The Pilot Who Almost Subconsciously Killed 186 People | Tarom Flight 381

[Music] this is the story of tehran airlines flight 381 on the 24th of september 1994 a taram airbus a310 was making its way from bucharest to paris orly airport as flight 381 neared orly the airport's atis system indicated that runway 2-6 was the runway in use they only had about 10 kilometers of visibility and a few clouds at 2 400 feet a perfect day for flying at 1 30 pm paris time flight 381 was out of 35 000 feet and began its descent at this point they were about 40 nautical miles from the runway at paris six minutes later they were passing through 15 000 feet but atc was not happy with their rate of descent atc wanted flight 381 down at six thousand feet in two minutes as flight 381 descended the controller was beginning to set up the plane for the approach to runway 2-6 the controller asked the pilots to turn to 3 3 0 degrees this would set the plane up for the base leg to runway 2 6. as they did so the plane overflew the melon vor their ground speed at this point was 400 knots which was way faster than they should have been they were carrying an extra bit of speed but they felt like they could make it down to the runway soon after this the controllers cleared the jet all the way down to 3 000 feet with the plane down at 3000 feet the controllers told the plane to turn to 310 degrees now this turn would help the pilots intercept the ils of runway 2 6. the ils is basically a radio beam that the plane can follow all the way down to the runway it's an aid that can make landings a lot easier for pilots sure you can land without it but using the ils just makes everything that much more easier as the pilots turned to intercept the ils the pilots had the runway in sight and some of the monuments in paris with the landing fast approaching the pilots started to configure the plane for landing they extended the slats flaps and the gear with that the plane made its final turn to line up with the runway but once it had lined up with the runway the pilots noticed that the plane wasn't locking on to the ils of runway 2 sets for some reason the captain didn't make too much of this and so he disengaged the autopilot and began to hand fly the plane all the way down to the runway when the plane passed through 1700 feet it had slowed all the way down to 195 knots and the captain asked for the flaps to be extended to 20. as soon as that had been done the throttles advanced and the engine surged due to all of this power the nose of the plane began to pitch up the pilots were trying their best to counter the pitch of the plane they immediately brought the throttles back to idle but something was trimming the nose of the plane up within seconds the horizontal stabilizer on the a310 had reached its nose up stops at the same time the elevators were at their maximum nose down positions this plane was trying to do two things at the same time the plane began to climb away from the gradual descent profile that the pilots had put it on and within no time the jet was pitching up at 60 degrees for some context when you're taking off a passenger plane will be pitching up at about 10 degrees so take whatever you feel on take off and make it six times worse that's what's happening to this plane over paris with the engine set idle and the nose pitching up wildly the plane could not sustain its steep climb it slowly lost speed as it climbed and then at 4100 feet it slowed all the way down to 35 knots that's 40 miles an hour picture a passenger jet at 4 000 feet traveling at 40 miles per hour that's what this plane was doing without the forward momentum that it needed to keep itself in the air flay 381 stalled and started falling from the sky the 60 degree nose up pitch was gone and now it was diving for the ground the pilots did not have much time to react at the rate that they were going at they'd impact the ground in mere seconds but as the plane dived it regained some of the speed that it had lost and soon after that the pilots were able to recover the plane and not a moment too soon because when the pilots pulled out of the dive the plane was at 800 feet that's all that separated this plane from certain disaster after recovering from the dive the pilots went around for another try and made a safe landing on attempt number two looking into the incident the investigators started to go through the flight data recorders and the cockpit voice recorder i presume they were quite shocked at how close this plane was to crashing the 186 people on board were really lucky for the investigators the pilots raised a few eyebrows they did not perform an approach briefing and they noticed that the plane was much faster and higher than it should have been the plane was so fast that the captain was really rushing to get the plane into the landing configuration for example the captain brought out the flaps as soon as the plane hit the maximum allowable speed for that particular configuration one small action played a huge part in the accident you see the vfe or maximum flap's extended speed for flaps 20 was 195 knots that means that if you have your flaps at 20 you cannot go above 195 knots this captain set the flaps to 20 the instant they hit 195 knots because he was trying to bleed off his airspeed as fast as possible after he did that the most random thing happened a small gust of wind hit the plane and that sent the plane speed to 197 knots for just a few seconds but this small gust of wind set off a terrifying chain of events the catalyst for that chain was a seemingly innocent action that the pilots had taken prior on in the approach the pilots had set their go around altitude to 4 000 feet this was so that the autopilot could take the plane up to a safe altitude if they needed to abandon the approach and try again this is standard procedure but these pilots had set the go around altitude much earlier on in the approach than they usually would have because they were hurrying on this approach in addition to that the plane was already in its landing configuration so when that gust of wind sent the speed of the plane over 195 knots for two seconds all the conditions had been satisfied for what's known as a mode reversion basically what happened was that the autopilot went from the vertical speed mode into the climb mode because of airbus's speed protection feature in essence the speed protection on the airbus keeps the plane in this goldilocks zone when it comes to speed not allowing the plane to get too slow or too fast in addition to that as i mentioned before it sends the autopilot from the vertical speed mode into the climb mode if you recall they had already set 4000 feet as their go around altitude since the autopilot was in the climb mode it decided to climb to 4000 feet that's why the engines surged to max power the gust of wind had sent them over their max speed causing the computer to change modes and since 4000 was already selected on the autopilot the plane decided to climb to that altitude but this does not explain the accident not one bit sure a surge of power can catch you off guard but it's easy enough to deal with in fact these pilots pull the throttles back pretty quickly something else was at play here when i first read what had happened i could not believe it i was like no way that this happened i'll read a bit from the report that perfectly summarizes what had happened while the throttle levers were advancing at their normal speed on automatic by one degree per second an action which seems to have been unintentional and unconscious by one of the pilots on the elevator trim control button left to the deflection of the ths at constant angular velocity over 10 seconds up to the maximum values of 13 degrees nose up end quote in simpler terms someone in the cockpit was trimming the nose of the plane up as the accident sequence started airplanes have what's known as trim trim is basically a way to get the airplane to do something without any control inputs for example if you trim the nose up then the plane would pitch up even if you did not touch the controls that's exactly what happened to flight 3 h1 someone in the cockpit was asking for full nose up trim while they pulled the engines back to idle if that's not a perfect recipe for stalling airplane then i don't know what is now the big question is why why was someone commanding max of nose trim when that's the last thing that they should have been doing since the captain was the one flying they looked into him the investigators had two theories as to why the captain would command a nose up one was that he just got his buttons wrong in the confusion and the second one is a bit more intricate the captain had extensive experience on the bac-111 now on the bac-111 the autopilot disconnect button was near the left hand of the captain on the airbus a310 the trim switches were in that position so the investigators think that the captain reverted back to his old habits when things in the cockpit got too heated and accidentally commanded a nose up so as absurd as the sounds the stall that nearly crashed this plane which had 186 people on board came down to one captain doing what he thought was right the really scary thing is this could have ended really really badly even though they did recover just 800 feet off the ground that's scary for example in the case of atlas air flight 3591 a surge in engine power did bring down a jet this could have easily been a situation like that why do you think the captain hid the trim switches instead of the autopilot disconnect do you think his finger just slipped or do you think he regressed into his old ways of flying the bac 111 let me know your thoughts in the comments below thank you for watching this episode of mini air crash investigation if you like the videos that i make do consider liking and subscribing it will really help the channel grow i will catch you guys next time stay safe [Music] foreign hmm [Applause] um is [Music] do you hear me two six

Channel: Mini Air Crash Investigation

Views: 124,597

Keywords: air crash investigation, why planes crash, air crash confidential, aviation safety, tarom, tarom airlines, tarom airlines flight 381, tarom airlines 371, tarom airlines crash, airbus a310 crash, airbus crash, 800 feet from crashing into paris, france air crash, near crash, mentour pilot, theflighthchannel, aviation education, avgeek, educational, historical, airbus near crash, tarom flight 371, tarom crash, paris air crash, french aviation, romania aviation

Id: wlYbpgpciTA

Length: 12min 23sec (743 seconds)

Published: Thu Apr 14 2022