How a terrible coincidence brought down this Aircraft | Tarom flight 371

this video is brought to you together with skillshare use the link in the description below for your special deal it's the 31st of march 1995 and an airbus a310 from taron airlines is flying its standard instrument departure from the 08 right in bucharest initially everything looks okay but about a minute and a half into the flight it's obvious that something is not right the aircraft starts banking more and more towards the left the nose starts dropping and they find themselves in an almost vertical nose dive down towards the ground seconds later the worst aviation accident in romanian history is a fact how come that a pretty minor technical malfunction have led up to this and what has happened to the pilots well in order to understand this we once again have to turn our attention towards the final report so stay tuned the aircraft involved in this incident was an eight-year-old airbus a310 initially it had been bought by pan-american airlines and when they went bankrupt delta airlines had taken it over and then about a year prior to the accident the taram airlines had bought the aircraft this aircraft did have some technical issues specifically with its outer truss systems the atf what had a tendency to happen was that as the aircraft was transitioning from its takeoff phase into its climb phase well then the trust should be reduced back to what we call climb thrusts but on this particular aircraft when that happened several times instead of just setting the trust the number one trust lover the one that's controlling the left-hand engine had started reducing back towards idol while the number two engine would have stayed at the take-off thrusts now airbus was aware that there was some issues with the autotron systems on the early airbus a310s and they have found out that it probably had to do with some excessive friction between the linkages of the couplings that you can engage with the truss levers and the truss levels themselves and because there was only one motor driving the truss levers if one of the truss levers got stuck well then the mechanism would feel that actually you know the trust that we have asked it to set is not set and it will continue to drive so the trust level that did not have an issue would drive backwards all the way to idle while the truss lever that got stuck would just sit where it was sitting this particular failure had occurred both when the aircraft was owned by delta airlines and also at least 12 times when tarum had taken it over but the issue here was that any time that the pilots would report this the aircraft would come down on the ground maintenance would take over and they would start to try to replicate the failure to see where it was but they were unable to replicate the failure instead they would follow the guidance that airbus had sent out something called service information letters which is basically um a step below a service bulletin okay a service information ledger is something that the manufacturer would send out when they are aware of what they think of causing this but they haven't found a permanent solution to it and in this case it was replacing the bearings but replacing some of the linkages and also just kind of lubricating the whole system and anytime that maintenance did this it would solve the problem right they wouldn't be able to replicate it and it would take several months before the same problem would come back again because of this therm airlines had actually issued something called the briefing card to its crews and that's a permanent entry into the tech log where all of the crews that are flying the aircraft when they're looking through the technical status of the aircraft they will see that okay there's a briefing card and they will see that time and time again this spurious failure would come in so make sure that you're guarding the trust levels during the departure phase um in case you'd come back and then obviously put it into the tech log and the last entry into the tech log that was referring to this particular failure was about 15 days earlier on the 16th of march however subsequent investigations would show that this failure had actually happened on the flight preceding the accident flight as well when the aircraft was flying from dubai to bucharest but the crew had not entered it into the tecla the reason behind that we will never really know but it is possible that the previous crew knowing that this was actually stated in the briefing card didn't think it was important enough to put it into the tech log again in the flight deck of terrorism flight 371 was captain livio bartanio he is 48 years old had 14 312 hours of which 1735 was on the airbus a310 his previous experience prior to that was mainly on the back 111 and on the boeing 707. together with him in the cockpit was first officer ian l stoy he had 8988 hours of which 650 was on the airbus a310 and his previous experience prior to that was mainly on soviet-based aircraft like the illusion 1 8 and the illusion 62. there was also nine cabin crew members and 49 passengers onboard this flight terror flight 371 was scheduled to fly from bucharest international airport over towards brussels international airport the weather on the day of the departure was not great it was cloudy with some low hanging clouds and also some snow showers in the area and because of the snow showers the crew decided that they needed to de-ice the aircraft prior to departure they loaded the aircraft up with about 20 tons of fuel to bring them towards brussels and because of the icing they got a little bit delayed when they were preparing for the um taxi out now during the pre-flight inspection and during the pre-flight briefing there was discussions regarding the briefing card so the crew clearly knew that this aircraft had had issues with its ats system before because of this the captain decided that the first officer was going to be the pilot flying for the leg and he the captain was going to be guarding the trust levels not only during the takeoff which is what we always do but also during the climb about to make sure that the trust lovers wouldn't start going back and starting to get this trust level disagreement at times 05 54 utc the crew was ready for departure and they called up the tower to ask for pushback and startup clearance soon after that they started taxiing out for departure runway 08 right in bucharest during the taxi out once again the captain restated who was going to do what during the departure that it was going to be a standard briefing for a right seat departure on the 08 right and when they had received their departure clearance they were expecting to climb straight ahead for a couple of nautical miles and then turn left towards a vor a pro trade called sierra tango juliet and this left-hand turn is actually going to play a major part in what's about to happen at times zero six zero six and 44 seconds utc the uh aircraft starts rolling down the runway and everything looks completely normal during the takeoff roll the only thing that's noted on the cockpit voice recorder is the captain telling first officer to remove his hands from the trust levels and put both of them on the control column um this this is considered quite normal normally during the takeoff role the captain is the one that's guarding the trust levels in case a rejected takeoff will be needed the aircraft rotates normally gets airborne captain calls out positive rates to which the first officer responds with asking to get the gear up the captain retracts the gear and also does a couple of associated extra things like turning off the landing lights and disarming the aerodynamic brakes the aircraft continues to climb normally and at the time zero six zero seven twenty so that's about 30 seconds after departure the captain contacts the departure controller the virtual controller comes in and tells the aircraft that they can turn left early towards sierra tango juliet now remember that they were expecting to fly straight ahead so the fact that they're now getting a clearance to turn to the left early means that they have to go into the flight management computer and tell the aircraft that they have to make a turn so the first officer asks the captain to do this this is also standard procedure the pilot flying concentrates on flying and any updates to the navigation is done by the pilot monitoring but as the captain is now reaching down to the flight management computer to update the new clearance they reach about 2000 feet which is about 1500 feet above ground level i remember this is where the outer truss system now couples with the truss levels again to drive it from take of trust back towards climb trust so as the captain is working on the computer here the trust levels start to move and the failure reappears so the number one trust lever which is connected to the left hand engine is now starting to reduce backwards towards idle slowly with about one degree of trust level movement per second number two anden is stuck in take off trust but because the the captain has left the trust levels and is now focusing on the fmc it's likely that he does not notice that this is starting to happen and also on top of this remember that they're expecting to make a left-hand turn well if this would happen if you start to get asymmetric trust so that the trust is reducing on your left hand side but staying the same on the right if you're staying on a straight ahead track you would notice this because the aircraft would want to yaw towards the engine with less thrust but because this aircraft is now initiating a left-hand turn this is now likely masking the fact that they're starting to get asymmetric trust and because this is not an engine failure or a failure of any sort that is connected to any kind of warning there is no indication to the crew other than the position of the truss levers that this is happening the aircraft continues to climb first officer is in a initially quite soft left banked turn with about 15 to 20 degrees of bang but the bank angle is steadily increasing and this might be because of the asymmetric trust that they're now facing but none of the pilots are noticing this issue and as they climb through about 3 000 feet the captain looks up at the primary flight display and notices that the speed is not accelerating as it should then he calls out speed first officer acknowledges that pitches down a little bit in order for the speed to continue to accelerate and soon after that at about 3 300 feet or so the first officer says 250 knots inside flaps up captain responds and selects the flaps up but here something else is going wrong because as the aircraft continues to climb now the first officer asks for the slats to be retracted which is a separate thing to do on the airbus 310 but he doesn't get a response back from the captain so he calls it out again nothing happens instead on the cockpit voice reporter you could hear something that can be interpreted as the sound of human pain as in someone groaning on the flight deck first officer is asking what's what's the matter with you what's up with you but it doesn't get any reply so the aircraft is now in a left-hand turn the trust's asymmetry is starting to increase more and more and at this point it's at about 0.19 epr the first officer would be very concerned at this point remember they've just taken off and there's obviously something wrong with his colleague so the workload that the first officer is feeling is going to start to increase very rapidly here and you have two things that is happening at the same time both the incapacitation of his colleague potentially and also this kind of subtle malfunction that's happening in the background the problem is though that this subtle malfunction to the ats system is going to have very real consequences on the flight controls of the aircraft the bigger the asymmetric trust becomes the more of a yaw is being introduced and as this aircraft is already in a turn the bank angle just continues to increase the bank angle of the aircraft is now approaching 30 degrees which is the normal maximum when we are in normal operations of the aircraft the trust's symmetry is at about 0.36 epr still increasing the aircraft is still climbing but the first officer is now becoming more and more concerned with his colleagues there are indications that he tried to make a quick radio call at this point but there's nothing indicated on the cockpit voice recorder instead the aircraft just continues to increase its bank angle now for any one of you who knows a little bit about flying aircraft or maybe i've seen my videos about how to make steep turns you know that the more the aircraft is banking the more back pressure you need in order to keep the noise above the horizon if the bank angle continues to increase and you don't do anything about it the nose is going to start to decrease and drop further and further down and the aircraft is going to start descending and this is what's starting to happen now as the aircraft continues to climb it reaches a maximum altitude of 4620 feet the bank angle is down about 43 degrees and as the bank angle continues to increase now the nose of the aircraft is going to drop below the horizon and a rapid descent follows at about this time there is an indication that the first officer is calling for the autopilot to be engaged and he actually reaches up and engages the autopilot as well but because he is still inputting back pressure on the control column the autopilot only engages for about one second before it disengages again and when an autopilot disengages it will come with an alarm to you know basically tell the pilots that the autopilot hasn't engaged properly this is called the cavalry alarm on the on the airbus and it's a very loud alarm this alarm goes off and it keeps sounding for the remainder of this flight as the aircraft is now descending down through 3600 feet there is a call on the cockpit voice recorder where the first officer says this one has failed which indicates that he is now trying to understand what is going on with this aircraft but you have to understand that at this point when the first officer likely is looking up and on to his instruments he's finding himself in a really really critical attitude the nose has dropped well below the horizon in fact at the worst point here it's pointing downward with as much as 83 degrees which is basically straight down towards the ground the role is continuing and in fact the aircraft rolls completely around its roll axis and as the aircraft is now heading straight down towards the ground the speed is increasing very very rapidly here there's also an indication that the trust levers are starting to be reduced and the reason for that is likely that the aircraft is overspeeding and there is a protection mode in the ats in the autotrust system that feels if the speed is getting too high it will start moving the truss levers back again and it's very possible that whatever was holding the number two truss level up before has now given way and the trust is starting to decrease this however has no real implication to what's about to happen to this aircraft what is a little bit interesting is that there was no overspeed warning the reason for that during the subsequent investigation was thought to be that the cavalry charge the autopilot disconnect alarm is actually set as a higher priority than the overspeed alarm so that if the autopilot disconnect alarm was going then the overspeed alarm would not be heard similarly it's also interesting to understand why they didn't get any gpws warning ground proximate warning system which was included in this aircraft the the thought behind that was that because the gpws is using the radio altimeter which is situated at the belly of the aircraft to measure closure rate towards the ground if the aircraft was actually rolled over almost completely well then there would be no readings from the radio altimeter either as they were now hurling towards the ground the highest speed recorded before the aircraft impacted with the ground was 324 knots and a negative attitude of 50 degrees so when the aircraft impacted the ground less than two minutes after departure it did so with an absolutely horrendous force it was a completely non-survivable event and all 49 passengers and 11 crew members perished immediately the crash site was only a couple of kilometers away from bucharest airport and fortunately it happened outside of any populated area the aircraft investigators came to the scene and started to to try to get a picture of what had happened and because of the very high angle that the aircraft impacted the ground with and the actual crash site was relatively small but part of the aircraft was found as deep into the ground as five meters it was not possible to make any post mortem on the first officer and the captain because of the severity of the damages so we will never really know what happened to the captain or to what extent that he was incapacitated but what we do know from both the cockpit voice recorder and from the flight data recorder which was recovered from the crash site is that after that initial groan that was hard on the cbr there was no more input neither voice or inputs on the controls from the captain so it's likely that the first officer was completely by himself during this event so now the issue for the investigation team is to try to figure out why this happened in the first place they very quickly honed in on the issues that have been previously recorded on this aircraft with the auto trust system and they understood that it's likely that this was a piece of the apostle but what they couldn't understand was why this would have caused this crash in the first place and it was only when they looked into the cvr and they realized the combination of when this issue started appearing at around 2000 feet the captain was heads in onto the computer trying to update the fmc and then the subsequent incapacitation by the captain first officer being potentially preoccupied with what was happening to his colleague as this was happening at the same time and this could potentially explain why the deteriorating attitude of the aircraft went undetected for so long but it doesn't explain why the first officer was unable to rectify the situation once he realized how bad it was but we're gonna get to that in a few minutes guys i hope that you are finding this air crash investigation series that i'm doing fascinating and if you do so i hope that i've earned a subscription from you there are many more videos in this series and you can check them all out up here and when i come back in just a short minute after this message i'll tell you how the training of commercial pilots have changed after this accident so stay tuned i also want to take a few seconds here to say a special thank you to the sponsor of this episode which is skillshare now i know that you are watching this because you are a curious person a lifelong learner someone who constantly wants to improve and understand the world around you better and in that case skillshare is definitely something that you should be checking out okay they have thousands of high quality video courses and pretty much anything that you can imagine a course that i'm using myself at the moment is five minutes creativity with jasmine cheyenne where she gives kind of hands-on tips on how to chisel out a few minutes to be creative every single day and it's something that i personally really need but there are also courses in you know storytelling creative photography or even how to use your own home simulator to improve and prepare before you start your private pilot license something that i've been doing together with my oldest son lucas and he really really enjoys in any case the 1000 first of you guys who uses the link in the video description here below you'll get a free trial with skillshare and if you find something that you like or if you want to try out different courses then signing up is really cheap it's less than ten dollars per month so you can support me by supporting them go down click the link and let me know what your favorite course on skillshare is so i can check it out myself the final report came to the conclusion that the following casual factors was the reason for the crash number one there was trust asymmetry number two a incapacitation of one of the pilots in this case the captain and number three the insufficient corrective actions from the co-pilot in order to rectify the situation that came from the first two points there were two safety recommendations that came out of the final report both of them were aimed at airbus industries the first one basically said that there needed to be some kind of service bulletin or air boardness directive issued in order to make sure that the underlying reasons for the trust asymmetry was dealt with airbus fairly promptly issued two service bulletins to deal with this on all of the aircraft affected by this potential increase in friction between the couplings and the trust levels the second one had to do with language used in the maintenance manual for example but none of these recommendations talked about the pilot and why the pilot would have lost control in the first place and this is something that really stuck with me um i i didn't feel that the final report gave me sufficient closure on this one because from all i could read when it came to the experience of the first officer and his training records and everything is that this was a very good pilot right he had really good training um history he had he was liked by his colleagues everything pointed towards a really experienced high-functioning pilot and the only thing really wrong here except for the fact that the captain was incapacitated was some trusty symmetry and actually when he found himself in that attitude the trusty symmetry likely wasn't even there because the trust lever on engine number two had already come back so why was it that he wasn't able to recover the aircraft so i brought this to detention of my patreon crew i love going to my patreon crew and kind of talk to them about things like this and one of my patreons who called dimitri brought my attention to a specific part of the first officer's experience and what he brought to my attention was the type of experience that the first officer had the first officer had close to 9 000 hours in total but out of those 9 000 hours only 650 was flown on western built aircraft the rest over 8 000 hours was actually on illusion 1 8 and illusion 62. now there is a crucial difference between western and soviet-built aircraft when it comes to one of the most important instruments in the cockpit which is the artificial horizon that's the instrument that shows how the aircraft is actually flying in relation to the horizon because as we're flying inside of a cloud we cannot feel what is up and down okay it's impossible g-forces makes it impossible for our inner ear to understand that we have to have something to look at that tells us an accurate picture of what's going on and the primary instrument for that is the artificial horizon on western-built aircraft the horizon is moving there is an aircraft symbol and then the artificial horizon is moving depending on the attitude of the aircraft now on soviet-built aircraft the horizon stays fixed in the gyro and it's the little aircraft symbol that is moving instead so if you look at the attitude in a western built aircraft but your mental model is the russian built aircraft well then if you straighten out the horizon it will actually look like the aircraft is turning the opposite way if you as a pilot find yourself in a really high stress situation like the first officer in this case definitely found himself in you look up and your attitude is severely out of what you would consider to be normal well then the way that your brain interprets the information in front of you is going to be crucial for your actions following that and if you for just a split second misinterpret what you're seeing in front of you and put the wrong inputs into the controls or too little inputs into the controls or even no inputs as in you're struggling to to understand what it is that you're seeing in front of you this might be fatal especially at a low altitude like this but if this actually did play a part it wouldn't have been the first time in fact another crash crosshair flight 49er 8 was also partially blamed to the pilots misinterpreting their artificial horizon this accident was like every other aviation accident a huge tragedy but like we've learned throughout this series of air crash investigations we as an industry always try to learn from anything like this and to make sure that the industry as a whole becomes better and safer afterwards and this is also true with rom flight 371 after this accident and other incident that involved palliative capacitation the way that we train commercial pilots to deal with pallet incapacitation was upgraded so right now if you are going for your initial type rating on any commercial aircraft you are going to be practicing this in different phases of light and the emphasis and the priority whenever you find out pilot incapacitation is for the remaining pilot to focus on flying the aircraft right make sure that the aircraft is fully under control get it up to a safe altitude get the autopilot in and only after that then you can pay some attention to your colleague the first thing that you do is to verify that they haven't inadvertently touched any switches or any gauges or done anything to the flight deck so you verify that the flight deck is completely safe the automatics is in and then you call a mayday to air traffic control ask for as much help as you need from them and you also contact the cabin crew to come in and help you to potentially administer cpr or secure the pilots in its seat so that's what i wanted to tell you with this video guys as always i'd love to hear from you i'd love to hear what you want me to cover next if there is something that you want me to explain or whatever file it into the comments below or contact me either on my free mentor aviation app or inside of my discord server and today i really want to highlight the discord server guys because i'm really proud of it with more than 3500 people in there at the moment and it's a great community and last weekend for example we had a group flight where some guys got together in the discord server they they set a date and a time and they went island hopping in microsoft flight sim 2020 discussing talking amongst each other on the discord server most of them had my livery which by the way if you want it it's absolutely free and you can go to metropolitan.com and download it today it's there for all of the types on microsoft flight sim 2020 but anyway it's just a really really nice community we do aviation quizzes most sundays we're discussing flight training and we're swapping pictures with each other anything really that has to do with any aviation in any form so if this sounds interesting to you go get the discord server it's metropilot.com discord or there's a link in the description below have an absolutely fantastic day and i'll see you next time you

Channel: Mentour Pilot

Views: 384,061

Rating: 4.9401331 out of 5

Keywords: tarom flight 371, tarom flight 371 air crash investigation, tarom flight 371 cvr, tarom flight 371 crash animation, tarom flight crash, Aircrash, air crash investigation, air crash, air crash investigation 2021, air crash documentary, Mentour Pilot, mentour pilot crash, Pilot life, How to become a pilot, fear of flying, fear of flying help, nervous flyer help, why do planes crash, Airbus A310, Airbus A340, aviation incident, final report, Bucharest, Romania, auto throttle

Id: SMUAZ1stSLk

Length: 30min 24sec (1824 seconds)

Published: Fri Apr 23 2021

Reddit Comments

[u/kioleanu]

Îmi aduc aminte perfect unde eram și ce făceam când am auzit de accident, deși aveam 7 ani. Eram la țară, în fața casei și am auzit la radio, care era în cameră cum intrai în stânga. Nu ajunsesem de mult de la București și trecusem cu trecul fix pe acolo, cu ~2 ore înainte.

[u/tomskyD]

SRI-ul a doborât domle avionul, era un american cu niste documente importante la el și urma să-i demaște pe ăștia.

/s off course, pt cine nu știe astea erau titlurile și articolele din ziarele de atunci.

[u/sendme__]

tl;dr Pilotul a fost de vina.