Original subtitles

The landing is the most

dangerous part of any flight.

dangerous part of any flight.

Have you seen the runway?

No.

Both pilots did not adhere to standard operating procedures.

Both pilots did not adhere to standard operating procedures.

It was hazardous behavior.

Ah!

Ah!

Ah!

Investigations confirm that when

pilots ignore the rule book...

pilots ignore the rule book...

Terrain!

Terrain!

Yeah, yeah, yeah.

...the consequences can be deadly.

...the consequences can be deadly.

Why would they do this?

Why would they do this?

I have ground contact.

We're continuing on.

Three flights end in tragedy...

Three flights end in tragedy...

Instinct can let the pilot down.

...when flight crews improvise on final approach.

...when flight crews improvise on final approach.

Ah!

Ah!

Ladies and gentlemen, we are starting our approach.

Ladies and gentlemen, we are starting our approach.

We lost both engines.

SW mode. Emergency response.

Mayday!

Mayday!

Mayday!

Brace for impact!

He's gonna crash!

He's gonna crash!

Crossair Flight 3597 cruises at 27,000 feet

Crossair Flight 3597 cruises at 27,000 feet

en route from Berlin to Zurich.

Captain Hans Ulrich Lutz is in command.

He's been with the airline for more than 22 years.

He's been with the airline for more than 22 years.

So tell me about the runway and the conditions.

Uh, overcast with light snowfall.

Uh, overcast with light snowfall.

Visibility, 3,000 meters.

First officer Stefan Lohrer

First officer Stefan Lohrer

is a newcomer to the airline.

He's had a pilot's license for only a year and a half.

He's had a pilot's license for only a year and a half.

There are 28 passengers on board the Avro 146 airliner.

It's due to land in less than half an hour.

It's due to land in less than half an hour.

According to the latest information,

we'll be using Runway 14.

we'll be using Runway 14.

What kind of approach?

ILS approach.

OK.

OK.

An ILS, or instrument landing system,

approach employs radio signals beamed from the airport

approach employs radio signals beamed from the airport

to guide pilots to the runway.

In Zurich, it's now snowing.

Visibility is deteriorating.

Visibility is deteriorating.

Cirque approach.

Crossair 3597.

Please confirm the approach in use is the ILS 14.

Please confirm the approach in use is the ILS 14.

Crossair 3597, you're identified.

It will be VOR/DME approach, Runway 28.

It will be VOR/DME approach, Runway 28.

Ah, hell.

What next?

What next?

The captain is annoyed because the landing

plan has changed.

Damn.

Damn.

To reduce noise over neighboring towns,

Runway 14 shuts down at 10:00 PM.

Runway 14 shuts down at 10:00 PM.

But the alternate runway, Runway 28,

is not equipped for ILS landings.

is not equipped for ILS landings.

It employs a less accurate navigational system that

makes landing more complicated.

makes landing more complicated.

A VHF radio beacon sends information

to the aircraft about its distance from the runway

to the aircraft about its distance from the runway

and whether it's left or right of it.

and whether it's left or right of it.

But it provides no guidance on the plane's altitude.

He would always prefer an ILS approach because he gets

He would always prefer an ILS approach because he gets

guidance on the approach slope.

Nearing Zurich, the plane enters dense clouds.

Flaps three three.

Flaps three three.

Flaps three three selected.

Do we have ground contact?

Yes.

With the ground now visible,

the captain expects to see the runway within seconds.

the captain expects to see the runway within seconds.

Crossair 3597, cleared to land.

Runway 28.

24, the minimum.

24.

24.

The flight is hit decision height,

2,400 feet above sea level.

Decision height is the minimum height you can descend

Decision height is the minimum height you can descend

before you need to see the runway

and continue the approach visually,

and continue the approach visually,

or you have to make a decision to go around.

or you have to make a decision to go around.

I have ground contact.

We're continuing on.

500.

They continue descending.

300.

300.

But they still can't see the runway.

Think I go around?

Yeah.

Yeah.

Go around!

Go around.

Damn!

Crossair 3597, this is Zurich tower.

Do you copy?

Do you copy?

This is Zurich tower.

We have a possible emergency in approach sector east.

We have a possible emergency in approach sector east.

I repeat, approach sector east.

Crossair Flight 3597 has crashed northeast of Zurich

Crossair Flight 3597 has crashed northeast of Zurich

near the village of Bassersdorf.

near the village of Bassersdorf.

Over here!

Over here!

24 of the 33 people on board

are dead, including Captain Lutz and first officer Stefan

are dead, including Captain Lutz and first officer Stefan

Lohrer.

A team from Switzerland's Aircraft

Accident Investigation Bureau arrives at the crash site.

Accident Investigation Bureau arrives at the crash site.

4 kilometers and 50 meters from the runway?

The location of the wreckage

so far from the airport raises their interest.

so far from the airport raises their interest.

The aircraft was not where he was intended to be.

He collided with a... with a hill east of Runway 28.

He collided with a... with a hill east of Runway 28.

So obviously, he was too low.

And the first question was, why was

And the first question was, why was

this... this aircraft too low?

Investigators wonder if the crew

Investigators wonder if the crew

received proper guidance during the descent to Zurich airport.

Crossair 3597, continue speed reduction

Crossair 3597, continue speed reduction

to final approach speed.

I was covering the approach west position

on the night of the accident.

Could the air traffic controller

have misdirected the plane?

have misdirected the plane?

She was relatively young, and let's say she didn't

have that much experience.

have that much experience.

The team scrutinizes control tower transcripts.

They find no indication that the controller gave

the crew flawed instructions.

the crew flawed instructions.

Focus turned to the captain.

Visibility, approaching.

Gear down.

He has the final say on any landing.

A pilot can always say no.

He can always recheck the clearance

He can always recheck the clearance

if he thinks that landing is probably not possible.

if he thinks that landing is probably not possible.

He is free to retract an approach clearance

and ask for a different one.

and ask for a different one.

With reduced visibility at Zurich,

the team questions why the captain

didn't ask to come in on the original approach to Runway 14.

didn't ask to come in on the original approach to Runway 14.

Approach course, one.

He could have made an instrument

He could have made an instrument

guided, or ILS, approach.

It would have been much easier to fly out of this approach

It would have been much easier to fly out of this approach

in this kind of weather.

For an experienced pilot, this was a really basic mistake.

For an experienced pilot, this was a really basic mistake.

100 and 78 in court.

Investigators hope they'll find answers

Investigators hope they'll find answers

in the cockpit voice recording.

6 miles is checked.

6 miles is checked.

100 above.

In the final moments before the accident...

I have ground contact.

I have ground contact.

We're continuing on.

...the crew sounds confident that the runway

will soon come into view.

But they crashed 2 and 1/2 miles short of their destination.

But they crashed 2 and 1/2 miles short of their destination.

300.

300.

300.

The team wonders if the plane's

distance measuring equipment, or DME, was malfunctioning.

distance measuring equipment, or DME, was malfunctioning.

The DME is supposed to indicate a plane's

distance from the airport.

6 miles is checked.

Yes.

Investigators compare the time

Investigators compare the time

Lutz checked his distance with radar data

showing the aircraft's location.

They confirm his reading was accurate.

They confirm his reading was accurate.

So we knew that the pilots had an indication for the distance

So we knew that the pilots had an indication for the distance

available at that time.

But if his distance instrument

was functioning, why did Flight 3597

was functioning, why did Flight 3597

was functioning, why did Flight 3597

come down short of the airport?

Damn!

Investigators find a clue in the CVR transcripts.

Investigators find a clue in the CVR transcripts.

I don't see anything after 6 miles.

Do we have ground contact?

Do we have ground contact?

They discover that neither pilot

checked their distance after the 6-mile reading.

Yes.

Yes.

Captain Lutz wasn't monitoring

the vital instrument during the final minutes of his approach.

the vital instrument during the final minutes of his approach.

Instead, he was preoccupied with looking

for the lights of the runway.

The pilot flying is supposed to keep his eyes

on the instruments because all the information he needs

on the instruments because all the information he needs

is there.

He only switches to flying by sight when the nonflying

pilot says runway insight.

pilot says runway insight.

If Lutz had checked his instruments,

If Lutz had checked his instruments,

he would have known how far from the runway he actually was.

500.

500.

Ignoring his instruments,

and without a visual fix on the runway,

and without a visual fix on the runway,

Captain Lutz began his descent to Zurich airport.

100.

It's alarming behavior.

It's alarming behavior.

But investigators know there was a safeguard that could

have prevented the disaster.

24, the minimum.

24.

Aircraft making nonprecision approaches

into Zurich are supposed to level

into Zurich are supposed to level

off and stay at 2,400 feet until they have the runway in sight.

off and stay at 2,400 feet until they have the runway in sight.

But the recovered flight data recorder reveals Captain Lutz

But the recovered flight data recorder reveals Captain Lutz

sped right through 2,400 feet.

sped right through 2,400 feet.

I have ground contact.

We're continuing on.

He claimed to have the ground in sight.

He claimed to have the ground in sight.

But could he see the runway?

No, he couldn't see the runway because there was a hill

No, he couldn't see the runway because there was a hill

between him and the runway.

And at that altitude, there is no way he could see it.

The conclusion?

Captain Lutz clearly ignored the minimum descent altitude

Captain Lutz clearly ignored the minimum descent altitude

and then slammed into a hill.

Whether there is flat terrain or hills, minimums are...

Whether there is flat terrain or hills, minimums are...

are... are set accordingly.

And in no way you can just pass the minimums,

whether there's hills or not.

whether there's hills or not.

2-4, the minimum.

2-4.

The pilot was improvising...

The pilot was improvising...

We're continuing on.

...in the midst of a difficult landing.

Investigators want to know why.

Investigators want to know why.

Investigators dig into Captain Hans

Investigators dig into Captain Hans

Ulrich Lutz's flying record.

Years of flying and flying hours

don't say anything about competence.

don't say anything about competence.

The record reveals he repeatedly failed exams

The record reveals he repeatedly failed exams

regarding navigational systems.

I personally do pilot assessments.

I personally do pilot assessments.

And he would never have gone through my assessment

with a positive recommendation.

with a positive recommendation.

Oh, hell.

What next?

Captain Lutz broke from procedure while landing

Captain Lutz broke from procedure while landing

on November 24, 2001.

I have ground contact.

We're continuing on.

That cost 24 people their lives.

That cost 24 people their lives.

Instinct can let the pilot down.

Instinct can let the pilot down.

He shouldn't have to work on instinct.

It should be a thought through, considered safety

It should be a thought through, considered safety

action based on design, experience,

and policies and procedures.

and policies and procedures.

Landing procedures are designed to minimize danger.

So when pilots improvise, they put everyone on board at risk.

Trigana Air Service Flight 267 takes off

on an afternoon flight from Sentani Airport

in Papua Province, Indonesia.

Landing gear up.

Landing gear is up.

Landing gear is up.

Captain Hasanuddin and First Officer Aryadin

Captain Hasanuddin and First Officer Aryadin

are at the controls of the ATR 42 aircraft.

49 passengers are on board.

49 passengers are on board.

The 40-minute flight will take them from Sentani

to a remote airport in Oksibil.

to a remote airport in Oksibil.

Water?

The trip is so short...

I'll call Oksibil.

...the captain is already

preparing for the descent to their destination.

Oksibil, Trigana 267.

Trigana 267, Oksibil, copy.

Trigana 267, Oksibil, copy.

We are beginning our approach.

We'd like to descend from 11,500 feet.

We'd like to descend from 11,500 feet.

Confirm descent from 11,500.

Let me know when you are positioned over Oksibil.

Let me know when you are positioned over Oksibil.

Oksibil is a small airport situated in a valley.

The mountains surrounding it reach as high as 11,000 feet.

The mountains surrounding it reach as high as 11,000 feet.

It lacks the advanced landing systems

available at bigger airports.

available at bigger airports.

Pilots must keep the runway in sight during approach.

Cabin crew, prepare for landing.

In preparation, please straighten your back

and store your tray.

I'll be coming around to collect any garbage you may have.

I'll be coming around to collect any garbage you may have.

Typically, the flights of a commuter aircraft

would be an hour or less.

So the typical duty day for a pilot

So the typical duty day for a pilot

might include four or more takeoffs and landings.

Flap 15.

Flap 15.

It's challenging in the sense of taking off

and landing are the most risky parts of any aircraft flight.

and landing are the most risky parts of any aircraft flight.

Gear down.

Just before 3:00 PM, the plane

begins its final descent.

5 minutes later, the air traffic controller at Oksibil

5 minutes later, the air traffic controller at Oksibil

realizes Flight 267 is not reporting

from the next location.

from the next location.

Trigana 267, Oksibil.

Do you copy?

Trigana 267, Oksibil.

Do you copy?

One of the common things that happens when an airplane

One of the common things that happens when an airplane

doesn't land at an airport for some reason

is that they may divert to another airfield.

Hey, this is Oksibil.

Hey, this is Oksibil.

We've lost contact with Flight 267.

Have you heard from the pilots?

You haven't?

We might have a problem here.

We might have a problem here.

News of the plane's disappearance quickly spreads.

News of the plane's disappearance quickly spreads.

A team of investigators from Indonesia's

National Transportation Committee, the KNKT,

National Transportation Committee, the KNKT,

monitors the situation.

My first impression was that something wrong had happened.

My first impression was that something wrong had happened.

It's not looking good.

It's not looking good.

The following day, a search plane flying out

The following day, a search plane flying out

of Oksibil Airport sees smoke billowing

from nearby Tangok Mountain.

It's the wreckage of Flight 267, 10 miles northwest

of Oksibil Airport and off course from where

of Oksibil Airport and off course from where

it was supposed to be.

How did they end up over there?

How did they end up over there?

Two days after Flight 267 disappeared from radar,

Two days after Flight 267 disappeared from radar,

a search team finds the wreckage 8,300 feet

a search team finds the wreckage 8,300 feet

up the rugged Tangok Mountain.

Go ahead, Oksibil.

Jakarta, we've reached the crash site.

Jakarta, we've reached the crash site.

No survivors.

OK.

OK.

Once you catch your breath, the number-one priority

is to find the black boxes.

OK.

OK.

KNKT investigators need to find out why Flight 267

slammed into a mountain 10 miles west

slammed into a mountain 10 miles west

of the usual approach path.

Blue is the flight path in the approach chart.

Blue is the flight path in the approach chart.

Here's where they crashed.

I'd like to know more about the terrain around here.

The team uses special software

to generate a topographical map for the area.

to generate a topographical map for the area.

It shows the pilots were flying a treacherous route.

It shows the pilots were flying a treacherous route.

They was surrounded by mountains as high as 9,000

feet.

Why didn't they fly above them?

Investigators hope Flight 267's

Investigators hope Flight 267's

black boxes recovered from the crash site

will provide answers.

will provide answers.

Certainly there would have been something in the flight

data recorder that may have given an indication

data recorder that may have given an indication

that some system on the aircraft wasn't

operating as it should have.

operating as it should have.

But when they try to retrieve the data,

they discover the recorder wasn't working

at the time of the crash.

Useless.

That leaves the cockpit voice recorder

as the team's next hope to piece together the events leading up

as the team's next hope to piece together the events leading up

to the crash.

All right, we're ready?

OK, play it.

The recording contains 2 hours of audio

The recording contains 2 hours of audio

and includes two previous trips they made.

and includes two previous trips they made.

I'll call down and let them know we're coming.

Investigators listen to an earlier descent

Investigators listen to an earlier descent

into Oksibil.

Confirmed descent from 11,500.

Confirmed descent from 11,500.

Let me know when you are positioned over Oksibil.

Oksibil, we won't be over the airport.

We're going to fly direct to the left base leg to Runway 11.

We're going to fly direct to the left base leg to Runway 11.

Copy that.

Left base leg?

Left base leg?

That's not what it says in the charts.

They took a shortcut?

The official approach directs

aircraft to fly over the airport and then circle back and land.

aircraft to fly over the airport and then circle back and land.

But on this earlier flight, the pilots flew directly to Runway

But on this earlier flight, the pilots flew directly to Runway

11 without looping around.

Did the pilots repeat that shortcut

just before they crashed?

just before they crashed?

Let's skip ahead to the accident flight.

Confirmed descent from 11,500.

Let me know when you are positioned over Oksibil.

Let me know when you are positioned over Oksibil.

Oksibil, we're flying direct to our left base leg

to Runway 11.

Copy that.

So they take the same shortcut for the accident flight.

So they take the same shortcut for the accident flight.

Big plans with the family?

Big plans with the family?

Investigators listen closely for any signs

of potential danger.

Yeah, looking forward to some time off.

Yeah, looking forward to some time off.

It's been very busy these past few days.

It's been very busy these past few days.

But it's what they don't hear

that raises their interest.

They're not doing their approach

briefing and checklist.

briefing and checklist.

Briefings and checklists give the flight crew

a better understanding of their environment.

a better understanding of their environment.

Not doing that makes it less likely

that the pilot will remember to do certain things

that the pilot will remember to do certain things

or to take certain precautions.

Flaps 15.

Gear down.

Gear down.

Listening to the final moments before the crash,

investigators make another surprising discovery.

investigators make another surprising discovery.

That's it?

Normally, at the last second of the flight,

Normally, at the last second of the flight,

the pilot would have been scream or do something.

the pilot would have been scream or do something.

It happened so fast.

It sounds like they didn't even see the mountain.

Investigators suspect that clouds

might have obscured the pilot's view of the mountain.

might have obscured the pilot's view of the mountain.

The team scrutinizes weather data recorded less than an hour

before the crash.

Oksibil was covered by dense clouds.

Oksibil was covered by dense clouds.

How's the weather looking for our approach?

How's the weather looking for our approach?

You've got a cloud base of 8,000 feet.

They're not doing their approach

briefing or checklists.

The pilots' decision to continue

The pilots' decision to continue

their approach despite so much cloud

cover surprises investigators.

Gear down.

Gear down.

The visual approach is not allowed to be

done in the cloudy condition.

done in the cloudy condition.

Instead of following approved landing procedures...

The base of the clouds was 8,000 feet.

The base of the clouds was 8,000 feet.

...the pilots improvised, hoping they would

eventually see the runway.

They were descending, expecting to drop out

They were descending, expecting to drop out

of the clouds at any minute.

of the clouds at any minute.

Instead, they crash into a mountain at 8,300 feet.

Instead, they crash into a mountain at 8,300 feet.

But even if the pilots couldn't see the mountain,

the plane's warning system should have detected it.

the plane's warning system should have detected it.

We still don't know why they didn't know they

were in the path of a mountain.

were in the path of a mountain.

When a plane is in close proximity to terrain or about

to hit an object, there's a warning

to hit an object, there's a warning

system that warns the pilot when the plane

system that warns the pilot when the plane

is very close to terrain.

So why didn't that system activate?

We need to check their warning system.

Investigators want to know why Flight 267's ground

proximity warning system didn't alert the pilots that they were

proximity warning system didn't alert the pilots that they were

about to fly into a mountain.

The warning system uses GPS and a terrain database

The warning system uses GPS and a terrain database

to monitor an aircraft's height above the surrounding terrain.

to monitor an aircraft's height above the surrounding terrain.

If the plane comes too close to the ground,

the system will warn the flight crew with audio messages...

the system will warn the flight crew with audio messages...

Terrain, terrain.

Pull up!

...telling the pilots to take immediate action.

...telling the pilots to take immediate action.

Were there any warnings going off in the cockpit?

No, there's nothing in the transcript.

No, there's nothing in the transcript.

Was the aircraft's warning

system functioning properly?

The team studies the terrain data it uses.

This area is not very well mapped.

This area is not very well mapped.

Some of the Papau area was very rough data.

Some of the Papau area was very rough data.

The precision of the data was not as

close to the actual conditions.

Did the pilots fly into a mountain

whose elevation was not properly recorded

whose elevation was not properly recorded

in the terrain database?

Investigators interviewed Trigana pilots who regularly

fly in the Oksibil area to find out if the system gives

fly in the Oksibil area to find out if the system gives

adequate terrain warnings.

And what do you normally do when you keep

And what do you normally do when you keep

getting these false warnings?

They learned the system does provide warnings.

They learned the system does provide warnings.

But an excessive number turn out to be

false alarms due to the poor quality of terrain data.

false alarms due to the poor quality of terrain data.

If you're flying within a mountainous area,

it can give you a false warning or unnecessary warnings.

it can give you a false warning or unnecessary warnings.

Imagine you are trying to land in a small airport

in the middle of the valley.

in the middle of the valley.

You can see the airport in front of you

and the visual conditions, and then the system

starts giving a warning.

Terrain, terrain.

Terrain, terrain.

Pull up!

You think, well, I can see the airport in front of me.

I can see the terrain behind it.

That... that... that warning is... is... it's annoying.

That... that... that warning is... is... it's annoying.

OK, thank you.

They just pull the breaker to get rid of the false warnings.

Terrain, terrain.

Pull up!

Terrain, terrain.

Terrain, terrain.

Apparently, it's common practice.

Are you kidding me?

Are you kidding me?

Did Flight 267 not get terrain

warnings because the pilots deliberately

warnings because the pilots deliberately

shut down the system?

Terrain, terrain.

Yeah, yeah, yeah.

Yeah, yeah, yeah.

The KNKT examines the captain's employment records

and finds that he not only made a habit of pulling

and finds that he not only made a habit of pulling

the circuit breaker, but also that the company was

well aware of it.

Hmm.

Hmm.

It says here that they scheduled a briefing

with him to address it.

with him to address it.

Based on this information, we assume

that that day, on the accident day,

the captain also inactivate the system.

the captain also inactivate the system.

Terrain, terrain.

Pull up! Terrain, terrain.

Pull up! Terrain, terrain.

I got this.

Pull up!

Terrain, terrain.

Pull...

Investigators now believe the pilots

Investigators now believe the pilots

intentionally disabled their warning

system on an earlier flight that day and then never reset it.

system on an earlier flight that day and then never reset it.

If the system was active, I am sure that the accident would

If the system was active, I am sure that the accident would

have been avoided because the last seconds

of the flight before the impact, the system

of the flight before the impact, the system

will scream, pull up, pull up.

will scream, pull up, pull up.

The pilot would then take action to save the flight.

The pilot would then take action to save the flight.

The investigation concludes that the pilots

became overconfident flying that route

became overconfident flying that route

and regularly improvised...

Terrain, terrain.

Pull up! Terrain, terrain.

I got this.

Pull up!

Pull up!

Terrain, terrain.

...by taking shortcuts and turning

off vital warning systems.

off vital warning systems.

The practice resulted in the deaths of 49 passengers.

The practice resulted in the deaths of 49 passengers.

No landing is routine.

No landing is routine.

Overconfident pilots who improvise

can be caught off guard with disastrous results.

can be caught off guard with disastrous results.

On a rainy summer evening, TransAsia Flight 222

On a rainy summer evening, TransAsia Flight 222

is in a holding pattern 3,100 feet above the Taiwan Strait.

The pilot flying is Captain Le Yi-liang.

The pilot flying is Captain Le Yi-liang.

Heading 240.

He's a former military pilot with 22

years of commercial experience.

years of commercial experience.

TransAsia 222, heading 240.

TransAsia 222, heading 240.

TransAsia 222, heading 240.

Approved.

First Officer Chiang Kuan-hsing is monitoring

First Officer Chiang Kuan-hsing is monitoring

the plane's instruments.

He's been in the job for just 2 and 1/2 years.

He's been in the job for just 2 and 1/2 years.

There are 54 passengers on board the ATR 72,

a popular short-haul aircraft.

a popular short-haul aircraft.

Flight 222 departed from Kaohsiung City, the

second largest city in Taiwan.

second largest city in Taiwan.

It's headed for Magong in the Penghu

Archipelago, a popular Taiwanese vacation spot.

Archipelago, a popular Taiwanese vacation spot.

But bad weather is delaying arrival.

But bad weather is delaying arrival.

Excuse me?

How long before we land?

How long before we land?

OK.

The flight skirts the edge

of Typhoon Matmo, a category two storm

of Typhoon Matmo, a category two storm

passing through the region.

There was a typhoon just passing through Taiwan area

There was a typhoon just passing through Taiwan area

and moving to China.

And there was thunderstorm, heavy rain,

and a very strong wind.

and a very strong wind.

TransAsia 222, request Runway 20 VOR.

TransAsia 222, request Runway 20 VOR.

TransAsia 222, Roger.

TransAsia 222, Roger.

Fly heading 02360.

Radar vector.

VOR approach.

VOR approach.

The plane's distance measuring equipment, the DME,

will tell the crew how far they are from the runway.

will tell the crew how far they are from the runway.

Cabin crew, prepare for landing.

Speed check.

Speed check.

Flap 15 set.

TransAsia 222, clear to land.

TransAsia 222, clear to land.

Flaps 30.

Gear down.

500.

500.

Um, 300.

Um, 300.

Set altitude 300.

Set altitude 300.

Altitude set 300.

Altitude set 300.

200.

The captain reduces the plane's altitude.

They are now less than 30 seconds from the ground.

They are now less than 30 seconds from the ground.

Have you seen the runway?

No.

No?

No, sir.

No, sir.

OK, OK.

Terrain, terrain.

Pull up!

Go up!

Ah!

Ah!

Pull up!

Terrain, terrain.

TransAsia Flight 222...

Go up!

...is in jeopardy.

Ah!

Flight 222 crashes into the village of Huxi,

Flight 222 crashes into the village of Huxi,

less than a mile from the airport

where it was scheduled to land.

Of the 58 people on board, 48 are

Of the 58 people on board, 48 are

dead, including both pilots.

Investigators from Taiwan's Aviation Safety Council

begin mapping the crash site.

In the beginning, we do not understand why the aircraft

In the beginning, we do not understand why the aircraft

while flying to residential area instead

while flying to residential area instead

of landing on the runway.

They determine the plane was not lined up

They determine the plane was not lined up

with the runway on its descent.

This is the heading they should have been on.

Why were they so far off course?

The team wonders if Typhoon Matmo

The team wonders if Typhoon Matmo

contributed to the accident.

Typhoon Matmo probably just a medium-sized typhoon,

Typhoon Matmo probably just a medium-sized typhoon,

but even that, they will bring a lot of water and, of course,

but even that, they will bring a lot of water and, of course,

strong wind.

The investigation takes

The investigation takes

a close look at weather data.

Wind speed, 11 knots gusting to 21 knots.

Wind speed, 11 knots gusting to 21 knots.

Well within the operational limits of the aircraft.

It's enough to push the commuter plane off course

It's enough to push the commuter plane off course

but not enough to bring it down.

What about the visibility?

I've got images from the airport at that time.

I've got images from the airport at that time.

It's starting to be more than just rain.

That's... that's a serious storm.

That's... that's a serious storm.

The visibility decrease very quickly just after 7 o'clock.

The visibility decrease very quickly just after 7 o'clock.

A minimum range of clear visibility

A minimum range of clear visibility

is required for pilots to attempt a landing.

The team estimates that visibility was so limited,

The team estimates that visibility was so limited,

the TransAsia crew would have had

difficulty seeing the runway.

difficulty seeing the runway.

The visibility was decreasing from 1,600 feet to 800 feet,

The visibility was decreasing from 1,600 feet to 800 feet,

all the way down to 500 feet because the heavy rain.

Visibility can't be more than a couple of hundred meters.

Visibility can't be more than a couple of hundred meters.

The pilots made a critical mistake

by attempting to land in such poor conditions.

by attempting to land in such poor conditions.

But why Flight 222 crashed so far from Magong Airport...

TransAsia 222, do you copy?

TransAsia 222, do you copy?

...remains a mystery.

How did you end up way over here?

I've got the data all ready now.

Investigators scan the recovered flight data recorder

Investigators scan the recovered flight data recorder

looking for anything unusual.

Wait a minute.

Wait a minute.

1 minute before impact, they were at 200 feet?

What was the minimum descent altitude?

According to the rules of the Magong approach,

pilots must not fly below a preset minimum descent

pilots must not fly below a preset minimum descent

altitude, or MDA, until they can see the runway.

If they can't see it, they are to do what's

called a missed approach...

called a missed approach...

Have you seen the runway?

...abort the landing, go

around, and try to land again.

No.

Or they divert to a different airport entirely.

It says the minimum descent altitude was 330 feet.

It says the minimum descent altitude was 330 feet.

Take a look at this.

Wang can see that the aircraft drops to 200 feet,

Wang can see that the aircraft drops to 200 feet,

well below the minimum altitude.

It holds there for almost 14 seconds.

It holds there for almost 14 seconds.

The weather data suggests that at their position,

the pilots wouldn't have been able to see the runway.

If the visibility was so bad, why did they ignore the MDA?

If the visibility was so bad, why did they ignore the MDA?

Why would they do this?

We need to hear what was going on in that cockpit.

Investigators turn to the cockpit voice recording.

Investigators turn to the cockpit voice recording.

Ready?

Ready?

Let's start near the end, just before landing.

TransAsia 22, request heading 240.

TransAsia 22, request heading 240.

Before landing checklist.

Gear down.

Flaps 30.

Flaps 30.

Control auto.

Take off lights on.

Icing lights off.

Runway 20, clearance received.

Runway 20, clearance received.

Before landing checklist complete.

Wind two niner zero.

Wind two niner zero.

Wait, stop.

Was that their before-landing checklist?

Was that their before-landing checklist?

Pilots are supposed to acknowledge each item

on a checklist with a standardized call-and-response

communication.

communication.

Just keep going.

But that's not what happens.

Both pilots did not adhere to standard operating procedures.

Both pilots did not adhere to standard operating procedures.

It puts the aircraft and the people around them at risk.

It puts the aircraft and the people around them at risk.

Ready.

Gear down.

Investigators then hear

the pilots break another rule while executing their landing.

the pilots break another rule while executing their landing.

200.

Hold it there.

They knew the minimum descent altitude was 330 feet,

but the captain seemed to just ignore that, too.

but the captain seemed to just ignore that, too.

Maybe they can see the runway, after all.

Let's find out.

Have you seen the runway?

No, sir.

When they descend to 200 feet, they are

When they descend to 200 feet, they are

still looking for the runway.

No?

No, sir.

Oh, OK.

OK.

They cannot see the runway, but they

decide to just descend the aircraft,

decide to just descend the aircraft,

try to find the runway.

When they descend to 72 feet, they are

When they descend to 72 feet, they are

still looking for the runway.

still looking for the runway.

Another 13 seconds pass before the pilots

take any action.

Go up!

Go up!

Go around!

Why did the crew of Flight 222

ignore the rules on such a demanding approach?

ignore the rules on such a demanding approach?

TransAsia 222...

Investigators continue to search Flight 222's cockpit

Investigators continue to search Flight 222's cockpit

voice recording for clues.

8 miles from airport for VOR Runway 20.

8 miles from airport for VOR Runway 20.

Why did they wait so long to do anything?

I want to hear it again from the beginning.

I want to hear it again from the beginning.

Anti-skid test.

Check.

Check.

Stand by.

After-start checklist complete.

What they hear next is disturbing.

What they hear next is disturbing.

Sir, do we preset next altitude 340 or 400?

Time and again, the pilots struggle

Time and again, the pilots struggle

with basic procedures...

Huh?

...everything from checklists to setting altitude.

...everything from checklists to setting altitude.

Preset next altitude 400.

It's always surprising when you have

It's always surprising when you have

a recording that indicates that pilots are

violating standard procedures.

violating standard procedures.

The recording then reveals

why the crew was struggling.

I'm so tired.

I'm so tired.

Sir, are we holding here?

Yes.

OK.

Right orbit or left orbit?

In the CVR, we clearly heard the pilot was yawning

and saying that he was tired.

and saying that he was tired.

Investigators look at the flight crew's work schedule

before the accident.

It shows that over the past 90 days,

the captain flew 278 hours, the first officer, 264.

the captain flew 278 hours, the first officer, 264.

the captain flew 278 hours, the first officer, 264.

Over the past three months, they flew an average

of six flights a day.

of six flights a day.

When an airline increases the frequency of flights,

you may get into a situation where people are

more fatigued, where people are flying

more fatigued, where people are flying

beyond what is reasonable.

Investigators determine TransAsia management

Investigators determine TransAsia management

was overworking their pilots.

The discovery raises more questions.

How common was it for pilots to ignore

How common was it for pilots to ignore

standard operating procedures?

OK, gentlemen, whenever you're strapped in,

we'll start the simulation.

we'll start the simulation.

And did TransAsia's management practices

affect their pilots in other ways?

affect their pilots in other ways?

They ask a group of the company's ATR 72 pilots

They ask a group of the company's ATR 72 pilots

to fly the route from Kaohsiung to Magong in a simulator

to fly the route from Kaohsiung to Magong in a simulator

with the added challenge of a nearby typhoon.

Pilot after pilot failed to follow the proper procedures.

Pilot after pilot failed to follow the proper procedures.

This was not a one-off sort of thing happening just in this

flight, but this was something that was systemic within

flight, but this was something that was systemic within

the airline, because this shows that this

sort of behavior was normal.

sort of behavior was normal.

This sort of behavior was acceptable.

OK, we're done here.

Just about every single one of them

ignored standard operating procedures.

ignored standard operating procedures.

We educate all the pilot.

We educate all the pilot.

We have to do things according to the procedures.

We have to do things according to the procedures.

I was surprised that there were still pilot doing

something by their own way.

something by their own way.

Ladies and gentlemen, we are about to begin

our approach to Magong Airport.

Investigators finally understand what

Investigators finally understand what

led to the crash of Flight 222.

Two overworked and fatigued pilots improvise their landing

Two overworked and fatigued pilots improvise their landing

during a worsening storm...

Assuming the runway would eventually appear ahead of them

through the rain...

Have you seen the runway?

Have you seen the runway?

...they dropped so low...

No.

No.

...they clipped the trees and sealed their fate.

- Terrain, terrain. - Go up!

Go up!

Up!

In their final report, investigators call on TransAsia

to fully review its safety management system

to fully review its safety management system

and pilot training program.

and pilot training program.

Three flight crews improvised during hazardous landings.

Relying on instinct rather than the rulebook,

Relying on instinct rather than the rulebook,

they made mistakes that caused tragedy.

The ability for a person to make a mistake is there.

Training, and process, and procedure, and regulation,

Training, and process, and procedure, and regulation,

and lessons that we've learned are all things

that exist to allow us to kind of

that exist to allow us to kind of

mitigate and deal with those human errors should they occur.