A Plane's Flight Path That Paints A "Baffling Picture" | Flight 409 | Mayday: Air Disaster

[Applause] it's just past midnight at rafiq hariri international airport in beirut lebanon fuel is good load is calculated in a typical departure the flight crew reviews its load reviews the fuel reviews the route then runs through the company checklist to get the airplane underway captain habtamu nagasa has been flying with ethiopian airlines for over 20 years and has more than 10 000 hours in the cockpit exterior checks complete check complete no problems the first officer is far less experienced is a recent graduate of the ethiopian airlines flight academy tonight there are 82 passengers aboard the boeing 737 they are preparing for an overnight flight to addis ababa ethiopia many passengers are lebanese some are ethiopians returning home after working abroad there's also an undercover security officer on board tonight's flight flight security officer is there post 911 to intercept anybody who attempts to interfere with the flight crew beirut airport has seen its share of trouble it was the site of the 1983 barracks bombing that killed 241 american servicemen [Music] more recently all three runways were destroyed by israeli missiles during the lebanon war 2006 today the rebuilt airport is again open to flights from around the world [Music] beirut airport is a very busy very well put together civil airport its only difficulty is presented by the mountains directly to the east the lebanon mountains rise sharply from the coast forcing all flights to take off towards the mediterranean sea flight 409's flight plan calls for it to head southwest then make a u-turn towards a navigational checkpoint called checker ethiopian 409 wins nearly kong clear for takeoff 2-1 the air traffic controller gives flight 409 its final takeoff instructions immediate right turn to check roger clear for takeoff runway 2-1 immediate right turn to check up ethiopian 409 left side is clear right side is clear the captain sets his radar to display the weather brother's on my side roger terrain on my side while the first officer monitors the terrain the weather that night had mixed clouds with bases from 2000 feet overcast up to 20 000 feet and there were scattered thunderstorms in the area take off thrust set the 737 accelerates down the runway speed increasing check you see that rotate ethiopian airlines 409 lifts off just after 2 30 in the morning their takeoff procedure and the initial part of the takeoff seemed entirely routine and ordinary and well executed [Music] gear up heading select heading select check the captain begins banking the plane to the right as he climbs ethiopian 409 control 193 the tower controller bids the crew goodbye and hands the flight off to another colleague ethiopian 409 good morning clown flight level two niner zero the area controller instructs flight 409 to climb to twenty nine thousand feet flight level two nine zero ethiopian four zero nine but the weather ahead is becoming fierce if there's lightning in the area you see the flashes you're beginning to feel turbulence sir i suggest that due to the weather you follow heading 270 to be in the clear 2-1 say again confirm heading two one zero just a few minutes into the flight something is going wrong an alarm warns the crew that their turn is becoming dangerously steep the airplane is being banked beyond its normal operational limits captain nagasa is struggling to correct the problem he veers back to the left towards the thunderstorm the controller wants him to avoid as you enter heavy precipitation the cockpit can become very noisy with a tremendous whoosh it gets your attention the controller sees that flight 409 is starting to veer back towards beirut he warns the pilots again that they need to turn ethiopian 409. turn right heading 270 at this moment the controller was probably most concerned with the fact that the crew had overshot its heading would be conflicting with inbound traffic and had to be moved away from a possible conflict with terrain right heading 2-7-0 raj okay what heading did he say two seven zero set the cockpit fills with a disturbing sound what is it the control columns vibrate warning them that the plane is about the captain pushes the throttle all the way up to sir follow heading 270 turn right heading 270 now whenever a controller tells a pilot to do something now the controller is telling the flight that they're immediate danger speed is going down he was worried that the crew was going to fly the airplane into the hills behind beirut airport but their situation is even more dire the chaotic motion of the plane is torture for passengers it's horrible you're feeling a 3g load it's pushed you down in your seat you're getting squashed your fellow passengers some of them are silent some of them are screaming oh god oh god ethiopian 409 beirut ethiopian 409 beirut we've lost an aircraft ethiopian uh we don't know what's happened and we don't know his position ethiopian 409 has plunged into the mediterranean just five minutes after takeoff the evidence needed to explain the crash is sinking fast within minutes of the crash the lebanese military issues a distress call to all available ships in the area local boats as well as foreign warships joined the search my first reaction was this accident was very unusual very unlikely that really required a very good investigation to see what we could learn from it it's the first major commercial aircraft accident in lebanon in nearly 35 years within hours of the crash the lebanese civil aviation authority dispatches handy shouk to take charge as soon as i reached the airport i had to try to manage the environment of the accident the hardest part is how to deal with all the search and rescue of major parties from defense to the interior ministry to all the concerned parties who have never done this before a former pilot he's one of the few experienced investigators in the country so we got to make this in our search area right here on this grid okay we have ships here here and here okay so mohamed aziz is his second in command first of all we wanted if by any miracle anybody had escaped we wanted to be able to pick any survival especially that the first hours they discovered two or three bodies most probably they were thrown out of the plane when it crashed [Music] have you any sign of wreckage negative nothing is under great pressure to locate the wreckage fast so you want to answer very important questions to the family why my relative died it goes to your head as an investigator always i want to know the truth but nothing here no no but the storm flight 409 was trying to avoid is still raging the major deterrent to the search and rescue operation was whether bad weather was high waves in the sea and so on so this makes the search and rescue operation difficult okay let's see what kind of weather they were flying could the storm have been face enough to bring down a 737 oh there were thunderstorms west of the airport thunderstorms can be very dangerous they can interrupt the flight and the airplane structurally and they complicate the safe operation of the airplane in rare cases a lightning strike can damage the electronics that control the aircraft while a lightning strike on an airplane is not uncommon and usually doesn't create damage to the airplane it can under some circumstances at the same time rumors are spreading quickly flight 409 was the target of a terrorist bombing when you live in a country like lebanon every now and then you have fighting you have explosions and the first thing that comes to mind when you lose an aircraft just like that is maybe there is an explosion on board the flight as day breaks wreckage begins to wash up on shore navy ships recover floating debris and some human remains it's painfully obvious there are no survivors lebanese army have already recovered seven bodies 82 passengers and eight crew are dead [Music] most of the plane is still missing without more wreckage investigators may never know what brought down flight 409 at beirut airport they question witnesses who lend support to the sabotage theory the controllers who were on duty at the time of the crash i saw a bright orange flash it looked like the plane exploded the controller he saw a ball of fire at the place he presumed that the plane crashed so some people they say that it could be an explosion hard evidence of sabotage requires a close examination of the wreckage you have to go back to the evidence because the evidence speaks the part itself of the plane can tell you how the accidents happen and so far the inexperienced team is having trouble locating the plane lola have you searched this sector here yeah we looked everywhere we looked here we were able to determine where probably the aircraft would have been yet when the navy and the air force started to lock the search for the plane they could not find it a navy ship is searching for signals from the plane's black boxes these begin transmitting an alert as soon as they come in contact with water there is what we call a finger and it emits a signal for about 30 days after the crash but two days in the search hits a major hurdle investigators learn the navy sonar they've been using can't home in on the signals it's not precise enough we'll never find them this way we don't have the right equipment we could not sleep we were always thinking that we need the recorders xiao contacts aviation authorities in france for help we're hoping you can come immediately yeah it's quite urgent they have the equipment and the expertise to find the recorders okay great all right thanks great they're on their way it was a learning curve for everybody the leaders or divers or the navy people with the right gear thank you for coming the team should be able to search more quickly but valuable time has been lost and investigators have few leads these type of airplanes are flying all over the world and if there is a problem we need to take whatever corrective action that's needed the united states also sends help because the 737 is american-made the national transportation safety board's dennis jones joins the team welcome to beirut thanks we still didn't have a crash site per se the flight recorded which is always a big concern of interest was still yet to be found yeah with no wreckage to study jones and shouk turn to a record of the plane's flight path look at the radar track from the airport this should show us exactly what they did when we first got there some of the information we had that was helpful was the radar data and air traffic control information in general so we were able to start evaluating that pretty quickly the radar paints a baffling picture it's like no one's flying exactly almost from takeoff the plane follows an unusual and erratic path once you see what happened to the plane you would wonder what what really were happening as if there were no crew in the cockpit it is almost similar of a situation where nobody's in control of the plane now that they've seen the strange flight path okay so here's the track so they could be anywhere along here okay investigators are more anxious than ever to get at the wreckage and search for answers and what we're seeing is basically an external view with the radar data and air traffic control but we didn't get an idea what was actually going on board the aircraft itself so we became even more eager to to get the recorded that's it that's it that's exactly what we're looking for finally eight days after the crash the french equipment detects the vital signals wonderful that it was found 45 meters deep and five kilometers southwest of beirut airport cameras mounted on unmanned subs capture the first images of what remains of flight 409 we had the odyssey submarine that been used for taking photos and survey for the wreckage located on the seabed it's too expensive to bring all the wreckage to the surface so investigators focus on the tail section where the two black boxes are stored retrieved the tail the horizontal stabilizer with the tail cone as well they are still attached together and they found the if they are located underneath it we were quite delighted about that and the lebanese government immediately started making plans on having that transported to a facility to be evaluated but they only find the flight data recorder what about the cvr the cockpit voice recorder should be nearby but it's not right so it's got to be in this sector that's what we think while the divers continue their search investigators study underwater video of the wreckage for clues okay let's start mapping this out when a plane explodes in mid-air the debris falls in a circular pattern but if a plane hits the water intact the debris will fall in a linear pattern the underwater video allows investigators to map the position of every piece of wreckage another one here lining up nice and neat in this case we found all the pieces laying in the bed of the water in almost 300 meter straight line they also search for any sign of fire damage you would look for a certain um signature to show us the perhaps there might have been some heat damage or fire damage go back i want to see that piece again there's no sign that the metal was ripped open by a blast and no burn marks on any of the wreckage we looked at the footage we couldn't identify any black spot black suit or anything of the sort we saw none at all there's no sign of any explosion ethiopian 409 beirut they conclude that the tower controller may have been fooled by a trick of the light it was a stormy night so throughout the night you were hearing thunderstorms lightning and they do sound exactly like explosion and they give you a bright light even stronger than any big explosion still puzzled about the cause of the crash investigators turned to the newly available data from the fdr nothing so far there are more than a thousand parameters to analyze the flight data recorder um records essentially the instruments um and other parameters from the aircraft uh basically what the aircraft is doing and that retains in this case 25 hours of information almost all the data is normal but one number stands out take a look at that stabilizer setting it's a bit low but still in the green the stabilizer is part of the tail pilots adjust its angle depending on the weight of the plane move it up and the plane pitches up move it down and it forces the nose down okay feels good load is calculated check complete no problems the fdr reveals that flight 409 stabilizer was set further down than normal for takeoff such a small variation probably wouldn't cause the pilots to lose control of their plane but investigators won't know its effect until they can test the configuration in a flight simulator at that point obviously everything was on the table we knew we had a lot more factual finding to do oh i got it oh here it is okay the investigation takes a huge step forward when the search for the missing recorder finally pays off that's it hey aziz we got it oh we found it yeah i have to praise the lebanese navy diver because with the equipment they had they had to do a real hand surge 45 meters underwater which is quite difficult but they were able to recover it at the end investigators can only hope that the pilots said something that will reveal why their plane went down investigators sync up the conversation on the cvr exterior checks complete with the plane's known flight path check complete no problems they listen for any sign of trouble we want to try to get a better understanding if there might have been some kind of mechanical problem based on what they were perceiving ethiopian 409 wins nearly calm clear for takeoff 2-1 immediate right turn to checkup roger declared for takeoff runway two one immediate right turn to shekel 409 everything seemed to be going just right now once they took off the first part of the takeoff was normal turn right initially heading three one five three one five roger investigators hear the controller give the pilots a new heading but the plane goes off in a different direction as they approached the heading that they had been assigned they overshot the heading he was supposed to turn this far but he just kept going mark they're way off course sir i suggest that due to the weather you follow heading 270 to be in the clear each time the pilots tried to correct their course they turned too far and banked too steeply it's a sure indication that the airplane has lost control ethiopian 409 you are going into the mountains the airplane was rolling into an ever steeper bank its lift factor was decreasing so the nose was dropping toward the sea ultimately leading to a spiral the plane was out of control there's nothing on the recording to suggest there was a mechanical failure we just was not hearing anything that showed a malfunction which was consistent with the flight data recorder it was just something that we certainly didn't have any answers for in the beginning desperate to know what brought down the 737 investigators dig into maintenance records they learn that some 737s have a small but dangerous floor in a vital part of the tale hey dennis i think we need to check those trim tabs trim tabs are small control surfaces set into the tail of the plane they counteract the powerful flow of air pushing against the tail making it easier for the pilot to fly the plane to use an analogy with cars it's like a power steering as compared to manual steering if the trim tabs were damaged it could explain why the captain was struggling to control the aircraft left heading two seven zero roger enough to be two seven zero my experiences of flying an airplane out of trim it can make it extremely difficult to fly it can even go beyond the forces that the pilot could actually use or input to counter it you can bring that over here investigators are in luck the stabilizer and trim tabs are among the few pieces of wreckage recovered from the sea the team assembled and to evaluate this aircraft hit the water close to 400 knots so we're expecting a lot of things to be damaged so we wanted to kind of evaluate it to see if there's anything that was pre-existing that might have somehow contributed to the sickness of events but it's another dead end a close inspection of the trim tabs reveals no damage at all no sign of any malfunction they did not affect the pilot's ability to steer the plane wire 737 carrying 82 passengers plunged into the sea only minutes after takeoff is still a mystery [Music] investigators travel to seattle washington to boeing's state-of-the-art flight simulator okay we're going to run the ethiopian 409 i'm going to set the trim to match theirs the flight data has shown that flight 409 stabilizer was set to a shallower than normal takeoff angle they now need to know if that somehow affected the pilot's ability to handle the plane you kind of get a front row seat of perhaps what the the flight crew were seeing at the time and how the aircraft was handling okay let's see how this thing is going to fly the low angle of the nose makes the plane difficult to handle at first it's definitely not happy [Music] the trim was miss set for takeoff by a small margin but nevertheless by enough to create an undesirable pressure for the pilot on the controls so the pilot was always fighting the airplane to one degree or another in the simulator the pilot has no difficulty correcting the problem okay well try it with no trim at all [Music] every single time we tried to recover this aircraft we were able to recover it [Music] they should have been able to recover they conclude that the low stabilizer setting did not cause this crash something else made the 737 spiral into the sea officials from ethiopian airlines still believe terrorism is to blame they insist that an onboard bomb cannot be ruled out until more of the wreckage is recovered from the mediterranean the investigators don't agree we told them whether it's it's quite a remote possibility that there was something put on board that plane was when the plane explodes with the one one board it just flies its own route and it explodes it doesn't go up left and right and up and down and then something explodes on the plane but stamping out rumors is never easy investigators are under growing pressure to explain what happened if it wasn't a bomb then what did bring down flight 409 an aircraft accident investigation often the best approach is the sherlock holmes approach what you do is eliminate everything you know didn't happen what's left is probably what did happen the controllers did their job turn right initially heading 315. the ground-based navigational systems were working the airplane was functioning properly so what we have left is the crew investigators returned to the cvr they hope the crew's conversation can shed light on why two qualified pilots lost control of a mechanically sound airplane exterior check complete no problems they notice something odd the mood even the the speed of the voice or even the tone feels good load calculated did not reflect what is really actually happening in the aircraft during the takeoff role you see that the captain saw something because he tells his first officer did you see that but then there was no reaction from the first officer the first officer is uncharacteristically quiet okay engage the autopilot even worse he's not following his captain's commands hold on stop for a second i would have changed things the advantage of engaging the autopilot in that situation is that the pilot can then let the autopilot worry about the attitude of the airplane while he sits back and takes the big picture maintains situational awareness the autopilot can adjust the throttles to maintain a safe airspeed and can keep the plane on the right heading but investigators learn it was impossible for the autopilot to engage on flight 409 [Music] there's no way it could come on it's designed not to switch on if one of the pilots is pulling on the control column as the captain was for some reason the first officer didn't give his captain a crucial piece of information that the autopilot did not come on had the autopilot been engaged when the captain ordered the first pilot to engage it would have saved the whole flight the interaction between the crew members were not what we would expect from professional crew at the time the crew's behavior is baffling it forces investigators to consider an unlikely explanation for what went wrong something called subtle incapacitation it's very difficult to recognize a satellite capacitation if the pilot at the control has a stroke and slumps over the control wheel there's no question that you've got a person who's incapacitated confirm heading two one zero negative sir to proceed direct checker turn left now heading two seven zero left heading two seven zero roger left heading two seven zero however if the pilot at the controls starts to lose the picture and does so silently and starts to misapply controls or push the wrong buttons it may take a while before the other crew members pick up on that failure that sequence is called subtle incapacitation it's a controversial idea that goes beyond the usual definition of pilot error subtle incapacitation can come from physiological reasons psychological reasons or a combination of both it could be something minor uh medications could cause it stress could cause it fatigue could cause it because commercial aviation demands such high levels of performance drug and alcohol use by pilots is closely scrutinized drug testing is part of any transportation employee from baggage handlers all the way up to cockpit managers typically it's done on a random basis it's done but there's no formal test for fatigue other accidents with the same kind of sequence of events taking place the best known example is colgan air flight 3407 in 2009 two overtired pilots failed to react properly to a warning that their plane was about to stall all 49 people on board were killed this room doesn't make you sleepy investigators continue to analyze the cockpit recording what are these guys doing they listen to what the pilots were saying just before takeoff this room doesn't make you sleepy if you hear someone on the recorder saying sleep immediately our antennas stick up i don't never know who we are up there was there weed in it did you feel dizzy oh i i couldn't sleep well me too [Laughter] investigators are shocked to hear the pilots joking about being tired and the reference to weed subtle incapacitation may not be such an unlikely cause after all trying to explain the behavior of the pilots on that particular night was really the most difficult part of this investigation and this is why we considered every single issue starting from the food they had the type of rest they had piecing together the pilot's movements in the hours leading up to the crash what time did he check in is now the top priority in the case of this accident the pilot's bodies weren't recovered so there was no way they could do post-mortem examinations we immediately called the hotel to check the garbage if there was any bottle of alcohols any drugs that they see the crew out having drinks or something they study security footage for any signs that the pilots were impaired we also looked at the footage of the crew coming into the airport they were walking normally everybody we spoke to they said no no they were normal investigators travel to ethiopia to interview family members about the crew's habits thank you for uh taking the time to see me i'm very sorry for your loss uh i just want to ask you a few questions about your brother did he ever drink no there's no evidence to suggest either pilot abused alcohol or drugs the captain didn't drink at all so he was a sport guy concentrating on his sports subtle incapacitation is difficult to prove in the crash of flight 409 the evidence so far is mixed but what investigators discover next could tip the balance [Music] gear up employment records detailing the pilot's flight hours reveal critical information about the captain of flight 409 he'd been working almost non-stop for nearly two months the 51 days he probably flew something like 45 days out of the 51 daily daily daily flying just taking the minimum rest it's legal but it is quite a lot of work work work work the crew's last chance to rest was a scheduled stopover after flying into beirut i could use some food that didn't come from an airplane what do you say yeah good meal will be good all right let's do it [Music] [Music] prior to the flight they had a heavy launch and they were not able to rest properly so they were commenting on not being able to rest properly prior to the flight did you feel dizzy oh i i couldn't sleep investigators suspect that the heavy meal affected their sleep indigestion and the fatigue they definitely they affect the pilot behavior throughout the flight process sir i suggest that due to the weather you follow heading two seven zero to be in the clear 2-1 see again [Music] the storm conditions likely added to the pilot's stress the weather could be a factor in adding pressure on the pilots fatigued and under increasing stress they lost track of where they were and what they were doing this flight was in jeopardy from the outset it seems that the crew was never fully on top of what was go around go happening roger [Music] investigators conclude the accident was caused by a crew that was simply too tired or too confused to recover from the first wrong turn it's a textbook example of subtle incapacitation we could prove that the symptoms that we saw are similar to the symptoms of somebody who has a subtle incapacitation the accident exposes a risk to aviation that no amount of engineering can overcome [Music] after the crash of flight 409 investigators suggest ethiopian airlines introduce much more rigorous rules regarding crew rest it's one thing to have the experience and the expertise to do the work but you have to be in good condition in order to perform as long as airplanes are operated by humans fatigue distraction and other human weaknesses can only be managed never erased [Music] i'm not sure that we can prevent subtle incapacitation but we should at least try to eliminate all the possibilities that are related to human factors because human factors are still the majority of most of the accents check complete no problems [Music] you

Channel: Mayday: Air Disaster

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Id: oqK9ZsjDhmM

Length: 43min 51sec (2631 seconds)

Published: Wed Aug 17 2022