- [Petter] There's nothing
wrong with this aircraft but still it has flipped over into
a 115-degree bank and the pilots are struggling for their lives
to get the aircraft back under control. Outside, it's dark and stormy, but it's not the weather
that has caused this upset. Stay tuned.
- 100, 50, 40, 30, 20, 10. - Kenya Airways Flight 507
was a normal passenger flight scheduled in the evening
of the 4th of May, 2007. And it was divided into two legs. The first flight was scheduled
from Abidjan in the Ivory Coast and then bound
for Douala, in Cameroon. There, the crew was supposed
to make a short stop to refuel and then take up some
new passengers before they continue towards their final destination
in Nairobi, Kenya. The flight was scheduled
to be operated through the evening and early night with a departure time of 18:30 from Abidjan
and a final arrival time in Nairobi around three o'clock at night, making it potentially a quite
tiresome flight combination to do. The captain of the flight
was a 52-year-old Kenyan national who had been flying for over
16 years at the time of the accident. He had just under
8,700 hours of total time of which 3,464 were flown
as pilot-in-command. The majority of this experience
was flown on the Boeing 737, which was the aircraft that they
were going to fly on this flight. The first officer
was a 23-year-old Kenyan citizen with considerably less experience. He had accumulated just
about 800 hours of total time, of which around 200
was flown on the 737, making him a very
new commercial pilot. Now, the personalities
of these two pilots will play a very
important role in this story, so it's worth explaining
a little bit more about them before we move on. The captain had a quite chequered
training history behind him. During his command upgrade training,
back in 2002, several instructors had noted performance deficiencies including lack of
crew resource management, poor adherence to
standard operating procedures, cockpit scans, and just overall
situational awareness. Now, the notes that really stood out
to me from his training records was that even though he had shown okay handling skills,
as in stick and rudder handling, his personality showed
a touch of arrogance, that he was overbearing
towards his co-pilots, and that he showed
insufficient flight discipline which affected his cockpit scans, and then, ultimately, his
situational awareness. These are quite serious issues
but obviously the whole point of participating in a training
programme is to train and improve deficiencies noted. And that's exactly
what Kenya Airways did. At the end of his
command upgrade training, he had been recommended
for his final command upgrade line check which he didn't pass due
to similar issues as had been shown during his training. But then he was scheduled for a recheck which he,
ultimately, managed to pass. After this, several
subsequent line checks and recurrent simulator checks
within the airline, followed a similar pattern
with issues that the airline then dealt with and trained him back up to sufficient standard before he
was let back onto the line. Finally, though, the head of training had contacted him after
a poor simulator result in August of 2006, and told him
that his performance was under review, and that the airline needed to determine if these performance lapses
had to do with complacency or incompetence. Now, that's not something that you ever want to hear
from any employer, by the way. Having said all this,
it's also worth noting that several of his colleagues
did actually say that overall, he was perceived as a pretty nice guy. So this meant that the airline
was keeping an eye on him. But as long as he kept passing
the checks or the rechecks, there wasn't really much
that they could do. He had been evaluated
to be below average, but still at an acceptable standard. And the very last simulator check
that he had done, prior to this flight, he had actually passed it
with no poor comments noted from the examiner. Now as an instructor, one thing
that I have found is that poor attitude is normally very hard
to do anything about. And that's because as part
of poor attitude is often included in a sense of entitlement
and poor self-criticism. And if you don't think
that you're doing anything wrong, or you blame others for your failures, well, then you will never work
on improving yourself. And this is why self-critique
is such a crucial skill to have. This brings us to the first officer. Now, he was in the
very beginning of his career, but he had also racked up
a less than perfect training history. He had failed
his initial radiotelephony test as well as his IFR skill test
during his initial training. And during the last
simulator proficiency check which he had done back
in the early 2007, his instructors had noted that although
the overall standard was satisfactory, he needed to monitor errors
made by the pilot flying more carefully and call them out,
as well as monitor the performance of the autopilot. Here it's important to point out
that especially feedback about calling out deviations
is really common feedback to new first officers. It can be sometimes
intimidating to call out deviations, especially in a check environment
to a much more senior captain but assertiveness is absolutely
crucial in this occupation. Calling out things when they
start looking odd or wrong is probably the single most
important job that any pilot has to do so this is drilled into us
during training and checking, especially in the beginning. Anyway, judging from their
combined training history, it looks like the pilots
of Kenya Airways Flight 507 comprised of a slightly
overbearing and arrogant captain, prone to lapses and situational
awareness and cockpit scans and a new young first officer
who wasn't yet fully comfortable with speaking up in the cockpit. And this will become important very soon. When the pilots started preparing
for the flight, they saw that the weather over Douala,
their first destination didn't look very good. There were loads of thunderstorms
forecasted for the entire period that they were going to be there
but with quite mild winds and okay visibility between the storms. This would have likely caused
a little bit of concern but providing that they carried enough fuel,
it shouldn't be really a big problem. Thunderstorms
are often temporary in nature, so providing that they could wait
long enough, they would likely be able to squeeze in
and land between them. And if that wouldn't be possible,
well, then they could just divert. Once the pre-flight preparation
was complete, the pilots walked over to the cabin crew and then briefed them about the flight times
and the possible turbulence that these storms could cause. And after that, they walked out
to the aircraft and started preparing it for the first flight. The aircraft that they were going to fly
was a relatively new Boeing 737-800, which had been delivered to Kenya Airways
about seven months prior to the flight. It had no technical malfunctions
recorded in the tech log, but there had been some earlier issues
with the autopilot A, but those particular problems
had not been noticed after its latest maintenance overhaul. So once the safety inspection
was complete, the crew began boarding
their 55 passengers and at time 18:30 local time,
the aircraft took off normally and proceeded towards Douala. That first flight proceeded
without any kind of problems and they landed
in Douala at 22:01 local time. And after landing,
they taxied into a position close to stand Charlie-seven,
but because there was no marshaller present to guide them on to the stand, they had
to shut down the engines and await a tow truck to tow them
into the correct parking position, which took about 20 minutes or so. And after that, the passengers who were getting off
were allowed to disembark. Now before I continue to explain
the full accident sequence, here comes a short message
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Now let's continue the story. As the pilots were waiting
for all of the passengers to disembark, they received a briefing package
with updated weather information by the dispatcher. The weather was still forecasted
to be quite bad for the departure with moderate thunderstorms forecasted to last
until the early morning. After having looked at that weather,
the captain decided that he was going to be pilot flying
for the next flight which is a sensible decision to take because when we're flying
in very tricky weather conditions, it's pretty common for the captain
to be pilot flying especially when he's flying with
a very inexperienced copilot which was the case here. The pilots decided to uplift
9,500 kilos of fuel, bringing the total
amount of fuel on board to 14,200 kilos which was going to be sufficient for their
long flight towards Nairobi. And once the fueling has been completed, they started boarding
all of their new passengers. In total, 38 passengers disembarked
in Douala and 91 passengers got on, bringing the total number
of people on board to 114, 108 passengers and six crew members. During the cockpit preparation, the first officer called up
the Douala tower controller to get the latest weather. Initially there was some slight confusion regarding which callsign
that the aircraft was going to use but once that has been resolved, the tower gave the pilots
the follow weather information: temperature, 27 degrees Celsius; dew point, 25;
air pressure, 1010 hectoPascals; winds, calm and Runway 12 for takeoff. This sounded like quite nice weather so the captain proceeded
with briefing the expected departure, the EDEBA 1-Echo,
without raising any extra attention to the possible weather impact. Once all the cockpit preparation
was completed, and the cabin was ready, the first officer,
again, got into contact with the tower to ask for their engine startup clearance which they received at time 23:20. Immediately after this call,
a Royal Air Maroc aircraft also contacted the tower
to ask for a weather update, and they asked for it
to be given to them in French. Now the reason they asked
for this update was likely that a moderate to heavy rain shower had now moved in over the airfield. And it became so intense
that the pilots of Flight 507 actually called the tower back up
and requested to delay their engine start until that storm had passed. This took a further 17 minutes
or so and the time 23:54, the pilots again called the tower
and said that they were now ready to start their engines again,
which was immediately approved. Here it's worth pointing out
that this very heavy rainstorm that now had just passed
overhead the airfield, should have prompted the captain
to revise his departure briefing to include contingency
procedures for the bad weather that was now clearly
present around the airport but that was never done. Instead, Flight 507's
engines were started as per standard operating procedures and at time 23:59, the first officer asked
for taxi clearance. But instead of receiving clearance
to start moving the tower now told Flight 507 to hold
position and wait instead. The aircraft was, at this point,
standing parallel with the runway with the nose pointing
in the departure direction. So the captain used this time
to switch on his weather radar in order to get a better overview
of the weather that lay ahead of them. The picture that they saw was very bleak. There were a lot of storm returns
from the departure direction and the captain exclaimed that,
"This thing is moving," likely referring to one of the storms directly in front of them
and then he continued, "There's no way here." Whilst the pilots of Flight 507
were waiting to get their taxi clearance, the Royal Air Maroc aircraft,
again, in French asked for an update to the current weather. And now, a so-called SPECI
or special weather report had been issued for the airfield,
indicating a much worsening condition with 800 metres visibility and moderate thunderstorms
in all directions. This special weather report
was only given in French at this point, so it's unlikely
that the pilots of Flight 507 understood the severity of it. This was later pointed out
as a major mistake by air traffic control
but to be completely honest, the fact that there
was moderate storms around and that it was raining heavily would have been
quite obvious to the crew. So this SPECI information
would likely not have changed the minds of the pilots
in any major way. About one minute later,
Flight 507 was finally cleared to taxi, enter and then backtrack Runway 12. The first officer read back this,
together with the total number of people on board
and the endurance of the aircraft which was five hours and 45 minutes. During the taxi out,
the first officer expressed some concern about the weather around them and he also hinted at the fact
that he felt that the procedures were a bit rushed. The captain reassured him but he did so
in a slightly condescending way, laughing at him, at least, twice. This points to the same type of attitude that the captain had shown earlier
in his career and it would have likely made the first officer even less prone
to speak up than he already was. As the aircraft was now
backtracking runway, the tower controller called them
to give them their departure clearance and he also told them to call him back
when they were ready for departure. The first officer read back
the clearance and confirmed that they would call him
when they were ready. Now the cabin crew called
the cockpit and told them that they were ready for departure,
prompting the first officer to give a quick PA to the passengers, emphasising the need for them to check that they had
their seatbelts fastened, and he also seated
the cabin crew for departure. Both the captain and the first officer
now had weather radar selected on their navigation displays
and as the aircraft turned around on the runway, the captain started to study the picture he saw
to try to find it there's way that they could deport safely. Up until this point,
most of the cockpit work had been done by the first officer, including initiating
the before takeoff checklist, which would normally
be the captain's job to do. This could possibly be because
the captain was focused on the weather situation
they were in or it could be a further indication of the captain's
lack of overall cockpit discipline. In any case, the captain
now suddenly took over the radios from the first officer and asked
the tower controller if they could get a modification of
their departure clearance to maintain a heading slightly left
of the runway heading after departure to avoid some weather. The first officer corrected him
by saying, "No, right." And the captain continued,
"Oh, sorry, slightly right," which the tower then approved. After this, the captain immediately started advancing
the thrust levels to 40% N1. He called, "Stable. N1. TOGA." Pushed the TOGA buttons
and then started the take-off roll. Has any one of you noticed
what's missing at this point? Yeah, remember how the controller
told him to call him back when they were ready for departure? Well, that was never done,
possibly because the captain had taken over the radios
from the first officer, disrupting normal communication flow, and this meant that the aircraft
was now taking off without takeoff clearance
which is a major procedural breach. In any case, the takeoff roll
proceeded normally and at six minutes past midnight,
the aircraft took off and started climbing into the stormy night. After takeoff, the gear was selected up and almost immediately,
the aircraft started a slight bank towards the right. This was easily counteracted
by the captain who just inputted a little bit of left aileron to keep
the aircraft climbing straight ahead. And the reason
for this tiny roll tendency was likely that there was
a little bit of right rudder trim still selected from the previous flight. Also, aircraft are not
100% perfectly symmetrical, so very minor roll tendencies
do exist on almost all aircraft. And this wouldn't have been
of any significance at all, if it wasn't for what's
about to happen next because as the aircraft passed
about 1,000 feet climbing, all recorded pilot inputs on the captain's control wheel
suddenly stopped. This coincided with the captain
calling, "Heading select," and the first officer confirming
that the lateral navigation mode HDG SEL was actually active. This meant that the captain
had completely released his controls here but why did he do that? Well, we can't know this for sure but he was likely concentrated
at this point, on planning the path that the aircraft needed
to follow in order to navigate between the storm clouds. 1,000 feet is normally
where we engage the autopilot and there is a possibility that he tried to push
the autopilot button, but that he did so whilst
he was still in putting a little bit of force on the yoke. And if you do that,
the autopilot will not engage. I have actually seen
this happen in real life. And it's one of the many reasons,
it is so important to always follow the procedure of select, verify and call whenever any type of selection is made. What this basically means
is that we first select the mode or action that we want,
then we must visually verify on the flight mode annunciator
that the mode has actually engaged and only after that, can we call it out. But is there no warning telling the pilots that the autopilot
is not engaged? Yes, there is but that warning only activates if the
autopilot is disconnected. And in this case, it was never
connected in the first place. In any case, after this,
there was no one controlling the aircraft, not the pilots
and not the autopilot. It was literally just flying by itself. The captain was most
likely looking outside and on the weather radar. And he now started turning
the heading bug on the mode control panel away
from the runway heading towards the right just like they had planned to do. He selected 132 degrees
and as he was doing that, remember that tiny right roll tendency
that we talked about earlier? Well, now as there was no one holding on to the controls
to counteract it, the aircraft started rolling
slowly over to the right and that was likely misunderstood by the captain as
the autopilot doing its job, turning towards the heading
that he had selected. It is likely that none of the pilots
were closely monitoring their instruments at this point because if any of them
would have looked down on to their flight mode annunciator and below, they would have seen
that the aircraft was still flying on FD or flight director mode and not in CMD or command as it should have said
if the autopilot was engaged. The captain now said,
"I'll keep it somewhere there," likely pointing out the track
that he intended to follow between the storm clouds. He then moved
the heading bug further to the right onto heading of 139 degrees, causing the magenta flight
director command bars on his primary flight display
to turn further towards the right showing him how to turn. And even that, should have been
a clue to him that something wasn't right here because when the autopilot is engaged, it always follows
the flight director exactly. It never leaves the middle
of the command bars. But in this case, since the
aircraft was just slowly increasing its bank towards the right,
he command bars would have indicated
a further right turn needed as the aircraft was only banking with around six degrees
and not the 25 to 30 degrees that it would normally do. As the aircraft
passed 1,500 feet climbing, the autothrottle reduced the thrust
from takeoff thrust back to climb thrust and the first officer called this out. The aircraft was now banking
about 11 degrees to the right and the speed had started
to increase as the nose was slowly dropping. This speed increase would have caused
the aircraft speed trim system to start moving the trim wheels
which it's designed to do in case the pilots aren't trimming
within certain speed and time parameters. And the fact that the automatic trimming was now happening,
might have further confirmed the captain's belief
that the autopilot was indeed engaged
but that was not the case. Since they were now
about to turn past the selected 139 degrees,
the flight director command bar started indicating a left roll needed
to keep that heading, but this change in indication
was not noticed by any of the pilots. Instead, the captain called out,
"Okay, command," indicating that he now
had selected the autopilot on. At this point, the aircraft
had been flying without any inputs for about 18 seconds
and even though he had now called it out, the autopilot was still not engaged. So this might just
have been a delayed call for what he thought he had done earlier. Like I said before,
the select verifying call procedure is critical and it's equally important that the pilot monitoring
also verifies the selection after the pilot flying has called it. And this is an excellent example of that. Anyway, the aircraft now
continued its uncontrolled right hand turn and meanwhile, the first officer started talking
to the captain about which page he should have selected
on the FMC CDU. The aircraft's heading had now passed through 139 degrees
and was continuing to the right, meaning that the
flight director command bars were now indicating full left. The captain now moved
the heading bug to the left onto a heading of 120 degrees. But, of course, the aircraft just
continued its right roll and the command bars
still showed full left deflection. The fact that he didn't notice
that the aircraft wasn't following his change in heading command
suggests that he wasn't monitoring his primary instruments
at all at this point. And neither was the first officer
or, at least, he wasn't saying anything. Instead, when the aircraft climbed
through 2,400 feet, the first officer suggested that they should
set standard on their altimeters. They were cleared to climb
to their cruise altitude of flight level 370
so this wasn't wrong to suggest but, again, this pressure-setting change
should have been led by the pilot flying and there was no hurry to do this. The flaps were still extended
and they still had a lot of work to do before the after takeoff checklist
was supposed to be completed. So at this point, it would have
been way more important for the first officer to monitor
what the aircraft was actually doing. The next thing that happened
was that the captain called, "Now we're getting into it," probably referring to the storms outside and likely, an increase in the amount
of turbulence and precipitation. The first officer responded, "Okay." And then he said,
"I continue with heading?" Followed by the heading bug being moved from 120 degrees
to 165 degrees. This was possibly done by the first officer
to match the heading and, therefore also,
the flight directors with what the aircraft was actually doing. But, of course,
we can't be sure of that. But when the autopilot's engaged, which the pilot thought that it was, only the pilot flying
should change values on the mode control panel. So if the first officer saw something that he didn't like,
he should have called it out rather than trying to fix it. As the aircraft reached about 2,600 feet, the captain asked,
"Through here is okay, isn't it?" Obviously still preoccupied
by looking at his weather radar and trying to find
a way through the storm. The first officer responded, "Okay?" And six seconds later,
the aircraft right bank had increased to 34 degrees. And the captain let
out a shocked exclamation. This was then immediately followed by a-- - Bank angle.
- Warning. And now the captain finally
put his hands back on the controls and started trying to correct
the aircraft attitude. The problem was
that this sudden realisation of the high bank angle
must have given him an instant startle because what he now did was he abruptly turned
the yoke almost fully to the right. Now his primary instrumentation
would have clearly shown that the aircraft already was in the right-hand turn. And outside his window,
there was only storm clouds and darkness so he wouldn't have been able
to use any of the outside references unless what he saw outside
actually confused him in some way. Sometimes when we're flying in clouds,
a slanting cloud mass can give the illusion of a horizon
and that's one reason why it is so important
to concentrate on the aircraft instrument. In this case, it's also possible
that his prolonged lack of instrument scan
and this sudden onset of a bank angle warning led
to a startle and a knee-jerk reaction rather than a balanced
thought-through correction. Anyway, this initial right input
caused the aircraft to rapidly roll further to the right, reaching
a bank angle of around 50 degrees, which is a quite steep turn. After this, the captain continued
making both left and further right inputs clearly showing confusion
about the orientation of the aircraft. He also started pushing rudder
which is something that we just never do in the Boeing 737 during normal flight. The turns are normally coordinated
by the yaw dampers so inputting rudder was a very odd thing to do,
further indicating his startle and possible disorientation. But it could possibly also indicate
that he initially thought that they had some kind of flight control problem. The next thing that happened was that the autopilot now
was suddenly engaged. At this point, the captain
had likely noticed that it wasn't engaged
and instead of first, stabilising the aircraft
like he should have done, he just pushed the button. Now when the autopilot is engaged
and heading select has been selected as the roll mode, it normally tries
to continue flying the aircraft in heading select. But since the autopilot was engaged
with the selected heading way off, and the flight directors
indicating full left turn, it wasn't able to do that. Instead, the autopilot engaged in a mode called
control wheel steering roll. This is a lower form
of automation mode where the aircraft basically continues to fly the bank angle
selected by the pilot. It will however, not accept
a higher bank angle than 30 degrees so if the captain would have just
left the autopilot alone, it likely would have stabilised
the turn and brought it back from the very steep turn
that they were now in. But instead of doing that,
only five seconds after engaging the autopilot, the captain again started inputting on the yoke
and the rudder pedals. He first moved the yoke to the right
and then to the left and then right again together with large bursts
of right rudder inputs. Now, if an aircraft is in
a steep right turn and you push the rudder to the right,
this will yaw the aircraft to the right but since it's banking
when a yaw happens, that yaw will start pointing
the aircraft nose down towards the ground,
which is exactly what happened here. The captain called out,
"We're crashing," while still moving
the controls in full panic. The first officer responded,
"Right, yeah, we're crashing, right," as the bank now reached 70 degrees
and the aircraft started diving down towards the ground. The captain continued
to push right rudder even though, he eventually moved
the yoke fully to the left but with the high bank angle
that they were already in and enormous rudder
being pushed to the right, this left aileron wasn't enough to decrease
the bank angle fast enough. The first officer, likely understanding that the captain
was completely disoriented, started calling out corrections
but unfortunately, what he called was, "Right, captain! Left, left, left.
Correction, left." Possibly adding to the confusion which by this point
must have been utterly terrifying. At time seven minutes
and 35 seconds past midnight, the aircraft reached
its highest bank angle of 115 degrees to the right. After this, the continuous
left control wheel input started having an effect
and the bank eventually decreased towards 70 degrees, but at that point, there were only 1,300 feet off the ground and the nose was pointing
almost 50 degrees down. Seven seconds later,
one minute and 42 seconds into the flight, the aircraft crashed
into the mangrove swamp below with a speed up 270 knots
and 48 degrees nose down. All 114 people on board
were immediately lost in the impact. The search and rescue work
started almost immediately, but was hampered by the poor weather and the swampy terrain
where the accident had happened. Eventually, both the flight data recorder
and the cockpit voice recorder was found in the five-metre deep crater that the aircraft had created
in the soft mud. The investigation ultimately concluded
that the accident had been caused by a loss of control by the crew
due to spatial disorientation after a long slow roll, during which
no instrument scanning was done and in the absence
of external visual references due to darkness and the cloudy weather. Inadequate operational control,
lack of crew coordination, poor monitoring and confusion
in the use autopilot was what ultimately led to the accident. The investigation team came
with several recommendations to both the airline
and the governing authorities but the single most
important recommendation was the implementation
of a formalised upset prevention and recovery technique training programme for commercial pilots. Remember, this happened back in 2007, which was two years before
the accident of Colgan Air 3407 and Air France 447 which also drove home the need
for this crucial pilot training. All commercial pilots are now
undergoing modules of this training every sixth month of their career. I think that this accident also serves
as a good reminder of the importance of proper pilot selection. If you are thinking
about becoming a pilot, before you start
any of your pilot training, you should do a pilot suitability test. And you should be doing that,
both for your own sake, to make sure that you aren't spending
a lot of money on training, just to find out that you won't be able to pass the airline acceptance test, but also for the sake of everyone
who's going to fly with you in the future. Now if you want to check
your suitability, I highly recommend you to check out the Airline Pilot Club. It's a free resource that will give you one of those indicative tests for free, as well as a lot of other great support
and guidance for future pilots. And I've linked to them
in the description below. Now, check out this video next
which I think you're going to find really interesting
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