How Mismatched Crews Ended In TRAGEDY | Bad Pilot Pairings | Mayday: Air Disaster

okay we're marker inbound don't forget to give me my call outs capture the first officer to work together as a team but cockpits containing [Music] domineering captains adding two three zero understand poor communicators you have to say we stopped 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 do many lives [Music] investigators must now unravel three needless tragedies come here to have it they're failing his check rights stemming from Bad pilot parries [Music] [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 we take off there are 108 passengers on board the new Boeing 737-800 flight 507 began in Abidjan earlier in the day it's stopping over at diwala and flying on to Nairobi Kenya but the storm has caused an hour's delay Captain Francis wamuea is in command see what this storm is doing he's got more than 8 000 flying hours 23-year-old Andrew Kuru is the first officer it might be a week around it Tower Kenya 507. looks like there's a break in the weather requesting startup okay [Music] startup checklist quickly please generate us on okay request taxi clearance as the plane taxis to the runway the first officer focuses on takeoff preparations wait till we line up okay usually things happen quickly though right okay try to keep up [Music] Captain wamwea verifies the position of a thunderstorm let's have a look before confirming a route around it Talent Kenya 507 we would like to maintain a heading slightly left of Runway due to weather ahead right ah sorry slightly right okay take off trust is set speed building on both check 80 knots check D1 rotate just after midnight Kenya Airways flight 507 finally takes off [Music] okay 1000 feet and climbing the 737 begins turning to avoid the storm anyone after reaching 1500 feet the captain calls for the autopilot to be engaged so should I remain on this heading yep 2400 feet and climbing now we're getting into it [Music] suddenly the 737 rolls dangerously to the right thank you ankle the captain struggles to level the plane [Music] flight 507 has plunged into a swamp search teams spend two days looking for the wreckage it's found in a mangrove swamp southeast of the airport [Music] all 114 people on board the 737 are dead [Music] 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 going with so much of the physical evidence obliterated investigators face a huge challenge the team gets a break when the 737's flight data recorder is recovered well looks pretty good considering search for the cockpit voice recorder continues [Music] 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 see what we've got the data showed us the airplane was behaving as we would expect it to it was a perfectly airworthy aircraft there's no question about it as investigators examine the data look at this the Pilot's control wheel inputs after takeoff attract their attention they make a surprising discovery he was turning left from the moment they left the ground [Music] that information showed us that right after takeoff 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 clean 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 gave 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 banking the discovery explains why the captain kept his control column turned to the left immediately after takeoff [Music] well that's weird but it doesn't account for some readings in the flight data look at this Captain's control wheel input seem to stop it's like you just let go of it six degrees right he does nothing 11 degrees 15 degrees 20 degrees 30 degrees and still nothing why did the crews stop leveling the plane despite banking further and further to the right where the airplane just continues to roll right up to 110 degrees of Bank the crew didn't recover it before impact the data paints a baffling picture of the short flight s 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 507's crash it takes five weeks for Searchers to recover Kenya Airways flight 507's cockpit voice recorder from a swamp near diwala International Airport investigators hope it will reveal why the pilots didn't take action until the aircraft reached an extreme right Bank angle selected check that's the call to activate the autopilot so should I remain on this heading yup 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's at 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 chilling Discovery gives the investigation a new Focus why didn't the autopilot turn on the captain calls for the autopilot to be engaged 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 no one getting into it it seems the captain assumed the autopilot was controlling the aircraft and the pre-selected right turn the pilots only noticed there was a problem when the bank angle warning sounded this means the plane exceeded a 35 degree roll and was flying into Danger yet the 737's 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 the low standard yikes get up can't we discovered the captain had a history of training difficulties and lack of systems knowledge for auto flight systems and so forth so he had some red flags in his history the first officers 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 [Music] 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 degrees to the right 20 left 45 right then 11 to the left that's not helping we're crashing yeah we are crushing then yes we are crashing left left the timing of the first officer's response is significant it took him 10 seconds to speak up first officer read the situation correctly the pilots needed to turn left left back angle so why did first officer keyuru stay silent they go back to the first leg of the flight from Abidjan to duala on the recording for Clues let's hear it sorry did you say an altitude of 14 000 feet 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 did you not hear the instruction the first officers seemed to kind of shut down Eddie two three zero 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 and checking each other and catching errors Captain wamuea'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 city 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 thank you [Music] in the wake of Flight 507's 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 standout room procedures about who's responsible for engaging the 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 you may be in trouble [Music] and when another professional mismatch leads to panicking the cockpit 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 pavil grujin is in command he's ready and Rasta slav kolasar is first officer check this completed both Pilots came from Eastern Europe to work in Switzerland bigger power set tonight they're flying a Saab 340 turbo prop get up before the aircraft clears the clouds the controller makes a slight change to the flight path to Zurich East across here 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 left [Music] Crosshair 498 confirm you are turning left peace stand by the plane should be turning left but instead it's banking to the right okay continue right to Zurich East [Music] foreign Flight 498 slams into the ground just four miles from the airport all seven passengers and three crew die on impact the next morning investigators inspect the wreckage the crash site itself provides them with their first lead if you can't see a bigger structure of an aircraft and you see a crater that leads you to the idea that this aircraft has to be come quite steep into the ground [Music] 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 foreign traffic controllers tell investigators Crosshair 498 turned right and not left as instructed Crosshair 498 confirm you are turning left the controller assumed the captain wanted to follow a different route and approve the course change okay continue out to xerkist moments later the plane spiraled out of control Brighton developed which led to a coalition with ground but there was no indication 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 debris provides a big lead [Music] a pilot's mostly intact flight bag it belongs to Captain groogin and its contents are disturbing [Music] there were some personal items in there and with them we found this medication No Label or box with it it is quite uncommon that you find some medication in a in a pilot's bag [Music] investigators consider a deeply troubling scenario was a drug impair 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 grujin took any before stepping into the cockpit get this to the lab [Music] the test results identify for nazepam 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 investigators must wait for the results of the tissue analysis couldn't impaired pilot with a 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 grujin had traces of a sedative in his system the tests don't reveal if the amount was sufficient to affect his flying we're not able to rule out this effect in the accident but we were not we were also not sure that this 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 [Applause] they listened to the Pilot's conversation in the cockpit alongside the flight data right here the turn is starting to get very steep the captain's sudden agitated reaction provides a clue that timing can't 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 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 right [Music] I think the problem was that he was not aware what was going on what so confused and experienced pilot that he was unable to distinguish left from right the team examines the Pilot's records across air nothing yet investigators need to dig deeper into the cruise training search for an answer takes them to Russia where Captain grujin learned to fly thank you for seeing us Captain grujin was trained on soviet-era aircraft the first officer on Western Plains 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 in the western part 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 Plains 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 a probable cause of this accident under stress and possibly affected by a sedative Captain groogin may have reverted to what he learned when he first became a pilot 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 coming number 110 Crosshair 4908 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 level 110 across here 4908 investigators discover the first officer must have been looking down to adjust some settings or was focused on the overhead panel 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 shut left [Music] 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 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 it is hard to communicate fluently to communicate concerns well enough all he had to say was stopped 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 Bloc 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 black aircraft but when mistrusting the cockpit reaches a fever pitch autopilot all the way don't touch a straightforward Landing turns into disaster Tony what did you do I didn't nothing [Music] United Express flight 6291 is on route from Washington Dulles 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 like it really Anthony Samuels is his first officer he's been with United Express for three months [Music] starting to get the hang of it oh yeah they're piloting a brand new jet stream 4100 a small twin-engine turboprop there are only five passengers plus a flight attendant in the cabin flight 6291 is cruising at an altitude of 14 000 feet just had to report some Icing at one four thousand Indianapolis Center United Express 6291 can we get one five thousand for a while [Music] ignited Express 6291 climb and maintain one five thousand one five thousand United Express 6291 after flying for several minutes above the bad weather I'm in the approach chair the pilots are ready to begin descent 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 two eight left cleared to land wind 300 at four knots okay if you have all the speeds don't worry about it anymore ref is 112. I gotta input that I did it for you [Music] can we Mark our inbound Roger don't forget to give me my call outs the captain reminds the first officer to report the altitude and AirSpeed readings as the plane pushes through the mist and drizzle the runway comes into view clubs 15 learning checks Club 16 landing gear down three green yellow damper foreign [Music] [Music] [Music] flight 6291 crashes into a warehouse only a mile short of the runway 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 flight 6291's AirSpeed and altitude the team tracks the plane's descent a okay this is the ice that they flew through the data gives the investigators a lead wow 240 knots they are screaming through this 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 thank you and zero knots in response the crew moves the thrust to idle and doesn't adjust it again [Music] investigators discover the plane drops to 100 knots well below 130 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 low [Music] sifting through United Express flight 6291's data it's here the investigators make a surprising discovery they're doing all this with autopilot on so right up until before they crashed they were using the autopilot to help them land [Music] while an aircraft on autopilot can follow the Descent path perfectly the captain still needs to Monitor and control the airspeed that's why Pilots almost always land manually so they move thrust to idle the plane slows down below the safe approach speed which makes it descent 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 stall foreign [Music] 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 AirSpeed to save the plane the cockpit voice recording for Clues United Express reduce speed to 170 knots just as the pilots are clear to land investigators hear things going wrong because there's definitely tension in the cockpit can we Mark our inbound Roger don't forget to give me my call outs okay flaps night you know slaps man waiting for three green collapse fifteen Landing checks 5 16 landing gear down three Grit wait did anyone hear any call-ins 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 autopilot all the way don't touch don't touch hold another disconnecting the your 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 your damper don't touch and the first officer's 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 trust [Music] okay that's the stick Shaker it's stalling that only happens when the airspeed is approaching the stall speed they must take immediate action where the airplane will likely crash 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 flaps up in a stall [Music] there is no training that involves flaps up during any kind of a go-round situation with its flaps up the plane needs more speed than usual to pull out of a stall 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 ride [Music] 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 airspeed as he should have and therefore it's pretty clear that the team of the captain and the first officer was ineffective investigators wonder how these Pilots ended up together in the cockpit in the first place they study the pair's professional histories for answers I got the captain's records and the first officers the first officer's Airline records are surprisingly thin that's it this guy's totally green hired six months before the accident he's only got two and a half hours of line experience on the jet stream 4100. the captain's records also raise serious questions look at this [Music] you made a habit and failing his check rights check rides verify a pilot's competency and skill very rare that a captain or first officer will fail the check run 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 4100 [Music] unfortunately the organization needed Pilots to fly the 4100 because they had been expanding and they chose to pair this pair up and uh and it wasn't a good pairing the NTSB recommends more trading 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 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 left three bad pilot pairings that ended in disaster each a lesson for greater scrutiny of a pilot's history and the creation of compatible Partnerships in the cockpit he put 93 000 flights from 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 safe foreign foreign

Channel: Mayday: Air Disaster

Views: 260,225

Keywords: Fullepisode series, Heat of the Moment, Mayday Air Disaster episodes, Mayday: Air Disaster, air accident investigation, air disaster exploration, aircraft crashes analysis, aircraft disasters, airline disasters, aviation safety, brand-new 737 disaster, catastrophic events, cockpit protocols review., fatal flight scenarios, fatal takeoff routine, flight crew errors, mismatched crew, split-second decisions, survivor stories, tragic accidents, tragic flights

Id: 5zR3lfvvlYQ

Length: 42min 37sec (2557 seconds)

Published: Mon Aug 07 2023