Original subtitles

It's the worst aviation

disaster in Portuguese history.

144 people are killed.

144 people are killed.

The scope of the devastation was remarkable.

The wreckage provides little evidence.

The wreckage provides little evidence.

They're way too damaged to test.

Air traffic control offers no insight.

Air traffic control offers no insight.

Were they advised to use the ILS?

Yes.

Yes.

Only the final seconds of Independent Air flight

1851...

Pull up.

Pull up.

They had 7 seconds until impact.

...revealed the whole story.

...revealed the whole story.

They don't say anything?

I've never encountered anything like this

before, and I never encountered anything like this afterwards.

before, and I never encountered anything like this afterwards.

To say it was unique would be an understatement.

To say it was unique would be an understatement.

Ladies and gentlemen, we are starting our approach.

We lost both engines.

...alert emergency...

...alert emergency...

May day.

May day.

Brace for impact!

I think I lost one.

I think I lost one.

It's going to crash!

Independent Air flight 1851 cruises

above the Atlantic Ocean.

There are 137 tourists on board the American charter flight.

There are 137 tourists on board the American charter flight.

Santa Maria, Independent Air 1851 requesting met report.

Santa Maria, Independent Air 1851 requesting met report.

Less than 30 minutes before landing,

Less than 30 minutes before landing,

the crew prepares for descent.

1851, wind 260, 14 knots.

1851, wind 260, 14 knots.

1851, wind 260, 14 knots.

34-year-old flight engineer Jorge Gonzalez

checks the weather ahead.

He's a US Air Force veteran with a sterling reputation.

He's a US Air Force veteran with a sterling reputation.

41-year-old Captain Leon James Dougherty

41-year-old Captain Leon James Dougherty

also has a military background and has been flying

jetliners for almost a decade.

Let's request descent.

Let's request descent.

Santa Maria control, Independent Air 1851

Santa Maria control, Independent Air 1851

would like to descend.

36-year-old first officer

Sammy Adcock just started with Independent Air two weeks ago.

Sammy Adcock just started with Independent Air two weeks ago.

Independent Air 1851, clear

Independent Air 1851, clear

to descend to flight level 40.

Cleared to flight level 40.

Cleared to flight level 40.

Independent Air 1851.

Independent Air 1851.

The crew was a balanced crew.

They had flown together for about a week or 10 days,

They had flown together for about a week or 10 days,

and they were doing fine.

They're flying the four-engine Boeing 707.

The long-range, narrowbody jetliner

The long-range, narrowbody jetliner

has dominated passenger travel for more than three decades.

It wasn't a modern jet at the time.

It wasn't a modern jet at the time.

It was 21 years old.

But it was well maintained within all

the safety regulations.

the safety regulations.

Today's flight from Bergamo, Italy,

Today's flight from Bergamo, Italy,

will refuel at Santa Maria, an island in the remote Azores,

before continuing to its final destination, Punta Cana,

before continuing to its final destination, Punta Cana,

in the Dominican Republic.

in the Dominican Republic.

Santa Maria was a popular destination

for refueling because of its location in the Atlantic.

for refueling because of its location in the Atlantic.

It's a small island with a large mountain in the center.

It's a small island with a large mountain in the center.

That mountain is called Pico Alto

At almost 2,000 feet, Pico Alto, or "High Peak,"

At almost 2,000 feet, Pico Alto, or "High Peak,"

is the highest point of a mountain range

stretching across Santa Maria.

stretching across Santa Maria.

Hey, close the door.

It's a jungle out there.

Are you finished with those?

Yeah.

Thanks.

Thanks.

Thank you.

What's your passing

level, Independent Air 1851.

level, Independent Air 1851.

Passing flight level 220.

60 miles from the airport, the first officer

60 miles from the airport, the first officer

tunes into the frequency for Santa Maria.

Good afternoon, Santa Maria tower.

Good afternoon, Santa Maria tower.

Today, a trainee in the tower

is guiding in the flight with the help of a supervisor.

is guiding in the flight with the help of a supervisor.

Independent Air 1851

passing flight level 200 to flight level 40.

passing flight level 200 to flight level 40.

Independent 1851, roger.

Independent 1851, roger.

In 1989, I would describe the Santa Maria air

traffic control facility as being very

traffic control facility as being very

unsophisticated, very small.

The airport is also not equipped with radar.

The airport is also not equipped with radar.

There were only three scheduled

airline flights per day.

It doesn't justify the cost of air traffic

It doesn't justify the cost of air traffic

control radar, which is very challenging for air traffic

control.

You're cleared 3,000 feet on QNH 1027.

You're cleared 3,000 feet on QNH 1027.

Runway will be one niner.

Expect ILS approach.

Runway one niner.

Report reaching 3,000.

Report reaching 3,000.

The controller is relying solely on position

The controller is relying solely on position

reports from the pilot.

So they have to be meticulous about protecting the airspace

So they have to be meticulous about protecting the airspace

and documenting the altitude at the aircraft is at.

and documenting the altitude at the aircraft is at.

Is that what they said?

1027 on the millibars.

Yep.

Yep.

Just over 13 minutes from the airport,

the crew readies the plane for landing.

the crew readies the plane for landing.

Seat belt and shoulder harness.

Seat belt and shoulder harness.

Secured.

We're having fun now.

We're having fun now.

Hey, hey.

On that day, the weather in Santa Maria

was fine.

was fine.

There was just some cloud cover in the vicinity of Pico Alto.

That is very common.

Switching off autopilot.

The captain takes control of the aircraft.

The captain takes control of the aircraft.

The captain would likely be hand flying the airplane to get

comfortable controlling it.

comfortable controlling it.

It ain't looking too hot out there.

Yeah, we'll get down below.

Yeah, we'll get down below.

Depends on what level those are.

There's cloud cover ahead.

There's cloud cover ahead.

If conditions get worse, the crew

will have to make the approach using only their instruments

for reference.

for reference.

OK.

I'm going to go ahead and put the ILS in on my side.

OK.

OK.

ILS or Instrument Landing System

is a navigation system that provides

vertical and horizontal guidance to the runway.

vertical and horizontal guidance to the runway.

That means that he can fly in clouds until he

That means that he can fly in clouds until he

gets onto final approach.

It's always better to have help.

35 miles from the airport, the coastline

of Santa Maria comes into view.

of Santa Maria comes into view.

When approaching from the East,

you will see some big cliffs, some green... a lot of green.

you will see some big cliffs, some green... a lot of green.

Where's the airport?

It's on the other side of the island.

It's on the other side of the island.

As they approach the island, an alert in the cockpit

As they approach the island, an alert in the cockpit

tells the pilots that they're 500 feet

above their selected altitude.

above their selected altitude.

400 to go.

Don't know if we're going to get visual or not here.

Starting to pass through the layers.

Starting to pass through the layers.

As they cross the coast of Santa Maria,

weather conditions worsen.

The winds can be pretty severe around the Pico Alto.

And this can present a challenge for the pilots

And this can present a challenge for the pilots

to maintain control of their aircraft.

Can't keep this damn thing level.

Help you?

No.

Just two minutes from the airport,

flight 1851 is seen flying very low overhead.

flight 1851 is seen flying very low overhead.

Pull up.

Pull up.

Pull up.

Terrain.

Terrain.

Pull up.

The equipment is telling the crew they are in a potentially

The equipment is telling the crew they are in a potentially

dangerous situation.

Just 4 and 1/2 miles from the Santa Maria airport

Just 4 and 1/2 miles from the Santa Maria airport

in the Azores, Portuguese firefighters and civilians

discover a horrific scene of devastation.

discover a horrific scene of devastation.

Independent Air flight 1851 has crashed into the island's

Independent Air flight 1851 has crashed into the island's

highest mountain.

The jet hit Pico Alto very near the top of the mountain.

The jet hit Pico Alto very near the top of the mountain.

The accident site was a bit of a chaotic scene.

The accident site was a bit of a chaotic scene.

The wreckage was strewn all over the mountain.

There were some small fires.

There were some small fires.

It was a very steep terrain.

It very difficult for rescuers to work there.

It very difficult for rescuers to work there.

It soon becomes clear that all 144 passengers

It soon becomes clear that all 144 passengers

and crew have been killed.

It was a big challenge for the locals

It was a big challenge for the locals

mostly to deal with that.

Santa Maria has only 5,000 people living there,

and in a flash they became the scenario of the worst air

and in a flash they became the scenario of the worst air

disaster to occur in Portugal.

disaster to occur in Portugal.

Rescuers work through the night.

By daybreak, the Portuguese Civil

Aviation Authority, known as the DGAC,

arrives at the crash site.

They're soon joined by American representatives

They're soon joined by American representatives

from the NTSB, the National Transportation Safety Board.

The terrain that we traversed was... was very challenging.

The terrain that we traversed was... was very challenging.

There was a lot of personal effects

that people who were just vacationing...

there were children who whose dolls I could see in the trees.

there were children who whose dolls I could see in the trees.

The scope of the devastation, it was remarkable.

The scope of the devastation, it was remarkable.

Investigators need to get a better perspective

if they are to understand why flight

1851 crashed into a mountain so close to Santa Maria's airport.

1851 crashed into a mountain so close to Santa Maria's airport.

The overhead view revealed to us just how

concentrated the wreckage was on the side of the mountain

concentrated the wreckage was on the side of the mountain

where the airplane struck it.

That was something I had not seen before.

So this is the flight path.

The plane impacts the East side of Pico Alto.

The plane impacts the East side of Pico Alto.

Correct.

Investigators examine the wreckage

Investigators examine the wreckage

pattern for clues as to how flight

1851 was flying before impact.

1851 was flying before impact.

All concentrated right here, sending

All concentrated right here, sending

debris over the mountain ridge.

Scars on the ridge give investigators

Scars on the ridge give investigators

their first clues.

Looks like low angle, high velocity.

Looks like low angle, high velocity.

They must have been flying level.

CFIT?

Looks like it.

Looks like it.

They quickly recognize this incident

to be a Controlled Flight Into Terrain or CFIT.

to be a Controlled Flight Into Terrain or CFIT.

If one looks at CFIT accidents,

there are really two times.

One where an airplane descends prematurely,

One where an airplane descends prematurely,

the other where it hits the side of a mountain.

They must have known about the mountains.

They must have known about the mountains.

What was the altitude where they hit?

What was the altitude where they hit?

1,795 feet.

1,795 feet.

And Pico Alto, what does the Jeppesen chart show?

It's listed as 1,936 feet.

It's listed as 1,936 feet.

Pico Alto is clearly identified in the Santa Maria

Pico Alto is clearly identified in the Santa Maria

approach chart.

So they struck the mountain 140 feet below what

So they struck the mountain 140 feet below what

was listed on their chart.

What were they doing so low?

What were they doing so low?

The possibilities were, one, they were the crew

was of course.

was of course.

Two, there was an altitude error.

It was our job to find out which of those

would explain the accident.

would explain the accident.

What's the minimum sector altitude?

3,000 feet.

3,000 feet.

The minimum sector altitude

is at least 1,000 feet above all terrain

is at least 1,000 feet above all terrain

within 25 miles of the airport.

Plenty of room.

Plenty of room.

According to the company's operations manual,

there should be at least two Jeppesen sharks on board

the plane at all times.

the plane at all times.

They had to have known.

Yeah.

This was the question.

This was the question.

I mean, why did these guys descend so low when they knew

by the charts that the minimum altitude was 3,000 feet

by the charts that the minimum altitude was 3,000 feet

and there was a mountain there?

So this was the last flight of the day?

So this was the last flight of the day?

Yes, it was.

Yes, it was.

What was the minimum sector altitude you gave them?

The team turns to the air traffic

controller for insight into why the aircraft

controller for insight into why the aircraft

was flying below 3,000 feet.

was flying below 3,000 feet.

3,000 feet.

You're sure?

You're sure?

Yeah, I even made a note of it on my flight strip.

He was perfectly calm.

He had a normal behavior.

He thought he had done a good job.

He thought he had done a good job.

Were you the only controller on duty at the time?

My supervisor was also there.

My supervisor was also there.

It was such a slow airport,

it was certainly not unusual for a supervisor

it was certainly not unusual for a supervisor

to provide on-the-job training for an air traffic trainee.

What was the weather like?

What was the weather like?

Fairly good at the airport.

No rain or strong winds.

Visibility wasn't limited.

Visibility wasn't limited.

However, the top of Pico Alto was in cloud,

However, the top of Pico Alto was in cloud,

and winds can be unpredictable up there.

The weather was OK.

The weather was OK.

The focus for the investigators was on how the cloud layer

The focus for the investigators was on how the cloud layer

affected the pilots ability to see and avoid

the top of the mountain.

Were they advised to use the ILS?

Were they advised to use the ILS?

Yes.

Expect ILS approach, runway one niner, report reaching 3,000.

Expect ILS approach, runway one niner, report reaching 3,000.

The investigator learns

that the pilots did encounter cloud cover near Pico Alto.

that the pilots did encounter cloud cover near Pico Alto.

But they shouldn't have had a problem using their instruments

to get them to the runway.

to get them to the runway.

Did the crew report any mechanical issues?

Did the crew report any mechanical issues?

No, not to me anyways.

Thank you for your time.

Thank you for your time.

I couldn't find anything that explains

what happened from this part.

what happened from this part.

So if the controller gave them the proper clearance,

So if the controller gave them the proper clearance,

why are they so low?

What if there was an issue with the plane

that they didn't report?

that they didn't report?

The team must now consider if a mechanical issue

that wasn't reported to the controller

that wasn't reported to the controller

prevented the crew from maintaining a safe altitude

above the mountain.

It was possible... we couldn't rule this out

until we looked more closely at the evidence...

that something very quickly happened,

that something very quickly happened,

something catastrophic, just before impact.

Is this is everything?

Is this is everything?

So far.

Investigators turned to the wreckage of flight 1851

Investigators turned to the wreckage of flight 1851

for clues to explain why it descended

below minimum altitude and crashed into a mountain.

below minimum altitude and crashed into a mountain.

Let's start here.

Could a malfunctioning engine

have forced the aircraft below the minimum safe altitude?

have forced the aircraft below the minimum safe altitude?

It says here the jet had less than 45,000 hours in the air

It says here the jet had less than 45,000 hours in the air

with seven service bulletins over the last six years.

with seven service bulletins over the last six years.

Any issues?

Well, in 1983, engine two had suffered turbine failure.

Well, in 1983, engine two had suffered turbine failure.

It looks like it was repaired.

It looks like it was repaired.

Is it full of wood and dirt?

A quick examination provides an answer.

There's nothing wrong with these engines.

There's nothing wrong with these engines.

Engines that are generating power at impact,

if they hit a field of trees, will ingest part

if they hit a field of trees, will ingest part

of the vegetation into the engines

of the vegetation into the engines

and that will bring the engine fan blades to a stop.

And that's what happened here.

Engines that are not turning, that are not working,

Engines that are not turning, that are not working,

won't do that.

won't do that.

What about the altimeter?

If the altimeters were malfunctioning,

If the altimeters were malfunctioning,

the crew might have believed they were flying

higher than they actually were.

Hi.

Thank you.

Look.

Way too damaged to test.

Way too damaged to test.

What do the service records say?

They were last calibrated four months ago.

They were last calibrated four months ago.

No problems.

It's another dead end.

It's another dead end.

Maybe the altitude alert survived.

Maybe the altitude alert survived.

Let's take a look.

The altitude alert warns the crew

The altitude alert warns the crew

with an audio alert when they're approaching a preset altitude.

Hang on.

Hang on.

Is this it.

Yeah.

That's it.

That's it.

It doesn't look too bad.

Yeah, check this out.

The altimeter alert's set to 2,000.

The altimeter alert's set to 2,000.

Investigators discover the altitude alert

was set for 2,000 feet, not the required

was set for 2,000 feet, not the required

altitude of 3,000 feet.

I remember this shocked all of us.

We... we just couldn't believe it...

We... we just couldn't believe it...

how that could happen.

Why would the altimeter alert be

set to 2,000 when the controller gave them a clearance of 3,000?

set to 2,000 when the controller gave them a clearance of 3,000?

Maybe the controller remembered wrong.

Maybe the controller remembered wrong.

Let's check the tapes.

ATC recordings gives you

ATC recordings gives you

what's exchanged during the different phases of the flight

so you can confirm absolutely what was said,

so you can confirm absolutely what was said,

either contacting the plane or inside the ATC.

Good afternoon, Santa Maria tower.

Will the air traffic control

Will the air traffic control

audio recording confirm what the trainee told investigators?

audio recording confirm what the trainee told investigators?

Independent 1851, roger.

You're clear to 3,000 feet on QNH 1027, runway one niner.

You're clear to 3,000 feet on QNH 1027, runway one niner.

You're clear to 3,000 feet on QNH 1027, runway one niner.

Expect ILS approach, runway one niner, report reaching 3,000.

Expect ILS approach, runway one niner, report reaching 3,000.

Stop there.

He said it.

Twice.

The control tower recording

confirms that the controller gave a 3,000 foot clearance.

confirms that the controller gave a 3,000 foot clearance.

Listening to the clearance did not explain the 1,000 foot

Listening to the clearance did not explain the 1,000 foot

error in the altimeter alert.

We needed to listen to the CVR.

We needed to listen to the CVR.

Take it from the point where they

first contact the controller.

first contact the controller.

Investigators now listen to the cockpit

conversation to determine why the crew descended

conversation to determine why the crew descended

below the 3,000 foot minimum sector altitude

given by the controller.

given by the controller.

Good afternoon, Santa Maria tower.

Independent Air 1851 passing flight

Independent Air 1851 passing flight

level 200 to flight level 40.

That's the first officer.

Independent 1851, roger.

Independent 1851, roger.

You're clear to 3,000 feet on QNH 1027.

You're clear to 3,000 feet on QNH 1027.

SAMMY ADCOCK (ON RADIO): Clear to 2,000.

SAMMY ADCOCK (ON RADIO): Clear to 2,000.

Did the first officer just say 2,000?

Go back.

Play it again.

SAMMY ADCOCK (ON RADIO): Clear to 2000.

SAMMY ADCOCK (ON RADIO): Clear to 2000.

Investigators wonder why the first officer

misheard the altitude clearance as 2,000

feet instead of 3,000 feet.

feet instead of 3,000 feet.

Maybe he heard "to 3,000," and mistook it for 2,000.

Maybe he heard "to 3,000," and mistook it for 2,000.

Maybe he heard "to 3,000," and mistook it for 2,000.

It's possible.

It looked to us that perhaps the word three never was

It looked to us that perhaps the word three never was

listened by the first officer.

So the first officer only listened...

So the first officer only listened...

you're clear 2,000.

Not "to 3,000," but 2,000.

Not "to 3,000," but 2,000.

So he never heard the word three.

So he never heard the word three.

The CVR recorded the first officer reading

back an incorrect clearance.

back an incorrect clearance.

It was very puzzling to us when we heard the CVR

why the crew did not act.

why the crew did not act.

It was clear that that wasn't given much credence.

The controller should have corrected him too but doesn't.

The controller should have corrected him too but doesn't.

Why?

And that's an important part

of this accident investigation.

of this accident investigation.

We couldn't figure out why the air traffic controller did

not correct the first officer.

not correct the first officer.

Hang on a second.

The first officer's readback of 2,000 feet

isn't in the controller's transcript.

So he never heard it?

So he never heard it?

How is that possible?

We couldn't figure out

how they could miss each other.

It was... it was inexplicable.

All right.

So the first officer mishears the altitude.

He reads it back to the controller

He reads it back to the controller

as 2,000 at 13:56:59.

as 2,000 at 13:56:59.

Investigators compare the conversations

between the controller and the first officer of flight 1851

between the controller and the first officer of flight 1851

to better understand why there was

miscommunication between them.

What does the controller say next?

What does the controller say next?

Well, he repeats the clearance by saying

expect ILS approach, runway one niner, report reaching 3,000.

expect ILS approach, runway one niner, report reaching 3,000.

That's it?

Hang on.

They were talking at the same time.

They were talking at the same time.

Yeah.

They cancelled each other out.

It's a troubling realization...

It's a troubling realization...

an overlap of communication between the tower

and the pilot.

Passing flight level 200 flight level 40.

Passing flight level 200 flight level 40.

You're clear to 3,000 feet on QNH 1027, runway one niner.

You're clear to 3,000 feet on QNH 1027, runway one niner.

You're clear to 3,000 feet on QNH 1027, runway one niner.

Expect ILS approach.

We're clear to 2,000 feet, and...

Runway one niner...

...1027.

...report reaching 3,000.

...report reaching 3,000.

It was stunning.

We were stunned to finally understand

We were stunned to finally understand

how the two transmissions overlapped perfectly

to cancel each other out.

to cancel each other out.

I was an investigator for over 30 years with the NTSB.

I've never encountered anything like this before,

I've never encountered anything like this before,

and I never encountered anything like this afterwards.

They're both talking at the same time.

They're both pushing their PTTs.

They're both pushing their PTTs.

That's right.

Pilots and controllers use

a Push-To-Talk or PTT button.

a Push-To-Talk or PTT button.

When it's pressed, the radio transmits but cannot receive.

To think that so many people died because of a simple error,

To think that so many people died because of a simple error,

that was just... that's sad.

That's hard to deal with as an investigator.

That's hard to deal with as an investigator.

So the controller doesn't hear it,

but he should still insist the first officer

read it back or repeat it.

read it back or repeat it.

There are some readbacks in air traffic control that you

simply have to get back every single time,

simply have to get back every single time,

and altitude is one of them.

The trainee controller did not request an altitude read back,

The trainee controller did not request an altitude read back,

and the supervisor didn't notice.

And that was Unfortunate

What about the supervisor?

What about the supervisor?

Good question.

According to the controller, she was there.

According to the controller, she was there.

Maybe she was busy with other things?

It's possible.

Investigators wonder if the supervisor monitoring

Investigators wonder if the supervisor monitoring

the trainee during the approach clearance

was somehow distracted.

was somehow distracted.

Check this out.

According to the phone records, she

According to the phone records, she

took a call during her shift.

You don't want to take a phone call during something

important like a descent clearance because they

have to give them a course to follow

have to give them a course to follow

and an altitude to maintain.

Really important stuff that you cannot possibly miss.

Really important stuff that you cannot possibly miss.

Something doesn't line up.

The plane's altimeter alert was incorrectly set to 2,000 feet.

The plane's altimeter alert was incorrectly set to 2,000 feet.

Even at that altitude, they would have cleared

Even at that altitude, they would have cleared

the ridge by some 200 feet.

Yeah.

Yeah.

We still had to explain why the airplane struck

the mountain 200 or so feet even further below the altitude

the mountain 200 or so feet even further below the altitude

that they were trying to maintain.

Something had to explain that.

Something had to explain that.

What else affects altitude?

QNH.

QNH is a pressure selling pilot's input

QNH is a pressure selling pilot's input

so their altimeter measures the proper height above sea level.

It can change with weather conditions.

It can change with weather conditions.

If the altimeter is set to a higher QNH than is actual,

If the altimeter is set to a higher QNH than is actual,

the aircraft will actually be lower than what the altimeter

is telling the pilots.

is telling the pilots.

It says here they were given a QNH of 1019 at 1:44 PM.

It says here they were given a QNH of 1019 at 1:44 PM.

Then they were given a reading of 1027 at 1:56 PM.

Then they were given a reading of 1027 at 1:56 PM.

OK.

So it changed eight millibars in 12 minutes.

So it changed eight millibars in 12 minutes.

Could that be right?

I'll check the weather reports.

For an eight millibar change to occur in 12

For an eight millibar change to occur in 12

minutes would be something that may occur during a hurricane

or something like that.

or something like that.

I don't see anything that would make that possible.

So how much would they drop with an 8 millibar increase?

So how much would they drop with an 8 millibar increase?

Investigators calculate the change

Investigators calculate the change

in altitude between the two QNH values.

That QNH brought them at least 200 feet below 2,000.

That QNH brought them at least 200 feet below 2,000.

Right into the mountain.

The team concludes that an incorrect altimeter

setting put the flight on a collision course

setting put the flight on a collision course

with Pico Alto.

When you're close to the ground in restricted visibility

When you're close to the ground in restricted visibility

conditions, an accurate altimeter setting

is everything that will protect the airplane

is everything that will protect the airplane

from a CFIT foot accident.

Thanks for talking with me again.

Thanks for talking with me again.

Yeah, of course.

Just one follow-up question here...

what was the pressure setting you gave them?

what was the pressure setting you gave them?

Investigators conduct a second interview

with the controller to understand

with the controller to understand

why he gave the pilot two very different QNH settings.

why he gave the pilot two very different QNH settings.

1019 was on the met report.

12 minutes later, when you gave them a 3,000 foot

12 minutes later, when you gave them a 3,000 foot

clearance, you said QNH 1027.

clearance, you said QNH 1027.

clearance, you said QNH 1027.

I asked the controller directly

about the QNH he had given to the plane,

about the QNH he had given to the plane,

and he couldn't explain why he had given that QNH at all.

and he couldn't explain why he had given that QNH at all.

In my view, it's just he didn't notice he was

giving the wrong information.

Sorry.

I don't know where I got that second number.

For that QNH to change so rapidly,

it should have been noticed by both the air traffic trainee,

it should have been noticed by both the air traffic trainee,

and their supervisor, and the pilots as Well I'm surprised

and their supervisor, and the pilots as Well I'm surprised

that the pilots didn't reach out and say,

hey, can you repeat that QNH again?

hey, can you repeat that QNH again?

After the first officer gets the minimum descent altitude

wrong, he questions the QNH.

wrong, he questions the QNH.

Is that what they said?

1027 on the millibars?

1027 on the millibars?

Yep.

He was right to question it.

But the captain just dismisses it.

But the captain just dismisses it.

Thank you.

And the first officer just accepts it.

And the first officer just accepts it.

Because of the different experience levels,

because of the prominence and assertiveness with which

because of the prominence and assertiveness with which

the captain said it shut off any discussion, when, in fact,

there should have been.

It makes you wonder what else these guys missed.

It makes you wonder what else these guys missed.

Yeah.

Let's play the tape.

Investigators return to the cockpit voice recording

Investigators return to the cockpit voice recording

to learn how the crew of Independent Air flight 1851

to learn how the crew of Independent Air flight 1851

allowed so many errors to accumulate

on approach to Santa Maria.

Altimeters.

Altimeters.

Set and cross-check.

Set and cross-checked.

Seatbelts and shoulder harness.

Secured.

We're having fun now.

LEON JAMES DOUGHERTY Hey, hey.

That's it?

That's it?

Stop the tape.

They discover the pilots missed important steps

They discover the pilots missed important steps

on the checklist.

They don't even mention the minimum descent altitude.

They don't even mention the minimum descent altitude.

For Pico Alto...

here.

They hear a briefing that doesn't include

reference to the navigation charts that

reference to the navigation charts that

were available to the pilots.

Had they done the approach of briefing

and reviewed the information and articulated the information

as required, it's highly unlikely,

as required, it's highly unlikely,

in my opinion, that they would have struck the mountain.

in my opinion, that they would have struck the mountain.

Another unfortunate error.

There were a couple of things

There were a couple of things

in the performance of the captain that were questionable.

He didn't try to understand what was

He didn't try to understand what was

the real QNH that was given.

Then he didn't insist in a complete checklist.

Then he didn't insist in a complete checklist.

Let's hear what comes next.

Let's hear what comes next.

It ain't looking too hot out there.

It ain't looking too hot out there.

Yeah, we'll get down below.

Depends on what level those are.

OK.

I'm going to go ahead and put the ILS in on my side.

I'm going to go ahead and put the ILS in on my side.

OK.

After 2,000, yeah, we'll get below these clouds.

After 2,000, yeah, we'll get below these clouds.

Stop.

Right there, 2,000 again.

But the captain says nothing and descends to 2,000.

But the captain says nothing and descends to 2,000.

Why?

Why?

The captain is ultimately responsible as the pilot

in command, but each crew member failed in that respect.

in command, but each crew member failed in that respect.

Play the tape.

SAMMY ADCOCK (ON RADIO): 1,000 to go.

SAMMY ADCOCK (ON RADIO): 1,000 to go.

LEON JAMES DOUGHERTY 1 to go.

Wow, look.

There's the island.

Stop it.

Stop it.

Who is that?

Investigators hear an unknown female speaking in the cockpit

Investigators hear an unknown female speaking in the cockpit

on approach into Santa Maria.

She appears twice over 16 minutes, starting

when they begin their descent.

when they begin their descent.

The flight attendant maybe, but what is she doing there?

I don't know.

There's not what I call a sterile cockpit.

There's not what I call a sterile cockpit.

And the captain lets it happen.

The captain violated the sterile cockpit rule which

The captain violated the sterile cockpit rule which

bans nonessential conversation in the cockpit

bans nonessential conversation in the cockpit

below 10,000 feet

below 10,000 feet

I believe that violating the sterile cockpit rule

I believe that violating the sterile cockpit rule

was consistent with the way they flew the approach.

They weren't sitting on the edge of their seats.

They were far too relaxed.

They were far too relaxed.

LEON JAMES DOUGHERTY There

is no place like Santa Maria.

Is it nice?

Is it nice?

Yeah, to have a beer.

See you on the ground.

Ignoring standard procedures, distractions...

Ignoring standard procedures, distractions...

the list keeps growing.

SAMMY ADCOCK (ON RADIO): Starting

to pass through the layers.

to pass through the layers.

Can't get this damn thing level.

Help you.

No.

No.

Pull up.

Pull up.

Pull up.

Pull up.

Pull up.

They don't say anything?

When the GPWS went off, there was no response from the crew.

There was not even a "what's that," "what's going on."

There was not even a "what's that," "what's going on."

There was nothing.

They don't say anything, but do they do anything?

They don't say anything, but do they do anything?

Thank you.

Thank you.

So this is the plane's descent approaching Santa Maria.

Investigators examine the flight data

Investigators examine the flight data

to determine how the pilots responded to the ground

proximity Warning.

So they're descending at about 2,500 feet per minute.

So they're descending at about 2,500 feet per minute.

They level off here.

And the GPWS goes off here, and they

And the GPWS goes off here, and they

crash about 7 seconds later.

No reaction.

No change in altitude.

The data show there were no inputs from the pilots

The data show there were no inputs from the pilots

to recover the aircraft.

It's like they ignored the alarm.

It's like they ignored the alarm.

When the GPWS goes on, you apply maximum power,

When the GPWS goes on, you apply maximum power,

climb at the maximum rate, and get the heck out of there.

7 seconds... they had 7 seconds from

the first warning until impact.

They could have climbed over the mountain in that time

had they done what they should have done.

had they done what they should have done.

And they didn't do that, and we couldn't figure that out.

Pull up.

Pull up.

Why didn't the crew respond to the warning?

Surely the crew was trained to respond to the ground Proximity

warning.

Investigators closely examine the training

Investigators closely examine the training

manuals for Independent Air.

You are not going to believe this.

You are not going to believe this.

The simulators were programmed with different approach speeds

and flap settings in the accident aircraft.

What does that mean?

It means that the GPWS would go

off during normal approaches.

off during normal approaches.

Independent Air rented time on another company's 707

Independent Air rented time on another company's 707

simulator.

It was configured differently from the accident aircraft.

It was configured differently from the accident aircraft.

Flaps 40.

Pull up.

Pull up.

Sir?

Pull up.

By training the crew to ignore the GPWS

By training the crew to ignore the GPWS

in the simulators, they gave the crew the message to ignore

the GPWS IN the airplane.

the GPWS IN the airplane.

I can't believe how many things went wrong.

I can't believe how many things went wrong.

Investigators conclude that by avoiding any one

of the minor errors, flight 1851 would have cleared Pico Alto,

of the minor errors, flight 1851 would have cleared Pico Alto,

preventing the deaths of 144 people.

preventing the deaths of 144 people.

It all starts with the first officer mishearing

the minimum sector altitude.

the minimum sector altitude.

Independent 1851, roger.

You're clear to 3,000 feet.

You're clear to 3,000 feet.

Clear to 2,000.

Clear to 2,000.

Make it 3.

If the first officer had referred to his charts...

If the first officer had referred to his charts...

Roger.

Good catch.

...the altitude alert would have been set

...the altitude alert would have been set

at the proper elevation, and the aircraft

would have cleared the mountain by more than 1,000 feet.

would have cleared the mountain by more than 1,000 feet.

would have cleared the mountain by more than 1,000 feet.

Same result IF the air traffic controller

had asked for a readback.

Independent Air 1851, you're clear to 3,000.

Independent Air 1851, you're clear to 3,000.

I say again, report reaching 3,000.

Over.

Over.

Or if the captain kept a sterile cockpit.

Or if the captain kept a sterile cockpit.

After 2,000, yeah, we'll get below these clouds.

After 2,000, yeah, we'll get below these clouds.

Wow, look.

There's the island.

It should be 3,000, not 2,000.

It should be 3,000, not 2,000.

It's time to return to the cabin.

You cannot be inattentive, especially in the last

You cannot be inattentive, especially in the last

period of the flight.

Even with all those mistakes, if the trainee controller

had given them the proper altimeter setting...

had given them the proper altimeter setting...

You're clear to 3,000 on QNH 1027.

You're clear to 3,000 on QNH 1027.

Correction, 1019.

Correction, 1019.

...flight 1851 with a clear Pico Alto by 200 feet.

Whoa.

It would have been close.

Finally, the GPWS.

Finally, the GPWS.

Pull up.

If the crew had the proper GPWS training...

If the crew had the proper GPWS training...

Go around!

...they would have had one last chance

...they would have had one last chance

to avoid hitting the mountain.

They might have made it.

I have never seen an accident with these many factors

happen where any one of which had they not been there,

happen where any one of which had they not been there,

we wouldn't have had an accident.

In the wake of the crash, the NTSB

recommends a careful review of airline training programs,

recommends a careful review of airline training programs,

with a focus on international operations

and safety, especially those related to the GPWS response.

and safety, especially those related to the GPWS response.

The major lesson was that airlines

The major lesson was that airlines

need to train their crews better to improve aviation safety.

need to train their crews better to improve aviation safety.

Independent Air later settled with the victims' families

Independent Air later settled with the victims' families

for $34 million before a compensation

case ever went to trial.

Independent Air went out of business in 1990.

Independent Air went out of business in 1990.

In the aviation business,

there is no room at all for complacency.

The longer we do a job, the more complacent we tend to get.

The longer we do a job, the more complacent we tend to get.

After a while, some of the things

we do, even if they're unsafe, start to appear to be safe.

we do, even if they're unsafe, start to appear to be safe.

And unfortunately, we can have an accident like the one

that we witnessed here.