Air Crash Investigation - mixed signals
Air Crash Investigation - mixed signals
Description
Air Crash Investigation (or just Mayday in some countries), is a Canadian documentary television program examining air crashes, near-crashes, hijackings, bombings, and other disasters.[1]
Throughout the episodes, the victims or relatives and friends of the victims are interviewed adding more information about the cases with their relatives. Additionally, retired aviation experts, pilots and researchers are interviewed about the tests and explain how these emergencies occurred and how they could have been prevented.
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Description
Air Crash Investigation (or just Mayday in some countries), is a Canadian documentary television program examining air crashes, near-crashes, hijackings, bombings, and other disasters.[1]
Throughout the episodes, the victims or relatives and friends of the victims are interviewed adding more information about the cases with their relatives. Additionally, retired aviation experts, pilots and researchers are interviewed about the tests and explain how these emergencies occurred and how they could have been prevented.
#aircrashinvestigation #maydayairdisaster #boeingcrash #maydayairdisasteryoutubechannel #worstplanecrashes #wherecaniseemayday #aircrash #maydayfullepisodes #maydayairdisastertvseries #wheretowatchplanecrashes #wheretowatchaircrashinvestigation #planecrashesdocumentary #maydayairdisasterstreaming #planecrash #planecrashes #boeing737crash #maydayaircrash #boeing #airdisasters #maydayairdisasterfullepisodes #aviation #aviationdisasters #maydayaircrashinvestigation #smithsonianaviation #investigation #crash #pilot #documentary #mayday #flying
air crash investigation
mayday air disaster
boeing crash
mayday air disaster youtube channel
worst plane crashes
where can i see mayday
air crash
mayday full episodes
mayday air disaster tv series
where to watch plane crashes
where to watch air crash investigation
plane crashes documentary
mayday air disaster streaming
plane crash
plane crashes
boeing 737 crash
mayday air crash
#boeing
air disasters
mayday air disaster full episodes
#air crash investigation
aviation
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boeing
mayday air crash investigation
smithsonian aviation
#investigation
#crash
pilot
#documentary
Transcript
00:00 It's the worst aviation disaster in Portuguese history.
00:04 144 people are killed.
00:07 The scope of the devastation was remarkable.
00:10 The wreckage provides little evidence.
00:14 They're way too damaged to test.
00:16 Air traffic control offers no insight.
00:19 Were they advised to use the ILS?
00:21 Yes.
00:23 Only the final seconds of independent air flight 1851.
00:28 Pull up.
00:30 They had seven seconds until impact.
00:32 Reveal the whole story.
00:35 They don't say anything?
00:37 I've never encountered anything like this before.
00:41 And I never encountered anything like this afterwards.
00:44 To say it was unique would be an understatement.
00:47 Mayday, mayday.
00:49 Pull up.
00:54 [radio chatter]
00:59 Independent air flight 1851 cruises above the Atlantic Ocean.
01:14 There are 137 tourists on board the American charter flight.
01:23 Santa Maria, independent air 1851 requesting MET report.
01:28 Less than 30 minutes before landing, the crew prepares for descent.
01:33 1851, wind 260, 14 knots.
01:40 34-year-old flight engineer Jorge Gonzalez checks the weather ahead.
01:46 He's a US Air Force veteran with a sterling reputation.
01:50 41-year-old captain Leon James Doherty is also from the military
01:56 and has been flying jetliners for almost a decade.
01:59 Let's request descent.
02:01 Santa Maria control, independent air 1851 would like to descend.
02:08 36-year-old first officer Sammy Adcock
02:11 just started with independent air two weeks ago.
02:15 Independent air 1851, clear to descent to flight level 40.
02:21 Clear to flight level 40, independent air 1851.
02:26 The crew was a balanced crew.
02:34 They had flown together for about a week or 10 days
02:37 and they were doing fine.
02:41 They're flying a four-engine Boeing 707.
02:45 The long-range, narrow-bodied jetliner
02:47 has dominated passenger travel for more than three decades.
02:51 It wasn't a modern jet at the time.
02:59 It was 21 years old, but it was well maintained
03:02 within all the safety regulations.
03:07 Today's flight from Bergamo, Italy, will refuel at Santa Maria,
03:12 an island in the remote Azores,
03:14 before continuing to its final destination,
03:16 Punta Cana in the Dominican Republic.
03:19 Santa Maria was a popular destination for refuelling
03:24 because of its location in the Atlantic.
03:27 It's a small island with a large mountain in the centre.
03:32 That mountain is called Pico Alto.
03:36 At almost 2,000 feet, Pico Alto, or High Peak,
03:41 is the highest point of a mountain range
03:43 stretching across Santa Maria.
04:02 You closed the door. It's a jungle out there.
04:06 Are you finished with those?
04:10 Yeah. Thanks.
04:12 Thank you.
04:14 What's your passing level? Independent Air 1851.
04:18 Passing flight level 220.
04:23 60 miles from the airport,
04:25 the first officer tunes in to the frequency for Santa Maria Airport.
04:31 Good afternoon. Santa Maria Tower.
04:34 Today, a trainee in the tower is guiding in the flight
04:38 with the help of a supervisor.
04:40 Independent Air 1851, passing flight level 200 to flight level 40.
04:48 Independent 1851. Roger.
04:51 In 1989, I would describe the Santa Maria Air Traffic Control Facility
04:59 as being very unsophisticated, very small.
05:02 The airport is also not equipped with radar.
05:05 There were only three scheduled airline flights per day.
05:08 It doesn't justify the cost of air traffic control radar,
05:11 which is very challenging for air traffic control.
05:14 You're cleared 3,000 feet on QNH 1027.
05:22 Runway will be one-niner.
05:28 Expect ILS approach. Runway one-niner. Report reaching 3,000.
05:34 The controller is relying solely on position reports from the pilot,
05:42 so they have to be meticulous about protecting the airspace
05:46 and documenting the altitude that the aircraft is at.
05:49 Is that what they said? 1027 on the millibars?
05:54 Yep.
05:56 Just over 13 minutes from the airport, the crew readies the plane for landing.
06:01 Seatbelts and shoulder harness.
06:20 (BEEPING)
06:22 Secured. We're having fun now.
06:30 Hey, hey!
06:32 On that day, the weather in Santa Maria was fine.
06:35 There was just some cloud cover in the vicinity of Pico Alto.
06:40 That is very common.
06:42 Switching off autopilot.
06:47 The captain takes control of the aircraft.
06:50 The captain would likely be hand-flying the airplane
06:56 to get comfortable controlling it.
06:59 It ain't looking too hot out there.
07:04 Yeah, we'll get down below. Depends on what level the winds are.
07:08 There's cloud cover ahead.
07:10 If conditions get worse, the crew will have to make the approach
07:13 using only their instruments for reference.
07:17 OK, I'm going to go ahead and put the ILS in on my side.
07:20 OK.
07:21 ILS, or instrument landing system,
07:24 is a navigation system that provides vertical and horizontal guidance
07:28 to the runway.
07:30 That means that he can fly in clouds until he gets on to final approach.
07:35 It's always better to have help.
07:37 35 miles from the airport, the coastline of Santa Maria comes into view.
07:45 When approaching from the east, you will see some big cliffs.
07:49 Some green, a lot of green.
07:51 Where's the airport? It's on the other side of the island.
07:56 As they approach the island, an alert in the cockpit tells the pilots
08:04 that they are 500 feet above their selected altitude.
08:08 400 to go.
08:10 Don't know if we're going to get visual or not here.
08:13 We're going to get visual.
08:15 Starting to pass through the layers.
08:25 As they cross the coast of Santa Maria, weather conditions worsen.
08:31 The winds can be pretty severe around the Pico Alto,
08:36 and this can present a challenge for the pilots
08:38 to maintain control of their aircraft.
08:41 [♪♪♪]
08:44 Can't keep this damn thing level.
09:08 -Help you? -No.
09:10 Just two minutes from the airport,
09:15 Flight 1851 is seen flying very low overhead.
09:19 Pull up.
09:21 Pull up.
09:23 Hooray, hooray.
09:25 Pull up.
09:26 The equipment is telling the crew they are in a potentially dangerous situation.
09:31 [♪♪♪]
09:34 Just four and a half miles from the Santa Maria airport in the Azores,
09:43 Portuguese firefighters and civilians discover a horrific scene of devastation.
09:48 Independent Air Flight 1851 has crashed into the island's highest mountain.
09:55 The jet hit Pico Alto very near the top of the mountain.
10:00 The accident site was a bit of a chaotic scene.
10:05 The wreckage was strewn all over the mountain.
10:08 There were some small fires.
10:10 It was a very steep terrain.
10:13 It was very difficult for rescuers to work there.
10:16 It soon becomes clear that all 144 passengers and crew have been killed.
10:24 It was a big challenge for the locals mostly to deal with that.
10:28 Santa Maria has only 5,000 people living there.
10:31 And in a flash, they became the scenario of the worst air disaster to occur in Portugal.
10:37 Rescuers work through the night.
10:41 By daybreak, the Portuguese Civil Aviation Authority, known as the DGAC, arrives at the crash site.
10:48 They are soon joined by American representatives from the NTSB, the National Transportation Safety Board.
10:55 The terrain that we traversed was very challenging.
11:01 There was a lot of personal effects.
11:04 People were just vacationing.
11:05 There were children whose dolls I could see in the trees.
11:08 The scope of the devastation, it was remarkable.
11:12 Investigators need to get a better perspective if they are to understand why Flight 1851 crashed into a mountain so close to Santa Maria's airport.
11:22 The overhead view revealed to us just how concentrated the wreckage was on the side of the mountain where the airplane struck it.
11:32 That was something I had not seen before.
11:35 So, this is the flight path.
11:37 The plane impacts the east side of Pico Alto.
11:41 Correct.
11:44 Investigators examine the wreckage pattern for clues as to how Flight 1851 was flying before impact.
11:52 All concentrated right here.
11:57 Sending debris over the mountain ridge.
12:00 Scars on the ridge give investigators their first clues.
12:05 Looks like low angle high velocity.
12:08 It must have been flying level.
12:10 Seafaring?
12:12 Looks like it.
12:13 They quickly recognize this incident to be a controlled flight into terrain.
12:20 If one looks at seafit accidents, there are really two types.
12:23 One where an airplane descends prematurely.
12:26 The other where it hits the side of a mountain.
12:29 They must have known about the mountains.
12:32 What was the altitude where they hit?
12:35 1795 feet.
12:38 That's a lot of altitude.
12:43 It's a lot of altitude.
12:48 And Pico Alto?
12:50 What does the Jefferson chart show?
12:53 It's listed as 1936 feet.
12:56 Pico Alto is clearly identified on the Santa Maria Approach Chart.
13:01 So, they struck the mountain 140 feet below what was listed on their chart.
13:08 What were they doing so low?
13:12 The possibilities were one, they were flying low.
13:16 The other possibilities were one, the crew was off course.
13:19 Two, there was an altitude error.
13:22 It was our job to find out which of those would explain the accident.
13:26 What's the minimum sector altitude?
13:29 3000 feet.
13:31 The minimum sector altitude is at least 1000 feet above all terrain within 25 miles of the airport.
13:40 There's plenty of room.
13:44 According to the company's operations manual, there should be at least two Jefferson charts on board the plane at all times.
13:48 They had to have known.
13:51 This was the question. Why did these guys descend so low when they knew by the charts that the minimum altitude was 3000 feet and there was a mountain there?
14:02 So, this was the last flight of the day?
14:07 Yes, it was.
14:09 What was the minimum sector altitude you gave them?
14:14 The team turns to the air traffic controller for insight into why the aircraft was flying below 3000 feet.
14:21 3000 feet.
14:26 You're sure?
14:28 Yeah, I even made a note of it on my flight strip.
14:31 He was perfectly calm. He had a normal behavior. He thought he had done a good job.
14:42 Were you the only controller on duty at the time?
14:44 My supervisor was also there.
14:46 It was such a slow airport. It was certainly not unusual for a supervisor to provide on-the-job training for an air traffic trainee.
14:54 What was the weather like?
14:57 Fairly good at the airport. No rain or strong winds. Visibility was unlimited.
15:10 However, the top of Pico Alto was in cloud and winds can be unpredictable up there.
15:16 The weather was okay. The focus for the investigators was on how the cloud layer affected the pilot's ability to see and avoid the top of the mountain.
15:29 Were they advised to use the ILS?
15:31 Yes.
15:33 Expect ILS approach. Runway one-niner. Report reaching 3000.
15:38 The investigator learns that the pilots did encounter cloud cover near Pico Alto.
15:45 But they shouldn't have had a problem using their instruments to get them to the runway.
15:50 Did the crew report any mechanical issues?
15:53 No, not to me anyway.
15:57 Thank you for your time.
16:03 I couldn't find anything that explains what happened from his part.
16:07 So if the controller gave them the proper clearance, why did they say hello?
16:14 What if there was an issue with the plane that they didn't report?
16:18 The team must now consider the possibility of a mission.
16:23 The team must now consider if a mechanical issue that wasn't reported to the controller prevented the crew from maintaining a safe altitude above the mountain.
16:31 It was possible. We couldn't rule this out until we looked more closely at the evidence.
16:36 That something very quickly happened, something catastrophic, just before impact.
16:43 Is this everything?
16:44 So far.
16:46 Investigators are looking for clues in the wreckage of flight 1851 to explain why it descended below minimum altitude and crashed into a mountain on Santa Maria Island.
17:01 Let's start here.
17:13 Could a malfunctioning engine have forced the aircraft below the minimum safe altitude?
17:19 It says here the jet had less than 45,000 hours in the air with seven service bulletins over the last six years.
17:30 Any issues?
17:31 No.
17:33 1983 engine two had suffered turbine failure.
17:37 Looks like it was repaired.
17:39 It's full of wood and dirt.
17:42 A quick examination provides an answer.
17:45 There's nothing wrong with these engines.
17:47 Engines that are generating power at impact, if they hit a field of trees, will ingest part of the vegetation into the engines
17:59 and that will bring the engine fan blades to a stop.
18:01 And that's what happened here.
18:03 Engines that are not turning, that are not working, won't do that.
18:08 What about the altimeter?
18:10 If the altimeters were malfunctioning, the crew might have believed they were flying higher than they actually were.
18:20 Hi.
18:24 Thank you.
18:26 Look, way too damaged to test.
18:28 What are the service records, sir?
18:29 They were last calibrated four months ago.
18:34 No problems.
18:36 It's another dead end.
18:39 Maybe the altitude alert survived.
18:42 Let's take a look.
18:44 The altitude alert warns the crew with an audio alert when they're approaching a pre-set altitude.
18:55 Hang on.
19:00 Is this it?
19:03 Yeah, that's it.
19:05 Doesn't look too bad.
19:07 Yeah, check this out.
19:14 Altimeter alert set to 2,000.
19:18 Investigators discover the altitude alert was set for 2,000 feet, not the required altitude of 3,000 feet.
19:26 I remember this shocked all of us.
19:28 We just couldn't believe it, how that could happen.
19:31 Why would the altimeter alert be set to 2,000 when the controller gave them a clearance of 3,000?
19:37 Maybe the controller remembered wrong.
19:41 Let's check the tapes.
19:46 ATC recordings give you what's exchanged during the different phases of the flight.
19:51 So you can confirm absolutely what was said, either contacting the plane or inside the ATC.
19:57 Good afternoon, Santa Maria Tower.
20:02 Will the air traffic control audio recording confirm what the trainee told investigators?
20:09 Independent 1851, roger.
20:14 You're clear to 3,000 feet on QNH 1027.
20:18 Runway one-niner.
20:21 Expect ILS approach.
20:24 Runway one-niner. Report reaching 3,000.
20:28 Stop there.
20:32 He said it.
20:35 Twice.
20:36 The control tower recording confirms that the controller gave a 3,000 foot clearance.
20:42 Listening to the clearance did not explain the 1,000 foot error in the altimeter alert.
20:49 We needed to listen to the CVR.
20:51 Take it from the point where they first contact the controller.
20:55 Investigators now listen to the cockpit conversation to determine why the crew descended below the 3,000 foot minimum sector altitude given by the controller.
21:10 Good afternoon, Santa Maria Tower. Independent Air 1851 passing flight level 200 to flight level 40.
21:18 That's the first officer.
21:21 Independent 1851, roger. You're clear to 3,000 feet on QNH 1027.
21:31 Clear to 2,000.
21:35 Did the first officer just say 2,000?
21:40 Go back. Play it again.
21:41 Clear to 2,000.
21:46 Investigators wonder why the first officer misheard the altitude clearance as 2,000 feet instead of 3,000 feet.
21:56 Maybe he heard 2, 3,000 and mistook it for 2,000.
22:03 It's possible.
22:09 It looked to us that perhaps the word 3 never was listened by the first officer.
22:15 So the first officer only listened, you're clear, 2,000.
22:20 Not 2, 3,000, but 2,000. So he never heard the word 3.
22:26 The CVR recorded the first officer reading back an incorrect clearance.
22:34 It was very puzzling to us when we heard the CVR why the crew did not act.
22:39 It was clear that that wasn't given much credence.
22:42 The controller should have corrected him too, but doesn't. Why?
22:48 And that's an important part of this accident investigation.
22:51 We couldn't figure out why the air traffic controller did not correct the first officer.
22:56 Hang on a second.
23:03 The first officer's read back of 2,000 feet isn't in the controller's transcript.
23:06 So he never heard it? How is that possible?
23:10 We couldn't figure out how they could miss each other. It was inexplicable.
23:15 Alright, so the first officer mishears the altitude. He reads it back to the controller as 2,000 at 1356.59.
23:27 Investigators compare the conversations between the controller and the first officer of flight 1851
23:33 to better understand why there was miscommunication between them.
23:37 What does the controller say next?
23:40 Well, he repeats the clearance by saying, "Expect ILS approach, runway 1-9, report reaching 3,000."
23:46 That's it?
23:48 [Music]
23:57 Hang on.
23:59 They were talking at the same time.
24:08 Yeah. They cancelled each other out.
24:13 It's a troubling realization. An overlap of communication between the tower and the pilot.
24:19 Passing flight level 2-0-0 for flight level 4-0.
24:25 You're clear to 3,000 feet on QNH 1-0-2-7.
24:30 Runway 1-9.
24:38 We're clear to 2,000 feet and runway 1-9, report reaching 3,000.
24:43 It was stunning. We were stunned to finally understand how the two transmissions overlapped perfectly to cancel each other out.
24:54 I was an investigator for over 30 years at the NTSB.
24:58 I've never encountered anything like this before and I never encountered anything like this afterwards.
25:03 They're both talking at the same time. They're both pushing their PTTs.
25:06 That's right.
25:08 Pilots and controllers use a push-to-talk or PTT button.
25:16 When it's pressed, the radio transmits but cannot receive.
25:20 To think that so many people died because of a simple error, that was just, that's sad.
25:27 That's hard to deal with as an investigator.
25:34 So the controller doesn't hear it, but he should still insist the first officer read it back or repeat it.
25:40 There are some readbacks in air traffic control that you simply have to get back every single time.
25:46 And altitude is one of them.
25:48 The trainee controller did not request an altitude readback and the supervisor didn't notice and that was unfortunate.
25:55 What about the supervisor?
25:57 Good question.
25:59 According to the controller, she was there.
26:02 Maybe she was busy with other things?
26:05 Possible.
26:07 Investigators wonder if the supervisor monitoring the trainee during the approach clearance was somehow distracted.
26:15 Check this out. According to the phone record, she took a call during her shift.
26:22 You don't want to take a phone call during something important like a descent clearance because they have to give them a course to follow and an altitude to maintain.
26:31 Really important stuff that you cannot possibly miss.
26:35 Something doesn't line up.
26:44 The plane's altimeter alert was incorrectly set to 2,000 feet.
26:48 Even at that altitude, they would have cleared the ridge by some 200 feet.
26:55 Yeah.
26:57 We still have to explain why the airplane struck the mountain 200 or so feet even further than it was supposed to.
27:07 We still have to explain why the airplane struck the mountain 200 or so feet even further below the altitude that they were trying to maintain.
27:16 Something had to explain that.
27:18 What else affects altitude?
27:20 QNH.
27:22 QNH is a pressure setting pilots input so their altimeter measures the proper height above sea level.
27:33 It can change with weather conditions.
27:37 If the altimeter is set to a higher QNH than is actual, the aircraft will actually be lower than what the altimeter is telling the pilots.
27:45 It says here they were given a QNH of 1019 at 144 pm.
27:52 Then they were given a reading of 1027 at 156 pm.
27:59 Okay.
28:01 So it changed.
28:04 Eight millibars in 12 minutes?
28:07 Could that be right?
28:11 Check the weather reports.
28:13 For an eight millibar change to occur in 12 minutes would be something that may occur during a hurricane or something like that.
28:21 I don't see anything that would make that possible.
28:25 So how much would they drop with an eight millibar increase?
28:32 Investigators calculate the change in altitude between the two QNH values.
28:37 That QNH brought them at least 200 feet below 2000.
28:41 Right into the mountain.
28:43 The team concludes that an incorrect altimeter setting put the flight on a collision course with Pico Alto.
28:51 When you're close to the ground in restricted visibility conditions, an accurate altimeter setting is everything.
29:01 That will protect the airplane from a seafaring accident.
29:04 Thanks for talking with me again.
29:07 Yeah, of course.
29:09 Just one follow-up question here.
29:10 What was the pressure setting you gave them?
29:13 Investigators conduct a second interview with the controller to understand why he gave two very different QNH settings to the pilots.
29:23 1019 was on the MET report.
29:28 Twelve minutes later, when you gave them a 3000 foot clearance, you said QNH 1027.
29:36 I asked the controller directly about the QNH he had given to the plane, and he couldn't explain why he had given that QNH at all.
29:54 In my view, it's just he didn't notice he was giving the wrong information.
29:58 Sorry, I don't know where I got that second number.
30:08 For that QNH to change so rapidly, it should have been noticed by both the air traffic trainee and their supervisor and the pilots as well.
30:22 I'm surprised that the pilots didn't reach out and say, "Hey, can you repeat that QNH again?"
30:28 After the first officer gets the minimum descent altitude wrong, he questions the QNH.
30:42 Is that what they said? 1027 on the millibars?
30:45 Yep.
30:46 He was right to question it.
30:50 But the captain just dismisses it. Thank you.
30:52 And the first officer just accepts it.
30:55 Because of the different experience levels, because of the prominence and assertiveness with which the captain said it,
31:04 shut off any discussion when in fact there should have been.
31:06 Makes me wonder what else these guys missed.
31:10 [Music]
31:14 Now let's play the tape.
31:22 Investigators return to the cockpit voice recording to learn how the crew of independent air flight 1851
31:30 allowed so many errors to accumulate on approach to Santa Maria.
31:34 [Music]
31:38 Altimeters?
31:40 Set and cross-checked.
31:42 Set and cross-checked.
31:43 Seatbelts and shoulder harness.
31:45 Secured.
31:51 We're having fun now.
31:52 Hey, hey!
31:53 That's it?
31:56 Stop the tape.
32:00 They discover the pilots missed important steps on the checklist.
32:04 They don't even mention the minimum descent altitude.
32:07 Or pico alto, here.
32:10 They hear a briefing that doesn't include reference to the navigation charts that were available to the pilots.
32:24 Had they done the approach briefing and reviewed the information and articulated the information as required,
32:30 it's highly unlikely, in my opinion, that they would have struck the mountain.
32:35 Another unfortunate error.
32:38 There were a couple of things in the performance of the captain that were questionable.
32:45 He didn't try to understand what was the real QNH that was given.
32:52 Then, he didn't insist on a complete checklist.
32:55 Let's hear what comes next.
32:59 It ain't looking too hot out there.
33:04 Yeah, we'll get down below.
33:06 Depends on what level those are.
33:08 Okay, I'm going to go ahead and put the ILS in on my side.
33:11 Okay.
33:16 Uh, after 2,000, yeah, we'll get below these clouds.
33:22 Stop.
33:24 Right there, 2,000 again.
33:26 The captain says nothing and descends to 2,000.
33:30 Why?
33:33 The captain's ultimately responsible as the pilot in command, but each crew member failed in that respect.
33:40 Play the tape.
33:42 Uh, 1,000 to go.
33:45 1 to go.
33:46 Wow, look.
33:48 There's the island.
33:52 Stop it.
33:56 Who is that?
33:58 Investigators hear an unknown female speaking in the cockpit on approach into Santa Maria.
34:05 She appears twice over 16 minutes, starting when they begin their descent.
34:13 The flight attendant, maybe.
34:15 But what is she doing there?
34:16 I don't know. That's not what I call a sterile cockpit.
34:20 And the captain lets it happen.
34:22 The captain violated the sterile cockpit rule, which bans non-essential conversation in the cockpit below 10,000 feet.
34:39 I believe that violating the sterile cockpit rule was consistent with the way they flew the approach.
34:44 They weren't sitting on the edge of their seats. They were far too relaxed.
34:48 There is no place like Santa Maria.
34:51 Is it nice?
34:54 Yeah. To have a beer.
34:56 Ignoring standard procedures. Distractions. The list keeps growing.
35:08 Starting to pass through the layers.
35:10 Can't keep this damn thing level.
35:16 Help you?
35:20 No.
35:21 Pull up.
35:25 Pull up.
35:27 Pull up.
35:29 Pull up.
35:33 Pull up.
35:34 They don't say anything?
35:41 When the GPWS went off, there was no response from the crew.
35:47 There was not even a, "What's that? What's going on?" There was nothing.
35:51 They don't say anything. But do they do anything?
35:55 Do they do anything?
35:56 Thank you.
36:07 So this is the plane's descent approaching Santa Maria.
36:11 Investigators examined the flight data to determine how the pilots responded to the ground proximity warning.
36:22 So they're descending at about 2,500 feet per minute.
36:25 They level off here.
36:27 And the GPWS goes off here.
36:31 And they crash about seven seconds later.
36:34 No reaction.
36:37 No change in altitude.
36:39 The data shows there were no inputs from the pilots to recover the aircraft.
36:45 It's like they ignored the alarm.
36:48 When the GPWS goes on, you apply maximum power, climb at the maximum rate, and get the heck out of there.
36:57 Seven seconds. They had seven seconds from the first warning until impact.
37:03 They could have climbed over the mountain in that time had they done what they should have done.
37:11 And they didn't do that. And we couldn't figure that out.
37:14 Pull up.
37:17 Why didn't the crew respond to the warning?
37:19 Surely the crew was trained to respond to the ground proximity warning.
37:25 Investigators closely examined the training manuals for independent air.
37:32 You are not going to believe this.
37:38 The simulators were programmed with different approach speeds and flap settings in the accident aircraft.
37:46 What does that mean?
37:47 It means that the GPWS would go off during normal approaches.
37:51 Independent Air rented time on another company's 707 simulator.
37:59 It was configured differently from the accident aircraft.
38:02 Flaps 40.
38:04 Pull up.
38:08 Sir?
38:10 Pull up.
38:12 Pull up.
38:13 By training the crew to ignore the GPWS in the simulators, they gave the crew the message to ignore the GPWS in the airplane.
38:26 I can't believe how many things went wrong.
38:34 Investigators conclude that by avoiding any one of the minor errors, Flight 1851 would have cleared Pico Alto, preventing the deaths of 144 people.
38:44 It all starts with the first officer mishearing the minimum sector altitude.
38:49 Independent 1851, roger.
38:52 You're clear to 3,000 feet.
38:55 Clear to 2,000.
38:57 Make it three.
39:03 If the first officer had referred to his charts...
39:06 Roger. Good catch.
39:09 ...the altitude alert would have been set at the proper elevation...
39:13 ...and the aircraft would have cleared the mountain by more than a thousand feet.
39:19 Same result if the air traffic controller had asked for a re-back.
39:25 Independent Air 1851, you're clear to 3,000.
39:32 Say again. Report reaching 3,000. Over.
39:34 Or if the captain kept a sterile cockpit.
39:40 Uh, after 2,000... yeah, we'll get below these clouds.
39:46 Wow, look.
39:48 There's the island.
39:50 It should be 3,000, not 2,000.
39:52 It's time to return to the cabin.
40:01 You cannot be inattentive, especially in the last period of the flight.
40:05 Even with all those mistakes, if the training controller had given them the proper altimeter setting...
40:10 You're clear to 3,000 on QNH 1027.
40:14 Uh, correction. 1019.
40:20 Flight 1851 would have cleared Pico Alto by 200 feet.
40:25 Whoa.
40:29 Whoa.
40:30 We're close.
40:35 Finally, the GPWS.
40:38 Pull up.
40:41 If the crew had the proper GPWS training...
40:44 Go around.
40:46 ...they would have had one last chance to avoid hitting the mountain.
40:58 They might have made it.
40:59 I have never seen an accident with these many factors happen where any one of which, had they not been there, we wouldn't have had an accident.
41:10 In the wake of the crash, the NTSB recommends a careful review of airline training programs...
41:18 ...with a focus on international operations and safety, especially those related to the GPWS response.
41:26 A major lesson was that airlines need to train their crews better to improve aviation safety.
41:32 Independent Air later settled with the victims' families for 34 million U.S. dollars...
41:41 ...before a compensation case ever went to trial.
41:44 Independent Air went out of business in 1990.
41:51 In the aviation business, there is no room at all for complacency.
41:55 The longer we do a job, the more complacent we tend to get.
41:58 After a while, some of the things we do, even if they're unsafe, start to appear to be safe...
42:03 ...and unfortunately, we can have an accident like the one that we witnessed here.
42:07 [Music]
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