Original subtitles

In the sky's over Portugal...

What's happening?

I have no control.

I have no control.

...the pilots of a passenger jet

are in the fight of their lives.

Mayday, mayday, mayday.

Mayday, mayday, mayday.

I had never seen such an abrupt drop

in altitude in an airplane.

This flight was the roller coaster ride from hell.

The crew is forced to make an unthinkable decision.

The crew is forced to make an unthinkable decision.

I think we have to ditch.

That's very unlikely that they would have had a good outcome.

That's very unlikely that they would have had a good outcome.

When investigators pore over the plane's history...

When investigators pore over the plane's history...

This is confusing.

...they discover critical evidence

that the plane was impossible to control.

that the plane was impossible to control.

That's one big mistake.

What really surprised us was the fact

What really surprised us was the fact

that no one really noticed.

Ladies and gentlemen, we are starting our approach.

We lost both engines.

We lost both engines.

Mayday, mayday.

Brace for impact!

I think I lost one.

I think I lost one.

The investigation is starting.

It's gonna crash.

Air Astana Flight 1388 prepares to take off

Air Astana Flight 1388 prepares to take off

from Alverca do Ribatejo, an air base 15 miles

northeast of Lisbon, Portugal.

northeast of Lisbon, Portugal.

Before takeoff checklist.

Roger.

40-year-old Vyacheslav Aushev is the captain.

40-year-old Vyacheslav Aushev is the captain.

The veteran pilot has been flying with Air

Astana for seven years.

Astana for seven years.

Radar.

On.

The captain of this crew had considerable time

The captain of this crew had considerable time

with Air Astana flying this aircraft, on which he

had a great deal of experience.

He's got 6,000 flight hours.

He's got 6,000 flight hours.

Flaps.

32-year-old first officer Bauyrzhan Karasholakov

32-year-old first officer Bauyrzhan Karasholakov

is the pilot monitoring.

He's been with Air Astana for five years.

He's been with Air Astana for five years.

Set for takeoff.

Before takeoff check is complete.

Before takeoff check is complete.

Request takeoff clearance.

This flight crew was highly experienced

This flight crew was highly experienced

in the normal commercial operation role.

So they were selected because of those strengths.

So they were selected because of those strengths.

Runway 04 clear for takeoff.

Cleared for takeoff.

Cleared for takeoff.

Looking forward to getting back home.

To help with the journey,

the airline has sent along an extra pilot,

26-year-old Sergey Sokolov.

26-year-old Sergey Sokolov.

There, I was a relief pilot because the flight was long,

There, I was a relief pilot because the flight was long,

and I could switch my colleague if somebody tired.

and I could switch my colleague if somebody tired.

After undergoing maintenance in Portugal,

today's 10-hour flight has a stop in Minsk

before finally reaching Air Astana's home

before finally reaching Air Astana's home

base of Almaty, Kazakhstan.

There are no paying customers on board Flight 1388,

just three maintenance staff employed by Air Astana.

just three maintenance staff employed by Air Astana.

Well, the three passengers on board

were made responsible for supplying

were made responsible for supplying

the parts for their maintenance work in Portugal.

They were excited to come home.

They were excited to come home.

The recently serviced plane is

The recently serviced plane is

a Brazilian made Embraer E190.

a Brazilian made Embraer E190.

It is a narrow-bodied single-aisle

twin-engined aircraft which is used for medium range.

twin-engined aircraft which is used for medium range.

B1.

B1.

Rotate.

The flight takes off just after 1:30 PM.

Let's go home.

But seconds later...

What the?

What the?

...the plane hit turbulence, causing it to bank

unusually hard to the left.

Well, after takeoff, first indication was that aircraft

began to make a roll.

began to make a roll.

So that is wrong movement of airplane.

That's not normal.

What's happening?

There's something wrong with the yoke.

There's something wrong with the yoke.

I've never felt anything like this before.

I felt that aircraft has too much escalations,

I felt that aircraft has too much escalations,

and captain looked at me that we have some problem

with flight controls.

with flight controls.

No warnings or caution messages.

The pilots can't explain

The pilots can't explain

the plane's erratic movements.

Flight 1388 is in serious trouble.

Flight 1388 is in serious trouble.

I have no control.

Maybe it's the control column.

The pilots search for a solution.

The pilots search for a solution.

Engage autopilot.

Autopilot on.

It was reasonable to expect that the autopilot to go, OK,

It was reasonable to expect that the autopilot to go, OK,

forget about the control column.

I will look after it because I've been programmed

I will look after it because I've been programmed

for the next phase of flight.

Autopilot failed.

Autopilot failed.

The pilots are running out of options.

They need help, and fast.

They need help, and fast.

We were in the clouds, an uncontrollable airplane

in turbulent conditions.

in turbulent conditions.

This is a mayday.

Mayday, mayday, mayday.

Climbing to 4,000 feet on heading 060.

Climbing to 4,000 feet on heading 060.

Kilo Zulu Romeo 1388, roger.

Mayday.

Mayday.

Controller Viviana Durao receives the distress

call from the aircraft.

call from the aircraft.

Go ahead with your request.

As soon as Air Astana departed,

they declared mayday on the first contact.

they declared mayday on the first contact.

We're all trained to deal with these kinds of emergencies,

but inevitably your heartbeat goes a little bit faster,

but inevitably your heartbeat goes a little bit faster,

and your adrenaline peaks.

There's nothing in the quick reference handbook.

There's nothing in the quick reference handbook.

We have to get back to the airport.

Agreed.

Agreed.

Asta line 1388 requesting back to airport.

Kilo Zulu Romeo 1388, you can turn left or right as you wish,

Kilo Zulu Romeo 1388, you can turn left or right as you wish,

heading 280.

heading 280.

Roger.

But heading back to the airport

is an enormous challenge.

is an enormous challenge.

Every time we bank, we lose altitude.

Every time we bank, we lose altitude.

You've got to get higher to turn back.

To turn around safely, they need to climb, or risk

To turn around safely, they need to climb, or risk

hitting terrain when they bank.

If you roll excessively, the pitch doesn't actually

If you roll excessively, the pitch doesn't actually

change much in terms of altitude and, in fact, will

allow the aircraft to drop.

allow the aircraft to drop.

And that was alarming, to say the least.

Let's try to control from your side.

Let's try to control from your side.

My controls.

I don't think it's any better, but I'll try to climb.

What about the flight computers?

What about the flight computers?

Maybe there's a software bug?

The pilots speculate the problem is related

The pilots speculate the problem is related

to the replacement of four flight

computers, something they learned about prior to takeoff.

They knew that there had been a new software load

for the flight control system.

So it's very, very easy and sensible to make the conclusion

So it's very, very easy and sensible to make the conclusion

that this is possibly the result of a glitch

in the uploaded software.

in the uploaded software.

Prepare to engage direct mode.

By engaging direct mode,

By engaging direct mode,

pilots can bypass the flight computers,

giving them full control.

My controls.

Roger, your controls.

Ready to engage direct mode?

Engage direct mode for the roll.

Engage direct mode for the roll.

The aircraft's performance improves.

Let's see if we can get back to Alverca.

But the pilot's relief does not last.

It's not enough.

It's not enough.

I don't have enough control to get us back to the airport.

The difficulty this crew had was they couldn't

The difficulty this crew had was they couldn't

steer the airplane in any way.

So to get back to the airport with the best will in the world

So to get back to the airport with the best will in the world

wasn't going to happen.

What are we going to do?

With nothing working and the plane

With nothing working and the plane

continuing to drop, the crew is faced with a grim option.

I think we have to ditch.

Ditching means attempting

a very risky landing on water.

We go over the big populated city

on uncontrollable airplane, and we could

on uncontrollable airplane, and we could

hit the ground at any time.

We decided to ditch.

This was one thing to stop this aircraft.

This was one thing to stop this aircraft.

Request vectors for the ocean.

Request vectors for the ocean.

Sergey, take over comms, and I will

need help with the throttle.

need help with the throttle.

Asta line 1388.

Ditching.

The correct heading for ditching.

There is a... like a bad dream, yes, or bad movie.

There is a... like a bad dream, yes, or bad movie.

The aircraft is... is uncontrollable.

1388, fly heading 260.

1388, fly heading 260.

So I was very concerned

because I don't think any pilot requests ditching lightly.

because I don't think any pilot requests ditching lightly.

So if they thought that that was their best option,

that meant they were in big trouble.

that meant they were in big trouble.

1388, you can reach the sea on a heading

of 210, approximately 36 miles.

of 210, approximately 36 miles.

For 18 minutes, Flight 1388

For 18 minutes, Flight 1388

has been flying erratically over Portugal,

trying to reach the Atlantic Ocean for a ditching.

trying to reach the Atlantic Ocean for a ditching.

We keep losing altitude.

Their biggest struggle is keeping

the plane stable enough to reach a safe altitude

the plane stable enough to reach a safe altitude

above the clouds.

If you can climb above the cloud,

then you do have that visual horizon again,

which is going to help you.

which is going to help you.

That buys you time to resolve the problem.

And so altitude is good.

And so altitude is good.

But just when nothing seems to be working,

the captain gets an idea.

Let's try the flaps.

Let's try the flaps.

Give me flaps two.

Roger.

Flaps two.

We kept the flaps extended.

It helped us to stabilize the aircraft.

It helped us to stabilize the aircraft.

30 minutes after takeoff, Flight 1388

finally rises above the clouds.

17,000 feet, and we have visual

meteorological conditions.

meteorological conditions.

That was actually a good sign, because if they could control

the aircraft enough to climb over clouds,

the aircraft enough to climb over clouds,

they weren't going to crash anytime soon.

they weren't going to crash anytime soon.

This was very good news.

But then, without warning,

the plane plummets toward the Earth

at 20,000 feet per minute.

at 20,000 feet per minute.

Then we suddenly plunged to the left

Then we suddenly plunged to the left

and dived with quick descent.

Physically, it was horrible.

For the three passengers on board,

For the three passengers on board,

it's a rough and terrifying ride.

Oh, no.

Oh, no.

I had never seen such an abrupt drop in altitude

in an airplane, and this was very

scary because we had no idea when they were going to stop.

scary because we had no idea when they were going to stop.

Pull up!

Pulling up.

40 seconds into the dive, the plane

descends below cloud cover.

descends below cloud cover.

Keep it up.

We've got this.

We've got this.

Sergey, we need power.

During that rapid descent,

During that rapid descent,

there would have been slightly less than 1g,

1 times the force of gravity.

But at the point at which you pull

But at the point at which you pull

the aeroplane out of the dive, that g level picks up.

And in this case, almost to fighter pilot levels.

And in this case, almost to fighter pilot levels.

The extreme maneuver stresses

the airframe to its limit.

We heard, like, some cracking...

...of the airplane of the g load.

...of the airplane of the g load.

I saw the hill was at risk in front of us.

It was close.

The plane holds together.

The plane holds together.

8,000 feet and climbing.

The pilots pull out of the dive just in time.

The pilots pull out of the dive just in time.

Well done.

Yeah.

Wow, we're out of this nightmare.

Wow, we're out of this nightmare.

OK, let's try to get back on the course towards the ocean.

OK, let's try to get back on the course towards the ocean.

Asta line 1388, can you confirm our position

Asta line 1388, can you confirm our position

in relation to the sea, please?

If you fly southbound, you need to go 36 miles.

If you fly southbound, you need to go 36 miles.

But the battered aircraft

still isn't responding predictably

still isn't responding predictably

to the crew's inputs.

It's no good.

I can't get to 220.

I can't get to 220.

See if I can stay on this heading.

1388, we are flying through a storm.

1388, we are flying through a storm.

Can we get to the sea on our current heading?

The weather was very bad, very windy, raining,

and the cloud ceiling was very low.

If you could fly westbound, you will reach the sea.

If you could fly westbound, you will reach the sea.

VYACHESLAV AUSHEV OK.

35 minutes into the flight, air traffic control

35 minutes into the flight, air traffic control

calls the Portuguese Air Force for help.

The Air Astana was still in an area with very bad weather.

The Air Astana was still in an area with very bad weather.

They were having trouble navigating,

and so we hoped that, with the guidance of the F-16s,

and so we hoped that, with the guidance of the F-16s,

they could reach an area with... with better weather conditions.

they could reach an area with... with better weather conditions.

Lieutenant Colonel Nuno Monteiro

is one of two F-16 pilots sent to guide

the aircraft to better weather and a place to ditch safely.

the aircraft to better weather and a place to ditch safely.

It was the worst day in terms of weather.

It was the worst day in terms of weather.

I was in the squadron, and I knew

I was in the squadron, and I knew

that, if the bell would ring that day, we had to act fast.

that, if the bell would ring that day, we had to act fast.

But can the F-16s reach Flight 1388 in time to help?

But can the F-16s reach Flight 1388 in time to help?

The struggle to control Flight 1388

The struggle to control Flight 1388

has endured for almost an hour.

Still climbing.

Anybody need water?

The pilots are exhausted.

It was very hard for us, physically and emotionally.

It was very hard for us, physically and emotionally.

Can one of you bring us some water up here, please?

Can one of you bring us some water up here, please?

Your controls.

My controls.

What do you know about the maintenance

that was done on this aircraft?

They did a lot of work, replaced some parts, too.

They did a lot of work, replaced some parts, too.

Anything flight control related?

We ordered new aileron cables.

We ordered new aileron cables.

New aileron cables?

When we learned that aileron cables were changed,

When we learned that aileron cables were changed,

we realized the possible cause of the problem.

we realized the possible cause of the problem.

Ailerons are flight control surfaces

on the rear edge of each wing.

on the rear edge of each wing.

They move up and down to help control an aircraft's roll.

Let's check them.

I've got visuals on the right wing.

I've got visuals on the right wing.

Inputting ailerons right.

As the captain turns the control

As the captain turns the control

column to the right, the right wing aileron should lift.

Aileron going down, turning left.

Aileron going down, turning left.

That's wrong.

That's wrong.

Let's try the reverse.

Inputting aileron left.

We put inputs,

and we realized that these ailerons

and we realized that these ailerons

is responding opposite.

is responding opposite.

The ailerons are reversed.

With opposite inputs, we might be

able to control the aircraft.

able to control the aircraft.

Now we know what's happening.

Now we know what's happening.

Let's start to work with this.

OK, let's fly this aircraft opposite.

If you want to turn left, turn to the right.

If you want to turn left, turn to the right.

It's a bit better, but it's still hard to fly.

This is going to take some getting used to.

This is going to take some getting used to.

Against his instincts and muscle memory,

Against his instincts and muscle memory,

the captain tries to keep the plane's wings level

and climb to better weather.

You have to learn a completely different process

You have to learn a completely different process

against the ingrained teaching you've already had,

and that's very difficult.

and that's very difficult.

61 minutes into the flight, help finally arrives.

61 minutes into the flight, help finally arrives.

Asta line 1388, you have two F-16s reaching your position.

Copy that.

Copy that.

Zero, zero, Romeo.

This is Portuguese Air Defense at 21.

This is Portuguese Air Defense at 21.

How can we assist?

The altitude, heading, speed were far from being stable,

The altitude, heading, speed were far from being stable,

and I had a lot of doubts at this moment.

What can we do to help Air Astana flight?

What can we do to help Air Astana flight?

We have a flight control problem,

and, uh, no visibility.

Maintaining flight level 140 westbound

Maintaining flight level 140 westbound

and will make ditching on sea.

I thought, come again?

I thought, come again?

I have never heard this call in my life as a... as a pilot,

I have never heard this call in my life as a... as a pilot,

and I've been an aviator for the past 25 years.

and I've been an aviator for the past 25 years.

I feared for them.

But given the weather, would they even survive

But given the weather, would they even survive

a ditching in the ocean?

If the sea is very rough,

and you're trying to land across 3 meters or so of swell,

and you're trying to land across 3 meters or so of swell,

that's very unlikely that they would have had a good outcome.

that's very unlikely that they would have had a good outcome.

Lieutenant Colonel Montero

proposes a different plan.

If you have 70 miles of fuel, you could Beja.

If you have 70 miles of fuel, you could Beja.

The closest airport with good weather

The closest airport with good weather

is Beja, a military airport 70 miles to the south.

is Beja, a military airport 70 miles to the south.

If you follow the F-16s, do you

think we could land this thing?

We have enough fuel.

Let's try.

Let's try.

Now we could stably climb above the clouds.

Now we could stably climb above the clouds.

The F-16 means we are not alone in the sky,

and F-16 can lead us to a airport with better weather.

and F-16 can lead us to a airport with better weather.

The aircraft is a little bit more controllable.

The aircraft is a little bit more controllable.

Yes, sir.

We'll help you out.

We'll help you out.

Can you confirm heading for Beja Airport?

Can you confirm heading for Beja Airport?

Beja is a suitable aerodrome heading 195.

Beja is a suitable aerodrome heading 195.

Right heading 195.

OK.

Let's see if we can land this plane.

Let's see if we can land this plane.

Using the F-16 on their left

as a visual reference, Flight 1388 heads to Beja airfield.

as a visual reference, Flight 1388 heads to Beja airfield.

NUNO MONETEIRO (ON RADIO): I'll guide you in.

NUNO MONETEIRO (ON RADIO): I'll guide you in.

Do you have a visual on me?

Affirmative.

Thank you for helping, sir.

Thank you for helping, sir.

We disregarded the ditching because now we at least

know how to fly this aircraft.

know how to fly this aircraft.

Now we need to land it.

Now we have a chance to survive.

Now we have a chance to survive.

When you're flying oppositely, it's

really hard to keep it straight and level 100% of the time.

really hard to keep it straight and level 100% of the time.

We understood that landing will not be easy.

We understood that landing will not be easy.

We are now six miles from runway.

After 15 minutes of flying towards Beja airfield,

After 15 minutes of flying towards Beja airfield,

the crew begins to configure the plane

for a challenging landing.

for a challenging landing.

Flaps full.

Whoa.

Watch out.

Watch out.

But the stability of the aircraft gets worse.

We flew flaps two, and now flaps five, landing gear down.

We flew flaps two, and now flaps five, landing gear down.

So these conditions is new for... for this airplane.

So it means you have to learn to fly it again.

So it means you have to learn to fly it again.

With the ailerons reversed,

Flight 1388 is almost impossible to control.

Flight 1388 is almost impossible to control.

Both F-16s position themselves behind the plane,

Both F-16s position themselves behind the plane,

giving the crew plenty of space without distraction.

1,000 feet.

You got this.

Guys support me and say, yes, yes, you're doing right.

Everything will be OK.

We will survive.

Less than 1,000 feet from the runway, the pilots

Less than 1,000 feet from the runway, the pilots

struggle to keep the plane level.

It was the low speed on the approach.

It was the low speed on the approach.

You have to have minor input on the yoke,

and it's really difficult.

and it's really difficult.

The aircraft begins to veer away from the runway.

Go around.

Go around.

Going around.

It's too dangerous to put the plane down.

They abort the landing.

They abort the landing.

I don't think I can do this.

We have to try something else.

The pilots are determined to try again,

The pilots are determined to try again,

but can they make it?

I looked at the guys,

I looked at the guys,

and I saw that we all wanted to solve this problem

and bring in this aircraft to the ground.

and bring in this aircraft to the ground.

Warning, warning.

Blocked.

Blocked.

After nearly two hours in the air and two

unsuccessful landing attempts, Flight 1388

unsuccessful landing attempts, Flight 1388

approaches the runway again.

Turning left.

Turning left.

Heading 189.

I'm going to take us back in.

NUNO MONETEIRO Roger.

NUNO MONETEIRO Roger.

With the captain and the first officer exhausted,

the relief pilot takes the controls

for the third landing attempt.

for the third landing attempt.

That's like in football.

When you need a win goal, you change the player.

When you need a win goal, you change the player.

It's going to try and get away from you.

It's going to try and get away from you.

Be ready for anything.

I was less tired, but I realized that it's really

difficult to control airplane.

difficult to control airplane.

There's 1,000.

Watch for the right roll as we get down.

1,000.

You're drifting too far to the left.

I'm trying to get back to center.

I'm trying to get back to center.

A mile from the runway, the weather

impedes the landing attempt.

The wind conditions changed.

The wind conditions changed.

The plane started to deviate again to the left.

The plane started to deviate again to the left.

The captain quickly improvises an alternate plan.

We can make it to the other runway there, 19 left.

We can make it to the other runway there, 19 left.

I see it.

I'll try.

Can we land on the left runway?

Can we land on the left runway?

NUNO MONETEIRO (ON RADIO): Confirmed.

Clear to land on left runway.

Roger.

Here we go.

Here we go.

After a grueling two hours in the air,

After a grueling two hours in the air,

Flight 1388 lands safely in Beja.

We did it.

With teamwork and determination,

the crew has made a stunning landing.

I was happy.

The flight is finished.

Aircraft brought in to stop, and we

Aircraft brought in to stop, and we

finally can say we've done it.

NUNO MONETEIRO (ON RADIO): God is good, man.

NUNO MONETEIRO (ON RADIO): God is good, man.

I'm so glad you're on the ground.

It was one of the happiest moments in my life

as a... as a military pilot.

as a... as a military pilot.

I felt relieved, and I felt extremely thankful to see

I felt relieved, and I felt extremely thankful to see

that aircraft on the ground.

The only injury is a sprained ankle to one

of the maintenance staff.

of the maintenance staff.

I felt relief.

I was very happy that made... we made it,

and we landed the aircraft in one piece.

and we landed the aircraft in one piece.

Now it's up to Portuguese air

and rail accident investigators to find

out why it happened at all.

out why it happened at all.

Within two hours of landing, investigators

from the Portuguese safety investigation authority

arrive at Beja Air Base.

arrive at Beja Air Base.

Jose Figueiredo is the lead investigator

overseeing the investigation.

overseeing the investigation.

Good to see it's in one piece.

We knew that something was wrong... really wrong...

with the aircraft.

Investigators examine the aircraft

Investigators examine the aircraft

for signs of damage.

Nose looks fine.

Check this out.

Deformations.

There wasn't any visible damage

as we approached the aircraft.

as we approached the aircraft.

However, we found wrinkles on the surface of the fuselage

However, we found wrinkles on the surface of the fuselage

and on the leading edge of the wing.

The damage indicates that Flight 1388 suffered

The damage indicates that Flight 1388 suffered

extreme forces in flight.

I can't believe they landed this plane.

I can't believe they landed this plane.

The incident is declared an accident because

of the severity of the damage.

of the severity of the damage.

The aircraft is a write off.

The definition of an accident typically

The definition of an accident typically

involves the destruction of the aircraft and fatalities,

but we decided to classify this event an accident,

but we decided to classify this event an accident,

rather than an incident, because we

felt it was important to draw attention

to what happened here.

to what happened here.

Let's see what the crew can tell us.

We called the control tower at Beja

We called the control tower at Beja

and requested the pilots to stay on the aircraft

until we arrived there.

It was key for us to speak to the pilots

so that we could get a firsthand account of what had occurred,

so that we could get a firsthand account of what had occurred,

and to try and get as much valuable information from them

as possible.

as possible.

When did you realize there was a problem?

Immediately after takeoff.

The plane started rolling back and forth.

The plane started rolling back and forth.

What's happening?

There's something wrong with the yoke.

There's something wrong with the yoke.

I've never felt anything like this before.

There's a total disconnect between the control

yoke and the aircraft.

yoke and the aircraft.

Were there any alerts or indications of what went wrong?

No, but one of the maintenance team on board

No, but one of the maintenance team on board

remembers ordering new aileron cables for the aircraft.

remembers ordering new aileron cables for the aircraft.

So we did the visual inspection, and it seems that ailerons

were moving in reverse.

We couldn't believe it when the crew told

We couldn't believe it when the crew told

us, we wanted to perform an operational test

to confirm for ourselves what was the real issue.

to confirm for ourselves what was the real issue.

OK, show us the left aileron.

Copy.

Copy.

Investigators test the ailerons

to verify that they were moving in opposite directions.

to verify that they were moving in opposite directions.

Yoke to the left.

Two control surfaces work

in tandem to turn the plane.

Both the aileron and the spoiler must move upwards in the wing

Both the aileron and the spoiler must move upwards in the wing

to turn the plane to the left.

The spoiler is fine, but the left aileron

moved down instead of up.

moved down instead of up.

It's reversed.

So it's as if the steering wheel of your car

was giving inverted commands, or the handlebar of your bicycle

was giving inverted commands, or the handlebar of your bicycle

was inverted, as well.

was inverted, as well.

Plane would have been next to impossible to control.

The next big question the investigation was facing

The next big question the investigation was facing

was, how did this happen?

Maintenance began on October 2.

Maintenance began on October 2.

Investigators review Flight 1388's maintenance

records for an explanation of why the ailerons were inverted.

records for an explanation of why the ailerons were inverted.

And it continued up until the morning of the accident.

And it continued up until the morning of the accident.

The aircraft was serviced

in Portugal for a month by a subsidiary owned by Embraer.

in Portugal for a month by a subsidiary owned by Embraer.

When airlines don't have the maintenance facilities

When airlines don't have the maintenance facilities

capable of doing the deep servicing,

they contact external suppliers, and that was the case here.

they contact external suppliers, and that was the case here.

It was necessary to find out what

had happened during the month or so that the aircraft was

had happened during the month or so that the aircraft was

in maintenance.

Investigators meet with a maintenance supervisor

to find out more about the work performed on the aircraft.

to find out more about the work performed on the aircraft.

Why did the plane require aileron maintenance service?

Why did the plane require aileron maintenance service?

The aileron cables were old.

When commanded, four cables

move the ailerons up and down.

move the ailerons up and down.

Each cable moves through a pulley system.

Friction against the pulleys can cause

Friction against the pulleys can cause

the cables to wear prematurely.

We replaced the pulley system with a frictionless one

We replaced the pulley system with a frictionless one

to prevent future wear and tear.

Operator says, complaining to Embraer

about the premature wear on the stainless steel cables.

about the premature wear on the stainless steel cables.

So Embraer came up with a design fix to this issue,

So Embraer came up with a design fix to this issue,

and the aircraft was being refitted

with the new contactless system.

with the new contactless system.

It says here the aileron maintenance began on October 9.

It says here the aileron maintenance began on October 9.

Correct.

Uh, the structures team started by removing

the old pulleys and cables.

The new design mostly uses

square metal frames instead of pulleys

square metal frames instead of pulleys

to guide the cables through the wing.

This minimizes any wear caused by friction.

And what did the structures team to do next?

They reinstalled the old cables as a temporary measure

until the flight control team installed the new cables.

until the flight control team installed the new cables.

The structures team reinstalled the old cables

once they had finished replacing the hardware

because that is what the procedures required them to do.

They were following the instructions.

They were following the instructions.

Is it possible that they inverted the old cables

Is it possible that they inverted the old cables

when they reinstalled them?

It's possible.

I'm told they had a hard time following the instructions.

I'm told they had a hard time following the instructions.

Where did they struggle with the instructions?

Right here.

They identify a key section

where the structures team had difficulty

where the structures team had difficulty

understanding what to do.

This looks like the reverse zone.

This looks like the reverse zone.

The reverse zone is a 2-meter-long section

inside the wing where the cable routing changes

from horizontal to vertical.

from horizontal to vertical.

This is confusing.

This is confusing.

Did the technician ask for help?

I'm told he asked another engineer on the team.

I'm told he asked another engineer on the team.

The structural engineer consulted a colleague

The structural engineer consulted a colleague

who had also limited experience, and the manual instructions

were quite difficult to follow.

were quite difficult to follow.

Did you test the reinstallation?

They weren't required to.

They weren't required to.

This kind of work

requires extensive experience.

So without surprise, they did it incorrectly.

So without surprise, they did it incorrectly.

Not only did the structures team incorrectly

reinstall the old cables, they never

reinstall the old cables, they never

tested the ailerons to confirm that they

were working correctly.

were working correctly.

The structure team were informed

that the flight control team will came

later to replace those cables.

later to replace those cables.

Did the flight control team catch the error?

Not likely.

I'm told they installed the new cables

following the same routing.

The flight control team replaced the cables one by one,

The flight control team replaced the cables one by one,

installing the new cables as a direct replacement

and without verifying the previous routing.

and without verifying the previous routing.

So why didn't the flight control team discover

So why didn't the flight control team discover

the mistake after they finished the installation

and then tested the ailerons?

and then tested the ailerons?

Investigators checked the fault history database for answers.

The fault history database records

The fault history database records

data about the maintenance work that was done on the aircraft.

data about the maintenance work that was done on the aircraft.

So it will tell us, for example, when the aircraft was powered

up, when it was powered down, what systems were operating,

up, when it was powered down, what systems were operating,

and at what time.

Installation of the new cables was

completed on October the 17th.

Well, according to this, they couldn't

Well, according to this, they couldn't

test the ailerons on the 17th.

The plane was still under maintenance.

The plane was still under maintenance.

The investigation knew that the ailerons had not

been checked on that day because you

need to power up the aircraft.

need to power up the aircraft.

And from the data that we could see in the fault history

database, this never happened.

database, this never happened.

When did they complete the maintenance?

On October 26, they finished the additional maintenance

On October 26, they finished the additional maintenance

and powered up the plane.

Did they test the ailerons then?

Did they test the ailerons then?

It doesn't look like they could.

Oh, they got a fault warning in the cockpit.

Oh, they got a fault warning in the cockpit.

Flight control, no dispatch.

Flight control, no dispatch is a catch all message

Flight control, no dispatch is a catch all message

which alerts the flight crew that something needs

attention before going flying.

attention before going flying.

It could be a sensor.

It could be a connection that is loose.

They didn't know what caused the fault.

Regardless, they can't fly with the error message.

Regardless, they can't fly with the error message.

While the error message had nothing

to do with the inverted aileron cables,

it diverted technicians' attention

it diverted technicians' attention

away from the aileron repair.

And so when they experienced the flight control,

And so when they experienced the flight control,

no dispatch, this put a lot of pressure

on all of the maintenance technicians.

on all of the maintenance technicians.

What did you do when your crew got the flight

control, no dispatch message.

Investigators delve into how the maintenance team of Flight

Investigators delve into how the maintenance team of Flight

1388 dealt with a no fly error message

after completing maintenance work on the plane.

after completing maintenance work on the plane.

I dispatched a team to investigate.

I dispatched a team to investigate.

Were they able to determine the issue

and clear the problem?

No.

No.

The maintenance team started

The maintenance team started

by referring to the manuals.

They also asked support from the manufacturer.

They also asked support from the manufacturer.

However, all of these efforts had limited results.

However, all of these efforts had limited results.

How did they resolve the error message?

They replaced the flight control computers.

They replaced the flight control computers.

With no success resolving the error message,

With no success resolving the error message,

the maintenance team considers the possibility

that the issue involves the flight control computers.

that the issue involves the flight control computers.

These were new computers, so these, being new computers,

These were new computers, so these, being new computers,

they had clean memories.

When they powered up the plane,

When they powered up the plane,

the error message was gone.

When those four flight control modules were

When those four flight control modules were

replaced, the message disappeared, and the plane

was cleared to fly.

was cleared to fly.

Did you test the ailerons after that?

Sure did.

We checked all the flight controls.

And what about a visual check?

And what about a visual check?

Absolutely.

They were moving up and down no problem.

Did they check to see that they were

Did they check to see that they were

moving in the right direction?

I'm sorry.

I'm sorry.

I'm not sure if they did or not.

The operational checks were performed.

The operational checks were performed.

However, no one really noticed that, despite the movement

However, no one really noticed that, despite the movement

of the ailerons, that, in fact, they

were moving in the opposite direction

to what is being commanded.

to what is being commanded.

Thanks for your time.

Well, that's one big mistake that nobody caught.

Well, that's one big mistake that nobody caught.

Investigators finally understand what happened

Investigators finally understand what happened

to Air Astana Flight 1388.

to Air Astana Flight 1388.

The groundwork for the terrifying flight

was laid a month earlier when a maintenance team

inverted the aileron cables because the instructions were

inverted the aileron cables because the instructions were

confusing.

When they prepared to test the aileron cables,

When they prepared to test the aileron cables,

they get distracted by a mysterious error message.

Maintenance technicians clear the error message

by replacing flight computers.

But when they check that the ailerons are working,

they never look to see what direction they are moving.

they never look to see what direction they are moving.

What's happening?

What's happening?

There's something wrong with the yoke.

I've never felt anything like this before.

This chain of events sets Flight 1388 on

a harrowing 116 minute flight.

a harrowing 116 minute flight.

There's 1,000.

Watch for the right roll as we get down.

Watch for the right roll as we get down.

1,000.

Remarkably, the pilots are

able to overcome their difficulties through focus

able to overcome their difficulties through focus

and good teamwork.

NUNO MONETEIRO (ON RADIO): I'll guide you in.

NUNO MONETEIRO (ON RADIO): I'll guide you in.

Do you have a visual on me?

The aid of an experienced fighter pilot

finally helps them to land the plane.

finally helps them to land the plane.

The situation looked dire for a long time,

and knowing that they had landed safely

was just a tremendous relief.

was just a tremendous relief.

The really impressive thing

is that this crew, who were not experienced flight test pilots

is that this crew, who were not experienced flight test pilots

who come across completely nonstandard situations before,

who come across completely nonstandard situations before,

and just how quickly they settled down

to work it through logically.

to work it through logically.

They did really well.

They did really well.

As a result of this accident and investigation,

several safety changes are made.

There are a lot of changes at Embraer

in terms of revising their manuals

in terms of revising their manuals

and making the instructions much clearer

when it comes to replacing the aileron control cables.

when it comes to replacing the aileron control cables.

Air Astana installed more

robust procedures for checking aircraft

robust procedures for checking aircraft

after completing maintenance.

New procedures were made for checking

New procedures were made for checking

the flight controls, including making

sure the correct movement of the ailerons.

sure the correct movement of the ailerons.

Maintenance errors have occurred in the past,

Maintenance errors have occurred in the past,

and I think what this event demonstrates

is that it underscores the importance that all

is that it underscores the importance that all

of the stakeholders, including maintenance, play

in achieving flight safety.

in achieving flight safety.