What REALLY happened this doomed flight?? Inex-Adria 1308

on december 1st 1981 a brand new mcdonald douglas md-82 carrying 173 tourists made its approach to ajaxio airport on the french island of corsica this was an unusual flight it was a day trip organized by a slovenian travel agency all of the passengers would be disembarking at ajaxio taking in the sights of the city and then flying home that same evening as a result this was the pilot's first time flying to this particular airport and they were unfamiliar with the area as the aircraft descended into the clouds above the island a series of misunderstandings began to take place between the pilots and air traffic control minute by minute these misunderstandings began to compound the mental picture of the airplane's position held by the pilots began to diverge from that of air traffic control this dissonance would lead to disaster flight 1308 sent shockwaves across the aviation industry and raised serious questions about everything from the way pilots and air traffic controllers communicate to the way that approach charts are designed the story of inex adria fight 1308 shows that under certain circumstances a tiny misunderstanding can snowball into a full-blown catastrophe in the early morning of december 1st 1981 173 passengers and seven crew boarded index adria airways flight 1308 in the slovenian capital of libyana they were bound for corsica a french island in the mediterranean sea about an hour and a half away this was not to be a routine flight in fact flight 1308 was somewhat out of the ordinary from the beginning the various ways in which this fight was unusual would combine in the most unfortunate way on this day a travel agency had organized this flight to celebrate a yugoslav national holiday the plan was to fly 130 passengers to the scenic city of ajaxio in corsica where the passengers would disembark and go on a tour of the city then that same evening they would hop back on the plane and return to slovenia the aircraft which was originally intended to take the tourists on this trip a dc-9 wouldn't fit all the passengers so inex-adria airlines instead used one of their brand new mcdonald douglas md-82s the md-82 had just begun rolling off the production line the previous year in 1980 it was a stretched version of the dc9 with more powerful engines more advanced cockpit avionics and improved fuel economy this new aircraft had so much room in fact that after the travel agency's seats had been filled there was space for an additional 43 passengers the airline filled this up with their own employees and their families as well as those of the travel agency the flight ended up being so full that airline employees flying as passengers were assigned to the flight attendant seating areas and an airline mechanic who had boarded the plane to service it in corsica was sitting behind the pilots in the cockpit jumpsuit the captain of this flight was 55 year old ivan kunovic he had over 12 000 hours of flying experience and had flown for the yugoslav air force for many years before joining inexadria in 1970. because of how new the md-80 was at the time he had just 188 hours on it by the time of this flight having just completed training on it in the united states that summer the first officer was 40 year old frank turglov he had over 4000 hours of flying experience and actually had slightly more time flying the md-80 than the captain having logged 288 hours on the type turglov had brought his young song along for this flight to show him the new aircraft and to see the city of ajaxio this would be both pilots first trip to ajaxio as this was not a scheduled service for the airline as we'll see this will prove to be more than a minor detail on this day at just before eight in the morning fight 1308 departed libiana for the 90-minute flight to corsica the crew received clearance to climb to their cruising altitude of 33 000 ft and began charting their course out over the adriatic sea there was a party atmosphere on board the flight with passengers coming up to visit the cockpit as the plane cruised over italy at one point the mechanic left the jumpsuit and went to take a seat in the passenger cabin so that the first officer's son could sit in the jumpsuit for the approach into ajaxio at half past eight that morning the pilot started their descent into corsica as this was their first time flying there they would need to brief the approach carefully here's a copy of the exact chart they were using the approach to ajaxio required them to fly first to a radio beacon to the south of the airport known as the ajaxio vor then they would enter a holding pattern around this beacon while descending once they had descended low enough to begin their approach they would leave this holding pattern flying away from the ajaxio via war on a compass heading of 247 degrees roughly southwest then do a descending 320 degree turn to line up with runway 03 at ajaxia from here they would either fly an ils approach to runway 03 or if the opposite direction runway was in use runway 2-1 they would descend until they could see the runway and then circle around and land from the other side they would have to conduct this approach without much help from air traffic control as the airport out of jaxio had no radar as such controllers relied on position reports from pilots to know where they were as the crew briefed this approach during the descent they were interrupted on two occasions by the first officer son who pointed out mountains through the windows this was the first link in a chain of misfortune on this day with their attention only half on the approach briefing the pilots missed a key piece of information the plane leveled off at 11 000 feet and approached the ajaxia beacon from the northeast around this time at about a quarter to nine the captain contacted approach control bonjour ajaxio adria julia papa 1308 we are level one one zero approaching ajaxio via war and for the descent juliet papa one three zero eight ajax your approach good morning number one in approach you maintain one one zero until you reach alpha juliet oscar via war it will be for a procedure from the vr qnh1009 qfe1008 surface wind is 280 degrees for 20 knots runway 21 in use you report over alpha juliet oscar via war and then descending over alpha juliet oscar via war this was a pretty normal transmission from the controller he provided the flight with the latest weather information the active runway and he detailed the approach they would be flying however there was one crucial thing that was missing the controller didn't explicitly clear the fight for the standard approach outlined in the charts rather he just said it will be for a procedure from the vor in the controller's mind this constituted a clearance to fly the standard approach however from the pilot's point of view as the word clearance was not used which is the standard phraseology they were used to they were just being cleared to the vor and from there they would receive further instructions this small misunderstanding set the stage for disaster but the flight was not doomed yet because the controller had in his mind cleared the flight to fly the published approach he didn't give the crew further descent clearance from their current altitude of 11 000 feet their approach charts outlined the altitudes they were to be at during each part of the approach so as far as the controller was concerned they were free to descend as they needed to the pilots on the other hand were waiting for descent clearance from the controller all they knew was that they were to fly to the vor and await further instructions without radar the controller had no idea that the crew were maintaining 11 000 feet a few minutes later at 10 minutes to 9 the aircraft reached the ajaxio via war and the pilots entered the holding pattern there at 11 000 feet the captain informed the controller of this and the controller thinking that the crew were merely reporting their position for his information merely acknowledged this and told the crew to advise him when they were leaving the holding pattern but this isn't what the captain wanted he wanted further dissent clearance okay sir we are just over at jacksonville war and we are requesting further descent this led to a critical misunderstanding the controller thought that as the captain had just said he was over the via war he was now flying away from it and commencing his approach towards the airport he assumed that the captain like many pilots who regularly flew into the airport simply skipped the holding pattern and took up the 247 degree radial from the ajaxio vor as soon as he reached it what the controller didn't know was that this was both pilots first time flying into ajaxio and they didn't know about this technique they were flying the approach exactly as it was described in their charts so when the captain asked for a descent clearance the controller gave this assuming that the crew were now about to commence their approach to the runway 1308 you are cleared to descend 3000 qnh1009 on the radial 247 alpha juliet oscar and new report leaving off of juliet oscar the captain replied roger will do we are leaving 1-1 for 3000 radial 247 out of 110. the captain's phrasing of this read back could not have been more unfortunate in the first part he described what he was doing we are leaving one one for three thousand in the second part he said what he had been cleared to do but not what he was doing at that moment radial 247 the controller simply fit this statement into the model that he had in his mind which was that the crew were skipping the holding pattern and were now beginning their descent towards the airport the crew thought that the controller was clearing them to descend to 3000 feet in the hold and that once they had reached that altitude he would instruct them to leave the hold and commence the approach to the runway at this point something that happened earlier in the flight would come back to bite the pilots minutes earlier when they're briefing the approach the first officer's son had interrupted them to point out the scenery around the aircraft this distraction had meant that the crew had missed a vitally important piece of information on their charts the minimum safe altitude for the holding pattern the minimum safe altitude of 8600 feet had been designed to keep aircraft above the 4500 foot high monsant pietro which was located 24 kilometers southeast of the airport under no circumstances should a crew descend below the minimum safe altitude in an area but at around nine o'clock that morning the crew of flight 1308 began their descent from 11 000 feet blissfully unaware that the controller thought they were safely over the sea and making their way towards the airport generally holding patterns require pilots to fly in a racetrack pattern in particular directions between particular altitudes and within a certain range of speeds however holding patterns have no defined size rather they have defined timings pilots are required to time each leg and then turn once that time is reached this means that the size of the holding pattern flown by an aircraft depends on the speed it's flying at the faster a plane is going the more sweeping its turns are the longer its segments are and therefore the bigger the holding pattern in the case of the hold at the ajaxio via war the long segments of this holding pattern were one minute in length the maximum speed of this holding pattern as stated on the chart was 210 knots or about 390 kilometers per hour however the size of the holding pattern depicted on the chart was for an aircraft travelling at 150 knots this was a much smaller holding pattern and as you can see here on the chart it doesn't involve the aircraft flying anywhere near the high terrain nowhere on the chart did it say that the size of the holding pattern depicted was correct only for a slow-moving aircraft at a speed of 210 knots which is what the pilots of flight 1308 were flying at the holding pattern was much bigger and took them directly over the mountainous terrain to the southeast of the vor the pilots were completely unaware of this as they began their descent they would have assumed that the size of the holding pattern depicted on their chart was roughly correct for the speed of 210 knots listed on the chart what's more they thought the controller would never clear them to descend to an altitude that wasn't safe after all he knew where the holding pattern was and he knew what altitudes were safe for it but what the controller didn't know was that the pilots were staying in the holding pattern just to make sure the controller understood that they were in the holding pattern the captain said we are in holding over ajaxio call you inbound on radial 247. however the controller did not realize that this transmission didn't fit with his mental image of what the aircraft was doing this phenomenon is known as confirmation bias where we focus on information that fits with our mental model of the world and ignore information which doesn't the captain had told the controller that he was holding over ajaxio and that he would let him know when he was inbound on the 247 degree radial inbound as in heading towards the beacon not away from it which is what the controller thought he was doing rather than noticing and seeking to clarify this the controller simply replied roger two minutes later when the aircraft was turning back towards the ajaxio beacon the captain contacted air traffic control saying we are rolling inbound out of six thousand the controller responded roger 1308 report turning inbound the captain tried to clarify that he was already turning inbound and said turning inbound to ajaxia because right now we're in cloud the lack of specificity here meant that neither the controller nor the pilots had a chance to notice the discrepancy in their mental models of the situation when the captain said that he was turning inbound to ajaxio he meant the ajaxio vor the beacon he was in a holding pattern around the controller thought that he meant he was turning inbound to ajaxio airport this was the final link in the chain of critical misunderstandings there was now little to stop the aircraft from meeting its fate and the terrain below as a result of this misunderstanding the controller then cleared them for the approach saying roger 1308 report charlie tango on final surface wind 280 degrees 20 knots this should have alerted the crew that something was wrong they began looking at their charts trying to find out where this charlie tango waypoint was and why the controller wanted them to report passing it they located it on their charts but seconds later the grand proximity warning alarm sounded in the cockpit alerting them the collision with the ground was imminent terrain terrain at exactly that moment the controller radioed the flight 1308 it would be as it was in the left-hand side the pilots were caught off guard by this confusing combination of the controller's voice and the cockpit warnings seconds later the captain shouted power and the first officer pushed the throttles fully forward and pulled back in his control column but it was too late the plane was in a 30 degree bank and its left wing clipped the side of the mountain shearing off the outermost eight meters of it the plane turned on its back and the pilots fought hopelessly for control for seven seconds before the plane plowed nose first into the side of a ravine over two thousand feet below all 180 people on board perished instantly on impact in the plane's final dive one of the pilots had accidentally keyed the radio and the controller had heard a strange whistling sound over the radio he tried to make contact with the fight repeatedly until it became clear that something was seriously wrong he sounded the alarm and search and rescue teams began looking for the aircraft in the sea on the approach path to the airport it would be another five hours before two helicopter crews noticed the wreckage on the side of the san pietro mountain the aircraft had shattered into millions of pieces and was immediately clear that no one could have possibly survived investigators from france's bea arrived at the site and got to work immediately in their final report published two years after the fight crashed they determined that the primary cause of the accident was the crew's decision to descend below the minimum safe altitude with contributing factors including the misunderstanding between the controller and the pilots the bea made a number of recommendations to ensure that accidents like this would never happen again these included the development of a standard lexicon for pilots and controllers so that awkward or unusual phrasing could never lead to a misunderstanding they also recommended the crews be trained to consider that air traffic control may give clearances which are below minimum safe altitude and they recommended that approach charts depict holding patterns in a shape which corresponds to the maximum holding speed for ajaxio airport in particular the bea recommended that radar be installed and that the holding pattern be moved out over the sea where common sense would have said that it should always have been these recommendations have all since been implemented especially important is the fact that around the world radio phraseology between pilots and controllers is now highly standardized wherever you fly controllers and pilots use the same terms in the same way with only minor regional differences to this day the crash of flight 1308 remains the second worst air crash on french soil and the worst crash anywhere involving an md-80 aircraft if you'd like to help this channel grow and get some cool perks like early access to new videos you can do so by tapping on the links here on screen i'd especially like to thank joey and max sal for their very generous contributions i hope you enjoyed this video thanks again for watching and i'll see you soon for another episode

Channel: Green Dot Aviation

Views: 757,877

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Id: VAneL2ZWFU4

Length: 17min 56sec (1076 seconds)

Published: Tue May 24 2022