Faulty Autopilot Causes The Crash Of United Express Flight 6291 | Mayday: Accident Files

[Music] okay and marker inbound don't forget to give me my call outs Captain the first officers to work together as a team but cockpits containing Tony what did you do domineering captains adding 2 3 Z understand poor communicators no well he had to say we stop you're turning the wrong way and intimidated rookies I did nothing let the personal don't be so stupid get in the way of the professional there were words that you wouldn't expect to hear in a professional crew environment and doom many lives investigators must now unravel three needless tragedies made to have it I'm failing his check rides stemming from we're cring bad pilot [Music] pairings mayday mayday [Music] [Music] in duala Cameroon Kenya Airways flight 507 is waiting for a bad storm to pass ladies and gentlemen we are going to wait for the weather conditions to improve before the takeoff there are 108 passengers on board the new Boeing 737800 flight 507 began in abigan earlier in the day it's stopping over at dalala and flying on to Nairobi Kenya but the storm has caused an hours delay Captain Francis wam WEA is in command let's see what this storm is doing he's got more than 8,000 flying hours 23-year-old Andrew KIU is the first officer there might be a way around it Tower Kenya 507 looks like there's a break in the weather requesting startup okay 507 startup approved startup checklist quickly please generators on okay request taxi clearance as the plane taxies to the runway the first officer focuses on takeoff preparations wait till we line up okay usually things happen quickly though okay try to keep up [Music] Captain Wan WEA verifies the position of a thunderstorm let's have a look before confirming a route around it Tower Kenya 507 after departure we would like to maintain a heading slightly left of Runway due to weather ahead right ah sorry slightly right approved okay takeoff thrust is set speed building on both check 18 kns check V1 rotate just after midnight Kenya Airways flight 507 finally takes off get up okay 1,000 ft on climbing the 737 begins turning to avoid the storm anyone after reaching 1500 ft the captain calls for okay command the autopilot to be engaged so should I remain on his heading yep 2400 ft and climbing now we're getting into [Music] it than anle than anle suddenly the 737 rolls dangerously to the right anle Bank ankle Bank ankle the captain struggles to level the plane Bank ankle Bank angle angle cring angle yeah we are crashing left angle angle B angle B angle [Music] flight 507 has plunged into a swamp search teams spend 2 days looking for the wreckage it's found in a mangrove swamp southeast of the airport all 114 people on board the 737 are [Music] dead an international air accident team arrives in Cameroon to investigate the case this was the toughest accident scene I've been on in my career Bo with so much of the physical evidence obliterated investigators face a huge challenge the team gets a break when the 737s flight data recorder is recovered oh looks pretty good considering the search for the cockpit voice recorder [Music] continues in the meantime investigators can search the flight data for Clues they hope it will reveal why a new Boeing aircraft crashed so soon after takeoff let's see what we've got the data showed us the airplane was behaving as we would expected to it was a perfectly airworthy aircraft there's no question about it as investigators examine the data but look at this the Pilot's control wheel inputs after takeoff attract their attention rotate they make a surprising discovery he was turning left from the moment they left the ground that information showed us that right after take off the aircraft started to roll to the right a little bit and the pilot corrected it and then he keeps making corrections to the left looks like he's trying to keep the plane level investigators wonder what caused the aircraft's slight roll to the right they dig deeper into the flight data bingo it's the way the flaps are rigged give it a slight right roll on this particular 737 the left flap provided slightly more lift than the one on the right while climbing Pilots needed to compensate for the difference by making constant adjustments to the roll it's similar to driving down the freeway in your car and just letting go of the wheel then it'll start to drift off one way or another that's the way the airplane was slowly and naturally Bing it the discovery explains why the captain kept his control column turned to the left immediately after [Music] takeoff well that's weird but it doesn't account for some readings in the flight data look at this the captain's control wheel input seem to stop it's like it just let go of it 6° right he does nothing 11° 15° 20° 30° and still nothing why did the crew stop leveling the plane despite banking further and further to the right Bank angle Bank angle the airplane just continues to roll right up to 110° of Bank the crew didn't recover it before impact the data paints a baffling picture of the short flight who flies like that with little physical evidence to go on and perplexing flight data the team is eager to locate the plane's cockpit voice recorder it may be all they have to solve the mystery of Flight 57s crash it takes 5 weeks for Searchers to recover Kenya Airways flight 507s cockpit voice recorder from a swamp near duala International Airport started investigators hope it will reveal why the pilots didn't take action until the aircraft reached an extreme right Bank angle selected check N1 okay command that's the call to activate the autopilot so should I remain on this heading yep flight data confirms that the captain released the control column after calling for the autopilot to be engaged but investigators spot a problem the autopilot didn't come on he thought the 737 was flying itself investigators are stunned after the captain released the control column 55 seconds passed before Pilots noticed the plane was out of control there was nobody flying the control so nothing was controlling the airplane the chilling Discovery gives the investigation a new Focus N1 okay command why didn't the autopilot turn on the captain calls for the autopilot to be engaged but the first officer does not respond investigators suspect that the first officer was so focused on inputting the route around the storm that he never engaged the autopilot now we're getting into it it seems the captain assumed the autopilot was controlling the aircraft and the pre-selected right turn B angle angle B angle the pilots only noticed there was a problem when the bank angle warning sounded angle Bank angle this means the plane exceeded a 35 degree roll and was flying into danger we're crashing yet the 737s bank angle warning is designed to give Pilots enough time to regain control so why didn't the crew recover they should have been trained for such a scenario investigators dig into the Pilot's background for Clues wait look at this they find serious shortcomings in the captain's training records inadequate knowledge of systems and procedures insufficient flight discipline poor cockpit scans below standard yikes get up can't we discovered the captain had a history of training difficulties and lack of systems knowledge for autoflight systems and so forth so he had some red flags in his history the first officer's report isn't any better the first officer was young and fairly inexperienced he had had some training feedback like you need to be more proactive about calling out deviations and so forth not an a-level crew it's a troubling Discovery but it still doesn't add up it should have been a simple recovery even a less experienced captain and a novice first officer would have had basic upset recovery skills was there something here that we were missing in the investigation they returned to the flight data and the voice recording for additional Clues thank angle when the bank warning came on and the aircraft was in a right role the captain turned it further to the right and which aggravated the situation when he realized the autopilot was disengaged the captain activated it but when the plane didn't level immediately he turned the control column erratically those inputs overrode the autopilot 22° to the right 20 left 45 right then 11 to the left that's not helping are you declaring emergency sir watch all episodes of ice Pilots watch on mobile devices or the big screen all for free no subscription required download de now crashing yeah we are crashing anle then yes we are crashing left left left correction left correction the time in of the first officer's response is significant it took him 10 seconds to speak up the first officer read the situation correctly we're crashing yeah we are crashing the pilots needed to turn left left left angle so why did first officer KIU stay silent they go back to the first leg of the flight from abuan to duala on the recording for Clues let's hear it sorry did you say an altitude of 14,000 fit yes don't be so stupid write it down if you can't remember wow there were words like stupid shut up stuff like that that you wouldn't expect to hear in a professional crew environment what is wrong with you did you not hear the instruction the first officer seemed to kind of shut down heading 2 3 0 understand investigators believe the captain's intimidating manner prevented the first officer from speaking up sooner the captain's Behavior toward the first officer on the first flight likely caused him to adopt sort of a passive role you need both Pilots actively engaged in checking each other and catching errors so heightened eagle really history Captain WWE's treatment of his first officer leads investigators to delve deeper into his professional history he had a lot of concerning things in his training Files about being overbearing being authoritarian in terms of how he dealt with other crew members so we have a young reserved first officer and an overbearing Captain a lethal combination so should I remain on this heading yep in the end investigators conclude that one major mistake lay at the heart of the tragedy the crew's failure to ensure the autopilot was engaged Additionally the pairing of a domineering verbally abusive Captain with an apprehensive young pilot compounded the danger an anle [Music] in the wake of flight 507 crash cameroon's Commission of inquiry made a series of recommendations including regularly updating safety manuals relating to cockpit procedures and crew responsibility they made changes to the stand operating procedes about holding responsible for engaging your autopilot and improved pilot training with a focus on upset recovery Bank angle Communication in a cockpit is kind of like the fabric that holds holds a good flight together and when these break down then then you may be in [Music] trouble and when another professional mismatch leads to panic in the cockpit left left left a short commuter flight goes horribly wrong it's a cold and rainy night at Zurich International Airport passengers on board crossair Flight 498 are waiting for takeoff to Dresden Germany Captain pil gruan is in command you ready and rastislav kisar is first officer objec is completed both Pilots came from Eastern Europe to work in Switzerland set take off power take a f set tonight they're flying a s 340 turbo prop get before the aircraft clears the clouds the controller makes a slight change to the flight path 498 turn left to Zur East cing left to Zur East crossair 4 ner 8 the new route takes the plane south of the airport over a navigation Beacon and on to Dresden as the plane begins to turn the first officer notices something wrong turning turning left to Z we should left crossair 498 confirm your turning left please stand by the plane should be turning left but instead it's banking to the right okay continue right to Zer East [Music] no m Flight 498 slams into the ground Just 4 miles from the airport all seven passengers and three crew die on [Music] impact the next morning investigator inspect the wreckage the crash site itself provides them with their first lead if you can't see a a bigger structure of an aircraft and you see a a crater that leads you to the idea that this aircraft has to be come quite steep into the ground the debris field tells investigators the direction the plane was flying they discover it was turning in the opposite direction to its designated flight path they question air traffic controllers working the night of the accident why weren't they flying the standard departure 498 turn left to Zur East air traffic controllers tell investigators crossair 498 turned right and not left as instructed crossair 498 confirm your turning left please stand by the controller assumed the captain wanted to follow a different route and approved the course change okay continue right to Zer East moments later the plane spiraled out of control a deep right turn developed which led to a collision with with ground but uh there was no indication uh about the reason for that the team hopes the black boxes will help Focus the investigation while experts recover the Recorder's data crash site de provides a big lead a pilot's mostly intact flight bag it belongs to Captain gruan and its contents are [Music] disturbing there were some personal items in there and with them we found this medication No Label or box with it it is uh quite uncommon that you find some medication in a in a pilot's B turning left to zast we should left investigators consider a deeply troubling scenario was a drug impaired captain at the controls on the night of the crash it is always of great concern because we all know that we're not supposed to take any kind of drugs when we go flying the team must identify the medication and determine whether Captain Gran took any before stepping into the cockpit get this to the lab [Music] okay the test results identify for napam a powerful sedative similar to Valium the drug is often used to treat anxiety disorders in this case there was a medication which was very strong and which can have an effect on your capability to fly an airplane in investigators must wait for the results of the tissue analysis could an impaired pilot be the reason 13 people lost their lives in a tragic accident the investigation into the crash of crossair Flight 498 comes to a dead end with the results from the tissue analysis though Captain Gran had traces of a sedative in his system the tests don't reveal if the amount was sufficient to affect his flying we were not not able to rule out this effect in the accident but uh we were not we were also not sure that this uh medication had an effect for sure with the data from the black boxes now available the team turns to the cockpit voice recording for answers it up they listen to the Pilot's conversation in the cockpit alongside the flight data right here the turn is starting to get very steep oh no no the captain's sudden agitated reaction provides a clue that timing can be coincidence investigators know that the captain's flight display changes the moment a turn becomes too steep the system is designed that if you go into a abnormal bank or pitch angle he removes unnecessary information to make the recovery easier for for the pilot the timing of the captain's remark convinces investigators his instruments were working but for some reason the pilot turned further to the [Music] right I think the problem was that he was not aware what was uh going on what so confused an experienced pilot that he was unable to distinguish left from right the team examines the Pilot's records at Crosshair nothing yet you investigators need to dig deeper into the crew's training the search for an answer takes them to Russia where Captain grin learned to fly thank you for seeing us Captain Gran was trained on Soviet era aircraft the first officer on Western planes investigators learned that both Pilots completed their training successfully but then Russian experts share a troubling cluster of similar accidents Pilots trained on Soviet era aircraft were becoming confused by a crucial flight instrument on Western planes the attitude indicator or Artificial Horizon this was very surprising for us because this problem was not well known at this time uh in the western uh part of of Aviation pilots in the former Soviet Union were trained to fly using an attitude indicator that looks very different from the ones in Western planes turning left to Zur East crossair 49 or8 in the west the aircraft symbol at the center is static while the background moves Soviet or Eastern attitude indicators work in the opposite way the aircraft symbol moves and the Horizon remains static it's easy to see how a pilot might get confused this discovery was really crucial for probable cause of this accident under stress and possibly affected by a sedative Captain gruan may have reverted to what he learned when he first became a pilot no in his confusion he became convinced he was in a steep left turn so he turned right putting the aircraft into a deadly spiraling dive but a question remains unanswered what prevented the first officer from noticing his Captain's mistake before it was too late climbing level 110 cross 498 it was the first officer's job to monitor the instruments investigators reconstruct the flight to see what the first officer was doing when things started to go wrong cross f98 climbing flight level 110 climbing level 110 cross 4 98 investigators discover the first officer must have been looking down to adjust some settings or was focused on the overhead panel pleas on said climb power coming these duties keep a pilot's gaze well away from the attitude indicator by the time the first officer could see what was happening the plane was already in a steep right Bank uh turning left to zist should left crossair 498 confirm your turning left please stand by no the stress in the first officer's voice suggests he knew there was a problem but couldn't communicate it clearly left left and the captain thinking his plane was already turning left didn't understand what his first officer was trying to tell him their English was basically Aviation English and and uh it is hard to communicate fluently and to communicate concerns well enough all you had to say was stop you're turning the wrong way in the end the pairing of two pilots with very limited English language skills proved lethal after the crash of Flight 498 the aviation industry improved training for pilots from former Soviet block countries and passing an English language proficiency test became a requirement recommendations did arise from the accident people upgrading to Western machines received much more training on the differences between Western and Eastern block aircraft but when mistrust in the cockpit reaches a fever pitch y damper autopilot all the way don't touch a straightforward Landing turns into disaster Tony what did you do I did nothing United Express flight 6291 is on route from Washington Dallas airport to Columbus Ohio a winter cold front is dropping temperatures below freezing in the region cold enough for you Captain Derek white is in the cockpit actually I kind of L here really Anthony Samuels is his first officer he's been with you United Express for 3 months s to get the hang of it oh yeah they're piloting a brand new jet stream 4100 a small twin engine turbo prop there are only five passengers plus a flight attendant in the cabin flight 6291 is cruising at an altitude of 14,000 ft United Express 6291 one be advised to just had a report of some Icing at 14,000 Indianapolis Center United Express 6291 can we get one 5,000 for a while United Express 6291 climb and maintained 15,000 15,000 United Express 6291 after flying for several minutes above the bad weather I'm in the approach turn the pilots are ready to begin descent Express 6291 reduced speed to 170 knots the plane needs to slow down to make a safe approach reduce speed to 170 knots United Express 6291 United Express 6291 Columbus Tower Runway 28 left clear to land wind 3 0 at 4 knots okay if you have all the speeds don't worry about it anymore ref is 112 I got to input that I did it for [Music] you okay and remarker inbound Roger don't forget to give me my call outs the captain reminds the first officer to report the altitude and air speed readings as the plane pushes through the mist and drizzle the runway comes into view flaps 15 Landing checks flap 16 landing gear down three green yeah [Music] damper Tony what did you do I did nothing give me flaps up no no no hold it hold it hold up give me flaps up hold [Music] Tian flight 6291 crashes into a warehouse only a mile short of the runway be right behind a family of three escapes the fiery wreckage they are the only ones to survive after Sunrise lead investigator Al Dickinson and his team from the national Transportation safety board are on the scene the fire was very intense and it made it hard just to try to identify the different pieces yes now that's what I wanted to see the flight data recorder and cockpit voice recorder are found buried deep in the wreckage using f flight 62 91's air speed and altitude the team tracks the plane's descent okay this is the ice that they flew through the data gives the investigators a lead wow 240 knots they are screaming through this and looks like a slam dunk a slam dunk is when a plane approaches high and then descends rapidly to the runway it's usually done to get through bad weather quickly but it's a risky maneuver you can fly really fast to get through ice but if you don't look well ahead of the aircraft you can easily slam it right into the Earth here they're going so fast the controller has to slow them down United Express 6291 reduce speed to 170 knots in response the crew moves the thrust to idle and doesn't adjust it again investigators discover the plane drops to 100 knots well below 100 13 knots which is the minimum speed to prevent a stall so they go from way too fast to way too slow why would Pilots reduce their speed so dangerously [Music] low sifting through United Express flight 62 91's data it's here the investigators make a surprising discovery they were doing all this with the auto pilot on so right up until before they crashed they were using the autopilot to help them [Music] land while an aircraft on autopilot can follow the Descent path perfectly the captain still needs to Monitor and control the air speed that's why Pilots almost always land manually so they move thrust to idle the plane slows down down below the safe approach speed which makes it descend and the autopilot tries to climb because flight 6291 drops below the prescribed descent path or Glide slope the autopilot pitches the nose up to regain altitude but this slows the plane even more and takes it into a [Music] stall Tony what did you do I did knock it investigators now know the sequence of events that led to the crash but they still don't know why the pilots didn't increase their air speed to save the plane okay let's go the team listens to the cockpit voice recording for Clues United Express 6291 reduced speed to 170 knots reduce speed to 170 knots just as the Pilots are cleared to land investigators hear things going wrong okay if you have all the speeds don't worry about it anymore ref is 112 I I got to in for that I did it for you oh there's definitely tension in the cockpit okay and remark your inbound Roger don't forget to give me my call outs okay flaps 9 Gear down flaps 9 waiting for three green flaps 15 Landing checks flaps 15 landing gear down three gr wait did anyone hear any call outs he should have been calling out altitudes he should have been calling out air speeds but he wasn't doing any of that the first officer's Omission is revealing y damper autopilot all the way don't touch don't touch holding on the Y damper disconnecting the Y damper would turn off the autopilot he doesn't want to lose the autopilot this heated exchange tells investigators the captain has little faith in his own skills to land manually and even less faith in his first officer's abilities the captain's comment y' damn don't touch and the first officer response don't touch told us a lot about the Dynamics between the captain and first officer it Illustrated the tension between the two of them and the lack of [Music] trust okay that's the stick Shaker it's stalling that only happens when the air speed is approaching the stall speed they must take immediate action or the airplane will likely crash Tony what did you do I did nothing rather than increase air speed as he should have done the captain wasted precious seconds chastising his first officer his first assumption was that the first officer had done something wrong which wasn't the case I was dumbfounded give me flaps up no no no hold it hold it give me flaps up flaps up in a stall what were these guys thinking there is no training that involves flaps up during any kind of a go around situation with its flaps up the plane needs more speed than usual to pull out of a stor yet the crew doesn't notice their air speed is already too slow up until that time he could have recovered but after that he was along for the [Music] ride it's pretty clear that the captain did not feel he could rely on the first officer it's also clear the first officer did not diagnose the need for the captain to increase the air speed as he should have and therefore it's pretty clear that the team of the captain and first officer was ineffective investigators wonder how these Pilots ended up together in the cockpit in the first place they study the pairs professional histories for answers I got the captain's records and the first officers the first officer Airline line records are surprisingly thin that's it this guy's totally green hired 6 months before the accident and he's only got 2 and 1/2 hours of line experience on the jet stream 4100 the captain's records also raise serious questions look at this you made to have it and failing his check rides check rides verify a pilot's competency and skill it's very rare that a captain or first officer will fail to check Rod this Captain failed two check rides within about a year investigators then talk to other first officers who have flown with the captain to find out more about his habits when Landing so he usually used the autopilot while he was Landing thank you when a pilot constantly uses autopilot in reality he doesn't have confidence himself to fly approaches and Pilots need to have that confidence investigators conclude that United Express should not have paired a novice first officer and a captain with a history of failures on the [Music] 4100 unfortunately the organization needed Pilots to fly the 4100 cuz they had been expanding and they chose to pair this pair up and uh it it wasn't a good pairing the NTSB recommends more training to enable Pilots to recognize and recover from a stall and to manage high-speed approaches today many more factors are considered before Pilots are placed in the cockpit together this cockpit Resource Management training now has moved great bounds so that the first officer feels he can question the decision from his Captain he can suggest solutions to a situation and he will be listened to we're crouching left left three bad pilot pairings that ended in disaster no each a lesson for greater scrutiny of a pilot's history and the creation of compatible Partnerships in the cockpit you put 93,000 flights in the air over the Earth every day and get every one of them back almost all the time without anything going seriously wrong and teamwork is what gets airplanes with people back on the ground [Music] [Applause] safely [Music]

Channel: Wonder

Views: 47,293

Keywords: Crossair Flight 498, Kenya Airways Flight 507, Wonder, air crash investigation, air crash reconstructions, air crash scenarios, aviation accidents, aviation mysteries, binge-worthy, communication breakdown, disaster analysis, dramatic recreations, empowering stories, engine separation, extreme stories, fatal stall, flight safety measures, mayday episodes, survival skills, survival tales, tragic consequences

Id: O2u4MDjSn-0

Length: 43min 22sec (2602 seconds)

Published: Sun Apr 07 2024