Original subtitles

(alarm sounding) (narrator): China Airlines Flight 676 falls out of the sky,

crashing into a residential neighbourhood in Taipei.

- It was a horrific crash.

Pieces of the wreckage fell onto houses.

(narrator): More than 200 people are dead,

making this the worst aviation disaster in Taiwan's history.

- Okay, let's get to work. I want photos of everything.

(narrator): Amid the devastation,

recovery teams locate the crucial flight recorders.

- Hopefully the NTSB can extract some useful data from them.

(narrator): Crash experts from around the world assist in the investigation.

- I've got something for you. - We're on it.

(narrator): But 11 seconds of the flight

are almost impossible to explain.

- What the heck happened here?

- And 11 seconds is like an eternity.

That verges on unbelievable.

- Mayday, Mayday!

- It's going up!

(indistinct radio chatter)

- At least the weather's improved.

- For now.

(narrator): China Airlines Flight 676 is cruising over the South China Sea

as it nears Taipei City, Taiwan.

- The flight is scheduled to land at Taipei's Chiang Kai-shek Airport,

the primary gateway to Taiwan,

and it's the busiest airport on the island.

(narrator): This evening, Captain Long-Lin Kang is at the controls.

An Air Force veteran, he's clocked over 2,000 hours on the Airbus A-300.

This flight is special.

- I hope you're enjoying the flight tonight. Can I give you some water?

(narrator): His wife and children are on board,

returning from a holiday in Bali.

- It's a special moment for the family.

There is no one that you would have rather fly them than yourself,

ensuring of their safety.

(narrator): Tonight's flight left Bali at 3:27 p.m.

and is scheduled to touch down in Taipei just after 8:00.

- I'll talk to the cabin? We're seven minutes from descent.

(narrator): Tonight, Kang is paired with a rookie.

- Okay, thanks.

(narrator): He has far more experience on the A-300

than his first officer, Der-Sheng Jiang.

- The first officer's job is help pilot flying to handle all the non-essential job,

or non-essential duty,

so the pilot flying can concentrate on flying the aircraft.

- Yes, hello? - Hi. We're about seven minutes until we start descent.

(narrator): The descent is the busiest,

most critical phase of any flight.

- Weather is 16° and cloudy.

We won't need any wheelchairs tonight, right?

- No, not tonight.

- Look at the ECAM, the trim tank.

(narrator): The captain notices an error message concerning the trim tank.

The trim-tank system moves fuel between tanks in the wings and tail,

keeping the plane balanced and fuel-efficient.

- Let's see what we can do.

- The... auto trim, um...

It seems like we don't need to do anything.

- Yeah, we do. See the Trim Tank System Fault?

(narrator): The captain guides the first officer through the issue.

- Trim Tank System Fault?

- Trim-tank system in flight if no forward transfer.

Not our case.

(narrator): It's not a critical problem.

- Okay, clear.

So you see, that's it. That's the Trim Tank System Fault procedure.

- It's just a minor hiccup,

and it's easy to clear the message.

(narrator): The plane is now 25 minutes from the airport.

- Descent.

(narrator): The captain prompts the first officer to check in with controllers.

- Okay.

Control, Dynasty 676...

requesting descent.

- Dynasty 676,

descend and maintain flight level 250.

(narrator): The tower issues a new altitude of 25,000 feet.

- Descending to flight level 250,

heading 360.

On our way.

- Check the gate.

(narrator): The crew also needs to confirm

their gate information with airline operations on the ground.

- Operations, Dynasty 676.

- Disregard. Dynasty 676.

(narrator): The first officer makes a careless mistake.

- This side.

- Unfortunately, the FO made the request on the ATC channel,

so not the correct frequency of the company radios.

It's quite embarrassing,

because basically, you call the operation with your call sign,

so every pilot in that areas know he made a mistake.

(narrator): The plane is now 45 miles from the airport.

And the weather is getting worse.

- Did you see that? The lightning's pretty strong.

The power of that lightning.

- Lightning does not pose a direct physical threat to the aircraft,

but it usually comes with severe thunderstorms, strong winds.

That's not the kind of conditions that you want to land at the airport.

(narrator): The captain wants to get his plane on the ground before the storm worsens.

- Flaps: 20. (narrator): Three miles from the airport,

the pilots extend the flaps as they reduce speed.

- Flaps: 20.

(narrator): Below them,

the busy streets of Taipei's sprawling suburbs are shrouded in fog and mist.

- Visibility is always a concern for pilots, especially when landing.

If you can't see the runway, you pose a danger to the safety of the aircraft.

You could either miss the runway altogether,

or, even worse, a controlled flight into terrain.

- God, that tailwind's really strong.

(narrator): The captain pitches the nose down for the descent.

- Landing lights.

- On.

(narrator): They're just moments from landing...

- Landing Checklist complete.

- ...but the captain doesn't like the approach.

- GO lever. Go-around.

(narrator): Just 1,300 feet from the ground,

the captain aborts the landing attempt.

- Pilots can go around for any reasons, like a...

non-stable approach,

or runway is blocked,

or by ATCs,

or pilot not satisfied for the approach.

And we have go-arounds in the airports,

maybe one go-around per days.

It's quite common operations.

(narrator): But this go-around is going tragically wrong.

(passengers crying out)

- Dynasty 676, confirm go-around?

(alarm sounding)

(narrator): An alarm warns the crew that the plane is losing lift.

- With no lift...

...airplane nose will drop,

and then airplane will dive.

And then you get in trouble fast. - No!

(whooping) (TAWS): Sinking, sinking.

Don't sink.

(passengers screaming) - The aircraft is out of control,

it's veering left of the runway,

and falling towards a densely populated residential area.

- Dynasty 676, Taipei. What is your status?

(passengers screaming) - Brace, brace, brace!

(pilots groaning) (alarm sounding) (TAWS): Terrain. Pull up.

- All vehicles, an A-300 has just crashed on the roadway north of 05 Left.

(sirens wailing)

(narrator): The burning remains of China Airlines Flight 676

are scattered along a busy road near Chiang Kai-shek Airport.

- It was a horrific crash.

There was a severe fire from the jet fuel,

and it took more than 60 firefighters

from across the city to put out the fire.

(narrator): How could a modern jetliner performing a go-around

fall out of the sky

and crash into a residential neighbourhood?

- Any survivors?

(narrator): All 182 passengers and 14 crew

on board China Airlines Flight 676 are dead,

including the captain's family.

Six more people have been killed on the ground.

- It fell into a residential neighbourhood.

Pieces of the wreckage fell onto houses, into cars.

(narrator): It's Taiwan's worst air disaster.

- It was a very devastating incident; you know,

with many innocent lives lost in an instant.

(narrator): It's also China Airlines' second crash in less than five years.

In 1994, Flight 140 crashed in Nagoya, Japan,

killing 264 of the 271 on board.

That aircraft was also an A-300.

- The Taiwanese people are very concerned and frightened,

because they want to make sure that the government would ensure

that the airline is safe to travel.

(narrator): Desperate to allay the public's fears,

the government grounds the airline's entire fleet of A-300s

until the planes can be checked for faults.

The decision throws Taiwan's air travel into chaos.

- Taiwan is an island, so air transport is incredibly important.

And with the aircraft grounded, a lot of flights were cancelled,

and many people's travel plans were out the window.

(narrator): The Taiwanese Civil Aeronautics Administration

will lead the high-profile investigation.

The pressure to find answers is intense.

- Okay, let's get to work.

I want photos of everything.

- We all want to know what happened quickly and get this solved.

By the same token,

you don't want to leave something unfound because you rushed through it.

And so even though there may be pressure from the government,

you have to push back, say, "We'll do this as fast as we can."

(narrator): Amid the devastation,

investigators focus first on recovering as much of the plane as they can.

- Some pieces may not be important, but the first thing is to...

do you have all the parts of the airplane?

Do you have the wing tips, the tail tips, the nose?

But when you have buildings and cars and everything else,

it becomes a lot more difficult.

(narrator): They also plot the position of every piece of debris.

Soon, a pattern emerges that paints a vivid picture of the way the plane came down.

- Whatever went wrong, it caused them to come in steep and flat.

They pancaked.

- Looking just at the impact, it gives the initial indication that this airplane,

although it was coming down vertically very quickly,

it didn't have a lot of forward velocity to it.

And also the pitch attitude of the airplane wasn't severely pitched down or pitched up.

It was a kind of more of a flat impact, which is a little bit unusual.

(narrator): The high-velocity impact destroyed most of the plane,

but both engines survived.

- I see a distinct damage pattern.

- If the engines are running at impact,

basically you'll bend or shear off the fan blades

opposite to the direction of rotation.

Also, you'll see where they ingest a fair amount of debris,

usually vegetation, at the same time.

- Engines were running when they hit.

Hard to know for sure if they were working properly.

- So there are numerous mechanical hints that investigators can get

to determine if there's power on the engine.

How much power? Well, that's a bit different.

Then you need to turn to flight recorders or some sort of recorded data to get at that.

(narrator): Investigators also recover the jackscrew mechanism

used to operate the flaps.

- If a pilot chooses the wrong flap settings, there can be two dangers.

One is you select flaps at too high of a speed,

and that can structurally damage the flaps.

The other danger is that you could be at a low speed, retract flaps;

now you don't have enough lift,

and the airplane is gonna start coming out of the air.

- The nut's almost at the stop.

So the flaps were partially extended at 20.

- Flaps: 20.

(narrator): There's no sign of structural failure,

and the flaps were in the correct position.

- Early on in the investigation, the process is fairly simple.

It's a shotgun approach. We're looking at everything.

(narrator): There's one theory in particular that investigators want to explore.

- Maybe the weather had something to do with this.

- We know from the weather forecast that the weather was gonna get worse.

There was fog moving in, there was lightning.

And so you start looking at all those factors. (thunder)

- The power of that lightning.

(narrator): Investigators turn coller

for more insight into the weather

around Chiang Kai-shek Airport at the time China Airlines 676 crashed.

- So what kind of winds are we looking at?

(narrator): Did a dangerous condition called "windshear"

bring the plane down?

- God, that tailwind's really strong.

(narrator): Windshear is caused by powerful winds

that can form close to the runway during thunderstorms,

creating forces so powerful,

they can slam a plane into the ground.

- Visibility was above minimum, no windshear.

The weather was fine.

(narrator): The weather theory is quickly ruled out.

- We knew there was lightning approaching the airport.

Uh, the winds, however, were fairly light.

No severe turbulence and no severe downdraft.

We didn't see any weather out there that, by itself,

should cause this airplane to be pushed out of the sky.

- Take a look at this.

(narrator): But controllers did notice something

which is troubling about the flight.

- Interesting.

(narrator): Airliners usually descend to the runway

at a gradual three-degree angle.

But Flight 676 had a much faster, steeper descent.

- You're right. They were way too high on approach all the way in.

- At a point that's about five miles from the runway,

the airplane is 1,000 feet higher than it should be for that position.

And so they've got a problem.

- GO lever. Go-around.

(narrator): The finding explains why the captain called for a go-around.

But it still doesn't explain what caused the crash.

- A go-around, in and of itself, is not a cause for concern.

(narrator): At the crash site, the painstaking search of the debris pays off.

Investigators find both of the black-box flight recorders.

- Great job.

- The flight-data recorders are essential

for finding those little bits of information that you can't see

in the wreckage itself.

It gives us a lot more data

to now put into our little basket of information.

(narrator): Investigators get more critical information

with the discovery of the plane's FADECs,

or Full Authority Digital Engine Controllers.

- The FADEC is just like a flight-data recorder,

except it's specific only to the engine operation,

or if there were any engine anomalies that were occurring during the flight.

- Hopefully, the NTSB can extract some useful data from them.

(narrator): Recovering the data from the U.S.-made controllers requires special expertise,

so investigators ask the National Transportation Safety Board

to oversee the download.

- They were slightly damaged, but they weren't burned.

And that gave investigators hope.

(narrator): While the FADECs are transported to Connecticut in the United States...

- Welcome to Canberra.

- ...the flight recorders are sent to the Bureau of Air Safety Investigation,

or BASI, in Canberra, Australia.

- Well, we've had expertise and facilities for the replay and analysis of flight recorders

going back to the 1970s.

Let's find you some answers.

We've had close links in the Asia-Pacific region for many decades.

So it's natural that our expertise would be made available to the Taiwanese.

- In these international accident investigations,

each country brings a different area of expertise.

And the purpose behind this is global aviation safety, because...

if an accident happened in one place,

it could've happened easily in your own country.

(narrator): In Connecticut...

- Hold it there. - ...NTSB Systems Analyst Jeff Guzzetti begins recovering

the data from the FADECs of Flight 676,

with help from the manufacturer.

- The manufacturer is very much needed. It's their laboratory.

However, the procedure is dictated by the investigators.

That box was not opened until investigators,

like myself, showed up and, in front of everybody,

we unlocked, unsealed the boxes,

and began to extract the components that we needed.

(sighing) Well, here goes nothing.

(narrator): There's no guarantee that the data survived.

- These chips were not designed to be crash-worthy.

They were designed so that an airline can download information from the FADEC

and conduct maintenance on the engines as needed.

(narrator): Today... they get lucky.

- So I was very relieved to see that the memory did survive on the chips of the FADEC.

So now we had something to work with.

Okay, let's see what we've got.

(narrator): Were the engines functioning properly?

- The FADEC memory will not only point out the anomaly of an engine,

but exactly when it happened and at what altitude.

And that data is crucial for investigators.

(narrator): The data confirms the investigators' observation

that the engines were working when the plane hit the ground.

But something inexplicable happened 20 seconds before that.

- What the heck happened here?

Engines were operating normally during the entire accident flight,

except during a certain portion of the go-around,

in which both engines surged at the same time,

which is anomalous, shouldn't happen.

(narrator): Aircraft engines ingest huge quantities of air

and use it to spin a turbine to create thrust.

If that air is disrupted,

the engine can't produce enough thrust and will backfire or surge.

- It's kind of like, uh, walking into a room that suddenly has no air...

(panting) ...and you're gasping and you're surging.

(phone ringing)

- Campbell. - I've got something for you.

(narrator): The NTSB updates the Australians about their findings.

- Engine surge?

Okay, we're on it.

(narrator): But what caused the surge?

- It could be ingesting birds into the engine.

It could be a... a mechanical malfunction

that's allowing too much fuel or too little air into the engine.

We just didn't know.

- Let's take a look.

(narrator): At the Australian Bureau of Air Safety Investigation,

Neil Campbell reviews a simulation

of the final seconds of Flight 676

based on the information captured by the flight-data recorder.

- In this case, the flight-data recorder

recorded 115 separate parameters.

It tells us things about the aircraft performance, its configuration,

whether the flaps are up or down, the landing gear's up or down.

It tells us what the crew inputs were, uh...

the aircraft responses to those inputs,

and also the status of various aircraft systems.

- Nearly at the airport.

(narrator): Campbell scrutinizes the data carefully,

looking for anything that might explain

why the engines of a modern A-300 surged and lost thrust.

- Here comes the go-around.

- GO lever. Go-around.

- Hold on. What have we here?

(narrator): Fifteen seconds after the go-around begins,

investigators notice something surprising.

- Stop.

We saw the aircraft pitched up to a pitch attitude of over 40 degrees.

This is a very large value, very unusual.

Normally during a go-around, we'd expect to see 15 degrees pitch attitude.

No wonder the engines surged.

(narrator): With the nose of the plane pitched up so steeply,

air can't flow through the engine to create thrust. (rattling)

- The airplane was at a very high attitude.

This prevented the engine from taking in smooth, continuous airflow.

Oh, no.

(narrator): The steep angle has another disastrous consequence.

If an aircraft pitches up too steeply,

it disrupts airflow over the wings,

preventing them from providing lift.

- Pitched up so high, they stalled the plane.

- And when an airliner turns straight up at such a high angle,

the airspeed bleeds off significantly,

and gets you closer to an aerodynamic stall. (alarm sounding)

(narrator): With the loss of airflow into the engines and lift from the wings,

Flight 676 begins to drop from the sky.

- You're not flying, you're almost becoming a falling object at that point.

- Let's see that again?

He's trying to get the nose down.

(narrator): The data shows the captain did what he could to regain control.

- The pilots were trying to get the nose down and get the speed back up,

get airflow over the wings again.

This'll take time in a situation where seconds are a big deal.

(narrator): But it's too late.

- They ran out of time.

Unfortunately, the altitude was too low,

and they were not able to recover the aircraft in time.

If they'd had another few thousand feet,

there's a good possibility

that the crew would've been able to recover the aircraft successfully.

(narrator): It's a tragic discovery.

But why did Flight 676 pitch up so steeply in the first place?

Campbell combs through data from earlier in the flight.

- Throughout the investigative process,

everything gets looked at and relooked at.

- Look at this.

That's weird.

(narrator): Something strange took place on board Flight 676

just seconds before the stall.

(rattling)

- Bring up pitch and elevator, please.

You can see the pilots making control inputs here... and here.

But during these 11 seconds...

...the plane is pitching up.

(narrator): Investigators determine

that once the pilots initiated the go-around,

no inputs on the control column were made

as the plane continued to pitch up dangerously.

- The aircraft will naturally want to pitch up as the engine thrust increases.

So I would expect the crew to counteract that pitching-up

by pushing down on the controls.

While looking at the flight-recorder data

and seeing that there was no... pitch controls, no changes in those controls,

it did make me wonder... what the crew were thinking.

So no one's flying the plane?

It's very unusual that there would be no control inputs by the pilots

during this period, very surprising.

- And 11 seconds in this situation's like an eternity. In fact,

to... just sit there and do nothing

while this airplane is pitching up,

losing speed, having issues,

um... that verges on unbelievable.

- Do you think the controls were jammed?

- Just for these 11 seconds? No way.

- There's three independent flight-control systems for...

uh, pitch, roll and... yaw,

so it's the elevators, ailerons and rudder.

All those systems showed that there was no activity for that 11-second period.

But prior to the go-around, during the early part of the flight,

and during the recovery from the stall,

there were inputs made on all those systems,

and the aircraft response was as expected.

- If the controls were working,

why didn't the crew do anything?

- This was a stunning finding to us.

Whenever you're faced with evidence of improper actions by a flight crew,

you have to ask why.

Was it because they were perhaps intoxicated?

Was it perhaps because they were incapacitated?

You really have to get into the human-factor element of this.

- We need to know everything about these guys.

Background, training, favourite foods, the works.

Thank you.

(narrator): Investigators search to explain

why two trained pilots allowed Flight 676 to pitch up so steeply

that it lost lift and stalled.

- When you see a situation where the pilot actions, frankly, don't make any sense,

you wonder: Is there something medically wrong with the pilots?

Alcohol, drugs, you know, anything else going on?

(narrator): They review the pilots' postmortem toxicology tests.

- No sign they were incapacitated.

- You have to be very methodical.

You can't allow any biases,

or opinions, to get in the way of you collecting facts,

because at this point, that's all you're doing.

- No red flags in the crew's flying records, either.

- Nothing stood out that would explain what happened here.

- Thank you.

(narrator): Investigators pin their hopes of finding answers

on the cockpit voice recorder.

- Okay, let's hear it.

- The cockpit voice recorder gives you

those little pieces of information otherwise you wouldn't have.

It's critical to understand timing of the crew,

how are they working together, what's the tone of the cockpit?

(FO): Weather is 16° and cloudy.

We won't need any wheelchairs tonight, right?

(narrator): The team starts the recording 30 minutes before the end of the flight.

- Look at the ECAM, the trim tank.

(narrator): They listen intently to everything the pilots said.

- Trim-tank system in flight if no forward transfer.

Not our case.

Okay, clear. So you see, that's it.

That's the Trim Tank System Fault procedure.

- This captain's spending an awful lot of time helping his first officer.

- Normally you have a division of labour.

However, this captain is doing almost all the flying and monitoring himself.

He's not engaging the first officer in really helping with things.

- Operations, Dynasty 676.

- Disregard. Dynasty 676.

(narrator): When the first officer uses the wrong channel

to call airline operations on the ground...

- This side.

- ...the captain intervenes by making radio calls himself,

which is contrary to procedure.

- I think in the captain's mind:

This guy's incompetent and I can't trust him to do a simple task.

(chuckling) And so the captain, what'd he do?

He started doing more on his own.

- Don't write that down. We're descending. - Okay.

(narrator): The captain begins criticizing the first officer's actions.

- Okay.

- The captain felt that the first officer

was not performing his tasks up to his standards,

and it might be easier and faster to do everything himself.

- What are you doing?

- I'm-I'm keying in the data.

- Don't waste too much time on that. What's the QNH?

(narrator): It's a risky situation. - It sets up a problem...

where this first officer may be almost afraid

to take action without the captain's permission.

- Statistics show that over 80% of aircraft accidents

have human performance as a contributing factor.

So it's very, very important to work together effectively as a team,

to have good communication,

and to make the best decisions they can,

even under stressful situations.

(thunder)

- Did you see that? The lightning's pretty strong.

(narrator): The worsening weather puts even more pressure

on the busy captain.

(Captain): The power of that lightning.

- Bad teamwork, task overload, and now... weather.

- The cockpit was a stressful environment.

The captain in particular was worried

about the deteriorating weather at Taipei,

and whether he might need to divert or not.

(narrator): It's what investigators hear next that gives them a vital clue.

(CVR aural warning)

- Hold on. Hear that again?

(rewinding)

(CVR aural warning)

Huh. That's the autopilot switching off.

- There's a distinct sound or an aural warning that occurs

when the autopilot disengages, and it's called a cavalry charge.

(aural warning) Switching the autopilot off is a routine part of the flight.

- Landing lights.

- On.

- But at this stage of the flight, it was unusual to hear it,

and very unusual that there was no comment by the crew.

(narrator): The pilots don't discuss why the autopilot has disengaged.

- Come on, guys, talk to each other.

- You would expect the captain to say, "I'm taking over. I have control."

Or at least some comment between the two crew

about the fact the autopilot's disengaged,

but there was no comment at all.

- Landing Checklist complete.

- In my opinion, after the criticism by the captain...

to the first officer,

he was just going to respond to any direct requests from the captain.

- GO lever. Go-around.

(narrator): Six seconds after investigators hear the autopilot disengage,

the captain initiates a go-around.

Without the autopilot,

the captain needs to make inputs manually on the yoke to control pitch.

But he doesn't.

- The autopilot is crucial, because...

that autopilot prevents the airplane from pitching up

whenever you're initiating a go-around.

- I don't think the captain knows the autopilot is off.

- What the captain didn't seem to catch was that the autopilot

is no longer flying the airplane.

(narrator): Even if the captain doesn't realize the autopilot is disengaged,

and the first officer doesn't bring it to his attention,

it doesn't explain why neither pilot noticed

the plane was pitching up to the point of stalling.

- Looking at your instrumentation,

you can tell that things are going wrong; you should make corrections.

It becomes very difficult in investigation to figure that part out.

- Tee up to the st he go-around.

(narrator): Investigators focus on the pilot's actions

during the critical 11 seconds that led to a devastating stall

of China Airlines Flight 676.

(Captain): GO lever. Go-around.

Gear up.

- Gear... down.

(narrator): They discover that while the plane is pitching up,

the pilots debate how to configure the plane for the go-around manoeuvre.

- Gear up.

- Gear up first. He should be calling for flaps before gear.

- Heading select plus...?

Plus 10?

- Flaps!

(narrator): It distracts them from their instruments,

which show the plane is in danger of stalling.

- What a mess.

- During the go-around, that's when you really have to have your act together.

You're close to the ground, a lot of things are happening,

and you've gotta be on the same page.

That didn't happen here.

(narrator): Investigators now have a better understanding

of the pilots' behaviour prior to the stall.

But it doesn't answer a key question.

- Who turned the autopilot off, and why?

- The captain was under a lot of stress and high workload. Under those conditions,

people can make mistakes.

- He's near the end of his approach and he's too high.

(narrator): The team returns to the flight-data recorder for clues.

- Somehow, the autopilot gets switched off.

- God, the tailwind's really strong.

(narrator): Data reveals the captain did something unusual

right before the autopilot is disengaged.

- Here, he's really at a crunch point. He's still too high,

so he gives the control column an extra push.

(narrator): Investigators suspect the captain pushes the nose down hard

to try to salvage his too-high approach.

But when they dig into the Airbus-300 manual,

they find the captain's actions had another tragic consequence.

- Take a look at this.

- The autopilot is designed to be disengaged in a number of ways.

There's the routine way of just switching it off normally.

But on this aircraft,

if you apply 33 pounds of force,

it will automatically disengage.

- He disengaged the autopilot by accident.

- And I think that's due to the task overload he's going through,

that there's so much going on in his mind, there's so much happening here,

that he doesn't catch the fact that he's been pushing like mad,

and... whoops, the autopilot just disengaged.

(narrator): Investigators now understand

why China Airlines Flight 676 fell from the sky.

- It starts with bad teamwork in the cockpit.

- It seems like we don't have to do anything.

- Yeah, we do. See the Trim Tank System Fault.

Trim-tank system in flight...

- In aviation, it's definitely not a good idea

to do everything yourself in a two-person cockpit.

There should be a proper division of labour. If there isn't,

that one pilot that's doing everything becomes saturated with tasks

and doesn't have adequate capacity to handle potential challenges.

- God, that tailwind's really strong.

(narrator): The overworked captain is too high on approach.

And when he attempts to descend faster,

he unintentionally disengages the autopilot.

(aural warning) - Landing lights.

- On.

(narrator): Neither pilot comments on the autopilot.

- Landing Checklist complete.

(narrator): When they are still too high on approach...

- GO lever. Go-around.

- ...Captain Kang calls for a go-around.

Not realizing the autopilot has shut off,

he assumes it will control the plane.

It doesn't.

(passengers crying out)

The Airbus pitches so high, it begins to stall.

By the time the captain notices...

...it's too late.

(pilots crying out) (TAWS): Terrain, terrain. Pull up.

- What a shame. It was totally preventable.

- The aircraft was serviceable.

And if the crew had acted differently,

then the end result would've been different, as well.

(narrator): In the final report,

investigators recommend more training,

including better cockpit communication, for all China Airlines pilots.

In response, China Airlines begins recruiting pilots with proven track records,

while improving their pilot-training program.

- After the loss of this aircraft,

crew resource management training was required

to improve the communication and teamwork skills between the pilots.

(narrator): Taiwan also overhauls its Transportation Safety Board.

- It's now got an international reputation

for their expertise in the technical aspects of investigation,

including recorders,

and also in publishing high-quality reports.

So that's been a real positive after the accident, as well.

- In all accidents, you want to gain the most out of it,

so you can prevent the next one.

So from this tragedy, we learned,

and we adjusted the system.

And what we'd like to have

is that we never see an accident like this again.

Subtitling: difuze