HOW did they forget THIS?! Malaysia 134

immediately after takeoff from Brisbane in Australia the pilots of Malaysia Airlines flight 134 find themselves in a deadly situation all three of the instruments which tell them their speed have failed alarm Bells fill the cockpit as the pilots struggle to understand what has gone wrong with their massive jet behind them 215 passengers are oblivious to the danger they are in can they make it back to the airport or will they join hundreds of other passengers over the years who didn't survive this exact type of emergency this is the terrifying story of Malaysia Airlines flight 134 foreign 2018 215 passengers and 14 crew boarded a Malaysia Airlines Airbus A330 at Brisbane International Airport in Australia they were Bound for Kuala Lumpur in Malaysia an eight-hour Journey however seconds after takeoff the pilots would find themselves in a critical situation one which would ensure that they would not make it to Kuala Lumpur on this night as the passengers settled in for the long journey outside the aircraft was a hive of activity refuelers had filled the plane's tanks with over 50 000 kilograms of jet fuel while baggage handlers were loading the passenger bags and ground Engineers topped up the engine oil this process looked chaotic from the outside but everybody involved had their own distinct role while all of this was happening in the cockpit the two pilots prepared the aircraft for a departure in the left-hand seat was a highly experienced captain he had been flying with Malaysia Airlines since 1993. during which time he had racked up over 10 000 hours flying Boeing 737s and 747s before transitioning to the Airbus A330 a year previously as such he was relatively new to the Airbus with just over 500 hours on the aircraft sitting to his right was the first officer who while less experienced than the captain overall had almost 10 times the amount of flying hours on the A330 the first officer had started his career with Malaysia Airlines in 2009 when he flew the Boeing 737 before training to fight the A330 in 2011. both Pilots were well rested and as they prepared their plane for departure everything appeared routine but on this night this very routineness would lull a number of key people including the captain into a false sense of security at 5 minutes to 11 that night the captain descended the stairs onto the tarmac and began the exterior walk around the aircraft Pilots carried this out before every flight to ensure that their plane is fit to fly it involves as the name suggests walking around the aircraft along a predefined route and looking out for anything abnormal like leaking hydraulic lines dents on the skin of the aircraft or Tire threads that are too shallow as it was dark outside the captain carried a torch to help him carry out this inspection most of the time nothing of note is discovered on these walkarounds but on this note something was waiting for the captain just below his own cockpit window on the left hand side of the aircraft's nose were the pitot tubes and on this night they were covered pitotubes are Hollow cylinders that stick out from the side of the aircraft to measure its speed through the air they are one of the most important instruments on the entire aircraft and as such there are three of them one for the captain one for the first officer and one backup if they're blocked there is no way for the pilots to tell how fast they're going through the air which in an aircraft can be fatal blocks Pito tubes have led to hundreds of Passenger deaths over the years in fact I've covered two such incidents here on the channel but in Brisbane its standard procedure while an aircraft is on the ground for ground Crews to block the pitot tubes on purpose the reason for this is that Brisbane is home to a kind of insect known as a mud wasp which makes its nest in exactly these kind of structures in fact mud wasps have caused a number of serious incidents on passenger Jets ground Crews at Brisbane had placed covers in the pitot tubes of flight 134 after it pulled up at the gate earlier in the evening they should have been removed by the time the captain was carrying out his walk around but because of his communication between ground staff and ambiguity over whose role it was to remove these covers this hadn't happened it was now up to the captain to discover them this shouldn't have been a problem after all ensuring that the Peter tubes are unobstructed is one of the most important parts of the walk around yet for whatever reason as the captain made his way around the aircraft with his torch he appeared not to notice these bright red covers on the pitot tubes this here is a still image from a CCTV camera which shows him shining his torch on the Pito tubes for a few moments before moving on it appeared as if he simply did not register the fact that these vital instruments were covered the stage was now set for disaster meanwhile the first officer was open the cockpit programming the aircraft's route into the flight management computer and checking that the fuel and aircraft weights were within safe limits he had no idea that just beneath him a fateful mistake was being made he was the designated Pilot Flying for the journey to Kuala Lumpur on this night and he was about to assume control of one of the most crippled aircraft he could ever have expected to fly about 90 seconds after beginning the walk around the captain climbed the stairs and re-entered the cockpit both Pilots then completed their final checks and requested clearance to push back from the gate at 20 past 11 that night flight 134 pushed back disaster was approaching but there was now one final chance for somebody to notice the pitot tubes were covered as part of his duties the dispatch coordinator who walked with the aircraft during the pushback was meant to complete a final external check of the aircraft however on this night he assumed that this had already been carried out by the maintenance engineer his final Duty was to remove the nose wheel steering pin from the nose wheel assembly and to show this to the pilots before they taxied out to the runway here is a CCTV image of him doing just that the pitot tubes are plainly in view here but the dispatch coordinator had simply failed to notice them as the pilots taxed out to Runway 0-1 they were blissfully unaware that just outside their cockpit Windows all three of their pitot tubes were covered these Pilots were about to unwittingly join an unfortunate group of fight Crews over the years who would experienced a similar problem many of whom did not live to tell the tale the 215 passengers behind them were similarly clueless about the danger that they were in 25 past 11 the first officer powered up the engines for takeoff the giant jet began to accelerate but mere seconds after applying takeoff power the first sign of trouble emerged as the aircraft accelerated through 50 knots or about 90 kilometers per hour the captain noticed that his primary flight display was not showing any speed reading he mentioned this to the first officer saying ah speed speed things happen extremely quickly during takeoff and Pilots have seconds to decide whether to stop the plane on the runway before there's not enough room left and they have to fly the pilots were only just beginning to get to grips with the unusual situation when the plane blew past 100 knots or about 180 kilometers an hour the captain looked at the ground speed indicator and called out 100 knots which is part of standard procedure because Above This speed Pilots are encouraged to be what's known as go-minded as in they should bias towards taking off rather than aborting time was running out the first officer responded a then abort huh this was a critical juncture the pilot now had seconds to make a decision continue with the takeoff or abort it at their current speed neither was ideal but which was better the captain again highlighted the malfunctioning speed tape to his first officer if there was ever a time to abort the takeoff it was now but the pilots continued in a last-ditch effort to get a reliable AirSpeed to show up on their instruments the first officer said go to 80 or 3. he hoped that by getting an AirSpeed reading from a different pitot tube he would be able to get a reliable indication of airspeed but unbeknownst to him all three tubes were blocked within seconds of this the aircraft had sped past the point of no return the end of the runway was fast approaching the pilots were now committed to carrying out the most dangerous takeoff of their careers they were about to take a fully loaded passenger jet into the air with no idea of how fast they were going the first officer began pulling back on his side stick and the aircraft's nose started Rising the plane was now Airborne but immediately it started sending out warnings to the pilots the master caution Chimes sounded indicating that something was seriously wrong which the pilots needed to pay attention to immediately the autotrust disengaged because without knowing how fast it was going the plane couldn't adjust its engine power to control its speed the first officer acknowledged this and he kept the thrust lever set at what's known as maximum continuous thrust which provided the greatest amount of engine power that the engines could sustain over extended periods now that he was in the air his main priority was to prevent an aerodynamic stall this occurs when a plane simply doesn't fly fast enough to keep itself in the air if the first officer let his plane get too slow it would simply fall out of the sky foreign however at this point the pilots missed an opportunity to carry out an important procedure they had identified that their speed indications were not working yet they did not carry out the unreliable speed indication procedure part of this procedure included items which the pilots were supposed to carry out from memory rather than referring to checklists the reason for this is that their situation was so critical that precious time could not be wasted looking for the appropriate checklist whatever margin of safety the pilots had was now diminishing importantly this procedure involved pushing the engines to their maximum setting known as toga thrust or takeoff go around thrust and pitching the nose up to 15 degrees this would ensure that the plane climbs safely away from the ground without losing speed and stalling it didn't occur to the pilots to carry out this procedure and as a result they were lower and slower than they would have wanted to be again the first officer switched his attention to troubleshooting he wanted to get some indication of how fast the plane was going he again asked the captain to put the air data reference switch to 3 which would change which pitot tube was providing AirSpeed data to his instruments the first officer figured that while one or two Pito tubes could be blocked it was almost impossible that all three of them were and yet that was exactly their situation the pilots moved this switch to adr3 but there was still no change in their instrumentation the speed displaying on their instruments was completely false just when the pilots thought that their situation couldn't get any worse a new warning displayed on their instruments it alerted them that their plane had entered what's known as alternate law alternate law is Airbus terminology for a much diminished state of automation which the plane falls back to when certain systems fail in this case the loss of AirSpeed information had caused the plane to lose its stall protection this is a critical piece of technology in an Airbus as it prevents pilots from putting the aircraft in a position where it can enter an aerodynamic stall and ironically without AirSpeed information the pilots were even more likely to stall the aircraft than ever just when they most needed star protection they had lost it the pilots were now under immense pressure they were climbing into thinner Air at night and they had no idea what their AirSpeed was on top of this the computerized protections which would normally prevent them from putting their aircraft in a dangerous position had been lost I made a cacophony of alarms and warning Chimes the two pilots now had to figure out what to do the lives of 215 passengers depended on the choices they would make over the next few minutes at this point Air Traffic Control was unaware of their situation Pilots are taught that in an emergency they must prioritize flying the plane then navigating and only then communicating without traffic control this is summarized by the phrase aviate navigate communicate the controller told the pilots to switch over to the departure frequency 134 connect departures 118 decimal four five minutes but In the Heat of the Moment the captain forgot to switch His Radio to the new frequency the first officer then declared a pan-pan signal to air traffic control which is one step below declaring an emergency and request to maintain the runway track and request to climb to uh but this transmission fell on deaf ears the planes radio was still tuned to the tower frequency and the tower controller wasn't expecting to hear another call from the flight it would be a few moments before this misunderstanding was rectified meanwhile the first officer called for the unreliable speed indication procedure which the captain located finally the crew were beginning to approach their problem systematically the first officer then contacted the departure controller advising him of their situation [Applause] Malaysian 134 Brisbane approach copied tan climbed to one zero thousand maintained heading when able advising tension [Applause] the pilots were now clear to climb to 10 000 feet under current heading this would give them time to troubleshoot their issues but flying an aircraft manually without any speed indications is a tremendously taxing exercise the first officer's full attention was devoted to ensuring that he was flying the aircraft safely and because it was night time he couldn't look out the window to determine his speed or his position relative to the horizon he had to rely fully on the instruments in front of him tension was high and the cockpit voice recorder picked up increased breathing rates from both Pilots the captain was eager to lighten the first officer's workload so that they could troubleshoot the problem together the first officer after all had nearly 10 times the amount of arrows on the A330 his experience would be invaluable in dealing with this situation the captain asked the first officer if they could turn on the autopilot so that they could focus on fixing the problem but the first officer told him that that wasn't possible without an indication of AirSpeed there was no way the autopilot could fly the aircraft the pilots would have to troubleshoot this problem and get the aircraft back to Brisbane all while flying the aircraft manually at Malaysia Airlines it was standard procedure during an emergency for the captain to fly the aircraft but on this flight the captain decided to forego this procedure he knew that the first officer had significantly more experience flying the A330 and that his attention was best spent doing that while the captain himself focused on managing the situation and making decisions about the flight this decision to allow the first officer to continue flying the plane demonstrated accident crew resource management it ensured that both he and the first officer were playing to their respective strengths as the plane climbed the pilots began actioning the unreliable speed indication procedure this involved putting the engines to a setting known as maximum continuous thrust and keeping the nose between 9 degrees and 12 degrees above the horizon during flight tests Airbus had found that this combination of thrust and Pitch would ensure that the aircraft stayed climbing at a safe speed finally the crew had managed to stabilize their situation their aircraft was under control and they were troubleshooting its problems systematically but a big task lay ahead of them they had started to aviate but now they would have to safely navigate back to the airport all while coordinating their return with air traffic control as the plane approached 10 000 feet the first officer asked Air Traffic Control if he could climb to 15 000. in their situation it was never a bad idea to put more distance between themselves and the ground [Applause] with the first officer flying the plane the captain called out the required pitch and power settings to keep the aircraft within safe parameters as it climbed however at one point the first officer told the captain to pause this procedure as he needed to focus on flying the aircraft again this showed excellent management of the situation by the pilots their priorities were in the correct order first and foremost they had to fly the plane Malaysian 134 when you're able to advise I have some questions at this point the first officer stabilized the plane at eleven thousand feet it was beginning to Dawn on the crew that they might not get their AirSpeed indications working the longer they spent in the air the more time they would have to make a mistake which could Doom their plane they had to return to Brisbane the first officer asked air traffic control to direct him back to the airport Elijah 134 turned right heading one six zero the crew then resumed the unreliable speed indication procedure if they could get any of their AirSpeed indicators working they would easily be able to return to the airport as part of this procedure they moved the air data switch between its three different positions Each of which took ASP data from a different pitotube either the captains the first officers or the standby each time the pilots switch the air data source the first officer described to the captain which air data system was providing data to which cockpit display and what speeds they were displaying The Hope was that at least one of the Pito tubes would give them a reasonable looking AirSpeed indication however after switching between the three positions multiple times the pilots were still not getting a valid indication of airspeed this was a real blow to their morale it was beginning to look as if they would never get their speed indications working without speed indications they had to rely on the charts which airbrush had provided for pitch and power settings and just hope that these would put them at a safe air speed as they troubleshooted the problem [Music] as solution after solution didn't pan out the pilots eventually reached a part of the procedure which they had hoped they would never have to use the procedure now dictated that they should disable all three air data computers on an ordinary flight this would be unthinkable the air data computers provide both the pilots and the aircraft's computers with information on their AirSpeed altitude and their position among other important pieces of information to disable these systems would be to seriously handicap the aircraft and what's worse turning off the adrs is an irreversible action if the pilots did it there would be no turning back and yet there was one huge benefit of doing this which we'll see in a moment however just to be sure that turning the systems off was the right thing to do the pilots decided to switch roles the first officer handed control of the aircraft over to the captain and told him which thrust and Pitch settings he had been using to keep the aircraft flying safely the captain handed the checklists over to the first officer who began independently reviewing the unreliable speed indication procedure by switching roles each pilot would now be able to catch any mistakes made by the other pilot before carrying out the irreversible step of disabling the air data computers once the first officer had gone through the procedure as well and arrived at the same conclusion as the captain the pilots contacted Air Traffic Control Elijah 134 cleared in the block one zero thousand to flight level one two zero zero two levels where the turning off the adiors would cause them to lose their altitude information and to have to rely on the less accurate GPS to determine their altitude the pilots asked Air Traffic Control if rather than having to stay at 11 000 feet they could fly between ten thousand and twelve thousand this would give them some wiggle room while flying manually and would provide a margin for error in case their altitude readings were inaccurate after swapping duties the pilots had now reached the point of no return on their checklists they would have to turn off all adrs the first officer read off all the items in the checklist before carrying them out just so both Pilots knew what to expect then at about 15 minutes to midnight he disabled all three air dot computers [Music] look as well as having significant downsides turning off the adores had one enormous benefit immediately a new graphic was displayed on the Pilot's primary flight displays this is known as the bus or backup speed system Malaysia Airlines had asked Airbus to install this system in its a330s at a cost of 300 000 US dollars per aircraft for exactly this type of scenario it provided the pilot with an instantly understandable indication of their airspeed it worked not by using the Pito tubes which are obstructed but ingeniously by using the angle of attack sensors also located on the nose of the aircraft because of this the backup speed scale couldn't give the pilots a specific number for AirSpeed however it was able to tell them roughly whether they were flying too fast or too slow as long as the pilots stayed within the green zone they would be safe this significantly reduced the crew's workload up until now they had been using performance charts to determine what setting the engine should be at and what their pitch attitude should be they simply had to do this and hope for the best but now they had a real-time indication of whether they were flying the plane at a safe speed things were starting to look up for flight 134 just to be sure the pilots asked Air Traffic Control if they could provide an indication of their speed over the ground while this wouldn't match their AirSpeed exactly it would give them a rough idea of it and would serve to validate the indications on the backup speed system 134 still 210 knots thank you guys 210 knots was perfect but the trouble was not over yet disabling all three air data computers had turned the plane into a much more simple flying machine and it had prevented some important systems from working the spoilers on the wings which are used to slow the plane down on landing were not working this meant that the plane would use up much more Runway than normal after a touchdown what's more with a heavy load of fuel the plane would be landing 24 000 kilograms above its maximum Landing weight this meant that the pilots would really have to make sure they touched down gently but at the same time it also meant that they would use up a lot more runway on Landing the pilots could dump some of their fuel over the ocean but they figured that given the urgency of their situation it would be safer to land now even if it meant Landing overweight to add an extra layer of complication the normal hydraulically powered method of lowering the landing gear had stopped working so the pilots would have to allow the gear to drop under the force of gravity alone the pilots discussed these limitations and once they were both on the same page they began to prepare the aircraft for landing the first officer briefed the cabin crew manager about their situation and the captain contacted Air Traffic Control requesting clearance to descend [Applause] relation 134 descent to 7000. [Applause] the pilots began descending to 7000 feet and continued planning for the landing at Brisbane they wanted to be lined up with the runway from a long way out so that their approach would be as stable and predictable as possible meanwhile Air Traffic Control helped by providing the crew with their ground speed 134 your grand speed indicates 220 knots 220 knots this reassured the pilots that they are flying within safe limits as they made their way back towards the airport the pilots had some time to discuss the approach in landing step by step they didn't want to face any surprises on Final Approach they knew that one challenge they would face on Landing aside from the inoperative wing spoilers and the fact that they were overweight was that the steering on the nose landing gear wasn't working this too had been disabled when they turned off the air data computers without nose wheel steering they would have to rely on the rudder alone to steer the aircraft on touchdown this also meant that when the plane came to a stop on the runway they wouldn't be able to steer it off and return to the gate the pilots told air traffic control that they would need a tug to come and steer them back to the gate once they had landed [Applause] and uh due to a North Wheels carrying loss 134 that's copied we will arrange that and uh do you have an indication of how long before you return to the aerodrome ready Elijah 134 that's understood if uh you can accept or put you on vectors back towards uh the aerodrome I can offer you Runway one nine if you require 134. Elijah 134 Roger decent to 5000 and turn right heading two one zero 134 the crew continued their descent down to 5000 feet and began to turn towards the Southwest almost parallel with the runway it was a clear night and they could see the airport from where they were in the back all the passengers knew was that there was something wrong with the plane and that they would be returning to Brisbane they had no idea quite how serious their situation was Air Traffic Control continued devising the crew of their ground speed and the crew began planning their approach with the controller Malaysian 134 I can clear you uh or put you on a vector for an intercept Sports Glen if you want it would be a very sharp intercept that Glenn if I gave you direct ly I appreciate a long final step lines to intercept before we come into Canada 134 that is understood turn right heading two two zero for an extended downwind and I'll give you a 2-0 mile final on the ILS Runway zero one Thirty Four now that they had more or less planned the approach in landing the pilots began discussing what they would do if they needed to carry out a missed approach this is a high workload procedure in the best of times but with only an approximate indication of their AirSpeed the pilots would have to plan this procedure extremely carefully as they leveled off at what their GPS told them was four thousand feet they decided that it would be best to have air traffic control confirmed that this was indeed their altitude standby normally controllers are able to tell what altitude planes are at because the planes themselves send this information to the ground via their transponders but because flight 134's normal systems weren't working the plane wasn't transmitting an altitude to air traffic control the pilots simply had to hope that the altitude displaying on their instruments was correct Elijah 134 I have no mode Charlie Charlie uh primary radar only gives you the location so I'm unable to advise I'll give you 5000 yeah Legend 134 you can go to any level of 4000 or above Malaysian 134 that's understood for your planning I'll keep you at 4 000. until approximately one six miles to run on the localizer reference Terrain finally after receiving vectors from Air Traffic Control the pilots were lined up with the runway there are nearly 40 kilometers from the airport and luckily the visibility was so good that they could see it from that distance the legend 134 thank you the first officer began descending towards the runway as he got closer and the captain carefully monitored the flight path when it came time the pilots extended the landing gear using the gravity gear extension lever to their relief this worked as planned and the gear locked into position they were now minutes from touchdown and the first officer was fully focused on keeping the aircraft speed within the green range on its primary flight display this would be without a doubt the most challenging Landing of his career his plane was overweight and he didn't know his AirSpeed and on top of that neither the ground spoilers nor the nosebleed steering were working the pressure mounted as he neared the runway just to provide an extra margin of safety the first officer asked her traffic control to warn him if his speed got too low foreign [Music] [Applause] was about eight kilometers from the runway the controller occluded to land three four wind on the ground from my zero one foreign the pilots had done everything they could think of by this point all that was left now was to land their massive aircraft on the runway and to get it to stop before the end the plane touched down in Brisbane at half past midnight the first officer applied maximum braking and reverse thrust and after a long Landing roll the plane finally came to a stop all 215 passengers and 14 crew were safe at this point the captain called the ground engineer who was a passenger on the flight into the cockpit he told them about the problems that they had encountered and immediately the engineer connected the dots he opened the captain's cockpit window leaned out and sure enough there were the red tags hanging from the Pito tubes following the incident the Australian Transportation safety board began an investigation which lasted nearly four years as a result of this they made a number of recommendations aimed at preventing similar incidents from ever happening again they recommended that Malaysia Airlines introduced procedures where ground engineers make an entry in the tech log anytime that Pito tubes are covered while on the ground the tech log is signed off by the captain before every flight which reduces the chance that both ground Crews and Pilots will miss this vital piece of information before a departure they also recommended that Airbus change their software to provide both an oral and visual warning during takeoff when unreliable AirSpeed is detected this would have made it easier for the pilots to identify that they had a serious problem which necessitated an aborted takeoff following the incident Malaysia Airlines issued a flight safety bulletin to all flight Crews advising them to be more Vigilant during exterior walkarounds and to ensure that all covers to any sensors are removed before flight events like that of Malaysia fight 134 are thankfully rare but only because so many people are involved in ensuring the high standards of safety are maintained on Commercial passenger aircraft above all this incident demonstrates how easy it is from mistakes to slip through the cracks if complacency takes hold at multiple levels special thanks to the patreon and YouTube members for helping to make this video possible if you'd like to see more of these videos consider supporting the channel on patreon I put the link here on screen I'd especially like to thank Joey Steve Wilcox and JB funk for their very generous support Green Dot Aviation now has a Discord server so if you'd like to join a growing community of people discussing all things Aviation just tap the link in the video description and I'll see you there thanks again for watching and I'll see you soon for the next episode

Channel: Green Dot Aviation

Views: 920,387

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Id: guHZQb0_YOw

Length: 36min 19sec (2179 seconds)

Published: Sun Nov 27 2022