A Cascade of Deadly Errors That Doomed KLM Flight | Mayday: Accident Files

mday M engine flame out a dash cam video captures the last moments of a horrific plane crash a minor flight issue right engine oil pressure turns into a crisis there was several places where the airplane could have been saved fire a revolutionary new aircraft breaks up during a critical flight three tragedies caused by fateful decisions Made In the Heat of the Moment the tendency is always let's solve the problem right this minute and we've lost a lot of airplanes that [Music] way taipe capital city of Taiwan near its Center lies s Shen airport the next plane scheduled for departure this morning is trans Asia Flight 235 the first officer is leot chuong he has almost 7,000 hours of flying time oil pressure Jack the captain Leo chunsong is a former military pilot a third pilot is observing today's flight trans Asia 235 is a 1-hour commuter flight from Taipei to the Taiwanese island of kinman just off the coast of mainland China transor 235 Runway 1 wind 1 0° ner KN cleared for takeoff okay cleared for [Music] takeoff immediately after takeoff the captain engages the autopilot Gear Up Gear Up flight 235 climbs over Metropolitan Taipei home to more than 7 million people seconds later the master warning sounds the master warning is indicative of an emergency situation requiring an immediate response trans Asia 235 has lost an engine the captain disengages the auto pilot I have control you have control heading mode he needs a heading back to the airport below 2500 ft turn to heading it's come on 0 09 or5 check when you lose an engine in a twin engine aircraft you need to be able to maintain your client [Music] performance okay engine flame out check check the speed and climb rate are dropping fast watch the Speed stop stop stop the stall warning indicates the plane is flying too slowly to maintain lift the stall warning at low altitudes a critical situation that no pilot ever wants to end up in terrain ahead Tower transia 2 3 5 m m engine flame out engine flame out both sides how is this possible the crew was surrounded by high density housing highrise apartment blocks a heavily populated area impact PR for impact oh no oh no transasia flight 235 has gone down in the kyong river spend all takeoff and Landing operations begin emergency procedures Rescuers rush to the scene of the 58 people on board only 15 make it out alive all three Pilots are [Music] dead investigators from taiwan's Aviation Safety Council need to start collecting evidence at the scene but even before they leave headquarters take a look at this a stunning piece of evidence from a dashboard camera surfaces [Music] what what was happening on that [Music] plane what do you think left engine when you watch the video clip we know there's something wrong about the engine the prop seems very [Music] slow is this the left engine uh yes investigators can see in the dash cam video that the plane was banked steeply to the left a faulty left engine is the most likely [Music] suspect but the recovered engine shows no sign of a fault left engine completely operational ah strange when they study the right engine what they find is equally [Music] mystifying look at the blades they're feathered feathered is a propeller's fail safe position when a propeller engine loses power in Flight the blades automatically rotate parallel to the Airstream to reduce drag and allow the plane to operate with one engine why would the right engine be feathered when the dash cam video clearly shows the plane banking to the left it doesn't make any sense let's have a look when we discover a feather of the propeller we know there should be something wrong about engine but their inspection shows the right engine is also in working condition if both engines were operational or why did this plane crash investigators hope the plane's flight data recorder which records dozens of flight parameters can tell them more but all data points indicate the plane was operating normally except for one take a look at this the torque is all over the place torque is the twisting rotational Force created by the engine it increases and decreases during specific phases of flight but it's not supposed to fluctuate in such rapid bursts why is it doing it they dig deeper studying how the Pratt and Whitney engine measures torque so we try to find out the design Logic for the system what's the connection between the torque and the feather [Music] propellers they learned that the engine's Auto Feathering system includes an electronic torque sensor it measures how much rotational Force the engine is producing an extremely low torque reading indicates that the engine has failed and triggers automatic Feathering but investigators have already concluded the engine was operational they need to find the reason incorrect torque readings would cause the right engine to feather maybe the sensor is sending a faulty reading triggering the auto Feathering unit investigators find the circuit board from the right engine and look for any defects that could have caused the propeller to feather in Flight it's a broken Soder they discover microscopic faults in the circuit board with a broken circuit board the sensor couldn't detect torque even though the engine was functioning perfectly so the system autom a atically feathered the propeller okay engine play out check check they Now understand why the right side propeller feathered investigators now face an even bigger mystery losing thrust in the right engine should cause a right bank but the dash cam video clearly shows the plane banking left the power lever angle when investigators check the throttle settings on on the left or number one engine they make a stunning Discovery unbelievable the power of the number one engine was gradually being reduced reduced and eventually be shut off on this atr72 the throttles can only be moved by hand it had to have been shut down by one of the pilots so we start to wondering why the pilot was shut down the good engine that's [Music] crazy how is this possible investigators turned to the cockpit voice recording to help explain why transasia Flight 235 crashed in taipei's kyong River trans Asia 235 contact approach a 11 Niner decimal 7 good day we still have number one engine produce power normally but for some reason the pilot decided to shut down the good engine we have to find out why what's that sound must be the engine to fault warning investigators already know a faulty torque sensor caused the right engine to feather and lose thrust this is a crucial moment let's hear what they're going to do next I have control investigators hear the sound of the autopilot turning off he's disengaging the autopilot he shouldn't be doing that he just made a difficult situation worse okay engine flame out check check there's a checklist procedure on the screen if they follow the procedure do everything correctly they should be able to fly back to land with without any problem but instead of following the emergency checklist watch the Speed the captain does something inexplicable pull back number one both engines are capable of producing power but because the right engine has feathered it has lost thrust behaving like a car in neutral gear when the captain then pulls back the left engine throttle he leaves himself with no thrust at all how could he do such a thing the captain of Flight 235 has shut down the plane's only working engine no wait a second cross check the pilot monitoring to his credit did try to stop the pilot flying from manipulating the engine number one power lever and he announced he wanted a cross check heading mode but the captain interrupted the first officer to ask for a new heading come on Zer 0 ner 5 all of a sudden they've got a dual engine failure and the pilot monitoring I think has been caught off guard and he's not really sure what's going on restart the engine I can't restart the engine when the captain realizes his mistake oh well I shut off the wrong engine there's no time to restart the [Music] engine impact bra back investigators now have an even more puzzling question to answer why didn't the captain understand what he was doing did taking manual control of the plane distract the pilot from verifying which engine failed watch the Speed he could have been suffering from change blindness change blindness people are focused or fixated on on another item or area of interest and so they miss what would be considered a very distinguishable change in the environment but they don't perceive it I will pull back engine one throttle even when all the systems were telling him it was engine two his perception told him it was doing the right thing AG blus investigators finally understand what went wrong aboard transasia Flight 235 a microscopic crack in a circuit board disabled a sensor in the right engine causing the system to incorrectly determine that the engine had failed this was a series of mistakes on the part of the captain when Engine took to feathered the captain reacted before he had properly assessed the [Music] situation the captain should have followed a checklist I have control but In the Heat of the Moment he turned off the autopilot and reduced power in the wrong engine I will pull back engine one throttle he shut down their only working engine by the time he realizes it's too late restart the engine I can't restart the engine well I shut off the wrong engine the crash of Flight 235 would be the last accident for Trans Asia Airways in November 2016 the company went out of business when you talk about the trans Asia situation in taipe we've got a situation there where if they hit had just delayed until they had enough altitude and air speed doing anything they would have probably lived Runway Insight but sometimes when a split-second decision is made steer steer even a minor issue can turn [Music] [Applause] deadly it's Easter Monday 1994 at Amsterdam's skipple airport Set tor my controls KLM City Hopper flight 433 is preparing to fly from Amsterdam to Cardiff Wales torque set flying time is an hour and 20 minutes V1 rotate the plane is a Sab 340b a dual turbo prop designed for short Regional flights the captain on flight 433 is 37-year-old Garrett lard the first officer Paul stassen is 34 there are 21 passengers on board Amsterdam km4 433 go ahead 433 is flight level 200 available climb to 200 you are reced flight level 200 thank you sir climbing flight level 200 km 433 but on the way up to 20,000 ft right engine oil pressure check take action copy taking action first officer stassen consults the engine oil pressure warning checklist there are several reasons where oil pressure could drop in an engine primarily due to leaks or some sort of damaging event in the engine system emergency checklist for engine and propeller oil pressure low the checklist tells him to monitor the warning light and the oil pressure gauges if the warning light is on or the gauge is below 30 then then you can continue but if you have both then shut down the engine that's not the case the crew decides it's safe to keep flying but then okay uh we're not climbing anymore approaching 177,000 ft Captain levart notices the plane is not climbing as quickly as it should be no we need to return to am Dam make a pan call request to maintain flight level 160 tell them we have a technical issue a pan call means there's an unusual situation please pay attention to us we need extra help Amsterdam km 433 pan pan pan pan pan pan we have an engine problem and we'd like to maintain 160 for return to skiple that's copy sir you may turn right heading to skipple km 433 can you give me any details km 433 Situation's under control we have an engine oil pressure problem in engine number two yes okay we can bring you in for 06 you're number one 5 minutes later the plane lines up with the runway runway in sight laps 20 lapse 20 outer marker check km 433 is just 5 500 ft above the ground watch your speed the plane has slowed to the point that it could stall I'm on it suddenly the plane Banks to the right going around set torque flap seven gear up Captain lart attempts a go around but the plane keeps banking [Music] right steer steer steer get it get it get [Music] it crash crash crash Runway 06 emergency Runway [Music] 06 km flight 433 has crashed in a field next to the runway of the 24 people on board two passengers and the captain are dead eight passengers and the first officer are seriously injured investigators from the netherland's aviation safety board recover the plan's black boxes and send them off for [Music] processing meanwhile lead investigator Ben groin bike is eager to speak with air traffic control we go to the Tower and approach uh and we get the first information they issued a pan call we're coming back to the airport Amsterdam km 433 pan pan pan pan pan pan we have an engine problem and we'd like to maintain 160 for return to [Music] skipple did they tell you what the problem was yeah they said it had to do with the oil pressure km 433 Situation's under control we have an engine oil pressure problem in engine number two next thing I knew they were going around going around set torque flap 7 Gear Up Pilots conduct a go around if their Landing becomes unstable they increase the power they gain altitude they circle around and they try a second time for that Landing right before the aircraft is about to touch down steer steer the potential for danger is much much higher than if the same problem happened at [Music] altitude in a hangar at skiple airport the investigators try to determine the nature of the oil pressure problem and if it contributed to the crash he you could have a seizure of an engine or overheating because the oil is not there well turbines are moving but curiously they find no evidence of any oil pressure issues any damage is from the impact not from oil pressure it seems the pilots reported a problem that didn't [Music] exist why would they report a problem if they didn't have one what were they looking at investigators now wonder did the cockpit instruments on KLM flight 433 somehow malfunction and mislead the pilots right engine oil pressure check take action copy taking action when investigators test the oil pressure system one thing jumps out ah okay there's a short circuit in the switch now they understand what the pilots were seeing a false [Music] warning right engine oil pressure but a false warning alone is not enough to cause a [Music] crash investigators turn to the cockpit voice recorder okay let's hear it they hope it will tell them how a false warning which required no action still led the pilots to turn back to skiple airport here's the warning right engine oil pressure let's see how they handle it check take action copy taking action the pilots consult an emergency checklist that should help them solve the problem if the warning light is on or the gauge is below 30 then you can continue on the St 340 the warning system and the oil measuring system are two separate systems and if there is a confusion between the two the guidance in the emergency checklist is to continue normal operations so the light is on but we're above 30 PSI so continue normal operation the recording reveals that the pilots knew it was safe to continue their flight why the heck did they decide to turn [Music] back okay uh we're not climbing anymore no that must be why they turned back engines are fine why are they not [Music] climbing investigators now turn to the flight data recorder what's going on here right side engine thrust it's dropping it's a major Discovery it suggests pilot error may have caused the deadly disaster right here right after the alarm goes off he actually pulls the power back all the way to idle the captain may have been trying not to further damage what he thought was a crippled engine when he powered back and look he keeps it in idle for the remainder of the flight well no wonder they couldn't climb did having an idle engine cause this accident let's see the data from the Final Approach the data shows how the right engine being at idle affected the landing at this point they're too slow watch your speed I'm on [Music] it the captain advances power to the left engine pushing the aircraft to the right because the right engine isn't producing thrust [Music] now at this point there's no way they're going to make the landing so they have no choice but to attempt to go around going around set torque flap seven gear up to climb the captain pushes the left engine to maximum power but that only sends the plane into an even steeper right Bank steer steer get it get it get what a blunder investigators finally understand the sequence of events that brought down km City Hopper flight 433 right engine oal pressure check take action taking action In the Heat of the Moment the captain reduces right engine power before his first officer has a chance to read the checklist this fools them both into thinking they have an engine problem when they didn't the right power lever remained in the position of flight the idol and they didn't discuss the consequences of [Music] that going around set torque flap seven gear up attempting a go around using just one engine is the final mistake Ste steer steer gett Garett gett the Netherlands Aviation safety board determines that the cause of those errors goes beyond the cockpit the final report recommends km review pilot testing techniques establish cockpit Management training and improve guidance on flying with an idle engine there's an old adage in aviation about the level of forgiveness of an airplane but one of the things it's not going to forgive is failing to do the things that are in the checklist appropriately checklists are there for a reason it's an adage that holds for even the best pilot in the most advanced planes at the Mojave air and Spaceport in Southern California a revolutionary new aircraft is about to undertake a test flight it's called spaceship 2 system booting the spaceship is designed by American Aerospace company scaled composits for Virgin Galactic showing green across the board copy [Music] that virgin galactics owner Sir Richard Branson hopes this unique craft will soon carry paying customers to the edge of space and back together we can make space accessible in a way that has only been dreamt of before now now the success of this stage of the program rests on the shoulders of these two test pilots 43-year-old Peter seabold is an award-winning engineer he's piloted 11 different types of experimental aircraft his co-pilot 39-year-old Mike Alsbury is also a seasoned test pilot and an aeronautical engineer they spent almost 99 months training for this Mission these guys are test pilots uh very very experienced Pilots these are the best of the best of the best their rocket powered spaceship is suspended from a jet powered plane with a 140t wingspan the launch plane is called White Night 2 White Night 2 will carry the spaceship up to 46,000 ft at that altitude spaceship 2 will detach from the airplane fire its rocket motor and climb another 100,000 ft up into the Earth's atmosphere flying four times higher than a typical commercial aircraft it will then glide back to Earth monitoring today's flight is a flight director he communicates with a team of flight engineers and the four Pilots at 9:20 a.m. White Knight 2 you are [Music] go takeoff speed is 150 [Music] knots once spaceship 2 is released Captain seabold will take the control column while co-pilot Alsbury monitors the instruments and configures the craft for its descent you're clear to arm a Pyon release I'll call fire in the minutes before launch the pilots review the flight checklists they've been training for months to memorize call pitch up Pitch down trim feather unlock 1.4 things happen very very very quickly they do not have the time physically to go and pull out the checklist and read the checklist because the these things are happening second after second after second Glide trims good green for release okay here we go stick stick us forward and five 4 3 2 1 release as spaceship 2 drops from its carry plane we release Mike Albury engages the experimental rocket motor arm fire fire 6,000 lb of thrust propel them towards the speed of sound good L spaceship 2 its top speed is close to three Mac so three times the speed of sound other 2,000 mph it's a very very rough ride so you think about the worst turbulence you've been in an a craft liner and then magnify that by 10 it was supposed to be a 38c burn of the engine but just 14 seconds after ignition something goes terribly wrong spaceship 2 lies in pieces after breaking up over California's MAV desert co-pilot Mike Alsbury was killed in the crash amazingly Captain Pete seabold parachuted to safety he's badly injured but alive emergency responders Rush him to the hospital while a team from the NTSB Combs through the wreckage spread over the Mojave [Music] Desert one of the things that we were able to tell by being on scene was that the motor was not an issue as to why the vehicle broke up investigators hope the Craft's external cameras will provide Vital Information see here the tailboom folded in on the aircraft along the hinge of the feather system it went into feather mode feather mode refers to the defining feature of spaceship 2's design the spaceship actually changes shape during flight after reaching maximum altitude the pilots rotate twin Rudders into the feather position to increase drag and slow their descent the craft can then drop safely back into Earth's atmosphere before gliding to a [Music] Runway lorenda Ward reviews the video from a cockpit camera so he unlocked the feather system correct but did he actually deploy it no and that's the weird thing no one touch the handle there are two steps to Feathering the spaceship first the pilots unlock the feather system so the tail boom can pivot when commanded second the Pilots must pull the feather handle to actually deploy the tail boom so we have the video of the co-pilot unlocking but we never see him actually operate the feathers but we know from external video that the feathers moved so we knew that we had a performance or a dynamic issue somehow the system designed to slow The Craft on descent deployed while the crew was accelerating towards the speed of sound to learn more about the feather system investigators consult engineers at scaled composits The Firm that designed spaceship 2 so when is he supposed to unlock the feather system between Mach 1.4 and 1.8 want to play that 48 unlocking the co-pilot had actually unlocked the feather system early isn't it safer to unlock it at lower speed no ma'am it can be catastrophic in the transonic phase you get a huge amount of upward force on the tail boom on the tail of the spacecraft and the feather system was not designed to deal with that sort of load it's a devastating discovery that points to Pilot error unlocking when co-pilot Mike Alsbury unlocked the feather system 16 seconds early aerodynamic forces were so strong they pulled the tail into the feathered position and tore the aircraft [Music] apart but why would a highly experienced test pilot like Mike Alsbury who had already carried out eight previous flights on spaceship 2 unlock the tail Boom at the deadliest possible moment the team Paws over training materials we need to figure out what they were told about unlocking the feather system early records show that co-pilot Alsbury flew 112 simulator runs for this Mission never once did the co-pilot unlock the feather early hold on now but the records do reveal that on one occasion he unlocked the feather too late 12° feather unlock 14° Mission abort Mission abort if they didn't unlock by 1.8 they would have had aborted the flight aborting emission is not fatal but it could be a major setback for the program 0.8 investigators Wonder did this error in training months ago lead Alsbury Mission abort Mission abort to act prematurely investigators believe a time crunch may be one reason Mike Alsbury decided to unlock the feather system early if they don't unlock the feather mechanism by Mac 1.8 then the flight is aborted so obviously that's going to be weighing on the co-pilot's mind you want to get that out of the way then they make another Discovery can I see that simulator video again the training simulator did not vibrate or mimic G forces the pilots didn't feel the actual sensation of a powered flight even if you're a very very good test pilot that has to be a little bit unnerving to get all this vibration and g- loads and the speed and everything else investigators finally know what happened he had a lot to do made a decision to unlock early perhaps not realizing the deadly implications the NTSB faults Scaled Composites for not ensuring Pilots understood the consequences of unlocking the feather system early and for failing to take steps to prevent that from happening it even just having a sensor that physically prevents them from unlocking until it passes the appropriate threshold would have prevented this accident in its final report the NTSB States the probable cause of the disaster was a failure to protect against the possibility that a single human error could trigger a catastrophe the common thread in all these tragedies is that people took action Without Really examining what action was was needed and they move too fast8 unlocking we do know how to prevent them and that is by sitting on your hands in most cases until you are sure you need to take action you don't take action because if you take the wrong action it can lead you into a major problem or a disaster

Channel: Mayday: Air Disaster

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Id: Fzk_GxL_BVE

Length: 42min 36sec (2556 seconds)

Published: Mon Apr 22 2024