1 00:00:01,927 --> 00:00:03,299 Ladies and gentlemen, 2 00:00:03,300 --> 00:00:04,679 we're beginning our descent towards 3 00:00:04,680 --> 00:00:06,073 Amsterdam Schiphol Airport. 4 00:00:07,540 --> 00:00:08,372 Thank you. 5 00:00:08,373 --> 00:00:10,669 Turkish Airlines Flight 1951 6 00:00:10,670 --> 00:00:12,843 is preparing to land in Amsterdam. 7 00:00:14,790 --> 00:00:17,889 Amsterdam, Turkish 1951. 8 00:00:17,890 --> 00:00:21,460 Descending to 7,000, speed two, five, zero. 9 00:00:23,590 --> 00:00:24,639 The crew is flying 10 00:00:24,640 --> 00:00:27,183 a state-of-the-art Boeing 737. 11 00:00:28,100 --> 00:00:29,083 Flaps, 15. 12 00:00:32,553 --> 00:00:35,547 Localizer alive, localizer capture. 13 00:00:38,480 --> 00:00:40,439 In the final moments of the flight, 14 00:00:40,440 --> 00:00:42,323 the landing turns into a catastrophe. 15 00:00:43,540 --> 00:00:45,909 The plane falls like a rock. 16 00:00:45,910 --> 00:00:48,619 The crash of Turkish Airlines Flight 1951 17 00:00:48,620 --> 00:00:51,479 involves the most popular plane on Earth. 18 00:00:51,480 --> 00:00:53,819 With nearly one and a half million passengers 19 00:00:53,820 --> 00:00:58,039 boarding 737s every day, investigators need to figure out 20 00:00:58,040 --> 00:00:59,689 if the problem was with the plane 21 00:00:59,690 --> 00:01:01,799 or with the pilots flying it. 22 00:01:05,416 --> 00:01:07,290 Mayday, Mayday. 23 00:01:25,290 --> 00:01:29,239 On the morning of February the 25th, 2009, 24 00:01:29,240 --> 00:01:32,889 Turkish Airlines Flight 1951 becomes the first plane 25 00:01:32,890 --> 00:01:35,269 to crash at Amsterdam's Schiphol Airport 26 00:01:35,270 --> 00:01:36,743 in more than 10 years. 27 00:01:38,838 --> 00:01:40,799 It smashed into the ground really hard. 28 00:01:40,800 --> 00:01:42,839 It made a tremendous noise. 29 00:01:48,070 --> 00:01:50,399 The plane hits the ground in a muddy field 30 00:01:50,400 --> 00:01:53,047 just north of runway 18 Right. 31 00:01:55,210 --> 00:01:57,649 Since the crash was so close to the airport 32 00:01:57,650 --> 00:01:59,692 rescue workers arrive quickly. 33 00:02:01,960 --> 00:02:04,179 Most of the passengers have survived 34 00:02:04,180 --> 00:02:05,673 but many are badly injured. 35 00:02:07,490 --> 00:02:10,306 Survivors are taken straight to local hospitals. 36 00:02:13,470 --> 00:02:15,279 Images of the Amsterdam accident 37 00:02:15,280 --> 00:02:17,399 quickly spread around the world. 38 00:02:17,400 --> 00:02:19,649 This is the third crash of a passenger jet 39 00:02:19,650 --> 00:02:21,233 in the past six weeks. 40 00:02:22,190 --> 00:02:25,223 The sudden nature of this accident adds to the mystery. 41 00:02:29,880 --> 00:02:32,139 It doesn't take long for the Dutch Safety Board 42 00:02:32,140 --> 00:02:33,393 to arrive at the scene. 43 00:02:36,770 --> 00:02:39,059 They will be investigating this accident 44 00:02:39,060 --> 00:02:40,769 but they won't be alone. 45 00:02:40,770 --> 00:02:43,199 The crash involved an American made plane 46 00:02:43,200 --> 00:02:45,839 so the U.S. National Transportation Safety Board 47 00:02:45,840 --> 00:02:47,459 sends Joe Sedor. 48 00:02:47,460 --> 00:02:50,823 One of its most experienced investigators to Amsterdam. 49 00:02:51,730 --> 00:02:54,439 When it's a non U.S. registered aircraft 50 00:02:54,440 --> 00:02:57,779 that crashes overseas, such as this Turkish Airlines, 51 00:02:57,780 --> 00:03:00,219 we are the state of manufacturing 52 00:03:00,220 --> 00:03:01,899 and design of the airframe. 53 00:03:01,900 --> 00:03:04,339 And also in this case the engines. 54 00:03:04,340 --> 00:03:07,029 Fuselage in three large pieces. 55 00:03:07,030 --> 00:03:09,713 Engines forward of the main wreck site. 56 00:03:11,100 --> 00:03:12,959 Flight 1951 was one 57 00:03:12,960 --> 00:03:15,919 of the most advanced aircraft in the skies. 58 00:03:15,920 --> 00:03:19,079 The Boeing seven 37 800 series. 59 00:03:19,080 --> 00:03:23,039 It's designed to travel longer routes at higher altitudes. 60 00:03:23,040 --> 00:03:25,579 The new generation 737 is still 61 00:03:25,580 --> 00:03:27,543 the best airplane Boeing ever built. 62 00:03:28,380 --> 00:03:32,159 We developed an airplane that had an improved wing, 63 00:03:32,160 --> 00:03:36,009 improved avionics, simpler systems 64 00:03:36,010 --> 00:03:38,219 that required less maintenance. 65 00:03:38,220 --> 00:03:41,489 Investigators know this isn't just any plane. 66 00:03:41,490 --> 00:03:45,173 The 737 is the world's best selling commercial jet. 67 00:03:46,150 --> 00:03:49,469 Finding out why this one crashed is imperative. 68 00:03:49,470 --> 00:03:52,319 There are more than 5,000 of them in the skies. 69 00:03:52,320 --> 00:03:56,319 They carry about one and a half million passengers a day. 70 00:03:56,320 --> 00:03:58,939 Investigators must quickly determine if there's a flaw 71 00:03:58,940 --> 00:04:01,949 with the plane that could cause another accident. 72 00:04:01,950 --> 00:04:04,699 What they know so far is that Flight 1951 73 00:04:04,700 --> 00:04:08,053 had been traveling from Istanbul, Turkey to Amsterdam. 74 00:04:09,670 --> 00:04:13,719 There were 128 passengers on board the early morning flight 75 00:04:13,720 --> 00:04:16,083 including four engineers from Boeing. 76 00:04:18,813 --> 00:04:19,699 Ladies and gentlemen, 77 00:04:19,700 --> 00:04:21,119 we're beginning our descent towards 78 00:04:21,120 --> 00:04:22,909 Amsterdam Schiphol Airport. 79 00:04:22,910 --> 00:04:24,909 Please raise your seat backs to the upright position 80 00:04:24,910 --> 00:04:26,460 and stow away your tray tables. 81 00:04:28,530 --> 00:04:29,979 There was no mention on board 82 00:04:29,980 --> 00:04:31,880 of any kind of trouble in the cockpit. 83 00:04:35,120 --> 00:04:38,739 The crash has killed nine people, including three members 84 00:04:38,740 --> 00:04:41,623 of the Boeing team and the pilots in the cockpit. 85 00:04:43,730 --> 00:04:45,919 See if you can get me some aerials of the crash site. 86 00:04:45,920 --> 00:04:47,439 There are eerie similarities 87 00:04:47,440 --> 00:04:50,969 to another recent accident involving a Boeing aircraft. 88 00:04:50,970 --> 00:04:53,279 British Airways Flight 38. 89 00:04:53,280 --> 00:04:55,049 Approximately a year before this, 90 00:04:55,050 --> 00:04:58,719 there had been a 777 short landing at Heathrow, 91 00:04:58,720 --> 00:05:00,549 which had a dual engine flame up. 92 00:05:00,550 --> 00:05:02,979 In that accident, a Boeing 777 fell 93 00:05:02,980 --> 00:05:04,733 to the ground short of the runway. 94 00:05:06,420 --> 00:05:08,169 The British Airways pilots reported 95 00:05:08,170 --> 00:05:10,759 that both their engines stopped delivering power 96 00:05:10,760 --> 00:05:12,003 just before landing. 97 00:05:13,230 --> 00:05:15,309 At the time of the Turkish Airways crash 98 00:05:15,310 --> 00:05:18,167 the cause of that accident hasn't been found. 99 00:05:21,600 --> 00:05:23,779 Like in that case, investigators have plenty 100 00:05:23,780 --> 00:05:25,599 of clues to work with. 101 00:05:25,600 --> 00:05:29,079 The plane and its engines are largely intact. 102 00:05:29,080 --> 00:05:31,749 The flight data recorder and cockpit voice recorder 103 00:05:31,750 --> 00:05:33,609 are found in good condition. 104 00:05:33,610 --> 00:05:35,339 There are also plenty of survivors 105 00:05:35,340 --> 00:05:36,893 to describe what happened. 106 00:05:38,710 --> 00:05:41,869 According to the passengers, the landing had been routine, 107 00:05:41,870 --> 00:05:44,139 but then suddenly the plane simply dropped out 108 00:05:44,140 --> 00:05:46,498 of the sky and hit the ground. 109 00:05:52,640 --> 00:05:53,879 But perhaps the biggest clue 110 00:05:53,880 --> 00:05:55,939 comes from the crash site itself. 111 00:05:55,940 --> 00:05:58,359 The wreckage is not spread out. 112 00:05:58,360 --> 00:06:00,189 It tells investigators that the plane 113 00:06:00,190 --> 00:06:02,539 could not have been traveling forward at high speed 114 00:06:02,540 --> 00:06:03,690 when it hit the ground. 115 00:06:04,780 --> 00:06:07,829 The way the aircraft had crashed, it did appear 116 00:06:07,830 --> 00:06:10,159 to be some sort of a landing accident 117 00:06:10,160 --> 00:06:13,899 in which there was moderate control of some sort. 118 00:06:13,900 --> 00:06:15,269 The pattern of debris 119 00:06:15,270 --> 00:06:17,689 and the passenger reports point investigators 120 00:06:17,690 --> 00:06:19,639 to an immediate suspect. 121 00:06:19,640 --> 00:06:20,473 The engines. 122 00:06:21,750 --> 00:06:24,179 The engines issue was a very big issue 123 00:06:24,180 --> 00:06:27,469 in my thought process at the time, initially. 124 00:06:27,470 --> 00:06:30,169 There's no evidence of fire on the fuselage. 125 00:06:30,170 --> 00:06:34,319 In many crashes fuel in the planes tanks ignites on impact. 126 00:06:34,320 --> 00:06:37,099 The lack of fire raises an obvious question. 127 00:06:37,100 --> 00:06:40,096 Did the engine stop running because Flight 1951 128 00:06:40,097 --> 00:06:42,619 had simply run out of gas? 129 00:06:42,620 --> 00:06:44,269 That was one of the first thoughts that I had 130 00:06:44,270 --> 00:06:46,959 was did this airplane have fuel aboard 131 00:06:46,960 --> 00:06:49,809 because otherwise how does a 737 literally fall out 132 00:06:49,810 --> 00:06:52,749 of the sky on approach to an airport? 133 00:06:52,750 --> 00:06:54,369 But the location and condition 134 00:06:54,370 --> 00:06:55,869 of the plane's engines suggest 135 00:06:55,870 --> 00:06:58,069 that perhaps they didn't quit in flight. 136 00:06:58,070 --> 00:06:59,519 Sure looks like it was running. 137 00:06:59,520 --> 00:07:02,243 When we first looked at where the engines ended up, 138 00:07:03,208 --> 00:07:05,609 at the initial impression was that they probably 139 00:07:05,610 --> 00:07:08,049 were producing thrust that had impact, 140 00:07:08,050 --> 00:07:11,509 given that they were so far forward of the main wreckage. 141 00:07:11,510 --> 00:07:15,463 That was just a very general conclusion. 142 00:07:16,300 --> 00:07:17,829 Only the flight data recorder 143 00:07:17,830 --> 00:07:20,449 can tell investigators how much power the engines 144 00:07:20,450 --> 00:07:23,183 were generating in the seconds before the crash. 145 00:07:25,520 --> 00:07:27,099 Lots of fuel. 146 00:07:27,100 --> 00:07:28,519 Rules that out. 147 00:07:28,520 --> 00:07:29,959 It doesn't take long to discover 148 00:07:29,960 --> 00:07:32,759 that there was plenty of fuel in the planes tanks. 149 00:07:32,760 --> 00:07:37,340 Flight 1951 definitely did not run out of gas. 150 00:07:38,930 --> 00:07:41,079 Passengers report that in the final seconds 151 00:07:41,080 --> 00:07:44,919 before the crash, the plane hit what felt like turbulence. 152 00:07:44,920 --> 00:07:47,889 It points investigators to a well-known culprit. 153 00:07:47,890 --> 00:07:49,359 A microburst. 154 00:07:49,360 --> 00:07:51,609 A microburst is a powerful column of air 155 00:07:51,610 --> 00:07:53,489 that shoots out of storm clouds. 156 00:07:53,490 --> 00:07:57,159 It can literally slam a low flying plane to the ground. 157 00:07:57,160 --> 00:07:59,959 If an airplane flies into that at approach speed, 158 00:07:59,960 --> 00:08:01,239 you're not gonna be flying anymore, 159 00:08:01,240 --> 00:08:02,989 you're gonna come out of the sky. 160 00:08:02,990 --> 00:08:04,139 Certainly it was one of the things 161 00:08:04,140 --> 00:08:05,959 that all of us took a look at at the beginning, 162 00:08:05,960 --> 00:08:07,496 was there a microburst. 163 00:08:12,920 --> 00:08:15,879 In 1985, a Delta Airlines flight 164 00:08:15,880 --> 00:08:17,849 was caught in a microburst while landing 165 00:08:17,850 --> 00:08:20,159 at Dallas Fort Worth Airport. 166 00:08:20,160 --> 00:08:22,969 The plane hit the ground short of the runway. 167 00:08:22,970 --> 00:08:27,943 137 people were killed. 168 00:08:29,540 --> 00:08:31,859 Investigators learned that there were heavy clouds 169 00:08:31,860 --> 00:08:34,899 above the airport at the time of the accident. 170 00:08:34,900 --> 00:08:38,210 A powerful gust of wind may well have accompanied them. 171 00:08:40,350 --> 00:08:42,939 The flight data recorder would have recorded wind speeds 172 00:08:42,940 --> 00:08:44,083 outside the plane. 173 00:08:45,130 --> 00:08:47,729 Investigators will need to analyze the flight data 174 00:08:47,730 --> 00:08:49,543 to prove the microburst theory. 175 00:08:50,710 --> 00:08:54,223 In the meantime, the rescue has led to an unusual discovery. 176 00:08:55,150 --> 00:08:57,879 There was three pilots in the cockpit. 177 00:08:57,880 --> 00:09:01,139 Which is unusual, this is a two crew cockpit. 178 00:09:01,140 --> 00:09:04,129 So why was that third pilot there? 179 00:09:04,130 --> 00:09:05,659 Since none of the three pilots 180 00:09:05,660 --> 00:09:08,629 survived the accident, it's all the more urgent 181 00:09:08,630 --> 00:09:10,709 for investigators to retrieve the data 182 00:09:10,710 --> 00:09:12,353 from the cockpit voice recorder. 183 00:09:13,520 --> 00:09:15,623 It records conversations in the cockpit. 184 00:09:16,830 --> 00:09:18,049 They're in luck 185 00:09:18,050 --> 00:09:20,199 Because of the way that the aircraft crashed the access 186 00:09:20,200 --> 00:09:21,759 to the recorders and the condition 187 00:09:21,760 --> 00:09:23,539 of the recorders was excellent. 188 00:09:23,540 --> 00:09:25,219 The reason for the third pilot 189 00:09:25,220 --> 00:09:26,679 is soon uncovered. 190 00:09:26,680 --> 00:09:29,209 Flying standard arrival route. 191 00:09:29,210 --> 00:09:31,769 Visibility 3,500 meters. 192 00:09:31,770 --> 00:09:34,839 Expected to decrease to 2,500 meters. 193 00:09:34,840 --> 00:09:37,139 For First Officer Murat Sezer, 194 00:09:37,140 --> 00:09:39,579 this had been a training flight of sorts. 195 00:09:39,580 --> 00:09:41,799 He was new to the airline and was being shown 196 00:09:41,800 --> 00:09:44,313 the intricacies of landing at Amsterdam's Airport. 197 00:09:45,869 --> 00:09:48,199 In the Jeppesen charts which is what all pilots use 198 00:09:48,200 --> 00:09:50,279 to navigate to and from Schiphol, 199 00:09:50,280 --> 00:09:53,569 there's 102 pages of information on Schiphol alone. 200 00:09:53,570 --> 00:09:55,919 So there's dozens of approaches. 201 00:09:55,920 --> 00:10:00,789 Runway 18 Right has three high-speed exits to the left. 202 00:10:00,790 --> 00:10:02,769 The Captain, Hasan Arisan 203 00:10:02,770 --> 00:10:04,293 was doing double duty. 204 00:10:05,210 --> 00:10:07,249 He was training his first officer... 205 00:10:07,250 --> 00:10:10,239 Make small corrections as we get close to the runway. 206 00:10:10,240 --> 00:10:13,419 And was in command of Flight 1951. 207 00:10:13,420 --> 00:10:15,849 It's because Captain Arisan was teaching 208 00:10:15,850 --> 00:10:18,699 that there was the third pilot in the cockpit. 209 00:10:18,700 --> 00:10:21,359 Olgay Ozgur was a Safety Pilot. 210 00:10:21,360 --> 00:10:23,829 He was there to keep an eye on the flights progress 211 00:10:23,830 --> 00:10:26,039 during this training mission. 212 00:10:26,040 --> 00:10:28,749 The purpose of that second set of eyes 213 00:10:28,750 --> 00:10:33,409 is to make sure that the Captain and the First Officer 214 00:10:33,410 --> 00:10:35,869 if they're in a situation where it's a little bit 215 00:10:35,870 --> 00:10:38,009 of a training portion of the flight, 216 00:10:38,010 --> 00:10:40,349 that they don't miss something. 217 00:10:40,350 --> 00:10:41,700 We got a clean recording. 218 00:10:43,490 --> 00:10:44,959 The voice recorder reveals 219 00:10:44,960 --> 00:10:47,389 that the three crew members began preparations 220 00:10:47,390 --> 00:10:50,343 for landing when still above 8,500 feet. 221 00:10:53,632 --> 00:10:55,640 Amsterdam, Turkish 1951. 222 00:10:56,640 --> 00:10:58,449 Descending to 7,000. 223 00:10:58,450 --> 00:11:00,967 Speed, two, five, zero. 224 00:11:00,968 --> 00:11:01,849 But the voice recorder 225 00:11:01,850 --> 00:11:04,099 has picked up an unusual sound. 226 00:11:04,100 --> 00:11:07,809 A warning that makes no sense at this stage of the flight. 227 00:11:07,810 --> 00:11:09,369 One of the investigators from Boeing 228 00:11:09,370 --> 00:11:13,559 was an engineering pilot that came 229 00:11:13,560 --> 00:11:15,789 and helped with the CVR. 230 00:11:15,790 --> 00:11:19,529 And he's listening to see are there any unusual sounds 231 00:11:19,530 --> 00:11:21,409 that can be heard that would not be normal. 232 00:11:21,410 --> 00:11:23,560 Feet okay for ILS, 18 Right. 233 00:11:25,920 --> 00:11:28,029 Descent to 4,000. 234 00:11:28,030 --> 00:11:29,476 ILS 18 Right. 235 00:11:30,510 --> 00:11:32,439 The alarm keeps sounding. 236 00:11:32,440 --> 00:11:35,979 It's the landing gear configuration warning horn. 237 00:11:35,980 --> 00:11:38,413 Captain Arisan continually dismisses it. 238 00:11:39,660 --> 00:11:44,660 Turkish 1951, descent 4,000 ILS 18 Right. 239 00:11:49,350 --> 00:11:50,744 Landing gear. 240 00:11:52,901 --> 00:11:54,479 Is that the landing gear warning? 241 00:11:54,480 --> 00:11:56,909 They're 8,300 feet here. 242 00:11:56,910 --> 00:11:59,429 The warning is a solid clue. 243 00:11:59,430 --> 00:12:01,299 But investigators can't yet see 244 00:12:01,300 --> 00:12:03,813 how it could possibly have caused a crash. 245 00:12:05,670 --> 00:12:08,459 The crew of Turkish Airlines Flight 1951 246 00:12:08,460 --> 00:12:10,719 got warnings to extend their landing gear 247 00:12:10,720 --> 00:12:12,883 while still thousands of feet in the air. 248 00:12:13,730 --> 00:12:17,619 On the initial listen, we heard a gear warning horn 249 00:12:17,620 --> 00:12:20,809 occur as the aircraft was approaching when it was still up 250 00:12:20,810 --> 00:12:23,623 and it was coming in about 10,000 feet below. 251 00:12:24,750 --> 00:12:26,179 Investigators now turn 252 00:12:26,180 --> 00:12:28,639 to the flight data recorder to help solve some 253 00:12:28,640 --> 00:12:30,929 of the mystery surrounding this flight. 254 00:12:30,930 --> 00:12:32,589 The analysis of wind speeds 255 00:12:32,590 --> 00:12:34,749 outside the aircraft is completed. 256 00:12:34,750 --> 00:12:36,959 It's clear none are drastic enough 257 00:12:36,960 --> 00:12:39,098 to have brought down the plane. 258 00:12:39,099 --> 00:12:40,599 No evidence of a microburst. 259 00:12:43,330 --> 00:12:45,329 But the flight data recorder does provide 260 00:12:45,330 --> 00:12:47,399 some valuable insight into the cause 261 00:12:47,400 --> 00:12:49,665 of the landing gear warning. 262 00:12:51,260 --> 00:12:53,669 One of the instruments that measures altitude 263 00:12:53,670 --> 00:12:55,893 had the plane already on the ground. 264 00:12:57,180 --> 00:12:59,723 When we looked and saw the radio altimeter data, 265 00:13:00,660 --> 00:13:03,009 on the recorder it said about 8,000 feet 266 00:13:03,010 --> 00:13:06,329 and then immediately it went down to about minus eight. 267 00:13:06,330 --> 00:13:08,799 Minus eight feet is an indication that the aircraft's 268 00:13:08,800 --> 00:13:11,470 on the ground, but of course it's still at 2,000 feet. 269 00:13:12,510 --> 00:13:14,459 The Boeing 737 is equipped 270 00:13:14,460 --> 00:13:16,549 with two separate altimeters. 271 00:13:16,550 --> 00:13:18,649 One measures air pressure to determine 272 00:13:18,650 --> 00:13:20,350 the planes height above sea level. 273 00:13:21,660 --> 00:13:24,159 That reading is displayed prominently in the cockpit 274 00:13:24,160 --> 00:13:25,963 on both pilots flight display. 275 00:13:27,410 --> 00:13:28,242 Sensor. 276 00:13:28,243 --> 00:13:29,469 The plane is also equipped 277 00:13:29,470 --> 00:13:31,639 with a radio altimeter. 278 00:13:31,640 --> 00:13:34,279 It's made up of four antennas. 279 00:13:34,280 --> 00:13:36,559 Two transmit signals to the ground 280 00:13:36,560 --> 00:13:39,289 and two others read the signal that bounces back 281 00:13:39,290 --> 00:13:40,890 to determine the plane's height. 282 00:13:41,804 --> 00:13:43,630 It's precise. 283 00:13:43,631 --> 00:13:45,139 It's very, very precise. 284 00:13:45,140 --> 00:13:50,140 Pressure altimeters can sometime be not as accurate. 285 00:13:50,430 --> 00:13:53,769 And radar altimeters are a 100% accurate. 286 00:13:53,770 --> 00:13:55,182 If they're working properly. 287 00:13:59,410 --> 00:14:00,899 One antenna feeds the reading 288 00:14:00,900 --> 00:14:02,513 to the First Officer's display. 289 00:14:03,820 --> 00:14:06,033 The other feeds the Captains instruments. 290 00:14:07,300 --> 00:14:11,379 In the case of Flight 1951, the Captain side was wrong 291 00:14:11,380 --> 00:14:13,043 most of the flight. 292 00:14:15,340 --> 00:14:17,749 Investigators go back over the CVR 293 00:14:17,750 --> 00:14:19,363 and make a puzzling discovery. 294 00:14:20,330 --> 00:14:23,043 Amsterdam, Turkish 1951. 295 00:14:23,950 --> 00:14:25,886 Descending to 7,000. 296 00:14:25,887 --> 00:14:27,945 Speed, two, five, zero. 297 00:14:31,290 --> 00:14:32,849 Radio altimeter. 298 00:14:32,850 --> 00:14:34,859 Captain Arisan seems to have known 299 00:14:34,860 --> 00:14:37,079 that the landing gear warning was being caused 300 00:14:37,080 --> 00:14:39,189 by a faulty radio altimeter. 301 00:14:39,190 --> 00:14:41,279 The airplane thought that it was low to the ground 302 00:14:41,280 --> 00:14:42,679 and the gear was not down. 303 00:14:42,680 --> 00:14:44,709 And the Captain recognized that the problem 304 00:14:44,710 --> 00:14:47,759 was really in the radio altimeter. 305 00:14:47,760 --> 00:14:49,989 Showing him that they should be on the ground 306 00:14:49,990 --> 00:14:52,579 and he goes, "It's just the radio altimeter." 307 00:14:52,580 --> 00:14:54,129 Throughout much of the approach, 308 00:14:54,130 --> 00:14:57,069 the Captain's radio altimeter had been displaying a reading 309 00:14:57,070 --> 00:14:58,659 of minus eight feet. 310 00:14:58,660 --> 00:15:01,319 Triggering the warning to lower the gear. 311 00:15:01,320 --> 00:15:03,682 They treated it like it was a nuisance. 312 00:15:05,360 --> 00:15:07,453 Turkish 1951, descent to 2,000. 313 00:15:10,077 --> 00:15:12,433 2,000, 1951. 314 00:15:16,260 --> 00:15:19,679 Investigators dig for any other abnormalities. 315 00:15:19,680 --> 00:15:23,569 They learn that with Flight 1951 still about 17 kilometers 316 00:15:23,570 --> 00:15:26,569 from the airport controllers directed the pilots 317 00:15:26,570 --> 00:15:29,999 to begin their final turn to line up with the runway. 318 00:15:30,000 --> 00:15:32,039 Turkish 1951. 319 00:15:32,040 --> 00:15:34,379 Left heading , two, one, zero. 320 00:15:34,380 --> 00:15:37,323 Clear approach, one eight right. 321 00:15:38,350 --> 00:15:40,009 Left, two, one, zero. 322 00:15:40,010 --> 00:15:42,733 Clear ILS, Turkish 1951. 323 00:15:45,700 --> 00:15:47,610 Two, one, zero, set, sir. 324 00:15:48,570 --> 00:15:50,849 This turn puts flight 1951 325 00:15:50,850 --> 00:15:53,303 in line with runway 18 Right. 326 00:15:55,120 --> 00:15:57,449 It's equipped with an instrument landing system, 327 00:15:57,450 --> 00:16:00,829 which sends out a signal outlining the ideal descent path 328 00:16:00,830 --> 00:16:02,130 to the foot of the runway. 329 00:16:03,580 --> 00:16:06,559 The autopilot follows that glide path until the plane 330 00:16:06,560 --> 00:16:08,839 is a few hundred feet from the ground. 331 00:16:08,840 --> 00:16:10,253 Then the pilot takes over. 332 00:16:11,170 --> 00:16:13,769 It makes landing almost effortless. 333 00:16:13,770 --> 00:16:15,449 The ILS is pretty easy to follow. 334 00:16:15,450 --> 00:16:16,579 It's a video game. 335 00:16:16,580 --> 00:16:19,649 My daughter has a flown in a simulator 336 00:16:19,650 --> 00:16:23,853 and can land a 737 using the ILS. 337 00:16:27,860 --> 00:16:29,849 The crew begins configuring their plane 338 00:16:29,850 --> 00:16:32,529 for landing unfazed by the warning horn 339 00:16:32,530 --> 00:16:33,759 that's repeatedly triggered 340 00:16:33,760 --> 00:16:35,833 by the malfunctioning radio altimeter. 341 00:16:37,000 --> 00:16:37,963 Flaps 15. 342 00:16:39,730 --> 00:16:42,989 10 kilometers out, Flight 1951 picks up 343 00:16:42,990 --> 00:16:45,893 the ILS signal that will guide the plane to the runway. 344 00:16:47,547 --> 00:16:49,003 Localizer alive. 345 00:16:51,543 --> 00:16:53,109 Localizer capture. 346 00:16:53,110 --> 00:16:55,229 The Safety Pilot, Olgay Ozgur, 347 00:16:55,230 --> 00:16:58,799 now reminds Captain Arisan about the failed altimeter. 348 00:16:58,800 --> 00:17:01,001 We have radio altimeter failure, sir. 349 00:17:01,002 --> 00:17:02,703 Okay. 350 00:17:05,560 --> 00:17:06,393 Turkish 1951. 351 00:17:08,320 --> 00:17:11,969 Runway one, eight, right. 352 00:17:11,970 --> 00:17:13,549 Cleared to land. 353 00:17:13,550 --> 00:17:14,579 Cleared the land. 354 00:17:14,580 --> 00:17:16,219 Thank you. 355 00:17:16,220 --> 00:17:18,409 Investigators are stumped. 356 00:17:18,410 --> 00:17:20,399 The crew knew about the malfunction 357 00:17:20,400 --> 00:17:22,399 and continued their approach. 358 00:17:22,400 --> 00:17:25,279 How had it then caused them to crash? 359 00:17:25,280 --> 00:17:27,159 Clearly, there was more to this accident 360 00:17:27,160 --> 00:17:28,929 than a faulty altimeter. 361 00:17:28,930 --> 00:17:31,339 The whole premise of airline safety 362 00:17:31,340 --> 00:17:32,869 and the way we build the airplanes, 363 00:17:32,870 --> 00:17:35,139 the way we fly them is based on the idea 364 00:17:35,140 --> 00:17:37,229 that we can have any number of failures 365 00:17:37,230 --> 00:17:39,999 and we should still be able to arrive safely. 366 00:17:40,000 --> 00:17:42,129 The radio altimeter is just one instrument. 367 00:17:42,130 --> 00:17:44,529 There's no way in the world that that one instrument 368 00:17:44,530 --> 00:17:48,679 if it fails should be a major cause of worry 369 00:17:48,680 --> 00:17:50,180 that we're gonna have a crash. 370 00:17:53,100 --> 00:17:55,139 Investigators wonder if the crew 371 00:17:55,140 --> 00:17:57,653 had been given proper guidance for their approach. 372 00:17:59,420 --> 00:18:01,396 They turned to exchanges between the pilots 373 00:18:01,397 --> 00:18:03,523 and the controller who guided them in. 374 00:18:06,150 --> 00:18:09,259 They carefully review every instruction. 375 00:18:09,260 --> 00:18:12,759 Turkish 1951, descend to 4,000. 376 00:18:12,760 --> 00:18:16,490 Speed okay for ILS, one, eight, right. 377 00:18:18,450 --> 00:18:21,203 Turkish 1951, descend to 2,000. 378 00:18:24,760 --> 00:18:29,099 Turkish 1951, left heading, two, one, zero. 379 00:18:29,100 --> 00:18:32,083 Cleared approach, one, eight, right. 380 00:18:33,290 --> 00:18:36,799 By following the controller's instructions 381 00:18:36,800 --> 00:18:40,333 the crew made their final turn much too close to the runway. 382 00:18:41,839 --> 00:18:44,979 For the intercept properly, they should be here. 383 00:18:44,980 --> 00:18:46,759 International guidelines, call 384 00:18:46,760 --> 00:18:48,859 for approaching planes to intercept the signal 385 00:18:48,860 --> 00:18:51,429 that guides them to the runway from below. 386 00:18:51,430 --> 00:18:53,699 It's so pilots don't have to make any drastic 387 00:18:53,700 --> 00:18:55,943 last minute course corrections to get to it. 388 00:18:57,479 --> 00:19:00,849 To intercept here, they had to descend. 389 00:19:00,850 --> 00:19:03,409 But Flight 1951 was given instructions 390 00:19:03,410 --> 00:19:05,579 that brought it to the threshold of the glide slope 391 00:19:05,580 --> 00:19:07,259 while still way above it. 392 00:19:07,260 --> 00:19:09,259 It's a common practice at Schiphol 393 00:19:09,260 --> 00:19:11,633 because it gets planes to the runway faster. 394 00:19:12,720 --> 00:19:13,989 Because they were so close, they had 395 00:19:13,990 --> 00:19:16,099 to capture the glide slope from above. 396 00:19:16,100 --> 00:19:18,329 Although it is an unusual situation, 397 00:19:18,330 --> 00:19:21,389 it is one that can be handled by a flight crew 398 00:19:21,390 --> 00:19:22,853 if it is managed properly. 399 00:19:23,710 --> 00:19:25,489 Approaching a glide slope from above 400 00:19:25,490 --> 00:19:27,899 is more difficult mostly because the crew has 401 00:19:27,900 --> 00:19:30,789 to suddenly slow the plane and descend rapidly 402 00:19:30,790 --> 00:19:32,799 to intercept the signal. 403 00:19:32,800 --> 00:19:35,609 We also call this a slam dunk approach. 404 00:19:35,610 --> 00:19:38,139 And some pilots like it, some pilots don't. 405 00:19:38,140 --> 00:19:41,099 It's a little bit harder and things happen quicker 406 00:19:41,100 --> 00:19:42,979 when you're above the glide path, trying 407 00:19:42,980 --> 00:19:44,899 to intercept from above. 408 00:19:44,900 --> 00:19:47,196 And it's just a challenge for a lot of pilots. 409 00:19:48,030 --> 00:19:49,069 The approach from above 410 00:19:49,070 --> 00:19:52,249 increased the crew's workload but it's standard practice 411 00:19:52,250 --> 00:19:53,619 at Schiphol Airport. 412 00:19:53,620 --> 00:19:56,913 I've flown into Schiphol dozens of times and I expect it. 413 00:19:57,900 --> 00:19:59,509 If the controller's instructions 414 00:19:59,510 --> 00:20:02,319 had somehow overtaxed this crew, 415 00:20:02,320 --> 00:20:04,293 their conversations would indicate it. 416 00:20:05,200 --> 00:20:07,899 They're just five kilometers from the runway. 417 00:20:07,900 --> 00:20:09,293 - Thousand. - Check. 418 00:20:11,399 --> 00:20:12,743 Flaps 40. 419 00:20:14,480 --> 00:20:15,353 Speed brake. 420 00:20:16,590 --> 00:20:17,739 Speed brake armed. 421 00:20:17,740 --> 00:20:18,572 Green light. 422 00:20:18,573 --> 00:20:19,600 One thing at a time. 423 00:20:20,690 --> 00:20:22,010 Landing gear. 424 00:20:24,060 --> 00:20:24,892 Gear down. 425 00:20:24,893 --> 00:20:25,726 Three green. 426 00:20:26,720 --> 00:20:28,809 - Flaps? - Flaps, 40. 427 00:20:28,810 --> 00:20:30,042 Greenlight. 428 00:20:33,520 --> 00:20:35,939 - 500. - All lights on. 429 00:20:35,940 --> 00:20:37,634 Please warn the cabin crew. 430 00:20:37,635 --> 00:20:38,567 Okay. 431 00:20:39,401 --> 00:20:40,299 Cabin crew. 432 00:20:40,300 --> 00:20:41,976 Take your seats. 433 00:20:42,810 --> 00:20:44,469 Then real trouble. 434 00:20:44,470 --> 00:20:45,563 A stall warning. 435 00:20:47,606 --> 00:20:50,090 - Speed, sir. - I have control. 436 00:20:50,091 --> 00:20:51,681 100 knots of speed. 437 00:20:54,820 --> 00:20:57,189 Arisan forced to save his plane. 438 00:20:57,190 --> 00:20:59,119 But just 400 feet above the ground, 439 00:20:59,120 --> 00:21:01,759 and only one and a half kilometers from the runway, 440 00:21:01,760 --> 00:21:05,749 the Boeing 737 suddenly fell straight down. 441 00:21:05,750 --> 00:21:08,350 It only took a few seconds for it to hit the ground. 442 00:21:15,400 --> 00:21:17,319 Turkish 1951. 443 00:21:17,320 --> 00:21:18,679 The recording sheds light 444 00:21:18,680 --> 00:21:20,430 on the final minutes of the flight. 445 00:21:21,430 --> 00:21:23,829 The crew was configuring their plane for landing 446 00:21:23,830 --> 00:21:26,226 well after it should have been done. 447 00:21:26,227 --> 00:21:28,629 - Flaps? - Flaps 40, green light. 448 00:21:28,630 --> 00:21:30,179 Most airlines have regulations 449 00:21:30,180 --> 00:21:32,739 that call for a flight to be stabilized 450 00:21:32,740 --> 00:21:34,799 to have all checklists completed 451 00:21:34,800 --> 00:21:37,719 by the time the plane hits 1,000 feet. 452 00:21:37,720 --> 00:21:41,059 In instrument conditions, you required at a 1,000 feet 453 00:21:41,060 --> 00:21:42,709 to have basically everything done. 454 00:21:42,710 --> 00:21:43,939 The airplane is configured. 455 00:21:43,940 --> 00:21:44,772 You have slowed. 456 00:21:44,773 --> 00:21:47,069 You have runned your before landing check 457 00:21:47,070 --> 00:21:49,169 and you have received your landing clearance 458 00:21:49,170 --> 00:21:50,899 and from a 1,000 feet on in, 459 00:21:50,900 --> 00:21:52,639 you just monitor the instruments 460 00:21:52,640 --> 00:21:54,290 and we're looking for the runway. 461 00:21:55,830 --> 00:21:57,496 Please warn the cabin crew. 462 00:21:57,497 --> 00:21:58,330 Yeah. 463 00:21:59,643 --> 00:22:00,475 Cabin crew. 464 00:22:00,476 --> 00:22:02,009 In fact, this crew was still running 465 00:22:02,010 --> 00:22:04,669 their checklist up to the moment the crisis hit, 466 00:22:04,670 --> 00:22:07,250 460 feet above the ground. 467 00:22:10,360 --> 00:22:12,569 This approach was not stabilized. 468 00:22:12,570 --> 00:22:14,179 Because of the aircraft was unstable 469 00:22:14,180 --> 00:22:17,049 the flight crew was in a very high workload environment 470 00:22:17,050 --> 00:22:20,729 in the last 1,000 feet of flight. 471 00:22:20,730 --> 00:22:23,079 The radio altimeter was malfunctioning. 472 00:22:23,080 --> 00:22:25,359 The aircraft was giving off warnings. 473 00:22:25,360 --> 00:22:28,009 The crew was assigned a challenging approach 474 00:22:28,010 --> 00:22:30,599 and they were executing a checklist late. 475 00:22:30,600 --> 00:22:34,699 But none of this explains why Flight 1951 crashed. 476 00:22:34,700 --> 00:22:37,979 In these types of accidents, you can never get inside 477 00:22:37,980 --> 00:22:39,529 the head of the pilots. 478 00:22:39,530 --> 00:22:42,349 And that's a very frustrating type of accident. 479 00:22:42,350 --> 00:22:43,649 But the flight data recorder 480 00:22:43,650 --> 00:22:46,499 does provide another intriguing clue. 481 00:22:46,500 --> 00:22:49,559 Moments before Flight 1951 hit the ground 482 00:22:49,560 --> 00:22:51,429 the planes engines were at idle, 483 00:22:51,430 --> 00:22:53,769 hardly providing any power. 484 00:22:53,770 --> 00:22:57,009 Perhaps this accident is a repeat of the Heathrow incident. 485 00:22:57,010 --> 00:22:59,949 The engines, it was interesting to note 486 00:22:59,950 --> 00:23:03,759 were at idle approximately the last two minutes 487 00:23:03,760 --> 00:23:06,079 of the flight until the very end 488 00:23:06,080 --> 00:23:09,439 when the thrust was increased again. 489 00:23:09,440 --> 00:23:12,239 That was a big red flag right there. 490 00:23:12,240 --> 00:23:14,513 The question is, is why was that the case? 491 00:23:15,510 --> 00:23:16,819 But then they spot something 492 00:23:16,820 --> 00:23:20,009 that's very different from the accident at Heathrow. 493 00:23:20,010 --> 00:23:21,533 Retard Flare Mode. 494 00:23:22,450 --> 00:23:23,669 For some reason, 495 00:23:23,670 --> 00:23:26,919 while still more than a 1,000 feet above the ground 496 00:23:26,920 --> 00:23:30,283 the planes computer began preparing to touch down. 497 00:23:31,550 --> 00:23:34,729 In Retard Flare Mode, engine power is reduced 498 00:23:34,730 --> 00:23:36,473 to idle by the flight computer. 499 00:23:37,990 --> 00:23:40,279 And the planes nose automatically pitches up 500 00:23:40,280 --> 00:23:41,543 to the flare position. 501 00:23:44,760 --> 00:23:46,929 Planes should only be in this configuration 502 00:23:46,930 --> 00:23:49,509 just before they touch the ground. 503 00:23:49,510 --> 00:23:52,209 The autopilot raises the nose to break the descent. 504 00:23:52,210 --> 00:23:55,449 The auto throttles brings the power back to flight idle. 505 00:23:55,450 --> 00:23:57,009 And you touched down with the power 506 00:23:57,010 --> 00:23:59,829 either all the way in idle or just about to be an idol. 507 00:23:59,830 --> 00:24:02,019 But Flight 1951 went 508 00:24:02,020 --> 00:24:05,839 into a slow nose up position well before touchdown. 509 00:24:05,840 --> 00:24:07,689 Causing the plane to fly slower 510 00:24:07,690 --> 00:24:09,743 and slower throughout its descent. 511 00:24:11,300 --> 00:24:14,805 So why was Flight 1951 in landing mode? 512 00:24:17,210 --> 00:24:19,509 And why hadn't any of the three crew members 513 00:24:19,510 --> 00:24:21,503 noticed how slowly they were flying? 514 00:24:32,220 --> 00:24:35,999 So what else was going on when the engines went to idle? 515 00:24:36,000 --> 00:24:37,749 The troubles seems to start 516 00:24:37,750 --> 00:24:39,969 with a malfunctioning altimeter. 517 00:24:39,970 --> 00:24:41,449 We have to look at the system as a whole 518 00:24:41,450 --> 00:24:42,899 and to see how that minus eight 519 00:24:42,900 --> 00:24:45,313 affected the other systems on the aircraft. 520 00:24:46,160 --> 00:24:49,609 And that was a very big portion of this investigation. 521 00:24:49,610 --> 00:24:53,699 We had to say, how did the autopilot use that data? 522 00:24:53,700 --> 00:24:56,929 More importantly, how did the auto throttle use that data? 523 00:24:56,930 --> 00:24:59,079 The computer that flies the plane consists 524 00:24:59,080 --> 00:25:03,579 of two main systems, the auto pilot and the auto throttle. 525 00:25:03,580 --> 00:25:05,919 The auto throttle determines how much power 526 00:25:05,920 --> 00:25:09,039 to ask the engines for while the autopilot controls 527 00:25:09,040 --> 00:25:11,166 the planes altitude and direction. 528 00:25:14,710 --> 00:25:17,569 The two systems work independently of each other. 529 00:25:17,570 --> 00:25:19,559 And only one of the radio altimeters 530 00:25:19,560 --> 00:25:22,499 provides information to the auto throttle. 531 00:25:22,500 --> 00:25:24,299 In this case, I had to learn everything there 532 00:25:24,300 --> 00:25:26,949 was about radio altimeters and auto throttle systems, 533 00:25:26,950 --> 00:25:28,809 which I didn't know before. 534 00:25:28,810 --> 00:25:31,159 The pieces of the puzzle begin coming together 535 00:25:31,160 --> 00:25:32,599 when they find the connection 536 00:25:32,600 --> 00:25:34,729 between the faulty radio altimeter 537 00:25:34,730 --> 00:25:35,823 and engine power. 538 00:25:36,910 --> 00:25:39,309 The radio altimeter provides information 539 00:25:39,310 --> 00:25:41,510 to the auto throttle from the Captains side. 540 00:25:51,230 --> 00:25:53,319 The only altimeter feeding information 541 00:25:53,320 --> 00:25:57,329 to the auto throttle was the captains and it was wrong. 542 00:25:57,330 --> 00:25:59,479 It showed minus eight feet throughout most 543 00:25:59,480 --> 00:26:01,473 of Flight 1951s approach. 544 00:26:03,950 --> 00:26:06,899 It's beginning to look like the faulty radio altimeter 545 00:26:06,900 --> 00:26:09,519 triggered the events that led to the crash. 546 00:26:09,520 --> 00:26:12,363 Investigators need to know what went wrong with it. 547 00:26:13,890 --> 00:26:17,319 On a 737, the transmitting and receiving antennas 548 00:26:17,320 --> 00:26:19,689 for both radio altimeters are lined up 549 00:26:19,690 --> 00:26:20,840 underneath the cockpit. 550 00:26:22,410 --> 00:26:25,569 Three of the antennas were all but destroyed in the crash. 551 00:26:25,570 --> 00:26:26,833 They can't be tested. 552 00:26:27,810 --> 00:26:30,873 But one antenna from the captain side is undamaged. 553 00:26:32,180 --> 00:26:35,129 Investigators consider two possibilities. 554 00:26:35,130 --> 00:26:37,349 A failure of one of the components 555 00:26:37,350 --> 00:26:38,909 or some sort of interference 556 00:26:38,910 --> 00:26:40,483 that caused the faulty reading. 557 00:26:41,490 --> 00:26:44,403 The only component that survived the crash checks out. 558 00:26:50,410 --> 00:26:54,229 The computers that control the system also work. 559 00:26:54,230 --> 00:26:57,919 But investigators do make a curious discovery about them. 560 00:26:57,920 --> 00:27:00,539 They aren't the same ones that were installed on the plane 561 00:27:00,540 --> 00:27:03,440 when it was delivered to Turkish Airlines seven years ago. 562 00:27:04,470 --> 00:27:08,199 This find changes the focus of the investigation. 563 00:27:08,200 --> 00:27:11,929 The maintenance aspect of this accident aircraft 564 00:27:11,930 --> 00:27:15,673 was one that we looked at as deeply as we could. 565 00:27:25,200 --> 00:27:28,009 When the plane's maintenance log is studied, 566 00:27:28,010 --> 00:27:31,099 investigators find that the radio altimeter on this plane 567 00:27:31,100 --> 00:27:32,869 had a problematic history. 568 00:27:32,870 --> 00:27:35,750 We got additional data from Turkish Airlines 569 00:27:36,680 --> 00:27:40,379 and that data showed that on this one aircraft 570 00:27:40,380 --> 00:27:43,529 of the past, I believe over a 1,000 flights 571 00:27:43,530 --> 00:27:45,569 there was about 150 flights 572 00:27:45,570 --> 00:27:47,923 that had faulty radio altimeter systems. 573 00:27:49,250 --> 00:27:51,069 The documents show that a little more 574 00:27:51,070 --> 00:27:54,899 than a year before the crash, both computers were replaced 575 00:27:54,900 --> 00:27:58,329 because of complaints, they were causing faulty readings. 576 00:27:58,330 --> 00:28:01,179 One of the incidents involved a radio altimeter reading 577 00:28:01,180 --> 00:28:02,523 of minus eight feet. 578 00:28:05,150 --> 00:28:07,689 So that was telling us that there was an issue 579 00:28:07,690 --> 00:28:08,839 that had been there. 580 00:28:08,840 --> 00:28:11,083 The issue did not just occur on this flight. 581 00:28:12,690 --> 00:28:15,259 The faulty readings persisted. 582 00:28:15,260 --> 00:28:17,759 Mechanics repeatedly swapped the computers 583 00:28:17,760 --> 00:28:20,663 and replaced the antennas to try to solve the problem. 584 00:28:22,790 --> 00:28:25,989 It's determined that Turkish Airlines tried several ways 585 00:28:25,990 --> 00:28:28,089 to fix the altimeter. 586 00:28:28,090 --> 00:28:30,337 But they couldn't find a repair that worked. 587 00:28:34,370 --> 00:28:37,359 At the time of the accident, Turkish Airlines had a fleet 588 00:28:37,360 --> 00:28:41,393 of 52 Boeing 737 800 series airplanes. 589 00:28:47,540 --> 00:28:49,309 It's on page 93. 590 00:28:49,310 --> 00:28:51,299 When we reviewed the maintenance data, 591 00:28:51,300 --> 00:28:53,199 we found that radio altimeter problems 592 00:28:53,200 --> 00:28:54,989 had been written up several times 593 00:28:54,990 --> 00:28:58,323 on both the accident airplane and the fleet. 594 00:28:59,510 --> 00:29:00,849 Investigators discover 595 00:29:00,850 --> 00:29:02,879 that in the year before the crash 596 00:29:02,880 --> 00:29:06,949 Turkish Airlines dealt with 235 system faults 597 00:29:06,950 --> 00:29:09,913 with the radio altimeters on their 737s. 598 00:29:11,890 --> 00:29:15,549 Fixes ranged from replacing and exchanging antennas, 599 00:29:15,550 --> 00:29:18,089 cleaning of the systems, exchanging 600 00:29:18,090 --> 00:29:19,600 and replacing the computers 601 00:29:20,550 --> 00:29:23,059 and installing gaskets to shield the system 602 00:29:23,060 --> 00:29:24,603 from possible water damage. 603 00:29:26,280 --> 00:29:29,249 It's not like they weren't doing anything about it. 604 00:29:29,250 --> 00:29:32,119 The Turkish Airlines maintenance personnel knew 605 00:29:32,120 --> 00:29:36,069 that the radio altimeter problem was one 606 00:29:36,070 --> 00:29:39,799 of their highest issues with regard to maintenance. 607 00:29:39,800 --> 00:29:42,379 16 of those altimeter repairs were made 608 00:29:42,380 --> 00:29:45,643 to the plane that crashed in February, 2009. 609 00:29:46,820 --> 00:29:50,089 If the problem was so widespread, investigators wonder 610 00:29:50,090 --> 00:29:53,423 why it hadn't caused serious problems before this accident. 611 00:29:56,370 --> 00:29:58,249 They don't have to dig too far back 612 00:29:58,250 --> 00:30:00,599 to find out that in fact it had, 613 00:30:00,600 --> 00:30:02,583 on this very same plane. 614 00:30:03,510 --> 00:30:06,360 On two recent flights, they had the exact same problem. 615 00:30:07,360 --> 00:30:09,619 Twice in the 48 hours leading up 616 00:30:09,620 --> 00:30:12,329 to the accident, the radio altimeter 617 00:30:12,330 --> 00:30:14,539 showed a negative reading, 618 00:30:14,540 --> 00:30:16,763 putting the plane into Retard Flare Mode. 619 00:30:18,430 --> 00:30:20,653 Both times the crew noticed the problem. 620 00:30:21,640 --> 00:30:23,799 Disengage the also throttles 621 00:30:23,800 --> 00:30:26,518 and brought the plane in for a safe landing. 622 00:30:31,860 --> 00:30:34,439 You just disconnect them and fly the airplane. 623 00:30:34,440 --> 00:30:36,289 In the months after the crash, 624 00:30:36,290 --> 00:30:39,969 other operators come forward with similar stories. 625 00:30:39,970 --> 00:30:43,909 In Australia, in the Netherlands, in Canada 626 00:30:43,910 --> 00:30:47,259 in Austria pilots report their 737s 627 00:30:47,260 --> 00:30:50,819 going into Retard Flare Mode when the left radio altimeter 628 00:30:50,820 --> 00:30:52,283 showed a faulty reading. 629 00:30:53,170 --> 00:30:56,219 Each of those crews reacted the same way. 630 00:30:56,220 --> 00:30:58,309 They disengage the auto throttle 631 00:30:58,310 --> 00:31:00,363 and push the power back up manually. 632 00:31:02,410 --> 00:31:03,873 They all landed safely. 633 00:31:06,170 --> 00:31:07,809 Things are gonna break on an airplane 634 00:31:07,810 --> 00:31:10,130 and usually you're able to identify that 635 00:31:11,010 --> 00:31:14,573 and make it so that it's not a threat for the landing. 636 00:31:16,360 --> 00:31:20,253 In 2008, Boeing received a whopping 2,569 637 00:31:22,210 --> 00:31:26,689 reports of faulty radio altimeters on their latest 737s. 638 00:31:26,690 --> 00:31:28,739 But very few of those cases involved 639 00:31:28,740 --> 00:31:31,499 the plane going into Retard Flare Mode. 640 00:31:31,500 --> 00:31:33,003 Hardly any reports at all. 641 00:31:34,980 --> 00:31:37,049 Boeing also tried, but couldn't find 642 00:31:37,050 --> 00:31:39,339 the cause of the failures. 643 00:31:39,340 --> 00:31:41,669 They concluded that the radio altimeter problem 644 00:31:41,670 --> 00:31:43,769 was not a threat to safety because 645 00:31:43,770 --> 00:31:46,459 the 737 gives off enough warnings 646 00:31:46,460 --> 00:31:49,344 so that crews can intervene and land safely. 647 00:31:51,750 --> 00:31:53,129 In fact, in every instance 648 00:31:53,130 --> 00:31:55,419 where the radio altimeter failed 649 00:31:55,420 --> 00:31:57,213 crews were able to recover. 650 00:32:00,337 --> 00:32:02,859 Turkish Airlines Flight 1951 seems 651 00:32:02,860 --> 00:32:04,133 to be the one exception. 652 00:32:08,210 --> 00:32:10,493 Investigators still don't know why. 653 00:32:11,890 --> 00:32:14,349 It really got us wondering of what happened. 654 00:32:14,350 --> 00:32:16,939 And that's when we started to look really closely 655 00:32:16,940 --> 00:32:20,529 at the actions of the flight crews 656 00:32:20,530 --> 00:32:22,409 while it was on that final approach 657 00:32:22,410 --> 00:32:23,883 in less than a 1,000 feet. 658 00:32:25,860 --> 00:32:29,169 Finally, as investigators again revisit 659 00:32:29,170 --> 00:32:32,199 the last minutes of Flight 1951, 660 00:32:32,200 --> 00:32:34,963 the circumstances of the tragedy become clear. 661 00:32:36,310 --> 00:32:38,609 They see a remarkable sequence of events 662 00:32:38,610 --> 00:32:40,943 that transpire to bring down this plane. 663 00:32:42,233 --> 00:32:44,089 So what was happening when 664 00:32:44,090 --> 00:32:46,329 the plane went into Retard Flare Mode? 665 00:32:46,330 --> 00:32:47,609 They discover that the plane 666 00:32:47,610 --> 00:32:50,509 went into landing mode and pulled back power 667 00:32:50,510 --> 00:32:52,379 at the worst possible moment. 668 00:32:52,380 --> 00:32:55,729 Exactly as the crew was descending to meet the glide slope. 669 00:32:55,730 --> 00:32:57,730 It masked what was actually happening. 670 00:33:00,240 --> 00:33:01,929 As the crew configured their plane 671 00:33:01,930 --> 00:33:04,419 to drop down to meet the glide slope, 672 00:33:04,420 --> 00:33:06,419 they expected the plane to slow down 673 00:33:06,420 --> 00:33:08,439 as part of that maneuver. 674 00:33:08,440 --> 00:33:10,389 But the plane was actually slowing down 675 00:33:10,390 --> 00:33:12,583 because the computer was in landing mode. 676 00:33:13,610 --> 00:33:15,959 That's why none of the three pilots said anything 677 00:33:15,960 --> 00:33:18,309 about the throttles moving to idle. 678 00:33:18,310 --> 00:33:19,409 It was insidious. 679 00:33:19,410 --> 00:33:21,809 Were it first captured in the Retard Mode, 680 00:33:21,810 --> 00:33:24,419 it didn't hurt them at all because they were actually high 681 00:33:24,420 --> 00:33:26,039 and they were a little bit fast. 682 00:33:26,040 --> 00:33:28,499 And the pilots actually wanted the power back anyway, 683 00:33:28,500 --> 00:33:29,679 in fact the throttles may have already 684 00:33:29,680 --> 00:33:32,839 been in the flight idle mode as they were trying 685 00:33:32,840 --> 00:33:34,443 to get down and slow down. 686 00:33:35,606 --> 00:33:38,149 Right the trouble starts here at 8,300 feet, 687 00:33:38,150 --> 00:33:42,189 13 miles out from the airport, minutes before the crash. 688 00:33:47,930 --> 00:33:52,539 Amsterdam, Turkish 1951 descending 7,000. 689 00:33:52,540 --> 00:33:54,360 Speed, two, five, zero. 690 00:33:56,560 --> 00:33:58,539 Turkish 1951. 691 00:33:58,540 --> 00:34:00,244 Descend to 4,000. 692 00:34:00,245 --> 00:34:01,121 Speed okay 693 00:34:01,122 --> 00:34:03,963 for ILS, one, eight, right. 694 00:34:05,660 --> 00:34:07,003 Radio altimeter. 695 00:34:11,790 --> 00:34:13,119 But would the crew have known 696 00:34:13,120 --> 00:34:14,759 that because of that radio altimeter 697 00:34:14,760 --> 00:34:16,747 they would've gone to a Retard Flare Mode 698 00:34:16,748 --> 00:34:18,019 in their throttles? 699 00:34:18,020 --> 00:34:18,853 No. 700 00:34:19,830 --> 00:34:21,699 It's a common problem at the airline 701 00:34:21,700 --> 00:34:25,089 that the crew couldn't see the risk it posed this flight. 702 00:34:25,090 --> 00:34:26,889 We have an airplane that was malfunctioning 703 00:34:26,890 --> 00:34:29,099 in a very minor way, but in a way 704 00:34:29,100 --> 00:34:32,139 that if not caught could and did metastasize 705 00:34:32,140 --> 00:34:33,883 into something much more virulent. 706 00:34:35,170 --> 00:34:36,897 Turkish 1951. 707 00:34:36,898 --> 00:34:38,603 Descend to 2,000. 708 00:34:38,604 --> 00:34:39,769 2,000. 709 00:34:39,770 --> 00:34:40,603 1951. 710 00:34:43,772 --> 00:34:45,809 Turkish 1951. 711 00:34:45,810 --> 00:34:48,159 Left heading two, one, zero. 712 00:34:48,160 --> 00:34:51,619 Clear approach, one, eight, right. 713 00:34:51,620 --> 00:34:53,369 Left two, one, zero. 714 00:34:53,370 --> 00:34:54,539 Clear ILS. 715 00:34:54,540 --> 00:34:56,519 Turkish 1951. 716 00:34:56,520 --> 00:34:59,039 Left at 210 degrees, 717 00:34:59,040 --> 00:35:01,269 maintaining 2,000 feet. 718 00:35:01,270 --> 00:35:03,879 Brings the flight in right here. 719 00:35:03,880 --> 00:35:06,039 Five point five miles out. 720 00:35:06,040 --> 00:35:09,223 We now have to intercept the the glide slope from above. 721 00:35:11,270 --> 00:35:14,419 At 2,000 feet with the glide slope below them 722 00:35:14,420 --> 00:35:16,409 the pilots have to reduce their speed 723 00:35:16,410 --> 00:35:17,833 while descending steeply. 724 00:35:18,990 --> 00:35:20,629 Speed, one, four, zero. 725 00:35:20,630 --> 00:35:22,499 They believe the throttles are moving back 726 00:35:22,500 --> 00:35:25,129 for the descent to the glide slope. 727 00:35:25,130 --> 00:35:27,849 In fact, the auto throttle is slowing the plane down 728 00:35:27,850 --> 00:35:29,650 because it's gone into landing mode. 729 00:35:30,610 --> 00:35:34,139 It will continue to slow the plane until it stalls. 730 00:35:34,140 --> 00:35:36,649 What we found is that when the flight crew 731 00:35:36,650 --> 00:35:40,169 was doing their before landing checklist, each one of them 732 00:35:40,170 --> 00:35:42,749 was doing something while they should've been 733 00:35:42,750 --> 00:35:44,619 monitoring their airspeed. 734 00:35:44,620 --> 00:35:46,523 For the next 100 seconds, 735 00:35:47,410 --> 00:35:49,769 no one notices what's happening. 736 00:35:49,770 --> 00:35:51,478 Until it's too late. 737 00:35:52,312 --> 00:35:55,209 Established altitude set, 1,000. 738 00:35:55,210 --> 00:35:56,649 Check. 739 00:35:56,650 --> 00:35:59,589 - Flaps, 40. - Speed, set. 740 00:35:59,590 --> 00:36:01,559 The experienced pilot recognize 741 00:36:01,560 --> 00:36:03,489 that the First Officer's probably a little bit behind 742 00:36:03,490 --> 00:36:06,169 on the approach so he calls for flaps 40 743 00:36:06,170 --> 00:36:08,939 and moves the lever, informing the First Officer 744 00:36:08,940 --> 00:36:10,329 that he has done so. 745 00:36:10,330 --> 00:36:12,879 He's trying to help the First Officer catch up 746 00:36:12,880 --> 00:36:14,289 to the position of the aircraft. 747 00:36:14,290 --> 00:36:16,729 - Speed brake. - Speed brake, armed. 748 00:36:16,730 --> 00:36:19,299 Green light. - One thing at the time. 749 00:36:19,300 --> 00:36:20,809 Landing gear. 750 00:36:20,810 --> 00:36:23,779 The plane is now 700 feet from the ground. 751 00:36:23,780 --> 00:36:26,259 - Gear down, three green. - Flaps. 752 00:36:26,260 --> 00:36:28,310 Flaps, 40, green light. 753 00:36:30,210 --> 00:36:32,709 In their haste to complete their checklist, 754 00:36:32,710 --> 00:36:35,139 none of the three crew members notice the warnings 755 00:36:35,140 --> 00:36:37,769 that their speed is dropping dangerously. 756 00:36:37,770 --> 00:36:40,653 First, a red bar appeared on their flight display. 757 00:36:41,600 --> 00:36:44,059 Then when the air speed continued to drop 758 00:36:44,060 --> 00:36:46,759 a flashing box appeared around their actual air speed 759 00:36:46,760 --> 00:36:48,824 to draw the pilot's attention to it. 760 00:36:49,750 --> 00:36:51,929 At this point, no one sees either. 761 00:36:51,930 --> 00:36:53,689 Cabin report confirmed. 762 00:36:53,690 --> 00:36:56,639 The aircraft is now 600 feet from landing. 763 00:36:56,640 --> 00:36:58,059 When things start changing colors, 764 00:36:58,060 --> 00:37:00,639 it's a warning to you, it's a caution to you 765 00:37:00,640 --> 00:37:03,009 that you're approaching the limits of the aircraft. 766 00:37:03,010 --> 00:37:04,379 Missed approach. 767 00:37:04,380 --> 00:37:06,899 Altitude set 500. 768 00:37:06,900 --> 00:37:09,129 So all of these indications the crew has in front 769 00:37:09,130 --> 00:37:12,699 of them saying that the aircraft is slowing down. 770 00:37:12,700 --> 00:37:15,999 During that time they were still completing their checklist. 771 00:37:16,000 --> 00:37:17,069 Of course the aircraft 772 00:37:17,070 --> 00:37:18,929 is getting closer to the ground. 773 00:37:18,930 --> 00:37:20,889 In fact, it's less than 500 feet 774 00:37:20,890 --> 00:37:21,722 from touch down. 775 00:37:21,723 --> 00:37:25,889 And right before the stick shaker started 776 00:37:25,890 --> 00:37:28,119 the captain told the Safety Pilot... 777 00:37:28,120 --> 00:37:30,399 Please warn the cabin crew. 778 00:37:30,400 --> 00:37:32,496 Cabin crew, take your seats. 779 00:37:33,870 --> 00:37:35,899 Speed, sir. - I have control. 780 00:37:35,900 --> 00:37:37,449 By the time they advanced their throttles 781 00:37:37,450 --> 00:37:40,359 to full power, it was unrecoverable. 782 00:37:40,360 --> 00:37:43,399 They were too low for the engines to catch up. 783 00:37:43,400 --> 00:37:44,669 And that's it. 784 00:37:44,670 --> 00:37:47,032 It's now too late to save this plane. 785 00:37:51,900 --> 00:37:54,079 They all knew about the altimeter problem 786 00:37:54,080 --> 00:37:55,673 but knowing didn't help. 787 00:38:03,400 --> 00:38:05,069 Boeing also didn't foresee 788 00:38:05,070 --> 00:38:07,993 the potentially deadly effect of a faulty altimeter. 789 00:38:08,850 --> 00:38:11,799 But on February the 25th, 2009, 790 00:38:11,800 --> 00:38:14,379 it triggered an unusual sequence of events 791 00:38:14,380 --> 00:38:17,593 that brought down a jetliner and killed nine people. 792 00:38:20,240 --> 00:38:22,009 The official report into the accident 793 00:38:22,010 --> 00:38:25,229 blames it on a convergence of circumstances. 794 00:38:25,230 --> 00:38:28,319 There is never ever just one cause to an airline accident. 795 00:38:28,320 --> 00:38:29,579 It simply doesn't exist. 796 00:38:29,580 --> 00:38:32,109 Maybe someday God will swap one out of the sky 797 00:38:32,110 --> 00:38:35,139 but until then, there's never one cause. 798 00:38:35,140 --> 00:38:36,939 The Dutch report also points out 799 00:38:36,940 --> 00:38:39,029 that Boeing could have realized the problem 800 00:38:39,030 --> 00:38:40,609 with the radio altimeter system 801 00:38:40,610 --> 00:38:43,179 could have had an impact on safety. 802 00:38:43,180 --> 00:38:44,809 Given that no one foresaw how 803 00:38:44,810 --> 00:38:46,763 that failure might cause a crash. 804 00:38:47,640 --> 00:38:50,663 The Turkish Airlines accident raises a big question. 805 00:38:51,630 --> 00:38:54,393 Are airplanes becoming too complex? 806 00:39:03,970 --> 00:39:05,509 Investigators have determined 807 00:39:05,510 --> 00:39:09,069 that Turkish Airlines Flight 1951 crashed mainly 808 00:39:09,070 --> 00:39:11,579 because the pilots didn't recognize the consequences 809 00:39:11,580 --> 00:39:13,573 of the warnings they were getting. 810 00:39:16,275 --> 00:39:17,643 Turkish 1951, descend to 4,000. 811 00:39:19,280 --> 00:39:20,519 This is not the first plane 812 00:39:20,520 --> 00:39:22,679 to crash because the crew didn't understand 813 00:39:22,680 --> 00:39:24,529 what their plane was telling them. 814 00:39:24,530 --> 00:39:26,279 Our problem is not the automation, 815 00:39:26,280 --> 00:39:28,379 our problem is the depth of the training 816 00:39:28,380 --> 00:39:30,229 and the ability of the human beings 817 00:39:30,230 --> 00:39:33,129 to recover from mistakes made in interfacing 818 00:39:33,130 --> 00:39:34,989 with the automation. 819 00:39:34,990 --> 00:39:37,379 Mica Endsley studies the relationship 820 00:39:37,380 --> 00:39:39,273 between pilots and technology. 821 00:39:40,800 --> 00:39:42,579 We haven't really designed the automation 822 00:39:42,580 --> 00:39:46,159 to take best advantage of what people do well 823 00:39:46,160 --> 00:39:49,949 and take away the parts that people don't do well. 824 00:39:49,950 --> 00:39:54,839 In 1996, the crew of an Aeroperu 757 crashed 825 00:39:54,840 --> 00:39:57,719 when the pilots couldn't decipher contradictory warnings 826 00:39:57,720 --> 00:39:59,623 about their altitude and airspeed. 827 00:40:00,860 --> 00:40:03,199 The plane flew into the Pacific Ocean. 828 00:40:03,200 --> 00:40:06,363 61 passengers and nine crew members were killed. 829 00:40:07,480 --> 00:40:11,559 In 1995, the flight management system on a Boeing 757 830 00:40:11,560 --> 00:40:14,509 could and should have stared the plane to a safe landing 831 00:40:14,510 --> 00:40:15,933 in Cali, Colombia. 832 00:40:17,110 --> 00:40:19,369 But a last minute change to the flight plan meant 833 00:40:19,370 --> 00:40:21,969 the crew had to reprogram their computer. 834 00:40:21,970 --> 00:40:23,459 They mistaken the entered a course 835 00:40:23,460 --> 00:40:26,939 that took them headlong into a 9,000 foot mountain. 836 00:40:26,940 --> 00:40:30,239 159 people died in the crash. 837 00:40:30,240 --> 00:40:31,392 The cautionary tale here is 838 00:40:31,393 --> 00:40:32,849 that we can get this equipment. 839 00:40:32,850 --> 00:40:34,539 We can get these silicon-based units, 840 00:40:34,540 --> 00:40:36,539 if you will, so sophisticated 841 00:40:36,540 --> 00:40:38,629 that we can't talk to them effectively. 842 00:40:38,630 --> 00:40:41,089 And when they go berserk or they have a problem 843 00:40:41,090 --> 00:40:44,519 or we misprogram them, we end up putting ourselves 844 00:40:44,520 --> 00:40:46,469 and our passengers in danger while we're trying 845 00:40:46,470 --> 00:40:48,139 to figure it out. 846 00:40:48,140 --> 00:40:49,689 NASA is working on something 847 00:40:49,690 --> 00:40:52,919 called the Integrated Intelligent Flight Deck. 848 00:40:52,920 --> 00:40:55,529 It's a project aimed at helping humans better use 849 00:40:55,530 --> 00:40:57,859 the technology that surrounds them in the cockpit. 850 00:40:57,860 --> 00:41:00,629 They're looking at automated flight manual systems, 851 00:41:00,630 --> 00:41:02,309 voice recognition systems. 852 00:41:02,310 --> 00:41:04,789 They've developed new kinds of microphones 853 00:41:04,790 --> 00:41:07,209 that are bone conducting chips. 854 00:41:07,210 --> 00:41:10,059 They're developing new displays for understanding 855 00:41:10,060 --> 00:41:13,529 the ground environment for being able to detect 856 00:41:13,530 --> 00:41:15,679 where other aircraft are in the environment. 857 00:41:15,680 --> 00:41:17,079 What some researchers are finding 858 00:41:17,080 --> 00:41:20,032 is that the best technology shouldn't replace pilots 859 00:41:20,033 --> 00:41:22,099 but work with them. 860 00:41:22,100 --> 00:41:24,899 Really integrating people with technology more effectively 861 00:41:24,900 --> 00:41:28,319 has to do with designing the displays so 862 00:41:28,320 --> 00:41:30,319 that you can really understand what it's doing 863 00:41:30,320 --> 00:41:32,689 and you can make it simpler to understand how 864 00:41:32,690 --> 00:41:34,499 to make it do what it is you want it to do. 865 00:41:34,500 --> 00:41:37,329 You shouldn't have to push 16 buttons through eight levels 866 00:41:37,330 --> 00:41:39,669 of menus to figure out what's going on with the system. 867 00:41:39,670 --> 00:41:41,929 It should be integrated and presented effectively. 868 00:41:41,930 --> 00:41:43,639 It should be as easy to communicate 869 00:41:43,640 --> 00:41:45,519 with as the person next to you. 870 00:41:45,520 --> 00:41:46,899 Boeing and Airbus, 871 00:41:46,900 --> 00:41:49,579 the two largest manufacturers of passenger planes 872 00:41:49,580 --> 00:41:52,039 take very different approaches to the relationship 873 00:41:52,040 --> 00:41:53,833 between humans and technology. 874 00:41:55,040 --> 00:41:57,029 Airbus gives the flight computer much 875 00:41:57,030 --> 00:41:59,569 of the decision-making power in the cockpit. 876 00:41:59,570 --> 00:42:01,649 In their view, this is a way to prevent a lot 877 00:42:01,650 --> 00:42:04,109 of human errors by my making sure the airplane 878 00:42:04,110 --> 00:42:06,329 doesn't do something that's gonna cause a crash, 879 00:42:06,330 --> 00:42:08,289 even if the humans want them to. 880 00:42:08,290 --> 00:42:10,279 But Boeing has a different view. 881 00:42:10,280 --> 00:42:12,399 Its philosophy is to provide information 882 00:42:12,400 --> 00:42:15,359 to pilots and have them make decisions. 883 00:42:15,360 --> 00:42:18,819 Having more information is better for the pilot, 884 00:42:18,820 --> 00:42:22,539 having the pilot in the loop, in the equation, 885 00:42:22,540 --> 00:42:25,589 so to speak, I kind of liked that. 886 00:42:25,590 --> 00:42:29,909 Airbus will argue vociferously and in continuous fashion 887 00:42:29,910 --> 00:42:32,629 that that view is archaic and incorrect. 888 00:42:32,630 --> 00:42:34,869 I think the jury is still out. 889 00:42:34,870 --> 00:42:35,829 The final report 890 00:42:35,830 --> 00:42:38,259 into the Turkish Airlines tragedy blames the crash 891 00:42:38,260 --> 00:42:41,969 of Flight 1951, partly on a failure of technology. 892 00:42:41,970 --> 00:42:44,629 The erroneous radio altimeter data caused 893 00:42:44,630 --> 00:42:47,609 the auto throttle to go to a improper mode 894 00:42:47,610 --> 00:42:50,319 that is of course not a good situation. 895 00:42:50,320 --> 00:42:52,309 The cause of the radio altimeter failure 896 00:42:52,310 --> 00:42:53,799 was never uncovered. 897 00:42:53,800 --> 00:42:55,779 The Dutch investigation asks Boeing 898 00:42:55,780 --> 00:42:58,299 to improve the reliability of the system. 899 00:42:58,300 --> 00:43:01,889 We learned a lot about the radio altimeter system 900 00:43:01,890 --> 00:43:04,699 and how it affects the auto throttle system. 901 00:43:04,700 --> 00:43:09,517 Boeing is currently working on system improvements 902 00:43:09,518 --> 00:43:14,518 to prevent this type of auto throttle event 903 00:43:15,170 --> 00:43:17,378 from occurring again. 904 00:43:19,520 --> 00:43:21,569 But the report also faults the crew 905 00:43:21,570 --> 00:43:23,589 for not noticing that their speed 906 00:43:23,590 --> 00:43:25,569 was dropping dangerously low. 907 00:43:25,570 --> 00:43:28,929 In spite of the fact that there were three pilots on board. 908 00:43:28,930 --> 00:43:31,219 Forget that you got an auto throttle, 909 00:43:31,220 --> 00:43:34,609 you look at the airspeed and you look at the altitude. 910 00:43:34,610 --> 00:43:36,669 You look out the damn window if you want to. 911 00:43:36,670 --> 00:43:39,069 But air speed is crucial component 912 00:43:39,070 --> 00:43:41,649 of staying alive in an airplane. 913 00:43:41,650 --> 00:43:44,779 And you always need to know what your speed is. 914 00:43:44,780 --> 00:43:46,719 But to Mica Endsley, the crew's failure 915 00:43:46,720 --> 00:43:49,699 to monitor instruments is entirely understandable 916 00:43:49,700 --> 00:43:53,369 and maybe more the fault of the instruments than the crew. 917 00:43:53,370 --> 00:43:55,249 It's actually very difficult for people 918 00:43:55,250 --> 00:43:57,749 to be monitors of automation. 919 00:43:57,750 --> 00:43:59,579 One of the things that people don't do a good job 920 00:43:59,580 --> 00:44:01,089 of actually is monitoring. 921 00:44:01,090 --> 00:44:03,719 We're very good on-the-spot decision makers. 922 00:44:03,720 --> 00:44:06,329 We're very good at coming up with creative solutions 923 00:44:06,330 --> 00:44:09,499 to problems, but repetitive monitoring 924 00:44:09,500 --> 00:44:10,729 is a kind of thing that actually people 925 00:44:10,730 --> 00:44:12,199 aren't very good at at all. 926 00:44:12,200 --> 00:44:14,429 So what we have to do is design automation 927 00:44:14,430 --> 00:44:16,999 to work with people in a way that keeps them more actively, 928 00:44:17,000 --> 00:44:19,099 cognitively involved and in the loop 929 00:44:19,100 --> 00:44:20,839 and not just monitoring a piece of automation 930 00:44:20,840 --> 00:44:23,340 to say is it doing what it's supposed to be doing? 931 00:44:24,691 --> 00:44:25,969 Who's the ultimate computer? 932 00:44:25,970 --> 00:44:26,802 The pilot. 933 00:44:26,803 --> 00:44:28,609 The individual who should be able to say, 934 00:44:28,610 --> 00:44:30,109 I don't know what this thing is doing to me 935 00:44:30,110 --> 00:44:32,009 but I'm punching it off and flying the airplane. 936 00:44:32,010 --> 00:44:33,285 Fly the jet. 937 00:44:33,286 --> 00:44:35,389 Probably the smartest thing we ever learned 938 00:44:35,390 --> 00:44:37,519 to say in our training in the airlines, 939 00:44:37,520 --> 00:44:40,499 fly the jet do that first or nothing else counts. 940 00:44:40,500 --> 00:44:42,693 That's what they forgot to do.