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1
00:00:01,001 --> 00:00:03,753
(aircraft engines)
2
00:00:03,837 --> 00:00:05,881
- GPWS: Terrain, terrain...
- PILOT: No, no, no, no, no, no.
3
00:00:05,964 --> 00:00:07,466
- GPWS: Pull up.
- (groans)
4
00:00:07,549 --> 00:00:10,844
(aircraft engines)
(explosion)
5
00:00:11,511 --> 00:00:17,308
NARRATOR: Security footage of Flydubai
Flight 981 captures its final moments.
6
00:00:17,642 --> 00:00:19,603
INVESTIGATOR 2:
Oh, it's diving hard.
7
00:00:19,686 --> 00:00:22,814
JOHN NANCE: The level of violence
of the impact was catastrophic.
8
00:00:22,897 --> 00:00:25,859
NARRATOR: 62 people are killed
in the fatal dive.
9
00:00:26,609 --> 00:00:30,315
Investigators soon discover
the pilots had aborted two landings.
10
00:00:30,405 --> 00:00:32,758
ÁLAVA: Rostov Tower, we're going around.
11
00:00:33,450 --> 00:00:36,620
PHIL DERNER: A go-around is done just when
conditions are not perfect.
12
00:00:36,703 --> 00:00:38,872
Did they say why they were going
around a second time?
13
00:00:38,955 --> 00:00:40,779
They just said, "Going around."
14
00:00:40,999 --> 00:00:42,083
Check your speed.
15
00:00:42,167 --> 00:00:43,209
(aircraft engine)
16
00:00:44,294 --> 00:00:46,964
CONTROLLER: The next thing I knew,
the plane was diving towards the runway.
17
00:00:47,047 --> 00:00:51,259
Investigators needed to find out
how the two go-arounds were different.
18
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INVESTIGATOR 1:
One turns to disaster. Why?
19
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- (thunder)
- PILOT (over radio): Mayday, mayday!
20
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(theme music)
21
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GWPS: Pull up.
22
00:01:04,606 --> 00:01:06,566
(indistinct radio transmissions)
23
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{\an8}(aircraft engines)
24
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{\an8}NARRATOR: Flydubai Flight 981 closes in
on Rostov-on-Don International Airport
25
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{\an8}in southwest Russia.
26
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Rostov Tower, Sky Dubai niner-eight-one.
We're at 2,600 feet.
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2,300 feet is our next target altitude.
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NARRATOR: Eleven miles out,
Captain Aristos Sokratous
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and First Officer Alejandro Cruz Álava
prepare the Boeing 737-800 for touchdown.
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DERNER: Both pilots
had a pretty good amount
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of flying hours in the 737 specifically.
These were experienced pilots.
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CONTROLLER (over radio): Flight
niner-eight-one, Rostov Tower.
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Wind, 240 degrees, gusts, 30 knots.
You're cleared to land on runway 2-2.
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NARRATOR: The controller reports the
weather conditions at the airport.
35
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Thick clouds cover Rostov-on-Don.
High winds are battering the runways.
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(rain)
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The weather in Rostov at that time was
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pretty low 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 around it,
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00:02:38,992 --> 00:02:41,661
then, yes, you can expect some challenges.
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{\an8}NARRATOR: Flydubai Flight 981 departedDubai International Airport at 10:37 PM.
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It's a four-hour flight
northwest to Rostov-on-Don.
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00:02:55,300 --> 00:02:58,845
It's a bumpy ride
for the 55 passengers onboard.
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00:02:59,971 --> 00:03:02,557
The flight is expected to land in minutes.
46
00:03:05,810 --> 00:03:06,853
150 knots.
47
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NARRATOR: Eight miles out,
the pilots reduce speed
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as they begin the final descent.
49
00:03:14,736 --> 00:03:17,823
DERNER: On approach, pilots know exactly
what the airplane is doing,
50
00:03:17,906 --> 00:03:20,325
they know the conditions
that they're flying in.
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00:03:20,408 --> 00:03:22,911
- Flaps 30.
- Flaps 30.
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00:03:23,661 --> 00:03:25,747
DERNER: They're going to drop
the flaps bit by bit
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when they're going to drop their landing
gear. It's a very gradual process.
54
00:03:30,793 --> 00:03:34,264
It should be a bit bumpy, and then later,
it should be calm.
55
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NARRATOR: The pilots expect turbulence on
approach, but anticipate a smooth landing.
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The runway is just four miles away,
but there's a threat ahead.
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COMPUTER: Go around.
Wind shear ahead.
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NARRATOR: The onboard radar
has detected dangerous winds.
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COMPUTER: Wind shear ahead.
Wind shear ahead.
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00:03:57,946 --> 00:04:02,575
NARRATOR: Wind shear is a rapid change
in direction and speed of wind.
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00:04:03,117 --> 00:04:07,830
If a pilot experiences a strong headwind
that suddenly changes to a tailwind,
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00:04:08,456 --> 00:04:11,585
{\an8}the aircraft might not have enough lift to
remain airborne,
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00:04:11,668 --> 00:04:13,336
{\an8}especially at low altitude.
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NANCE: The wind shear alert is built
into the aircraft's avionics to tell you
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00:04:18,091 --> 00:04:21,678
you're going into wind currents
that could be problematic.
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- COMPUTER: Wind shear ahead.
- Wind shear. Go around.
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00:04:25,431 --> 00:04:27,976
NARRATOR: Just 1,000 feet
above the ground,
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landing at Rostov-on-Don
becomes too risky.
69
00:04:31,354 --> 00:04:33,773
(aircraft engines)
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00:04:34,148 --> 00:04:36,443
ÁLAVA: Rostov Tower,
this is niner-eight-one.
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00:04:36,526 --> 00:04:39,232
We're conducting a go-around
due to wind shear.
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NARRATOR: The pilots abort their approach.
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KAMINSKI-MORROW: Every pilot is prepared
to make a go-around on every approach.
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It's something the pilots do
off the top of their heads.
75
00:04:51,874 --> 00:04:53,751
There's no manual involved.
76
00:04:53,960 --> 00:04:55,169
(plane engines)
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DERNER: They have no limit to the amount
of approaches that they can try
78
00:04:57,588 --> 00:05:01,883
as long they have enough fuel, so why not
go around and just try it again?
79
00:05:02,343 --> 00:05:04,012
Flight 981. Copy?
80
00:05:05,722 --> 00:05:08,975
NARRATOR: Flight 981 is
one of four incoming flights
81
00:05:09,058 --> 00:05:12,353
controllers are managing
as high winds delay landings.
82
00:05:13,646 --> 00:05:16,399
Aeroflot 1166, be advised.
83
00:05:16,482 --> 00:05:19,402
Sky Dubai 981
reports wind shear on landing.
84
00:05:20,570 --> 00:05:23,406
DERNER: The air traffic controller's
workload was definitely increased
85
00:05:23,489 --> 00:05:27,619
in this environment, and they have to
start juggling all those cards in the air.
86
00:05:27,702 --> 00:05:30,079
NARRATOR:
As Flight 981 climbs...
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00:05:31,539 --> 00:05:35,710
Aeroflot 1166, you're cleared
to land on runway 2-2.
88
00:05:35,793 --> 00:05:37,128
(airplane engines)
89
00:05:37,211 --> 00:05:39,859
NARRATOR: An Aeroflot flight
prepares to land.
90
00:05:43,343 --> 00:05:47,305
Captain Sokratous pays close attention
to its communications.
91
00:05:47,764 --> 00:05:49,882
I want to see what this guy will do.
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00:05:50,683 --> 00:05:52,727
DERNER: The crew at this
point is hoping that the crews
93
00:05:52,810 --> 00:05:54,896
of other flights are able
to give them some information
94
00:05:54,979 --> 00:05:59,391
that they might be able to use to make
some decisions about what to do next.
95
00:06:00,818 --> 00:06:04,113
NARRATOR: That flight can't land
at Rostov-on-Don either.
96
00:06:05,573 --> 00:06:09,118
PILOT: Aeroflot 1166,
we're going around due to wind shear.
97
00:06:10,453 --> 00:06:14,748
NARRATOR: The Aeroflot pilots also
encounter wind shear on final approach.
98
00:06:15,166 --> 00:06:16,584
They're forced to abort.
99
00:06:17,752 --> 00:06:21,381
That kind of seals the deal.
Flydubai's gonna have to either wait,
100
00:06:21,464 --> 00:06:24,464
or they're gonna have to go to
an alternate airport.
101
00:06:25,134 --> 00:06:29,972
NARRATOR: High over Rostov-on-Don,
passengers on Flight 981 are restless.
102
00:06:32,600 --> 00:06:35,144
The pilots are holding at 15,000 feet,
103
00:06:35,478 --> 00:06:38,898
circling near the airport,
waiting for a chance to land.
104
00:06:40,900 --> 00:06:42,193
DERNER: The pilots sit
in a holding pattern since they
105
00:06:42,276 --> 00:06:46,806
had enough fuel to be able to do so to
wait for weather conditions to improve.
106
00:06:46,989 --> 00:06:50,401
NARRATOR: Three other planes are
also in a holding pattern.
107
00:06:50,493 --> 00:06:53,663
The storm pounding
Rostov-on-Don isn't passing.
108
00:07:00,628 --> 00:07:03,673
PILOT: Aeroflot 1166. We're diverting.
109
00:07:06,801 --> 00:07:09,262
CONTROLLER (on radio): Sky Dubai 981,
for your information,
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00:07:09,345 --> 00:07:11,875
previous traffic
went to alternate airports.
111
00:07:12,056 --> 00:07:16,645
NARRATOR: All the other flights decide
to divert to alternate airports instead.
112
00:07:20,022 --> 00:07:21,816
KAMINSKI-MORROW: The problem
with diverting is that
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it's expensive and it's inconvenient.
114
00:07:25,319 --> 00:07:27,697
The passengers don't end up
at their destination.
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00:07:27,780 --> 00:07:29,722
They have to be put up in hotels.
116
00:07:30,074 --> 00:07:33,828
And with a low-cost airline,
it's the last thing it wants.
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00:07:35,204 --> 00:07:39,084
NARRATOR: Captain Sokratous continues
monitoring the weather radar.
118
00:07:39,167 --> 00:07:40,918
Finally, he spots a clearing.
119
00:07:41,335 --> 00:07:45,100
- I think I'd like to give it a try.
- ÁLAVA: I agree. Let's try.
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00:07:46,215 --> 00:07:48,927
KAMINSKI-MORROW: It's not unusual
for crews to take advantage
121
00:07:49,010 --> 00:07:53,389
if there happens to be a break in the
weather pattern that provides
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00:07:53,473 --> 00:07:55,650
safe conditions to land the aircraft.
123
00:07:56,601 --> 00:08:00,396
Sky Dubai 981.
Request descent for another approach.
124
00:08:01,314 --> 00:08:05,943
NARRATOR: 15,000 feet over Rostov-on-Don,
the pilots again prepare to land.
125
00:08:08,905 --> 00:08:13,493
Sky Dubai niner-eight-one, Rostov Tower.
You're cleared to land on runway 2-2.
126
00:08:16,454 --> 00:08:20,041
ÁLAVA (intercom): Good evening. Your first
officer here. We will be landing shortly.
127
00:08:20,124 --> 00:08:22,419
Once again, we apologize for the delay.
128
00:08:24,212 --> 00:08:29,383
NARRATOR: 13 miles from runway 2-2,
the pilots line up for a second approach.
129
00:08:31,928 --> 00:08:35,890
CONTROLLER: Be advised. Low altitude
headwind 53 knots, light icing.
130
00:08:36,974 --> 00:08:39,060
NARRATOR: Even though winds are strong,
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00:08:39,143 --> 00:08:42,313
controllers aren't reporting
wind shear at the runway.
132
00:08:45,900 --> 00:08:48,194
- Flaps 30.
- Flaps 30.
133
00:08:49,111 --> 00:08:53,288
NARRATOR: But as they approach,
they soon realize something's not right.
134
00:08:54,408 --> 00:08:55,408
Check your speed.
135
00:09:00,998 --> 00:09:01,832
OK. Go around.
136
00:09:03,626 --> 00:09:06,332
NARRATOR: The pilots execute
another go-around.
137
00:09:07,213 --> 00:09:09,632
(aircraft engines)
138
00:09:17,014 --> 00:09:18,725
ÁLAVA: Keep it at 15 degrees,
nose up.
139
00:09:18,808 --> 00:09:20,727
NARRATOR: Just 2,000 feet in the air,
140
00:09:20,810 --> 00:09:24,355
Captain Sokratous is wrestling
with the Boeing 737.
141
00:09:29,193 --> 00:09:30,361
Seconds later...
142
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(passengers scream)
143
00:09:38,452 --> 00:09:41,498
NARRATOR: Flight 981 is diving
straight at the runway.
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- GPWS: Terrain. Terrain. Pull up.
- (Álava yells)
145
00:09:45,835 --> 00:09:47,777
- GPWS: Pull up.
- (Álava gasping)
146
00:09:48,129 --> 00:09:49,255
Oh, my God!
147
00:09:49,338 --> 00:09:50,256
GPWS: Terrain.
148
00:09:52,967 --> 00:09:55,011
(explosion)
149
00:09:56,387 --> 00:10:00,516
(sirens)
150
00:10:00,600 --> 00:10:04,645
NARRATOR: Fire and emergency crews
rush to the end of runway 2-2.
151
00:10:05,813 --> 00:10:08,566
KAMINSKI-MORROW: The aircraft
punched a crater in the runway
152
00:10:08,649 --> 00:10:13,946
about a meter and a half deep with
wreckage thrown everywhere.
153
00:10:16,824 --> 00:10:20,354
NARRATOR: Firefighters battle
the flames through the night...
154
00:10:22,121 --> 00:10:24,063
but there's no one to be rescued.
155
00:10:25,541 --> 00:10:29,920
All 62 people onboard Flight
981 are killed in the crash.
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00:10:33,174 --> 00:10:36,260
Grieving families and the world
demand answers.
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00:10:44,018 --> 00:10:49,565
NARRATOR: Hours after Flydubai Flight 981
crashes on the runway at Rostov-on-Don,
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00:10:50,066 --> 00:10:55,696
investigators from the IAC, the Interstate
Aviation Committee, arrive on the scene.
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00:10:58,366 --> 00:11:03,204
KAMINSKI-MORROW: The IAC is the lead air
accident investigation agency,
160
00:11:03,496 --> 00:11:07,202
not just for Russia but for several of
the former Soviet states.
161
00:11:08,167 --> 00:11:11,962
NARRATOR: The IAC must find
the cause for the horrific tragedy.
162
00:11:14,757 --> 00:11:19,303
OK. That's great.
That belongs over here.
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00:11:20,179 --> 00:11:22,682
NARRATOR: Wreckage
from Flight 981 is laid out
164
00:11:22,765 --> 00:11:25,476
in a nearby hangar for closer inspection.
165
00:11:26,143 --> 00:11:29,967
A team from the United Arab Emirates
assists in the investigation.
166
00:11:30,564 --> 00:11:32,358
(sighs)
167
00:11:33,526 --> 00:11:35,938
So how fast did the plane hit the ground?
168
00:11:42,785 --> 00:11:46,956
SOEJATMAN: The size of the debris would
tell whether it is a high-speed impact,
169
00:11:47,039 --> 00:11:51,627
whether it is a low-speed impact.
There are clues in pieces of wreckage.
170
00:11:52,503 --> 00:11:54,880
(sighs) There's not much left of it.
171
00:11:58,634 --> 00:12:00,428
SOEJATMAN: It was all small pieces.
172
00:12:00,511 --> 00:12:05,891
It describes a very high-speed and
violent impact with the ground.
173
00:12:08,644 --> 00:12:11,115
It makes us question what really happened.
174
00:12:14,442 --> 00:12:15,317
Let's see it.
175
00:12:17,611 --> 00:12:21,741
NARRATOR: Investigators wonder how the
plane could have gathered so much speed
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00:12:21,824 --> 00:12:23,492
during an attempted landing.
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00:12:24,452 --> 00:12:26,079
INVESTIGATOR:
Oh, it's diving hard.
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00:12:26,162 --> 00:12:31,292
NARRATOR: Security footage gives them a
look at the last moments of Flight 981.
179
00:12:37,381 --> 00:12:41,218
Flight 981's angle of descent
leads investigators to wonder
180
00:12:41,302 --> 00:12:44,714
if the pilots were having problems
controlling their plane.
181
00:12:44,972 --> 00:12:46,914
Maybe it's their flight controls?
182
00:12:49,351 --> 00:12:50,978
No, I've seen it before.
183
00:12:52,104 --> 00:12:55,983
NARRATOR: Boeing 737 flight controls
have a problematic history.
184
00:12:57,401 --> 00:13:00,279
(aircraft engines)
185
00:13:00,362 --> 00:13:02,698
March 3, 1991--
186
00:13:03,699 --> 00:13:06,994
United Airlines Flight 585
banks hard right
187
00:13:07,077 --> 00:13:11,415
and crashes while attempting
to land, killing all onboard.
188
00:13:11,874 --> 00:13:13,992
Three years later, it happens again.
189
00:13:14,460 --> 00:13:18,839
U.S. Air Flight 427 rolls left
and crashes near Pittsburgh.
190
00:13:21,717 --> 00:13:23,428
KAMINSKI-MORROW: Investigators
were tearing their hair out,
191
00:13:23,511 --> 00:13:24,923
trying to figure it out.
192
00:13:25,805 --> 00:13:30,351
NARRATOR: Two years pass without incident.
Then, while on approach to land,
193
00:13:30,434 --> 00:13:34,688
the pilots of Eastwind Airlines Flight
517 lose control.
194
00:13:36,273 --> 00:13:39,318
This time, the pilots regain
control of their plane
195
00:13:39,401 --> 00:13:41,862
and land safely in Richmond, Virginia.
196
00:13:45,241 --> 00:13:49,453
The plane is intact.
Investigators get their best lead yet.
197
00:13:50,371 --> 00:13:52,373
KAMINSKI-MORROW: After
a five-year investigation,
198
00:13:52,456 --> 00:13:56,544
the National Transportation
Safety Board concluded that
199
00:13:56,627 --> 00:14:00,005
a power unit in the rudder
had been responsible
200
00:14:00,089 --> 00:14:02,967
for what's called a rudder hard-over.
201
00:14:03,384 --> 00:14:05,970
The rudder had moved to one side,
202
00:14:06,345 --> 00:14:11,934
and that caused the aircraft to roll over
and then dive into the ground.
203
00:14:12,768 --> 00:14:15,855
NARRATOR: Movements of rudder
and other control surfaces
204
00:14:15,938 --> 00:14:19,483
occur when pilots push their
rudder pedal or pull the yoke.
205
00:14:20,401 --> 00:14:22,528
Power control units turn those commands
206
00:14:22,611 --> 00:14:25,364
into actual movements
of the control surfaces.
207
00:14:25,906 --> 00:14:28,436
It's similar to
the power steering on a car.
208
00:14:32,538 --> 00:14:36,041
Hey there.
Um, did you recover the PCUs?
209
00:14:36,584 --> 00:14:41,290
NARRATOR: Investigators want to know if
any of Flight 981's control units failed.
210
00:14:43,257 --> 00:14:46,199
- Yup, they're here.
- Great. We need to test them.
211
00:14:46,969 --> 00:14:51,223
NARRATOR: Much of the Boeing 737 was
destroyed during high-speed impact,
212
00:14:51,765 --> 00:14:54,589
but two of the power
control units have survived.
213
00:14:55,060 --> 00:14:57,355
They could provide crucial information.
214
00:14:58,522 --> 00:15:01,859
NANCE: PCUs are the heart and soul
of the flight controls of the airplane.
215
00:15:01,942 --> 00:15:03,736
And one of the first questions,
if you have an airplane
216
00:15:03,819 --> 00:15:07,231
that came screaming out of
the sky at a 50-degree angle is:
217
00:15:07,656 --> 00:15:10,598
"Did we have a PCU problem
in the flight controls?"
218
00:15:12,745 --> 00:15:17,166
NARRATOR: Investigators carefully examine
the PCUs of Flight 981.
219
00:15:19,043 --> 00:15:21,220
They look for signs of a malfunction.
220
00:15:29,345 --> 00:15:30,993
Nothing wrong with the PCUs.
221
00:15:32,014 --> 00:15:36,894
NANCE: They were extensively examined and
found to have had absolutely no connection
222
00:15:36,977 --> 00:15:39,566
to what brought this airplane
out of the sky.
223
00:15:40,314 --> 00:15:42,775
NARRATOR: With flight control
issues ruled out,
224
00:15:42,858 --> 00:15:45,447
the team turns to the controller
for insight.
225
00:15:46,904 --> 00:15:48,610
Take me through what you saw.
226
00:15:49,323 --> 00:15:50,991
They were on final approach.
227
00:15:54,411 --> 00:15:56,372
CONTROLLER (on radio):
Flight 981, Rostov Tower.
228
00:15:56,455 --> 00:15:58,632
You're cleared to land on runway 2-2.
229
00:16:02,002 --> 00:16:05,355
CONTROLLER: Then they aborted
their first attempt to land.
230
00:16:06,507 --> 00:16:07,978
They reported wind shear.
231
00:16:09,259 --> 00:16:11,845
ÁLAVA (on radio):
Rostov Tower, this is 981.
232
00:16:11,929 --> 00:16:14,694
We are conducting a go-around
due to wind shear.
233
00:16:15,307 --> 00:16:19,249
CONTROLLER: Sky Dubai 981,
make holding pattern at your convenience.
234
00:16:20,396 --> 00:16:24,044
- They climbed and began holding.
- How long were they holding?
235
00:16:25,401 --> 00:16:26,610
For a long time.
236
00:16:26,694 --> 00:16:29,572
NARRATOR: Investigators learn
that the pilots held
237
00:16:29,655 --> 00:16:32,950
for almost two hours, waiting
for the weather to improve.
238
00:16:35,160 --> 00:16:38,622
ÁLAVA: Sky Dubai 981.
Request descent for another approach.
239
00:16:39,373 --> 00:16:41,375
CONTROLLER: Then they asked to land.
240
00:16:41,458 --> 00:16:45,988
NARRATOR: But something went wrong when
the pilots made their second approach.
241
00:16:47,297 --> 00:16:51,592
ÁLAVA (on radio): Rostov Tower, this is
Sky Dubai 981. We're going around.
242
00:16:52,428 --> 00:16:55,264
Did they say why they were going
around the second time?
243
00:16:55,347 --> 00:16:58,976
CONTROLLER: No. They just said,
"Going around." That's all.
244
00:17:00,310 --> 00:17:03,958
The next thing I knew, the plane was
diving towards the runway.
245
00:17:09,528 --> 00:17:11,572
Did they report any problems
with the plane?
246
00:17:11,655 --> 00:17:13,115
No. Nothing.
247
00:17:14,491 --> 00:17:17,578
NARRATOR: IAC Investigators
still can't explain
248
00:17:17,745 --> 00:17:22,833
why Flight 981 suddenly banked
and then dived into runway 2-2.
249
00:17:23,751 --> 00:17:25,503
Something had gone wrong on
the second go-around,
250
00:17:25,586 --> 00:17:29,590
but investigators didn't know what.
Was there a problem with the airplane?
251
00:17:29,673 --> 00:17:33,085
Did the pilots make a mistake?
There was no knowing it yet.
252
00:17:38,515 --> 00:17:44,855
OK. Two go-arounds.
One turns to disaster. Why?
253
00:17:44,980 --> 00:17:47,039
Let's take a look at the first one.
254
00:17:47,357 --> 00:17:50,235
NARRATOR: Investigators turn to
FDR data
255
00:17:50,319 --> 00:17:54,239
to better understand why
Flydubai Flight 981 performed
256
00:17:54,323 --> 00:17:58,035
one successful go-around
but crashed during the second.
257
00:17:58,577 --> 00:17:59,787
Investigators needed to figure out
258
00:17:59,870 --> 00:18:02,988
how the two go-arounds
were different from each other.
259
00:18:03,540 --> 00:18:04,374
Zoom in a bit.
260
00:18:08,796 --> 00:18:09,914
{\an8}INVESTIGATOR: Look.
261
00:18:11,048 --> 00:18:12,967
NARRATOR: They confirm the pilots reacted
262
00:18:13,050 --> 00:18:16,011
to a wind shear alarm
during the first approach.
263
00:18:18,430 --> 00:18:19,901
And how did they respond?
264
00:18:20,099 --> 00:18:21,688
The thrust jumps up to 102.
265
00:18:25,312 --> 00:18:27,077
INVESTIGATOR (mutters): Power.
266
00:18:29,608 --> 00:18:32,778
So he applied max power.
What about the flaps?
267
00:18:33,529 --> 00:18:39,451
Flaps at 30.
And gear, it remained down.
268
00:18:47,668 --> 00:18:50,904
- Textbook wind shear go-around.
- INVESTIGATOR 2: Yeah.
269
00:18:51,338 --> 00:18:52,757
KAMINSKI-MORROW:
If a pilot encounters wind shear,
270
00:18:52,840 --> 00:18:56,723
he'll typically perform what's called
a wind shear escape maneuver.
271
00:18:57,427 --> 00:19:00,639
And that involves increasing
the engine power to maximum.
272
00:19:00,722 --> 00:19:03,605
You leave the flaps down.
You leave the gear down.
273
00:19:03,934 --> 00:19:05,523
COMPUTER: Wind shear ahead.
274
00:19:05,644 --> 00:19:06,939
Wind shear. Go around.
275
00:19:08,105 --> 00:19:12,026
DERNER: The first go-around was pretty
routine. They responded appropriately.
276
00:19:12,109 --> 00:19:14,639
They did exactly
what they should have done.
277
00:19:18,365 --> 00:19:21,827
This is the second go-around.
278
00:19:22,661 --> 00:19:25,831
NARRATOR: Investigators analyze
the second attempt at landing,
279
00:19:25,914 --> 00:19:28,917
focusing in on the last moments
before the crash.
280
00:19:29,459 --> 00:19:33,130
Now did they get another wind shear
warning the second time?
281
00:19:33,547 --> 00:19:34,840
No. Nothing.
282
00:19:41,763 --> 00:19:42,598
Look.
283
00:19:42,681 --> 00:19:47,311
There's a leap in airspeed
from 153 to 176 in seconds.
284
00:19:49,062 --> 00:19:51,190
NARRATOR: Ten seconds before the
pilots abort,
285
00:19:51,273 --> 00:19:54,450
a sudden increase in the plane's
airspeed was recorded.
286
00:19:54,568 --> 00:19:57,571
SOEJATMAN: The investigators saw
the airspeed fluctuating
287
00:19:57,654 --> 00:20:00,991
for more than 20 knots
within a few seconds.
288
00:20:01,617 --> 00:20:06,323
It's a pretty strong gust of wind. They
can see that on the flight data recorder.
289
00:20:07,539 --> 00:20:12,069
NARRATOR: Investigators determine that
a strong gust of wind struck the plane.
290
00:20:13,212 --> 00:20:16,507
NANCE: You can feel the wind increase
on the nose of the airplane.
291
00:20:16,590 --> 00:20:19,927
It's probably also moving the airplane
a little bit left or right.
292
00:20:20,010 --> 00:20:22,304
It's not a pleasant position to be in.
293
00:20:24,223 --> 00:20:27,282
- How did the pilots respond this time?
- Let me see.
294
00:20:29,478 --> 00:20:31,939
Well, they added max power.
295
00:20:32,898 --> 00:20:33,732
OK, go around.
296
00:20:40,864 --> 00:20:43,335
And what about the flaps and landing gear?
297
00:20:44,159 --> 00:20:50,290
Flaps are retracted, gear retracted.
298
00:20:52,584 --> 00:20:55,671
NARRATOR: The data reveals that
on the second go-around,
299
00:20:55,754 --> 00:20:58,225
the pilots performed
a different procedure.
300
00:20:59,800 --> 00:21:01,510
KAMINSKI-MORROW: They didn't fly the wind
shear escape maneuver
301
00:21:01,593 --> 00:21:03,241
during the second go-around.
302
00:21:04,221 --> 00:21:07,516
Well, it looks like they were
doing a standard go-around.
303
00:21:08,725 --> 00:21:13,137
NARRATOR: On a standard go-around,
the flaps and landing gear are retracted.
304
00:21:14,606 --> 00:21:16,489
Except they did it at max power.
305
00:21:17,651 --> 00:21:19,612
KAMINSKI-MORROW: Given
how streamlined the aircraft is,
306
00:21:19,695 --> 00:21:23,115
with the landing gear up
and the flaps largely retracted,
307
00:21:23,657 --> 00:21:26,743
the use of maximum power is
very much overkill.
308
00:21:27,786 --> 00:21:31,040
NARRATOR: Investigators conclude
that on the second attempt,
309
00:21:31,123 --> 00:21:33,959
the crew flew a hybrid of two procedures.
310
00:21:37,713 --> 00:21:40,882
They used the power of
a wind shear escape maneuver
311
00:21:41,258 --> 00:21:44,670
with the gear and flap settings
of a traditional go-around.
312
00:21:50,142 --> 00:21:52,978
So what would that do to the plane?
313
00:21:54,438 --> 00:21:57,497
We'll need to take a look at all
the factors at play.
314
00:22:02,904 --> 00:22:05,115
They were holding on for nearly two hours.
315
00:22:05,198 --> 00:22:10,203
That's... four tons of fuel they burned.
316
00:22:10,829 --> 00:22:13,165
NARRATOR: The weight of the Boeing 737
317
00:22:13,248 --> 00:22:16,013
is a critical factor in the plane's
performance.
318
00:22:17,210 --> 00:22:19,152
Adding the weight of the plane...
319
00:22:22,924 --> 00:22:25,344
Total weight, that's 54 tons.
320
00:22:29,222 --> 00:22:30,987
- That's a light plane.
- Yeah.
321
00:22:33,643 --> 00:22:38,232
SOEJATMAN: At this weight, you know,
the crew would feel a faster acceleration.
322
00:22:42,944 --> 00:22:47,616
Max power, no drag from flaps
or landing gear, low weight.
323
00:22:51,620 --> 00:22:55,165
This plane could have been
accelerating dangerously fast.
324
00:22:55,791 --> 00:22:58,919
This is really an accelerated situation.
325
00:22:59,002 --> 00:23:01,213
This is a very powerful
airplane doing something
326
00:23:01,296 --> 00:23:04,002
that feels like you
just went into afterburner.
327
00:23:04,299 --> 00:23:08,845
How much quicker did this plane pick up
speed on the second go-around?
328
00:23:13,642 --> 00:23:15,466
We need to do modeling on this.
329
00:23:17,312 --> 00:23:19,732
It was really incumbent
upon the investigators
330
00:23:19,815 --> 00:23:22,943
to look further into the question
of the acceleration.
331
00:23:25,320 --> 00:23:29,825
NARRATOR: Investigators turn to computer
modeling to answer a crucial question.
332
00:23:29,908 --> 00:23:31,702
Here's all the data for
the first and second go-around.
333
00:23:31,785 --> 00:23:32,869
Yeah.
334
00:23:34,037 --> 00:23:38,959
NARRATOR: How did the rate of acceleration
differ at the start of the two attempts?
335
00:23:45,048 --> 00:23:50,470
INVESTIGATOR 2: First go-around,
the speed increased by 17 knots.
336
00:23:51,054 --> 00:23:51,937
And the second?
337
00:23:59,104 --> 00:24:04,818
INVESTIGATOR 2: Second go-around...
25-knot increase.
338
00:24:05,235 --> 00:24:07,446
It's a difference of 8 knots
between the two go-arounds.
339
00:24:07,529 --> 00:24:08,822
Mm. Yeah.
340
00:24:09,239 --> 00:24:11,075
NANCE: It was a key part of the findings
341
00:24:11,158 --> 00:24:14,036
when they realized that
over 40% difference existed
342
00:24:14,119 --> 00:24:18,414
between the acceleration from the first
go-around to the second go-around.
343
00:24:19,249 --> 00:24:22,127
NARRATOR: Could the increase
in acceleration have affected
344
00:24:22,210 --> 00:24:23,753
the pilots themselves?
345
00:24:24,838 --> 00:24:27,721
They calculate the impact
of the second go-around.
346
00:24:33,346 --> 00:24:37,100
Wow. Look at the backward force
experienced by the pilot.
347
00:24:38,602 --> 00:24:41,230
McGRATH: And that faster acceleration
on the second go-around
348
00:24:41,313 --> 00:24:43,725
would have pushed him back into the seat.
349
00:24:44,399 --> 00:24:48,399
NARRATOR: The team also examines
the impact of vertical acceleration.
350
00:24:54,284 --> 00:24:58,049
INVESTIGATOR 2: The G-force would have
lifted the pilots upwards.
351
00:24:59,289 --> 00:25:01,333
McGRATH: The pilot would have
felt a slight unweighting.
352
00:25:01,416 --> 00:25:03,358
He would come up out of the seat.
353
00:25:03,752 --> 00:25:10,717
So a sudden acceleration like this,
both horizontal and vertical...
354
00:25:12,552 --> 00:25:14,494
that'll play tricks on your mind.
355
00:25:15,138 --> 00:25:19,100
NARRATOR: Were Captain Sokratous' senses
his worst enemy?
356
00:25:19,893 --> 00:25:22,482
Maybe he experienced
a somatogravic illusion.
357
00:25:26,149 --> 00:25:27,561
ÁLAVA: Check your speed.
358
00:25:29,694 --> 00:25:30,654
OK. Go around.
359
00:25:30,904 --> 00:25:35,951
NARRATOR: A somatogravic illusion is a
dangerous form of spatial disorientation.
360
00:25:36,826 --> 00:25:41,062
When a plane accelerates quickly with
no visual reference of the horizon,
361
00:25:41,414 --> 00:25:45,669
the gravitational forces cause a pitch-up
illusion in the inner ear.
362
00:25:46,503 --> 00:25:49,327
The little hairs in
the inner ear bend backwards,
363
00:25:49,756 --> 00:25:52,992
tricking the brain into
thinking the head is tilting up.
364
00:25:54,719 --> 00:25:57,973
Though you might be going level,
but if you cannot see outside,
365
00:25:58,056 --> 00:26:03,186
that sensation on your vestibular system
is overwhelming and, you know,
366
00:26:03,270 --> 00:26:05,918
you would really feel that
you're climbing up.
367
00:26:06,648 --> 00:26:07,983
KAMINSKI-MORROW: The somatogravic illusion
368
00:26:08,066 --> 00:26:11,236
is one of the most lethal
traps in aviation.
369
00:26:11,319 --> 00:26:13,572
Keep the nose up. 15 degrees!
370
00:26:14,489 --> 00:26:17,666
KAMINSKI-MORROW:
It's an extremely convincing illusion.
371
00:26:22,664 --> 00:26:24,541
What was the actual pitch of the plane
372
00:26:24,624 --> 00:26:27,448
after it accelerated
during the second go-around?
373
00:26:28,795 --> 00:26:30,589
Almost 20 seconds after,
374
00:26:30,672 --> 00:26:36,177
the actual pitch was 8.8 degrees, nose up.
375
00:26:37,137 --> 00:26:41,141
NARRATOR: Investigators look for evidence
that the pilots of Flight 981
376
00:26:41,224 --> 00:26:43,810
became severely disoriented in the dark.
377
00:26:43,893 --> 00:26:45,395
(aircraft engines)
378
00:26:46,771 --> 00:26:49,316
KAMINSKI-MORROW: If you imagine that this
glass of water
379
00:26:49,399 --> 00:26:54,904
represents the fluid in your ear, if you
accelerated this along a smooth surface,
380
00:26:54,988 --> 00:27:00,118
the water be pushed up against the
back of the glass, very much like this.
381
00:27:00,744 --> 00:27:05,498
In other words, it's the same effect
as if you'd simply tilted the glass.
382
00:27:06,750 --> 00:27:09,085
If you take visual information away,
383
00:27:09,836 --> 00:27:14,132
what tends to happen is that the pilot
forgets about the acceleration
384
00:27:15,133 --> 00:27:18,663
and assumes that everything he's feeling
is due to the pitch.
385
00:27:20,513 --> 00:27:23,808
- And what was the pilot's perceived pitch?
- Mm.
386
00:27:24,059 --> 00:27:26,520
McGRATH: Combining
the horizontal and vertical
387
00:27:26,603 --> 00:27:30,940
acceleration experienced by
the pilot, we can calculate
388
00:27:31,024 --> 00:27:33,436
the pitch that is perceived by the pilot.
389
00:27:33,652 --> 00:27:35,904
This is called the illusionary pitch.
390
00:27:36,571 --> 00:27:40,659
INVESTIGATOR 2: The pilot's perceived
pitch was 21.6 degrees.
391
00:27:41,826 --> 00:27:44,162
NARRATOR: They compare
the plane's actual pitch
392
00:27:44,245 --> 00:27:47,916
to the pilot's illusionary pitch
during the second go-around.
393
00:27:49,959 --> 00:27:54,255
INVESTIGATOR 2: Ten seconds later,
the plane is pitched up 3.9 degrees.
394
00:28:00,303 --> 00:28:07,102
And the pilot perceived it
to be 26.7 degrees, nose up.
395
00:28:14,359 --> 00:28:16,124
Wow. That's a huge difference.
396
00:28:22,617 --> 00:28:25,412
McGRATH: This puts the captain
into a situation that
397
00:28:25,495 --> 00:28:28,540
he potentially will be experiencing
a somatogravic illusion.
398
00:28:28,623 --> 00:28:32,976
The captain is feeling one thing, but the
aircraft is doing something else.
399
00:28:33,253 --> 00:28:39,592
Get this. Near the end of the flight,
the actual pitch is 7.6 degrees...
400
00:28:44,180 --> 00:28:48,268
and the perceived pitch becomes
well over 40.
401
00:28:50,353 --> 00:28:53,065
NARRATOR: Investigators discover
three instances
402
00:28:53,148 --> 00:28:55,025
where there was a dramatic difference
403
00:28:55,108 --> 00:28:58,903
between the plane's actual
and the pilot's perceived pitch.
404
00:29:01,030 --> 00:29:03,116
ÁLAVA:
Keep it at 15 degrees, nose up.
405
00:29:03,199 --> 00:29:05,786
NARRATOR: It's evidence that
the pilots may have experienced
406
00:29:05,869 --> 00:29:08,955
a somatogravic illusion
during the second go-around.
407
00:29:10,790 --> 00:29:14,085
Could the feeling of the rapid
acceleration have affected
408
00:29:14,169 --> 00:29:18,923
how the pilots flew the plane?
They dig deeper into the flight data.
409
00:29:20,467 --> 00:29:23,056
Well, the captain pushed forward
on the yoke.
410
00:29:24,220 --> 00:29:26,098
He was trying to pitch the plane downward.
411
00:29:26,181 --> 00:29:28,829
That's what his senses
were telling him to do.
412
00:29:30,226 --> 00:29:32,771
NANCE: The captain,
responding more to his feelings
413
00:29:32,854 --> 00:29:35,607
than to what he was seeing on any
instrumentation in front of him,
414
00:29:35,690 --> 00:29:38,527
he decides that he needs to push the
airplane forward
415
00:29:38,610 --> 00:29:40,779
and counteract this massive pitch up.
416
00:29:40,862 --> 00:29:43,333
He's trying to save them by pitching down.
417
00:29:44,657 --> 00:29:49,162
Wow. Check this out.
He pushed the stabilizer trim down.
418
00:29:51,247 --> 00:29:55,752
NARRATOR: From the data, investigators see
the captain didn't just push the yoke.
419
00:29:55,835 --> 00:29:56,878
Be careful!
420
00:29:58,171 --> 00:30:00,882
KAMINSKI-MORROW: The captain
applies the stabilizer trim
421
00:30:00,965 --> 00:30:04,907
because he's pushing - trying to push
the nose of the aircraft down.
422
00:30:05,929 --> 00:30:08,556
- But for how long?
- Hmm.
423
00:30:12,602 --> 00:30:15,480
Yeah, he held the
trim switch for twelve seconds.
424
00:30:17,440 --> 00:30:20,569
DERNER: Holding the switch
for 12 seconds is unheard of.
425
00:30:20,652 --> 00:30:23,535
That should never be held
for that amount of time.
426
00:30:24,239 --> 00:30:28,535
NARRATOR: The team discovers that
instead of pitching the plane up to climb,
427
00:30:28,618 --> 00:30:31,795
the captain is pitching
the plane towards the ground...
428
00:30:32,330 --> 00:30:33,683
No, no, no, no, no, no.
429
00:30:33,998 --> 00:30:37,351
NARRATOR: E ventually puttingthe plane into a fatal dive.
430
00:30:37,627 --> 00:30:39,379
(aircraft engines)
431
00:30:40,088 --> 00:30:42,559
The sudden change in direction is jarring.
432
00:30:43,800 --> 00:30:46,845
SOEJATMAN: At that time, you would feel
like you're in a rollercoaster.
433
00:30:46,928 --> 00:30:50,557
You know, when you're coming
up to the peak as you're diving at speed,
434
00:30:50,640 --> 00:30:52,464
it's similar to that sensation.
435
00:30:53,351 --> 00:30:57,940
NARRATOR: The pitch down has another
disorienting effect on the pilots' senses.
436
00:30:59,190 --> 00:31:02,694
The pitching down of the aircraft
would have caused both the captain
437
00:31:02,777 --> 00:31:06,198
and the first officer to experience
a dramatic change in the G-forces.
438
00:31:06,281 --> 00:31:07,740
Oh, my God!
439
00:31:07,824 --> 00:31:09,868
(gasps)
440
00:31:10,159 --> 00:31:12,496
McGRATH: That would increase the
confusion in the cockpit
441
00:31:12,579 --> 00:31:13,874
as to what's going on.
442
00:31:15,582 --> 00:31:20,378
NARRATOR: Investigators conclude that the
various G-forces on Captain Sokratous
443
00:31:20,461 --> 00:31:23,131
caused his complete spatial
disorientation.
444
00:31:24,966 --> 00:31:26,718
SOEJATMAN: The captain pushing
and pulling on the yoke,
445
00:31:26,801 --> 00:31:31,055
stomping on the rudder in the dive,
you know, that shows confusion.
446
00:31:31,139 --> 00:31:33,016
He's probably disorientated.
447
00:31:34,142 --> 00:31:35,018
Oh, my God!
448
00:31:35,476 --> 00:31:36,895
SOEJATMAN:
You know, he's trying desperately
449
00:31:36,978 --> 00:31:39,684
to get out of that sensation
that he's feeling.
450
00:31:41,149 --> 00:31:44,778
NARRATOR: But there's one question that
still troubles investigators.
451
00:31:44,861 --> 00:31:47,803
Was the first officer feeling
the illusion as well?
452
00:31:49,365 --> 00:31:51,076
McGRATH: Even though
the accelerations
453
00:31:51,159 --> 00:31:53,661
experienced by both pilots was the same,
454
00:31:55,330 --> 00:31:58,958
the perception of what is
happening can differ.
455
00:31:59,042 --> 00:32:01,545
And that can be due to
many different factors:
456
00:32:01,628 --> 00:32:07,008
expectation, what are they looking at,
their age, their experience.
457
00:32:07,759 --> 00:32:10,171
Start it at the second go-around, please.
458
00:32:11,012 --> 00:32:13,723
NARRATOR: The cockpit voice recorder
could tell investigators
459
00:32:13,806 --> 00:32:18,395
if the first officer was also under the
influence of the somatogravic illusion.
460
00:32:20,313 --> 00:32:22,666
SOKRATOUS (on recording): OK, go-around.
461
00:32:24,400 --> 00:32:25,360
Careful.
462
00:32:27,946 --> 00:32:28,947
(gasping)
463
00:32:29,113 --> 00:32:31,702
ÁLAVA (on recording):
No, no, no, no, no, no.
464
00:32:32,283 --> 00:32:34,118
Don't. Don't do that.
465
00:32:34,827 --> 00:32:36,239
He sees something wrong.
466
00:32:37,246 --> 00:32:39,791
ÁLAVA: No. Pull it. Pull it. Pull it!
467
00:32:40,708 --> 00:32:44,588
- He's telling him to pull back the yoke.
- ÁLAVA (on recording): Pull it!
468
00:32:44,671 --> 00:32:47,495
If he's feeling the same
illusion as the captain,
469
00:32:47,590 --> 00:32:50,355
it sure doesn't seem like he was
affected by it.
470
00:32:51,344 --> 00:32:54,347
KAMINSKI-MORROW: The first officer knew
how much trouble the aircraft was in.
471
00:32:54,430 --> 00:32:57,392
He knew the captain wasn't
responding the way he should.
472
00:32:57,475 --> 00:32:58,476
Oh, my God!
473
00:32:58,559 --> 00:33:01,677
- GPWS: Pull up. Pull up.
- (Álava yells on recording)
474
00:33:04,649 --> 00:33:09,414
NARRATOR: Investigators are left wondering
why the first officer didn't intervene.
475
00:33:12,824 --> 00:33:15,535
You look at this first officer
trying his best and wonder,
476
00:33:15,618 --> 00:33:19,414
"Why didn't you just take control
and say, 'I've got the airplane'?"
477
00:33:19,497 --> 00:33:21,332
(Álava grunts)
478
00:33:21,541 --> 00:33:25,753
(aircraft engines and explosion)
479
00:33:29,298 --> 00:33:32,510
(sighs)
480
00:33:34,846 --> 00:33:39,559
He's been flying the 737-800 for
nearly two years. He's fully certified.
481
00:33:40,309 --> 00:33:43,396
NARRATOR: Investigators look into the
first officer's background
482
00:33:43,479 --> 00:33:47,108
to understand why he didn't take control
of Flight 981
483
00:33:47,191 --> 00:33:50,486
when he saw that the captain
was making grave mistakes.
484
00:33:51,571 --> 00:33:52,807
INVESTIGATOR 2: Look.
485
00:33:53,322 --> 00:33:57,410
His trainer wrote notes on his assessment.
And this one's telling.
486
00:33:57,952 --> 00:34:02,600
NARRATOR: They find notes left by one
of his flight instructors that alarm them.
487
00:34:02,790 --> 00:34:05,835
One thing that could have
possibly saved this aircraft
488
00:34:05,918 --> 00:34:09,918
was discovered in a note that was left
behind by a flight instructor.
489
00:34:10,590 --> 00:34:14,135
"He needs to be a bit more assertive
in what is needed from the captain."
490
00:34:14,218 --> 00:34:15,219
And it continues.
491
00:34:16,262 --> 00:34:18,431
"Tell him what you want done
and do not wait
492
00:34:18,514 --> 00:34:22,769
"for the captain to enquire with you
or direct you in this regard."
493
00:34:25,730 --> 00:34:27,730
He's not the type to take control.
494
00:34:30,610 --> 00:34:34,238
No! Pull it. Pull it.
Pull it. Pull it!
495
00:34:34,322 --> 00:34:36,199
KAMINSKI-MORROW:
The first officer could see that
496
00:34:36,282 --> 00:34:41,204
the captain was experiencing enormous
problems, trying to control the go-around.
497
00:34:41,287 --> 00:34:44,999
He really should have taken some decisive
action and intervened.
498
00:34:45,083 --> 00:34:46,417
Oh, my God!
499
00:34:52,173 --> 00:34:54,300
I still don't understand something.
500
00:34:54,759 --> 00:34:57,877
Why did they try to land
the plane in the first place?
501
00:34:58,679 --> 00:35:01,683
DERNER: The big mystery was,
"Why was this crew so determined
502
00:35:01,766 --> 00:35:03,685
"to land at Rostov-on-Don
when every other flight
503
00:35:03,768 --> 00:35:05,269
"had already diverted?"
504
00:35:05,770 --> 00:35:08,732
NARRATOR: A storm was pummeling
Rostov-on-Don Airport
505
00:35:08,815 --> 00:35:11,234
as Flight 981 circled above.
506
00:35:13,236 --> 00:35:16,697
Why didn't the pilots
divert to another airport?
507
00:35:18,366 --> 00:35:22,078
Investigators look for answers
in the cockpit voice recording.
508
00:35:24,288 --> 00:35:25,874
CONTROLLER (on recording):
Sky Dubai 981,
509
00:35:25,957 --> 00:35:29,781
for your information, previous traffic
went to alternate airports.
510
00:35:30,378 --> 00:35:35,383
So the other flights diverted? There's no
need. I'm gonna keep flying.
511
00:35:37,635 --> 00:35:40,304
Investigators just couldn't understand why
512
00:35:40,388 --> 00:35:43,474
they wanted to fly in
circles for almost two hours.
513
00:35:44,851 --> 00:35:46,144
SOKRATOUS (on recording):
I'm gonna try this approach.
514
00:35:46,227 --> 00:35:48,933
And if I can't make it,
we'll have a go-around,
515
00:35:49,605 --> 00:35:52,358
and I will head to Mineralnye Vody, OK?
516
00:35:52,441 --> 00:35:54,402
DISPATCHER (on recording):
OK, Captain, understood.
517
00:35:54,485 --> 00:35:57,363
- Who's he talking to?
- Oh, the dispatcher in Dubai.
518
00:35:57,446 --> 00:35:59,824
NARRATOR: Investigators finally
get an indication
519
00:35:59,907 --> 00:36:03,369
of the captain's rationale for
attempting another landing.
520
00:36:03,452 --> 00:36:06,706
As the captain decides
whether to divert, he contacts
521
00:36:06,789 --> 00:36:10,751
Flydubai's flight dispatcher
in the United Arab Emirates.
522
00:36:11,794 --> 00:36:16,147
DISPATCHER (on radio): We would like to
recommend you hold max as possible.
523
00:36:16,465 --> 00:36:20,720
Dispatchers manage the entire
fleet's operation for a specific airline.
524
00:36:21,345 --> 00:36:22,722
NANCE: The dispatcher and the captain
525
00:36:22,805 --> 00:36:25,850
are co-equally responsible
for the safety of the flight.
526
00:36:25,933 --> 00:36:28,769
There is a very delicate dance
that goes on
527
00:36:28,853 --> 00:36:31,814
between and among the
dispatchers and the captains.
528
00:36:32,899 --> 00:36:36,194
The captain follows with the
dispatcher's recommendation.
529
00:36:36,986 --> 00:36:41,163
NARRATOR: Minutes turn to hours as the
pilots wait for a chance to land.
530
00:36:41,741 --> 00:36:45,741
I don't know, man. If we divert, we're
gonna exceed our flying hours.
531
00:36:49,415 --> 00:36:52,710
- What are you looking at?
- Maximum duty hours.
532
00:36:53,836 --> 00:36:55,719
He's calculating his duty hours.
533
00:36:57,089 --> 00:37:01,678
NARRATOR: Regulations limit how many hours
pilots can fly during a duty period.
534
00:37:02,803 --> 00:37:05,274
We've been in the air for 5 1/2 hours now.
535
00:37:06,224 --> 00:37:08,518
NARRATOR: The team learns that
the pilots were concerned they
536
00:37:08,601 --> 00:37:10,770
might exceed their duty hours.
537
00:37:11,854 --> 00:37:14,148
Stop. Roll the map.
538
00:37:17,568 --> 00:37:20,039
They'd been flying
for at least five hours.
539
00:37:20,279 --> 00:37:23,992
It will take another hour to reach their
alternate airport, wait out the storm.
540
00:37:24,075 --> 00:37:25,326
And they still have to get back
541
00:37:25,409 --> 00:37:27,880
to Rostov-On-Don
before returning to Dubai.
542
00:37:28,037 --> 00:37:30,707
Diverting would put them
over their duty hours for the day.
543
00:37:30,790 --> 00:37:31,624
Right.
544
00:37:32,750 --> 00:37:36,212
I think it will be clear by the time
we do this approach now.
545
00:37:36,295 --> 00:37:39,632
And even if we start now,
I think we'll be good.
546
00:37:40,549 --> 00:37:42,427
ÁLAVA (on recording): We'll be good.
547
00:37:42,510 --> 00:37:48,849
OK. Is he landing because it's clear, or
because he wants to get on the ground?
548
00:37:50,518 --> 00:37:53,980
DERNER: The conversation on the flight
deck before the second approach clearly
549
00:37:54,063 --> 00:37:57,775
showed that they weren't really thinking
so much about the safety of the landing,
550
00:37:57,858 --> 00:38:00,153
just the fact that they wanted to land.
551
00:38:01,821 --> 00:38:05,586
- I think I'd like to give it a try.
- ÁLAVA: I agree. Let's try.
552
00:38:06,367 --> 00:38:07,535
Stop the recording.
553
00:38:10,371 --> 00:38:13,165
So they decide to circle for two hours
554
00:38:13,749 --> 00:38:16,749
after a four-hour flight
in the middle of the night.
555
00:38:21,882 --> 00:38:26,647
NARRATOR: Did the long flight affect the
pilots' ability to land the plane safely?
556
00:38:27,471 --> 00:38:29,599
NANCE: Two hours of hold,
six hours total time.
557
00:38:29,682 --> 00:38:33,853
Aren't we seeing a decline in the decision
making capabilities because of fatigue?
558
00:38:33,936 --> 00:38:37,565
- Tired?
- (huff) No.
559
00:38:43,696 --> 00:38:46,574
NARRATOR: As investigators break
down flight 981's journey
560
00:38:46,657 --> 00:38:50,536
from Dubai to Rostov-on-Don,
they identify a glaring problem.
561
00:38:51,203 --> 00:38:54,457
INVESTIGATOR 1: They were actually
in the air for more than six hours.
562
00:38:54,540 --> 00:38:57,585
It's almost 5 AM their time
when they're landing.
563
00:38:58,836 --> 00:39:01,297
KAMINSKI-MORROW: The circadian rhythm is
564
00:39:01,380 --> 00:39:05,176
the body's natural alignment
with the day and night cycle.
565
00:39:05,509 --> 00:39:08,471
The quiet period is roughly
for a four-hour period
566
00:39:08,554 --> 00:39:11,554
between 2:00 in the morning
and 6:00 in the morning.
567
00:39:12,058 --> 00:39:17,146
That's the point at which your mental
ability is pretty much at its lowest.
568
00:39:19,023 --> 00:39:22,376
- I think I'd like to give it a try.
- I agree. Let's try.
569
00:39:24,820 --> 00:39:28,992
NARRATOR: Investigators determine the crew
was suffering from operational fatigue
570
00:39:29,075 --> 00:39:31,370
as they launched their second approach.
571
00:39:33,913 --> 00:39:37,583
Good evening. Your first officer here.
We will be landing shortly.
572
00:39:37,666 --> 00:39:39,961
Once again, we apologize for the delay.
573
00:39:40,711 --> 00:39:42,672
NARRATOR: The decision to make
a second attempt
574
00:39:42,755 --> 00:39:47,468
to land at Rostov-on-Don triggers a
chain of events that ends in catastrophe.
575
00:39:50,096 --> 00:39:51,431
ÁLAVA: Check your speed.
576
00:39:51,514 --> 00:39:53,641
As the aircraft
is hit by this sudden wind,
577
00:39:53,724 --> 00:39:56,977
the crew is forced into
executing another go-around.
578
00:39:58,521 --> 00:39:59,397
OK. Go around.
579
00:40:00,189 --> 00:40:02,358
And this time, it was all gonna go wrong.
580
00:40:02,441 --> 00:40:05,778
NARRATOR: Captain Sokratous
executes a wind shear go-around,
581
00:40:05,861 --> 00:40:08,155
pushing the throttle to maximum power.
582
00:40:08,989 --> 00:40:11,784
The first officer performs
a standard go-around,
583
00:40:11,867 --> 00:40:14,954
retracting the flaps
and raising the landing gear.
584
00:40:16,414 --> 00:40:20,376
Both pilots were essentially
flying two different airplanes from there.
585
00:40:20,459 --> 00:40:21,794
KAMINSKI-MORROW:
This blunder factors heavily
586
00:40:21,877 --> 00:40:24,046
into the catastrophe that followed.
587
00:40:24,922 --> 00:40:28,634
NARRATOR: Flight 981 climbs
from Rostov-on-Don at high speed.
588
00:40:30,136 --> 00:40:31,137
SOEJATMAN: When you're light on fuel
589
00:40:31,220 --> 00:40:34,220
and you put the maximum thrust,
you will accelerate.
590
00:40:36,642 --> 00:40:41,466
KAMINSKI-MORROW: It's what happened in the
last few seconds that doomed Flight 981.
591
00:40:43,524 --> 00:40:45,348
Keep it at 15 degrees, nose up.
592
00:40:45,609 --> 00:40:49,492
NARRATOR: At this moment, Captain
Sokratous fights an inner battle.
593
00:40:50,072 --> 00:40:53,117
KAMINSKI-MORROW: The acceleration of the
aircraft makes the captain feel
594
00:40:53,200 --> 00:40:58,038
as though the aircraft is pitching up a
lot more than it actually is.
595
00:40:58,497 --> 00:41:01,674
NARRATOR: His spatial orientation
deteriorates rapidly.
596
00:41:03,544 --> 00:41:06,047
NANCE: Your vestibular senses
in your middle ear
597
00:41:06,130 --> 00:41:08,248
are all telling you the wrong thing.
598
00:41:08,716 --> 00:41:12,303
NARRATOR: The captain counters the pitch-
up feeling of a somatogravic illusion
599
00:41:12,386 --> 00:41:14,388
by pushing the yoke forward.
600
00:41:17,099 --> 00:41:19,852
The captain has lost touch
with the reality
601
00:41:19,935 --> 00:41:22,053
of what's happening to the airplane.
602
00:41:22,188 --> 00:41:24,012
NARRATOR: Then, the final blow.
603
00:41:24,482 --> 00:41:28,659
The captain holds that stabilizer trim
button down for about 12 seconds.
604
00:41:29,945 --> 00:41:33,199
With the sudden forcing of
the aircraft's nose down
605
00:41:33,282 --> 00:41:37,411
and stabilizer trim,
the aircraft transitions
606
00:41:37,495 --> 00:41:41,457
from a climb very suddenly into a dive.
607
00:41:42,208 --> 00:41:45,211
McGRATH: The aircraft is now in
a very dangerous situation,
608
00:41:45,294 --> 00:41:47,647
which the captain is unable to overcome.
609
00:41:48,005 --> 00:41:50,591
- My God!
- GPWS: Terrain.
610
00:41:51,342 --> 00:41:53,010
NANCE:
They're accelerating rapidly.
611
00:41:53,093 --> 00:41:57,264
And the first officer finally
gets on the yoke and tries to pull,
612
00:41:57,806 --> 00:42:01,454
but the controls on the left side
govern where the airplane is.
613
00:42:03,145 --> 00:42:07,024
NANCE: And you get to a certain
point, and there's no recovery.
614
00:42:07,566 --> 00:42:10,194
NARRATOR: Nosediving at full
throttle towards the runway,
615
00:42:10,277 --> 00:42:13,656
Captain Sokratous
is completely disoriented.
616
00:42:14,114 --> 00:42:16,492
When he adds rudder at the last moment,
617
00:42:17,159 --> 00:42:20,120
he's lost all awareness of how
the plane is flying.
618
00:42:21,664 --> 00:42:22,498
(Álava yells)
619
00:42:22,665 --> 00:42:24,124
(aircraft engines)
620
00:42:28,212 --> 00:42:32,174
The pilots in this case were
conducting the flight very well
621
00:42:32,258 --> 00:42:39,223
right up until those last few moments,
and then it all really just fell apart.
622
00:42:39,306 --> 00:42:43,852
(helicopter)
623
00:42:44,353 --> 00:42:48,691
NARRATOR: The IAC investigation
into the crash of Flight 981
624
00:42:48,774 --> 00:42:53,779
is a landmark case of how spatial
disorientation can end in disaster.
625
00:42:54,905 --> 00:42:56,866
SOEJATMAN: This accident is
a wake-up call for the industry.
626
00:42:56,949 --> 00:42:58,659
This is one of the accidents
that paved the way
627
00:42:58,742 --> 00:43:02,496
into increased training
in spatial disorientation.
628
00:43:04,915 --> 00:43:07,877
NARRATOR: In their final report,
investigators blame
629
00:43:07,960 --> 00:43:12,214
the captain's string of errors
on his diminished psychological state.
630
00:43:12,923 --> 00:43:16,260
The IAC recommends that Flydubai
provide better training
631
00:43:16,343 --> 00:43:18,814
on the manual operation
of stabilizer trim,
632
00:43:20,389 --> 00:43:23,309
so their pilots don't make
the same mistake again.
633
00:43:24,393 --> 00:43:27,688
Research into human factors,
including situations like this,
634
00:43:27,771 --> 00:43:29,948
where disorientation likely occurred,
635
00:43:30,149 --> 00:43:32,914
is at the forefront
of aviation safety research.
636
00:43:33,652 --> 00:43:36,196
We are training our pilots on simulators
637
00:43:37,031 --> 00:43:39,867
to experience to illusions before
they experience them in the air
638
00:43:39,950 --> 00:43:42,245
{\an8}so they can recognize those situations.
639
00:43:45,539 --> 00:43:47,124
{\an8}KAMINSKI-MORROW: I think
the Flydubai accident shows
640
00:43:47,207 --> 00:43:51,795
{\an8}how quickly your senses can overtake you.
641
00:43:52,504 --> 00:43:57,635
{\an8}And one of the key lessons is
for pilots to trust in their instruments,
642
00:43:58,260 --> 00:44:02,723
{\an8}to take a step back from what they
may think they're experiencing,
643
00:44:03,098 --> 00:44:06,040
{\an8}to actually understand
what the aeroplane is doing.
644
00:44:06,477 --> 00:44:08,830
{\an8}You've got to keep the aeroplane flying.
60175
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