SAS flight 751, the Gottröra Miracle! Mentour Pilot tells the story

hi everybody everybody welcome to mentoring on the video podcast as always i hope you're doing absolutely fantastic today on the video guys we're going to be talking about scandinavian airlines flight 751 which is also referred to as the gotrora miracle you will hear a story about fantastic crew resource management bravery unsung heroes but also very surprising lacks of system knowledge and the errors that led up to this accident so stay tuned [Music] one three one zero one six three one [Music] this video is brought to you together with skillshare now skillshare is an online learning platform with thousands of high quality video courses and pretty much anything that you can imagine i've gotten a lot of questions from you about you know how do you write the perfect cv how do you apply for an airline job and what should you think about in a cover letter i did a quick search on skillshare today and i found dozens of courses on exactly this and one such course that i can recommend to you is the ultimate resume hack by jasir khan and it does pretty much exactly what it says it will now using skillshare is really affordable it's less than ten dollars per month and if you are among the first 1000 users to use this link here below you'll get two months of premium skillshare absolutely for free so you can go in you can check out which classes you like you can see if i'm lying to you which i'm not and if you find a class that you really really like send that to me because i love to continue learn all right guys so this is the story of scandinavian airlines flight 751 the way that i've done this is like with all of the other videos in this video series about accidents and incidents i have researched the final report i've read through the final report and i've also tried to find other kind of inputs and one of them that i've used is pietre documentar it's a swedish radio program that did a documentary on this accident i've linked to all of the sources down here so if you want to read it for yourself you can do that unfortunately the documentary is in swedish but there might be some of you who can enjoy it anyway let's go through it exactly the way that the fun report is written so we'll have a look at the synopsis of the accident you know how did it happen and then we'll have a look at what the accident investigation team came up with at the end what kind of recommendations they had and what led to this accident in the first place so sk flight 751 um was flown by an md-81 now the md-81 is a rather large passenger aircraft that is a um a prolongation and a bigger and more modern version of the dc-9 it has two tail mounted engines they have a t-tail and the tail mounted engines is going to become important very soon so this md-81 had flown the day before the accident happened on the 27th of december 1991 and on the 26th of december it came back from zurich at about 10 o'clock in the evening when it came back it still had about two and a half tons of fuel in each wing tank so it's quite a lot of fuel still there and during the flight from zurich it had there's been outside temperatures during the cruise phase of the flight of about minus 60 degrees celsius so the fuel inside of the tanks was extremely cold during the night there was mixed weather mixed with rain and light snowfall and a temperature between zero and plus one degrees celsius so quite standard swedish winter weather um when the line engineers technicians did walk around in the morning they noticed that there was quite a lot of slush that had accumulated on the top of the wings and also that there was um frost at the bottom of the wings that frost on the bottom of the wings is something that i am very familiar with because we have exactly the same problem with the 737 namely that if you have supercooled fuel in the wings well in that case that will form frost but that's okay as long as that's within the the kind of defined limits at least on the 737 it's not something that we have to worry about that much however if you have precipitation that's falling on top of that supercooled fuel then you have a different problem so the engineers they told the captain that was about to take over the flight which was captain steve rasmussen together with his first officer uh ulfc at the mark that there was quite a lot of slush on the other wings and the captain ordered the eye thing the icing truck came they used up about liters of the icing fluid which would be you know considered quite normal for the icing like that during the startup sequence of the engines the captain asks the the engineer whether or not the ice had been completely clear for the wings and the engineer who had been supervising the the icing said affirmative yes it's it's all gone now it's all clean even the captain even asked if the underside of the wings had been properly cleaned as well and the the icing crew had confirmed that that was the case the aircraft taxed it out perfectly normal it stated that the captain taxed it a bit slower than normal which is to be expected when you have wind drops outside and they took off from runway 08 in stockholm orlando the flag was supposed to fly from orlando down to copenhagen and then from copenhagen on to warsaw and for the first part of the take of roll and rotation everything was normal but then about 25 seconds into the flight uh they started hearing this really weird kind of humming noise like that the the flight crew hadn't heard before that was then quickly followed by something that sounded like a canon blasts and several of them were coming in very quick successions it so boom boom boom boom boom boom like that for each one of these bangs the aircraft jolted kind of backwards and forward and just like it suddenly decelerated for each boom the aircraft decelerated a little bit and then jolted forward so there was quite a lot of vibrations coming on and the captain captain rasmussen who was pilot flying he he didn't really know what to make of it he was looking over at the first officer kind of asking what's what's that now to be to be fair here the captain had not been trained on this particular problem in the simulator okay what they were experiencing is something called compressor stall now if you've followed my channel you know what i'm talking about i've done a separate episode about what compressor stalls is but the captain had not experienced it before nor had he had been trained on it in the simulator the first officer lucia mark he knew what this was or he recognized it because he had been flying the vegan in the swedish air force before he started flying for sas and the vegan is actually fitted with almost exactly the same type of engine as the md-80 one has um with an afterburner obviously so he knew that with that engine if if you took out too much g's with a vegan you could cause the engine to stall and when the engine stalled that was exactly the sound it was making and that was the kind of feeling you got from it okay just quickly if you haven't seen my engine my compressor stall episode basically what a compressor stall is is that something happens to the compressor stage of the jet engine compressor stage is supposed to push air backwards and compress it before it enters into the burn chamber and if something happens in the compressor stage um and it cannot do that it it's it can stall the like individual little propeller blades inside of the compressor and when that happens it stops pushing the air backwards instead pressure builds up on that stage and it pushes the air forward instead this is why they were feeling those kind of jolts because for each time that this pressure build up and then released forward you get that bang and you get that feeling of sudden deceleration so this is what was happening um now the way that we deal with compressor stalls now the kind of memory items that we have is that you have to disconnect the outer throttle and you have to move the trust on the side that this is happening backwards you can pull the thrust back until it stops surging the reason you're doing this is because since you're now taking less fuel into the burn chamber you're basically taking away pressure on the compressor stage so hopefully that will just you know make the individual stages stop stalling and the engine can go back to operating the way it was designed to do however if you have had some kind of foreign damage to the compressor so if something has been ingested bird ice or whatever it might be well then there might be a mechanical fault on the compressor stage and might not help but the captain did the correct thing here the captain started reducing trust on the right-hand engine which is where they had identified that they had the problems it was also stated that the the captain found it very difficult to read the the smaller digital gauges that they had on the new md81 because compared to the the old dc9 anyway as he reduced the thrust on the right side what he didn't notice was just after that trust was reduced suddenly the trust came back on again and actually not only that it actually increased the trust right because of everything that was going on the pandemonium that was happening none of the pilots actually noticed that this happened but this is going to provide a crucial clue to one of the findings of the investigation later on so anyway unbeknown to the crew the left-hand engine had also started searching at this place the fact that they didn't notice this was probably due to the just sheer amount of warnings and vibrations that was there already so the right engine was searching the left engine was surging and now if you don't do anything about these compressor stalls if you let them continue these continuous build up of pressure and these kind of constant surges is going to put the engine under so much pressure that it will eventually fail it will eventually kind of disintegrate so as these compressor stalls was now happening on both sides um and the thrust had increased back again it only took a few seconds for both engines to fail first the right engine failed followed by the left engine um this is not good all right in the back on seat 2 charlie there was a another pilot flying on this flight his name is pat holdenberry he was also a pilot on the md-81 and he had done a transition training onto the md81 from the dc-9 earlier on now paired with when he did his typewriting he had reacted to the fact that in the dc9 there is a checklist if you lose trust on both engines not only does the checklist tell the pilot how to try to regain one of the engines back in order to get some trust back again but also it would give kind of a plan for how to deal with flying the aircraft without engines and potentially than you know putting it down hopefully on a runway somewhere when he did the typewriting on the md-81 he reacted to the fact that that checklist had been removed it didn't exist anymore because he thought you know this newer more modern more effective engines was also much more susceptible to foreign damage right they were much more kind of delicate so he had actually sat down at home and he had concocted his own checklist in case i have dual engine failure on the mdu81 these are the steps i'm going to take based on the old dc-9 procedures now pad was sitting back and this was back in 1991 which meant that the cockpit door was not locked in fact a lot of pilots actually enjoyed having the cockpit door open so that the passengers can see what was going on in the cockpit and this was the case on this day so he was looking in and he realized he heard both engines searching he was also an ex-fighter pilot so he recognized all of the signs as well and he looked into the cockpit and he realized that there was not much going on inside of the cockpit so captain rasmussen who was at the controls he was flying but he was not giving much kind of advice or he wasn't calling for much from the first officer he looked quite lost the first officer was dealing with trying to to find the correct checklist but both of them were fairly new on type so pad decided that he wanted to help so he rushed forward he was in uniform he rushed into the cockpit and asked if he could help with something the pilots were really happy about this because first officer ul for example he now felt that he could kind of take some of the responsibility for reading the checklist and put that over to the more experienced captain that was now coming in and he could concentrate on talking to a traffic control and actually access actioning the checklist items that that pad was calling out the captain he was concentrating on just flying the aircraft he was still not 100 sure what was going on you could completely understand that remember that they're now flying an aircraft that hasn't got any engine working loads of different warning lights coming on uh it's eerily silent all of a sudden after that initial cacophony that they would have had before so when pat came into the cockpit he basically turned to the captain and just said look straight ahead fly the aircraft look straight ahead if you listen to or you look at the cockpit voice recorder transcript from this crash you'll see him saying that over and over again look forward look straight ahead and that's because he did not want the pilot flying to start dealing with something inside of the aircraft when he clearly needed to fly this stricken bird and to keep it from stalling so the captain asked the now assistant captain pad to start the um the apu which he did he also told him to tell the cabin crew to prepare for an on-ground emergency right so there was no pa done there was no real communication done from the cabin crew to the uh flight crew or vice versa but they could now communicate just through the door which was open so the aircraft reached its highest altitude of 3206 feet just after both engines had failed and now started its inevitable glide down towards the ground again um this is the first point of which the first officer could call air traffic control and it didn't call a mayday call but he called out that they had engine problems that they wanted to return back to orlando and also later on that he did not have any engines and probably couldn't return to orlando during this you have to remember that these guys are in cloud okay this is not like in the miracle of the hudson where he was in vertical in visible conditions and he could see what was going on around them no these guys were completely immersed in cloud and the cloud base was about a thousand feet they were three thousand feet now so they made a slight left turn on from a heading of zero eight zero which is the departure heading to about a noddly chord now descending slowly and the cabin crew who's heard what was going on who's seen the the assisting captain running into the uh to the cockpit heard that they needed to um to prepare for an underground emergency so what they did here and i'm i'm thoroughly impressed when i see this they they started making pas right they understood the severity of the problem and in a very very short time they made a pa both in english and in swedish about how people needed to prepare they started to instruct people on how to do the brace position in a very clear and concise way which is heads down grab ankles which is basically just getting people down into a kind of brace position like this so they were doing this pat holdenberry is still inside of the cockpit when they had the sand down to about a thousand feet they now broke out of clouds and they could for the first time see where they could potentially put this aircraft down they found a large field but the captain rasmussen decided that that's too far we're not going to reach it so he settled on the smaller field basically just straight ahead of the aircraft it just needed a slight right-hand turn to line up as he was flying the aircraft now the speed was bleeding off as the altitude was bleeding off as well pat hollenberg saw this happening and he had his little checklist that he's made in his head so as the speed was decreasing he now started without any input giving flaps right okay but this is really important because if you are to have any chance of survival um in a situation like this you want to make sure that when you do crash into a non-runway kind of environment you have as low speed as possible so the fact that he was now helping to take out flaps as the speed decreased helped the aircraft from stalling and enabled the aircraft to slow down but in a controlled way the captain there you know was still concentrating on flying the aircraft and realized oh i don't have flaps he looked over and he said uh flaps and performance said yeah i'm giving you final flaps now meanwhile the first officer still talking to our traffic control just looked over his shoulder and said should we take the gear what should we do with the gear captain did not respond pat holdenberry the assistant captain did respond and said yes take the gear down and just prior to the aircraft hitting the treetops the gear was down and locked now as this was happening as they're now getting really really close to actually crashing into the first trees the cabin crew called out to paddock to get out of there go sit down so he jumped out of the cockpit and just threw himself down on the floor behind a galley wall so he did not have the seat belt on when the aircraft hit the trees okay the last thing that's heard from sk flight 751 is the radio call from a very surprisingly cool first officer saying um orlando tower sk751 we're now crashing into the ground but in swedish the aircraft at this point was at about 121 knots which is still a high speed but it is about normal approach speed okay the gears down and locked which would provide a little bit of of kind of taking up some of the forces the first thing that hits the treetops is the right hand wing the right hand wing gets completely torn off as that happens the aircraft starts a slow roll towards the right and it hits the other wing the other wing also hits and part of it is being struck off and then the aircraft hits the ground with the tail first on that little field that they were aiming for it slides for about 110 meters and it breaks into three different pieces after this it's silent until all 129 passengers and crew manage to get out of this aircraft alive this is why this is referred to as the gotra miracle it happened just two days after christmas and even though this md 80 had lost both of his engines within about a minute and a half from them leaving the runway in orlando crashing down through the forest and into this field every single one survived there was some minor injuries and there was one severe injury a woman that that severely hurt her back um but apart from that everyone survived perhaps he was he he was you know basically unconscious because he wasn't strapped in but the the captain captain rasmussen pulled him out of the wreckage most of the of the passengers actually got out through the breakage points in the um in the aircraft because most of the emergency exits were actually blocked because of the impact and what they did was basically they a few of the passengers went to the closest house which turned out to be a little cabin at the edge of this of this clearing they knocked on the door and woke up a couple of teenagers who'd been sleeping there remember this is in the morning and when the teenagers opens the door outside they see 125 people and a completely torn up aircraft basically on their backyard so the passengers are calling rescue operations telling them that you know we're here we've survived we're standing on this field and about half an hour later the first helicopters and the first firefighting equipment arrives at the scene they cover everything on with with foam remember that the aircraft was fully fueled and it's full of of jet fuel everywhere now over the forest where they hit the trees and the right wing was broken off but also close to where the actual body of the aircraft is lying they help a few passengers out who were stuck but unharmed and that's basically it um it it was incredible that no one died in this um accident absolutely incredible okay so after um when when the air crash investigation team came in and started looking into this they had a few questions um first of all how come that these engines failed in the first place and they very very quickly honed in on the fact that they must have been clear eyes formed over the wing roots and given the fact that the engines are placed where they are basically straight behind the wing roots clear eyes would have broken off as the wings started flexing when they started you know taking out lift for taking off broken off and gone straight into the engines and in this case actually hit both engines and severely damaged them so that would indicate why the engines were damaged but they still didn't understand how come a the pilot couldn't identify or the captain couldn't identify this failure the compressor stores earlier and how to deal with it and also how come the trust was taken off and then immediately came back on again and here's where it starts to become really interesting it turns out during the investigation that the flight crews had not been trained on this particular failure as in compressor stalls was not part of the the type rating or the recurrent training so when captain rasmussen was flying and he got these kind of lurches and these kind of bangs that he was hearing he didn't naturally understand what it was nor were there any memory items associated with it on the md80 at the time so that's why he was so stunned and didn't understand what was going on all of his capacity went into trying to to to understand what was going on with this aircraft and it didn't make any kind of sense however first officer would see the mic which had the previous experience of flying in the in the vegan he could decipher it but it wasn't because of the training so there was a fundamental lack of training here when it came to the fact that the trust came back on the engines the investigation team noticed a system called atr which stands for automatic trust restoration okay this system scandinavian airline systems ses did not know existed on the md-81 turns out that this is a system that was primarily used under the faa rules in america where there was noise abatement procedures so the md-80 would take off normally and then they would reduce the trust in order to to you know keep as quiet as possible as they were flying over uh habitated areas and then they would add thrust and continue to climb this system was built in so that if during that kind of low thrust segment an engine would fail well then this system would jump in it would engage the outer throttle system and it would add trust and since the outer throttle could not just handle one individual truss lever it would add trust on both truss levels up to go around trust all right and this is actually what happened so as captain rasmussen very correctly reduced trust on the on the engine that was searching and then let it go there anticipating that it would stay where it's supposed to be the auto trust jumped in found that the criteria for engaging atr was there added on trust not only on the engine that was searching but also on the other endian which was also critically damaged even though they didn't know it at the time and this likely led to a quicker destruction of the engines right it is unclear because we don't know exactly the amount of damage that they had prior to this it's perfectly possible that the engines would have failed anyway because of the ingested ice and the damage that's done inside the components of the engine but one thing for sure that adding thrust during compressor stalls definitely doesn't help and the investigation team found it incredible that ses was not aware that this system existed on their aircraft nor had the pilots been told about it pilots did not know that this system existed it was there in the manuals right if you went in and you read the uh the the aircraft manufacturers actual core manual of the md-81 it was described there but it had then not been transferred over to the to the internal manual so that was also finding of the investigation team that obviously these kind of systems needs to be not only included in manuals but also trained and there has to be some kind of way for the crew in a situation like this to disengage the system so that it doesn't act against the will of the um of the pilots okay so the investigation came with 15 different points recommendations for increasing safety the way that these points are kind of made is that they're general like these points should be made it included things like for example being more careful and having a system enforced to make sure that you are really clear of clear eyes before you dispatch an aircraft both the flight crew and the icing crew and the airline needs to have system enforced quality of system and force to make sure that that is the case and then several points due to to pilot training and system knowledge like this what i want to say from my point of view though when i see this is that there's a couple of things that really makes my heart warm first of all it's something that we very often talk about here on the mental channel which is the importance when something like this happens to divide the roles so that the pilot flying concentrates on flying the aircraft monitoring concentrates on you know dealing with the problem which is what happened here even though captain rasmussen didn't understand fully what was going on nor did he give any real clear commands to his first officer they still worked quite well independently and he continued to fly the aircraft the aircraft never stalled nor did he you know move attention away from the uh his core duty which was flying the aircraft and on top of that you have the initiative of power holdenberry who risked his life by running into the to the cockpit and starting to take on roles and and applying his own system knowledge and his own situational you know technical situation awareness that he had attained by his own initiative of building that checklist and having that checklist in his head so together these three showed really good synergy and they managed to in a kind of quirky way work this situation into the best of possible outcomes in this situation right i love seeing how people work together and how one plus one plus one is more than three in this case on top of that i want to send a huge victory lap to the cabin crew i mean it's it's a it's a show of huge professionalism and knowledge and courage the way that they handle this um without getting any clear instructions from from the uh from the flight crew taking the initiative to to start you know to give the pas to to initiate the the call for for um brace position normally in a situation where we're about to land off field the pilots will give instruction to brace brace brace uh about 30 seconds prior to to impact that didn't happen the cabin crew took that initiative and did it as well and it's likely that their quick comprehension of what was going on their absolute professionalism in how they dealt with information to the passengers and how they got them into brace position was one of many reasons that this ended up in our soul within brackets positive way as it did that's it guys that's what i had i thought that this was a really interesting uh final report to read through i highly recommend you to you know start reading through find a report a really really interesting read and if you have questions about this you want to talk about it more then put in the questions in the comments below i hope that i have earned a subscription for you if you like this kind of content that i'm doing then subscribe to the channel give it a thumbs up and highlight the little notification bell so you know when i'm doing live streams or spontaneous videos or whatever it might be have an absolutely fantastic day wherever you are and the last thing i want to say is consider uh to to support my sponsor which is skillshare in this case you can support me by supporting them so use the link here below and the first thousand of you guys that uses this link will get two months of free skillshare so you can check out all of the awesome courses in there take care of yourself bye-bye right guys i really hope that you like that if you want more content like that more aviation content but then check this out i hope that you have subscribed to the channel and that you've highlighted a little notification belt see you inside of the mentor aviation app and have an absolutely fantastic day [Music] bye

Channel: Mentour Pilot

Views: 417,190

Rating: 4.9450979 out of 5

Keywords: SAS flight 751, Gottröra miracle, The Gottröra miracle, air crash investigation, scandinavian airlines, flight simulator, scandinavian airlines flight 751, Mentour, mentour pilot, mentour pilot 737 max, mentour pilot turbulence, Fear of flying, aviation explained, aviation facts, nervous flyer, nervous flyer help, pilot life, how to become a pilot, CRM, Captain Rasmussen, Per Holmberg, Ulf Cedermark, Boeing 737, Boeing 737 MAX, Boeing 747, Boeing 777, Airbus 320

Id: OR0WfTUDj-U

Length: 33min 35sec (2015 seconds)

Published: Fri Aug 21 2020