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Above the remote Alaskan wilderness…
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two planes collide.
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Mayday. Mayday.
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A witness races to help.
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All I saw was a whole
bunch of people floating.
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Six people are dead.
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A mid-air collision is probably the most
scary thing that could happen to you.
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NTSB investigators talk
to the surviving pilot.
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Look, he was just there.
I couldn't avoid him.
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When they examine
the on-board alerting system…
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Why didn't he turn away?
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the mystery deepens.
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We're missing something.
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But then investigators
get an unexpected glimpse,
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-Whoa.
-into a key moment in time.
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It was eerie and
disturbing to see the photos
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because they were taken
in a person's last moments.
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Mayday! Mayday!
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[warnings blaring]
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PULL UP!
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[indistinct radio chatter]
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It's a busy day at Alaska's
Misty Fjords floatplane base.
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Four cruise ship passengers
have booked a sightseeing
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flight over Alaska's
spectacular southeast coast.
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Okay, folks, get comfortable
and fasten your seat belts.
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46-year-old Randy Sullivan is the owner of
Mountain Air Services and its only pilot.
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Hey, looks like you're going
to have the best view in Alaska.
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I can hardly wait.
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This will be Sullivan's
second flight of the day.
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Just got a few things to
do before we get started.
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Randy Sullivan has spent most of
his career flying over Misty Fjords.
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Transponder on and broadcasting.
Okay, guys, put your headsets on.
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Mountain Air was a small operator
doing primarily sightseeing trips.
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Can you guys hear me okay?
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Okay, here we go.
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This would have been his
entire life running this company,
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and he would have loved what he was doing.
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All right.
Flight controls free and correct.
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Master fuel, check.
Landing lights, check.
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Just after 12 noon, the Mountain
Air floatplane is ready for takeoff.
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Okay, that's five minutes
since last departure.
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Pilots space out their takeoffs since
there's no air traffic control in this area.
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Misty traffic, this is
Beaver 52 Delta Bravo.
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Ready for a straight out.
Any conflicting? Misty traffic.
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Sullivan radios other pilots in the area.
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In airspace like the Misty Fjords,
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the pilots all control themselves,
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and it's primarily a see
and be seen situation.
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Without any air traffic
control to keep you separated,
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you have to maintain
that separation yourself.
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It's a textbook takeoff in light winds.
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Today's 40-mile flight will take
passengers from Rudyerd Bay to Ketchikan.
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They'll cross high mountains
and dramatic terrain.
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Misty Fjords is an
absolutely beautiful area.
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It's towering mountains,
glaciers, lakes, fjords, wildlife.
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And the best way to see a place
like that of course is from an airplane,
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where you can get the full impact of the
scenery and the immenseness of the area.
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Every year, more than 100,000 cruise ship
passengers visit Alaska's Misty Fjords.
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The flight tours have become
an essential experience
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for those who can
afford the luxury price tag.
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If you look out to your left,
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you'll see cliffs that were carved
smooth by the last great ice age.
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Randy Sullivan points out the
highlights throughout the flight.
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Being a single pilot operation
while you're doing the tours,
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you're multitasking with
your customers all the time,
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trying to give them the best
tour that you can give them.
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At the same time, you're
also multitasking as a pilot,
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where you're trying to maintain your
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situational awareness
of all the other aircraft,
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as well as you're a lot of times flying
at very low level through the terrain,
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which adds one more bit of
complexity to the entire operation.
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Mountain Air Services
operates a de Havilland Beaver,
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a single-engine prop plane.
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The Beaver was originally built for
the United States Air Force in 1951,
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but many are now operated
by northern bush pilots.
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De Havilland Beaver was a
uniquely designed airplane,
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and the takeoff and landing
is absolutely incredible.
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That's what makes it
so versatile in the bush,
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is that you can get it in and
out of pretty much any little lake. Uh.
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If you're on wheels or skis, you can get
it off short strips or short frozen lakes.
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Misty traffic, Beaver 2
Delta Bravo exiting Rudyerd,
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climbing through 1,900 westbound.
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Check that. 45 Mike Mike is just
off the water now and well behind you.
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It's May, and this part of Alaska is
enjoying exceptionally good weather.
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On the Alaska coast, the weather
can change extremely rapidly.
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It can go from a
beautiful clear day to just
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horrible weather within a
very short period of time.
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When the days are good,
all the aircraft are flying,
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everybody is out making
hay while the sun shines.
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-Have a good cruise so far?
-It's been great.
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The forecast for tomorrow
is low clouds and rain.
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So today, Sullivan plans to
operate a full day of flights.
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You all are pretty lucky. They call
this place the Misty Fjord for a reason.
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Weather like this is pretty rare.
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Beaver 8 Golf Mike is 2,700
feet in the climb, exiting the bay.
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We've got the Mountain Air Beaver ahead.
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We will fall in trail behind.
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Hey Dave, I've got you on
display, but I don't have you visual.
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As long as you can see me, we're good.
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I got you above and ahead
of me, Randy. Enjoy the ride.
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Oh, uh huh, uh
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even if we can't see each other the display
lets us know where the other planes are.
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Cool.
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The traffic systems will enhance
your ability for the see-and-avoid,
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because it will alert
you of aircraft that you
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may have missed because of visibility
issues, before you get too close.
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Coming up in about
two minutes on your right,
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you're going to see one of the highlights
of the trip, the majestic Mahoney Falls.
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20 minutes into the flight,
the Beaver approaches the waterfall.
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Passengers are treated
to a spectacular view.
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The Beaver and another aircraft collide.
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The Beaver basically came apart.
It free-fell 3,000 feet from the sky.
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A retired fisherman on George
Inlet is shocked by what he sees.
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Mayday. Mayday. This is Hotel
Sea calling Coast Guard radio.
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Go ahead, state the
nature of your emergency.
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The second plane involved is a
larger ten passenger de Havilland Otter.
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Two float planes down, George Inlet.
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The Otter was still largely
intact. There was damage.
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The pilot obviously kept his cool
and managed to control the aircraft.
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I saw a, an Otter floatplane crash
into the water with a huge splash and,
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I got closer and all I saw
was a whole bunch of people
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floating in the, in an area 50, 60 yards.
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But there was one person um,
that never made it out of the airplane.
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The ten survivors, including
the pilot, are rushed to hospital.
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There are no survivors from the
plane piloted by Randy Sullivan.
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How could two planes in one of the most
popular tourist destinations on Earth,
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collide in mid-air?
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Within hours, the National
Transportation Safety Board, or NTSB,
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dispatches a team of
investigators to search for wreckage.
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We still have to recover the planes,
and then we have to look at those,
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and it, it takes some significant work to
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really understand how
the two came together,
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but we have some great experts at
the NTSB who are well versed in that.
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Aaron Sauer is named lead investigator.
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The wreckage area of the Beaver
was scattered for about 3,000 feet.
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Uh, a portion of the main fuselage was
located upside down in the saltwater.
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There was a lot of debris that was mixed
into the terrain in that mountainous area.
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Vegetation was high. It was very
difficult to navigate to try and recover
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as much of the debris from
the Beaver that we could.
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The other aircraft, the Otter, is owned
by the largest tour operator in the area,
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Taquan Air.
It sank in 80 feet of water.
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The floats of the Otter were separated.
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They ended up washing ashore.
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But ultimately, they
were able to get divers
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down, locate the wreckage
almost immediately,
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and they were able to successfully
get that aircraft up on that barge.
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Um, tag the Beaver wreckage, and when the
Otter comes, we're going to put it there.
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The small sightseeing planes were
not required to carry black boxes.
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Keep an eye out for avionics, cameras,
phones, anything with photos or,
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data that will help
us piece this together.
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Without recorders, the investigation
becomes much more difficult.
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So without the cockpit voice
recorder and flight data recorder,
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we had to look for other sources of data.
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Hey, help me move this.
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As the team surveys the Beaver wreckage,
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they find evidence that can help
them piece together the violent collision.
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These are sawtooth marks, from
a propeller striking the right wing.
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We wanted to understand
what angle did we have.
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That was very important
for us to understand
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in order to recreate the collision
and aid us in the investigation.
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The pattern's in the inboard direction.
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So the Otter came from
behind and to the right.
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The discovery begins to unveil what
happened in the skies over Misty Fjord.
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The collision angle was important for us
because what it told us is both airplanes
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weren't necessarily on a
head-on collision course.
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They were more or less headed to the same
location with a shallow degree of angle.
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The collision was more of a sideswipe.
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Both planes took off from Rudyerd Bay here
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and headed to their
cruise ship in Ketchikan.
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The Beaver left first,
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and a few minutes later,
the Otter departed.
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With a basic understanding
of how the two planes collided,
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investigators try to pinpoint
where the accident occurred.
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We had one witness…
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who was located, here.
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We had a witness that
was hunting in the area
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that didn't see the
collision but heard the
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collision, which then
in turn gave us an idea
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of where exactly did this
happen up in a point in sky.
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Based on his account the collision
happened, somewhere in here.
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Investigators now know exactly
where the accident occurred,
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but they still don't know why.
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Maybe, they were converging on this point.
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The planes collided very
near the scenic Mahoney Falls.
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It is certainly possible.
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It has happened before.
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A similar mid-air collision
happened over Arizona in 1986.
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A Twin Otter and a helicopter
collided over the Grand Canyon,
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killing 25 people.
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Both aircraft were also approaching
a popular scenic attraction.
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Air tour flights have a higher rate of
mid-air collisions, statistically speaking,
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because they operate in areas with dense
traffic around various scenic landmarks.
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And in addition, they operate
without air traffic control separation.
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00:15:16,740 --> 00:15:18,490
What was the weather like that day?
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00:15:19,819 --> 00:15:21,242
I'll check it out.
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00:15:22,970 --> 00:15:27,315
Did Alaska's rapidly changing
weather play a role in the accident?
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00:15:28,480 --> 00:15:31,943
So weather conditions in
any accident are important
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00:15:32,026 --> 00:15:35,307
to understand the environment
that these pilots are operating in.
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00:15:35,390 --> 00:15:37,550
Are the weather conditions cloudy?
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00:15:37,633 --> 00:15:39,982
Does that limit their ability to see?
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00:15:40,065 --> 00:15:44,537
Does it limit their ability to
react to certain situations?
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00:15:46,463 --> 00:15:49,683
These are from a weather camera,
eight miles from the accident.
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00:15:50,966 --> 00:15:53,856
Investigators review
weather reports for nearby
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00:15:53,939 --> 00:15:56,380
George Inlet at the time of the accident.
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A few scattered clouds,
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-but much higher than they were flying.
-Mmhm
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00:16:04,990 --> 00:16:09,473
The weather conditions in Ketchikan
on the day of the accident were beautiful.
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00:16:09,556 --> 00:16:11,791
So at that point, we
knew that the conditions
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00:16:11,874 --> 00:16:15,022
were not going to be
a factor in this accident.
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00:16:15,106 --> 00:16:18,013
Something else prevented
these guys from seeing each other.
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00:16:29,830 --> 00:16:30,975
What if…
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00:16:34,423 --> 00:16:39,669
the pilots didn't have enough time
to look out the window for other traffic?
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00:16:41,605 --> 00:16:45,322
Or maybe the pilots were trying
to give their customers the best view.
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What prevented the pilots from seeing each
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00:16:49,879 --> 00:16:52,856
other as they converged
on the scenic waterfall?
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00:16:53,880 --> 00:16:58,246
Flying an aircraft full of tourists
can be a very challenging task.
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00:16:58,329 --> 00:17:02,226
You have a number of people
that all want to ask questions.
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00:17:02,309 --> 00:17:05,129
They all want to see different
things, especially in a
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00:17:05,218 --> 00:17:08,297
area like the Misty Fjords,
where there is so much to see.
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It is a lot for a pilot to
do all at the same time.
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Well the local pilots
certainly were concerned.
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Enough to create this.
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Investigators discover a set of guidelines
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agreed upon by tour operators to
enhance safety over Misty Fjords.
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The letter of agreement
between the operators
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00:17:32,312 --> 00:17:36,317
was intended to help them
coordinate their routes of flight,
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00:17:36,400 --> 00:17:39,557
and their call-outs, so that
they could become better aware
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00:17:39,640 --> 00:17:43,567
of where they would each be
operating and avoid each other.
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The companies were aware of
this hazard of mid-air collisions,
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and that they were attempting to implement
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00:17:50,459 --> 00:17:54,112
some procedural mitigations
against this hazard.
232
00:17:56,797 --> 00:18:00,011
It looks like most aircraft flying tours
233
00:18:00,094 --> 00:18:04,612
also had on board an
ADS-B traffic warning system.
234
00:18:06,426 --> 00:18:11,006
ADS-B, or Automatic Dependent
Surveillance-Broadcast,
235
00:18:11,090 --> 00:18:15,010
is a traffic alerting system
that transmits a plane's GPS
236
00:18:15,093 --> 00:18:19,233
location and altitude to ground
stations and other aircraft.
237
00:18:19,900 --> 00:18:22,490
If two airplanes get
too close to each other,
238
00:18:22,573 --> 00:18:24,977
an alert is issued in both cockpits.
239
00:18:25,060 --> 00:18:27,870
When your traffic system
tells you you've got a conflict,
240
00:18:27,953 --> 00:18:30,206
it's going to have your
attention immediately.
241
00:18:30,290 --> 00:18:34,203
It will only tell you that there's
a problem when there is.
242
00:18:34,287 --> 00:18:38,324
It looks like the Otter had an
alerting system installed on board.
243
00:18:38,408 --> 00:18:40,242
What about the Beaver?
244
00:18:40,326 --> 00:18:43,686
Yeah, it had a system
installed on it as well.
245
00:18:45,480 --> 00:18:50,897
It was important for us to understand
which aircraft had which equipment
246
00:18:50,980 --> 00:18:54,447
as far as alerting
capability traffic displays.
247
00:18:55,690 --> 00:18:57,667
Okay, here's the Otter's system.
248
00:18:58,686 --> 00:19:01,131
Investigators first examine the Otter,
249
00:19:01,215 --> 00:19:04,726
the aircraft that collided with
the smaller plane to its left.
250
00:19:06,646 --> 00:19:12,694
The Otter uses GPS and a radio transponder
to broadcast its altitude and position.
251
00:19:13,681 --> 00:19:18,873
A color screen inside the cockpit plots
other nearby aircraft on a moving map.
252
00:19:19,958 --> 00:19:21,916
What does the Beaver have?
253
00:19:22,000 --> 00:19:24,787
Well, the Beaver pilot
had a different system.
254
00:19:24,870 --> 00:19:27,440
It had a tablet to display traffic info.
255
00:19:29,770 --> 00:19:34,506
So we knew that both aircraft were equipped
with some level of traffic display.
256
00:19:34,590 --> 00:19:38,173
So the question was, were
they able to function as designed?
257
00:19:49,083 --> 00:19:50,906
Let's see what we got.
258
00:19:51,730 --> 00:19:54,540
Investigators review
whether ground stations
259
00:19:54,623 --> 00:19:57,866
received any GPS
transmissions from the aircraft,
260
00:19:57,950 --> 00:19:59,650
detailing their locations.
261
00:20:00,383 --> 00:20:01,333
There's the Beaver.
262
00:20:04,110 --> 00:20:08,406
Misty traffic.
Beaver 2 Delta Bravo exiting Rudyerd.
263
00:20:08,490 --> 00:20:10,610
Climbing through 1,900 westbound.
264
00:20:13,990 --> 00:20:15,276
And there's the Otter.
265
00:20:16,447 --> 00:20:20,254
All right, folks, if you look outside
your windows down at the hills below,
266
00:20:20,337 --> 00:20:22,014
you might just see some wildlife.
267
00:20:26,733 --> 00:20:30,679
Both airplanes were broadcasting their
position, but they still hit each other.
268
00:20:30,762 --> 00:20:31,776
Doesn't make sense.
269
00:20:34,657 --> 00:20:36,607
Maybe the system didn't issue an alert.
270
00:20:38,579 --> 00:20:39,929
The Otter pilot would know.
271
00:20:42,470 --> 00:20:44,686
Seems like so many of these investigations
272
00:20:44,769 --> 00:20:48,460
when you have a mid-air
are just not survivable.
273
00:20:48,551 --> 00:20:54,518
And so it was, it was very
fortunate to be able to talk to the pilot.
274
00:20:59,600 --> 00:21:01,951
Tell me about the flight.
275
00:21:02,034 --> 00:21:05,906
Investigators interview
the Otter pilot, Lou Beck,
276
00:21:05,990 --> 00:21:08,040
who has just been released from hospital.
277
00:21:09,370 --> 00:21:10,470
Passengers were happy.
278
00:21:11,273 --> 00:21:12,353
Air was smooth.
279
00:21:14,063 --> 00:21:16,460
Was it busy out there?
280
00:21:18,510 --> 00:21:20,600
Visually I, I never saw anyone else.
281
00:21:22,010 --> 00:21:24,607
What about the traffic alerting system?
282
00:21:24,690 --> 00:21:26,096
It was on.
283
00:21:26,180 --> 00:21:30,056
I saw targets on the screen but,
they were well south of me.
284
00:21:33,066 --> 00:21:34,709
Okay.
285
00:21:34,792 --> 00:21:36,842
Got one three miles out.
286
00:21:36,926 --> 00:21:38,756
Three o'clock.
287
00:21:38,840 --> 00:21:41,369
Opposite direction.
288
00:21:41,453 --> 00:21:42,986
No conflict.
289
00:21:44,992 --> 00:21:48,668
I flew a longer route,
than the other planes.
290
00:21:48,752 --> 00:21:51,435
Took me away from
most of the regular traffic.
291
00:21:51,518 --> 00:21:53,577
But you still ended up at the waterfall.
292
00:21:53,660 --> 00:21:54,867
I did.
293
00:21:54,950 --> 00:21:56,958
That's when all hell broke loose.
294
00:21:58,227 --> 00:21:59,406
Okay, folks.
295
00:21:59,490 --> 00:22:00,741
In a few seconds,
296
00:22:00,824 --> 00:22:02,817
we're going to arrive at the beautiful-
297
00:22:04,464 --> 00:22:07,111
Look, he was just there.
I couldn't avoid him.
298
00:22:08,100 --> 00:22:09,364
Hang on, everyone.
299
00:22:12,796 --> 00:22:15,199
Was there any alert from
the traffic system?
300
00:22:15,283 --> 00:22:16,356
Nothing.
301
00:22:16,439 --> 00:22:19,427
After the impact, I just
went into survival mode.
302
00:22:20,767 --> 00:22:22,629
Brace for impact!
303
00:22:22,713 --> 00:22:24,287
Brace, brace, brace!
304
00:22:34,440 --> 00:22:39,686
The pilot seemed very attentive
to mid-air collisions as a hazard.
305
00:22:39,770 --> 00:22:44,177
He was aware of the cockpit display
of traffic information in the cockpit,
306
00:22:44,260 --> 00:22:49,407
and he recalled looking at it
to scan for traffic before the collision.
307
00:22:49,490 --> 00:22:55,038
Look I just want to reiterate that
the, alert system did not sound an alert.
308
00:22:56,240 --> 00:22:57,214
Thank you.
309
00:22:58,390 --> 00:22:59,654
This was very helpful.
310
00:23:01,881 --> 00:23:06,324
Investigators are now confident the
collision happened without a warning
311
00:23:06,407 --> 00:23:08,367
to alert the Otter pilot.
312
00:23:09,625 --> 00:23:12,116
The question is, why?
313
00:23:12,200 --> 00:23:13,431
Hang on, everyone!
314
00:23:19,040 --> 00:23:21,890
Let's have a look at the
Otter's traffic alerting system.
315
00:23:23,013 --> 00:23:27,717
Investigators use the ground station
data to recreate what the Otter pilot
316
00:23:27,800 --> 00:23:30,237
would have seen on
his traffic alerting system
317
00:23:30,320 --> 00:23:32,909
moments before crashing into the Beaver.
318
00:23:34,570 --> 00:23:36,717
It's painting targets.
319
00:23:36,800 --> 00:23:39,147
There's the Beaver approaching.
320
00:23:39,230 --> 00:23:42,371
The alert should happen any second now.
321
00:23:42,454 --> 00:23:47,807
As the Beaver gets within two and
a half miles, an alert should sound.
322
00:23:47,896 --> 00:23:50,143
It's not doing anything. There's no alert.
323
00:23:57,576 --> 00:24:01,447
It was very surprising to us that the
cockpit display of traffic in the Otter
324
00:24:01,530 --> 00:24:04,417
didn't provide traffic alerts,
325
00:24:04,500 --> 00:24:08,867
because that's a really important
defense against mid-air collisions.
326
00:24:08,950 --> 00:24:11,710
There is something not
right with the alerting function.
327
00:24:15,439 --> 00:24:19,693
Okay, folks. In a few seconds,
we're going to arrive at the beautiful-
328
00:24:24,156 --> 00:24:29,869
The NTSB must now figure out why a
critical piece of safety equipment failed.
329
00:24:36,242 --> 00:24:39,801
Traffic alerting system, was installed…
330
00:24:41,485 --> 00:24:43,655
in 1999.
331
00:24:45,550 --> 00:24:47,970
One of the first in the country.
332
00:24:48,053 --> 00:24:52,453
They take a closer look at the de
Havilland Otter's traffic alerting system.
333
00:24:53,540 --> 00:24:58,126
Looks like the FAA paid for it as
part of an experimental program.
334
00:24:59,580 --> 00:25:02,527
The capstone project
that the FAA sponsored
335
00:25:02,610 --> 00:25:06,783
was a program to reduce mid-air
collision accidents in Alaska.
336
00:25:07,949 --> 00:25:10,737
In 2015,
337
00:25:10,820 --> 00:25:14,895
the Otter got an upgrade from the FAA.
338
00:25:14,979 --> 00:25:16,446
What kind of upgrade?
339
00:25:19,869 --> 00:25:21,190
Take a look.
340
00:25:24,240 --> 00:25:27,323
They swapped out a Garmin
transceiver for a Ranger 978.
341
00:25:27,406 --> 00:25:31,853
Yes, and take a look at what
wasn't included in the upgrade.
342
00:25:33,040 --> 00:25:36,207
When the traffic system
was upgraded on the Otter,
343
00:25:36,290 --> 00:25:38,839
its alerting function was removed.
344
00:25:41,203 --> 00:25:43,803
The FAA considered the traffic alerting
345
00:25:43,886 --> 00:25:48,440
audio capability to be
classified as immature
346
00:25:48,523 --> 00:25:51,277
and no longer part of the upgraded system.
347
00:25:51,360 --> 00:25:53,406
That was a head-scratcher for our team.
348
00:25:54,333 --> 00:25:57,655
But even if the Otter
pilot didn't receive an alert,
349
00:25:57,738 --> 00:26:01,044
the Beaver pilot should have
received one on his system.
350
00:26:02,380 --> 00:26:07,881
In this part of the world, alerting
systems are neither mandated nor regulated.
351
00:26:07,965 --> 00:26:11,737
Planes can have different
systems or none at all.
352
00:26:11,820 --> 00:26:16,686
The Beaver pilot had been utilizing an
iPad that was using an application
353
00:26:16,769 --> 00:26:21,736
for navigating and understanding where
traffic would be in his surrounding area.
354
00:26:23,668 --> 00:26:26,786
The pilot, paid for his own system.
355
00:26:26,870 --> 00:26:32,157
And so he would have had a fully functional
system including alerting capabilities.
356
00:26:32,240 --> 00:26:33,546
According to this,
357
00:26:34,619 --> 00:26:35,493
yes.
358
00:26:36,679 --> 00:26:39,790
I think it's clear the Beaver
pilot was concerned about safety.
359
00:26:39,873 --> 00:26:44,563
He had gone at his own expense
and installed ADS-B equipment
360
00:26:44,646 --> 00:26:48,399
in his airplane that was
not required per regulation.
361
00:26:49,390 --> 00:26:53,598
Did the Beaver's system
also fail to alert the pilot?
362
00:26:56,385 --> 00:27:00,962
Investigators use the ground station
data to recreate what the Beaver pilot
363
00:27:01,045 --> 00:27:04,478
would have seen and heard in
the cockpit leading up to the crash.
364
00:27:06,700 --> 00:27:08,035
The center is the Beaver.
365
00:27:09,485 --> 00:27:12,721
The Otter is at three miles out now.
366
00:27:16,080 --> 00:27:19,853
There is no alert,
warning of the approaching Otter.
367
00:27:23,170 --> 00:27:24,493
We're missing something.
368
00:27:25,620 --> 00:27:31,377
Determining why neither of the traffic
alerting systems in, in the airplanes
369
00:27:31,460 --> 00:27:34,517
warned the pilots about
the impending collision was,
370
00:27:34,600 --> 00:27:38,016
something that we had
to sort out in order to figure out,
371
00:27:38,100 --> 00:27:39,800
why the collision happened.
372
00:27:45,736 --> 00:27:49,081
Is that everything? Thank you.
373
00:27:51,350 --> 00:27:55,816
With the Beaver's ADS-B
system destroyed in the crash,
374
00:27:55,900 --> 00:27:59,686
the NTSB turns to the
only evidence that remains,
375
00:27:59,770 --> 00:28:03,966
salvaged parts of the
Otter's traffic alerting system.
376
00:28:04,049 --> 00:28:06,784
Hey, check this out.
377
00:28:09,716 --> 00:28:10,693
It's turned off.
378
00:28:11,985 --> 00:28:16,912
A key component was not
operating at the time of the crash.
379
00:28:16,995 --> 00:28:18,123
That is odd.
380
00:28:19,890 --> 00:28:25,770
There was a critical piece of equipment
on board the Otter called the GSL 71.
381
00:28:27,110 --> 00:28:31,774
The GSL 71 is a control
panel for the alerting system.
382
00:28:31,857 --> 00:28:36,197
It broadcasts the plane's altitude
to aircraft and ground stations.
383
00:28:39,047 --> 00:28:42,213
Let's see exactly how
these components work.
384
00:28:43,987 --> 00:28:49,136
Investigators examine the role of each
component of the Otter's traffic systems
385
00:28:49,219 --> 00:28:54,047
to consider the consequences
of having the GSL 71 turned off.
386
00:28:56,750 --> 00:28:59,142
Well this is not a simple setup.
387
00:29:01,179 --> 00:29:03,152
So a surprising thing about,
388
00:29:03,235 --> 00:29:08,173
the system on the Otter was that
it was a mixture of new and old parts.
389
00:29:08,257 --> 00:29:09,571
Look at this.
390
00:29:14,750 --> 00:29:18,436
If the GSL 71 is off,
391
00:29:18,520 --> 00:29:25,446
altitude information, will not,
be broadcast to other aircraft.
392
00:29:27,403 --> 00:29:32,008
If the Otter wasn't broadcasting, then
the Beaver would not have gotten an alert.
393
00:29:33,082 --> 00:29:36,046
Investigators get their biggest lead yet.
394
00:29:37,640 --> 00:29:40,003
Because the GSL 71 was off,
395
00:29:40,087 --> 00:29:45,532
other aircraft had no idea what altitude
the Otter was currently operating at.
396
00:29:47,430 --> 00:29:52,163
Was that airplane above them?
Below them? Same altitude? Unsure.
397
00:29:57,823 --> 00:30:01,770
When was the last time the Otter,
transmitted altitude data?
398
00:30:03,770 --> 00:30:07,103
Investigators review
when the Taquan Air Otter
399
00:30:07,186 --> 00:30:10,336
last broadcast its
altitude to ground stations.
400
00:30:12,720 --> 00:30:14,149
April 29th.
401
00:30:21,326 --> 00:30:27,879
The last inspection and
maintenance was on, April 30th.
402
00:30:29,316 --> 00:30:31,746
The day after its last broadcast.
403
00:30:32,589 --> 00:30:37,922
The team considers whether
the GSL 71 was turned off for maintenance
404
00:30:38,006 --> 00:30:41,815
two weeks before the crash,
and never turned on again.
405
00:30:42,932 --> 00:30:45,046
We spoke to maintenance personnel,
406
00:30:45,130 --> 00:30:50,772
but, during the course of interviews,
we never really were able to
407
00:30:50,855 --> 00:30:54,875
completely understand why
the unit was in the "OFF" position.
408
00:30:56,863 --> 00:31:00,236
Since the Otter wasn't
broadcasting its altitude,
409
00:31:00,330 --> 00:31:02,756
the Beaver never received an alert.
410
00:31:04,429 --> 00:31:06,748
Why didn't the Otter pilot check if he was
411
00:31:06,831 --> 00:31:09,777
broadcasting his altitude
on the day of the crash?
412
00:31:12,684 --> 00:31:15,744
I have some additional questions for you.
413
00:31:18,411 --> 00:31:22,045
Were you aware that
the control panel was off?
414
00:31:24,663 --> 00:31:26,591
No.
415
00:31:26,674 --> 00:31:28,304
Why not?
416
00:31:28,387 --> 00:31:33,761
I saw other aircraft on the display screen,
so that told me the system was working.
417
00:31:34,793 --> 00:31:39,010
Investigators discover that the
pilot didn't fully understand how
418
00:31:39,093 --> 00:31:42,299
all the components of the traffic
surveillance system worked.
419
00:31:43,513 --> 00:31:44,439
No conflict.
420
00:31:45,438 --> 00:31:49,486
We learned that there had
been other pilots in the airplane
421
00:31:49,570 --> 00:31:54,018
preceding the accident with
the accident pilot who apparently
422
00:31:54,101 --> 00:31:57,953
didn't catch that the GSL 71
was in the "OFF" position either.
423
00:31:58,037 --> 00:32:00,974
I think on one of those
flights he actually had the
424
00:32:01,057 --> 00:32:04,988
chief pilot of the company
with him and the GSL 71
425
00:32:05,071 --> 00:32:08,631
was still in the "OFF" position and we
know that because the data wasn't
426
00:32:08,714 --> 00:32:11,146
streamed, the pressure
altitude wasn't streamed.
427
00:32:12,244 --> 00:32:18,134
Did you check to see if the GSL unit
was on during your pre-flight checklist?
428
00:32:20,576 --> 00:32:25,849
No. It, wasn't a piece of equipment that
I ever touched or concerned myself with.
429
00:32:26,636 --> 00:32:30,662
They review the company's
pre-flight checklist with the Otter pilot,
430
00:32:30,745 --> 00:32:35,447
to understand why a crucial part
of the alerting system wasn't turned on.
431
00:32:37,177 --> 00:32:38,651
Radio set.
432
00:32:40,430 --> 00:32:41,904
Altimeter set.
433
00:32:43,566 --> 00:32:45,254
Fuel checked.
434
00:32:47,163 --> 00:32:49,083
It's not on my pre-flight checklist.
435
00:32:56,311 --> 00:32:57,151
Okay.
436
00:32:59,355 --> 00:33:00,188
Thank you.
437
00:33:02,316 --> 00:33:04,969
Investigators determine the Otter pilot
438
00:33:05,052 --> 00:33:09,422
wouldn't have checked
the status of the GSL 71.
439
00:33:09,505 --> 00:33:10,946
In an airline environment,
440
00:33:11,029 --> 00:33:14,242
something as critical as that
would definitely be on a checklist.
441
00:33:14,325 --> 00:33:17,227
And so, the fact that it wasn't might,
442
00:33:17,310 --> 00:33:20,610
lead him to think that
it wasn't super critical or,
443
00:33:20,693 --> 00:33:24,230
it would just not have risen to
the level of something that he would
444
00:33:24,314 --> 00:33:26,243
pay attention to each and every time.
445
00:33:29,463 --> 00:33:32,052
What did you learn from the Otter pilot?
446
00:33:32,135 --> 00:33:34,343
He didn't know the unit was turned off.
447
00:33:35,889 --> 00:33:38,594
It wasn't on his pre-flight checklist.
448
00:33:40,076 --> 00:33:43,638
You have to be so diligent at all
times when you're flying the aircraft,
449
00:33:43,721 --> 00:33:46,144
especially in a busy, busy area like that.
450
00:33:46,227 --> 00:33:49,889
As good as the traffic systems
can be, they can sometimes fail.
451
00:33:50,927 --> 00:33:55,563
The team now knows why neither
traffic system alerted the pilots.
452
00:33:56,343 --> 00:33:59,689
It still doesn't explain why
the pilots didn't see each other
453
00:33:59,773 --> 00:34:01,509
on a perfectly clear day.
454
00:34:02,943 --> 00:34:08,324
See-and-avoid is, the system by which
pilots are taught to avoid one another
455
00:34:08,407 --> 00:34:12,007
when air traffic control is not
providing positive separation.
456
00:34:13,027 --> 00:34:16,300
It is considered a last line
of defense, and it involves
457
00:34:16,383 --> 00:34:21,516
systematically scanning different parts
of the sky visible through the windscreen
458
00:34:21,599 --> 00:34:25,104
to ensure that there aren't any
other aircraft on a collision course.
459
00:34:28,659 --> 00:34:31,265
Okay, let's check out
the pilot's field of view.
460
00:34:32,430 --> 00:34:36,747
NTSB investigators consider
exactly what the pilots could see
461
00:34:36,831 --> 00:34:39,023
from the cockpits of their airplanes.
462
00:34:43,077 --> 00:34:48,180
So the Beaver pilot would
have been doing his scans.
463
00:34:48,264 --> 00:34:49,633
Looking left.
464
00:34:51,279 --> 00:34:53,159
No problem.
465
00:34:53,242 --> 00:34:54,910
Looking right.
466
00:34:56,900 --> 00:35:01,268
Hmm, there was a passenger in
the front seat restricting his view.
467
00:35:04,070 --> 00:35:08,416
And the Otter was to the
right coming from behind.
468
00:35:11,160 --> 00:35:15,818
The passenger sitting in your seat
might have been able to see it but,
469
00:35:15,902 --> 00:35:17,342
not the pilot.
470
00:35:18,315 --> 00:35:20,745
What about looking back through the cabin?
471
00:35:23,766 --> 00:35:24,886
I don't think so.
472
00:35:25,722 --> 00:35:29,046
The windows are too small,
and passengers are in the way.
473
00:35:31,390 --> 00:35:34,002
There's no way he could have seen,
474
00:35:34,086 --> 00:35:36,753
the Otter approaching
from behind and to the right.
475
00:35:38,233 --> 00:35:40,590
The Beaver has issues
with visibility because
476
00:35:40,673 --> 00:35:43,276
of the structural design of the airplane.
477
00:35:43,359 --> 00:35:47,819
You have door posts and window posts
and overhead structure, et cetera,
478
00:35:47,903 --> 00:35:50,091
that does obscure your view.
479
00:35:50,175 --> 00:35:54,438
And of course, in the old days,
that wasn't really a huge concern,
480
00:35:54,521 --> 00:35:57,578
because of course, there
was a lot less airplanes in the sky.
481
00:35:58,437 --> 00:36:04,727
The Otter pilot, might have had a perfect
view to the left and straight ahead.
482
00:36:06,597 --> 00:36:08,277
Let's figure that out.
483
00:36:13,723 --> 00:36:18,416
So, the Otter pilot said he was
lining up the waterfall to his right.
484
00:36:18,500 --> 00:36:23,426
So, this, was the pilot's field of view.
485
00:36:24,640 --> 00:36:29,488
Investigators consider what the Otter
pilot could see at the time of the crash.
486
00:36:31,206 --> 00:36:36,406
So let's assume, that he was looking
to his right, say about two o'clock.
487
00:36:37,172 --> 00:36:41,459
Eh, but the pilot was adamant that he
was still doing his full visual scans,
488
00:36:41,542 --> 00:36:43,682
left and right, up and down.
489
00:36:45,406 --> 00:36:50,980
So what would he see if he
looked to his left towards the Beaver?
490
00:36:54,450 --> 00:37:00,671
Using a 3D scan of an Otter cockpit,
the team recreates the pilot's view out of
491
00:37:00,754 --> 00:37:03,856
the left windshield in
the moments before the collision.
492
00:37:06,849 --> 00:37:08,994
This is just minutes before the collision.
493
00:37:10,507 --> 00:37:12,973
The Beaver is still three miles away,
494
00:37:14,517 --> 00:37:17,519
roughly in this area of the windscreen.
495
00:37:17,603 --> 00:37:21,088
The Beaver is little more
than a speck on the horizon.
496
00:37:22,495 --> 00:37:26,984
It's hard to pick out the Beaver against
the dark mountains in the distance.
497
00:37:27,068 --> 00:37:29,294
When two objects are converging,
498
00:37:29,378 --> 00:37:31,563
there is little relative
motion in a pilot's
499
00:37:31,647 --> 00:37:34,600
visual field to attract
a pilot's attention.
500
00:37:35,163 --> 00:37:36,790
Okay.
501
00:37:36,874 --> 00:37:40,034
We've got one three
miles out, three o'clock.
502
00:37:41,023 --> 00:37:43,356
Opposite direction.
503
00:37:43,439 --> 00:37:44,845
No conflict.
504
00:37:47,578 --> 00:37:50,125
The Beaver's an eighth mile away.
505
00:37:50,209 --> 00:37:52,662
Still don't see it.
506
00:37:52,746 --> 00:37:57,962
The window post, called an A pillar,
obstructs the view of the beaver.
507
00:37:58,046 --> 00:38:00,476
Okay, we're coming up
on the moment of impact.
508
00:38:03,659 --> 00:38:05,828
The Beaver came out of nowhere.
509
00:38:05,912 --> 00:38:08,499
I didn't see it until impact.
510
00:38:08,583 --> 00:38:11,410
The Otter's ADS-B system doesn't have the
511
00:38:11,493 --> 00:38:14,502
alerting capability to
warn of the other plane.
512
00:38:16,006 --> 00:38:18,919
And the pilot's view of it is obstructed.
513
00:38:20,135 --> 00:38:25,255
Okay, folks, in a few seconds,
we're going to pass our famous Mahon-
514
00:38:29,478 --> 00:38:32,620
The animation was fascinating because,
515
00:38:32,704 --> 00:38:38,054
it showed how almost perfectly
the Beaver was obscured by the window post
516
00:38:38,137 --> 00:38:41,252
in the cockpit of
the Otter from the pilot's perspective.
517
00:38:41,336 --> 00:38:45,316
And, it wasn't until the last half
second or so that it sort of
518
00:38:45,399 --> 00:38:49,555
blossomed from behind the
post and, became a red flash.
519
00:38:51,043 --> 00:38:53,717
But they can't be completely certain.
520
00:38:55,606 --> 00:38:57,987
It's hard to know for sure.
521
00:38:58,070 --> 00:39:01,649
His perspective is going to change
522
00:39:01,732 --> 00:39:04,507
depending on where his seat is set
523
00:39:04,590 --> 00:39:06,731
and where his head is.
524
00:39:06,814 --> 00:39:09,483
Investigators need more information.
525
00:39:11,186 --> 00:39:16,036
We can, change sight lines
we can, adjust angles,
526
00:39:16,120 --> 00:39:18,609
we can adjust views,
527
00:39:18,693 --> 00:39:22,600
but we do not have the ability
to say that that was in fact
528
00:39:22,683 --> 00:39:27,180
the pilot's position at any
point in time during that flight.
529
00:39:31,925 --> 00:39:36,651
The team performs a study
using 27 different eye positions
530
00:39:36,734 --> 00:39:40,240
to evaluate how the A pillar
would have blocked the Beaver
531
00:39:40,323 --> 00:39:42,541
from the Otter pilot's view.
532
00:39:42,624 --> 00:39:44,622
The Beaver's mostly hidden.
533
00:39:44,706 --> 00:39:46,532
Except for here.
534
00:39:48,120 --> 00:39:53,359
It's hard to be 100% certain without,
knowing the pilot's exact seat position.
535
00:39:57,482 --> 00:40:01,399
What about the cameras that,
we recovered from the wreckage?
536
00:40:01,483 --> 00:40:03,666
Maybe there's something on them.
537
00:40:03,750 --> 00:40:04,763
We'll check on that.
538
00:40:06,296 --> 00:40:10,853
Based on it being an air
tour operation, being in 2019,
539
00:40:10,936 --> 00:40:16,279
fortunately we were able to locate
quite a bit of still imagery and video.
540
00:40:17,903 --> 00:40:20,170
Okay let's see what we've got.
541
00:40:22,012 --> 00:40:25,129
After several weeks of painstaking work,
542
00:40:25,212 --> 00:40:29,552
investigators review images
taken by the Otter passengers.
543
00:40:33,443 --> 00:40:35,524
No, there's nothing here.
544
00:40:37,022 --> 00:40:40,491
There are no pictures taken
near the time of the collision.
545
00:40:41,470 --> 00:40:44,356
Let's check out the photos
taken from the Beaver.
546
00:40:47,889 --> 00:40:48,782
Whoa.
547
00:40:50,090 --> 00:40:54,800
They find a photo of the Otter
taken by a passenger in the Beaver.
548
00:40:55,550 --> 00:40:59,723
It was eerie and disturbing to see
the photos taken by the passengers.
549
00:41:00,779 --> 00:41:02,536
Let's take a closer look.
550
00:41:06,880 --> 00:41:11,600
The photo of the approaching Otter
was taken seconds before impact.
551
00:41:18,042 --> 00:41:20,173
It was a moving experience.
552
00:41:20,256 --> 00:41:24,032
You knew it was going to be the
last moments for some of those people.
553
00:41:26,649 --> 00:41:27,615
Um, zoom in.
554
00:41:29,096 --> 00:41:34,491
But can it answer the question of whether
the Otter pilot could see the Beaver?
555
00:41:34,574 --> 00:41:36,934
I can see into the Otter cockpit.
556
00:41:38,190 --> 00:41:41,426
It's the break the investigators needed.
557
00:41:41,510 --> 00:41:44,687
Uh, try to zoom in a little bit more.
558
00:41:44,770 --> 00:41:48,282
The photo captures
the Otter's exact position.
559
00:41:48,366 --> 00:41:51,546
The A pillar is blocking the pilot's head.
560
00:41:51,629 --> 00:41:54,955
If we can't see the Otter pilot's
head from this perspective,
561
00:41:55,039 --> 00:41:57,180
he wouldn't have seen the Beaver.
562
00:41:57,263 --> 00:42:02,494
Investigators are now certain that for
almost three minutes before the collision,
563
00:42:02,577 --> 00:42:04,922
the Otter's windshield structure blocked
564
00:42:05,005 --> 00:42:07,670
the pilot's view of the
approaching Beaver.
565
00:42:07,753 --> 00:42:11,271
It's crucial for us to
understand that at that point,
566
00:42:11,354 --> 00:42:16,830
the Otter pilot had very limited chance
of avoiding that collision due to his
567
00:42:16,919 --> 00:42:20,099
sight being obscured
by that aircraft structure.
568
00:42:22,159 --> 00:42:26,145
Investigators now understand
why the Mountain Air Beaver
569
00:42:26,228 --> 00:42:28,552
and the Taquan Air Otter collided.
570
00:42:31,110 --> 00:42:35,536
Okay, folks, in a few seconds,
we're going to pass our famous Mahon-
571
00:42:37,043 --> 00:42:40,310
Neither pilot could see nor be alerted to
572
00:42:40,393 --> 00:42:42,936
how close their aircraft
were to each other.
573
00:42:43,020 --> 00:42:44,313
Hang on, everyone!
574
00:42:46,729 --> 00:42:47,946
Brace for impact!
575
00:42:50,979 --> 00:42:54,442
You just can't afford not
to have a traffic system.
576
00:42:54,526 --> 00:42:59,330
When it's so busy as that in terrain
like that, when the pilot is so darn busy,
577
00:42:59,413 --> 00:43:02,056
he needs all the help he can get.
578
00:43:02,140 --> 00:43:08,729
The NTSB's final report highlights the
limitation of see-and-avoid for pilots,
579
00:43:08,813 --> 00:43:12,303
and recommends new rules for
preventing the downgrading
580
00:43:12,386 --> 00:43:15,657
or disabling of traffic alerting systems.
581
00:43:15,740 --> 00:43:20,316
This accident in a nutshell to me is about
the rolling back of safety protections
582
00:43:20,413 --> 00:43:23,514
without anybody taking a critical
look at what they were doing.
583
00:43:25,170 --> 00:43:30,836
The NTSB recommends regulations
requiring mandatory air traffic alerting
584
00:43:30,919 --> 00:43:34,430
for air tour operators
in high traffic areas.
585
00:43:35,534 --> 00:43:38,900
I have worked a number of
mid-air collisions during my career
586
00:43:38,983 --> 00:43:43,774
here at the NTSB, and
this accident was very preventable.
587
00:43:44,856 --> 00:43:49,006
There are limitations as all
of us all well know with the
588
00:43:49,090 --> 00:43:54,146
concept of see-and-avoid and the
technology that exists today should be
589
00:43:54,229 --> 00:43:58,480
in these aircraft to help reduce these
number of collisions that take place.
590
00:43:58,564 --> 00:44:00,026
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