Original subtitles

(Dynamic music)

♪

(Text on screen)

(narrator): Descending into heavy fog above Luxembourg...

- The hell is that?!

(narrator): ...something goes disastrously wrong

on Luxair Flight 9642.

- The airplane was impossible to recover.

(heavy crash)

(narrator): 20 of the 22 people onboard are killed.

- A lot of people died that day.

It was an accident that was hard to understand.

- I can't find anything wrong with either engine.

(narrator): But when investigators analyze

unusual sounds from the cockpit...

- It's a match? - Mm-hmm.

(narrator): ...they hear the pilots do something

which should be impossible.

- It's not supposed to happen.

There's supposed to be things that prevent it from happening.

- So it's not as foolproof as we thought.

(♪♪)

- Mayday! Mayday!

(opening theme)

(soft pensive music)

(narrator): It's just before 10:00 in the morning

at Luxembourg's International Airport.

A layer of fog blankets the runway,

preventing planes from landing.

- Cargolux 778 maintain runway heading

until LUTAX, then use own navigation.

Luxair 403 enter Diekirch hold flight level 60.

I will vector you later for ILS approach.

(narrator): Controllers are busy putting planes

into a holding pattern while waiting for the fog to clear.

- Luxair 4452 enter Diekirch hold flight level 90.

QNH is 1023.

Luxair 8362 descend level 80 to enter Diekirch hold.

Current RVR is 250.

(narrator): There are three planes circling 16 miles north

of the airport at a position known as Diekirch.

- In a situation with low visibility,

lots of holding, lots of aircraft

having different requirements,

the level of stress is fairly high.

Focus is really important.

You gotta concentrate on everything that you're doing.

- Luxair 9642 enter Diekirch hold flight level 90.

There will be vectors later for an ILS approach

on runway 24.

- That's all understood, Luxair 9642.

(narrator): One of the planes being directed

to the holding pattern is Luxair Flight 9642.

The plane is a Fokker 50 turboprop

heading to Luxembourg from Berlin.

- The Fokker 50 was a great performing aircraft overall.

It's a commuter airplane, to be flown in Europe.

We flew the aircraft day and night,

in all weather conditions.

(narrator): There are 19 passengers on the flight.

Most are German business officials

travelling to Luxembourg.

The first officer on this morning's flight

is 32-year-old John Arendt.

- I'll brief the folks.

Ladies and gentlemen, good morning.

Uh, unfortunately, the fog in Luxembourg is so dense

that at the moment we cannot land.

So we'll have to wait a little bit for an improvement.

We will proceed to a holding pattern

while we wait for the weather to clear.

We'll keep you updated as soon as we have some news.

(narrator): The captain is 26-year-old Claude Poeckes.

- And Luxair 9642 is

reducing speed to 160.

- Roger 9642.

(narrator): The crew navigates toward the holding area

north of the airport.

- What time can we hold till? How much fuel will we need?

- Uh, 550...

uh... 700.

No, we'll need 8-50 when we leave the hold.

- No. We need fuel to reach till our alternate

plus 20 minutes reserve. So we'll still need 600 kilos.

- Yes, but I want to keep--

(controller on radio): Luxair 9642 descend to 3,000 feet

on 1023, turn left heading 130.

(narrator): Before they reach the holding point,

the crew receives instructions

to turn towards the airport and begin descent.

- Is that for us? - Yes.

- Uh, descend to 3,000 feet. Say again the heading.

(controller on radio): 130.

- Left heading 130, Luxair 9642.

What kind of crap is that?

(narrator): The new instruction takes the crew by surprise.

- If you suddenly get startled that you are now number one,

and turning left, and descending for your approach as number one,

this can put you in a situation

which would add to your workload.

- What's the RVR now?

- I don't know, should we check with dispatch?

- Yes.

(narrator): RVR is Runway Visual Range.

It's the minimum visibility on the runway required

by a landing aircraft.

For the Luxair Fokker,

that distance is 300 metres, or 984 feet.

- If the runway visual range is below 300 metres,

you are not allowed to start the approach

or to land the aircraft.

- Dispatch, 9642, what's the current RVR?

(dispatcher on radio): Uh, 275.

- 275 metres. What do we do now?

- I don't know.

- If they don't have that visibility, they go around

and they'll probably get vectored for another approach

unless the RVR is too low, then they're gonna be vectored

to the holding pattern at Diekirch.

- So are we holding or is this for an approach?

- It's for an approach.

(controller): Luxair 9642

turn right heading 220.

Cleared for approach.

(Arendt): - Right heading 220, and uh,

cleared for approach, 9642.

- Tell him that if at ECHO we don't have 300 metres

that we'll do a go-around and enter the hold.

(narrator): The pilots come up with a compromise.

They'll continue their approach,

but if runway visibility doesn't improve,

they'll abort and join the holding pattern.

(Arendt): We need 300 metres for the approach.

- 9642, copied.

Continue your approach. I'll keep you advised.

(foreboding music)

(narrator): Passengers still believe they're headed

for an extended hold.

(engine buzzing)

(Arendt): Speed's 95, 105, 109.

- Landing altitude? - 275 metres.

- Set.

(narrator): The flight is now only 5 miles from the runway

and there's no word that visibility has improved.

Captain Poeckes makes his decision.

- Okay, we'll do a go-around. Missed Approach.

- Ground Idle Stop off.

(controller): Luxair 9642,

RVR is 300 metres.

(narrator): But before the crew can execute a go-around,

the controller issues a last-minute update

to runway conditions.

- 9642 continuing approach.

(narrator): The visibility now meets

the Fokker's minimum requirements.

The crew's plans have changed again.

(Krieger): Things change rather quickly for a flight crew

when they're doing an approach

which requires really precise coordination

among the crew members to make sure

that everything goes smoothly

and that they're stabilized on the approach.

(engine buzzing)

(narrator): 4 miles from the airport,

Flight 9642 is at an altitude

of 1,500 feet.

- Flaps?

- Uh, we are flaps 10.

- 9642, you are cleared to land,

wind 180 degrees, 5 knots.

(tense music)

- Uh, gear down? - Yeah.

- Cleared to land 9642.

(narrator): The flight is now two minutes

from landing in Luxembourg.

(hubbub, whirring)

- The hell is that?!

(engine buzzing)

(narrator): Something has gone wrong with the engines.

(whirring, clicking)

(passengers yelping)

- Oh!

(narrator): Now at less than 500 feet,

Flight 9642 plummets towards the ground.

(screaming)

(GPWS): Terrain. Terrain.

- Pull, pull, pull, pull, pull, pull, pull!

- The airplane suddenly went into a rapid

and uncontrollable descent in a very low altitude,

which was impossible to recover.

(engine buzzing)

(passengers screaming)

(devices beeping)

- 9642, Luxembourg.

Luxair 9642, Luxembourg.

Luxair 9642, Luxembourg, do you read?

We have a possible crash of a Fokker F50

on final approach to runway 27.

Please stand by.

(sirens wailing in distance)

(narrator): The wreckage is located

2 miles east of the airfield.

(helicopters buzzing)

Of the 22 people on board,

only two survive the crash,

including Captain Poeckes.

This is Luxembourg's deadliest aviation disaster.

(melancholic music)

(McNair): Well, this accident is serious

because there was loss of life. A lot of people died that day.

And it was, uh, an accident that was hard to understand.

(narrator): Investigators will need to examine the wreckage

of Flight 9642 to determine

why a landing at a modern, well-equipped airport

went so terribly wrong.

(heavy music)

- The tail hits here.

The left wing scrapes some trees,

and then the plane skids across the road.

(narrator): The wreckage tells investigators

that Flight 9642 hit the ground in a nose up position.

- The initial hypothesis would be that, in fact,

they were trying to avoid the ground

when the aircraft hit the ground.

- Engine failure? Windshear?

Mechanical issue?

(narrator): The debris pattern leaves investigators

with a few obvious possibilities.

(Friesacher): Aircrafts don't crash short of runways.

Do they have false indications? Were the engines running?

So there are lots of things you have to initially think about.

(narrator): As they gather wreckage from the accident site,

investigators wonder if the controller can provide

any insight into the flight's final minutes.

- Anything unusual? Out of the ordinary?

- The whole day was out of the ordinary.

(narrator): The controller explains that the weather

prevented planes from landing, forcing them into a hold.

- And that includes Flight 9642?

- At first, yes.

(heavy sigh)

Luxair 9642 enter Diekirch hold flight level 90.

But before they reach the hold, the weather cleared.

Luxair 9642 descend to 3,000 feet on 1023,

turn left heading 130.

(narrator): He also states

that because of its position,

Flight 9642 was the first plane

directed to the airport

when the weather began to clear.

- They needed 300 metres of visibility to land,

which we got at 10:05.

So I cleared them to land.

- Even though they were heading for the holding pattern,

the controller saw an opportunity.

They were in an ideal position

to the final approach fix and also the Luxembourg Airport.

- And then?

- That was the last we spoke.

- No emergency call? - No.

Nothing.

(narrator): The controller can't explain

why the Fokker ended up hitting the ground

2 miles from the airport.

(pensive music)

- From an air traffic control standpoint,

there was nothing in the communication

between the aircraft and air traffic

to indicate that there was any problem whatsoever

with the aircraft at all.

(narrator): Only Captain Poeckes can answer

why the Fokker went down short of the runway,

but he's been hospitalized and is in a coma.

Investigators will need to piece together

the final minutes of the flight without him.

(Friesacher): With the captain not being available,

the objective evidence,

the physical evidence talks to you.

(narrator): They begin by studying

the engine components for any signs of failure.

- They look like they're in pretty good shape.

(Friesacher): Engines normally hold

the aircraft in the air, and they fly towards the runway.

So I would suggest something happened to the engines

that they didn't make it

to the runway in the first place.

- No fire, no damage to any components,

the rotors are fine, fuel lines are intact,

intake is clear, pumps and PCUs all check out.

I can't find anything wrong with either engine.

(narrator): The state of the engines is puzzling.

If both were in good working order,

what could have caused the flight to fall from the sky

just short of the runway?

(mysterious piano music)

- This is where they're turned for the approach.

(narrator): Investigators use Luxembourg's radar data

to recreate Flight 9642's flight path.

- Seven minutes to impact.

- They're at 9,000 feet

when they're cleared for the approach.

Now he descends even more steeply,

and at 7,000 feet per minute.

- They're only 4 miles away from the runway.

15 seconds later, they hit the ground.

Here's the glideslope.

(soft investigative music)

- Whoa.

(narrator): When investigators compare the plane's descent

with the recommended descent,

they see that the flight was 300 feet too high

throughout the final stages of its approach.

- That explains why they were in such a hurry

to lose altitude.

- 300 feet above the glide slope,

this is a real problem because you now try

to descend the aircraft, slow down the aircraft,

and configure everything at the same time,

which is nearly impossible.

(narrator): Why did the pilots allow their plane

to get into such a difficult situation?

- Not a good idea to be rushing on an approach at all,

especially in low RVR, dangerous actually.

(investigative music)

(Poeckes on CVR): Heavy fog.

It will be a hard landing.

(narrator): The team listens to Flight 9642's

Cockpit Voice Recording, or CVR,

for clues that can explain

the pilots' dangerous predicament.

- Okay, they know the weather's going to be an issue.

(Poeckes on CVR): I'll call dispatch.

Dispatch, good morning, 9642.

(dispatcher): 9642, good morning.

- How is the weather at the moment?

(dispatcher): RVR is 250 at the moment.

If it doesn't get better,

you will be diverted to Saarbrücken.

- Okay, thank you.

Oh no. I will not go to Saarbrücken.

(soft chuckle)

- I'm with you.

(terminal on CVR): Wind 1-10, 4 knots.

Expect ILS approach,

runway 27, transition level 60.

- He does not want to divert.

(controller on CVR): Luxair 9642 enter Diekirch

hold flight level 90.

- They're being directed into the holding pattern.

(Arendt on CVR): No. We need fuel to reach to our alternate

plus 20 minutes reserve. So we'll still need 600 kilos.

- Okay. Good.

They want to make sure there's enough fuel

to reach their alternate.

(Poeckes on CVR): Yes, but I want to keep--

(controller on CVR): Luxair 9642 descend to 3,000 feet on 1023,

turn left heading 130.

- And then they're hit with a new plan.

(intriguing music)

(narrator): The recording reveals that the pilots

were surprised by the instruction

to begin their approach.

- What kind of crap is that?

- They were not happy about the change of plans.

(narrator): The sudden change meant

that instead of proceeding to the hold,

the pilots quickly initiated a left turn,

and began a steady descent towards the runway

all while configuring their plane for landing.

- So the crew were forced to rush themselves

down to the final approach fix.

(narrator): The rushed approach

now becomes the focus of the investigation.

(controller on CVR): Luxair 9642 turn right heading 220.

Cleared for approach.

- Okay, they're starting their approach.

- For a low visibility approach,

properly briefed and performed,

it's very structured, organized, and standardized,

so each pilot knows exactly

which task they have to do at which time.

- Should we switch the seatbelt sign on?

- Yes, yes. Not a bad idea.

(soft pensive music)

Localizer captured.

- Uh, check.

Missed approach heading.

- They're not running a checklist.

They're just throwing out random steps.

(narrator): Over the next few minutes,

investigators hear several clear indications

that the pilots are improvising this unexpected approach.

(Hildebrand): You must be fully established,

which means gear down, flaps extended,

landing checklist completed,

speed and altitude all at the correct spot.

- Hey, are we at the beacon yet?

- You should have it dialled in by now.

- I can use the DME instead.

- Yeah, yeah, yeah.

(narrator): Even basic steps such as configuring

the navigation system aren't performed.

(Friesacher): Flying an aircraft is about

a precise following of certain steps at certain times.

It's starting on an approach involving all the crew members.

It's about detailed planning.

- They're skipping steps and improvising the procedures.

The change of plans caught them by surprise.

(pensive music)

- They're racing against the clock.

- They started to rush themselves

in a quite high workload environment,

trying to get the airplane down, and doing the approach briefing,

all at once, which was quite tricky to achieve.

(narrator): Did the rushed approach result in the pilots

being too high as they neared the runway?

- They're getting closer and closer to the airport.

And at 3.5 miles out,

they should be at 2,500 feet,

but they're at 3,000 instead.

(♪♪)

(Arendt): Flaps? - Oh, we are flaps 10.

(controller): 9642, you are cleared to land.

(narrator): Instead of managing their altitude and speed,

they're rushing to get their plane properly configured.

(Hildebrand): Speed and altitude control

is actually important for every approach,

but especially for a low visibility approach

where you have to be established

much earlier than on a normal approach.

- So why all the confusion?

It can't just be the last-minute approach.

- I don't think they thought they'd be able to land.

Have a look.

- RVR, RVR, RVR...

(narrator): The cockpit recording makes it clear

to investigators that the crew didn't think

they'd have the required visibility to make the landing.

- What's the RVR now?

- I don't know, should we check with dispatch?

- Yes.

- They're told they have a visual range of 275 metres.

But they need 300 minimum to land.

- They're not sure how to proceed.

- Their plan is to do a go-around

if the visibility hasn't increased by the time

they get to the outer marker here.

- The outer marker can be seen as a decision or a cutoff point.

Once you pass the outer marker,

the RVR must be at the required minimum.

- But as soon as they get to the outer marker,

they get the magic words...

- "300 metres."

- Luxair 9642,

RVR is 300 metres.

You are cleared to land, wind 180 degrees, 5 knots.

- But they're too high and need to lose altitude fast.

(narrator): The CVR explains why

the pilots ended up above their target altitude.

They were rushed into the approach

and fixated on the poor runway visibility.

- Okay, so how does that lead to a crash 35 seconds later?

(controller on CVR): 9642, you are cleared to land.

(Arendt on CVR): Uh, gear down?

(Poeckes on CVR): Yeah.

(Arendt on CVR): Cleared to land 9642.

And done.

(hubbub) (static, whirring)

(Poeckes on CVR): The hell is that?!

(exhales) Oh!

(GPWS): Terrain. Terrain.

- What just happened?

- In the last few seconds of the CVR recording,

there was a loud noise.

The crew was startled by this.

- What happened in those last 20 seconds?

- And what was that noise we heard?

(investigative music)

(hubbub, whirring)

- The hell was that?!

(passengers yelping)

(engine buzzing)

(♪♪)

(narrator): Investigators hope

the Flight Data Recorder, or FDR,

can solve the mystery of what went wrong

in Flight 9642's final seconds.

- Okay, cruising along at 3,000 feet and 160 knots,

then they start to descend, go flaps 10

and accelerate rapidly towards the ground.

- Let's see what the engines were doing.

- What's happening here?

Turbine RPMs drop,

torque drops down to zero.

Looks like he's gone down below Flight Idle,

into Ground Mode.

(narrator): Ground Mode changes the angle of the propellers

so they can move the plane forward

while it's on the ground.

It's never used in the air.

- But then...

Turbine RPM spikes,

fuel flow and torque increase.

- All while the altitude starts to plunge.

- Could they have gone into Beta Mode?

(intriguing music)

(engine rumbling)

(narrator): Beta Mode is basically reverse thrust.

The propellers are positioned to move air forward

instead of back.

It's used to help stop the plane after it touches down.

- If you would put the power levers

into Beta Mode in the air,

this could lead to loss of control

where recovery might not be possible.

(narrator): Did the pilots of Flight 9642

put their engines into reverse and if so, why?

- Can we hear the last 20 seconds of that CVR again?

(Arendt on CVR): And done.

(hubbub) (static, whirring)

(Poeckes on CVR): The hell is that?!

Oh!

(GPWS): Terrain. Terrain.

- It's the propellers going into reverse.

(narrator): Investigators now have an explanation

for the deafening sound on the CVR.

- This is almost like hitting the brakes.

The aircraft would immediately dive into a rapid

and uncontrollable descent.

- How could the engines end up going into Ground Mode

and then into reverse Beta Mode?

How is that even possible?

- The turboprop airplane, like the F50,

it had a lot of safety, uh, features that would prevent

the propeller from going into Beta Range in flight.

(narrator): Before a plane can be put into reverse mode,

the thrust levers must first pass through Ground Mode.

A lock prevents this from happening.

Pilots can switch the lock off in flight

to prepare for landing.

(engine rumbling)

- Ground Idle Stop off.

(narrator): First Officer Arendt performed that step

as part of his Descent and Approach checklist.

With the lock disabled,

pilots can lift the Ground Range Selector

and move the thrust levers to Ground Mode

after landing to help slow the plane.

But instead, the data reveals that the engines

went into Ground Mode 25 seconds before the plane crashed.

(dramatic music)

- Did they do it on purpose?

(McNair): The question is, "How did they get there?" Did the crew select it?

Did they do it deliberately?

Was it something bad that happened,

the safety defences didn't work?

These are all things that have to be looked at.

- Okay, we're recording.

Let's start with the taxi lights.

(narrator): To find out if the crew intentionally put

the plane into Ground Mode before they were on the ground,

they record a number of different sounds

in the cockpit of another Fokker 50.

(pensive music)

- Every switch has a sound attached to it.

- Okay, let's try flaps to 10.

(intriguing music)

And now the Ground Range Selector.

And that does it.

- And this, uh, can be forensically analyzed

and filtered out.

- And you compare that to what you find from the Cockpit Voice Recorder.

- These three sounds were picked up on the CVR.

Let's start with this.

(clicking)

We were able to confirm that this sound

is the taxi lights being switched on.

(clicking)

(♪♪)

(rattling)

The test recording confirms that that's the flap handle

being moved to flaps 10 position.

(rattling)

And there's this.

(clicking)

We compared it to the sound recorded on the test plane.

- It's a match? - Mm-hmm.

(narrator): The audio analysis confirms

that Captain Poeckes deliberately lifted

the Ground Range Selector and moved his throttle

to Ground Mode while the plane was making

its approach to the airport.

- The key element found in the sound spectrum study

was the power lever was, in fact, moved

below the Flight Idle gate.

And this was something that meant the pilot had to do it.

(soft investigative music)

- Okay.

So we know he did this on purpose.

But why?

- There is no maneuver or procedure

asking the pilots to actually lift the Ground Range Selector

in flight and pull the power levers below Flight Idle.

It's a prohibited, non-standard procedure

and should never be done by the pilots.

(narrator): What could have prompted the pilots

to put their engines into Ground Mode?

- He's 5 miles away from the airport

when he decides to land, but he's 300 feet

above the glideslope and his speed is 165 knots.

If he wants to get down to the glideslope,

he needs to descend rapidly,

but his speed is already quite fast.

So instead, he slams on the brakes.

- Once the power levers are in Ground Idle,

this will produce extra drag on the propellers,

reducing the speed, and also allowing the aircraft

to descend at the same time.

(controller): Luxair 9642, RVR is 300 metres.

(narrator): Investigators believe that when the crew is told

that runway visibility has improved,

Captain Poeckes moved his engines to Ground Mode

to quickly reduce speed and lose altitude.

- Not sure that'll do it.

9642 continuing approach.

Flaps?

- They should have made a better decision and go around,

reposition, and fly a proper approach,

or divert to the alternate and not forcing it in.

- Okay, we can explain putting the engines into Ground Mode,

but reverse?

(hubbub) (beeping, whirring) - The hell is that?!

(passengers screaming)

Oh!

(engine buzzing)

- So the lock is only released when the plane is on the ground.

(narrator): Investigators know the pilots of Luxair Flight 9642

put their plane into Ground Mode before landing,

but it doesn't explain why the throttles were moved

further back to reverse,

while they were still hundreds of feet in the air.

- It should be impossible to do.

- To get to that range in flight, it's not supposed to happen.

There's supposed to be two things that prevent it from happening.

(narrator): An electrical lock prevents the power levers

from being moved into reverse in flight.

Once the plane is on the ground

and the wheels are spinning at at least 20 miles an hour,

a signal is sent to an electrical switch

that releases the Flight Idle Stop and allows the throttles

to move to the reverse position.

- This system is only meant to be used on the ground,

and that's why they have a lot of protections

to make that the only possibility that's gonna happen.

- Could the lock have somehow failed?

- The mechanical stop is installed

so that the pilots can, under no circumstances,

physically move the power levers

beyond Ground Idle,

so no reverse thrust possible.

(narrator): Investigators study the components

that make up the locking system.

- The anti-skid system checks out,

the wheel speed relays are fine,

and there's nothing wrong with the lock switch.

(investigative music)

(narrator): Investigators also check the anti-skid sensors

which measure wheel speed,

the computer that receives those signals,

and the switch controlling the lock.

- Everything seemed to check out normally.

- It shouldn't unlock unless the wheels are spinning.

So what went wrong?

(narrator): Investigators scrutinize

the electrical lock system that should have prevented

Flight 9642 from going into reverse.

- Anything in the maintenance record?

- There's this.

(narrator): They discover an incident

that happened 14 years earlier.

- "Power lever setting below Flight Idle possible in flight."

Huh.

(narrator): In 1988,

the Flight Idle Stop disengaged inadvertently

on another Fokker 50.

- So it's not as foolproof as we thought.

- The system design was actually well designed by Fokker.

But they knew the system had a problem.

(narrator): When the landing gear is lowered,

an electrical pulse could be sent to activate

the plane's anti-skid control unit.

That sends out a false indication

that the plane is on the ground,

just enough to unlock the Flight Idle Stop.

- This particular pulse in the anti-skid control unit

could, in fact, allow the power levers to go

back into the Beta range.

(engine buzzing)

(narrator): At the time, Fokker said the chance

of an inadvertent unlocking due to the glitch

was extremely unlikely.

- These three conditions must be met for the stop to unlock:

Gear down, the left and right gear locks releasing

at precisely the same instant,

and the power levers below Flight Idle.

- A lot of components had to line up

in very great precision to make it happen,

the perfect storm of bad things happening together.

- Could they have triggered the glitch?

(narrator): Investigators return to the voice recording

and flight data to determine if a short-lived electrical anomaly

allowed the engines to go into reverse while in flight.

- We know from the sound analysis the click

that we heard on the CVR is the Ground Range Selector being lifted.

(clicking)

Approximately 30 seconds before impact,

the captain moves his power levers below Flight Idle.

- Okay, so condition one is met.

- The first officer lowers the landing gear

13 seconds later and they unlock at the exact same time.

- Now that the conditions to trigger the glitch

have been met, for the next 16 seconds,

the levers can be moved to reverse.

- The aircraft thinks it's on the ground

and it will go into reverse in flight.

- And just three seconds later, the propellers go into reverse.

- That's it.

(jazzy investigative music)

- Ground Idle Stop off.

(narrator): They believe that in an effort

to lose altitude quickly,

the pilots of Flight 9642 unknowingly triggered

the electrical anomaly that allowed them to put

their engines into reverse.

The sequence of events begins

with the captain moving the throttles

to Ground Mode to reduce speed and altitude.

- I'm not sure that'll do it.

9642 continuing approach.

(narrator): The maneuver doesn't have the desired effect.

The plane is still too high.

(Arendt): Flaps? - Uh, we are flaps 10.

(narrator): The crew extends the flaps

to reduce speed even further.

Then...

(clicking)

- Uh, gear down? - Yeah.

(narrator): As Captain Poeckes keeps his throttles

pulled as far back as they can go,

the first officer lowers the landing gear,

unaware it will trigger the conditions

to unlock reverse.

(hubbub, whirring)

- The hell is that?!

Oh!

- There will be a loud bang.

Overall, everybody will hear that

in the cockpit and in the cabin.

There will be an immense increase in drag,

so you will literally feel your body shifting and shaking.

(engines whistling)

(narrator): Captain Poeckes doesn't even realize what's happened.

- Pull, pull, pull, pull, pull!

Ah! (GPWS): Terrain.

(horrified scream) (GPWS): Terrain.

(Hildebrand): Once the landing gear

was selected by the first officer,

suddenly both engines went into full reverse.

It was too late to recover.

(narrator): 25 seconds after the throttle

is inadvertently moved to reverse,

the plane crashes, resulting in 20 deaths.

(sorrowful piano music)

- If Fokker knew about this anomaly in 1988,

why didn't they just fix it?

(narrator): Investigators examine reports

to explain why Flight 9642

was allowed to fly despite the aircraft manufacturer

knowing about a potential glitch.

- They said the probability of this happening

was so low that no immediate action was required.

- It's a very short duration power up,

so therefore the timing has to be very precise

and the likelihood of it happening was low,

there's no doubt about it, but certainly it was not zero.

- They eventually came up with a modification

and issued this service bulletin about it a few years later.

(narrator): The manufacturer of the skid control unit

had issued a service bulletin

suggesting a simple fix that would prevent

the erroneous signal from being sent.

(McNair): To modify the anti-skid control unit

to the newer version that would not provide this power up pulse,

one merely had to add a few diodes and a capacitor,

so it wasn't a complicated fix. It wasn't difficult to do.

It wasn't expensive.

(narrator): But the notification was issued

as a Service Bulletin,

not an Airworthiness Directive

which would have made the fix mandatory.

(Friesacher): If an aircraft manufacturer is making

a modification to an aircraft, it gives out a Service Bulletin.

You don't need to do it.

An Airworthiness Directive is a state hazardous to the safety

of the operation of the aircraft

that might even ground the whole world fleet

of the aircraft till it's modified.

(narrator): Luxair never performed the suggested

1992 modification to its fleet of Fokker aircraft.

- If it comes as an Airworthiness Directive,

they would have complied, no doubt about that.

And the problem would have been fixed.

- The accident didn't happen here.

It happens here

when they accepted an approach they weren't prepared for.

- How much fuel will we need?

- Uh...

550...

We need 850 when we leave the hold.

- No. We need fuel to reach till our alternate

plus 20 minutes reserve, so we'll still need 600 kilos.

- Yes, but I want to keep--

(controller): Luxair 9642,

descend to 3,000 feet on 1023,

turn left heading 130.

- Is that for us? - Yes.

(narrator): Investigators believe

that the main cause of the crash of Flight 9642

was the crew's decision to accept

the approach instruction rather than join a holding pattern.

- Left heading 130, Luxair 9642.

What kind of crap is that?

(Friesacher): At the time they got their first heading

for the intercept for the localizer for the runway,

they should have said,

"No, we are not ready for the approach."

(Krieger): Had they simply rejected the approach

when the controller gave them those additional headings

and descent down to 3,000 feet,

the controller would have said that's fine.

- Here, they still don't have the visibility

they need to land, they're too high and too fast,

and still aren't properly configured.

If ever there was a case for a go-around.

- 9642 continuing approach.

(narrator): The investigators also fault the crew

for not executing a missed approach

when they had so much going against them.

(Hildebrand): Once the crew was surprised

by the ATC clearance to start the approach

as number one, a lot of events started,

putting the pilots in a kind of a tunnel vision,

or into a continuation bias,

focusing only on the approach and the landing,

without considering any other options.

(narrator): To prevent the plane from being put

into reverse in the air, the team also recommends

that the modification to the skid control box,

which stops any erroneous signal,

be made mandatory for all Fokker 50 airplanes.

Luxair makes the modification

to its entire fleet of Fokker aircraft.

- The accident, in fact, proves the fact

it was that serious and should have been addressed.

(narrator): Captain Poeckes was charged

with involuntary manslaughter.

He was fined and sentenced

to three-and-a-half years' probation.

- The lessons we have learned from this tragic Luxair accident

is always stick to standard operating procedures.

Stick to the aircraft's limitations.

Be aware of operational bulletins.

Unfortunately, most of these things were not done

by the Luxair crew and this led to this tragic accident.

Subtitling: difuze