:41:15,239
he unlocked the
feather too late.
1009
00:41:15,306 --> 00:41:16,774
12 degrees.
1010
00:41:15,306 --> 00:41:16,774
12 degrees.
1011
00:41:16,841 --> 00:41:18,275
Feather unlock.
1012
00:41:18,342 --> 00:41:19,276
14 degrees.
1013
00:41:19,343 --> 00:41:21,245
Mission abort, mission abort.
1014
00:41:24,281 --> 00:41:26,383
If they
didn't unlock by 1.8,
1015
00:41:26,450 --> 00:41:29,720
they would have had
to aborted the flight.
1016
00:41:26,450 --> 00:41:29,720
they would have had
to aborted the flight.
1017
00:41:29,787 --> 00:41:32,056
Aborting a
mission is not fatal,
1018
00:41:32,122 --> 00:41:34,758
but it could be a major
setback for the program.
1019
00:41:32,122 --> 00:41:34,758
but it could be a major
setback for the program.
1020
00:41:34,825 --> 00:41:36,694
0.8.
1021
00:41:36,760 --> 00:41:39,163
Investigators wonder,
did this error in training
1022
00:41:39,230 --> 00:41:41,232
months ago lead Alsbury...
1023
00:41:39,230 --> 00:41:41,232
months ago lead Alsbury...
1024
00:41:41,298 --> 00:41:43,734
Mission abort, mission abort.
1025
00:41:43,801 --> 00:41:45,002
I'll call fire.
1026
00:41:45,069 --> 00:41:46,971
to act prematurely?
1027
00:41:45,069 --> 00:41:46,971
to act prematurely?
1028
00:41:47,037 --> 00:41:49,373
Investigators believe a time crunch
1029
00:41:49,440 --> 00:41:52,109
may be one reason Mike
Alsbury decided to unlock
1030
00:41:52,176 --> 00:41:53,711
the feather system early.
1031
00:41:52,176 --> 00:41:53,711
the feather system early.
1032
00:41:53,777 --> 00:41:55,145
Unlocking.
1033
00:41:57,781 --> 00:41:59,083
If they don't unlock
1034
00:41:57,781 --> 00:41:59,083
If they don't unlock
1035
00:41:59,149 --> 00:42:01,752
the feather mechanism
by Mach 1.8,
1036
00:42:01,819 --> 00:42:03,020
then the flight is aborted.
1037
00:42:03,087 --> 00:42:04,054
So obviously that's
going to be weighing
1038
00:42:04,121 --> 00:42:05,289
on the co-pilot's mind.
1039
00:42:04,121 --> 00:42:05,289
on the co-pilot's mind.
1040
00:42:05,356 --> 00:42:08,325
You want to get
that out of the way.
1041
00:42:08,392 --> 00:42:12,496
Then they
make another discovery.
1042
00:42:08,392 --> 00:42:12,496
Then they
make another discovery.
1043
00:42:12,563 --> 00:42:14,765
Can I see that
simulator video again?
1044
00:42:20,404 --> 00:42:21,772
The training simulator did
1045
00:42:21,839 --> 00:42:25,109
not vibrate or mimic G-Forces.
1046
00:42:21,839 --> 00:42:25,109
not vibrate or mimic G-Forces.
1047
00:42:25,175 --> 00:42:27,912
The pilots didn't feel
the actual sensation
1048
00:42:27,978 --> 00:42:28,779
of a powered flight.
1049
00:42:27,978 --> 00:42:28,779
of a powered flight.
1050
00:42:31,582 --> 00:42:33,951
Yeehaw.
1051
00:42:34,018 --> 00:42:36,186
Even if you're
a very, very good test pilot,
1052
00:42:34,018 --> 00:42:36,186
Even if you're
a very, very good test pilot,
1053
00:42:36,253 --> 00:42:37,955
that has to be a little
bit unnerving to get all
1054
00:42:38,022 --> 00:42:41,125
this vibration, and G loads, and
the speed, and everything else.
1055
00:42:38,022 --> 00:42:41,125
this vibration, and G loads, and
the speed, and everything else.
1056
00:42:44,428 --> 00:42:47,932
Investigators finally know what happened.
1057
00:42:44,428 --> 00:42:47,932
Investigators finally know what happened.
1058
00:42:47,998 --> 00:42:52,403
He had a lot to do, made
a decision to unlock early,
1059
00:42:52,469 --> 00:42:57,474
perhaps not realizing
the deadly implications.
1060
00:42:57,541 --> 00:43:00,411
The NTSB
faults Scaled Composites
1061
00:42:57,541 --> 00:43:00,411
The NTSB
faults Scaled Composites
1062
00:43:00,477 --> 00:43:03,280
for not ensuring pilots
understood the consequences
1063
00:43:03,347 --> 00:43:05,849
of unlocking the
feather system early
1064
00:43:03,347 --> 00:43:05,849
of unlocking the
feather system early
1065
00:43:05,916 --> 00:43:09,386
and for failing to take steps
to prevent that from happening.
1066
00:43:09,453 --> 00:43:10,654
Catch up!
1067
00:43:09,453 --> 00:43:10,654
Catch up!
1068
00:43:10,721 --> 00:43:14,458
Even just having a
sensor that physically prevents
1069
00:43:14,525 --> 00:43:16,794
them from unlocking
until it passes
1070
00:43:14,525 --> 00:43:16,794
them from unlocking
until it passes
1071
00:43:16,860 --> 00:43:20,397
the appropriate threshold would
have prevented this accident.
1072
00:43:23,067 --> 00:43:25,402
In its
final report, the NTSB
1073
00:43:25,469 --> 00:43:27,571
states the probable
cause of the disaster
1074
00:43:27,638 --> 00:43:30,808
was a failure to protect
against the possibility
1075
00:43:27,638 --> 00:43:30,808
was a failure to protect
against the possibility
1076
00:43:30,874 --> 00:43:34,378
that a single human error
could trigger a catastrophe.
1077
00:43:37,381 --> 00:43:39,583
The common thread in
all of these tragedies
1078
00:43:39,650 --> 00:43:41,919
is that people took
action without really
1079
00:43:39,650 --> 00:43:41,919
is that people took
action without really
1080
00:43:41,986 --> 00:43:45,155
examining what action was
needed and they moved too fast.
1081
00:43:45,222 --> 00:43:49,460
0.8, unlocking.
1082
00:43:45,222 --> 00:43:49,460
0.8, unlocking.
1083
00:43:49,526 --> 00:43:51,528
We do know
how to prevent them,
1084
00:43:51,595 --> 00:43:54,498
and that is by sitting on
your hands in most cases
1085
00:43:51,595 --> 00:43:54,498
and that is by sitting on
your hands in most cases
1086
00:43:54,565 --> 00:43:56,900
until you are sure you
need to take action.
1087
00:43:56,967 --> 00:43:59,603
You don't take action because
if you take the wrong action,
1088
00:43:56,967 --> 00:43:59,603
You don't take action because
if you take the wrong action,
1089
00:43:59,670 --> 00:44:02,439
it can lead you into a
major problem or a disaster.
82099
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