The Strange case of Voyager Flight 333

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have you ever wanted to experience real weightlessness that's a dream for many but for the passengers and crew of this aircraft it turned into a nightmare as they suddenly from out of nowhere found themselves floating up and hitting the ceiling above them the first officer who was out for a break had to crawl upside down back into the cockpit to try to find out what was going on and what was going on is what I'm going to be explaining to you in this video so stay tuned this story is a bit different because it takes place in a specially produced and adapted civilian Airbus aircraft operated by military personnel from the United Kingdom this means that the final report was formatted a bit differently and I will use that as an excuse for creating a video that differs a bit from what you might be used to so let's see if we can figure this one out the story of Voyager flight 333 took place on the 9th of February 2014. the aircraft involved was a military configured Airbus A330 operated by air tanker Services Limited who as the name suggests provides air tanker services for the UK Ministry of this fans as well as some military passenger transport in its standard configuration the aircraft was able to carry 291 passengers and eight NATO Freight pallets and it was required to be able to swap between civilian and Military duties without reconfiguration meaning that it had to comply with all the normal civilian certification rules and regulations the aircraft was referred to by Airbus as the a330mrtt or multi-role tanker transport but the Royal Air Force had chosen to call them voyagers in their operational role both the pilots and cabin crew were military personnel but with valid type ratings and civilian training behind them the cabin crew were trained by British Airways and British Midlands and the way that the aircraft was operated was also in line with how civilian Airlines would do it so what were the differences then well some military systems and avionics had been fitted to it enabling air tankering of military receiving aircraft as well as identifications of friendly aircraft and also countermeasures against not so friendly ones this included a system called laircm or large aircraft infrared countermeasures as well as friendor Ford transponder equipment which both came with their own procedures but it didn't change the operation of the aircraft much However the fact that the pilots had military assignments and duties will play a part in this story on the 9th of February the aircraft was scheduled to fly a passenger transport Mission from their base at Raf Bryce Norton in the United Kingdom down to Camp Bastion in Afghanistan and the flight was planned to last around 8 hours and 20 minutes the captain who was a very experienced RAF officer with 30 years of military work behind him and over 5 500 hours of Total flying time arrived to the Voyager operations headquarters at around nine o'clock in the morning to start his flight planning the flight was not scheduled to leave until 11 25 UTC so he was in a bit before the rest of the crew who arrived around 30 minutes later in total there were 189 passengers scheduled to fly with them as well as two pilots and eight cabin crew but soon after check-in one of the cabin crew members called in sick this was a bit of an issue because the flight was only allowed to operate with seven cabin crew where one of them would have to be responsible for two emergency exits in case of a recovery flight back to base but that was not the case here the person got into contact with the Squadron commanding officer who gave the flight dispensation to operate with this reduced crew meanwhile the first officer had arrived and was helping the captain with the pre-flight planning the first officer was also very experienced but we don't know exactly how many hours he had since those crew details were redacted in the final report the information about the captain's experience comes from later newspaper articles the weather no terms and on Route short looked good for the flight but the captain noticed that according to the weight and balance document the aircraft would be above the maximum takeoff weight for departure and because of that he contacted the flight planning department and asked to change their alternate to a closer airport in Afghanistan so that they could uplift a bit less Fuel and therefore stay within limits the weather was good at the destination and the new alternate so this was approved and the flight plan was subsequently updated so after this had been resolved the crew proceeded out to the aircraft to start preparing it for the comic mission and before continue here it's probably worth explaining a few differences between civilian and military operations whilst we the palace in the civilian World need to bring our in-flight bags with us to the cockpit military personnel needs to bring a lot more than that these Pilots were also bringing two sets of body armor weapons combat survival waistcoats aircraft documentation to root bags plus a set of worldwide navigational charge and a bag of classified material some of these items had dedicated storage in the cockpit I'm hoping the weapons for example but other items were just stored where there was room available and there were no real rules for exactly how this was supposed to be stored the same was true for any personal equipment that the pilots chose to take with them like laptops cameras or mobile phones the only rules regarding these was that they were not to be transmitting during flight in other words they needed to be in flight mode this meant that the cockpit was quite cluttered with things and it's likely that a sense of normalcy around this clotted state had settled in for the pilots because there was really not much else that they could do there was some guidance in the new edition of the Airbus flight crew training manual regarding vigilance against loose items in the cockpit but the Voyager Crews had not been given access to this latest update and in any case this was seen as an advisory document in other parts of the RAF military transport arm there had been reports regarding loose items being found in the cockpit of the duties but not in the Voyager Fleet so far so the pilots loaded up the cockpit like they were used to and then started preparing it for departure the captain was going to be Pilot Flying for the route so the first officer went out to do the walk around and the captain started setting up the flight deck meanwhile the cabin crew prepared the aircraft and started boarding the passengers consisting of mainly military personnel who were going to deploy to Afghanistan but also to military aircraft ground Engineers who were going to handle the aircraft maintenance as well as at least one military doctor now due to some missing Freight paperwork and Catering the aircraft was about 20 minutes delayed when everyone finally were ready for startup the startup sequence was completely normal and when the off the start checklist were completed and the l a i RCM system had reached operational temperature the aircraft started taxing out for takeoff from Runway to six during the taxi out the crew received an e-camp system message advising them that the identification Friend or Foe or the iff1 transponder wasn't working properly the crew advised the ATC Tower controller that they would need to hold short of the holding point in order to troubleshoot the issue and they were immediately clear to do so they first tried to reset the iff1 system but when they did so the iff 2 system also shut down which prompted the pilots to ask the engineers that they had in the back to come up to the cockpit and see if they had any ideas on how to fix the issue the aircraft was not allowed to depart without at least one of these systems working and the engineers told the pilots that there was nothing that they could do whilst the engines were still running they would have to get outside to work on the problem as the pilot started getting ready to return to Stan the iff one fault suddenly cleared and after having checked the remaining fuel the captain decided that they would be okay to proceed with the flight since the aircraft was only 700 kilos below its maximum takeoff weight the crew required full runway length as well as a takeoff technique known as a bleeds of takeoff this means that the aircraft takes off without using bleed air from the engines to power the air conditioning and pressurization system and therefore allowing the engines to produce maximum possible thrusts the air conditioning and pressurization for the cabin is then handled by the auxiliary power unit until after takeoff when the air conditioning panel is reconfigured to use the engines again this procedure is something that we refer to as a supplementary procedure which is a completely normal procedure to do but it adds a little bit of workloads to the pilots anyway at time 1200 the Airbus A330 took off normally from Runway 26 in RAF Bryce Norton and started to follow the standard instrument departure down towards the southeast at 300 feet the autopilot was engaged and after that the crew received a few step climb clearances to their initial Cruise altitude of flight level 330 or 33 000 feet in front of them the crew now had about eight hours of flight in relatively nice conditions the departure had been intense and it's quite possible that the crew now felt quite relaxed and that the workload and stress level subsided considerably from now on their job was mainly to communicate with air traffic control record fuel figures on the flight plan as well as take on Route weather these are tasks that can quickly become a bit tedious and boring especially after a busy start of the flight like they had just had as the aircraft passed overhead Northern Germany they encountered some light turbulence and the captain switched on The Fast and seat belt sign for a short while but apart from that the flight progressed completely smoothly back in the passenger cabin the cabin crew served a meal to the passengers and after that a movie was thrown on the in-flight Entertainment System but if the passengers would have wanted to use their time more productively they could also have used today's sponsor brilliant brilliant is the perfect platform for any one of you who want to learn and expand your knowledge whether you are a student a professional or just someone who loves to learn new things brilliant will have something for you the courses range from math and computer science to neural networks and physics but there's always something for everyone on the platform one of my own personal favorite courses is astrophysics because as someone who is spending a lot of time in the air I've always been fascinated by the stars and planets above us and this course gives an awesome overview of the basics behind astronomy which I really think is 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comments about the length of the flight now since it was Winter over the Northern Hemisphere that they were flying the daylight soon disappeared and the Stars started appearing I can tell you from my own experience here that flying into the night Shadow as these Pilots were now doing is a true sight to behold from the flight deck at that altitude you can really see that the Knight is actually a shadow which is approaching and not just a slow dimming of the light it is spectacularly beautiful and as it was now getting darker the captain was looking up at the stars and commenting about it at time 1532 the first officer needed to stretch his legs a bit he handed over the radio the captain and asked if the captain wanted anything and the captain answered that he would like a cup of tea please the first officer then left the cockpit and came back a few minutes later with the tea before disappearing again into the forward Galley and closing the door it was completely okay according to the Voyager rules at the time to leave One Pilot alone in the cockpit providing that this remaining pilot only concentrated on operational procedures whilst he was alone and didn't allow himself to be distracted the captain set back into his seat with his cup of tea and then proceeded to take more pictures of the cockpit as well as of the night landscape that they were flying over the first officer was gone for quite a long time but again there were no set time limits for how long these leg stretches were allowed to be after about 15 minutes the Purser came into the flight deck the captain was just taking his last photo at that time and he put down his camera beside him and unpreceded to brief the person on the progress of the flight now in order to get a better angle for the conversation he also moved his Pilot's seat slightly forward using the electric buttons on the right side of the seat when the aircraft is being manually flown the seat position is really important and since the Airbus A330 is flown with a side stick the armrests are set in a way that the pilot can easily use them when moving the side stick both the pilots of this flight were quite tall so their seats were set slightly lower than what most Pilots would normally need but even at that setting the armrest could never come closer to the side stick than five centimeters the person and the captain continued talking for about two minutes before the person left the cockpit then at that time the first officer was still outside talking to a friend that he had just noticed was on board the flight about two minutes later at time 1549 and 38 seconds the aircraft suddenly started pitching violently forward the sudden forward pitch made everyone in the cabin instantly weightless and as the pitch continued to get steeper the aircraft started experiencing negative g-forces most of the passengers were sitting down with their seat belts fastened when this happened but those who were not including all cabin crew and the first officer was thrown violently headfirst into the ceiling now this must have been very disorienting but the first officer instantly realized that he needed to get back into the cockpit to help the captain with whatever it was that was happening he started crawling along the ceiling upside down and eventually pulled himself into the cockpit through the open cockpit door inside there he was met with a very chaotic scene the captain had within two seconds of the pitch starting grabbed onto the side stick and tried to pull back but found that it was not moving it was completely stuck he then tried to disconnect the autopilot even though the cavalry charge was already blaring indicating that the autopilot had already been disconnected the warning was continuous which was an indication that it had been disconnected by manual input and not by the disconnect switch the captain didn't hear that warning he just felt the sensation of being underwater from the negative g-forces so instead he just continued pushing the autopilot disconnect button but the fact that he did so meant that a priority left call could be heard from the aircraft the side stick that he was trying to pull was still stuck he continued to pull out it in sheer Panic as the pitch moved to 17 degrees nose down and the decent rate increased to 15 800 feet per minute which it did within the first 10 seconds of the event starting the aircraft's airspeed passed 300 knots and kept increasing rapidly now the first officer pulled himself forward across the overhead panel and with his feet still on the cockpit roof he reached down towards the side stick to see if he could try to stop the violent pitch down from continuing the the captain shouted that he couldn't disconnect the autopilot so the first officer still upside down by the way now pushed his autopilot disconnect switch then moved his side stick backward which must have felt really odd from the position that he was in he managed to wrestle himself down into the seat whilst continuing to pull back on his side stick which fortunately was not jammed on his side but since the captain was still pressing the autopilot disconnect switch on his side and no formal Handover of controls was initiated the first officer could not take full control the only thing that happened was that the two inputs from the left and right side sticks now started averaging themselves out as per standard Airbus input logic and when that happened a dual input the oral warning can also be heard luckily though the Airbus has several Protection Systems which work as long as the aircraft is operating on the normal law meaning that it doesn't suffer from any specific system degradation in this case when one of the pilot side sticks tries to pitch the aircraft fully forward the aircraft will only allow it to pitch down to 15 degrees nose down plus a small margin on top of that and that was the reason why it didn't pitch further down than 17 degrees on top of that the aircraft will also protect itself against overspeed conditions and as the speed had reached the limit of what the aircraft would allow it automatically reduced the thrust and then started pitching back up to almost level flight this coincided with the first officer starting to pull back on his side stick but it was actually the aircraft's own protection systems that started the recovery as this pitch up was now happening it caused a positive g-loading of 2.06 G's meaning that everyone and everything which had been pinned to the ceiling in the cabin and the cockpit by the way now came crashing back down again this also meant that the passengers and crew who had not been strapped in could now finally get themselves back into their seats and fasten their seat belts a significant amount of personal items bins bags and other things were flying around everywhere but the cabin in full chaos and people shouting in pure fear the whole sequence lasted about 31 seconds and during that time the aircraft lost a total of 4400 feet with a maximum vertical speed of 15 800 feet per minute and a maximum speed recorded at 358 knots or Mach 0.9 the g-forces had ranged from minus 0.58 G to Plus 2.062 during the extremes of the event about 33 seconds after the full pitch down command had started from the captain's side stick it suddenly disappeared and the aircraft appeared to be operating normally again the first officer reminded the captain that the trust was still in idle after the recovery so the captain moved the trust into toga detent and then climbed back to 31 000 feet whilst the first officer called out a made a call to the Turkish ATC units that they were in contact with none of the pilots had any idea at this point of what had happened and the captain said that he thought that there must be something wrong with the autopilot they discussed what to do and then they decided that they just wanted to get the aircraft down on the ground as soon as possible which is something that I can certainly understand they sent this request to the air traffic controller that they were talking to and they were initially told to turn to watch an airport called trabzon which was only 60 Nordic miles away but the captain thought that this was a bit too close and wouldn't give them enough time to properly prepare for the landing he was also not very familiar with the airport in itself and wasn't sure if it would be suitable for the aircraft so instead he asked if they could continue to watch Istanbul International which was situated about 500 nautical miles away from them in a Westerly Direction the air traffic controller initially agreed to this but then he came back with a suggestion of in Cyrillic Air Base instead which would suit them better as this was a military base and it was situated a bit closer about 340 miles away to the Southwest the captain agreed to this and started getting vectors towards the south at the same time back in the cabin the Purser and his crew was doing an absolutely outstanding job most of the crew had not been strapped in when the incident happened so they had been thrown into the ceiling and then slapped into the floor which had caused some head and neck injuries as well as burns from hot coffee and tea despite this and the shock the Purser had quickly taken control of the situation and checked on the status of his cabin crew colleagues the passengers as well as assessing the overall structural status of the aircraft he had moved through the cabin and with the help of the onboard ground Engineers they had assessed all of the damage and also removed some detached and damaged ceiling panels as they could potentially pose a threat for the passengers during Landing during The Descent he also made several Assurance PAs to the passengers and as he was moving through when checking the cabin he found out that one of the passengers was suffering from an acute stress reaction that meant that the person quickly summoned the onboard doctor to attend the passenger and administer oxygen this fact was then relayed to the pilots as well as the overall status of the cabin throughout the rest of this flight the cabin crew instilled the feeling of calm and control by Distributing drinks and playing in-flight entertainment to the passengers all in all this person and the rest of his crew did an outstanding job on this day and I really want to point out how important it is and what a difference a competent crew can make especially during a situation like this now the pilots also made several Pas during The Descent especially before configuration or pitch changes in order to minimize the stress to the passengers which I thought was a really good thing to do they guarded the controls and verify the system responses carefully and after a normal straight in eyeless approach the aircraft landed safely and then taxed back into stand where a normal disembarkation followed out of the 189 passengers and nine crew 32 reported minor injuries and several more reported suffering from psychological issues as a late result of this incident but what had actually happened this was the question that the accident investigators now had to try to figure out why had this Airbus A330 just suddenly started pitching down from out of nowhere there were several possibilities here and they all had to be investigated was it a deliberate or inadvertent act caused by human factors or was it a side stick malfunction and in that case what type it could also be an autopilot's fault or some Hardware or software buggers as well as a weight and balance issue or a controlled surface malfunction but there was also a chance that it could have been caused by the environment in the form of sudden turbulence or was referred to as a single event effect namely interference by charged atmospheric particles caused by a solar flare at the start of the investigation just as the case is in all investigations like this everything was possible and every possibility needed to be checked verified or discarded the captain who had been at the controls when the event happened said that he was sure that it was caused by some kind of aircraft malfunction and that's what he also wrote in his initial report fortunately the investigators this time had access to the undamaged aircraft and that also meant easy and quick access to the flight data recorder and the cockpit voice recorder after doing some research they found that there had been minimum solar flare activity and Associated radiation around the time of the inside them so they could discard that as a reason for for it happening the side stick module went through a CT scan and was later taken apart and no mechanical fault could be found the weight and balance of the aircraft was all in order and no load shift of the car got occurred so that was ruled out as well as problems with the flight controls they had all reacted exactly as they should to the inputs that they had received from the captain's side stick Airbus was of course involved at the very beginning in investigation and out of an abundance of caution the rest of the military A330 Voyager fleet was grounded until the course could be completely established now the investigators instead started looking closer onto the flight data recorder and the cockpit voice recorder to see what that could tell them they quickly noticed that a small fluctuating pitch down input was detected on the captain's side stick about 1 minute and 44 seconds prior to the event this input was smaller than the five Deca Newton force needed to disconnect the autopilot but it was constant and continued until the full nose down input came which then eventually caused the event but what was so strange with this input was that it was completely pure with no lateral input at all a human which is doing an input on the side stick will always sway just a little bit and therefore cause a combination of lateral and medial inputs but this input didn't show that this was also true for the later much larger input which was at a constant rate and also completely pure so what was going on now there was nothing in the captain's training history personal life medical history or anything else that pointed towards a deliberate act and on top of that the cockpit voice recorder showed genuine surprise when it happened his actions reaching for the side stick pulling on it and disconnecting the autopilot took four seconds to start which is exactly within the three to five seconds that it would take for someone who is genuinely taken by surprise to react then wait a minute the cockpit voice recorder was there anything on there that could possibly help explain this as the investigators started listening closer to the tape they could hear a low frequency distinctive noise which started at 1 minute and 44 seconds prior to the band and that coincided with the exact time as the first smaller pitch down input was recorded in the flight data recorder spectral analysis identified the sound as the electrical motor driving the captain's seat now because of the strong time correlation between the seat moving and the forward pitch the investigators now started suspecting that whatever caused the event had something to do with the captain's seat moving but how the answer came when they continued to interview the crew about what they had been doing before the first officer left the cockpit and the first officer mentioned that the captain had been taking photos with his camera the camera was retrieved from the cockpit where it was found in the very back and when checked the camera had pictures 28 of which was timestamped between 5 and 3 minutes prior to the event starting the side of the camera also had a distinct linear Dent running across it and when it determined the dent contained traces of the same material that the bottom of the hand grip flange on the side stick was made from this meant that the incident had been caused by the captain using his camera to take photos while the first officer was outside something that was against the rules as should only be focusing on the operational tasks when he was alone in the cockpit he had probably been interrupted by the Purser entering the cockpit which caused him to put the camera down between the armrest and the side stick when the person left the camera stayed there and the captain readjusted his seat slightly which caused the armrest to move forward and wedge the camera between itself and the lower part of the side stick this movement also pushed it Forward slightly which caused that initial pitch forward come on but it wasn't strong enough to disconnect the autopilot and hence it didn't have an effect on the aircraft at that point when the captain one minute and 44 seconds later moved his seat further forward to complete some other task the camera forced the side stick into full forward position which then disconnected the autopilot and initiated the dive since the camera was blocking the bottom of the side stick the captain was unable to pull the stick backwards but his desperate attempts to do so was what caused that long dent on the side of the camera the captain continued to try and disconnect the autopilot even though the cavalry charge clearly indicated that it was already disconnected but he claimed that he didn't hear these alarms which is further proof for how the human brain disregard sounds when the stress level increases the incident would have likely been far worse if it wasn't for the automatic pitch and speed protections of the Airbus who stopped the nose from going even lower and the speed from reaching dangerous levels but then how was the camera eventually dislodged we cannot know this for sure but the flight data recorder showed a couple of quick sideways movements of the captain's side stick just prior to the forward pitch command disappearing which would be the point where the camera obviously became dislodged experiments with a mock-up camera in the same Lodge position in a flight simulator later showed that this movements were very similar to what happens when someone reaches for the camera notices that it's there and then pulls it out in order to dislodge it the subsequent movements of the side stick were also very similar to it moving back to the neutral position which is a spring loaded to do and then someone grabbing onto it to resume control this theory was also corroborated by the captain being heard saying okay okay okay exactly as this was happening and then half a second later a thud could be heard on the CVR possibly resembling the noise of a camera being thrown backwards in the cockpit into the location that it was later found once the course of the incident had been properly identified the Voyager fleet was released a flight again since there was obviously no technical reason to keep them grounded and I think that this serves as an excellent example of how an incident or accident forensic investigation should be handled nothing is discarded and everything is possible until the evidence all point in one solid Direction the incident was ultimately found to have been caused by several organizational issues like the normalization of loose objects being allowed in the cockpit by the Voyager Crews which had then led to the use and improper storage of the camera who ultimately caused the incident non-adherence to rules regarding activities in the cockpit when left alone as well as Fosse rules regarding how long Pilots should stay away from the cockpit was also found to have aggravated the situation on top of that there were several other latent threats and circumstances that together led up to this happening not just one single unsafe act and that's something that I always try to highlight several recommendations were made to counteract these threats including regulations in the use of personal electronic equipment in the cockpit the possibility of installing cameras in the cockpit to help the investigations and other some more specific military recommendations the captain was later court-martialed for negligence but the outcome of that is something that you will have to Google yourself because assigning blame is not and will never be the point of these investigations but if you don't want to Google and instead prefer to continue to watch more of my videos well then check out this playlist I would love to get your support in continuing to create these videos and if you want to do so you can send the super tanks right now you can also buy some merch using the link below in the description or join my fantastic patreon crew it really helps have an absolutely fantastic day and I'll see you next time bye
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Channel: Mentour Pilot
Views: 1,811,654
Rating: undefined out of 5
Keywords: RAF, royal air force, british, united kingdom, voyager, army, Airbus, A330, MRTT, flight, aicraft, aviation, mentour pilot, storytelling, full episode, afghanistan, trabzon, Ahmad Shah Baba, Incirlik Air Base, Camp Bastion, camp shorabak, Kandahar Airfield
Id: Dl-Fl66Jfao
Channel Id: undefined
Length: 31min 17sec (1877 seconds)
Published: Sat Apr 08 2023
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