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No, no no no no no.
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NARRATOR: Security footage
of Flydubai Flight 981
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captures its final moments.
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Oh, it's diving hard.
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JOHN NANCE: The level of
violence of the impact
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was catastrophic.
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NARRATOR: 62 people are
killed in a fatal dive.
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Investigators soon
discover the pilots
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had aborted two landings.
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We're going around.
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PHIL DERNER: A go-around
is done just when
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conditions are not perfect.
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Did they say why they were
going around the second time?
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They just said going around.
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Check your speed.
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CONTROLLER: The next
thing I knew, the plane
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was diving towards the runway.
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Investigators needed
to find out how the two
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go-arounds were different.
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One turns to disaster.
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Why?
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PILOT (ON RADIO): Mayday!
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Mayday!
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Go up!
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NARRATOR: Flydubai
Flight 981 closes
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in on Rostov-on-Don
International
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Airport in Southwest Russia.
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Rostov tower, Skydubao
981, we're at 2,600 feet.
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2,300 feet is our
next target altitude.
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NARRATOR: 11 miles out, Captain
Aristos Sokratous and First
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Officer Alejandro Alava Cruz
prepare the Boeing 737-800
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for touchdown.
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PHIL DERNER: Both pilots had
a pretty good amount of flying
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hours in the 737, specifically.
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These were experienced pilots.
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CONTROLLER: Flight
981, Rostov Tower.
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Wind, 240 degrees.
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Gusts, 30 knots.
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You're cleared to
land on Runway 22.
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NARRATOR: The controller
reports the weather
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conditions at the airport.
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Thick clouds cover
Rostov-on-Don.
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High winds are
battering the runways.
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The weather in Rostov at
that time was pretty low
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cloud with wind gusts.
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It was typical for that
time of year for Rostov.
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If you look at the geography,
with the sea and the hills
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around it, then yes, you
can expect some challenges.
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NARRATOR: Flydubai Flight 981
departed Dubai International
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Airport at 10.37 PM.
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It's a four hour flight
Northwest to Rostov-on-Don.
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It's a bumpy ride for the
55 passengers on board.
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The flight is expected
to land in minutes.
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150 knots.
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NARRATOR: Eight miles out, the
pilots reduce speed as they
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begin the final descent.
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PHIL DERNER: On approach,
pilots know exactly
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what the airplane is doing.
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They know the conditions
that they're flying in.
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Flaps 30.
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Flaps 30.
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PHIL DERNER: They're going to
drop the flaps bit by bit, when
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to drop their landing gear.
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It's a very gradual process.
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It should be a bit bumpy and
then later it should be calm.
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NARRATOR: The pilots expect
turbulence on approach,
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but anticipate a smooth
landing, The runway
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is just four miles away,
but there's a threat ahead.
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AUTOMATED VOICE: Go around.
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Wind shear ahead.
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NARRATOR: The onboard radar
has detected dangerous winds.
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AUTOMATED VOICE:
Wind shear ahead.
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Wind shear ahead.
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NARRATOR: Wind shear is a rapid
change in direction and speed
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of wind.
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If a pilot experiences a strong
headwind that suddenly changes
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to a tailwind, the
aircraft might not
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have enough lift to remain
airborne, especially
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at low altitude.
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The wind shear alert is built
into the aircraft's avionics
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to tell you you're
going into wind currents
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that could be problematic.
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AUTOMATED VOICE:
Wind shear ahead.
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Wind shear, go-around.
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NARRATOR: Just 1,000
feet above the ground,
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landing at Rostov-on-Don
becomes too risky.
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ALEJANDRO ALAVA CRUZ:
Rostov Tower, this is 981.
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We are conducting a
go-around due to wind shear.
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NARRATOR: The pilots
abort their approach.
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Every pilot is
prepared to make
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a go-around on every approach.
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It's something that pilots do
off the top of their heads.
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There's no manual involved.
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PHIL DERNER: They have no limit
to the amount of approaches
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that they can try as long
as they have enough fuel.
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So why not go around
and just try it again?
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Flight 981, copy.
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NARRATOR: Flight
981 is one of four
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00:05:07,740 --> 00:05:09,942
incoming flights
controllers are managing
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as high winds delay landings.
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Aeroflot 1166, be advised
Skydubai 981 reports
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wind shear on landing.
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PHIL DERNER: The air traffic
controller's workload
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was definitely increased
in this environment,
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and they have to start juggling
all of those cards in the air.
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NARRATOR: As Flight 981 climbs--
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Aeroflot 1166, you're
cleared to land on runway 22.
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NARRATOR: --an Aeroflot
flight prepares to land.
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Captain Sokratous
pays close attention
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to its communications.
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I want to see what
this guy will do.
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PHIL DERNER: The
crew, at this point,
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is hoping that the
crews of other flights
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are able to give
them some information
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that they might be able to
use to make some decisions
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00:05:57,056 --> 00:05:58,191
about what to do next.
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00:06:00,760 --> 00:06:04,731
NARRATOR: That flight can't
land at Rostov-on-Dov either.
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PILOT (ON RADIO): Aeroflot 1156.
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00:06:07,400 --> 00:06:10,036
We're going around,
due to wind shear.
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00:06:10,103 --> 00:06:12,705
NARRATOR: The Aeroflot
pilots also encounter
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00:06:12,772 --> 00:06:15,074
wind shear on final approach.
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00:06:15,141 --> 00:06:17,744
They're forced to abort.
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That kind of seals the deal.
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Flydubai is going to
have to either wait
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or they're going to have to
go to an alternate airport.
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NARRATOR: High over
Rostov-on-Don, passengers
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on Flight 981 are restless.
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00:06:32,658 --> 00:06:35,194
The pilots are holding
at 15,000 feet,
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00:06:35,261 --> 00:06:38,498
circling near the airport,
waiting for a chance to land.
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00:06:40,600 --> 00:06:42,602
PHIL DERNER: The pilots sit in a
holding pattern, since they had
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enough fuel to be able to do so,
to wait for weather conditions
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to improve.
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00:06:47,273 --> 00:06:50,409
NARRATOR: Three other planes
are also in a holding pattern.
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00:06:50,476 --> 00:06:53,846
The storm pounding
Rostov-on-Don isn't passing.
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00:07:00,253 --> 00:07:02,388
PILOT (ON RADIO): Aeroflot 1166.
136
00:07:02,455 --> 00:07:03,856
We're diverting.
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00:07:06,926 --> 00:07:08,094
CONTROLLER (ON
RADIO): Skydubai 981,
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00:07:08,161 --> 00:07:10,129
for your information,
previous traffic
139
00:07:10,196 --> 00:07:11,798
went to alternate airports.
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00:07:11,864 --> 00:07:14,267
NARRATOR: All the other
flights decide to divert
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to alternate airports instead.
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00:07:19,705 --> 00:07:21,374
DAVID KAMINSKI-MORROW:
The problem with diverting
143
00:07:21,440 --> 00:07:25,244
is that it's expensive and,
yes, it's inconvenient.
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The passengers don't end
up at their destination.
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00:07:27,880 --> 00:07:29,816
They have to be
put up in hotels.
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00:07:29,882 --> 00:07:35,221
And with a low cost airline,
it's the last thing it wants.
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00:07:35,288 --> 00:07:36,956
NARRATOR: Captain
Sokratous continues
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monitoring the weather radar.
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Finally, he spots a clearing.
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00:07:41,394 --> 00:07:43,329
I think I'd like
to give it a try.
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00:07:43,396 --> 00:07:44,163
I agree.
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Let's try.
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00:07:46,065 --> 00:07:47,667
DAVID KAMINSKI-MORROW:
It's not unusual for crews
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00:07:47,733 --> 00:07:50,002
to take advantage
if there happens
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to be a break in
the weather pattern
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that provides safe conditions
to land the aircraft.
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Skydubai 981 request
descent for another approach.
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NARRATOR: 15,000 feet over
Rostov-on-Don, the pilots
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00:08:04,817 --> 00:08:06,352
again prepare to land.
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00:08:08,988 --> 00:08:11,324
Skydubai 981, Rosoff Tower.
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00:08:11,390 --> 00:08:13,392
You're cleared to
land on runway 22.
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00:08:15,428 --> 00:08:16,829
ALEJANDRO ALAVA
CRUZ (ON INTERCOM):
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00:08:16,896 --> 00:08:18,764
Good evening, your
first officer here.
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We will be learning shortly.
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00:08:20,099 --> 00:08:24,203
Once again, we
apologize for the delay.
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00:08:24,270 --> 00:08:26,472
NARRATOR: 13 miles
from runway 22,
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00:08:26,539 --> 00:08:28,941
the pilots line up
for a second approach.
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00:08:32,044 --> 00:08:33,546
CONTROLLER: Be advised,
low altitude head
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wind 53 knots, light icing.
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00:08:36,883 --> 00:08:38,484
NARRATOR: Even though
winds are strong,
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controllers aren't reporting
wind shear at the runway.
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Flaps 30.
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Flaps 30.
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00:08:49,228 --> 00:08:51,030
NARRATOR: But as they
approach, they soon
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realize something's not right.
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Check your speed.
177
00:09:00,640 --> 00:09:01,407
OK.
178
00:09:01,474 --> 00:09:03,576
Go-around.
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00:09:03,643 --> 00:09:06,579
NARRATOR: The pilots
execute another go-around.
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00:09:17,056 --> 00:09:17,990
Keep it at 15 degrees.
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00:09:18,057 --> 00:09:19,158
Nose up.
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00:09:19,225 --> 00:09:20,693
NARRATOR: Just 2,000
feet in the air,
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Captain Sokratous kratos is
wrestling with the Boeing 737.
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00:09:29,502 --> 00:09:30,903
Seconds later--
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00:09:37,743 --> 00:09:40,780
NARRATOR: --Flight 981 is
diving straight at the runway.
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Oh, my god.
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00:09:59,532 --> 00:10:00,800
NARRATOR: Fire and
emergency crews
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00:10:00,866 --> 00:10:02,601
rush to the end of Runway 22.
189
00:10:05,438 --> 00:10:06,806
DAVID KAMINSKI-MORROW:
The aircraft punched
190
00:10:06,872 --> 00:10:10,609
a crater in the runway about
a meter and a half deep,
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00:10:10,676 --> 00:10:12,278
with wreckage--
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00:10:12,345 --> 00:10:16,382
wreckage thrown everywhere.
193
00:10:16,449 --> 00:10:22,288
NARRATOR: Firefighters battle
the flames through the night,
194
00:10:22,355 --> 00:10:25,491
but there's no
one to be rescued.
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00:10:25,558 --> 00:10:29,829
All 62 people on board Flight
981 are killed in the crash.
196
00:10:33,232 --> 00:10:36,936
Grieving families and
the world demand answers.
197
00:10:45,644 --> 00:10:47,646
NARRATOR: Hours
after Flydubai Flight
198
00:10:47,713 --> 00:10:51,350
981 crashes on the
runway at Rostov-on-Don,
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00:10:51,417 --> 00:10:55,321
investigators from the IAC, the
Interstate Aviation Committee,
200
00:10:55,388 --> 00:10:56,322
arrive on the scene.
201
00:10:59,492 --> 00:11:05,097
The IAC is the lead air
accident investigation agency,
202
00:11:05,164 --> 00:11:07,333
not just for Russia,
but for several
203
00:11:07,400 --> 00:11:09,268
of the former Soviet states.
204
00:11:09,335 --> 00:11:13,339
NARRATOR: The IAC must find the
cause for the horrific tragedy.
205
00:11:16,342 --> 00:11:17,176
OK.
206
00:11:17,243 --> 00:11:19,278
That's great.
207
00:11:19,345 --> 00:11:21,547
That belongs over here.
208
00:11:21,614 --> 00:11:23,749
NARRATOR: Wreckage
from Flight 981
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00:11:23,816 --> 00:11:27,853
is laid out in a nearby
hangar for closer inspection.
210
00:11:27,920 --> 00:11:29,855
A team from the
United Arab Emirates
211
00:11:29,922 --> 00:11:32,391
assists in the investigation.
212
00:11:32,458 --> 00:11:37,696
So how fast did
the plane hit the ground?
213
00:11:45,171 --> 00:11:46,872
DAVID KAMINSKI-MORROW:
The size of the debris
214
00:11:46,939 --> 00:11:48,908
would tell whether it was a
high speed impact, whether it
215
00:11:48,974 --> 00:11:50,309
was a low speed impact.
216
00:11:50,376 --> 00:11:53,979
There are clues in the
pieces of wreckage.
217
00:11:54,046 --> 00:11:56,782
There's
not much left of it.
218
00:12:00,286 --> 00:12:02,221
GERRY SOEJATMAN: It
was all small pieces.
219
00:12:02,288 --> 00:12:06,392
It describes a very high
speed and violent impact
220
00:12:06,459 --> 00:12:07,293
with the ground.
221
00:12:10,329 --> 00:12:12,398
it makes us question
what really happened.
222
00:12:16,235 --> 00:12:17,069
Let's see it.
223
00:12:19,538 --> 00:12:20,940
NARRATOR: Investigators
wonder how
224
00:12:21,006 --> 00:12:23,342
the plane could have
gathered so much speed
225
00:12:23,409 --> 00:12:25,978
during an attempted landing.
226
00:12:26,045 --> 00:12:27,613
Oh, it's diving hard.
227
00:12:27,680 --> 00:12:30,683
NARRATOR: Security footage gives
them a look at the last moments
228
00:12:30,749 --> 00:12:33,185
of Flight 981.
229
00:12:38,591 --> 00:12:42,328
Flight 981's angle of
descent leads investigators
230
00:12:42,394 --> 00:12:44,797
to wonder if the pilots
were having problems
231
00:12:44,864 --> 00:12:46,098
controlling their plane.
232
00:12:46,165 --> 00:12:49,034
Maybe it's their
flight controls.
233
00:12:49,101 --> 00:12:51,437
Mm-hmm.
234
00:12:51,504 --> 00:12:53,272
Never I've seen it before.
235
00:12:53,339 --> 00:12:55,975
NARRATOR: Boeing
737 flight controls
236
00:12:56,041 --> 00:12:58,177
have a problematic history.
237
00:13:02,348 --> 00:13:04,884
March 3, 1991--
238
00:13:04,950 --> 00:13:08,387
United Airlines Flight
585 banks hard right
239
00:13:08,454 --> 00:13:13,726
and crashes while attempting
to land, killing all on board.
240
00:13:13,792 --> 00:13:16,295
Three years later,
it happens again.
241
00:13:16,362 --> 00:13:20,966
US Air Flight 427 rolls left
and crashes near Pittsburgh.
242
00:13:22,902 --> 00:13:24,236
DAVID KAMINSKI-MORROW:
Investigators
243
00:13:24,303 --> 00:13:26,906
were tearing their hair out
trying to figure it out.
244
00:13:26,972 --> 00:13:30,075
NARRATOR: Two years
passed without incident.
245
00:13:30,142 --> 00:13:34,413
Then, while on approach to land,
the pilots of Eastwind Airlines
246
00:13:34,480 --> 00:13:37,750
Flight 517 lose control.
247
00:13:37,816 --> 00:13:41,220
This time, the pilots regain
control of their plane and land
248
00:13:41,287 --> 00:13:43,122
safely in Richmond, Virginia.
249
00:13:46,892 --> 00:13:48,260
The plane is intact.
250
00:13:48,327 --> 00:13:51,931
Investigators get
their best lead yet.
251
00:13:51,997 --> 00:13:53,933
DAVID KAMINSKI-MORROW: After
a five year investigation,
252
00:13:53,999 --> 00:13:56,202
the National
Transportation Safety Board
253
00:13:56,268 --> 00:14:00,606
concluded that a power
unit in the rudder
254
00:14:00,673 --> 00:14:04,944
had been responsible for what's
called a rudder hard over.
255
00:14:05,010 --> 00:14:07,947
The rudder had
moved to one side,
256
00:14:08,013 --> 00:14:12,117
and that caused the
aircraft to roll over
257
00:14:12,184 --> 00:14:14,386
and then dive into the ground.
258
00:14:14,453 --> 00:14:17,189
NARRATOR: Movements of rudder
and other control surfaces
259
00:14:17,256 --> 00:14:22,094
occur when pilots push their
rudder pedal or pull the yoke.
260
00:14:22,161 --> 00:14:25,531
Power control units turn those
commands into actual movements
261
00:14:25,598 --> 00:14:27,766
of the control surfaces.
262
00:14:27,833 --> 00:14:30,035
It's similar to the
power steering on a car.
263
00:14:34,373 --> 00:14:35,975
Hey, there.
264
00:14:36,041 --> 00:14:37,610
Did you recover the PCUs?
265
00:14:37,676 --> 00:14:40,746
NARRATOR: Investigators want
to know if any of Flight
266
00:14:40,813 --> 00:14:44,883
981's control units failed.
267
00:14:44,950 --> 00:14:46,285
Yep, they're here.
268
00:14:46,352 --> 00:14:46,986
Great.
269
00:14:47,052 --> 00:14:48,320
We need to test them.
270
00:14:48,387 --> 00:14:50,990
NARRATOR: Much of the
Boeing 737 was destroyed
271
00:14:51,056 --> 00:14:52,558
during high speed impact.
272
00:14:52,625 --> 00:14:55,928
But two of the power
control units have survived.
273
00:14:55,995 --> 00:15:00,099
They could provide
crucial information.
274
00:15:00,165 --> 00:15:02,501
JOHN NANCE: PCUs are the
heart and soul of the flight
275
00:15:02,568 --> 00:15:04,069
controls of the airplane.
276
00:15:04,136 --> 00:15:05,604
And one of the first questions
if you have an airplane that
277
00:15:05,671 --> 00:15:08,340
came screaming out of the sky
they had a 50 degree angle
278
00:15:08,407 --> 00:15:12,077
is did we have a PCU problem
in the flight controls.
279
00:15:14,413 --> 00:15:15,814
NARRATOR:
Investigators carefully
280
00:15:15,881 --> 00:15:20,286
examine the PCUs of Flight 981.
281
00:15:20,352 --> 00:15:23,155
They look for signs
of a malfunction.
282
00:15:30,929 --> 00:15:33,432
Nothing wrong with the PCUs.
283
00:15:33,499 --> 00:15:36,001
JOHN NANCE: They were
extensively examined and found
284
00:15:36,068 --> 00:15:39,338
to have had absolutely no
connection to what brought
285
00:15:39,405 --> 00:15:41,507
this airplane out of the sky.
286
00:15:41,573 --> 00:15:44,343
NARRATOR: With flight
control issues ruled out,
287
00:15:44,410 --> 00:15:48,547
the team turns to the
controller for insight.
288
00:15:48,614 --> 00:15:50,883
Take me through what you saw.
289
00:15:50,949 --> 00:15:52,384
They were on final approach.
290
00:15:56,455 --> 00:15:58,223
CONTROLLER (ON RADIO):
Flight 081, Rostov Tower.
291
00:15:58,290 --> 00:16:00,225
You're clear to
land on runway 22.
292
00:16:03,529 --> 00:16:05,631
Then they aborted their
first attempt to land.
293
00:16:08,133 --> 00:16:10,703
They reported wind shear.
294
00:16:10,769 --> 00:16:13,205
ALEJANDRO ALAVA CRUZ:
Rostov Tower, this is 981.
295
00:16:13,272 --> 00:16:16,742
We're conducting a
go-around due to wind shear.
296
00:16:16,809 --> 00:16:22,047
Skydubai 981, make holding
pattern at your convenience.
297
00:16:22,114 --> 00:16:24,750
They climbed
and began holding.
298
00:16:24,817 --> 00:16:26,919
How long were they holding?
299
00:16:26,985 --> 00:16:28,420
For a long time.
300
00:16:28,487 --> 00:16:30,389
NARRATOR: Investigators
learn that the pilots
301
00:16:30,456 --> 00:16:32,691
held for almost
two hours waiting
302
00:16:32,758 --> 00:16:33,992
for the weather to improve.
303
00:16:36,662 --> 00:16:41,033
Skydubai 981, request
descent for another approach.
304
00:16:41,100 --> 00:16:43,268
CONTROLLER: Then
they asked to land.
305
00:16:43,335 --> 00:16:45,371
NARRATOR: But something
went wrong when the pilots
306
00:16:45,437 --> 00:16:48,273
made their second approach.
307
00:16:48,340 --> 00:16:51,176
ALEJANDRO ALAVA CRUZ: Rostov
Tower, this is Skydubai 981.
308
00:16:51,243 --> 00:16:53,912
We're going around.
309
00:16:53,979 --> 00:16:56,949
Did they say why they were
going around the second time?
310
00:16:57,015 --> 00:16:58,217
No.
311
00:16:58,283 --> 00:17:01,854
They just said going
around, that's all.
312
00:17:01,920 --> 00:17:04,523
The next thing I knew, the plane
was diving towards the runway.
313
00:17:10,662 --> 00:17:13,432
Did they report any
problems with the plane?
314
00:17:13,499 --> 00:17:15,801
No, nothing.
315
00:17:15,868 --> 00:17:18,070
NARRATOR: IAC
investigators still
316
00:17:18,137 --> 00:17:21,774
can't explain why Flight
981 suddenly banked
317
00:17:21,840 --> 00:17:24,810
and then dived into runway 22.
318
00:17:24,877 --> 00:17:27,246
Something had gone wrong
on the second go-around,
319
00:17:27,312 --> 00:17:29,048
but investigators
didn't know what.
320
00:17:29,114 --> 00:17:31,283
Was there a problem
with the airplane?
321
00:17:31,350 --> 00:17:33,152
Did the pilots make a mistake?
322
00:17:33,218 --> 00:17:34,553
There was no knowing it yet.
323
00:17:41,527 --> 00:17:42,828
OK.
324
00:17:42,895 --> 00:17:47,299
Two go-arounds, one
turns to disaster.
325
00:17:47,366 --> 00:17:48,500
Why?
326
00:17:48,567 --> 00:17:49,902
Let's take a look
at the first one.
327
00:17:49,968 --> 00:17:52,738
NARRATOR: Investigators
turn to FDR data
328
00:17:52,805 --> 00:17:55,541
to better understand
why Flydubai Flight
329
00:17:55,607 --> 00:17:59,378
981 performed one
successful go-around
330
00:17:59,445 --> 00:18:01,313
but crashed during the second.
331
00:18:01,380 --> 00:18:04,016
Investigators need to figure
out how the two go-arounds
332
00:18:04,082 --> 00:18:06,185
were different from each other.
333
00:18:06,251 --> 00:18:07,319
Zoom in a bit.
334
00:18:11,957 --> 00:18:13,559
Look.
335
00:18:13,625 --> 00:18:15,227
NARRATOR: They
confirm the pilots
336
00:18:15,294 --> 00:18:20,766
reacted to a wind shear alarm
during the first approach.
337
00:18:20,833 --> 00:18:22,901
And how did they respond?
338
00:18:22,968 --> 00:18:32,444
Thruster jumps up to 102.
339
00:18:32,511 --> 00:18:33,946
So he applied max power.
340
00:18:34,012 --> 00:18:34,680
Mm-hmm.
341
00:18:34,746 --> 00:18:36,515
What about the flaps?
342
00:18:36,582 --> 00:18:42,754
Flaps at 30, and
gear remained down.
343
00:18:50,696 --> 00:18:52,231
Textbook wind shear go-around.
344
00:18:52,297 --> 00:18:53,966
Yeah.
345
00:18:54,032 --> 00:18:55,801
If a pilot
encounters wind shear,
346
00:18:55,868 --> 00:18:57,803
he'll typically perform
a-- what's called
347
00:18:57,870 --> 00:19:00,272
a wind shear escape maneuver.
348
00:19:00,339 --> 00:19:03,475
And that involves increasing
the engine power to a maximum.
349
00:19:03,542 --> 00:19:04,810
You leave the flaps down.
350
00:19:04,877 --> 00:19:06,812
You leave the gear down.
351
00:19:06,879 --> 00:19:08,413
AUTOMATED VOICE:
Wind shear ahead.
352
00:19:08,480 --> 00:19:10,949
Wind shear, go-around.
353
00:19:11,016 --> 00:19:13,585
PHIL DERNER: The first go
round was pretty routine.
354
00:19:13,652 --> 00:19:14,953
They responded appropriately.
355
00:19:15,020 --> 00:19:17,055
They did exactly what
they should have done.
356
00:19:21,393 --> 00:19:24,997
This is the second go-around.
357
00:19:25,063 --> 00:19:27,666
NARRATOR: Investigators
analyze the second attempt
358
00:19:27,733 --> 00:19:32,304
at landing, focusing in on the
last moments before the crash.
359
00:19:32,371 --> 00:19:36,508
Now, did they get another wind
shear warning the second time?
360
00:19:36,575 --> 00:19:37,743
No, nothing.
361
00:19:45,050 --> 00:19:46,318
Look.
362
00:19:46,385 --> 00:19:51,823
There's a leap in air speed,
from 153 to 176 in seconds.
363
00:19:51,890 --> 00:19:53,425
NARRATOR: 10 seconds
before the pilots
364
00:19:53,492 --> 00:19:57,296
abort, a sudden increase in the
plane's airspeed was recorded.
365
00:19:57,362 --> 00:20:02,367
Investigators saw the airspeed
fluctuating for more than 20
366
00:20:02,434 --> 00:20:04,536
knots within a few seconds.
367
00:20:04,603 --> 00:20:06,371
It's a pretty
strong gust of wind.
368
00:20:06,438 --> 00:20:10,042
Now, they can see that on
the flight data recorder.
369
00:20:10,108 --> 00:20:12,878
NARRATOR: Investigators
determined that a strong gust
370
00:20:12,945 --> 00:20:16,048
of wind struck the plane.
371
00:20:16,114 --> 00:20:18,050
JOHN NANCE: You can
feel the wind increase
372
00:20:18,116 --> 00:20:19,518
on the nose of the airplane.
373
00:20:19,585 --> 00:20:21,853
It's probably also moving
the airplane a little bit
374
00:20:21,920 --> 00:20:23,055
left to right.
375
00:20:23,121 --> 00:20:27,159
It's not a pleasant
position to be in.
376
00:20:27,225 --> 00:20:28,694
How did the pilots
respond this time?
377
00:20:28,760 --> 00:20:29,795
Let me see.
378
00:20:32,798 --> 00:20:35,367
They added max power.
379
00:20:35,434 --> 00:20:36,201
OK.
380
00:20:36,268 --> 00:20:37,636
Go around.
381
00:20:43,442 --> 00:20:46,244
And what about the
flaps and landing gear?
382
00:20:46,311 --> 00:20:46,912
Hmm.
383
00:20:46,979 --> 00:20:50,849
Flaps are retracted.
384
00:20:50,916 --> 00:20:53,385
Gear, retracted.
385
00:20:55,621 --> 00:20:58,423
NARRATOR: The data reveals
that on the second go-around
386
00:20:58,490 --> 00:21:02,027
the pilots performed
a different procedure.
387
00:21:02,094 --> 00:21:03,095
DAVID KAMINSKI-MORROW:
They didn't
388
00:21:03,161 --> 00:21:04,930
fly the wind shear
escape maneuver
389
00:21:04,997 --> 00:21:06,598
during the second go-around.
390
00:21:06,665 --> 00:21:11,737
Well, it looks like they were
doing a standard go-around.
391
00:21:11,803 --> 00:21:13,071
NARRATOR: On a
standard go-around,
392
00:21:13,138 --> 00:21:17,676
the flaps and landing
gear are retracted.
393
00:21:17,743 --> 00:21:20,512
Except they did
it at max power.
394
00:21:20,579 --> 00:21:22,514
DAVID KAMINSKI-MORROW: Given
how streamlined the aircraft is
395
00:21:22,581 --> 00:21:26,418
with the landing gear up and
the flaps largely retracted,
396
00:21:26,485 --> 00:21:30,188
the use of maximum power
is very much overkill.
397
00:21:30,255 --> 00:21:33,925
NARRATOR: Investigators conclude
that on the second attempt
398
00:21:33,992 --> 00:21:36,962
the crew flew a hybrid
of two procedures.
399
00:21:40,599 --> 00:21:43,301
They used the power of a
wind shear escape maneuver
400
00:21:43,368 --> 00:21:47,139
with the gear and flap settings
of a traditional go-around.
401
00:21:53,145 --> 00:21:57,416
So what would that
do to the plane?
402
00:21:57,482 --> 00:21:59,518
We need to take a look
at all the factors at play.
403
00:22:05,624 --> 00:22:08,160
They were holding on
for nearly two hours.
404
00:22:08,226 --> 00:22:13,265
That's four tons of
fuel they burned.
405
00:22:13,331 --> 00:22:16,068
NARRATOR: The weight
of the Boeing 737
406
00:22:16,134 --> 00:22:20,005
is a critical factor in
the plane's performance.
407
00:22:20,072 --> 00:22:21,406
Adding the weight
of the plane--
408
00:22:25,911 --> 00:22:28,513
total weight, that's 54 tons.
409
00:22:32,217 --> 00:22:33,251
That's a light plane.
410
00:22:33,318 --> 00:22:34,152
Yeah.
411
00:22:36,555 --> 00:22:38,023
At this weight, you
know, the crew would
412
00:22:38,090 --> 00:22:40,292
feel a faster acceleration.
413
00:22:45,764 --> 00:22:50,602
Max power, no drag from flaps
or landing gear, low weight.
414
00:22:54,606 --> 00:22:58,844
This plane could have been
accelerating dangerously fast.
415
00:22:58,910 --> 00:23:01,980
This is really an
accelerated situation.
416
00:23:02,047 --> 00:23:03,615
This is a very
powerful airplane doing
417
00:23:03,682 --> 00:23:07,385
something that feels like you
just went into afterburner.
418
00:23:07,452 --> 00:23:09,054
How much quicker
did this plane pick up
419
00:23:09,121 --> 00:23:12,457
speed on the second go-around?
420
00:23:16,528 --> 00:23:20,198
We need to do
modeling on this.
421
00:23:20,265 --> 00:23:22,567
It was really incumbent
upon the investigators
422
00:23:22,634 --> 00:23:27,572
to look further into the
question of the acceleration.
423
00:23:27,639 --> 00:23:30,709
NARRATOR: Investigators
turn to computer modeling
424
00:23:30,776 --> 00:23:32,644
to answer a crucial question.
425
00:23:32,711 --> 00:23:34,913
Here's all the data for the
first and second go-around.
426
00:23:34,980 --> 00:23:36,414
Yeah.
427
00:23:36,481 --> 00:23:38,850
NARRATOR: How did the
rate of acceleration
428
00:23:38,917 --> 00:23:41,086
differ at the start
of the two attempts?
429
00:23:47,325 --> 00:23:53,865
First go-around, speed
increased by 17 knots.
430
00:23:53,932 --> 00:23:55,000
And the second?
431
00:24:02,007 --> 00:24:07,679
Second go-around,
25 knot increase.
432
00:24:07,746 --> 00:24:09,915
That's a difference of 8 knots
between the two go-arounds.
433
00:24:09,981 --> 00:24:10,849
Mm-hmm.
434
00:24:10,916 --> 00:24:12,450
Yeah.
435
00:24:12,517 --> 00:24:14,553
JOHN NANCE: It was a key part of
the findings when they realized
436
00:24:14,619 --> 00:24:18,390
that over 40% difference
existed between the acceleration
437
00:24:18,456 --> 00:24:22,093
from the first go-around
to the second go-around.
438
00:24:22,160 --> 00:24:24,262
NARRATOR: Could the increase
in acceleration have
439
00:24:24,329 --> 00:24:27,632
affected the pilots themselves?
440
00:24:27,699 --> 00:24:31,036
They calculate the impact
of the second go-around.
441
00:24:36,508 --> 00:24:37,709
Wow.
442
00:24:37,776 --> 00:24:41,479
Look at the backward force
experienced by the pilot.
443
00:24:41,546 --> 00:24:44,716
That faster acceleration on
the second go-around would have
444
00:24:44,783 --> 00:24:46,952
pushed him back into the seat.
445
00:24:47,018 --> 00:24:49,621
NARRATOR: The team also
examines the impact
446
00:24:49,688 --> 00:24:51,323
of vertical acceleration.
447
00:24:56,795 --> 00:24:59,397
The g-force would have
lifted the pilots upwards.
448
00:25:01,700 --> 00:25:04,302
BRADEN MCGRATH: The pilot would
have felt a slight unwaging.
449
00:25:04,369 --> 00:25:06,471
He would come up
out of the seat.
450
00:25:06,538 --> 00:25:10,275
So sudden
acceleration like this,
451
00:25:10,342 --> 00:25:15,413
both horizontal and vertical--
452
00:25:15,480 --> 00:25:18,149
that'll play tricks
on your mind.
453
00:25:18,216 --> 00:25:20,685
NARRATOR: Were Captain
Sokratous's senses
454
00:25:20,752 --> 00:25:22,687
his worst enemy?
455
00:25:22,754 --> 00:25:24,656
Maybe he experienced
a somatogravic illusion.
456
00:25:29,027 --> 00:25:30,328
Check your speed.
457
00:25:32,430 --> 00:25:32,998
OK.
458
00:25:33,064 --> 00:25:34,432
Go around.
459
00:25:34,499 --> 00:25:36,801
NARRATOR: A somatogravic
illusion is a dangerous form
460
00:25:36,868 --> 00:25:39,537
of spatial disorientation.
461
00:25:39,604 --> 00:25:42,607
When a plane accelerates
quickly with no visual reference
462
00:25:42,674 --> 00:25:45,710
of the horizon, the
gravitational forces
463
00:25:45,777 --> 00:25:49,347
cause a pitch up illusion
in the inner ear.
464
00:25:49,414 --> 00:25:52,350
The little hairs in the
inner ear bend backwards,
465
00:25:52,417 --> 00:25:57,455
tricking the brain into
thinking the head is tilting up.
466
00:25:57,522 --> 00:25:59,124
Well, you might
be going level.
467
00:25:59,190 --> 00:26:01,159
But if you cannot
see outside, that
468
00:26:01,226 --> 00:26:05,363
sensation on your vestibular
system is overwhelming.
469
00:26:05,430 --> 00:26:08,900
And, you know, you would really
feel that you're climbing up.
470
00:26:08,967 --> 00:26:10,735
DAVID KAMINSKI-MORROW: A
somatogravic graphic illusion
471
00:26:10,802 --> 00:26:14,239
is one of the most
lethal traps in aviation.
472
00:26:14,306 --> 00:26:16,908
Keep the nose up 15 degrees.
473
00:26:16,975 --> 00:26:19,411
DAVID KAMINSKI-MORROW: It's an
extremely convincing illusion.
474
00:26:27,152 --> 00:26:29,988
What was the actual pitch of
the plane after it accelerated
475
00:26:30,055 --> 00:26:33,091
during the second go-around?
476
00:26:33,158 --> 00:26:36,828
Almost 20 seconds
after the actual pitch
477
00:26:36,895 --> 00:26:41,232
was 8.8 degrees nose up.
478
00:26:41,299 --> 00:26:43,068
NARRATOR: Investigators
look for evidence
479
00:26:43,134 --> 00:26:46,404
that the pilots of Flight
981 became severely
480
00:26:46,471 --> 00:26:47,906
disoriented in the dark.
481
00:26:50,742 --> 00:26:51,843
DAVID KAMINSKI-MORROW:
If you imagine
482
00:26:51,910 --> 00:26:54,512
that this glass of
water represents
483
00:26:54,579 --> 00:26:56,348
the fluid in your ear--
484
00:26:56,414 --> 00:26:59,117
if you accelerated this
along a smooth surface,
485
00:26:59,184 --> 00:27:02,454
the water would be pushed up
against the back of the glass
486
00:27:02,520 --> 00:27:05,023
very much like this.
487
00:27:05,090 --> 00:27:08,460
In other words, it's the
same effect as if you'd
488
00:27:08,526 --> 00:27:11,162
simply tilted the glass.
489
00:27:11,229 --> 00:27:15,367
If you take visual information
away, what tends to happen
490
00:27:15,433 --> 00:27:19,204
is that the pilot forgets
about the acceleration
491
00:27:19,270 --> 00:27:24,876
and assumes that everything is
feeling is due to the pitch.
492
00:27:24,943 --> 00:27:28,279
And what was the
pilot's perceived pitch?
493
00:27:28,346 --> 00:27:30,882
BRADEN MCGRATH: Combining
the horizontal and vertical
494
00:27:30,949 --> 00:27:33,952
acceleration experienced
by the pilot,
495
00:27:34,019 --> 00:27:38,156
we can calculate the pH that
is perceived by the pilot.
496
00:27:38,223 --> 00:27:40,725
This is called the
illusionary pitch.
497
00:27:40,792 --> 00:27:46,231
Pilot's perceived
pitch was 21.6 degrees.
498
00:27:46,297 --> 00:27:48,500
NARRATOR: They compare
the plane's actual pitch
499
00:27:48,566 --> 00:27:54,139
to the pilot's illusionary pitch
during the second go-around.
500
00:27:54,205 --> 00:27:58,543
10 seconds later, the plane
is pitched up 3.9 degrees.
501
00:28:04,382 --> 00:28:18,696
And the pilot perceived it
to be 26.7 degrees, nose up.
502
00:28:18,763 --> 00:28:19,664
Wow.
503
00:28:19,731 --> 00:28:20,999
That's a huge difference.
504
00:28:27,105 --> 00:28:29,441
This puts the captain
into a situation
505
00:28:29,507 --> 00:28:31,676
that he potentially
will be experiencing
506
00:28:31,743 --> 00:28:32,944
as a somatogravic illusion.
507
00:28:33,011 --> 00:28:34,946
The captain is
feeling one thing,
508
00:28:35,013 --> 00:28:37,715
but the aircraft is
doing something else.
509
00:28:37,782 --> 00:28:39,284
Get this.
510
00:28:39,350 --> 00:28:48,460
Near the end of the flight, the
actual pitch is 7.6 degrees,
511
00:28:48,526 --> 00:28:54,265
and the perceived pitch
becomes, well over 40.
512
00:28:54,332 --> 00:28:58,036
NARRATOR: Investigators discover
three instances where there was
513
00:28:58,103 --> 00:29:00,972
a dramatic difference between
the plane's actual and
514
00:29:01,039 --> 00:29:02,974
the pilot's perceived pitch.
515
00:29:05,210 --> 00:29:07,145
Keep it at 16
degrees, nose up.
516
00:29:07,212 --> 00:29:09,714
NARRATOR: It's evidence
that the pilots may have
517
00:29:09,781 --> 00:29:11,950
experienced a
somatogravic illusion
518
00:29:12,016 --> 00:29:15,253
during the second go-around.
519
00:29:15,320 --> 00:29:17,822
Could the feeling of
the rapid acceleration
520
00:29:17,889 --> 00:29:21,159
have affected how the
pilots flew the plane?
521
00:29:21,226 --> 00:29:24,896
They dig deeper into
the flight data.
522
00:29:24,963 --> 00:29:28,399
When the captain push
forward on the yoke--
523
00:29:28,466 --> 00:29:30,568
He was trying to pitch
the plane downward.
524
00:29:30,635 --> 00:29:34,506
That's what his senses
were telling him to do.
525
00:29:34,572 --> 00:29:37,175
JOHN NANCE: The captain,
responding more to his feelings
526
00:29:37,242 --> 00:29:39,310
than to what he was seeing
on any instrumentation
527
00:29:39,377 --> 00:29:41,179
in front of him-- he
decides that he needs
528
00:29:41,246 --> 00:29:43,781
to push the airplane
forward and counteract
529
00:29:43,848 --> 00:29:45,150
this massive pitch up.
530
00:29:45,216 --> 00:29:48,853
He's trying to save
them by pitching down.
531
00:29:48,920 --> 00:29:49,687
Wow.
532
00:29:49,754 --> 00:29:51,022
Check this out.
533
00:29:51,089 --> 00:29:55,260
He pushed the
stabilizer trim down.
534
00:29:55,326 --> 00:29:58,596
NARRATOR: From the data,
investigators see the captain
535
00:29:58,663 --> 00:30:00,465
didn't just push the yoke.
536
00:30:00,532 --> 00:30:02,467
Be careful!
537
00:30:02,534 --> 00:30:04,269
DAVID KAMINSKI-MORROW:
Captain applies the stabilized
538
00:30:04,335 --> 00:30:07,472
trim because he's pushing--
539
00:30:07,539 --> 00:30:10,475
trying to push the nose
of the aircraft down.
540
00:30:10,542 --> 00:30:11,543
But for how long?
541
00:30:16,548 --> 00:30:17,482
Yeah.
542
00:30:17,549 --> 00:30:21,619
He held the trim
switch for 12 seconds.
543
00:30:21,686 --> 00:30:25,023
PHIL DERNER: Holding the switch
for 12 seconds is unheard of.
544
00:30:25,089 --> 00:30:28,059
That should never be held
for that amount of time.
545
00:30:28,126 --> 00:30:30,895
NARRATOR: The team discovers
that instead of pitching
546
00:30:30,962 --> 00:30:33,965
the plane up to climb,
the captain is pitching
547
00:30:34,032 --> 00:30:36,901
the plane towards the ground--
548
00:30:36,968 --> 00:30:38,469
No, no, no, no, no, no, no.
549
00:30:38,536 --> 00:30:41,306
NARRATOR: --eventually putting
the plane into a fatal dive.
550
00:30:44,475 --> 00:30:47,912
The sudden change in
direction is jarring.
551
00:30:47,979 --> 00:30:49,347
GERRY SOEJATMAN:
At that time you
552
00:30:49,414 --> 00:30:51,316
feel like you're in a
roller coaster, you know,
553
00:30:51,382 --> 00:30:53,351
when you're coming
up to the peak
554
00:30:53,418 --> 00:30:55,019
as you were diving at speed.
555
00:30:55,086 --> 00:30:57,655
It's similar to that sensation.
556
00:30:57,722 --> 00:31:00,091
NARRATOR: The pitch down
has another disorienting
557
00:31:00,158 --> 00:31:03,494
effect on the pilot's senses.
558
00:31:03,561 --> 00:31:06,097
Pitching down of the
aircraft would have caused both
559
00:31:06,164 --> 00:31:08,333
the captain and
the first officer
560
00:31:08,399 --> 00:31:10,868
to experience a dramatic
change in the g-forces.
561
00:31:10,935 --> 00:31:12,003
Oh, my god!
562
00:31:14,472 --> 00:31:16,941
That would increase the
confusion in the cockpit
563
00:31:17,008 --> 00:31:19,410
as to what's going on.
564
00:31:19,477 --> 00:31:23,081
NARRATOR: Investigators conclude
that the various g-forces
565
00:31:23,147 --> 00:31:25,783
on Captain Sokratous
caused his complete
566
00:31:25,850 --> 00:31:29,087
spatial disorientation.
567
00:31:29,153 --> 00:31:30,622
GERRY SOEJATMAN: The
captain pushing and pulling
568
00:31:30,688 --> 00:31:33,891
on the yoke, stomping on the
rudder, in the dive, you know,
569
00:31:33,958 --> 00:31:35,627
that shows confusion.
570
00:31:35,693 --> 00:31:37,962
He's probably disorientated.
571
00:31:38,029 --> 00:31:39,297
Oh, my god!
572
00:31:39,364 --> 00:31:40,898
GERRY SOEJATMAN: You
know, he's trying
573
00:31:40,965 --> 00:31:45,069
desperately to get out of that
sensation that he's feeling.
574
00:31:45,136 --> 00:31:46,871
NARRATOR: But there's
one question that
575
00:31:46,938 --> 00:31:49,207
still troubles investigators.
576
00:31:49,274 --> 00:31:53,544
Was the first officer
feeling the illusion, as well?
577
00:31:53,611 --> 00:31:56,281
BRADEN MCGRATH: Even though
the accelerations experienced
578
00:31:56,347 --> 00:32:02,453
by both pilots was the same, the
perception of what is happening
579
00:32:02,520 --> 00:32:03,588
can differ.
580
00:32:03,655 --> 00:32:05,990
And that can be due to
many different factors--
581
00:32:06,057 --> 00:32:09,327
expectation, what
are they looking at,
582
00:32:09,394 --> 00:32:12,063
their age, their experience.
583
00:32:12,130 --> 00:32:15,233
Start it at the second
go-around, please.
584
00:32:15,300 --> 00:32:16,501
NARRATOR: The cockpit
voice recorder
585
00:32:16,567 --> 00:32:19,003
could tell investigators
if the first officer
586
00:32:19,070 --> 00:32:22,373
was also under the influence
of the somatogravic illusion.
587
00:32:24,309 --> 00:32:25,109
ARISTOS SOKRATOUS: OK.
588
00:32:25,176 --> 00:32:26,210
Go around.
589
00:32:28,746 --> 00:32:29,647
Careful!
590
00:32:33,518 --> 00:32:36,921
No, no, no, no, no, no, no.
591
00:32:36,988 --> 00:32:39,190
Don't-- don't do that!
592
00:32:39,257 --> 00:32:41,526
He sees something wrong.
593
00:32:41,592 --> 00:32:42,360
No.
594
00:32:42,427 --> 00:32:43,027
Pull it!
595
00:32:43,094 --> 00:32:43,861
Pull it!
596
00:32:43,928 --> 00:32:45,163
Pull it!
597
00:32:45,229 --> 00:32:46,798
He's telling him to
pull back the yoke.
598
00:32:46,864 --> 00:32:48,700
ALEJANDRO ALAVA CRUZ: Pull it!
599
00:32:48,766 --> 00:32:51,703
If he's feeling the same
illusion as the captain,
600
00:32:51,769 --> 00:32:55,473
it sure doesn't seem like
he was affected by it.
601
00:32:55,540 --> 00:32:57,542
DAVID KAMINSKI-MORROW: The first
officer knew how much trouble
602
00:32:57,608 --> 00:32:59,944
the aircraft was in,
knew the captain wasn't
603
00:33:00,011 --> 00:33:01,946
responding the way he should.
604
00:33:02,013 --> 00:33:03,848
Oh, my god!
605
00:33:08,953 --> 00:33:12,323
NARRATOR: Investigators are left
wondering why the first officer
606
00:33:12,390 --> 00:33:13,791
didn't intervene.
607
00:33:17,795 --> 00:33:19,397
You look at this first
office you're trying his best
608
00:33:19,464 --> 00:33:21,299
and wonder why didn't
you just take control
609
00:33:21,366 --> 00:33:23,534
and say, I've got the airplane.
610
00:33:40,151 --> 00:33:43,454
He's been flying the
737-800 for nearly two years.
611
00:33:43,521 --> 00:33:44,889
He's fully certified.
612
00:33:44,956 --> 00:33:47,325
NARRATOR: Investigators look
into the first officer's
613
00:33:47,392 --> 00:33:50,128
background to understand
why he didn't take
614
00:33:50,194 --> 00:33:53,664
control of Flight 981
when he the captain
615
00:33:53,731 --> 00:33:56,601
was making grave mistakes.
616
00:33:56,667 --> 00:33:58,002
Look.
617
00:33:58,069 --> 00:34:01,439
His trainer wrote notes
on his assessment,
618
00:34:01,506 --> 00:34:02,907
and this one is telling.
619
00:34:02,974 --> 00:34:05,476
NARRATOR: They find notes
left by one of his flight
620
00:34:05,543 --> 00:34:07,478
instructors that alarm them.
621
00:34:07,545 --> 00:34:10,681
One thing that could have
possibly saved this aircraft
622
00:34:10,748 --> 00:34:13,418
was discovered in a
note that was left
623
00:34:13,484 --> 00:34:15,353
behind by a flight instructor.
624
00:34:15,420 --> 00:34:17,588
He needs to be a bit
more assertive in what
625
00:34:17,655 --> 00:34:19,457
is needed from the captain.
626
00:34:19,524 --> 00:34:21,259
And it continues.
627
00:34:21,325 --> 00:34:23,161
Tell him what you
want done, and do not
628
00:34:23,227 --> 00:34:25,463
wait for the captain
to inquire with you
629
00:34:25,530 --> 00:34:27,765
or direct you in this regard.
630
00:34:30,768 --> 00:34:32,270
He's not the type
to take control.
631
00:34:35,440 --> 00:34:36,674
No.
Pull it!
632
00:34:36,741 --> 00:34:37,508
Pull it!
633
00:34:37,575 --> 00:34:38,376
Pull it!
634
00:34:38,443 --> 00:34:39,544
Pull it!
635
00:34:39,610 --> 00:34:40,845
DAVID KAMINSKI-MORROW:
A first officer
636
00:34:40,912 --> 00:34:43,314
could see that the
captain was experiencing
637
00:34:43,381 --> 00:34:46,384
enormous problems trying
to control the go-around.
638
00:34:46,451 --> 00:34:50,354
He really should have taken some
decisive action and intervened.
639
00:34:50,421 --> 00:34:51,255
Oh, my god!
640
00:34:57,128 --> 00:34:59,397
I still don't
understand something.
641
00:34:59,464 --> 00:35:03,501
Why did they try to land the
plane in the first place?
642
00:35:03,568 --> 00:35:07,071
The big mystery was why was
this crew so determined to land
643
00:35:07,138 --> 00:35:10,975
at Rostov-onDon when every other
flight had already diverted.
644
00:35:11,042 --> 00:35:13,978
NARRATOR: A storm was pummeling
Rostov-on-Don Airport,
645
00:35:14,045 --> 00:35:18,249
as Flight 981 circled above.
646
00:35:18,316 --> 00:35:23,221
Why didn't the pilots
divert to another airport?
647
00:35:23,287 --> 00:35:26,991
Investigators look for answers
in the cockpit voice recording.
648
00:35:29,160 --> 00:35:30,394
CONTROLLER (ON
RECORDING): Skydubai 981,
649
00:35:30,461 --> 00:35:32,597
for your information,
previous traffic
650
00:35:32,663 --> 00:35:35,099
went to alternate airports.
651
00:35:35,166 --> 00:35:37,602
Two other flights diverted?
652
00:35:37,668 --> 00:35:39,403
There's no need.
653
00:35:39,470 --> 00:35:42,206
I'm gonna keep flying.
654
00:35:42,273 --> 00:35:45,076
Investigators just
couldn't understand
655
00:35:45,142 --> 00:35:48,779
why they wanted to fly in
circles for almost two hours.
656
00:35:48,846 --> 00:35:49,881
ARISTOS SOKRATOUS
(ON RECORDING):
657
00:35:49,947 --> 00:35:51,215
I'm gonna try this approach.
658
00:35:51,282 --> 00:35:54,285
And if I can't make it,
we'll have a go-around.
659
00:35:54,352 --> 00:35:56,621
And I will head to
Mineralyne Vody.
660
00:35:56,687 --> 00:35:57,855
OK?
661
00:35:57,922 --> 00:35:58,723
DISPATCHER (ON
RECORDING): OK, Captain.
662
00:35:58,789 --> 00:35:59,624
Understood.
663
00:35:59,690 --> 00:36:00,791
Who is he talking to?
664
00:36:00,858 --> 00:36:02,360
The dispatcher in Dubai.
665
00:36:02,426 --> 00:36:04,061
NARRATOR: Investigators
finally get
666
00:36:04,128 --> 00:36:06,264
an indication of the
captain's rationale
667
00:36:06,330 --> 00:36:08,933
for attempting another landing.
668
00:36:09,000 --> 00:36:11,802
As the captain decides
whether to divert,
669
00:36:11,869 --> 00:36:14,138
he contacts Flydubai's
flight dispatcher
670
00:36:14,205 --> 00:36:16,040
in the United Arab Emirates.
671
00:36:16,107 --> 00:36:17,742
DISPATCHER (ON RADIO): We
would like to recommend
672
00:36:17,808 --> 00:36:21,279
you hold max as possible.
673
00:36:21,345 --> 00:36:24,048
Dispatchers manage the
entire fleet's operation
674
00:36:24,115 --> 00:36:26,150
for a specific airline.
675
00:36:26,217 --> 00:36:27,652
JOHN NANCE: The
dispatcher and the captain
676
00:36:27,718 --> 00:36:30,821
are co-equally responsible
for the safety of the flight.
677
00:36:30,888 --> 00:36:33,157
There is a very
delicate dance that
678
00:36:33,224 --> 00:36:37,662
goes on between and among the
dispatchers and the captains.
679
00:36:37,728 --> 00:36:41,999
The captain follows with the
dispatchers recommendation.
680
00:36:42,066 --> 00:36:44,502
NARRATOR: Minutes turn
to hours as the pilots
681
00:36:44,569 --> 00:36:46,504
wait for a chance to land.
682
00:36:46,571 --> 00:36:47,939
I don't know, man.
683
00:36:48,005 --> 00:36:49,473
If we divert, we're gonna
exceed our flying hours.
684
00:36:54,579 --> 00:36:55,780
So what are you looking at?
685
00:36:55,846 --> 00:36:58,282
Maximum duty hours.
686
00:36:58,349 --> 00:37:01,953
He's calculating
his duty hours.
687
00:37:02,019 --> 00:37:04,288
NARRATOR: Regulations
limit how many hours pilots
688
00:37:04,355 --> 00:37:08,125
can fly during a duty period.
689
00:37:08,192 --> 00:37:11,128
Been in the air for
5 and 1/2 hours now.
690
00:37:11,195 --> 00:37:13,998
NARRATOR: The team learns that
the pilots were concerned they
691
00:37:14,065 --> 00:37:16,767
might exceed their duty hours.
692
00:37:16,834 --> 00:37:18,536
Stop.
693
00:37:18,603 --> 00:37:19,437
Roll the map.
694
00:37:22,440 --> 00:37:25,142
They've been flying for
at least five hours.
695
00:37:25,209 --> 00:37:27,878
It'll take another hour to
reach their alternate airport,
696
00:37:27,945 --> 00:37:29,280
wait out the storm.
697
00:37:29,347 --> 00:37:31,215
Then they still have to
get back to Rostov-on-Don
698
00:37:31,282 --> 00:37:32,850
before returning to Dubai.
699
00:37:32,917 --> 00:37:35,853
Diverting would put them over
their duty hours for the day.
700
00:37:35,920 --> 00:37:36,954
Right.
701
00:37:37,021 --> 00:37:38,556
Look.
702
00:37:38,623 --> 00:37:40,992
I think it'll be clear by the
time we do this approach now.
703
00:37:41,058 --> 00:37:45,563
And even if we start now,
I think we'll be good.
704
00:37:45,630 --> 00:37:47,565
We'll be good.
705
00:37:47,632 --> 00:37:49,233
OK.
706
00:37:49,300 --> 00:37:52,870
Is he landing because
it's clear or because he
707
00:37:52,937 --> 00:37:55,306
wants to get on the ground?
708
00:37:55,373 --> 00:37:56,974
PHIL DERNER: The conversation
in the flight deck
709
00:37:57,041 --> 00:38:00,244
before the second approach
clearly showed that they
710
00:38:00,311 --> 00:38:02,079
weren't really thinking
so much about the safety
711
00:38:02,146 --> 00:38:07,018
of the landing, just the fact
that they wanted to land.
712
00:38:07,084 --> 00:38:08,753
I think I'd like
to give it a try.
713
00:38:08,819 --> 00:38:09,587
I agree.
714
00:38:09,654 --> 00:38:11,088
Let's try.
715
00:38:11,155 --> 00:38:15,159
Stop the recording.
716
00:38:15,226 --> 00:38:18,496
So they decide to
circle for two hours
717
00:38:18,562 --> 00:38:21,399
after a four hour flight
in the middle of the night.
718
00:38:26,737 --> 00:38:29,874
NARRATOR: Did the long flight
affect the pilot's ability
719
00:38:29,940 --> 00:38:32,243
to land the plane safely?
720
00:38:32,309 --> 00:38:34,612
Two hours of hold,
six hours total time--
721
00:38:34,679 --> 00:38:37,248
aren't we seeing a decline
in the decision making
722
00:38:37,314 --> 00:38:39,016
capabilities because of fatigue?
723
00:38:39,083 --> 00:38:41,385
You tired?
724
00:38:41,452 --> 00:38:42,353
No.
725
00:38:47,525 --> 00:38:50,795
NARRATOR: As investigators
break down Flight 981's journey
726
00:38:50,861 --> 00:38:53,397
from Dubai to
Rostov-on-Don, they
727
00:38:53,464 --> 00:38:55,766
identify a glaring problem.
728
00:38:55,833 --> 00:38:58,769
They were actually in the
air for more than six hours.
729
00:38:58,836 --> 00:39:02,640
It's almost 5:00 AM their
time when they're landing.
730
00:39:02,707 --> 00:39:04,442
DAVID KAMINSKI-MORROW:
The circadian rhythm
731
00:39:04,508 --> 00:39:09,380
is the body's natural alignment
with the day and night cycle.
732
00:39:09,447 --> 00:39:11,782
A quiet period is
roughly for a four
733
00:39:11,849 --> 00:39:16,053
hour between 2:00 in the
morning and 6:00 in the morning.
734
00:39:16,120 --> 00:39:19,824
That's the point at
which your mental ability
735
00:39:19,890 --> 00:39:23,160
is pretty much at its lowest.
736
00:39:23,227 --> 00:39:24,829
I think I'd like
to give it a try.
737
00:39:24,895 --> 00:39:25,763
I agree.
738
00:39:25,830 --> 00:39:28,265
Let's try.
739
00:39:28,332 --> 00:39:30,835
NARRATOR: Investigators
determined the crew was
740
00:39:30,901 --> 00:39:33,003
suffering from
operational fatigue
741
00:39:33,070 --> 00:39:35,072
as they launched
their second approach.
742
00:39:37,408 --> 00:39:39,977
Good evening, your
first officer here.
743
00:39:40,044 --> 00:39:41,345
We will be landing shortly.
744
00:39:41,412 --> 00:39:44,515
Once again, we
apologize for the delay.
745
00:39:44,582 --> 00:39:46,517
NARRATOR: The decision
to make a second attempt
746
00:39:46,584 --> 00:39:50,187
to land at Rostov-on-Don
triggers a chain of events
747
00:39:50,254 --> 00:39:53,624
that ends in catastrophe.
748
00:39:53,691 --> 00:39:55,459
Check your speed.
749
00:39:55,526 --> 00:39:57,495
As the aircraft is
hit by this sudden wind,
750
00:39:57,561 --> 00:40:02,633
the crew is forced into
executing another go-around.
751
00:40:02,700 --> 00:40:03,768
OK, go around.
752
00:40:03,834 --> 00:40:06,370
And this time it was
all going to go wrong.
753
00:40:06,437 --> 00:40:08,305
NARRATOR: Captain
Sokratous executes
754
00:40:08,372 --> 00:40:12,810
a wind shear go-around, pushing
the throttle to maximum power.
755
00:40:12,877 --> 00:40:15,646
The first officer performs
a standard go-around,
756
00:40:15,713 --> 00:40:20,351
retracting the flaps and
raising the landing gear.
757
00:40:20,417 --> 00:40:22,453
Both pilots were
essentially flying two
758
00:40:22,520 --> 00:40:24,388
different airplanes from there.
759
00:40:24,455 --> 00:40:27,224
This blunder factors
heavily into the catastrophe
760
00:40:27,291 --> 00:40:28,793
that followed.
761
00:40:28,859 --> 00:40:33,864
NARRATOR: Flight 981 climbs from
Rostov-on-Don at high speed.
762
00:40:33,931 --> 00:40:36,333
When you're light on fuel
and you put the maximum thrust,
763
00:40:36,400 --> 00:40:38,135
you will accelerate.
764
00:40:40,237 --> 00:40:41,505
DAVID KAMINSKI-MORROW:
It's what happened
765
00:40:41,572 --> 00:40:47,478
in the last few seconds
that doomed Flight 981.
766
00:40:47,545 --> 00:40:49,413
Keep it at 15
degrees, nose up.
767
00:40:49,480 --> 00:40:51,749
NARRATOR: At this
moment, Captain Sokratous
768
00:40:51,816 --> 00:40:53,918
fights an inner battle.
769
00:40:53,984 --> 00:40:57,254
Acceleration of the aircraft
makes the captain feel as
770
00:40:57,321 --> 00:41:00,758
though the aircraft is
pitching up a lot more
771
00:41:00,825 --> 00:41:02,393
than it actually is.
772
00:41:02,459 --> 00:41:04,061
NARRATOR: His
spatial orientation
773
00:41:04,128 --> 00:41:07,565
deteriorates rapidly.
774
00:41:07,631 --> 00:41:09,667
JOHN NANCE: Your vestibular
senses and your middle ear
775
00:41:09,733 --> 00:41:12,570
are all telling you
the wrong thing.
776
00:41:12,636 --> 00:41:14,572
NARRATOR: The captain
counters the pitch up
777
00:41:14,638 --> 00:41:16,907
feeling of a
somatogravic illusion
778
00:41:16,974 --> 00:41:18,576
by pushing the yoke forward.
779
00:41:20,911 --> 00:41:24,415
The captain has lost touch
with the reality of what's
780
00:41:24,481 --> 00:41:26,050
happening to the airplane.
781
00:41:26,116 --> 00:41:28,419
NARRATOR: Then, the final blow.
782
00:41:28,485 --> 00:41:30,754
The captain holds that
stabilizer trim button
783
00:41:30,821 --> 00:41:33,958
down for about 12 seconds.
784
00:41:34,024 --> 00:41:37,294
With the sudden forcing of
the aircraft's nose down
785
00:41:37,361 --> 00:41:40,598
and stabilizer
trim, the aircraft
786
00:41:40,664 --> 00:41:46,237
transitions from a climb
very suddenly into a dive.
787
00:41:46,303 --> 00:41:47,638
BRADEN MCGRATH:
The aircraft is now
788
00:41:47,705 --> 00:41:49,974
in a very dangerous
situation which the captain
789
00:41:50,040 --> 00:41:51,942
is unable to overcome.
790
00:41:52,009 --> 00:41:52,776
My god!
791
00:41:54,511 --> 00:41:56,480
JOHN NANCE: They're
accelerating rapidly,
792
00:41:56,547 --> 00:42:00,050
and the first officer
finally gets on the yoke
793
00:42:00,117 --> 00:42:01,285
and tries to pull.
794
00:42:01,352 --> 00:42:03,487
But the controls
on the left side
795
00:42:03,554 --> 00:42:06,991
govern where the airplane is.
796
00:42:07,057 --> 00:42:11,495
And you get to a certain
point, and there's no recovery.
797
00:42:11,562 --> 00:42:13,264
NARRATOR: Nose diving
at full throttle
798
00:42:13,330 --> 00:42:15,499
towards the runway,
Captain Sokratous
799
00:42:15,566 --> 00:42:18,168
is completely disoriented.
800
00:42:18,235 --> 00:42:20,804
When he adds rudder
at the last moment,
801
00:42:20,871 --> 00:42:25,242
he's lost all awareness of
how the plane is flying.
802
00:42:31,582 --> 00:42:34,785
The pilots in this
case were conducting
803
00:42:34,852 --> 00:42:40,124
the flight very well right up
until those last few moments.
804
00:42:40,190 --> 00:42:43,093
And then it all really
just fell apart.
805
00:42:48,198 --> 00:42:52,336
NARRATOR: The IAC investigation
into the crash of Flight 981
806
00:42:52,403 --> 00:42:55,839
is a landmark case of how
spatial disorientation
807
00:42:55,906 --> 00:42:58,609
can end in disaster.
808
00:42:58,676 --> 00:43:00,177
GERRY SOEJATMAN: This
accident is a wake up
809
00:43:00,244 --> 00:43:01,312
call for the industry.
810
00:43:01,378 --> 00:43:02,513
This is one of
the accidents that
811
00:43:02,579 --> 00:43:05,215
pave the way into
increased training
812
00:43:05,282 --> 00:43:08,385
in spatial disorientation.
813
00:43:08,452 --> 00:43:11,288
NARRATOR: In their final
report, investigators
814
00:43:11,355 --> 00:43:13,624
blame the captain's
string of errors on his
815
00:43:13,691 --> 00:43:16,794
diminished psychological state.
816
00:43:16,860 --> 00:43:20,864
The IAC recommends that
Flydubai provide better training
817
00:43:20,931 --> 00:43:23,400
on the manual operation
of stabilizer trim,
818
00:43:23,467 --> 00:43:28,072
so their pilots don't make
the same mistake again.
819
00:43:28,138 --> 00:43:31,709
Research into human factors,
including situations like this
820
00:43:31,775 --> 00:43:33,844
where disorientation
likely occurred,
821
00:43:33,911 --> 00:43:37,414
is at the forefront of
aviation safety research.
822
00:43:37,481 --> 00:43:41,652
We are training our pilots
on simulators to experience
823
00:43:41,719 --> 00:43:43,921
these illusions before they
experience them in the air,
824
00:43:43,988 --> 00:43:46,490
so they can recognize
those situations.
825
00:43:49,593 --> 00:43:53,597
I think the Flydubai
accident shows how quickly
826
00:43:53,664 --> 00:43:56,567
your senses can overtake you.
827
00:43:56,633 --> 00:43:59,103
And one of the key
lessons is for pilots
828
00:43:59,169 --> 00:44:04,341
to trust in their instruments,
to take a step back from what
829
00:44:04,408 --> 00:44:06,944
they may think
they're experiencing,
830
00:44:07,011 --> 00:44:10,514
to actually understand
what the airplane is doing.
831
00:44:10,581 --> 00:44:13,450
You've got to keep
the aeroplane flying.
64198
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