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00:00On a challenging descent in the Himalayas...
00:05Landing on runway 02. Questions or concerns?
00:08No questions, no concerns, Commander.
00:11A passenger jet collides with the side of a mountain.
00:15What's happening? No, no, no, no, no!
00:19It really was a shocking moment.
00:22But when their most vital piece of evidence doesn't deliver...
00:29This is it.
00:34Investigators scramble for answers.
00:37Could be weather.
00:38Lots of thrust.
00:40Intruder in the cockpit.
00:42But the accidental discovery of a valuable clue...
00:44Could it be?
00:46Points to the origins of what went wrong.
00:49Come on, come on, come on!
00:51That was the eureka moment in this investigation.
00:59I can't remember anything, sir.
01:04Let me go, please.
01:05Let me go, please.
01:06Go, please.
01:07Visit the FFMNF15.
01:09The FFMNF 15th.
01:10The FFMNF, the UFNF 15th.
01:12Pakistan International Airlines Flight 268 is en route to Kathmandu, the capital of Nepal.
01:31The two-and-a-half-hour flight from Karachi is one of the few that flies to the Nepali capital, situated 4,600 feet above sea level.
01:42Landlocked between China and India, Nepal is home to eight of the world's ten tallest peaks, including the mighty Everest.
01:52Kathmandu is a favourite destination for travellers to the Himalayas, many of whom are making their way to Nepal for the start of the popular trekking season.
02:02Could I have a tea, please?
02:04Among them are Mick Hardwick and his friend Dave Harries, both mountaineering instructors back home in Britain.
02:12Thank you for climbing to the Alps.
02:15There were certainly very, very good climbers in a variety of different disciplines in alpine work, really at the top of the tree.
02:23They're on their way to climb Annapurna, the tenth highest mountain in the world.
02:31Annapurna was certainly an ambitious programme, but it wasn't foolhardy.
02:35It was well thought out and well planned. It would have been a huge moment for them.
02:40It would have been a trip of a lifetime.
02:43In the distance, they get their first look at the Himalayas.
02:48Have a look at that.
02:52Finally.
02:53On the flight deck, Captain Iftikhar Janjua is in command.
03:03He's a former officer in the Pakistani Air Force, who's now a senior pilot instructor with the airline.
03:09Captain Mohamed Hussein flew around the world with Captain Janjua on many different flights.
03:16I knew him for a period of about five years.
03:20He had no ears about him, you know, he was quite a simple person.
03:24He was a family man.
03:25He never smoked.
03:26He didn't drink.
03:27That way he was a straight guy.
03:29I don't like the look of the clouds ahead.
03:35The first officer is Hassan Akhtar, a junior pilot with the airline, with almost 1,500 hours flying the Airbus A300.
03:45How about we divert around them?
03:47Yes, Commander. Agreed.
03:49It's nearing the end of monsoon season.
03:52Large storms are still frequent along the route.
03:55Kathmandu, Pakistan 268.
03:57We are 10 to 15 miles right of the track to avoid a build-up en route.
04:02To avoid the storm, Captain Janjua notifies Kathmandu Air Traffic Control of his change to Flight 268's approach.
04:10Roger. 10 to 15 miles right of track. Copied.
04:16Could get bumpy.
04:18Let's keep them seated.
04:19Agreed, Commander.
04:22Fast and seatbelt sign is on.
04:24We're about to begin our descent into Kathmandu.
04:27We are entering an area of turbulence, and I request all of you to remain seated.
04:32The descent until was quite scary, because the plane seems to be descending forever.
04:37You sort of lose track of where you actually are.
04:40We're expecting it to be a little choppy.
04:43Well, here comes the mountains.
04:44Then, you're on the runway, and it's always a relief when the plane comes to a halt.
04:56I'll take over from here, Doctor.
04:58Yes, Commander.
05:00I have control.
05:01You have control.
05:02The first officer hands over control of the aircraft to the captain.
05:10Flight 268 leaves its cruising altitude as it begins the approach into Kathmandu.
05:16In 1992, Kathmandu Airport doesn't use radar to track its planes.
05:27Every movement, planned or otherwise, must be accurately reported by the flight crew.
05:32In the absence of radar, it requires good communication between the aircraft and the air traffic controller.
05:39They have to communicate very carefully.
05:42Pakistan 268 approaching overhead.
05:45Simran 150.
05:47Pakistan 268 descent to 11,500.
05:50No delay expected.
05:53Roger, sir.
05:53Down to 11,500.
05:54The problem with Kathmandu is that you have a range of mountains to the south that you have to get over,
06:02and then you have to drop down quite steeply in order to be able to land at the threshold of the runway.
06:10There is a danger of arriving at the threshold too fast or even a little bit high.
06:15The mountains surrounding Kathmandu require pilots to make what's known as a stepped approach.
06:20Pilots must descend to a series of lower altitudes at certain distances from the airport.
06:30We can expect descent clearance by 16 miles.
06:33Descent angle is steep, so we need to be at flaps 15 by 16 miles.
06:38Landing on runway 02.
06:40Watch for stray animal and birds.
06:42Questions or concerns?
06:43No questions, no concerns, Commander.
06:46Pakistan 268 report, 16 miles.
06:48Wind 180.
06:49Expect Sierra approach.
06:52Roger, call you at 16 miles.
06:53Expecting Sierra approach.
06:55Sierra approach, Commander.
06:59Here it is.
07:01Watch my levels.
07:02The details of the stepped approach are laid out on a chart for the pilots.
07:06The approach chart is designed to keep you clear of terrain, so you have to follow the approach chart.
07:11As flight 268 begins its final approach towards Kathmandu, passengers and crew prepare for landing.
07:24Sun and blue skies would be nice.
07:25Alpha Charlie Hotel, surface wind 2-0-0-0-0-5.
07:33Pakistan 268 is at 16 miles.
07:3711,500.
07:3816 miles from the airport, the pilots report their altitude as 11,500 feet.
07:45Roger, Pakistan 268.
07:47Report 1-0 miles.
07:49Roger, call you at 1-0 miles.
07:50Pakistan 268.
07:52The crew works its way through the steps towards Kathmandu, approaching from the south.
07:58They should be touching down in about six minutes.
08:09Alpha Charlie Hotel, continue to taxiway number 2.
08:15Pakistan 268 is at 10 miles.
08:18Report your level.
08:24We crossed out of 8,500.
08:27200 now.
08:29Roger, clear for final.
08:30Report 4 miles, runway 0-2.
08:34We'll call you at 4 miles, Pakistan 268.
08:37Clear for final, runway 0-2.
08:39Runway 0-2.
08:41Flight 268 is now less than 10 miles from the runway.
08:45Air traffic control waits for the flight crew's next position report.
08:58Air traffic control waits for the flight crew's next position report.
08:58Flight 268 should have reported that they've reached the next step by now.
09:10Flight 268 should have reported that they've reached the next step by now.
09:23As the minutes tick by, air traffic control has come to a horrifying realization.
09:25As the minutes tick by, air traffic control has come to a horrifying realization.
09:38Flight 268 is missing somewhere in the Himalayas.
09:51It doesn't take much time for Kathmandu air traffic controllers to get word that PIA flight 268 has crashed somewhere in the Himalayas.
10:00It doesn't take much time for Kathmandu air traffic controllers to get word that PIA flight 268 has crashed somewhere in the Himalayas.
10:14Within hours, the plane's wreckage is found on the side of a mountain.
10:25The flight was carrying more than 20 tons of fuel.
10:30And the plane is completely consumed by fire.
10:36All 167 people on board have died.
10:39Tonight, investigators refuse to speculate on possible causes of the crash.
10:47So dangerous are the conditions...
10:48We're all back in North Wales and news filtered through into the office.
10:52We're just sort of...
10:54Stared in disbelief, really.
10:56We couldn't believe it.
10:57You hear of these things happening, but when it happens to people you've been in contact with on a daily basis,
11:03year in, year out, and worked with on the cliffs and the crags,
11:07it's just disbelief.
11:09As the flames die down, Nepal faces a chilling reality.
11:15A passenger jet has crashed near the Kathmandu runway for the second time in two months.
11:23The first was a Thai Airways Airbus with 113 people on board.
11:28Canadian accident investigator Dave McNair is already in Nepal, leading the Thai Airways investigation.
11:42There hadn't been an accident in Kathmandu for many, many years.
11:44There was the one accident that happened back in July, and then a second accident of a major aircraft in the same place.
11:51And it really was a shocking moment.
11:54Yeah.
11:55Within hours, the Nepalese government launches an investigation into the crash of Flight 268.
12:02We need to get there as soon as the weather clears.
12:04Already stretched thin by the Thai Airways investigation, the Nepalese ask British investigators for help.
12:12Thanks for coming, Andrew.
12:13Andrew Robinson from Britain's Air Accidents Investigation Branch is one of the investigators assigned to the case.
12:20Let's see what we're dealing with here.
12:23My role in the investigation was to look at the engineering aspects of the accident.
12:28So I would be looking at the site, the wreckage distribution, the wreckage itself, the components within it,
12:35and trying to work out what the impact attitude was, whether all the aircraft was present at the impact site, that sort of thing.
12:44Kathmandu Airport is the main hub of Nepal's tourist industry.
12:48The pressure is on the team to figure out what caused this accident as quickly as possible.
12:57We wanted to find out, obviously, if there was something wrong with Kathmandu Airport or procedures involved in approaching or landing at it.
13:06So, yes, there was a huge concern within the aviating community.
13:12The Nepalese government deploys the military to help investigators get to the remote crash site.
13:18Which is more than 7,000 feet above sea level.
13:22I was part of the team to go up there to look at the initial wreckage survey.
13:26It was quite of a perilous drive to get there.
13:29We got to the base camp, and then we had to walk about two kilometers up a path to get to the site.
13:37It was an emotional walk because as we're walking up, people are bringing the remains down.
13:42When we first encountered the wreckage site, you couldn't even recognize an airplane except for the tail.
13:54And, of course, you could see some of the souvenirs that people had were lying on the ground.
13:58A little child's sock was there.
14:00So, you know, that related to the people who were on the airplane.
14:03But in this case, it was just the aircraft was just totally destroyed.
14:07It was just complete obliteration of the aircraft.
14:10The team begins examining the wreckage.
14:14But conditions are treacherous.
14:17The aircraft had crashed into the side of a mountain about 150 feet from the top.
14:23And getting about on the site to inspect it was actually quite difficult because the average slope was about 45 degrees.
14:30Investigators quickly conclude that it's too dangerous to examine the wreckage on site.
14:35The actual workers were Nepalese who had to deal with some steep slopes and had to work very, very carefully to make sure nobody was injured on the site.
14:46As the investigation gets underway, one thing is obvious.
14:50Flight 268's final altitude.
14:53This is the location of the crash site, nine miles south of the airport.
14:57The aircraft collided with the mountain at an elevation of 7,280 feet.
15:08Investigators plot the location and altitude of the crash site.
15:13Just below the summit.
15:15Where should they be?
15:17Can you pass me that approach chart, please?
15:19At 10 miles out, he should have been at 8,200 feet.
15:31How do you hit a mountain you're supposed to clear by 1,000 feet?
15:35You know it hit the mountain, there's no doubt about that.
15:38But you don't know why it was as low as it was when it hit the mountain.
15:41As yet more mystery swirls around Flight 268, a makeshift morgue is set up outside the airport.
15:50The people of Kathmandu must come to terms with a second tragedy in as many months.
15:56And pressure builds to find out why that happened.
16:04Nepalese soldiers have retrieved the aircraft's black boxes from the wreckage of PIA Flight 268.
16:10Put that over there, please.
16:12The Digital Flight Data Recorder, or DFDR, contains information about critical aircraft operations and performance.
16:20They look pretty banged up.
16:22The cockpit voice recorder records conversations between the pilots.
16:27They'll both be sent to France, where the data will be downloaded and analyzed.
16:33Flight recorders are extremely vital for investigations.
16:35The most important part is it really brings you closer to understanding the entire reason for the accident.
16:46But until they get the data, investigators must look elsewhere for clues.
16:50They hope the air traffic controller can provide some insight.
16:54I've been running through every conversation we had and studying my notes.
16:57Does anything stand out?
16:59They had to deviate around some bad weather.
17:06Kathmandu, Pakistan 268.
17:08We are 10 to 15 miles right of the track to avoid a buildup en route.
17:13The controller tells investigators that the crew reported some storm clouds on the way to Kathmandu.
17:19It's usually very hazy in the Kathmandu Valley.
17:22In most conditions, when you've got mountains, you invariably have clouds.
17:25That's common this time of year.
17:29Anything else after that?
17:31Standard position reports by the book.
17:37Pakistan 268 is at 10 miles.
17:39Report your level.
17:40We crossed out of 8,500.
17:42200 now.
17:44Roger.
17:45Clear for final.
17:45Report 4 miles.
17:47Runway 02.
17:48We'll call you at 4 miles, Pakistan 268.
17:50He said he'd contact me when he got 4 miles out, but I never heard from them after that.
18:02Okay, let's see what the wreckage can tell us.
18:06When an aircraft is destroyed, there are still things you can get from the accident site.
18:11Investigators consider the possibility the jet was flying out of control when it crashed.
18:16They scrutinize the crash site for clues.
18:18Look at this.
18:21The right wing impacts up here.
18:25A large scar shows Robinson precisely where the wings hit the side of the mountain.
18:34He also notices that just 1.3 meters below the impact scar, the top of a tree has been cut cleanly.
18:42The wing couldn't have cut that tree.
18:44So what did?
18:45The aircraft cut some tree branches.
18:48So you can actually use that to measure angles of impact.
18:51Then you can use other evidence to find out what happened to the airplane.
18:58What about...
18:59The flaps?
19:07Fully extended.
19:09Exactly 1.3 meters below the wing.
19:13For the team, it's a critical clue.
19:15As the Airbus A300 slows for landing, its wing flaps extend by as much as 25 degrees.
19:25Hanging below the wings, the extended flaps would shave the top of the tree as it slams into the mountain.
19:37Wings level.
19:38No pitch down.
19:39Flaps extended.
19:40Flaps extended.
19:41Flaps extended.
19:42In other words, the exact landing configuration.
19:45This plane was absolutely not out of control.
19:50Flaps 10.
19:52Flaps 10.
19:53This is an indication that, in fact, the crew was deliberately flying it there.
19:57But what was abnormal was the fact the airplane was being flown too low.
20:02The question is, why was that?
20:07To answer that question, the team creates a list of every conceivable scenario based on the evidence they've collected so far.
20:15Any thoughts?
20:17Loss of thrust?
20:23Clear for final runway 02.
20:25Runway 02.
20:29Loss of engine number one.
20:31We're losing number two as well.
20:33Investigators consider a loss of thrust in both engines.
20:37Okay, watch my altitude.
20:39Come on, come on, come on!
20:417800.
20:42Initiate restart, either engine.
20:43And a rapid loss of altitude.
20:457500.
20:46We're not going to make it!
20:47Leading to the collision with the mountain.
20:56Robinson studies what's left of the plane's engines.
21:09Only one way this got in so deep.
21:11The damage and debris inside tell Robinson the fan blades were spinning when they hit the ground.
21:22And further examination of the device that controls fuel flow shows they were at the lowest thrust setting.
21:29Flight idle.
21:30That's precisely where they should be for an A300 descending towards the runway.
21:37The thrust from the engines was symmetrical and at low power.
21:42There was no indication of loss of control, so that was dismissed.
21:46So we then had to sit down and think of reasons why the pilot might have been too low.
21:56With mechanical failure ruled out.
21:58What?
21:59Okay.
22:00Not the engines.
22:01And the black box data still in Paris.
22:03What else?
22:04Investigators turned their attention to what was happening in the cockpit.
22:07Robert Bohr is an aviation psychologist who has studied the course of this investigation.
22:17Accident investigators will typically approach this kind of investigation as though they were detectives.
22:22And they're going to raise a wide range of questions, hypotheses that they will want to test out.
22:28Okay.
22:30What about an intruder in the cockpit?
22:32Unlawful interference is something that's around us. It's everywhere.
22:38We spend our lives dealing with it every time we check in at the airport.
22:42So we know it's out there.
22:44The team now wonders, were the 167 people on board victims of a terrorist attack?
22:52Investigators are concerned an act of terrorism may have brought PIA flight 268 to a violent end in the Himalayas.
23:11Pakistan International Airlines has been on high alert for over a decade since one of its planes was hijacked for 13 days in 1981.
23:20As a result, the airline routinely places armed guards on high risk routes.
23:29There were four air guards on this flight.
23:32They turn to the passenger manifest for more information.
23:36Here, here, here and here.
23:42As often happened in Pakistan Airways flights, there were a number of security guards on board,
23:47which would probably tend to suppress unlawful interference.
23:53The controller reported that the first officer's final radio call, just 32 seconds before impact, was calm and professional.
24:02We'll call you at four miles, Pakistan 268.
24:06No hint of a struggle.
24:07That helps us to understand that on the flight deck, things were pretty normal.
24:12The crew were probably therefore not being interfered with by a hijacker.
24:16I think we can rule out an intruder.
24:20Now what?
24:22Could be weather?
24:24In Kathmandu, they're quite often build up some clouds.
24:29And they can develop into thunderstorms or cumulonimbus types clouds.
24:32And the suspicion was maybe there was some sort of cloud like that on the approach.
24:38This is everything from the time of the accident.
24:41Investigators examine weather conditions throughout the flight.
24:46The report was cloudy with a potential for storms.
24:49But because the crew had deviated around bad weather.
24:57Kathmandu, Pakistan 268.
24:59We are 10 to 15 miles right of track to avoid the build up on route.
25:03It's unlikely they then flew into a thunderstorm.
25:10By now, the team has ruled out all possible external factors for this accident.
25:15Flaps were out, engines spinning, no intruder, no serious weather on approach.
25:23They're left with only one conclusion.
25:26They must not have known that they were flying too low.
25:29Clear for finals, runway 02.
25:33Runway 02.
25:35Next altitude is 6800 at 8 miles.
25:39Now crossing through 7500, 7400.
25:45It's clear in this situation that the pilots have built up a picture of the outside world that is not true and accurate.
25:58Which leads to the crash.
26:00However, we have to ask questions why that may be.
26:07Investigators look into two possibilities for the flight's dangerously low altitude.
26:12Either they ignored their chart and were doing a visual approach, or they somehow misread the chart.
26:18Nothing else makes sense.
26:20We had no way of knowing why it was too low.
26:24So that became a matter of studying the data and having a general round table discussion.
26:30Right. Let's start with the visual approach.
26:32Roger, Pakistan 268. Report 1-0 miles.
26:33Roger, call you at 1-0 miles, Pakistan 268.
26:35We can save some time by going visual. Watch my speed. We should soon see the runway.
26:48On a visual approach, pilots fly based almost entirely on what they can see.
26:53Yes, Commander. Visual to runway 02.
26:55Rather than a predetermined route.
26:58Flaps 10.
27:00Flaps 10.
27:02Flaps 15.
27:04Flaps 15.
27:06In many instances, visual landings are easier for pilots.
27:11Watch for the runway.
27:13But with a greater risk of human error.
27:15What's happening?
27:16No, no, no, no!
27:17It's possible, but...
27:27Almost total cloud coverage throughout the entire approach.
27:31Plus, they knew the terrain.
27:33The captain made this approach at least seven times.
27:36The first officer, five.
27:38Investigators conclude it's highly unlikely the flight crew attempted a visual approach in thick clouds.
27:45It's a complicated arrival.
27:48It requires a step down at various points toward the runway threshold.
27:53And perhaps most significantly, the meteorological conditions were not conducive to a visual approach.
27:59Pakistan 268, report 16 miles.
28:02The only theory left is that the pilots somehow misinterpreted their approach chart.
28:07Seattle approach, Commander.
28:08Here it is. Watch my levels.
28:13Everything was working, technically.
28:16It didn't appear to be any interference on the flight deck by anyone.
28:20And so the only conclusion that we can take from this is that, for some reason, the pilots had clearly misinterpreted data.
28:27All right. Let's look at this.
28:35Investigators hope the flight's black box data, back from Paris, will help solve the mystery.
28:42They look at the plane's flight path as the crew prepares for landing.
28:46They started their descent. At 16 miles out, they're at 10,500 feet.
28:51Then down to 9,500 at 13 miles.
28:558,200 at 10 miles.
28:57Then quickly down to 7,500 until impact at 7,280.
29:02The data reveals an astonishing fact.
29:05So, 1,000 feet too low, right from the get-go.
29:08The approach to Kathmandu is one of the last places on Earth a pilot would risk flying too low.
29:24Wait a minute.
29:26There you go.
29:28Perfect match.
29:31They were flying the approach, but one step ahead.
29:34What the aircraft flew was pretty much what the chart said, except that the pilot had got one step ahead of himself.
29:45So, he's flying the correct altitude for the next position, which was a sort of eureka moment, I think, in this investigation.
29:56He's adjusting his descent to hit the lower altitudes.
30:00It's no accident.
30:01We obviously started to wonder why this should be the case.
30:08Still working in the shadow of the Thai Airways crash just two months earlier.
30:13Are we ready? Let's hear it.
30:15Investigators now hope the Pakistan Airways cockpit voice recording will shed light on what happened in the cockpit in the lead-up to the fatal collision.
30:24But as the team begins listening to the CVR, they get a gut-wrenching shock.
30:34The cockpit voice recording of PIA flight 268 is playing the last thing investigators want to hear.
30:53Silence.
30:54But then...
30:55We are entering an area of turbulence and I request all of you to remain seated.
31:05The tape has recorded the announcements made to the cabin and conversations with controllers, but not the conversations between the two pilots.
31:13Okay, I saw nothing from the cockpit mic.
31:20It's a major setback.
31:24Back to the drawing board.
31:25Without the full cockpit voice recording, investigators need to find other ways of understanding why the pilots of flight 268 were flying a thousand feet too low at every step of their approach.
31:41We have to therefore build a picture of what might have been going on in their minds, in the relationship between the two pilots and in their relationship between themselves, the physical environment and air traffic control.
31:56What if the problem is the actual approach chart itself?
32:00To avoid the mountains surrounding Kathmandu, pilots follow an approach chart about the size of a large postcard.
32:06It provides the specific altitudes pilots must take at set distances from the airport.
32:13They study the same chart used by the flight crew.
32:17So is, let's say, 8200 feet the right altitude for 10 miles or 8 miles?
32:25It's hard to say.
32:27Even harder when it's actual size.
32:29The operations team spent a lot of time looking at the chart that the crew had been using.
32:36They concluded that there was a large amount of information on it.
32:39It was a lot of clutter.
32:42Investigators need to know how the crew would have prepared themselves for the complicated approach.
32:49They examine the cockpit layout of an identical Pakistan International Airlines Airbus A300.
32:55There's no place to clip an approach chart here.
33:00Most aircraft have little clips on the control column to attach the approach plates to.
33:07Now this particular aircraft didn't.
33:09There is just here.
33:11Now only the captain can see it.
33:13And he'd have to keep turning his head.
33:15Unlikely they use that.
33:17More likely he put it here.
33:20The other clip is a full three feet away from either pilot.
33:24That's not much better.
33:26It's almost impossible to read.
33:28And that handle is blocking the descent profile.
33:31They learn that Pakistan International Airlines has only two places for pilots to clip their charts.
33:36Both positions make it very difficult to read a four inch wide piece of paper.
33:41It's difficult to make a quick reference if you're having to sort of look to the right or to the left for a chart.
33:45Could it be?
33:48Then quite by accident the investigators discover a key clue regarding the pilot's misreading of the approach chart.
33:59If you pick up the chart and happen to put your thumb over the 11,500 foot mark for 16 nautical mile marker.
34:09In that case it might have guided his eye to the next height fix and he might have assumed that that was the correct height for the 16 mile marker point.
34:19This definitely makes it look like 10,500 is the correct altitude at 16 miles.
34:27Robinson finally has a theory he can put to the test.
34:30Good afternoon Pakistan 268 25 miles at 11,500.
34:40Just a few minutes before impact the first officer reports being 25 miles from the airport at the correct altitude of 11,500 feet.
34:49Pakistan 268 report 16 miles, wind 180, expect Sierra approach.
34:57Roger, call you at 16 miles, expecting Sierra approach.
35:00Sierra approach, commander.
35:02But when the captain looks at the approach chart, his thumb may have obscured the correct next altitude.
35:09Here it is. Watch my levels.
35:10Now instead of maintaining 11,500 feet, Captain Janjua dials in the next altitude on the chart.
35:19Descending to 10,500.
35:22Oblivious that his plane's approach is now one step ahead.
35:27The crew has now made a fatal mistake, unaware the airliner is now descending towards a violent collision with the side of a mountain.
35:35So that was where it all started.
35:41Investigators now pursue the new theory that the pilots of flight 268 misread the altitudes on a cluttered approach chart.
35:52At 16 miles, they should be at 11,500. But they've descended to 10,500.
35:58The team has a surprising realization.
36:00But then they report being at 11,500.
36:09At the 16-mile mark, the first officer reports the altitude they should be at, 11,500 feet.
36:16Pakistan 268 is at 16 miles, 11,500.
36:20Instead of 10,500, the lower altitude they're actually at.
36:24The investigators have uncovered a new mystery that goes right to the heart of what went so horribly wrong.
36:35Why did they descend to 10,500 and then report being at 11,500?
36:39Andrew Robinson's team returns to the flight data, hoping to understand why the pilots of flight 268 misread and misreported their approach altitudes before the crash.
36:56A slat extension, a frequency change, and then flaps and landing gear.
37:00He was a busy guy.
37:03It's a fast and steep approach, and unless you're a pilot with considerable experience flying this route maybe several times in a week, it's going to be very testing.
37:13Descending to 10,500. Initiating descent.
37:18Investigators now believe that as the distracted flight crew approached 16 miles...
37:22Throttles to flight idle, slats 15.
37:26Their attention was consumed by the demands of the busy descent.
37:30Flats 10.
37:32Flats 10.
37:33Flats 15.
37:35Landing gear down.
37:37By now, the captain has already dialed the flight's descent a thousand feet too low.
37:42Gear down. Three green.
37:44We're at 16. Report our position.
37:47Pakistan 268 is at 16 miles.
37:49Investigators think the first officer hastily misreports the altitude on the approach chart.
37:5511,500.
37:58Without double checking his altimeter.
38:01Then, Captain Janjua is too busy to notice the discrepancy between the reported and actual altitudes.
38:09In quite a stressful environment, such as the arrival at this airport,
38:13the build-up of pressure inside the pilot must be quite considerable.
38:19And their capacity to assimilate, take in information, read what's going on around, is going to be severely taxed.
38:26Can we hear his next report, please?
38:32Pakistan 268 is at 10 miles.
38:35Report your level.
38:36We crossed out of 8,500... 200 now.
38:40When he makes this report, he's at 8,100 feet.
38:44We crossed out of 8,500... 200 now.
38:59Roger. Clear for final.
39:01Report four miles. Runway.
39:02Both pilots seem to have made mistakes.
39:05But air traffic control could have caught them and sounded the alarm.
39:10Why did the air traffic controllers not speak up? Why did they not say anything?
39:19Investigators head to Kathmandu Airport to find out why air traffic controllers didn't warn Flight 268 it was flying too low before it crashed.
39:30I did not know his exact position.
39:33So I had no way of knowing what the terrain below him was.
39:36In this case, without radar, it's really the responsibility of the crew to make sure of where they're flying in their approach.
39:43They also learned that pilots flying into Kathmandu often reported being at altitudes lower than the ones specified on the chart.
39:51When the mountaintops are covered in clouds, pilots will sometimes dip under them and fly over this valley instead.
39:57We crossed out of 8,500... 200 now.
40:04If the pilots of Flight 268 had detoured around the mountain, 8,200 feet would be a safe altitude.
40:12Radar coverage in this area was not well developed.
40:16And therefore, it was very much a procedural approach and not one that relied on inputs from the air traffic controllers themselves.
40:23They were recipients of information and not really guiding the aircraft in.
40:29It all starts with the initial misreading of the chart and spirals forward from there.
40:34Investigators believe they've finally developed an explanation for how the tragic accident unfolded.
40:40The first mistake is made before the 16-mile marker, where the captain likely misreads the approach chart.
40:53Here it is. Watch my levels.
40:55And enters the altitude for the 13-mile marker one step ahead.
41:00Descending to 10,500.
41:03Land the gear down.
41:07Gear down.
41:09We're at 16. Report our position.
41:11Then, likely distracted by the busy approach, the first officer misreports their altitude.
41:16Pakistan 268 is at 16 miles.
41:20He reports where they should have been.
41:2311,500.
41:25Not where they actually are.
41:28Investigators believe that if the captain had caught and checked that discrepancy, the flight's outcome might have been completely different.
41:36At that point, there was scope to correct and get back on track.
41:42But the profile suggests that they thought they were on the correct altitude and everything stemmed from there.
41:50So they carried on being that one step ahead.
41:54Flight 268 remains 1,000 feet below the recommended safe altitude for what's left of its fatal descent.
42:05We crossed out of 8,500.
42:09200 now.
42:11Next altitude is 6,800 at 8 miles.
42:15Now crossing through 7,500.
42:187,400.
42:22Attack!
42:24No, no, no, no, no!
42:27Three minutes after they first misread the chart, they impact the ground.
42:32What is quite striking is that it is a very difficult approach.
42:36And in spite of that, the pilots are actually operating effectively, but not safely.
42:42This is at the heart of crew resource management.
42:45And that has failed in this accident.
42:48In the end, if the plane had been just a few hundred feet higher, it would have missed the mountain and 167 lives would have been spared.
43:01In the aftermath of the flight 268 tragedy, investigators make a number of recommendations to prevent another accident due to a misread approach chart.
43:10Chief among them is simplifying the Sierra approach itself, to make it less complex and challenging.
43:19They also recommend installing air traffic radar at Kathmandu, and suggest Pakistan International Airlines install clips on the control columns of all its A300 airplanes.
43:32Minor things like the provision of chart clips, installation of radar, it's a gradually improving picture.
43:40And things hopefully still will continue to improve.
43:44A memorial to the victims of flight 268 stands at the foot of the mountain where it crashed.
43:49They're still remembered by people of my generation.
43:54They're still remembered as people who did a lot and would have done a lot more in the world of mountain training.
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