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All that is left of Ethiopian Airline’s Flight 409
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lies at the bottom of the Mediterranean Sea.
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This accident was very unusual, very unlikely
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Everybody was shocked
that we had a major crash in Lebanon
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A 737 fell from the sky ,
just minutes after leaving Beirut
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Now, rumours of a terrorist attack
are spreading through the streets.
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They speculate
that the plane could be hit by a bomb
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and investigators are struggling
to understand the plane's bizarre flightpath.
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Often, the best approach
is the Sherlock Holmes approach...
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Eliminate everything you know didn't happen
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What is left...
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...is probably what did happen
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The evidence leads to a finding, so controversial
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some still refuse to believe it.
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ALARM IN THE COCKPIT
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This is a true story
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It is based on official investigations
and eyewitness reports
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Heading for disaster
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It is just past midnight...
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...at Rafik Hariri International Airport
in Beirut, Lebanon
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The fuel is good
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The load is calculated.
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In a typical departure,
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the flight-crew reviews its load,
reviews the fuel, reviews the route
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then runs through the checklist
to get the airplane underway.
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Captain Habtamu Negasa has been flying
with Ethiopian Airlines for over 20 years
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and has more than 10,000 hours in the cockpit
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check is complete
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Check complete no problems.
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The First Officer is far less experienced
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Allulah Beyene
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is a recent graduate of the
Ethiopian Airlines Flight Academy
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Tonight, there are 82 passengers aboard the 737.
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They are preparing for an overnight flight
to Addis Ababa, Ethiopia.
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Many passengers are Lebanese.
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Some are Ethiopians returning home
after working abroad.
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There is also an undercover security officer
on-board tonight's flight.
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The flight security officer is there
post 911 to intercept anybody
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who attempts to interfere
with the flight-crew.
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00:03:02,983 --> 00:03:06,735
Beirut Airport has seen its share of trouble
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It was the site of the 1983 barracks bombing
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that killed 241 American servicemen.
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More recently,
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all 3 runways were destroyed by Israeli missiles
during the Lebanon War of 2006.
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Today, the rebuilt airport is again open
to flights from around the world.
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Beirut Airport is a very busy,
very well put together civil airport.
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Its only difficulty is presented
by the mountains directly to the East.
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The Lebanon mountains rise sharply from the coast,
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forcing all flight to take off
towards the Mediterranean Sea.
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Flight 409's flight-plan calls for it
to head South West,
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then, make a U-turn
towards a navigational checkpoint called CHEKKA.
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Ethiopian 409, the wind is nearly calm,
cleared for take off Runway 21
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The Air Traffic Controller gives 409 its final
take off instructions.
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Immediate right turn to CHEKKA
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Cleared for take off runway 21
immediate right turn to CHEKKA, Ethiopian 409.
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The left side is clear
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The right side is clear
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The captain sets his radar to display the weather.
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While the first officer monitors the terrain
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The weather that night had mixed clouds
with bases from 2000 ft
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overcast up to 20,000 ft
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and there were
scattered thunder storms in the area.
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Take off thrust: set.
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The 737 accelerates down the runway.
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Speed increasing
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Do you see that?
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Rotate
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Ethiopian Airlines 409 lifts off,
just after 2:30 AM
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Their take off procedure
and the initial part of the take off
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seemed entirely routine and ordinary,
and well executed.
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Gear up.
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Heading select.
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Check
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The captain begins banking the plane to the right
as he climbs.
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The tower controller bids the crew goodbye
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and hands the flight off to a colleague
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Ethiopian 409, good morning,
climb flight level 29,000 ft
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The area controller instructs Flight 409
to climb to 29,000 ft
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Flight level 290,
Ethiopian 409.
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But the weather ahead is becoming fierce.
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There is lightning in the area,
you see the flashes
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You are beginning to feel turbulence.
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Sir, I suggest that, due to the weather,
you follow heading 270 to be at the clear
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21?, say again
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Confirming 210
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Just a few minutes into the flight,
something is going wrong.
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An alarm warns the crew
that their turn is becoming dangerously steep.
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The airplane is being banked
beyond its normal operational limits.
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Captain Negasa is struggling
to correct the problem
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He veers back to the left,
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towards the thunderstorm
the controller wants him to avoid.
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As you enter heavy precipitation
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the cockpit can become very noisy
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with a tremendous whoosh.
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The controller sees that Flight 409
is starting to veer back towards Beirut
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He warns the pilots again that they need to turn.
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Ethiopian 409,
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follow heading 270,
turn right heading 270
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At this moment,
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the controller was probably
the most concerned with the fact
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that the crew had overshot its heading,
would be conflicting with inbound traffic
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and had to be moved away
from a possible conflict with terrain
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What?
Heading 270
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What heading did he say?
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270, set
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The cockpit fills with a disturbing sound
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The control columns vibrate
warning them that the plane is about to stall.
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00:08:02,585 --> 00:08:03,811
What is it?
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00:08:03,835 --> 00:08:05,835
Go around
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Go around
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00:08:10,031 --> 00:08:12,983
The captain pushes the throttle all the way up
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to go around-power
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Ethiopian 409,
follow heading 270, sir
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Follow 270
Turn right heading 270 now.
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Whenever a controller tells a pilot
to do something NOW
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the controller is telling the crew
that they are in immediate danger.
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The speed is going down
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Ethiopian 409, you are going into the mountain
turn right now heading 270
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00:08:49,982 --> 00:08:53,982
He was worried that the crew
was going to fly the airplane into the hills
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behind Beirut Airport
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but their situation is even more dire.
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The chaotic motion of the plane
is torture for passengers.
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00:09:02,810 --> 00:09:04,693
It's horrible,
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00:09:04,718 --> 00:09:10,697
you are feeling a 3 g load
is pushing down in your seat
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00:09:10,721 --> 00:09:12,721
as if you are getting squashed
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Some of them were silent
some of them were screaming.
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Ethiopian 409 Beirut
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Ethiopian 409, Beirut.
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We've lost an aircraft, Ethiopian
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We don't know what has happened
and we don't know its position.
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00:09:59,922 --> 00:10:06,584
Ethiopian 409 has plunged into
the Mediterranean Sea 5 minutes after take off
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00:10:06,608 --> 00:10:11,193
The evidence needed to explain the crash
is sinking fast.
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00:10:19,192 --> 00:10:24,197
Within minutes of the crash
the Lebanese military issues a distress call
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00:10:24,221 --> 00:10:26,658
to all available ships in the area.
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00:10:27,252 --> 00:10:29,978
Local boats, as well as foreign warships,
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join the search.
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00:10:32,369 --> 00:10:37,116
My first reaction was:
this accident is very unusual...
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...very unlikely...
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00:10:39,696 --> 00:10:44,823
...that really required
a very good investigation
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00:10:44,848 --> 00:10:47,869
to see what we could learn from it.
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00:10:48,167 --> 00:10:51,682
It is the first
major commercial aircraft accident in Lebanon
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in nearly 35 years.
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Within hours of the crash,
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the Lebanese Civil Aviation Authority
dispatches Hamdi Chaouk
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to take charge.
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00:11:03,373 --> 00:11:05,145
As soon as I reached the airport,
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I had to try to manage
the environment of the accident
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00:11:09,364 --> 00:11:14,324
The hardest part is how
to deal with all the search and rescue
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of major parties, from Defence
to the Interior Ministry to all the parties
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00:11:20,200 --> 00:11:22,200
We have never done this before.
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00:11:22,645 --> 00:11:27,059
A former pilot, he is one of the few
experienced investigators in the country.
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So, we are going to make this search area
right here on this grid
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We have ships here, here and here
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00:11:33,536 --> 00:11:37,450
Mohammed Aziz is his second in command
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First of all,
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we wanted, if by any miracle anybody had escaped,
to be able to pick any survivor
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especially that the first hours
say discovered to our sweet bodies
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most probably they were thrown out of the plane
when it crashed.
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00:12:01,294 --> 00:12:04,441
Have you any sign of wreckage?
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00:12:04,466 --> 00:12:06,466
Negative,
Nothing.
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00:12:07,701 --> 00:12:11,528
Chaouk is under great pressure
to locate the wreckage fast.
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so, you want to answer very important questions
to the family:
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why my relative died.
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It will cost your head as an investigator always:
I want to know the truth
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But the storm Flight 409 was trying to avoid
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is still raging
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The major deterrent to this search
and rescue operation was bad weather
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High waves on the sea and so on
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00:12:40,919 --> 00:12:44,801
So, this makes
the Search & Rescue operation difficult
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00:12:48,661 --> 00:12:52,961
Could the storm have been fierce enough
to bring down a 737?
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00:12:52,985 --> 00:12:55,710
There were thunderstorms West of the airport
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Thunderstorms can be very dangerous.
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They can interrupt the flight
and the airplane structure
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00:13:01,687 --> 00:13:05,986
and they complicate
the safe operation of the airplane.
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00:13:06,671 --> 00:13:07,842
In rare cases,
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a lightning strike can damage the electronics
that control the aircraft
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00:13:12,484 --> 00:13:17,468
While a lightning strike on an airplane
is not uncommon,
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it usually doesn't create damage to the airplane,
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00:13:21,226 --> 00:13:23,874
It can, under some circumstances
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00:13:24,835 --> 00:13:28,374
At the same time, rumours are spreading quickly.
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00:13:28,398 --> 00:13:32,582
Flight 409 was the target of a terrorist bombing.
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When you live in a country like Lebanon,
every now and then you have fighting,
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you have explosions,
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and the first thing that comes to mind when
you loose an aircraft just like that is
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maybe there is an explosion
on-board the flight.
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00:13:56,343 --> 00:14:00,514
As day breaks,
wreckage begins to wash up on shore.
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00:14:06,335 --> 00:14:09,358
Navy ships recover floating debris
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00:14:11,607 --> 00:14:13,607
and some human remains.
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00:14:13,990 --> 00:14:17,241
It is painfully obvious there are no survivors.
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00:14:17,741 --> 00:14:22,748
The Lebanese army have recovered 7 bodies
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00:14:22,772 --> 00:14:26,108
82 passengers and 8 crew are dead.
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00:14:29,733 --> 00:14:32,180
Most of the plane is still missing.
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00:14:32,344 --> 00:14:33,820
Without more wreckage,
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investigators may never know
what brought down Flight 409.
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00:14:40,813 --> 00:14:42,239
At Beirut Airport,
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they question witnesses who lend support
to the sabotage theory.
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00:14:46,446 --> 00:14:50,133
the controllers
who were on duty on the time of the crash
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00:14:50,157 --> 00:14:53,649
I saw a bright orange flash,
it looked like the plane exploded.
199
00:14:54,688 --> 00:14:57,133
The controller saw a ball of fire
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00:14:57,157 --> 00:15:00,250
At his place, he presumed that the plane crashed
201
00:15:00,500 --> 00:15:04,156
Some people say that it could be an explosion.
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00:15:13,089 --> 00:15:18,581
Hard evidence of sabotage
requires a close examination of the wreckage.
203
00:15:22,401 --> 00:15:25,980
I have to go back to the evidence,
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00:15:27,113 --> 00:15:29,574
because the evidence speaks.
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00:15:29,598 --> 00:15:34,206
The part of the plane can tell you
how the accident happened.
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00:15:34,230 --> 00:15:39,698
And so far, the inexperienced team
is having trouble locating the plane.
207
00:15:39,722 --> 00:15:41,722
No luck, yet
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00:15:41,746 --> 00:15:44,464
Have you searched this sector here?
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00:15:44,488 --> 00:15:48,511
We looked everywhere,
we looked here and here
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00:15:48,535 --> 00:15:53,464
We were able to determine
where probably the aircraft would have been.
211
00:15:53,488 --> 00:15:59,182
Yet, when the NAVY and the air-force started
the search for the plane
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00:15:59,207 --> 00:16:01,207
they could not find it.
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00:16:03,090 --> 00:16:07,199
A NAVY ship is searching for signals
from the plane's black boxes.
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00:16:07,465 --> 00:16:11,957
These begin transmitting an alert
as soon as they come in contact with water
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00:16:14,527 --> 00:16:19,636
There is what we call a pinger
and it emits a signal for about 30 days.
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00:16:21,636 --> 00:16:23,636
But two days in
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00:16:23,660 --> 00:16:26,286
the search hits a major hurdle.
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00:16:26,310 --> 00:16:27,568
Investigators learn
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00:16:27,593 --> 00:16:31,365
the NAVY sonar they have been using
cannot home in on the signals;
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00:16:31,389 --> 00:16:33,389
it is not precise enough.
221
00:16:33,413 --> 00:16:37,498
We'll never find them this way,
we don't have the right equipment.
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00:16:37,522 --> 00:16:41,264
We could not sleep,
we were always thinking that we need the recorders
223
00:16:41,288 --> 00:16:44,538
Chaouk contacts aviation authorities in France
for help.
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00:16:44,562 --> 00:16:47,460
We're hoping you can come immediately,
225
00:16:47,484 --> 00:16:49,484
It is quite urgent.
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00:16:49,891 --> 00:16:54,752
They have the equipment and the expertise
to find the recorders.
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00:16:56,781 --> 00:16:58,079
They are on their way
228
00:16:58,103 --> 00:17:02,524
It was a learning curve for everybody
the leaders or divers...
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00:17:02,548 --> 00:17:04,548
...or the NAVY people.
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00:17:04,572 --> 00:17:06,321
With the right gear,
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00:17:07,071 --> 00:17:10,275
the team should be able to search more quickly,
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00:17:10,299 --> 00:17:12,768
but valuable time has been lost,
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00:17:12,792 --> 00:17:15,916
and investigators have few leads.
234
00:17:16,893 --> 00:17:19,369
This type of airplane is flying all over the world
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00:17:19,393 --> 00:17:24,416
and if there is a problem,
we take whatever corrective action is needed.
236
00:17:25,119 --> 00:17:28,135
The United States also sends help.
237
00:17:28,159 --> 00:17:34,454
Because the 737 is American made,
the NTSB's Dennis Jones
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00:17:34,478 --> 00:17:36,104
joins the team.
239
00:17:36,129 --> 00:17:38,502
Welcome to Beirut
240
00:17:38,526 --> 00:17:42,901
We still didn't have the crash site
the flight-recorder which is always a big concern
241
00:17:42,925 --> 00:17:45,893
of interest was still yet to be found
242
00:17:45,917 --> 00:17:47,909
With no wreckage to study,
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00:17:47,934 --> 00:17:51,386
Jones and Chaouk turned to a record
of the plane's flight path
244
00:17:51,410 --> 00:17:53,410
We have the radar track of the airport
245
00:17:53,434 --> 00:17:56,207
It should show us exactly what they did.
246
00:17:56,231 --> 00:17:59,387
When we first got there,
some of the information we had was helpful
247
00:17:59,411 --> 00:18:03,207
that was the radar data
and Air Traffic Control information in general
248
00:18:03,231 --> 00:18:06,816
We were able to start evaluating that
pretty quickly.
249
00:18:06,840 --> 00:18:10,199
The radar paints a baffling picture.
250
00:18:10,223 --> 00:18:12,223
It is like no one is flying
251
00:18:12,247 --> 00:18:14,247
Exactly.
252
00:18:15,340 --> 00:18:17,340
Almost from take off
253
00:18:19,340 --> 00:18:22,785
the plane follows an unusual and erratic path.
254
00:18:23,839 --> 00:18:29,454
Once you see what happened to the plane,
you would wonder what is really happening.
255
00:18:31,988 --> 00:18:36,262
As if there were no crew in the cockpit
It is almost similar...
256
00:18:38,169 --> 00:18:42,747
...of a situation
where nobody is in control of the plane.
257
00:18:45,154 --> 00:18:47,826
Now that they've seen the strange flightpath...
258
00:18:53,592 --> 00:18:59,435
...investigators are more anxious than ever
to get at the wreckage and search for answers.
259
00:18:59,756 --> 00:19:05,529
What we are seeing is an external view
of the radar data and ATC.
260
00:19:05,553 --> 00:19:10,170
But we didn't get an idea
of what actually was going on board the aircraft
261
00:19:13,982 --> 00:19:17,615
We became even more eager to get the recorder
262
00:19:20,889 --> 00:19:22,123
That is it!
263
00:19:22,148 --> 00:19:24,148
It is exactly what we are looking for.
264
00:19:24,172 --> 00:19:27,047
Finally, 8 days after the crash,
265
00:19:27,071 --> 00:19:30,312
the French equipment detects the vital signals.
266
00:19:30,710 --> 00:19:36,296
It was found 45 meter deep
and 5 km South West of Beirut Airport
267
00:19:39,617 --> 00:19:41,890
Camera's mounted on unmanned subs
268
00:19:41,937 --> 00:19:46,273
capture the first images
of what remains of Flight 409.
269
00:19:46,499 --> 00:19:51,453
We had the Odyssey submarine
that has been used for taking photos
270
00:19:51,477 --> 00:19:54,898
and for the wreckage,
located on the seabed
271
00:19:55,445 --> 00:19:59,227
It is too expensive
to bring all the wreckage to the surface,
272
00:19:59,251 --> 00:20:04,343
so, investigators focus on the tail section
where the 2 black boxes are stored.
273
00:20:08,436 --> 00:20:12,410
They retrieve the tail,
the horizontal stabilizer
274
00:20:12,434 --> 00:20:16,340
the tail-part as well
They are still attached together
275
00:20:16,364 --> 00:20:21,132
And they found the Flight Data Recorder,
located underneath it.
276
00:20:21,613 --> 00:20:23,777
We were quite delighted about that
277
00:20:23,801 --> 00:20:26,980
The Lebanese government
immediately started making plans
278
00:20:27,005 --> 00:20:30,840
on having it transported
to a facility to be evaluated.
279
00:20:30,864 --> 00:20:33,824
But they only find the Flight Data Recorder.
280
00:20:33,848 --> 00:20:35,848
What of the Cockpit Voice Recorder?
281
00:20:35,872 --> 00:20:38,676
The CVR should be nearby...
282
00:20:38,700 --> 00:20:40,700
...but it is not.
283
00:20:42,990 --> 00:20:46,142
So, it has got to be in this sector
284
00:20:47,798 --> 00:20:50,189
While the divers continue their search
285
00:20:50,213 --> 00:20:54,291
investigators study
underwater video of the wreckage for clues.
286
00:20:54,619 --> 00:20:57,400
OKAY, let's start mapping this out.
287
00:20:58,298 --> 00:21:03,447
When a plane explodes in mid air,
the debris falls in a circular pattern
288
00:21:03,471 --> 00:21:08,627
but if a plane hits the water intact,
the debris will fall in a linear pattern.
289
00:21:10,384 --> 00:21:16,084
The underwater video allows investigators
to map the position of every piece of wreckage.
290
00:21:16,109 --> 00:21:19,069
Another one here,
lining up nice and neat.
291
00:21:22,781 --> 00:21:23,844
In this case,
292
00:21:23,869 --> 00:21:27,055
we found all the pieces laying
in the bed of the water
293
00:21:27,079 --> 00:21:30,719
in an almost 300 meter straight line
294
00:21:30,743 --> 00:21:34,289
They also search for any sign of fire damage.
295
00:21:34,734 --> 00:21:38,701
You would look for a certain signature to show us
296
00:21:38,726 --> 00:21:43,632
perhaps there might have been
some heat damage or fire damage.
297
00:21:46,452 --> 00:21:50,294
But there is no sign
that the metal was ripped open by a blast
298
00:21:50,318 --> 00:21:53,662
and no burn marks on any of the wreckage.
299
00:21:54,225 --> 00:21:56,001
We looked at the footage
300
00:21:56,026 --> 00:22:00,686
we couldn't identify any black spots, black soot
or any thing of the sort
301
00:22:00,710 --> 00:22:02,710
We saw none at all.
302
00:22:03,718 --> 00:22:06,608
There is no sign of any explosion.
303
00:22:07,108 --> 00:22:09,514
Ethiopian 409 Beirut.
304
00:22:09,538 --> 00:22:13,022
They conclude that the tower controller
may have been fooled
305
00:22:13,046 --> 00:22:14,397
by a trick of the light.
306
00:22:14,421 --> 00:22:21,478
It was a stormy night, so throughout the night
you were hearing thunderstorms, lightning,
307
00:22:23,663 --> 00:22:26,870
and they do sound exactly like explosions
308
00:22:26,894 --> 00:22:31,651
and they'd give you a bright light
even stronger than any big explosion.
309
00:22:32,581 --> 00:22:35,245
Still puzzled about the cause of the crash,
310
00:22:35,269 --> 00:22:41,058
investigators turn to the newly available data
from the Flight Data Recorder
311
00:22:41,082 --> 00:22:42,792
Nothing, so far.
312
00:22:42,816 --> 00:22:46,605
There are more than a 1000 parameters to analyze.
313
00:22:46,629 --> 00:22:50,589
The FDR records essentially
the instruments
314
00:22:51,074 --> 00:22:55,754
another parameter from the aircraft
Basically what the aircraft is doing
315
00:22:56,707 --> 00:23:01,824
and that retains in this case
25 hours of information.
316
00:23:03,129 --> 00:23:05,761
Almost all the data is normal
317
00:23:05,785 --> 00:23:07,785
but one number stands out.
318
00:23:09,676 --> 00:23:12,537
Take a look at that stabilizer setting.
319
00:23:15,983 --> 00:23:18,933
It is a bit low, but still in the green.
320
00:23:19,483 --> 00:23:22,162
The stabilizer is part of the tail.
321
00:23:22,186 --> 00:23:26,123
Pilots adjust its angle,
depending on the weight off the plane.
322
00:23:26,147 --> 00:23:28,951
Move itr up,
and the plane pitches up
323
00:23:28,975 --> 00:23:32,045
Move it down
and it forces the nose down
324
00:23:35,209 --> 00:23:37,209
The fuel is good
325
00:23:38,403 --> 00:23:41,154
The load is calculated
326
00:23:41,178 --> 00:23:43,896
Check complete, no problems.
327
00:23:43,920 --> 00:23:50,271
The FDR reveals that Flight 409's stabilizer was
set further down than normal for take off
328
00:23:51,006 --> 00:23:56,204
Such a small variation probably wouldn't cause
the pilots to loose control of their plane,
329
00:23:56,228 --> 00:23:58,394
but investigators won't know its effect
330
00:23:58,419 --> 00:24:02,478
until they can test the configuration
in a flight simulator.
331
00:24:02,502 --> 00:24:06,149
At that point, obviously
everything was on the table.
332
00:24:06,173 --> 00:24:11,068
We knew we had a lot more factual finding to do.
333
00:24:14,883 --> 00:24:18,023
The investigation takes a huge step forward
334
00:24:18,048 --> 00:24:22,616
when the search for the missing
recorder finally pays off
335
00:24:22,641 --> 00:24:25,000
Aziz, we got it
336
00:24:26,570 --> 00:24:31,155
I have to praise the Lebanese NAVY-diver,
because with the equipment they had
337
00:24:31,179 --> 00:24:36,761
they had to do real hand-search 45 m under water
which is quite difficult
338
00:24:36,786 --> 00:24:39,304
but they were able to recover it at the end
339
00:24:39,328 --> 00:24:41,333
Investigators can only hope
340
00:24:41,358 --> 00:24:46,233
that the pilots said something
that will reveal why their plane went down.
341
00:24:52,773 --> 00:24:57,411
Investigators sync up the conversation
on the Cockpit Voice Recorder
342
00:24:57,599 --> 00:24:59,599
with the known flightpath
343
00:25:00,802 --> 00:25:03,348
They listen for any sign of trouble.
344
00:25:03,372 --> 00:25:08,411
We want to try to get a better understanding
if there might have been a mechanical problem,
345
00:25:08,435 --> 00:25:11,145
based on what they were perceiving
346
00:25:25,893 --> 00:25:30,861
Now, once they took off,
the first part of the take off was normal
347
00:25:35,172 --> 00:25:38,015
Turn right, initially heading 315
348
00:25:40,664 --> 00:25:44,289
Investigators hear the controller
give the pilots a new heading
349
00:25:44,313 --> 00:25:47,195
but the plane goes off in a different direction.
350
00:25:48,797 --> 00:25:53,053
As they approached the heading
they have been assigned
351
00:25:53,077 --> 00:25:54,827
they overshot the heading.
352
00:25:54,851 --> 00:26:00,991
He was supposed to turn this far,
but he just kept going.
353
00:26:01,015 --> 00:26:03,749
Mark, they are way off course
354
00:26:08,523 --> 00:26:12,388
Each time the pilots try to correct their course..
355
00:26:12,413 --> 00:26:15,928
...they turn to far and banked too steeply.
356
00:26:15,952 --> 00:26:20,732
It is a sure indication
that the airplane has lost control.
357
00:26:21,279 --> 00:26:27,443
Ethiopian 409, You are going into the mountain!
Fly right now heading 270
358
00:26:28,178 --> 00:26:32,162
The airplane was rolling
into an ever steeper bank.
359
00:26:32,186 --> 00:26:37,506
Its lift factor was decreasing,
so the nose was dropping toward the sea,
360
00:26:43,638 --> 00:26:46,917
ultimately leading to a spiral.
361
00:26:54,041 --> 00:26:57,018
The plane was out of control.
362
00:26:57,080 --> 00:27:01,837
There is nothing on the recording
to suggest there was a mechanical failure.
363
00:27:01,868 --> 00:27:06,993
We just could not hear anything
that showed a malfunction,
364
00:27:07,017 --> 00:27:10,501
which was consistent with the FDR.
365
00:27:10,526 --> 00:27:15,463
It was something that we certainly did have
any answers for in the beginning.
366
00:27:18,892 --> 00:27:22,297
Desperate to know what brought down the 737
367
00:27:22,322 --> 00:27:25,494
investigators dig in to maintenance records.
368
00:27:27,205 --> 00:27:31,885
They learn
that some 737s have a small but dangerous flaw
369
00:27:31,909 --> 00:27:34,519
in a vital part of the tail.
370
00:27:35,002 --> 00:27:38,150
Hey, Dennis,
I think we need to check those trim tabs
371
00:27:38,175 --> 00:27:42,573
Trim tabs are small control surfaces
set into the tail of the plane.
372
00:27:42,901 --> 00:27:46,589
They counteract the powerful flow of air,
pushing against the tail,
373
00:27:46,613 --> 00:27:50,081
making it easier for the pilot to fly the plane.
374
00:27:50,511 --> 00:27:52,151
To use an analogy with cars:
375
00:27:52,176 --> 00:27:55,637
it is like power-steering as
compared to manual steering
376
00:27:55,662 --> 00:27:57,700
If the trim tabs were damaged,
377
00:27:57,733 --> 00:28:02,934
it could explain why the captain was struggling
to control the aircraft.
378
00:28:05,684 --> 00:28:07,684
Left heading 270?
379
00:28:08,973 --> 00:28:10,973
Roger, 270
380
00:28:13,582 --> 00:28:14,613
In my experience,
381
00:28:14,638 --> 00:28:18,872
if I fly an airplane out of trim
that can make it extremely difficult to fly
382
00:28:18,896 --> 00:28:26,374
It can even go beyond the forces
that the pilot can handle.
383
00:28:32,249 --> 00:28:33,900
You can bring that over here.
384
00:28:33,924 --> 00:28:36,111
Investigators are in luck:
385
00:28:36,135 --> 00:28:39,930
the stabilizer and trim-tabs
are among the few pieces of wreckage,
386
00:28:39,955 --> 00:28:42,103
recovered from the sea.
387
00:28:45,527 --> 00:28:48,464
The team assembled to evaluate
388
00:28:48,489 --> 00:28:51,237
This aircraft hit the water close to 400 knots
389
00:28:51,261 --> 00:28:53,925
so, we're expecting a lot of things to be damaged.
390
00:28:53,949 --> 00:28:58,159
We wanted to evaluate to see
if there is anything that was pre-existing
391
00:28:58,183 --> 00:29:02,144
that might have contributed
to the sequence of events.
392
00:29:02,168 --> 00:29:04,168
But it is another dead end:
393
00:29:04,192 --> 00:29:08,190
A close inspection of the trim tabs
reveals no damage at all,
394
00:29:08,214 --> 00:29:10,934
no sign of any malfunction.
395
00:29:11,410 --> 00:29:15,083
They did not affect the pilots' ability
to steer the plane.
396
00:29:16,637 --> 00:29:23,014
Why a 737, carrying 82 passengers
plunged into the sea, only minutes after take off
397
00:29:23,038 --> 00:29:25,038
is still a mystery.
398
00:29:41,499 --> 00:29:44,499
Investigators travel to Seattle, Washington
399
00:29:44,523 --> 00:29:48,077
to Boeing state of the art flight simulator
400
00:29:49,803 --> 00:29:53,568
OKAY, we are going to run the Ethiopian 409
401
00:29:53,803 --> 00:29:56,577
We are going to set the trim to match their's
402
00:29:56,874 --> 00:30:03,460
The flight data has shown that 409's stabilizer
was set to a shallower take off angle
403
00:30:04,936 --> 00:30:09,113
They now need to know if that somehow
affected the pilot's ability
404
00:30:09,138 --> 00:30:11,256
to handle the plane.
405
00:30:13,748 --> 00:30:17,950
You get a front row seat
of what the flight crew were seeing at the time
406
00:30:17,975 --> 00:30:20,670
and how the aircraft was handling.
407
00:30:20,695 --> 00:30:23,820
OKAY, let's see how this thing is going to fly.
408
00:30:31,603 --> 00:30:36,306
The low angle of the nose
makes the plane difficult to handle at first.
409
00:30:36,330 --> 00:30:38,330
It is definitively not happy
410
00:30:46,830 --> 00:30:49,611
The trim was mis-set for take off
411
00:30:49,635 --> 00:30:52,447
by a small margin, but nevertheless
412
00:30:52,471 --> 00:30:58,471
by enough to create an undesirable pressure
for the pilot on the controls.
413
00:30:58,495 --> 00:31:03,807
So, the pilot was always
fighting the airplane to one degree or another.
414
00:31:06,479 --> 00:31:12,379
But in the simulator,
the pilot has no difficulty correcting the problem
415
00:31:15,730 --> 00:31:19,012
OKAY, we try it with no trim at all
416
00:31:23,557 --> 00:31:26,705
Every single time
we tried to recover this aircraft
417
00:31:26,730 --> 00:31:28,730
we were able to recover it.
418
00:31:38,483 --> 00:31:41,315
They should have been able to recover.
419
00:31:41,776 --> 00:31:46,495
They conclude that the low stabilizer setting
did not cause this crash.
420
00:31:46,924 --> 00:31:51,591
Something else made the 737 spiral into the sea.
421
00:31:54,458 --> 00:31:58,639
Officials from Ethiopian Airlines
still believe terrorism is to blame.
422
00:31:59,412 --> 00:32:03,069
They insist
that an on-board bomb cannot be ruled out
423
00:32:03,093 --> 00:32:07,147
until more of the wreckage
is recovered from the Mediterranean.
424
00:32:07,171 --> 00:32:09,514
The investigators don't agree
425
00:32:09,538 --> 00:32:14,788
We told them it is quite a small possibility
that there was something put on-board that plane
426
00:32:14,812 --> 00:32:19,792
but when the plane explodes
with a bomb on board,
427
00:32:19,817 --> 00:32:24,673
it doesn't go up and left, and right,
and up and down and then
428
00:32:24,697 --> 00:32:27,457
something explode on the plane.
429
00:32:27,481 --> 00:32:30,957
But stamping out rumours is never easy
430
00:32:30,981 --> 00:32:34,840
Investigators are under growing pressure
to explain what happened
431
00:32:34,864 --> 00:32:39,793
If it wasn't a bomb
then what did bring down Flight 409?
432
00:32:39,817 --> 00:32:42,059
An aircraft accident investigation
433
00:32:42,083 --> 00:32:45,504
often the best approach
is the Sherlock Holmes approach
434
00:32:45,528 --> 00:32:49,724
You eliminate everything you know didn't happen...
435
00:32:52,777 --> 00:32:56,365
...what is left, is probably what did happen.
436
00:32:56,389 --> 00:32:58,389
The controllers did their job,
437
00:33:00,959 --> 00:33:03,713
the ground base navigational systems were working
438
00:33:03,737 --> 00:33:07,135
the airplane was functioning properly.
439
00:33:07,768 --> 00:33:10,596
So what we have left is the crew.
440
00:33:11,964 --> 00:33:15,065
Investigators return to the Cockpit Voice Recorder
441
00:33:15,089 --> 00:33:20,050
They hope the crew's conversation
can shed light on why two qualified pilots
442
00:33:20,074 --> 00:33:23,409
lost control of a mechanically sound airplane.
443
00:33:27,049 --> 00:33:29,439
Check complete, no problems
444
00:33:29,463 --> 00:33:31,993
They notice something odd
445
00:33:32,252 --> 00:33:35,946
The mood, even the speed of the voice
or even the tone
446
00:33:40,431 --> 00:33:45,004
They did not reflect on what is actually happening
447
00:33:45,457 --> 00:33:51,167
during the take off roll,
the captain saw something because he tells
448
00:33:51,192 --> 00:33:52,417
'Did you see that?'
449
00:33:52,441 --> 00:33:56,128
But then,
there was no reaction from the First Officer
450
00:33:56,152 --> 00:34:00,034
The First Officer is uncharacteristically quiet
451
00:34:02,597 --> 00:34:05,440
OKAY, engage the AUTOPILOT
452
00:34:05,464 --> 00:34:10,086
Even worse,
he is not following his captain's commands.
453
00:34:14,445 --> 00:34:17,953
The advantage of engaging the AUTOPILOT
in that situation
454
00:34:17,977 --> 00:34:23,898
is that the pilot can then let
the AUTOPILOT worry about the attitude
455
00:34:23,922 --> 00:34:27,988
while he sits back and takes the big picture:
456
00:34:28,012 --> 00:34:30,855
Maintain situational awareness.
457
00:34:32,761 --> 00:34:36,847
The AUTOPILOT can adjust the throttles
to maintain a safe airspeed
458
00:34:36,871 --> 00:34:39,605
and can keep the plane on the right heading
459
00:34:39,629 --> 00:34:45,680
but investigators learn it was impossible
for the AUTOPILOT to engage on Flight 409.
460
00:34:46,930 --> 00:34:49,815
There's no way it can come ON
461
00:34:50,290 --> 00:34:52,290
OKAY, engage the AUTOPILOT
462
00:34:53,540 --> 00:34:58,250
It is designed not to switch ON if
one of the pilots is pulling on the control column
463
00:34:58,274 --> 00:35:00,274
as the captain was.
464
00:35:00,469 --> 00:35:01,640
For some reason,
465
00:35:01,665 --> 00:35:05,828
the First Officer didn't give his captain
a crucial piece of information
466
00:35:05,852 --> 00:35:08,820
that the AUTOPILOT did not come ON.
467
00:35:08,845 --> 00:35:11,689
Had the AUTOPILOT be engaged,
468
00:35:11,735 --> 00:35:15,429
when the captain ordered the First Officer
to engage it
469
00:35:15,453 --> 00:35:18,211
would have saved the whole flight.
470
00:35:20,008 --> 00:35:24,726
The interaction between the crew-members
were not what we would expect
471
00:35:24,750 --> 00:35:27,343
from professional crew at that time
472
00:35:27,367 --> 00:35:30,312
The crew's behaviour is baffling.
473
00:35:30,337 --> 00:35:35,586
It forces investigators to consider
an unlikely explanation for what went wrong.
474
00:35:35,610 --> 00:35:38,773
Something called subtle incapacitation.
475
00:35:38,797 --> 00:35:41,992
It is very difficult
to recognize a subtle incapacitation
476
00:35:42,016 --> 00:35:46,656
If the pilot had the control, has a stroke,
and slams over the control wheel
477
00:35:46,680 --> 00:35:50,000
there is no question that
you have got a person who is incapacitated
478
00:35:50,024 --> 00:35:52,024
Confirm heading 210
479
00:35:52,446 --> 00:35:53,635
Negative, sir
480
00:35:53,660 --> 00:35:58,446
to proceed direct CHEKKA,
turn left now heading 270
481
00:36:01,095 --> 00:36:03,605
Left heading 270?
482
00:36:04,363 --> 00:36:06,363
Roger, left heading 270
483
00:36:06,387 --> 00:36:10,254
However, if the pilot at the controls...
484
00:36:10,278 --> 00:36:12,278
...starts to loose the picture...
485
00:36:12,302 --> 00:36:14,668
...and does so silently...
486
00:36:15,419 --> 00:36:21,371
...and starts to misapply controls,
push the wrong buttons...
487
00:36:21,395 --> 00:36:25,988
...it may take a while before
the other crew-members pick up on that failure.
488
00:36:26,012 --> 00:36:29,355
That sequence is called subtle incapacitation.
489
00:36:32,479 --> 00:36:38,401
It is a controversial idea that goes
beyond the usual definition of pilot error.
490
00:36:39,495 --> 00:36:43,057
Subtle incapacitation can come
from physiological reasons
491
00:36:43,081 --> 00:36:45,081
psychological reasons
492
00:36:45,105 --> 00:36:47,361
or a combination of both
493
00:36:47,386 --> 00:36:49,129
It could be something minor,
494
00:36:49,153 --> 00:36:52,426
medications could cause it, stress,
495
00:36:52,450 --> 00:36:54,520
fatigue could cause it
496
00:36:57,239 --> 00:37:02,139
Because commercial aviation demands
such high levels of performance
497
00:37:02,163 --> 00:37:06,319
drugs and alcohol, used by pilots
is closely scrutinized.
498
00:37:06,756 --> 00:37:11,131
Drug testing is part of
any transportation employee
499
00:37:11,155 --> 00:37:13,787
from baggage handlers
all the way up to the cockpit.
500
00:37:13,811 --> 00:37:17,100
It is typically done on a random basis.
501
00:37:19,045 --> 00:37:22,740
But there is no formal test for fatigue.
502
00:37:23,006 --> 00:37:28,170
Other accidents, but
the same kind of sequence of events taken place.
503
00:37:31,147 --> 00:37:36,082
The best known example is ColganAir Flight 3407
504
00:37:36,106 --> 00:37:37,647
In 2009,
505
00:37:37,672 --> 00:37:44,051
two overtired pilots failed to react properly
to a warning that their plane was about to stall.
506
00:37:44,075 --> 00:37:47,359
All 49 people on board were killed.
507
00:37:52,062 --> 00:37:54,252
This room doesn't make you sleepy?
508
00:37:54,276 --> 00:37:57,853
Investigators continue to analyze
the cockpit recording
509
00:37:57,877 --> 00:37:59,877
What are these guys doing?
510
00:37:59,901 --> 00:38:03,642
They listen to what the pilots were saying,
just before take off
511
00:38:03,666 --> 00:38:05,666
This room doesn't make you sleepy?
512
00:38:05,690 --> 00:38:08,096
the recorder say: Sleep
513
00:38:08,120 --> 00:38:10,829
Immediately, our attention stuck up
514
00:38:12,064 --> 00:38:14,064
What are they doing up there?
515
00:38:14,088 --> 00:38:16,088
Was there weed in it?
516
00:38:18,173 --> 00:38:19,783
Did you feel dizzy?
517
00:38:19,807 --> 00:38:21,807
Al right, I couldn't sleep
518
00:38:21,831 --> 00:38:23,831
Well, me too
519
00:38:28,347 --> 00:38:32,922
Investigators are shocked
to hear the pilots joking about being tired
520
00:38:32,946 --> 00:38:34,946
and the reference to weed.
521
00:38:34,970 --> 00:38:38,788
Subtle incapacitation may not be
such an unlikely cause after all.
522
00:38:38,812 --> 00:38:42,304
Trying to explain the behaviour of the pilots
on that particular airline
523
00:38:42,329 --> 00:38:45,858
was really
the most difficult part of this investigation
524
00:38:45,882 --> 00:38:51,428
This is why we considered every single issue
starting from the food they had,
525
00:38:51,452 --> 00:38:54,147
the type of rest they had.
526
00:38:55,350 --> 00:39:00,764
Piecing together the pilots' movements
in the hours leading up to the crash
527
00:39:00,788 --> 00:39:02,788
is now the top priority
528
00:39:04,812 --> 00:39:06,913
In the case of this accident
529
00:39:06,938 --> 00:39:09,218
the pilots' bodies weren't recovered,
530
00:39:09,243 --> 00:39:13,015
so there was no way they could do
post mortal examinations.
531
00:39:13,039 --> 00:39:16,468
We immediately called the hotel
to check the garbage,
532
00:39:16,492 --> 00:39:20,640
if there was any bottle of alcohol,
any drugs.
533
00:39:20,664 --> 00:39:26,046
Did they see a crew out,
having drinks or something
534
00:39:26,742 --> 00:39:32,031
They study security footage for any signs
that the pilots were impaired.
535
00:39:33,459 --> 00:39:37,537
We also looked at the footage of the crew,
coming in to the airport
536
00:39:37,561 --> 00:39:42,912
They were walking normally
everybody who spoke to, said they were normal
537
00:39:47,850 --> 00:39:50,334
Investigators travel to Ethiopia
538
00:39:50,358 --> 00:39:54,607
to interview family members
about the crew's habits
539
00:39:55,021 --> 00:39:59,630
Thank you for taking the time to see me
I am very sorry for your lost
540
00:39:59,655 --> 00:40:02,450
I just want to ask you
a few questions about your brother
541
00:40:02,474 --> 00:40:04,365
Did he ever drink?
542
00:40:04,390 --> 00:40:05,216
No
543
00:40:05,240 --> 00:40:09,942
There is no evidence to suggest
either pilot abused alcohol or drugs.
544
00:40:09,966 --> 00:40:14,512
The captain didn't drink at all,
so he was a sport-guy
545
00:40:14,536 --> 00:40:17,684
concentrating on his sports.
546
00:40:18,129 --> 00:40:22,161
Subtle incapacitation is difficult to prove.
547
00:40:22,286 --> 00:40:27,152
In the crash of Flight 409,
the evidence so far is mixed.
548
00:40:27,176 --> 00:40:31,695
but what investigators discover next,
could tip the balance.
549
00:40:38,796 --> 00:40:42,342
Employment records
detailing the pilots' flight hours
550
00:40:43,622 --> 00:40:49,067
reveal critical information about the captain.
551
00:40:49,608 --> 00:40:53,514
He'd been working almost none stop
for nearly 2 months
552
00:40:53,538 --> 00:40:58,131
In 51 days,
he probably flew something like 45 days
553
00:40:58,155 --> 00:41:01,209
Daily, daily, daily flying
just taking the minimum rest
554
00:41:01,233 --> 00:41:03,951
It is legal, but it is quite a lot of work.
555
00:41:11,675 --> 00:41:13,675
Work, work, work
556
00:41:15,496 --> 00:41:18,863
The crew's last chance to rest
was a scheduled stop over
557
00:41:18,888 --> 00:41:20,730
after flying into Beirut.
558
00:41:23,418 --> 00:41:27,300
I could use some food
that didn't come from an airplane
559
00:41:27,683 --> 00:41:30,574
Yeah, a good meal would be good
560
00:41:30,598 --> 00:41:32,598
Alright, let's do it
561
00:41:47,156 --> 00:41:51,468
Prior to the flight, they had a heavy lunch
and they were not able to rest properly
562
00:41:51,493 --> 00:41:56,445
so they were commenting on not being able
to rest properly prior to the flight
563
00:41:56,469 --> 00:41:58,469
Did you feel dizzy?
564
00:41:58,493 --> 00:42:00,493
I couldn't sleep
565
00:42:01,235 --> 00:42:05,275
Investigators suspect
that the heavy meal affected their sleep.
566
00:42:06,486 --> 00:42:10,743
Indigestion and the fatigue,
definitively affected the pilot's behaviour
567
00:42:10,767 --> 00:42:12,767
throughout the flight process
568
00:42:24,307 --> 00:42:28,432
The storm conditions likely added
to the pilots' stress.
569
00:42:33,854 --> 00:42:38,830
The weather could be a factor
and I think pressure on the pilots
570
00:42:38,854 --> 00:42:43,643
Fatigued and under increasing stress,
they lost track of where they were
571
00:42:43,667 --> 00:42:45,667
and what they were doing.
572
00:42:46,534 --> 00:42:50,581
This flight was in jeopardy from the outset
573
00:42:53,089 --> 00:42:58,792
It seems that the crew was never fully on top
of what was happening.
574
00:43:14,886 --> 00:43:16,163
Investigators conclude
575
00:43:16,188 --> 00:43:20,016
that the accident was caused by a
crew that was simply too tired
576
00:43:20,040 --> 00:43:23,925
or too confused
to recover from the first wrong turn.
577
00:43:23,949 --> 00:43:27,553
It is a textbook example of subtle incapacitation
578
00:43:27,577 --> 00:43:33,451
We could prove that the symptoms that we saw
are similar to the symptoms
579
00:43:33,475 --> 00:43:36,732
of somebody who has a subtle incapacitation.
580
00:43:43,193 --> 00:43:47,669
The accident exposes a risk to aviation
that no amount of engineering...
581
00:43:47,983 --> 00:43:49,474
...can overcome.
582
00:43:52,818 --> 00:43:57,022
After the crash of Flight 409,
investigators suggest
583
00:43:57,047 --> 00:44:02,797
Ethiopian Airlines introduce much more
rigorous rules regarding crew rest.
584
00:44:02,821 --> 00:44:06,711
It is one thing to have the experience,
expertise to do the work
585
00:44:06,736 --> 00:44:10,774
but you have to be in good condition
in order to perform.
586
00:44:11,915 --> 00:44:15,290
As long as airplanes are operated by humans
587
00:44:15,314 --> 00:44:20,165
fatigue, distraction, and other human weaknesses
can only be managed
588
00:44:20,189 --> 00:44:22,189
never erased.
589
00:44:23,782 --> 00:44:28,280
I'm not sure
that we can prevent subtle incapacitation,
590
00:44:29,554 --> 00:44:34,435
but we should at least try to eliminate
all the possibilities that are human factor
591
00:44:34,460 --> 00:44:39,366
because human factors are still
the majority of most of the accidents.
592
00:44:48,389 --> 00:44:50,389
Narrator
Jonathan Aris
593
00:44:50,413 --> 00:44:54,781
Subtitles
Rein Croonen
51391
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