TERRIFYING Dive | What went WRONG??

in the heart of a violent storm the pilots of a Boeing 737 are in a desperate fight for survival their plane is diving straight towards the ocean at almost the speed of sound will they be able to wrestle it back under control Before Time runs out for them and their 100 passengers what follows is a devastating tale of corruption on the ground and confusion in the air this is the horrifying story of adamir Flight 574 [Music] on New Year's Day in 2007 96 passengers and six crew boarded a Boeing 737 operated by adamere at jawanda International Airport in Surabaya Indonesia they were headed for manado in the north of the country most of the passengers were Indonesians heading home after the holidays though there was also an American family of three on board and one passenger from Germany as the passengers settled in for the two-hour Journey the pilots began preparing their aircraft for departure in command of the flight was 47 year old Captain referee rodoto he had joined adamere just six months previously but he had been flying for decades in this time he had built up over 13 000 hours of flying time sitting to his right was 36 year old first officer yoga cesanto he had about 4 000 hours total flying time just under a thousand of which were on the 737. both Pilots had progressed through adamera's training program without any serious issues but as we're about to see adamere was no ordinary Airline everything from its pilot training to its maintenance and Engineering practices were notoriously poor even in Indonesia a country with the less than Stellar Aviation record admir was an outlier that's why even though what happened to fight 574 was shocking the fact that it happened was anything but what we're about to see is what happens when pilots who are products of this system experience a situation which they were neither trained nor mentally prepared to deal with and it all started on the ground at Surabaya when the flight crew set up their navigation equipment for the flight to manado even on a relatively modern aircraft like the 737-400 pilots still use a rather old technology to determine their position in space in fact they use a technology which long predates GPS this system is known as an IRS or inertial reference system it uses three gyroscopes Each of which detects the plane's acceleration along one dimension once the pilots tell the system the plane's starting position the IRS combines the information from the three Gyros to precisely determine the plane's position as it moves across the planet the IRS is a sensitive instrument however and it requires maintenance and adamir was Infamous for its shoddy maintenance practices in the three-month period leading up to this flight over 150 recurring defects were noted in the logbook of this aircraft alone including repeated issues with the IRS problems with the captain's vertical speed indicator random disengagements of the autopilot during flight and an unreliable weather radar modern aircraft are complicated machines and small technical issues are common this level of dysfunction over a prolonged period of time was and will turn out to be Criminal as the pilots set up Flight 574 for departure they were well aware that this aircraft had problems with its inertia reference system what they weren't prepared for and what they couldn't be prepared for were the limitations of their own training which would become all too clear as they set out over the Java sea at around a quarter to two that afternoon Flight 574 pushed back from the gate at Surabaya its 98 passengers settled in for the short hop North most of them looking forward to being home by dinner time this part of the world might be known for its beaches and sunshine but it is also home to some of the most dangerous storms on the planet as the pilots taxied out to the runway at Surabaya they knew that the fight ahead of them would require them to carefully pick their way around these storm clouds this was and is a simple fact of life for Indonesian pilots and it was nothing that the experienced crew of Flight 574 couldn't handle but there were much more than storms lying in wait for this crew at two o'clock that afternoon the captain lined the aircraft up with the runway and set the engines to take off thrust [Music] the plane lurched into the stormy skies and began its Journey Northeast towards monado as the pilots climbed to their cruising altitude of 35 000 feet everything was going to plan they engaged the autopilot which followed the route programmed into the flight management system which is located here in the cockpit the flight management system or FMS is at the heart of how pilots fly modern planes they use it to monitor their progress along the Route to make changes to their route and to monitor their fuel consumption among other important aspects of the flight's operation captain madodo and first officer cesanto had programmed in their flight's route while the plane was at the gate in Surabaya that route was now displayed in map format by the magenta line on this display here normally to keep a plane flying in a straight line along this route the autopilot or the pilot doesn't need to do much with the controls planes are generally stable enough that they'll keep flying almost in a straight line by themselves autopilot or no autopilot but this being adamir things weren't quite so simple because of an unresolved maintenance issue with this plane's ailerons which are the control surfaces on the wing that turn it left and right the plane had a tendency to roll to the right to correct for this the autopilot had to continuously hold the control column slightly to the left this was a nuisance but as long as everything else progressed normally it shouldn't have posed any major problems as the aircraft climbed out over the Java sea the pilots noticed something unusual the captains and the first officers flight management systems each showed the aircraft to be in different locations immediately the pilots knew what the culprit must be the 737 has two independent inertial reference units one of which feeds information into the captain's flight management system while the other feeds information into the first officers this redundancy is what makes flying so safe and reliable but the problem which the pilots are fight 574 now faced was that they didn't know which of these systems to believe both seem to be giving plausible locations for the aircraft one of the inertial reference units was feeding wrong information into one of the fight management computers but which one was it and crucially the difference between the two locations was growing Greater by the minute the pilots had to figure out where they were fast or they would end up lost out over the ocean incredibly this was exactly the Fate which befell another Adam air crew less than a year previously the pilots of that flight wound up lost over the ocean at night after one of their inertial reference units failed it took them two hours to find their way back to an airport by which point they were dangerously low on fuel so when the pilots of fight 574 first spotted the IRS problem they knew the Clock Was ticking they had to figure out where they were and they had to do it while gigantic thunderstorms began crowding around them they could only hope that the plane's faulty weather radar didn't fail as well back in the main cabin the passengers were completely oblivious to what was happening up front the pilots they had entrusted their lives with had no idea where their plane was and they were about to fly into a storm cloud the captain told the passengers to fasten their seat belts and shortly afterwards the aircraft entered the clouds from here on their situation would go from bad to worse what you're about to hear is an excerpt from the cockpit voice recorder which captured the Pilot's confusion as they tried to get to grips with the problem the pilots were joking in order to ease the tension but there was no denying it their situation was serious and it was only getting worse the captain then asked the first officer to see if air traffic control how to fix on their position this must have struck the controller as a strange request to say the least Pilots often ask controllers for things like the current weather information but for a pilot to ask a controller where he was should have triggered alarm Bells something was going seriously wrong on Flight 574 5 Mike kilo Sierra was a radio Beacon the controller was telling them that they were 125 miles from the beacon and that they were on a heading of 307 degrees from it which is roughly Northwest the pilots now had a chance to rectify their problem they could see whether the controller's report matched up better with the captain's instruments or with the first officers but for some reason they never did this they simply continued in their confusion about the disparate FMS readings but the first officer didn't want the controller to know that they were having issues so in response to this he said in the cockpit the confusion only deepened [Music] I remember [Music] it would have been extremely straightforward for the pilots to tune their navigation radios to the frequency for the my kilo Sierra Beacon and check its distance against their two fight management systems to see which one was correct but they didn't do this either both Pilots were so fixated on finding the cause of the faulty IRS that they didn't think to prioritize the most important thing finding out where they actually were here there was an opportunity for the captain to take a step back and re-evaluate their options this was his responsibility as the leader of the two-person team but he didn't do this instead he and the first officer continued zooming ever further into the problem the fact that they were flying deeper and deeper into the thunderstorms only made their situation more urgent after minutes of befuddlement and haphazard troubleshooting the captain realized it would probably be best to find out if there were any procedures for dealing with an IRS failure he ordered the first officer to check the qrh or quick reference handbook to see if he could find anything after thumbing through the handbook the first officer finally found a section entitled IRS fault at last they had a procedure to follow something which could finally put an end to their confusion this is the actual checklist the pilots were using the steps involved were quite straightforward but this Simplicity hid the fact that the procedure would actually require a lot of attention on behalf of the pilots here's why the first step was to turn the IRS mode selector knob of the faulty IRS located here to the ATT or attitude position when this happened the first officer's attitude indicator here would go blank and importantly the autopilot would disconnect it would be up to the captain then to fly the aircraft manually using his instruments while the first officer continued with the checklist the checklist stated that the aircraft would need to be held level for 30 seconds while this was taking place again this was a straightforward procedure which simply required One Pilot to hold the aircraft steady for 30 seconds while the other rebooted the system but this is where the captain's fixation on the IRS would put him and everyone else on board in serious Danger when the first officer turned the IRS mode selector to the attitude position his attitude indicator went blank and the autopilot disengaged but rather than taking manual control of the plane one of the pilots reflexively silenced the alarm and the captain continued with his head up in the overhead panel watching over the first officer as he carried out the procedure and this is where that small problem we came across earlier would begin to have a vastly outsized effect as the crew carried out the checklist the autopilot now disengaged was no longer correcting that tendency of the plane to roll to the right so the plane slowly and imperceptibly at first began turning deep in the clouds there was no way the pilots could tell that their aircraft is turning by just looking out the window it was up to the captain to keep an eye on his instruments to see that this was happening but he wasn't doing this and the first officer's instruments were blank second by second the plane was banking further and further to the right when 30 seconds had passed the pilots became confused about why the first officer's displays were still blank why had the system not rebooted they had no idea that the reason for this was that the plane had not been held steady by the captain during the IRS checklist but the faulty IRS was about to be the least of their concerns within a few seconds the plane had reached 35 degrees of bank and an automated voice called out Bank angle Bank angle Bank angle this alerted the pilots that they were starting to roll way too much to one side they had to level the plane immediately but the captain panicked instead of simply looking at its primary instruments and flying the plane he hurriedly told the first officer to return the IRS switch to the nav position he was hoping that somehow this would reverse whatever problem they'd gotten themselves into but next the altitude alert horn sounded telling the crew that they were now leaving their selected altitude of 35 000 feet the plane was banking so much to one side that it was beginning to slip down towards the ocean this descent would soon become a dive the first officer went to correct the aircraft's bank but the captain admonished him to stop [Applause] the captain still thought that the plane was straight and level and he urged the first officer not to touch the controls because the plane needed to be level in order for the IRS to reboot properly but soon their situation became all too clear now the most terrifying warning of all sounded [Applause] with the plane now fully in a dive it was building up tremendous speed and was now traveling at more than 90 percent the speed of sound the overspeed warning was telling the pilots that if they didn't slow down now parts of their aircraft would start breaking off the captain was in a total state of panic at this point his aircraft was diving straight for the ocean and he had no idea what to do admir had not trained him on how to recover from what is known as an unusual attitude so because he had no training to fall back on he followed his Instinct and simply pulled back on his control column this had the effect of making the spiral dive even tighter which put even more stress on the aircraft structure in the passenger cabin all hell had broken loose the passengers were being pushed hard into their seats by the extreme g-forces of the spiraling descent all while the engines roared and a nearly supersonic wind howled past the fuselage the aircraft was now diving at a rate of over 50 000 feet per minute the first officer urged the captain to pull up but the aircraft was now traveling too fast any significant movements on the controls could risk tearing it apart and when the captain did pull back in the control column that's exactly what happened the horizontal stabilizer at the rear of the plane had been torn off by the extreme force of the air now there was nothing the pilots could do their aircraft was uncontrollable when the plane reached 9000 feet the cockpit voice recorder and flight data recorder went blank seconds later Flight 574 smashed into the ocean traveling at almost a thousand kilometers per hour all 102 people on board were killed instantly it all happened so fast that on the air traffic controller's scope the last position of the plane showed it at its cruising altitude of 35 000 feet but how had things ever gotten so bad that this accident could even happen in the first place what the investigators from Indonesia's National Transportation Safety Committee uncovered was shocking they discovered that the pilots of fight 574 had received woefully inadequate training from adamere so much so that they had never been trained on how to deal with an IRS fault or a fault in almost any other aircraft system not only had they not been trained and how to deal with these issues but the manuals which the airline gave to its Pilots were not the official Boeing manuals but were simply printed off from one of Boeing's websites and not only that but these manuals were explicitly marked as not for operational use investigators also found that the pilots hadn't been given what's known as upset prevention and Recovery training which was standard for airlines in other parts of the world and which would have allowed the crew to easily recover from the dive when it first developed when the plane first entered the dive the captain could have saved it by simply rolling the plane until the wings were level and then pulling out of the dive instead he pulled back on his control column which only worsened the spiral dive but perhaps worst of all the captain's fixation on the IRS and his failure to delegate the cockpit workload meant that all it took was an unfortunate series of inconveniences to Doom the flight investigators made a series of recommendations to prevent an incident like this from ever happening again including updating the training requirements for pilots and tightening regulations around aircraft maintenance Adam air went out of business a year after the crash of flight 574. of its 27737s three of them were written off due to accidents but this didn't make Indonesian Aviation much safer in 2021 another Indonesian 737 crashed under shockingly similar circumstances watch the video I made about that incident here to see how the lessons of Flight 574 are still a long way from being learned I'd like to say a special thanks to the YouTube and patreon members for helping to make these videos possible if you'd like to join us in making more of these videos you can help support us on patreon I've put the link up at the top of the screen somewhere here I'd especially like to thank Joey Steve Wilcox Simon Burbage Matt o'callaghan and Pete familton for their very generous support if you found this video interesting you might also like this one over here foreign

Channel: Green Dot Aviation

Views: 659,469

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Id: WZCXxCVqwuY

Length: 22min 39sec (1359 seconds)

Published: Sun Feb 26 2023