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[jet engine]
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FLIGHT ATTENDANT:
Ladies and gentlemen,
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we're beginning our descent
towards Amsterdam's Schiphol
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Airport.
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[non-english speech]
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Thank you.
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NARRATOR: Turkish
Airlines Flight 1951 is
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preparing to land in Amsterdam.
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Amsterdam, Turkish 1951,
descending to 7,000, speed 250.
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[beeping]
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NARRATOR: The crew is flying
a state of the art Boeing 737.
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Flaps 15.
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PILOT: Localizer are live.
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Localizer capture.
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NARRATOR: In the final
moments of the flight,
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the landing turns
into a catastrophe.
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The plane falls like a rock.
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The crash of Turkish
Airlines Flight 1951
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involves the most
popular plane on Earth.
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With nearly 1 and 1/2 million
passengers boarding 737 sevens
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every day--
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[screaming]
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--investigators
need to figure out
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if the problem
was with the plane
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or with the pilots flying it.
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FLIGHT ATTENDANT:
Ladies and gentlemen,
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we are starting our approach.
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PILOT: We lost both engines.
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FLIGHT ATTENDANT: [inaudible]
emergency descent.
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PILOT: Mayday, mayday.
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CHILD: We're going to die.
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[explosion]
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PILOT: This will
be the last one.
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REPORTER: The investigation
started when [inaudible]..
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MAN: It's going to crash.
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[somber music playing]
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NARRATOR: On the morning
of February 25, 2009,
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Turkish Airlines Flight
1951 becomes the first plane
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to crash at Amsterdam's Schiphol
Airport in more than 10 years.
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[non-english speech]
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INTERPRETER: It smashed
into the ground really hard.
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It made a tremendous noise.
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[crash]
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NARRATOR: The plane hits
the ground in a muddy field
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just North of Runway 18 Right.
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[sirens]
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Since the crash was so
close to the airport,
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rescue workers arrived quickly.
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Most of the passengers
have survived.
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But many are badly injured.
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Survivors are taken
straight to local hospitals.
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Images of the Amsterdam
accident quickly
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spread around the world.
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This is the third
crash of a passenger
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jet in the past six weeks.
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The sudden nature of this
accident adds to the mystery.
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[inaudible speech over radio]
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It doesn't take long for
the Dutch Safety Board
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to arrive at the scene.
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They will be investigating
this accident.
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But they won't be alone.
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The crash involved an
American-made plane.
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So the US National
Transportation Safety Board
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sends Joe Sedor, one of its
most experienced investigators,
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to Amsterdam.
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JOSEPH SEDOR: When it's a
non-US registered aircraft that
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crashes overseas, such
as this Turkish Airlines,
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we are the state of manufacture
and design of the air frame
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and also, in this
case, the engines.
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Fuselage in three large pieces.
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Engines forward of
the main wreck site.
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NARRATOR: Flight 1951
was one of the most
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advanced aircraft in the skies,
The Boeing 737 800 Series.
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It's designed to travel longer
routes at higher altitudes.
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The new generation 737 is
still the best airplane Boeing
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00:03:31,978 --> 00:03:35,949
ever built. We developed an
airplane that had an improved
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wing, improved avionics,
simpler systems
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that required less maintenance.
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NARRATOR: Investigators know
this isn't just any plane.
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The 737 is the world's
best-selling commercial jet.
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Finding out why this one
crashed is imperative.
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There are more than 5,000
of them in the skies.
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They carry about 1 and 1/2
million passengers a day.
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Investigators must
quickly determine
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if there's a flaw
with the plane that
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could cause another accident.
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What they know so
far is that flight
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1951 had been traveling from
Istanbul, Turkey to Amsterdam.
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There were 128 passengers on
board the early-morning flight,
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including four
engineers from Boeing.
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FLIGHT ATTENDANT:
Ladies and gentlemen,
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we're beginning our descent
towards Amsterdam's Schiphol
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Airport.
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Please raised your seat
backs to the upright position
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and stow away your tray tables.
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NARRATOR: There was no
mention on board of any kind
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of trouble in the cockpit.
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The crash has killed
nine people, including
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three members of the Boeing team
and the pilots in the cockpit.
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See if you can get me some
aerials of the crash site.
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NARRATOR: There are
eerie similarities
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to another recent accident
involving a Boeing aircraft,
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British Airways Flight 38.
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JOSEPH SEDOR: Approximately
a year before this,
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there had been Triple
Seven short landing
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at Heathrow, which had
a dual-engine flame out.
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NARRATOR: In that accident,
a Boeing Triple Seven
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fell to the ground,
short of the runway.
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The British Airways
pilots reported
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that both their engines
stopped delivering
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power just before landing.
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At the time of the
Turkish Airways crash,
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the cause of that accident
hasn't been found.
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As in that case,
investigators have
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plenty of clues to work with.
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The plane and its engines
are largely intact.
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The flight-data recorder
and cockpit voice recorder
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are found in good condition.
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There are also
plenty of survivors
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to describe what happened.
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According to the passengers,
the landing had been routine.
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But then suddenly, the plane
simply dropped out of the sky
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and hit the ground.
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[crash]
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But perhaps the
biggest clue comes
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from the crash site itself.
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The wreckage is not spread out.
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It tells investigators
that the plane could not
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have been traveling
forward at high speed
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when it hit the ground.
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JOHN NANCE: The way the
aircraft had crashed,
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it did appear to be some
sort of a landing accident
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in which there was moderate
control of some sort.
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NARRATOR: The pattern of
debris and the passenger
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reports point investigators
to an immediate suspect,
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the engines.
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The engines issue was a very
big issue in my thought process
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at the time, initially.
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NARRATOR: There's no evidence
of fire on the fuselage.
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In many crashes, fuel
in the plane's tanks
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ignites on impact.
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The lack of fire raises
an obvious question.
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Did the engine stop
running because flight
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1951 had simply run out of gas?
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JOHN NANCE: That was one of the
first thoughts that I had was,
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did this airplane
have fuel aboard?
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Because otherwise,
how does a 737
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literally fall out of the sky
on approach to an airport?
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NARRATOR: But the
location and condition
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of the plane's engines
suggest that perhaps
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they didn't quit in flight.
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JOSEPH SEDOR: Sure it
looks like it was running.
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When we first looked at
where the engines ended up,
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the initial impression was that
they probably were producing
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thrust at impact, given
that they were so far
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forward of the main wreckage.
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But that was just a
very general conclusion.
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NARRATOR: Only the flight-data
recorder can tell investigators
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how much power the engines
were generating in the seconds
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before the crash.
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It had lots of fuel.
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Rules that out.
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NARRATOR: It doesn't
take long to discover
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that there is plenty of
fuel in the plane's tanks.
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Flight 1951 definitely
did not run out of gas.
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Passengers report that in the
final seconds before the crash,
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the plane hit what
felt like turbulence.
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It points investigators
to a well-known culprit,
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a micro burst.
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A micro burst is a
powerful column of air that
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shoots out of storm clouds.
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It can literally slam a
low-flying plane to the ground.
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JOHN NANCE: If an airplane flies
into that at approach speeds,
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you're not going to
be flying anymore.
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You're going to
come out of the sky.
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Certainly, it was one of
the things that all of us
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took a look at,
at the beginning,
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was there a micro burst?
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[crash]
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NARRATOR: In 1985, a
Delta Airlines flight
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was caught in a micro
burst while landing
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at Dallas-Fort Worth Airport.
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The plane hit the ground
short of the runway.
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137 people were killed.
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Investigators learned
that there were
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heavy clouds above the airport
at the time of the accident.
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A powerful gust of wind may
well have accompanied them.
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The flight-data recorder
will have recorded
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wind speeds outside the plane.
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Investigators will
need to analyze
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the flight data to prove
the micro-burst theory.
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In the meantime, the rescue has
led to an unusual discovery.
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JOSEPH SEDOR: There was
three pilots in the cockpit
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which is unusual.
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This is a two-crew cockpit.
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So why was that
third pilot there?
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NARRATOR: Since none
of the three pilots
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survived the accident,
it's all the more
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urgent for investigators
to retrieve
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00:09:15,221 --> 00:09:18,190
the data from the
cockpit voice recorder.
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It records conversations
in the cockpit.
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They're in luck.
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00:09:23,729 --> 00:09:25,298
JOSEPH SEDOR: Because of the
way that the aircraft crashed,
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access to the recorders and
the condition of the recorders
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was excellent.
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00:09:28,567 --> 00:09:31,837
NARRATOR: The reason for the
third pilot is soon uncovered.
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Flying standard arrival route.
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Visibility, 3,500
meters, expected
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00:09:37,176 --> 00:09:39,979
to decrease to 2,500 meters.
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NARRATOR: For first
officer, Murat Sezer
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this has been a training
flight of sorts.
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He was new to the
airlines and was
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being shown the intricacies of
landing at Amsterdam's airport.
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BILL HUFF: When the
Jeppesen charts,
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which is what all pilots use to
navigate to and from Schiphol,
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there's 102 pages of
information on Schiphol alone.
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So there's dozens of approaches.
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Runway 18 right has three
high-speed exits to the left.
219
00:10:05,938 --> 00:10:10,209
NARRATOR: The captain, Hasan
Arisen was doing double duty.
220
00:10:10,209 --> 00:10:12,244
He was training
his first officer--
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Make small corrections as
we get close to the runway.
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NARRATOR: --and was in
command of flight 1951.
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It's because captain Arisen
was teaching that there was
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the third pilot in the cockpit.
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00:10:23,889 --> 00:10:26,392
Olgay Ozgur was a safety pilot.
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00:10:26,392 --> 00:10:28,861
He was there to keep an eye
on the flight's progress
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00:10:28,861 --> 00:10:31,230
during this training mission.
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00:10:31,230 --> 00:10:33,799
JOSEPH SEDOR: The purpose
of that second set of eyes
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00:10:33,799 --> 00:10:38,237
is to make sure that the
captain and the first officer,
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00:10:38,237 --> 00:10:40,439
if they're in a
situation where it's
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00:10:40,439 --> 00:10:43,042
a little bit of a training
portion of the flight,
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that they don't miss something.
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We've got a clean recording?
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00:10:48,914 --> 00:10:51,050
NARRATOR: The voice recorder
reveals that the three crew
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00:10:51,050 --> 00:10:53,219
members began
preparations for landing
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00:10:53,219 --> 00:10:58,491
when still above 8,500 feet.
237
00:10:58,491 --> 00:11:03,396
Amsterdam, Turkish
1951, descending to 7,000.
238
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Speed, 250.
239
00:11:04,864 --> 00:11:06,399
[beeping]
240
00:11:06,399 --> 00:11:07,466
NARRATOR: But the voice
recorder has picked up
241
00:11:07,466 --> 00:11:10,970
an unusual sound, a
warning that makes no sense
242
00:11:10,970 --> 00:11:12,471
at this stage of the flight.
243
00:11:12,471 --> 00:11:14,473
One of the
investigators from Boeing
244
00:11:14,473 --> 00:11:20,413
was a engineering pilot that
came and helped with the CVR.
245
00:11:20,413 --> 00:11:23,149
And he's listening to see when--
246
00:11:23,149 --> 00:11:25,017
are there any unusual
sounds that can be
247
00:11:25,017 --> 00:11:26,185
heard that would not be normal.
248
00:11:26,185 --> 00:11:27,153
AIR TRAFFIC CONTROLLER
(OVER RADIO):
249
00:11:27,153 --> 00:11:31,023
Speed OK for ILS 18 Right.
250
00:11:31,023 --> 00:11:35,361
PILOT: Descend
4,000, ILS 18 Right.
251
00:11:35,361 --> 00:11:37,196
NARRATOR: The alarm
keeps sounding.
252
00:11:37,196 --> 00:11:39,432
It's the
landing-gear-configuration
253
00:11:39,432 --> 00:11:40,332
warning horn.
254
00:11:40,332 --> 00:11:44,437
Captain Arisen
continually dismisses it.
255
00:11:44,437 --> 00:11:54,146
Turkish 1951, dissent
4,000, ILS 18 Right.
256
00:11:54,146 --> 00:11:55,147
Landing gear.
257
00:11:57,483 --> 00:11:59,285
Is that the
landing-gear warning?
258
00:11:59,285 --> 00:12:01,520
They're 8,300 feet here.
259
00:12:01,520 --> 00:12:04,156
NARRATOR: The warning
is a solid clue.
260
00:12:04,156 --> 00:12:06,892
But investigators can't
yet see how it could
261
00:12:06,892 --> 00:12:07,893
possibly have caused a crash.
262
00:12:13,366 --> 00:12:16,336
got warnings to extend their
landing gear while still
263
00:12:16,336 --> 00:12:18,338
thousands of feet in the air.
264
00:12:18,338 --> 00:12:19,539
JOSEPH SEDOR: On
the initial listen,
265
00:12:19,539 --> 00:12:22,809
we heard a gear
warning horn occur
266
00:12:22,809 --> 00:12:25,578
as the aircraft was approaching,
when it was still up.
267
00:12:25,578 --> 00:12:29,515
And it was coming in at
about 10,000 feet and below.
268
00:12:29,515 --> 00:12:32,418
NARRATOR: Investigators now
turn to the flight-data recorder
269
00:12:32,418 --> 00:12:34,220
to help solve some
of the mystery
270
00:12:34,220 --> 00:12:35,588
surrounding this flight.
271
00:12:35,588 --> 00:12:38,558
The analysis of wind
speeds outside the aircraft
272
00:12:38,558 --> 00:12:39,525
is completed.
273
00:12:39,525 --> 00:12:40,693
It's clear.
274
00:12:40,693 --> 00:12:43,229
None are drastic enough to
have brought down the plane.
275
00:12:43,229 --> 00:12:45,064
There's no evidence
of a micro burst.
276
00:12:47,900 --> 00:12:49,502
NARRATOR: But the
flight-data recorder
277
00:12:49,502 --> 00:12:52,338
does provide some valuable
insight into the cause
278
00:12:52,338 --> 00:12:55,908
of the landing-gear warning.
279
00:12:55,908 --> 00:12:58,411
One of the instruments
that measures altitude
280
00:12:58,411 --> 00:13:01,547
had the plane already
on the ground.
281
00:13:01,547 --> 00:13:03,249
JOSEPH SEDOR: When
we looked and saw
282
00:13:03,249 --> 00:13:06,252
the radio altimeter
data on the recorder,
283
00:13:06,252 --> 00:13:07,854
it said about 8,000 feet.
284
00:13:07,854 --> 00:13:11,024
And then immediately, it
went down to about minus 8.
285
00:13:11,024 --> 00:13:13,226
Minus 8 feet is an indication
that the aircraft's
286
00:13:13,226 --> 00:13:14,494
on the ground.
287
00:13:14,494 --> 00:13:17,263
But of course, it's
still at 2000 feet.
288
00:13:17,263 --> 00:13:19,298
NARRATOR: The Boeing
737 is equipped
289
00:13:19,298 --> 00:13:21,300
with two separate altimeters.
290
00:13:21,300 --> 00:13:24,103
One measures air pressure
to determine the plane's
291
00:13:24,103 --> 00:13:26,105
height above sea level.
292
00:13:26,105 --> 00:13:28,408
That reading is displayed
prominently in the cockpit
293
00:13:28,408 --> 00:13:30,943
on both pilots' flight display.
294
00:13:30,943 --> 00:13:33,479
PILOT: 210, sensor.
295
00:13:33,479 --> 00:13:35,214
NARRATOR: The plane is
also equipped with a radio
296
00:13:35,214 --> 00:13:36,983
altimeter.
297
00:13:36,983 --> 00:13:38,618
It's made up of four antennas.
298
00:13:38,618 --> 00:13:42,055
Two transmit signals to
the ground and two others
299
00:13:42,055 --> 00:13:44,357
read the signal that
bounces back to determine
300
00:13:44,357 --> 00:13:46,259
the plane's altitude.
301
00:13:46,259 --> 00:13:48,227
It's precise.
302
00:13:48,227 --> 00:13:50,096
It's very, very precise.
303
00:13:50,096 --> 00:13:54,967
Pressure altimeters can
sometimes be not as accurate.
304
00:13:54,967 --> 00:13:58,371
And radar altimeters
are 100% accurate
305
00:13:58,371 --> 00:13:59,539
if they're working properly.
306
00:13:59,539 --> 00:14:01,274
[jet engine]
307
00:14:03,910 --> 00:14:05,545
NARRATOR: One antenna
feeds the reading
308
00:14:05,545 --> 00:14:08,681
to the first officer's display.
309
00:14:08,681 --> 00:14:11,984
The other feeds the
captain's instruments.
310
00:14:11,984 --> 00:14:15,488
In the case of Flight
1951, the captain's side
311
00:14:15,488 --> 00:14:17,123
was wrong most of the flight.
312
00:14:20,159 --> 00:14:22,395
Investigators go
back over the CVR
313
00:14:22,395 --> 00:14:25,031
and make a puzzling discovery.
314
00:14:25,031 --> 00:14:28,501
PILOT (OVER RADIO):
Amsterdam Turkish 1951
315
00:14:28,501 --> 00:14:36,209
descending to 7,000, speed 250.
316
00:14:36,209 --> 00:14:37,510
Radio altimeter.
317
00:14:37,510 --> 00:14:39,545
NARRATOR: Captain Arisen
seems to have known
318
00:14:39,545 --> 00:14:42,181
that the landing-gear
warning was being caused
319
00:14:42,181 --> 00:14:43,950
by a faulty radio altimeter.
320
00:14:43,950 --> 00:14:46,185
The airplane thought that
it was low to the ground
321
00:14:46,185 --> 00:14:47,687
and the gear was not down.
322
00:14:47,687 --> 00:14:50,022
And the captain recognized
that the problem was really
323
00:14:50,022 --> 00:14:53,459
in the radio altimeter,
showing him that they
324
00:14:53,459 --> 00:14:54,961
should be on the ground.
325
00:14:54,961 --> 00:14:57,396
And he goes, it's just
the radio altimeter.
326
00:14:57,396 --> 00:14:59,065
NARRATOR: Throughout
much of the approach,
327
00:14:59,065 --> 00:15:01,567
the captain's radio
altimeter had been displaying
328
00:15:01,567 --> 00:15:04,170
a reading of minus
8 feet, triggering
329
00:15:04,170 --> 00:15:06,005
the warning to lower the gear.
330
00:15:06,005 --> 00:15:07,507
They treated it like
it was a nuisance.
331
00:15:09,242 --> 00:15:10,376
AIR TRAFFIC CONTROLLER
(OVER RADIO):
332
00:15:10,376 --> 00:15:15,014
Turkish 1951, descend to 2,000.
333
00:15:15,014 --> 00:15:21,087
2,000, 1,951.
334
00:15:21,087 --> 00:15:24,090
NARRATOR: Investigators dig
for any other abnormalities.
335
00:15:24,090 --> 00:15:28,394
They learn that with Flight
1951 a little over 10 miles
336
00:15:28,394 --> 00:15:30,730
from the airport,
controllers directed
337
00:15:30,730 --> 00:15:33,065
the pilots to begin
their final turn
338
00:15:33,065 --> 00:15:34,634
to line up with the runway.
339
00:15:34,634 --> 00:15:38,004
Turkish 1951, left heading.
340
00:15:38,004 --> 00:15:40,206
210, cleared approach.
341
00:15:40,206 --> 00:15:43,242
18 right.
342
00:15:43,242 --> 00:15:50,383
Left 210, clear
ILS, Turkish 1951.
343
00:15:50,383 --> 00:15:53,586
COPILOT: 210 set, Sir.
344
00:15:53,586 --> 00:15:56,422
NARRATOR: This turn
puts Flight 1951 in line
345
00:15:56,422 --> 00:16:00,059
with Runway 18 Right.
346
00:16:00,059 --> 00:16:02,662
It's equipped with an instrument
landing system which sends
347
00:16:02,662 --> 00:16:05,298
out a signal, outlining
the ideal descent
348
00:16:05,298 --> 00:16:08,467
path to the foot of the runway.
349
00:16:08,467 --> 00:16:10,636
The autopilot follows
that glide path
350
00:16:10,636 --> 00:16:13,439
until the plane is a few
hundred feet from the ground.
351
00:16:13,439 --> 00:16:15,741
Then the pilot takes over.
352
00:16:15,741 --> 00:16:18,644
It makes landing
almost effortless.
353
00:16:18,644 --> 00:16:20,279
The ILS is pretty
easy to follow.
354
00:16:20,279 --> 00:16:21,247
It's a video game.
355
00:16:24,116 --> 00:16:25,785
NARRATOR: The crew begins
configuring their plane
356
00:16:25,785 --> 00:16:28,287
for landing, unfazed
by the warning
357
00:16:28,287 --> 00:16:31,190
horn that's repeatedly triggered
by the malfunctioning radio
358
00:16:31,190 --> 00:16:33,125
altimeter.
359
00:16:33,125 --> 00:16:35,761
Flaps 15.
360
00:16:35,761 --> 00:16:38,598
NARRATOR: Six miles
out, Flight 1951
361
00:16:38,598 --> 00:16:40,633
picks up the ILS
signal that will
362
00:16:40,633 --> 00:16:43,436
guide the plane to the runway.
363
00:16:43,436 --> 00:16:44,670
Localizer are live.
364
00:16:47,473 --> 00:16:49,642
Localizer capture.
365
00:16:49,642 --> 00:16:51,310
NARRATOR: The safety
pilot, Olgay Ozgur,
366
00:16:51,310 --> 00:16:54,747
now reminds captain Arisen
about the failed altimeter.
367
00:16:54,747 --> 00:16:57,783
We have radio
altimeter failure, Sir.
368
00:16:57,783 --> 00:16:58,618
OK.
369
00:17:00,786 --> 00:17:01,787
AIR TRAFFIC CONTROLLER
(OVER RADIO):
370
00:17:01,787 --> 00:17:09,795
Turkish 1951, Runway 18
Right, clear to land.
371
00:17:09,795 --> 00:17:10,796
Cleared to land.
372
00:17:10,796 --> 00:17:12,498
Thank you.
373
00:17:12,498 --> 00:17:14,600
NARRATOR: Investigators
are stumped.
374
00:17:14,600 --> 00:17:16,602
The crew knew about
the malfunction
375
00:17:16,602 --> 00:17:18,638
and continued their approach.
376
00:17:18,638 --> 00:17:21,474
How had it then
caused them to crash?
377
00:17:21,474 --> 00:17:23,476
Clearly, there was
more to this accident
378
00:17:23,476 --> 00:17:25,378
than a faulty altimeter.
379
00:17:25,378 --> 00:17:28,147
JOHN NANCE: The whole premise
of airline safety, the way
380
00:17:28,147 --> 00:17:30,216
we build the airplanes,
the way we fly them,
381
00:17:30,216 --> 00:17:33,653
is based on the idea that we
can have any number of failures
382
00:17:33,653 --> 00:17:35,855
and we should still be
able to arrive safely.
383
00:17:35,855 --> 00:17:38,424
The radio altimeter is
just one instrument.
384
00:17:38,424 --> 00:17:40,860
There's no way in the world
that that one instrument, if it
385
00:17:40,860 --> 00:17:44,630
fails, should be a
major cause of worry
386
00:17:44,630 --> 00:17:45,665
that we're going
to have a crash.
387
00:17:49,468 --> 00:17:51,237
NARRATOR: Investigators
wonder if the crew
388
00:17:51,237 --> 00:17:55,675
had been given proper
guidance for their approach.
389
00:17:55,675 --> 00:17:57,777
They turn to exchanges
between the pilots
390
00:17:57,777 --> 00:17:59,679
and the controller
who guided them in.
391
00:18:02,648 --> 00:18:05,384
They carefully review
every instruction.
392
00:18:05,384 --> 00:18:07,353
AIR TRAFFIC CONTROLLER
(OVER RADIO): Turkish 1951,
393
00:18:07,353 --> 00:18:09,221
send to 4,000.
394
00:18:09,221 --> 00:18:14,727
Speed OK for ILS 18 Right.
395
00:18:14,727 --> 00:18:21,200
Turkish 1951, descend to 2,000.
396
00:18:21,200 --> 00:18:26,872
Turkish 1951, left heading,
210, cleared approach.
397
00:18:26,872 --> 00:18:29,442
18 Right.
398
00:18:29,442 --> 00:18:33,412
NARRATOR: By following the
controller's instructions,
399
00:18:33,412 --> 00:18:37,917
the crew made their final turn
much too close to the runway.
400
00:18:37,917 --> 00:18:40,920
So they intercept properly,
they should be here.
401
00:18:40,920 --> 00:18:43,489
NARRATOR: International
guidelines call for approaching
402
00:18:43,489 --> 00:18:46,492
planes to intercept the signal
that guides them to the runway
403
00:18:46,492 --> 00:18:47,793
from below.
404
00:18:47,793 --> 00:18:48,995
It's so pilots
don't have to make
405
00:18:48,995 --> 00:18:53,599
any drastic, last-minute course
corrections to get to it.
406
00:18:53,599 --> 00:18:56,869
To intercept here,
they had to descend.
407
00:18:56,869 --> 00:19:00,306
NARRATOR: But flight 1951 was
given instructions that brought
408
00:19:00,306 --> 00:19:03,576
it to the threshold of the glide
slope while still way above it.
409
00:19:03,576 --> 00:19:05,211
It's a common
practice at Schiphol
410
00:19:05,211 --> 00:19:08,714
because it gets planes
to the runway faster.
411
00:19:08,714 --> 00:19:10,249
JOSEPH SEDOR: Because
they were so close,
412
00:19:10,249 --> 00:19:12,451
they had to capture the
glide slope from above.
413
00:19:12,451 --> 00:19:14,653
Although it is an
unusual situation,
414
00:19:14,653 --> 00:19:17,623
it is one that that can be
handled by a flight crew
415
00:19:17,623 --> 00:19:19,825
if it is managed properly.
416
00:19:19,825 --> 00:19:21,961
NARRATOR: Approaching a
glide slope from above
417
00:19:21,961 --> 00:19:24,263
is more difficult, mostly
because the crew has
418
00:19:24,263 --> 00:19:27,333
to suddenly slow the
plane and descend rapidly
419
00:19:27,333 --> 00:19:28,968
to intercept the signal.
420
00:19:28,968 --> 00:19:31,537
BILL HUFF: We also call
this a slam-dunk approach.
421
00:19:31,537 --> 00:19:33,305
And some pilots like it.
422
00:19:33,305 --> 00:19:34,407
Some pilots don't.
423
00:19:34,407 --> 00:19:35,975
It's a little bit harder.
424
00:19:35,975 --> 00:19:38,811
And things happen quicker when
you're above the glide path,
425
00:19:38,811 --> 00:19:41,013
trying to intercept from above.
426
00:19:41,013 --> 00:19:43,816
And it's just a challenge
for a lot of pilots.
427
00:19:43,816 --> 00:19:45,518
NARRATOR: The
approach from above
428
00:19:45,518 --> 00:19:47,319
increased the crew's workload.
429
00:19:47,319 --> 00:19:49,855
But it's standard practice
at Schiphol airport.
430
00:19:49,855 --> 00:19:52,458
I've flown in to skip
over dozens of times.
431
00:19:52,458 --> 00:19:53,959
And I expect it.
432
00:19:53,959 --> 00:19:55,861
NARRATOR: If the
controller's instructions
433
00:19:55,861 --> 00:19:59,498
had somehow overtaxed this
crew, their conversations
434
00:19:59,498 --> 00:20:01,300
would indicate it.
435
00:20:01,300 --> 00:20:04,336
They're just three
miles from the runway.
436
00:20:04,336 --> 00:20:05,304
PILOT: 1,000.
437
00:20:05,304 --> 00:20:07,473
Check.
438
00:20:07,473 --> 00:20:10,609
PILOT: Flaps, 40.
439
00:20:10,609 --> 00:20:12,678
Speed brake?
440
00:20:12,678 --> 00:20:13,946
COPILOT: Speed brake armed.
441
00:20:13,946 --> 00:20:14,480
Green light.
442
00:20:14,480 --> 00:20:16,916
One thing at a time.
443
00:20:16,916 --> 00:20:20,319
Landing gear?
444
00:20:20,319 --> 00:20:20,953
COPILOT: Gear down.
445
00:20:20,953 --> 00:20:22,988
Three green.
446
00:20:22,988 --> 00:20:23,989
PILOT: Flaps?
447
00:20:23,989 --> 00:20:24,990
Flaps 40.
448
00:20:24,990 --> 00:20:25,825
Green light.
449
00:20:29,628 --> 00:20:30,496
PILOT: 500.
450
00:20:30,496 --> 00:20:32,364
All lights on.
451
00:20:32,364 --> 00:20:35,634
Please warn the cabin crew.
452
00:20:35,634 --> 00:20:38,003
Cabin crew, take your seats.
453
00:20:38,003 --> 00:20:39,038
[beeping]
454
00:20:39,038 --> 00:20:43,642
NARRATOR: Then, real
trouble, a stall warning.
455
00:20:43,642 --> 00:20:44,477
COPILOT: Speed, Sir.
456
00:20:44,477 --> 00:20:46,378
I have control.
457
00:20:46,378 --> 00:20:47,546
100 knots of speed.
458
00:20:51,016 --> 00:20:53,519
NARRATOR: Arisen fought
to save his plane.
459
00:20:53,519 --> 00:20:56,722
But just 400 feet above
the ground and less than a
460
00:20:56,722 --> 00:20:59,692
mile from the runway,
the Boeing 737
461
00:20:59,692 --> 00:21:02,061
suddenly fell straight down.
462
00:21:02,061 --> 00:21:05,364
It only took a few seconds
for it to hit the ground.
463
00:21:05,364 --> 00:21:06,365
[muffled screams]
464
00:21:06,365 --> 00:21:07,366
[crash]
465
00:21:12,897 --> 00:21:14,165
NARRATOR: The CVR
recording sheds
466
00:21:14,165 --> 00:21:18,570
light on the final minutes of
Turkish Airlines Flight 1951.
467
00:21:18,570 --> 00:21:21,740
The crew was configuring
their plane for landing well
468
00:21:21,740 --> 00:21:23,408
after it should have been done.
469
00:21:23,408 --> 00:21:24,542
Flaps 40.
470
00:21:24,542 --> 00:21:25,877
Green light.
471
00:21:25,877 --> 00:21:27,078
NARRATOR: Most airlines
have regulations that
472
00:21:27,078 --> 00:21:29,014
call for a flight
to be stabilized,
473
00:21:29,014 --> 00:21:31,683
to have all checklists
completed by the time
474
00:21:31,683 --> 00:21:33,618
the plane hits 1,000 feet.
475
00:21:33,618 --> 00:21:37,722
In instrument conditions, you
required a 1,000 feet to have,
476
00:21:37,722 --> 00:21:38,823
basically, everything done.
477
00:21:38,823 --> 00:21:40,392
The airplane is configured.
478
00:21:40,392 --> 00:21:41,326
You have slowed.
479
00:21:41,326 --> 00:21:43,094
You have run your
before-landing check.
480
00:21:43,094 --> 00:21:45,430
And you have received
your landing clearance.
481
00:21:45,430 --> 00:21:48,900
And from 1,000 feet on in, you
just monitor the instruments
482
00:21:48,900 --> 00:21:51,870
and were looking for the runway.
483
00:21:51,870 --> 00:21:55,440
Please warn the cabin crew.
484
00:21:55,440 --> 00:21:57,075
Cabin crew--
485
00:21:57,075 --> 00:21:59,511
NARRATOR: In fact, this crew was
still running their checklist
486
00:21:59,511 --> 00:22:03,048
up to the moment the crisis
hit, 460 feet above the ground.
487
00:22:06,785 --> 00:22:08,486
This approach
was not stabilized.
488
00:22:08,486 --> 00:22:10,588
JOSEPH SEDOR: And because
the aircraft was unstable,
489
00:22:10,588 --> 00:22:13,558
the flight crew was in a very
high-workload environment in
490
00:22:13,558 --> 00:22:16,561
the last 1,000 feet of flight.
491
00:22:16,561 --> 00:22:18,963
NARRATOR: The radio
altimeter was malfunctioning.
492
00:22:18,963 --> 00:22:21,099
The aircraft was
giving off warnings.
493
00:22:21,099 --> 00:22:23,735
The crew was assigned
a challenging approach.
494
00:22:23,735 --> 00:22:26,538
And they were executing
a checklist late.
495
00:22:26,538 --> 00:22:30,909
But none of this explains
why Flight 1951 crashed.
496
00:22:30,909 --> 00:22:32,944
In these type of
accidents, you can never get
497
00:22:32,944 --> 00:22:35,480
inside the head of the pilots.
498
00:22:35,480 --> 00:22:38,083
And that's a very
frustrating type of accident.
499
00:22:38,083 --> 00:22:39,951
NARRATOR: But the flight-data
recorder does provide
500
00:22:39,951 --> 00:22:41,753
another intriguing clue.
501
00:22:41,753 --> 00:22:45,857
Moments before Flight 1951 hit
the ground, the plane's engines
502
00:22:45,857 --> 00:22:48,960
were at idle, hardly
providing any power.
503
00:22:48,960 --> 00:22:51,629
Perhaps this
accident is a repeat
504
00:22:51,629 --> 00:22:53,498
of the Heathrow incident.
505
00:22:53,498 --> 00:22:56,034
JOSEPH SEDOR: The engines,
it was interesting to note,
506
00:22:56,034 --> 00:23:01,206
were at idle approximately the
last two minutes of flight,
507
00:23:01,206 --> 00:23:05,677
until the very end, when the
thrust was increased again.
508
00:23:05,677 --> 00:23:08,480
That was a big red
flag right there.
509
00:23:08,480 --> 00:23:11,082
The question is is,
why was that the case?
510
00:23:11,082 --> 00:23:13,118
NARRATOR: But then
they spot something
511
00:23:13,118 --> 00:23:16,187
that's very different from
the accident at Heathrow.
512
00:23:16,187 --> 00:23:18,723
Retard-flare mode.
513
00:23:18,723 --> 00:23:21,726
NARRATOR: For some reason,
while still more than 1,000 feet
514
00:23:21,726 --> 00:23:24,095
above the ground,
the plane's computer
515
00:23:24,095 --> 00:23:27,632
began preparing to touch down.
516
00:23:27,632 --> 00:23:30,969
In retard-flare mode,
engine power is reduced
517
00:23:30,969 --> 00:23:34,205
to idle by the flight computer.
518
00:23:34,205 --> 00:23:36,708
And the plane's nose
automatically pitches up
519
00:23:36,708 --> 00:23:37,442
to the flare position.
520
00:23:41,012 --> 00:23:43,114
Planes should only be
in this configuration
521
00:23:43,114 --> 00:23:45,650
just before they
touch the ground.
522
00:23:45,650 --> 00:23:48,586
The autopilot raises the
nose to break the descent.
523
00:23:48,586 --> 00:23:51,689
The auto throttles brings the
power back to flight idle.
524
00:23:51,689 --> 00:23:53,258
And you touch down
with the power
525
00:23:53,258 --> 00:23:56,227
either all the way in idle
or just about to be in idle.
526
00:23:56,227 --> 00:24:00,198
NARRATOR: But Flight 1951 went
into a slow, nose-up position
527
00:24:00,198 --> 00:24:03,001
well before touchdown,
causing the plane
528
00:24:03,001 --> 00:24:06,671
to fly slower and slower
throughout its descent.
529
00:24:06,671 --> 00:24:08,273
Speed, Sir.
530
00:24:08,273 --> 00:24:10,875
NARRATOR: So why was Flight
1951 in landing mode?
531
00:24:10,875 --> 00:24:13,611
COPILOT: [inaudible]
loss of speed.
532
00:24:13,611 --> 00:24:15,780
NARRATOR: And why hadn't any
of the three crew members
533
00:24:15,780 --> 00:24:18,249
noticed how slowly
they were flying?
534
00:24:18,249 --> 00:24:19,150
[crash]
535
00:24:19,150 --> 00:24:20,718
[screaming]
536
00:24:28,293 --> 00:24:32,263
So what else was going on
when the engines went to idle?
537
00:24:32,263 --> 00:24:34,866
NARRATOR: The trouble seems to
start with the malfunctioning
538
00:24:34,866 --> 00:24:36,668
altimeter.
539
00:24:36,668 --> 00:24:38,203
JOSEPH SEDOR: We had to look
at the system as a whole
540
00:24:38,203 --> 00:24:40,805
and to see how that minus 8
affected the other systems
541
00:24:40,805 --> 00:24:42,273
on the aircraft.
542
00:24:42,273 --> 00:24:45,610
And that was a very big
portion of this investigation.
543
00:24:45,610 --> 00:24:49,781
We had to say, how did the
autopilot use that data?
544
00:24:49,781 --> 00:24:53,151
More importantly, how did the
auto throttle use that data?
545
00:24:53,151 --> 00:24:54,319
NARRATOR: The
computer that flies
546
00:24:54,319 --> 00:24:58,056
the plane consists of two
main systems, the autopilot
547
00:24:58,056 --> 00:24:59,824
and the auto throttle.
548
00:24:59,824 --> 00:25:03,127
The auto throttle determines how
much power to ask the engines
549
00:25:03,127 --> 00:25:05,797
for while the autopilot
controls the plane's
550
00:25:05,797 --> 00:25:07,232
altitude and direction.
551
00:25:11,002 --> 00:25:12,804
The two systems
work independently
552
00:25:12,804 --> 00:25:15,673
of each other and only one
of the radio altimeters
553
00:25:15,673 --> 00:25:18,643
provides information
to the auto throttle.
554
00:25:18,643 --> 00:25:20,745
In this case, I had to
learn everything there was
555
00:25:20,745 --> 00:25:23,047
about radio altimeters
and auto throttle systems,
556
00:25:23,047 --> 00:25:24,849
which I didn't know before.
557
00:25:24,849 --> 00:25:26,084
NARRATOR: The
pieces of the puzzle
558
00:25:26,084 --> 00:25:28,119
begin coming together
when they find
559
00:25:28,119 --> 00:25:30,021
the connection between
the faulty radio
560
00:25:30,021 --> 00:25:33,191
altimeter and engine power.
561
00:25:33,191 --> 00:25:35,293
The radio altimeter
provides information
562
00:25:35,293 --> 00:25:37,262
to the auto throttle
from the captain's side.
563
00:25:44,936 --> 00:25:48,039
NARRATOR: The only altimeter
feeding information to the auto
564
00:25:48,039 --> 00:25:49,674
throttle was the captain's.
565
00:25:49,674 --> 00:25:50,942
And it was wrong.
566
00:25:50,942 --> 00:25:53,811
It showed minus 8
feet throughout most
567
00:25:53,811 --> 00:25:57,682
of Flight 1951's approach.
568
00:25:57,682 --> 00:26:00,385
It's beginning to look
like the faulty radio
569
00:26:00,385 --> 00:26:03,721
altimeter triggered the
events that led to the crash.
570
00:26:03,721 --> 00:26:07,825
Investigators need to know
what went wrong with it.
571
00:26:07,825 --> 00:26:11,329
On a 737, the transmitting
and receiving antennas
572
00:26:11,329 --> 00:26:13,865
for both radio
altimeters are lined up
573
00:26:13,865 --> 00:26:16,668
underneath the cockpit.
574
00:26:16,668 --> 00:26:19,904
Three of the antennas were all
but destroyed in the crash.
575
00:26:19,904 --> 00:26:21,773
They can't be tested.
576
00:26:21,773 --> 00:26:26,010
But one antenna from the
captain's side is undamaged.
577
00:26:26,010 --> 00:26:30,381
Investigators consider two
possibilities, a failure of one
578
00:26:30,381 --> 00:26:33,184
of the components or
some sort of interference
579
00:26:33,184 --> 00:26:35,386
that caused the faulty reading.
580
00:26:35,386 --> 00:26:38,356
The only component that
survived the crash checks out.
581
00:26:44,696 --> 00:26:47,966
The computers that control
the system also work.
582
00:26:47,966 --> 00:26:51,703
But investigators do make a
curious discovery about them.
583
00:26:51,703 --> 00:26:54,205
They aren't the same
ones that were installed
584
00:26:54,205 --> 00:26:56,741
on the plane when it was
delivered to Turkish Airlines
585
00:26:56,741 --> 00:26:58,443
seven years ago.
586
00:26:58,443 --> 00:27:02,280
This find changes the
focus of the investigation.
587
00:27:02,280 --> 00:27:03,348
JOSEPH SEDOR: The
maintenance aspect
588
00:27:03,348 --> 00:27:07,185
of this accident aircraft
was one that we looked
589
00:27:07,185 --> 00:27:09,387
at as deeply as we could.
590
00:27:18,830 --> 00:27:20,965
NARRATOR: When the plane's
maintenance log is studied,
591
00:27:20,965 --> 00:27:24,936
investigators find that the
radio altimeter on this plane
592
00:27:24,936 --> 00:27:26,871
had a problematic history.
593
00:27:26,871 --> 00:27:30,808
JOSEPH SEDOR: We got additional
data from Turkish airlines.
594
00:27:30,808 --> 00:27:35,413
And that data showed that, on
this one aircraft, of the past,
595
00:27:35,413 --> 00:27:37,982
I believe, over
1,000 flights, there
596
00:27:37,982 --> 00:27:43,454
was about 150 flights that had
faulty radio-altimeter systems.
597
00:27:43,454 --> 00:27:45,790
NARRATOR: The documents show
that a little more than a year
598
00:27:45,790 --> 00:27:48,393
before the crash,
both computers were
599
00:27:48,393 --> 00:27:50,294
replaced because
of complaints they
600
00:27:50,294 --> 00:27:51,963
were causing faulty readings.
601
00:27:51,963 --> 00:27:55,099
One of the incidents involved
a radio-altimeter reading
602
00:27:55,099 --> 00:27:56,901
of minus 8 feet.
603
00:27:56,901 --> 00:27:59,270
[beeping]
604
00:27:59,270 --> 00:28:01,172
JOSEPH SEDOR: So that was
telling us that there was
605
00:28:01,172 --> 00:28:02,807
an issue that had been there.
606
00:28:02,807 --> 00:28:06,811
The issue did not just
occur on this flight.
607
00:28:06,811 --> 00:28:09,480
NARRATOR: The faulty
readings persisted.
608
00:28:09,480 --> 00:28:11,849
Mechanics repeatedly
swap the computers
609
00:28:11,849 --> 00:28:17,021
and replace the antennas to
try to solve the problem.
610
00:28:17,021 --> 00:28:20,058
It's determined that Turkish
Airlines tried several ways
611
00:28:20,058 --> 00:28:22,193
to fix the altimeter.
612
00:28:22,193 --> 00:28:24,162
But they couldn't find
a repair that worked.
613
00:28:28,533 --> 00:28:31,269
At the time of the
accident, Turkish airlines
614
00:28:31,269 --> 00:28:35,740
had a fleet of 52 Boeing
737 800-series airplanes.
615
00:28:41,846 --> 00:28:43,381
JOSEPH SEDOR: It's on page 93.
616
00:28:43,381 --> 00:28:45,483
When we reviewed the
maintenance data,
617
00:28:45,483 --> 00:28:47,852
we found that radio-altimeter
problems had been
618
00:28:47,852 --> 00:28:50,888
written up several times
on both the Axon airplane
619
00:28:50,888 --> 00:28:53,558
and the fleet.
620
00:28:53,558 --> 00:28:56,027
NARRATOR: Investigators
discover that in the year
621
00:28:56,027 --> 00:28:58,362
before the crash,
Turkish Airlines
622
00:28:58,362 --> 00:29:02,033
dealt with 235 system
faults with the radio
623
00:29:02,033 --> 00:29:03,334
altimeters on their 737s.
624
00:29:06,070 --> 00:29:09,974
Fixes ranged from Replacing and
exchanging antennas, cleaning
625
00:29:09,974 --> 00:29:14,579
of the systems, exchanging
and replacing the computers,
626
00:29:14,579 --> 00:29:17,181
and installing gaskets
to shield the system
627
00:29:17,181 --> 00:29:20,485
from possible water damage.
628
00:29:20,485 --> 00:29:23,554
It's not like they weren't
doing anything about it.
629
00:29:23,554 --> 00:29:25,823
JOSEPH SEDOR: The Turkish
Airlines maintenance personnel
630
00:29:25,823 --> 00:29:29,060
knew that the
radio-altimeter problem
631
00:29:29,060 --> 00:29:33,898
was one of their highest issues
with regard to maintenance.
632
00:29:33,898 --> 00:29:36,000
NARRATOR: 16 of those
altimeter repairs
633
00:29:36,000 --> 00:29:40,505
were made to the plane that
crashed in February, 2009.
634
00:29:40,505 --> 00:29:43,074
If the problem
was so widespread,
635
00:29:43,074 --> 00:29:46,210
investigators wonder why it
hadn't caused serious problems
636
00:29:46,210 --> 00:29:47,411
before this accident.
637
00:29:50,414 --> 00:29:51,682
They don't have to
dig too far back
638
00:29:51,682 --> 00:29:57,622
to find out that, in fact, it
had, on this very same plane.
639
00:29:57,622 --> 00:30:01,259
On two recent flights, they
had the exact same problem.
640
00:30:01,259 --> 00:30:05,596
NARRATOR: Twice, in the 48 hours
leading up to the accident,
641
00:30:05,596 --> 00:30:08,533
the radio altimeter
showed a negative reading,
642
00:30:08,533 --> 00:30:12,570
putting the plane into
retard-flare mode.
643
00:30:12,570 --> 00:30:15,973
Both times, the crew
noticed the problem,
644
00:30:15,973 --> 00:30:18,943
disengaged the auto throttles,
and brought the plane
645
00:30:18,943 --> 00:30:19,544
in for a safe landing.
646
00:30:25,950 --> 00:30:28,486
You just disconnect
it and fly the airplane.
647
00:30:28,486 --> 00:30:30,454
NARRATOR: In the
months after the crash,
648
00:30:30,454 --> 00:30:34,292
other operators came forward
with similar stories.
649
00:30:34,292 --> 00:30:36,594
In Australia, in
the Netherlands,
650
00:30:36,594 --> 00:30:41,132
in Canada, in Austria,
pilots report their 737s
651
00:30:41,132 --> 00:30:45,136
going into retard-flare mode
when the left radio altimeter
652
00:30:45,136 --> 00:30:47,338
showed a faulty reading.
653
00:30:47,338 --> 00:30:50,341
Each of those crews
reacted the same way.
654
00:30:50,341 --> 00:30:52,543
They disengaged the
auto throttle and pushed
655
00:30:52,543 --> 00:30:56,447
the power back up manually.
656
00:30:56,447 --> 00:30:57,548
They all landed safely.
657
00:31:00,117 --> 00:31:02,053
BILL HUFF: Things are going
to break on an airplane.
658
00:31:02,053 --> 00:31:04,622
And usually, you're able
to identify that and take
659
00:31:04,622 --> 00:31:07,325
that out of-- make
it so that it's
660
00:31:07,325 --> 00:31:10,628
not a threat for the landing.
661
00:31:10,628 --> 00:31:13,130
NARRATOR: In 2008,
Boeing received
662
00:31:13,130 --> 00:31:18,302
a whopping 2,569 reports
of faulty radio altimeters
663
00:31:18,302 --> 00:31:20,605
on their latest 737s.
664
00:31:20,605 --> 00:31:23,307
But very few of those
cases involve the plane
665
00:31:23,307 --> 00:31:25,476
going into retard-flare mode.
666
00:31:25,476 --> 00:31:28,646
Hardly any reports at all.
667
00:31:28,646 --> 00:31:30,481
NARRATOR: Boeing also
tried, but couldn't
668
00:31:30,481 --> 00:31:33,184
find the cause of the failures.
669
00:31:33,184 --> 00:31:36,487
They concluded that the
radio-altimeter problem was not
670
00:31:36,487 --> 00:31:39,624
a threat to safety
because the 737 gives
671
00:31:39,624 --> 00:31:41,492
off enough warnings
so that crews
672
00:31:41,492 --> 00:31:43,160
can intervene and land safely.
673
00:31:45,663 --> 00:31:49,333
In fact, in every instance where
the radio altimeter failed,
674
00:31:49,333 --> 00:31:51,202
crews were able to recover.
675
00:31:54,205 --> 00:31:58,376
Turkish Airlines Flight 1951
seems to be the one exception.
676
00:32:02,413 --> 00:32:06,017
Investigators still
don't know why.
677
00:32:06,017 --> 00:32:08,552
It really got us
wondering of what happened.
678
00:32:08,552 --> 00:32:11,188
And that's when we started
to look really closely
679
00:32:11,188 --> 00:32:14,558
at the actions of
the flight crews
680
00:32:14,558 --> 00:32:16,394
while it was on
that final approach,
681
00:32:16,394 --> 00:32:17,395
in less than 1,000 feet.
682
00:32:23,185 --> 00:32:27,422
of Turkish Airlines Flight
1951, the circumstances
683
00:32:27,422 --> 00:32:30,091
of the tragedy become clear.
684
00:32:30,091 --> 00:32:34,095
They see a remarkable sequence
of events that transpire
685
00:32:34,095 --> 00:32:36,364
to bring down this plane.
686
00:32:36,364 --> 00:32:38,400
So what was happening
when the plane
687
00:32:38,400 --> 00:32:40,202
went into retard-flare mode?
688
00:32:40,202 --> 00:32:43,205
NARRATOR: They discover that
the plane went into landing mode
689
00:32:43,205 --> 00:32:46,441
and pulled back power at
the worst possible moment,
690
00:32:46,441 --> 00:32:48,410
exactly as the
crew was descending
691
00:32:48,410 --> 00:32:49,711
to meet the glide slope.
692
00:32:49,711 --> 00:32:53,748
It masked what was
actually happening.
693
00:32:53,748 --> 00:32:56,318
NARRATOR: As the crew configured
their plane to drop down
694
00:32:56,318 --> 00:32:59,588
to meet the glide slope, they
expected the plane to slow
695
00:32:59,588 --> 00:33:01,756
down as part of that maneuver.
696
00:33:01,756 --> 00:33:04,426
But the plane was
actually slowing down
697
00:33:04,426 --> 00:33:07,462
because the computer
was in landing mode.
698
00:33:07,462 --> 00:33:09,130
That's why none of
the three pilots
699
00:33:09,130 --> 00:33:12,567
said anything about the
throttles moving to idle.
700
00:33:12,567 --> 00:33:13,835
BILL HUFF: It was insidious.
701
00:33:13,835 --> 00:33:16,171
Where it first captured
in the retard mode,
702
00:33:16,171 --> 00:33:18,506
it didn't hurt them at all
because they were actually high
703
00:33:18,506 --> 00:33:20,175
and they were a little bit fast.
704
00:33:20,175 --> 00:33:22,644
And the pilots actually
wanted the power back anyway.
705
00:33:22,644 --> 00:33:23,645
In fact, the throttles
may have already
706
00:33:23,645 --> 00:33:27,182
been in the flight-idle
mode as they were trying
707
00:33:27,182 --> 00:33:29,284
to get down and slow down.
708
00:33:29,284 --> 00:33:32,354
All right, the trouble
starts here, at 8,300 feet,
709
00:33:32,354 --> 00:33:35,590
13 miles out from the airport,
minutes before the crash.
710
00:33:42,297 --> 00:33:49,804
PILOT: Amsterdam, Turkish 1951,
descending 7,000, speed 250.
711
00:33:49,804 --> 00:33:50,772
AIR TRAFFIC CONTROLLER
(OVER RADIO):
712
00:33:50,772 --> 00:33:54,342
Turkish 1951, descend to 4,000.
713
00:33:54,342 --> 00:33:56,778
Speed OK for ILS 18 Right.
714
00:33:56,778 --> 00:33:59,814
[beeping]
715
00:33:59,814 --> 00:34:00,815
Radio altimeter.
716
00:34:05,787 --> 00:34:07,389
JOSEPH SEDOR: Would
the crew have known
717
00:34:07,389 --> 00:34:09,157
that, because of
that radio altimeter,
718
00:34:09,157 --> 00:34:10,525
they would have gone
to a retard-flare mode
719
00:34:10,525 --> 00:34:11,893
in the throttles?
720
00:34:11,893 --> 00:34:13,795
No.
721
00:34:13,795 --> 00:34:15,830
It was a common
problem at the airline.
722
00:34:15,830 --> 00:34:19,367
But the crew couldn't see the
risk it posed this flight.
723
00:34:19,367 --> 00:34:21,903
We have an airplane that was
malfunctioning in a very minor
724
00:34:21,903 --> 00:34:24,439
way, but in a way
that, if not caught,
725
00:34:24,439 --> 00:34:28,476
could and did metastasize into
something much more virulent.
726
00:34:28,476 --> 00:34:29,644
AIR TRAFFIC CONTROLLER
(OVER RADIO):
727
00:34:29,644 --> 00:34:32,480
Turkish m descend send to 2,000.
728
00:34:32,480 --> 00:34:36,818
2,000, 1951.
729
00:34:36,818 --> 00:34:37,886
AIR TRAFFIC CONTROLLER
(OVER RADIO):
730
00:34:37,886 --> 00:34:42,891
Turkish 1951, left heading
210, cleared approach.
731
00:34:42,891 --> 00:34:45,760
18 Right.
732
00:34:45,760 --> 00:34:50,398
Left 210 clear
ILS, Turkish 1951.
733
00:34:50,398 --> 00:34:55,270
EXPERT: It left at 210 degrees,
maintaining 2,000 feet,
734
00:34:55,270 --> 00:35:00,308
brings the flight in
right here, 5.5 miles out.
735
00:35:00,308 --> 00:35:05,347
They now have to intercept
the glide slope from above.
736
00:35:05,347 --> 00:35:08,450
NARRATOR: At 2,000 feet, with
the glide slope below them,
737
00:35:08,450 --> 00:35:13,355
the pilots have to reduce their
speed while descending steeply.
738
00:35:13,355 --> 00:35:14,889
Speed, 140.
739
00:35:14,889 --> 00:35:16,725
NARRATOR: They believe the
throttles are moving back for
740
00:35:16,725 --> 00:35:18,927
the descent to the glide slope.
741
00:35:18,927 --> 00:35:22,464
In fact, the auto throttle is
slowing the plane down because
742
00:35:22,464 --> 00:35:24,265
it's gone into landing mode.
743
00:35:24,265 --> 00:35:28,403
It will continue to slow
the plane until it stalls.
744
00:35:28,403 --> 00:35:30,972
JOSEPH SEDOR: What we found is
that, when the flight crew was
745
00:35:30,972 --> 00:35:34,275
doing their before-landing
checklist, each one of them
746
00:35:34,275 --> 00:35:36,478
was doing something
while they should have
747
00:35:36,478 --> 00:35:38,813
been monitoring their airspeed.
748
00:35:38,813 --> 00:35:43,952
For the next 100 seconds, no
one notices what's happening
749
00:35:43,952 --> 00:35:46,554
'til it's too late.
750
00:35:46,554 --> 00:35:48,390
COPILOT: Established
altitude set.
751
00:35:48,390 --> 00:35:49,457
PILOT: 1,000?
752
00:35:49,457 --> 00:35:50,558
COPILOT: Check.
753
00:35:50,558 --> 00:35:52,360
PILOT: Flaps 40.
754
00:35:52,360 --> 00:35:53,795
Speed set.
755
00:35:53,795 --> 00:35:55,463
The experienced
pilot recognized
756
00:35:55,463 --> 00:35:57,332
that the first officer
was probably a little bit
757
00:35:57,332 --> 00:35:58,733
behind on the approach.
758
00:35:58,733 --> 00:36:01,736
So he calls for flap
40 and moves the lever,
759
00:36:01,736 --> 00:36:04,305
informing the first officer
that he has done so.
760
00:36:04,305 --> 00:36:06,808
He's trying to help the
first officer catch up
761
00:36:06,808 --> 00:36:08,610
to the position of the aircraft.
762
00:36:08,610 --> 00:36:09,744
PILOT: Speed break?
763
00:36:09,744 --> 00:36:10,812
COPILOT: Speed brake armed.
764
00:36:10,812 --> 00:36:11,513
Green light.
765
00:36:11,513 --> 00:36:13,515
PILOT: One thing at the time.
766
00:36:13,515 --> 00:36:14,983
Landing gear.
767
00:36:14,983 --> 00:36:17,819
NARRATOR: The plane is now
700 feet from the ground.
768
00:36:17,819 --> 00:36:19,487
COPILOT: Gear down, three green.
769
00:36:19,487 --> 00:36:20,522
PILOT: Flaps?
770
00:36:20,522 --> 00:36:24,392
COPILOT: Flaps 40, green light.
771
00:36:24,392 --> 00:36:26,661
NARRATOR: In their haste to
complete their checklist,
772
00:36:26,661 --> 00:36:28,530
none of the three
crew members noticed
773
00:36:28,530 --> 00:36:31,833
the warnings that their speed
is dropping dangerously.
774
00:36:31,833 --> 00:36:34,436
First, a red bar appeared
on their flight display.
775
00:36:34,436 --> 00:36:35,870
[beeping]
776
00:36:35,870 --> 00:36:38,373
Then, when the air
speed continued to drop,
777
00:36:38,373 --> 00:36:40,975
a flashing box appeared
around their actual airspeed
778
00:36:40,975 --> 00:36:43,678
to draw the pilot's
attention to it.
779
00:36:43,678 --> 00:36:45,847
At this point, no
one sees either.
780
00:36:45,847 --> 00:36:47,849
COPILOT: Cabin report confirmed.
781
00:36:47,849 --> 00:36:50,652
NARRATOR: The aircraft is
now 600 feet from landing.
782
00:36:50,652 --> 00:36:53,354
When things start changing
colors, it's a warning to you.
783
00:36:53,354 --> 00:36:55,657
It's a caution to you
that you're approaching
784
00:36:55,657 --> 00:36:57,292
the limits of the aircraft.
785
00:36:57,292 --> 00:36:58,560
PILOT: Missed approach.
786
00:36:58,560 --> 00:36:59,861
Altitude set.
787
00:36:59,861 --> 00:37:00,795
500.
788
00:37:00,795 --> 00:37:02,897
JOSEPH SEDOR: So all
of these indications
789
00:37:02,897 --> 00:37:05,800
the crew has in front of them,
saying that the aircraft is
790
00:37:05,800 --> 00:37:08,803
slowing down, during that
time, they were still
791
00:37:08,803 --> 00:37:09,938
completing their checklist.
792
00:37:09,938 --> 00:37:11,539
BILL HUFF: Of course,
the aircraft is
793
00:37:11,539 --> 00:37:13,074
getting closer to the ground.
794
00:37:13,074 --> 00:37:15,710
NARRATOR: In fact, it's less
than 500 feet from touchdown.
795
00:37:15,710 --> 00:37:19,013
And right before
the stick shaker
796
00:37:19,013 --> 00:37:22,517
started, the captain
told the safety pilot--
797
00:37:22,517 --> 00:37:24,686
PILOT: Please warn
the cabin crew.
798
00:37:24,686 --> 00:37:28,056
SAFETY PILOT: Cabin
crew, take your seats.
799
00:37:28,056 --> 00:37:28,623
COPILOT: Speed, Sir.
800
00:37:28,623 --> 00:37:30,391
PILOT: I have control.
801
00:37:30,391 --> 00:37:31,826
BILL HUFF: By the time
they advanced the throttles
802
00:37:31,826 --> 00:37:34,329
to full power, it
was unrecoverable.
803
00:37:34,329 --> 00:37:37,532
They were too low for
the engines to catch up.
804
00:37:37,532 --> 00:37:39,000
And that's it.
805
00:37:39,000 --> 00:37:41,402
It's now too late
to save this plane.
806
00:37:41,402 --> 00:37:42,737
[crash]
807
00:37:46,074 --> 00:37:48,343
They all knew about
the altimeter problem
808
00:37:48,343 --> 00:37:49,978
but knowing didn't help.
809
00:38:00,731 --> 00:38:03,066
of a faulty altimeter.
810
00:38:03,066 --> 00:38:07,904
But on February 25, 2009, it
triggered an unusual sequence
811
00:38:07,904 --> 00:38:10,407
of events that brought
down a jetliner
812
00:38:10,407 --> 00:38:11,641
and killed nine people.
813
00:38:14,010 --> 00:38:16,079
The official report
into the accident
814
00:38:16,079 --> 00:38:19,349
blames it on a convergence
of circumstances.
815
00:38:19,349 --> 00:38:20,917
JOHN NANCE: There is
never, ever just one
816
00:38:20,917 --> 00:38:22,619
cause to an airline accident.
817
00:38:22,619 --> 00:38:23,954
It simply doesn't exist.
818
00:38:23,954 --> 00:38:26,056
Maybe someday, God will
slap one out of the sky.
819
00:38:26,056 --> 00:38:28,725
But until then, there's
never one cause.
820
00:38:28,725 --> 00:38:32,062
NARRATOR: The Dutch report also
points out that Boeing could
821
00:38:32,062 --> 00:38:35,098
have realized that the problem
with the radio altimeter system
822
00:38:35,098 --> 00:38:37,100
could have had an
impact on safety.
823
00:38:37,100 --> 00:38:39,870
Given that no one foresaw
how that failure might
824
00:38:39,870 --> 00:38:42,939
cause a crash, the
Turkish Airlines
825
00:38:42,939 --> 00:38:45,809
accident raises a big question.
826
00:38:45,809 --> 00:38:47,944
Are airplanes
becoming too complex?
827
00:38:51,982 --> 00:38:54,951
Investigators have determined
the Turkish Airlines Flight
828
00:38:54,951 --> 00:38:58,488
1951 crashed mainly
because the pilots
829
00:38:58,488 --> 00:39:00,590
didn't recognize the
consequences of the warnings
830
00:39:00,590 --> 00:39:01,591
they were getting.
831
00:39:03,460 --> 00:39:05,395
AIR TRAFFIC CONTROLLER
(OVER RADIO): Turkish 1951,
832
00:39:05,395 --> 00:39:07,130
descend to 4,000--
833
00:39:07,130 --> 00:39:08,165
NARRATOR: This is
not the first plane
834
00:39:08,165 --> 00:39:10,901
to crash because the crew
didn't understand what
835
00:39:10,901 --> 00:39:12,469
their plane was telling them.
836
00:39:12,469 --> 00:39:14,504
JOHN NANCE: Our problem
is not the automation.
837
00:39:14,504 --> 00:39:17,107
Our problem is the depth of
the training and the ability
838
00:39:17,107 --> 00:39:19,910
of the human beings to
recover from mistakes
839
00:39:19,910 --> 00:39:23,180
made in interfacing
with the automation.
840
00:39:23,180 --> 00:39:25,582
NARRATOR: Mica Endsley
studies the relationship
841
00:39:25,582 --> 00:39:28,685
between pilots and technology.
842
00:39:28,685 --> 00:39:30,487
MICA ENDSLEY: And we haven't
really designed the automation
843
00:39:30,487 --> 00:39:33,990
to take best advantage
of what people do well
844
00:39:33,990 --> 00:39:35,992
and take them take
away the parts
845
00:39:35,992 --> 00:39:37,794
that people don't do well.
846
00:39:37,794 --> 00:39:42,632
NARRATOR: In 1996, the crew of
an AeroperĂș 757 crashed when
847
00:39:42,632 --> 00:39:45,969
the pilots couldn't decipher
contradictory warnings about
848
00:39:45,969 --> 00:39:48,839
their altitude and airspeed.
849
00:39:48,839 --> 00:39:51,107
The plane flew into
the Pacific Ocean.
850
00:39:51,107 --> 00:39:55,545
61 passengers and 9 crew
members were killed.
851
00:39:55,545 --> 00:39:59,816
In 1995, the flight management
system on a Boeing 757
852
00:39:59,816 --> 00:40:02,752
could and should have steered
the plane to a safe landing
853
00:40:02,752 --> 00:40:05,021
in Cali, Colombia.
854
00:40:05,021 --> 00:40:07,524
But a last minute change
to the flight plan
855
00:40:07,524 --> 00:40:09,726
meant the crew had to
reprogram their computer.
856
00:40:09,726 --> 00:40:12,829
They mistakenly entered a
course that took them headlong
857
00:40:12,829 --> 00:40:14,998
into a 9,000-foot mountain.
858
00:40:14,998 --> 00:40:18,134
159 people died in the crash.
859
00:40:18,134 --> 00:40:19,803
JOHN NANCE: The
cautionary tale here is
860
00:40:19,803 --> 00:40:21,204
that we can get this equipment.
861
00:40:21,204 --> 00:40:23,540
We can get these silicon-based
units, if you will,
862
00:40:23,540 --> 00:40:26,509
so sophisticated that we can't
talk to them, effectively.
863
00:40:26,509 --> 00:40:29,145
And when they go berserk
or they have a problem
864
00:40:29,145 --> 00:40:31,548
or we misprogramed
them, we end up
865
00:40:31,548 --> 00:40:33,984
putting ourselves and
our passengers in danger
866
00:40:33,984 --> 00:40:35,185
while we're trying
to figure out.
867
00:40:35,185 --> 00:40:37,554
NARRATOR: What some
researchers are finding
868
00:40:37,554 --> 00:40:40,557
is that the best technology
shouldn't replace pilots,
869
00:40:40,557 --> 00:40:41,992
but work with them.
870
00:40:41,992 --> 00:40:43,627
MICA ENDSLEY: Really,
integrating people
871
00:40:43,627 --> 00:40:46,763
with technology more effectively
has to do with designing
872
00:40:46,763 --> 00:40:49,833
the displays so that you can't
really understand what it's
873
00:40:49,833 --> 00:40:51,735
doing, and you can
make it simpler
874
00:40:51,735 --> 00:40:54,237
to understand how to make it do
what it is you want it to do.
875
00:40:54,237 --> 00:40:56,206
You shouldn't have
to push 16 buttons
876
00:40:56,206 --> 00:40:58,775
through 8 levels of menus
to figure out what's
877
00:40:58,775 --> 00:41:00,210
going on with the system.
878
00:41:00,210 --> 00:41:01,878
It should be integrated
and presented effectively.
879
00:41:01,878 --> 00:41:03,680
It should be as
easy to communicate
880
00:41:03,680 --> 00:41:05,248
with as the person next to you.
881
00:41:05,248 --> 00:41:08,151
NARRATOR: Boeing and Airbus,
the two largest manufacturers
882
00:41:08,151 --> 00:41:10,620
of passenger planes,
take very different
883
00:41:10,620 --> 00:41:14,958
approaches to the relationship
between humans and technology.
884
00:41:14,958 --> 00:41:17,060
Airbus gives the
flight computer much
885
00:41:17,060 --> 00:41:19,162
of the decision-making
power in the cockpit.
886
00:41:19,162 --> 00:41:21,264
In their view, this
is a way to prevent
887
00:41:21,264 --> 00:41:24,234
a lot of human errors, by making
sure the airplane doesn't do
888
00:41:24,234 --> 00:41:25,936
something it's going
to cause a crash,
889
00:41:25,936 --> 00:41:27,971
even if the humans want them to.
890
00:41:27,971 --> 00:41:29,739
NARRATOR: But Boeing
has a different view.
891
00:41:29,739 --> 00:41:33,109
Its philosophy is to provide
information to pilots
892
00:41:33,109 --> 00:41:35,145
and have them make decisions.
893
00:41:35,145 --> 00:41:37,847
Having more
information is better
894
00:41:37,847 --> 00:41:42,652
for the pilot, having the pilot
in the loop, in the equation,
895
00:41:42,652 --> 00:41:43,954
so to speak.
896
00:41:43,954 --> 00:41:45,088
I kind of like that.
897
00:41:45,088 --> 00:41:47,290
Airbus will
argue vociferously,
898
00:41:47,290 --> 00:41:50,894
and in continuous
fashion, that that view
899
00:41:50,894 --> 00:41:52,662
is archaic and incorrect.
900
00:41:52,662 --> 00:41:54,264
I think the jury is still out.
901
00:41:54,264 --> 00:41:57,133
NARRATOR: The final report into
the Turkish Airlines tragedy
902
00:41:57,133 --> 00:41:59,936
blames the crash of
Flight 1951 partly
903
00:41:59,936 --> 00:42:01,738
on a failure of technology.
904
00:42:01,738 --> 00:42:03,740
JOSEPH SEDOR: The erroneous
radio-altimeter data
905
00:42:03,740 --> 00:42:08,078
caused the auto throttle to
go to a improper mode that is,
906
00:42:08,078 --> 00:42:10,080
of course, not a good situation.
907
00:42:13,316 --> 00:42:15,185
NARRATOR: The
Dutch investigation
908
00:42:15,185 --> 00:42:18,154
asks Boeing to improve the
reliability of the system.
909
00:42:18,154 --> 00:42:19,689
JOSEPH SEDOR: We
learned a lot about
910
00:42:19,689 --> 00:42:22,959
the radio-altimeter
system and how it affects
911
00:42:22,959 --> 00:42:24,861
the auto throttle system.
912
00:42:24,861 --> 00:42:26,696
NARRATOR: Boeing ultimately
changed the throttle system
913
00:42:26,696 --> 00:42:30,000
so that one erroneous altitude
reading would never again
914
00:42:30,000 --> 00:42:31,267
trigger a similar tragedy.
915
00:42:36,973 --> 00:42:39,142
But the report also
faults the crew
916
00:42:39,142 --> 00:42:41,778
for not noticing that
their airspeed was dropping
917
00:42:41,778 --> 00:42:44,881
dangerously low, in spite
of the fact that there
918
00:42:44,881 --> 00:42:46,850
were three pilots on board.
919
00:42:46,850 --> 00:42:48,852
GORDON BETHUNE: Forget that
you got an auto throttle.
920
00:42:48,852 --> 00:42:50,186
You look at the airspeed.
921
00:42:50,186 --> 00:42:52,222
And you look at the altitude.
922
00:42:52,222 --> 00:42:54,190
You look out the damn
window if you want to.
923
00:42:54,190 --> 00:42:57,961
But airspeed is a crucial
component of staying alive
924
00:42:57,961 --> 00:42:59,763
in an airplane.
925
00:42:59,763 --> 00:43:01,731
And you always need to
know what your airspeed is.
926
00:43:01,731 --> 00:43:04,367
NARRATOR: But to Mica
Endsley, the crew's failure
927
00:43:04,367 --> 00:43:07,370
to monitor instruments is
entirely understandable
928
00:43:07,370 --> 00:43:10,907
and may be more the fault of
the instruments than the crew.
929
00:43:10,907 --> 00:43:13,043
MICA ENDSLEY: It's actually
very difficult for people
930
00:43:13,043 --> 00:43:15,378
to be monitors of automation.
931
00:43:15,378 --> 00:43:17,380
One of the things that people
don't do a good job of,
932
00:43:17,380 --> 00:43:18,381
actually, is monitoring.
933
00:43:18,381 --> 00:43:21,384
We're very good on-the-spot
decision makers.
934
00:43:21,384 --> 00:43:23,853
We're very good at coming
up with creative solutions
935
00:43:23,853 --> 00:43:25,422
to problems.
936
00:43:25,422 --> 00:43:27,690
But repetitive monitoring
is the kind of thing
937
00:43:27,690 --> 00:43:29,926
that actually, people
aren't very good at at all.
938
00:43:29,926 --> 00:43:32,829
So what we have to do is design
automation to work with people
939
00:43:32,829 --> 00:43:35,665
in a way that keeps them more
actively, cognitively involved
940
00:43:35,665 --> 00:43:37,400
and in the loop, and
not just monitoring
941
00:43:37,400 --> 00:43:39,836
a piece of automation
to say, is it doing
942
00:43:39,836 --> 00:43:42,238
what it's supposed to be doing?
943
00:43:42,238 --> 00:43:43,373
JOHN NANCE: Who's the
ultimate computer?
944
00:43:43,373 --> 00:43:46,376
The pilot, the individual
who should be able to say,
945
00:43:46,376 --> 00:43:47,377
I don't know what this
thing is doing to me
946
00:43:47,377 --> 00:43:49,846
but I'm punching it off
and flying the airplane.
947
00:43:49,846 --> 00:43:51,347
Fly the jet.
948
00:43:51,347 --> 00:43:53,716
Probably the smartest thing
we ever learned to say,
949
00:43:53,716 --> 00:43:56,052
in our training in the
airlines, fly the jet.
950
00:43:56,052 --> 00:43:58,121
Do that first or
nothing else counts.
951
00:43:58,121 --> 00:44:00,390
That's what they forgot to do.
74989
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