- 6 months ago
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00:00a brand new 737 takes off during an intense storm they should be there by
00:10now and then mysteriously falls from the sky over West Africa those who operate
00:19these type of aircraft they have the same question what happened what happened in
00:22Cameroon investigators scour the crash site for clues the ground over there this was
00:33the toughest accident scene I've been on in my career but look at this when the
00:39investigators review the flight data they discover there was an inexplicable fight
00:48for control in the cockpit
00:55who plays like that
01:18in Douala Cameroon Kenya Airways flight 507 is almost an hour behind schedule
01:28ladies and gentlemen we are going to wait for the weather conditions to improve before the
01:36tip-off a severe storm must pass before the pilots can depart there are 108 impatient
01:48passengers on board many need to catch connecting flights flight 507 began in
01:58Abidjan earlier in the day it's now bound for Nairobi Kenya 507 was a very common flight
02:08for Kenya Airways particularly last decade the amount of traffic from East Africa to
02:13West Africa has really increased partially because there's much more business going on
02:16the Boeing 737 ng recently acquired by Kenya Airways is the newest generation of twin engine commercial jets this was a new era of aviation in Africa where airlines and particularly the bigger ones invest in brand new aircraft
02:36captain Francis Wamweir is in command of tonight's flight he's an experienced pilot with more than 8000 hours in the cockpit
02:55Andrew Kiryu is his first officer
03:01the young pilot joined Kenya Airways a year ago
03:06let's see what this storm is doing
03:09the pilots use the 737's on-board weather radar to monitor the storm
03:15looks like there might be a way around it
03:19now that the storm has moved off the end of the runway
03:24captain Wamweir believes he can fly past it
03:28it's quite common that the weather may be a factor in delay in Africa because of its severity
03:33so it's not in that respect a surprise for the operator to find this kind of weather at that time of the night
03:38tower Kenya 507 looks like there's a break in the weather requesting start-off
03:47a few minutes before midnight flight 507 is finally ready for takeoff
04:06okay request taxi clearance
04:10Kenya 507 requesting taxi clearance
04:15taxi runway 12 Kenya 507
04:22taxi runway 12 Kenya 507
04:26put on the wipers
04:42right is clear
04:49the crew taxis to the runway
04:53there's one flight ahead of them Royal Air Maroc flight 287
04:57Royal Air Maroc flight 287
05:00Royal Air Maroc 287 in position
05:04runway 12 latest weather please
05:08visibility 800 meters
05:10welcome rain moderate thunderstorms
05:14alright
05:16287
05:17cleared for takeoff
05:19the Royal Air Maroc flight departs without incident
05:30wait till we line up
05:32okay
05:34usually
05:35things happen quickly though
05:37okay
05:39okay
05:40try to keep up
05:44okay
05:47captain
05:49when we are double checks
05:51the storms position
05:52let's have a look
05:54and confirms the route around the lingering storm cell
05:57tower
05:59Kenya 507
06:00after departure
06:02we would like to maintain a heading
06:04slightly left of runway
06:06due to weather ahead
06:07right
06:08ah
06:10sorry
06:11slightly right
06:12just after the aircraft took off
06:14just after the aircraft took off
06:16the plan was to make a small turn to the right
06:18to avoid the most active weather cells
06:19that they saw on the weather radar
06:21in front of them
06:22approved
06:24okay
06:25all done
06:27ladies and gentlemen
06:31a kind reminder to ensure your seatbelts
06:33are well fastened for takeoff
06:35cabin crew to your seats
06:37okay
06:50takeoff trust is set
06:52speed building on both
06:54check
06:5580 knots
06:57check
06:58V1
07:00rotate
07:02just after midnight
07:06Kenya Airways flight 507
07:09finally departs
07:10for Nairobi
07:13get up
07:14okay
07:251,000 feet and climbing
07:27heading select
07:30selected
07:31check
07:32the 737 starts turning right
07:38to avoid the storm
07:39anyone
07:41okay
07:42come on
07:43so
07:44should I remain on this heading
07:46yep
07:472400 feet and climbing
07:53now we're getting into it
08:00now we're getting into it
08:04hold on
08:10bank angle
08:12bank angle
08:13bank angle
08:14suddenly the 737 rolls dangerously to the right
08:18bank angle
08:19bank angle
08:20bank angle
08:21bank angle
08:22bank angle
08:23bank angle
08:24bank angle
08:25bank angle
08:26bank angle
08:27bank angle
08:28bank angle
08:29bank angle
08:30bank angle
08:31bank angle
08:32bank angle
08:33bank angle
08:34bank angle
08:35bank angle
08:36bank angle
08:37bank angle
08:38bank angle
08:39bank angle
08:40bank angle
08:41bank angle
08:42bank angle
08:43bank angle
08:44bank angle
08:45bank angle
08:46bank angle
08:47We're crashing!
08:56Yeah, we are crashing!
08:57Left! Left!
08:59Left correction!
09:00Three, three, four, up!
09:03Up! Up! Up!
09:17Five hours later, the controller in Douala is ending his shift.
09:34Doula Tower.
09:40No reason I can think of. They should be there by now.
09:43Kenya Airways Flight 507 should have landed in Nairobi 45 minutes ago, but the plane has still not arrived.
09:52Sure.
09:54And no one even knows where to start looking for it.
10:02Kenya Airways Flight 507 was due in Nairobi at 6.15 a.m. local time.
10:10But it never arrived.
10:13By morning, news of the missing 737 has spread.
10:20Families and friends of the passengers want to know where their loved ones are.
10:31Engelbert Zawar Etundi worked for Cameroon's Civil Aviation Authority.
10:35When I first heard that an aircraft was missing, I immediately thought we were going to have a catastrophe on our hands.
10:46Two days later, search teams finally locate the wreckage of Kenya 507.
10:57The 737 has crashed into a mangrove swamp and is submerged in mud and water.
11:09As a nation, we are united in grief.
11:22We are united in grief with the 20...
11:25It's a tragic turn of events.
11:29Victims, friends and family are demanding answers from the Cameroonian government.
11:34But the government has a problem.
11:38Cameroon did not have an agency in charge of air accident investigations.
11:43Investigators from several countries descend on Cameroon.
11:53Since the Boeing 737 is manufactured in the United States, Dennis Jones from the U.S. National Transportation Safety Board, the NTSB, joins the investigation.
12:09The fact that it was a relatively new airplane at the time certainly made it a little bit more compelling.
12:17But all around the world, those who operate these type of aircraft, they have the same question.
12:22What happened? What happened in Cameroon?
12:26It's all from detail.
12:30Looks like everything else is down in there.
12:34I saw a lot of debris from the town section.
12:36And we were not able to see the wreckage itself because we were in a swamp.
12:42And that was another challenge throughout the whole process.
12:53A technical advisor for Boeing, Mark Smith, also joins the team of investigators.
13:00This was the toughest accident scene I've been on in my career at Boeing.
13:05We're standing there looking around at the devastation, the destruction.
13:09So we have to, as a team, start working on what happened to where are the various pieces.
13:18A key piece of evidence is quickly found.
13:22The 737's flight data recorder.
13:25Well, looks pretty good, considering.
13:31The FDR is sent to Canada's Transportation Safety Board to be downloaded.
13:36While searchers continue looking for the cockpit voice recorder,
13:47investigators try to determine what caused the plane to crash so soon after takeoff.
13:53The airport is only three and a half miles away.
13:59They can't have been in here in more than two minutes.
14:03We really didn't have a clue.
14:07They're looking for explanations.
14:09We were able to start doing a lot of on-scene examination documentation,
14:14trying to get an idea how it impacted the ground.
14:16The layout of the wreckage tells investigators how the plane was flying on impact.
14:29Completely obliterated.
14:31So I haven't found the most of it.
14:34Looks like it came in hard and fast.
14:38When you have a high-speed impact like that in a nose-dine attitude,
14:41you usually get extensive fragmentation of aircraft.
14:44Actually, what we're trying to do is estimate, if we can,
14:49an angle and maybe even a speed of impact
14:53to try and get a feel for what happened.
14:55Because, once again, we don't yet have the FDR data.
15:01How deep does this go?
15:05More than 15 feet.
15:08I'll definitely hit nose first.
15:10And hard.
15:11So, was there some kind of loss of control that took place?
15:17That was what was kind of foremost on my mind.
15:25While they wait for the flight data,
15:27investigators turn to the controller on duty that night
15:30to help fill in some blanks.
15:32What can you tell me about that night?
15:36The first thing is that they delayed their take-off.
15:40Really?
15:42How come?
15:43There was a storm coming in from the east.
15:45Power, 5-0-7.
15:55You're going to wait for the storm to pass.
15:57Cancelling start-up.
16:00Roger, 5-0-7.
16:02Cancelling start-up.
16:04The storm can last all night, but visibility should improve.
16:06The airplane was on the tarmac, loaded, ready to go,
16:11waiting for the weather to clear,
16:13and then they would take off.
16:17But, 20 minutes later, they decide to take off.
16:20Why?
16:21It cleared a bit.
16:22And they were going to try to get around it.
16:24Tower, Kenya, 5-0-7.
16:33Looks like there's a break in the weather.
16:35Requesting start-up.
16:38OK, 5-0-7.
16:39Start-up approved.
16:43The controller explains how the crew planned to fly to the right of the storm.
16:47Is it possible the crew misjudged the storm's size and strength?
16:59NTSB investigator Bill Bramble also joins the team.
17:04They had a cell 8 miles off the end of the runway,
17:07so the crew was using their own radar to decide how to maneuver around the cell.
17:14Here's a manological report from that night.
17:17Thunderstorm and rain over the airport with winds gusting up to 20 knots.
17:25But it was starting to clear.
17:28Investigators wonder if the wind and rain were still severe enough to bring down a 737.
17:35He asked permission from the controller to go around the storm.
17:39To the right.
17:42Maybe the storm was worse than he thought.
17:44There was a weather delay for several flights.
17:49KQ-507 was one of four flights that were delayed on the ground for about an hour.
17:57Investigators need to speak to other pilots who took off from Douala that night.
18:02How intense was the storm once they were in the air?
18:06I will speak to one of the pilots tomorrow.
18:15Investigators interview a pilot who departed immediately after Kenya Airways Flight 507.
18:21They need to find out if he had any difficulty avoiding the storm.
18:29The flight crews solely depended on their own onboard systems to understand what they were getting into.
18:35There was no assistance from the ATC.
18:38He said the weather was smooth after they took off.
18:48They did the same thing too.
18:49They took off and turned to the right to circumnavigate the weather.
18:53Okay.
18:54Thank you for your time.
18:56Investigators conclude the pilots could have maneuvered around the storm on their flight path.
19:00With weather ruled out, the team wonders if there was a mechanical issue with a brand new 737.
19:12This was important because it was the first for the 800 series.
19:16And if there's an accident and it's not immediately understood what the problem is,
19:20it's really important to get to the bottom of it.
19:22Technicians in Canada have been able to extract the FDR data.
19:33Let's see what we've got.
19:35They read the data out.
19:38Altitude, airspeed, bank angle, pitch attitude, those sorts of things.
19:43Once you plot those out, you can start seeing what occurred.
19:48Any malfunction warnings during the flight would provide an important clue.
19:55There might have been some kind of mechanical issue that might have popped up.
20:00No warnings.
20:02They find no signs of any system failure.
20:06The data showed us the airplane was behaving as we would expect it to.
20:11It was a perfectly airworthy aircraft.
20:13There's no question about it.
20:14As the team continues looking through the data,
20:19But look at this.
20:21They discover that just over a minute into the flight,
20:24a different kind of alert did go off.
20:28Bank angle alert at an altitude of 2,800 feet.
20:32For investigators, this is their first real clue about what happened to flight 507.
20:38Any roll exceeding 35 degrees is considered extreme.
20:47Once reaching that angle, a warning alerts pilots of danger.
20:53Rotate.
20:55When investigators review the pilot's inputs after takeoff,
20:59they make a critical discovery.
21:02Get up.
21:03Okay.
21:04He was turning left from the moment they left the ground.
21:11That information showed us that right after takeoff,
21:14the aircraft started to roll to the right a little bit,
21:16and the pilot corrected it.
21:20And then he keeps making corrections to the left.
21:23Looks like he's trying to keep the plane level.
21:25But what caused the slow roll to the right in the first place?
21:36Bingo.
21:38That's the way the flaps are rigged.
21:40Give it a slight right roll.
21:43The aircraft had a tendency to roll to the right.
21:46The flaps increase a plane's lift at slower speeds.
21:52On this particular airplane,
21:54the left flap provided slightly more lift than the right one.
22:00It's similar to driving down the freeway in your car
22:04and just letting go of the wheel.
22:07If I was to do that,
22:09then it'll start to drift off one way or another.
22:12That's the way the airplane was slowly and naturally banking it.
22:18This discovery explains why the captain kept his control column
22:22turned to the left immediately after takeoff.
22:28Well, that's weird.
22:30But it doesn't explain an even more puzzling element of the flight data.
22:36Look at this.
22:37The captain's control wheel input seemed to stop.
22:41It's like he just let go of it.
22:43Six degrees right, he does nothing.
22:46Eleven degrees.
22:47Fifteen degrees.
22:49Twenty degrees.
22:50Thirty degrees and still nothing.
22:54As the plane's bank angle approached 35 degrees,
22:57neither pilot took action to stop the increasingly dangerous roll.
23:02Bank angle.
23:04Bank angle.
23:05Oh, look!
23:05Until the bank angle warning sounded.
23:08Bank angle.
23:10And then he does this.
23:13Right, left, right again, left again.
23:19In the last moments of the flight,
23:22we noticed an erratic movement of the control column
23:25that didn't make any sense.
23:27For 16 seconds after the bank angle warning,
23:37the aircraft continued its dangerous roll.
23:43The airplane just continues to roll right up to 110 degrees of bank.
23:49The crew didn't recover it before impact.
23:51Bank angle.
23:53Bank angle.
23:54The data paints a baffling picture of the one-and-a-half-minute flight.
24:04Who flies like that?
24:05That was puzzling to us.
24:11So it really highlighted that we need more information,
24:15we need more data,
24:16and that data is the CVR.
24:18The CVR is what tells us the conversation,
24:21what might they have been looking at.
24:23But after weeks of searching the crash site,
24:28there's still no sign of the cockpit voice recorder.
24:36It's been more than a month
24:37since the crash of Kenya Airways Flight 507,
24:41and the cockpit voice recorder has still not been found.
24:49We spent days scouring the site,
24:53up-track, down-track, everywhere,
24:56looking for the CVR, trying to find it.
25:01The team now uses a tracking device
25:03to scan the swamp for a signal from the box.
25:06Five weeks after the crash,
25:13the cockpit voice recorder is finally recovered.
25:17That was a very, very exciting time
25:20for everyone involved with the recovery,
25:22as well as the investigation group itself
25:24for having that information.
25:25Okay, let's start on the ground.
25:31Started.
25:33Investigators hope the recording
25:35will explain why the pilots
25:37let their plane bank so dangerously to the right.
25:42Tower.
25:43Kenya 507.
25:45Looks like there's a break in the weather.
25:48Requesting start-up.
25:49Okay, 507.
25:50Start-up approved.
25:52Okay.
25:53Request taxi clearance.
25:55They hope the recording will also explain
26:00how they ended up spiralling into a swamp.
26:041,000 feet and climbing.
26:07Heading select.
26:09Okay, this is where he stops making any inputs.
26:14Selected.
26:15Check.
26:17N1.
26:18Okay, command.
26:19That's the call to activate the autopilot.
26:25So, should I remain on this heading?
26:29Yep.
26:33After calling for the autopilot to be engaged,
26:36Captain Wamweer released the control column,
26:39trusting the autopilot to fly the plane.
26:41But there's a problem.
26:46The autopilot didn't come on.
26:49He thought the 737 was flying itself.
26:51There was nobody flying the control,
26:55so nothing was controlling the airplane.
26:57The discovery changes the course of the entire investigation.
27:04N1.
27:05Okay, command.
27:08Why didn't the autopilot come on?
27:11The captain calls for the autopilot to be engaged.
27:13The first officer does not respond.
27:18The procedure should be for the first officer
27:20to push the button and say,
27:22the autopilot engaged.
27:25Okay, command.
27:27So, should I remain on this heading?
27:30Yep.
27:33Investigators believe the first officer
27:35was so focused on inputting the route around the storm
27:38that he failed to engage the autopilot.
27:442,400 feet and climbing.
27:51Now we're getting into it.
27:53Meanwhile, the captain assumed the autopilot was engaged
27:57and controlling the pre-selected right turn.
28:01Ah!
28:02Bank angle, bank angle.
28:05The pilots only noticed a problem
28:07when the bank angle warning went off.
28:10Bank angle, bank angle.
28:13It's pretty clear the captain expected the autopilot
28:16to be engaged and it didn't get engaged.
28:19And then neither crew member picked up the fact
28:21that it wasn't engaged.
28:23We're crashing!
28:24Yeah, we are crashing!
28:26Left, left!
28:28Left direction!
28:29Jump!
28:29Jump!
28:30Why did neither crew member take the critical step
28:49of engaging the autopilot?
28:51Standard operating procedures provide a safety net for crews,
28:57but if crews don't adhere to the standard operating procedures,
29:00they lose that protection.
29:02They comb through Kenya Airways' procedures
29:05to see who has responsibility for activating the autopilot.
29:09It's not really clear who was supposed to do it.
29:17All it specifies is turn on
29:20when above minimum altitude for engagement.
29:23It's not very helpful.
29:24It wasn't really clear
29:28in the standard operating procedures
29:30of when the autopilot does come on,
29:32who's responsible for doing that
29:34and what the response should be to that.
29:37Hold on!
29:38Bank angle, bank angle.
29:42Recovering from a 35-degree bank
29:44is not a complicated procedure.
29:51Bank angle, bank angle.
29:53The bank angle warning is designed
29:55to give pilots enough time to react.
29:59But for some reason,
30:00this crew wasn't able to do that.
30:06The team digs into their records.
30:10This is what we have on one way up.
30:14Lots of experience.
30:1616 years as a pilot,
30:18most of those on the 737.
30:20Let's see what this storm is doing.
30:22The captain had been a flight attendant
30:25for Kenya Airways years and years ago
30:27and then went to flight school
30:29and got his ratings
30:31and transitioned into the role of pilot.
30:36Wait.
30:38Look at this.
30:40But the captain's training records
30:42reveal serious shortcomings.
30:44Inadequate knowledge of systems and procedures,
30:48insufficient flight discipline,
30:50poor cockpit scans,
30:52below standard.
30:53Yikes.
30:56Get up.
30:57Can't.
30:57We discovered the captain had a history of training difficulties
31:01and lack of systems knowledge
31:04for autoflight systems and so forth.
31:07So he had some red flags in his history.
31:09The first officer's report
31:13isn't any better.
31:15Feel to monitor autopilot when engaged.
31:19V1.
31:21Rotate.
31:22The first officer was young
31:23and fairly inexperienced.
31:25He only had a little over 800 hours of flight time
31:28and he had had some training feedback
31:32that involved things like
31:34you need to be more proactive
31:36about calling out deviations and so forth.
31:39Not an A-level crew.
31:45We're crashing!
31:48Left direction!
31:49Take angle.
31:50Did a lack of skills in the cockpit
31:53doom the 108 passengers on board the flight?
32:09Investigators need to determine
32:11if pilot error caused the horrific crash
32:14of Kenya Airways Flight 507.
32:20Okay.
32:23Allah.
32:24He's definitely surprised.
32:27Then 22 degrees to the right,
32:3220 left,
32:3445 right,
32:37then 11 to the left.
32:39That's not helping.
32:43Oh!
32:43Bank angle!
32:45Bank angle!
32:46Ah!
32:47When the bank warning came on,
32:50and the aircraft was on a right roll,
32:52the first response
32:53was the captain
32:54turned it further to the right
32:56and which aggravated the situation.
33:00Now the bank angle
33:01is approaching 50 degrees.
33:05As the situation
33:07grew worse
33:09after the bank angle warning
33:11and the confusion amongst the crew,
33:14the autopilot does engage
33:16and the captain pushed that button.
33:18Bank angle!
33:19Bank angle!
33:20Bank angle!
33:20The team discovers
33:21that when the captain
33:22finally realized
33:24the autopilot was not engaged,
33:26he activated it.
33:27Bank angle!
33:28Bank angle!
33:32Bank angle!
33:33Bank angle!
33:33Bank angle!
33:33But when it didn't immediately
33:35level the plane,
33:36the captain turned the control column
33:38erratically,
33:40an action which overrode
33:41the autopilot.
33:42Bank angle!
33:43We're crashing!
33:44Yeah, we are crashing!
33:45Bank angle!
33:46Bank angle!
33:47And yes,
33:47we are crashing!
33:48We are crashing!
33:49Left, left,
33:51left correction!
33:55So now one's trying to turn left
33:58while the other
33:59turns to the right.
34:02They're fighting each other's inputs.
34:05Left!
34:05Left!
34:07Left correction!
34:09Jump!
34:09Bank angle!
34:13Bank angle!
34:13Bank angle!
34:14I don't get it.
34:24It should have been
34:25a simple recovery.
34:28The back and forth
34:28was trying to
34:29do corrective actions,
34:31but it didn't seem like
34:32it was correcting anything.
34:36He's already banked
34:37onto the right
34:3834, 35 degrees.
34:40Why would he row further?
34:41Well, that's the question
34:43we have to answer
34:44right there.
34:46Investigators use
34:47a Boeing simulator
34:48to recreate
34:49the final stages
34:50of the flight.
34:52From the simulator,
34:54you can literally
34:54put yourself
34:54in the driver's seat
34:55and reconstruct
34:57the flight
34:57and be there
34:58at the pilot
34:59to be able to
35:00determine
35:00whether we can recover.
35:04Can we give it
35:04a 50 degree
35:05right bank, please?
35:10Activate the autopilot,
35:11please.
35:11Exactly what it's
35:17supposed to do.
35:18The roll is slowing.
35:21And the inputs
35:22we discussed.
35:25Right,
35:26left,
35:28right.
35:29Jeez.
35:30There goes the autopilot.
35:31Bank angle's
35:32increasing again.
35:36Bank angle!
35:37Bank angle!
35:38The simulation shows
35:39that if the captain
35:40had given the autopilot
35:41enough time
35:42to take control,
35:44the 737
35:45would have returned
35:46to a relatively safe
35:48bank angle.
35:49But his erratic inputs
35:51prevented that
35:52from happening.
35:55If only he'd done nothing.
35:56It was determined
35:58that recovery
35:59was still an option
36:00just a few seconds
36:03before impact, really.
36:06Investigators are puzzled.
36:08Why wasn't the
36:09experienced captain
36:10able to execute
36:11such a straightforward
36:12recovery?
36:13Was there something here
36:16that we were missing
36:17in the investigation
36:17that may have
36:19confused the crew?
36:21So we started
36:22looking harder
36:23at the possibility
36:24of spatial disorientation.
36:26from the simulator?
36:31Yeah.
36:32Just darkness outside.
36:34No reference at all.
36:37It was a completely
36:39black view
36:41out the windshield.
36:43If you look up
36:43out the windshield,
36:44you have no ground
36:45reference
36:46that could immediately
36:47have helped you
36:48straighten the airplane
36:49out.
36:50Hold on!
36:51Bank angle!
36:53Bank angle!
36:53Spatial disorientation
36:56is an inability
36:57to distinguish
36:58up from down,
36:59left from right.
37:00Bank angle!
37:02It has been known
37:03to hinder judgment
37:04and delay response times.
37:06Bank angle!
37:07Bank angle!
37:08We're crashing!
37:09Yeah, we are crashing!
37:11Left!
37:11Left!
37:13Left correction!
37:14Bank angle!
37:14Bank angle!
37:15Only the first officer
37:17seemed to assess
37:18the situation correctly.
37:19What the fuck are you doing?
37:21Bank angle!
37:22Bank angle!
37:22First thing he says
37:23is, yeah,
37:24we are crashing.
37:26It took him
37:26ten seconds
37:27to speak up.
37:31Bank angle!
37:32Bank angle!
37:38Bank angle!
37:39When the bank angle
37:41alert went off,
37:42there wasn't much
37:43discussion
37:43about what was happening
37:44until the captain
37:46said,
37:47we're crashing.
37:48Yeah, we are crashing!
37:49Bank angle!
37:49And the first officer
37:51didn't say anything
37:52until he said that.
37:54Left action!
37:55The team listens
38:00to the recording
38:01of the first leg
38:02of the flight
38:03from Abidjan
38:04to Douala.
38:05They are looking
38:06for clues
38:07as to why
38:08the first officer
38:08remains silent.
38:12Let's hear it.
38:14What is wrong with you?
38:16What they hear
38:17shocks them.
38:18When investigators
38:23listen to the cockpit
38:24voice recording
38:25of the first leg
38:26of Kenya Airways
38:27flight 507...
38:29Sorry, did you say
38:30an altitude of 14,000 feet?
38:33Yes.
38:34Don't be so stupid.
38:35Write it down
38:35if you can't remember.
38:37Wow.
38:39They're stunned
38:40by how the captain
38:41treated his first officer.
38:43It was pretty bad.
38:44The captain
38:46was sort of
38:47browbeating
38:47the first officer.
38:49There were words
38:49like stupid,
38:51shut up,
38:52stuff like that
38:53that you wouldn't
38:54expect to hear
38:54in a professional
38:55crew environment.
38:57What is wrong with you?
38:59Did you not hear
39:00the instruction?
39:02Heading
39:022-3-0.
39:05Understand?
39:08The first officer
39:09seemed to kind of
39:10shut down.
39:11Heading
39:122-3-0.
39:15Understand?
39:18He was
39:19at a certain point
39:20sort of reduced
39:21to responding
39:21with these sort of
39:22monosyllabic grunts.
39:27Investigators suspect
39:28this might explain
39:30why the first officer
39:31took so long
39:32to speak up.
39:33Hang on.
39:34The captain's
39:39behavior toward
39:40the first officer
39:41on the first flight
39:42likely caused him
39:44to adopt
39:44sort of a passive role.
39:46You need both pilots
39:47actively engaged
39:48in checking each other
39:50and catching errors.
39:51And if one pilot
39:52adopts a passive role,
39:54they're going to be
39:55less effective.
39:55Captain Wanwia's
40:02treatment of his
40:03first officer
40:04leads investigators
40:05to examine his
40:06professional history
40:08more closely.
40:08Tell me more information.
40:10We spent a lot of time
40:12going to pilot records,
40:14interviewing other
40:15flight crew members.
40:17Are they ready?
40:18Yes.
40:18They quickly learned
40:19that the captain's
40:20shortcomings were not
40:21limited to his
40:21flying abilities.
40:23He had a lot of
40:25concerning things
40:26in his training files
40:28about being overbearing,
40:30being authoritarian,
40:31in terms of how he dealt
40:32with other crew members.
40:36So, we have a young
40:39reserved first officer
40:40and an overbearing captain.
40:43This accident is kind
40:44of a throwback
40:45to those early days
40:46where we were focused
40:47on the issues
40:47of overly assertive
40:49authoritarian
40:50overbearing captains
40:51and submissive,
40:53inadequately assertive
40:54junior first officers.
40:55a lethal combination.
41:00Investigators conclude
41:01the bad pairing
41:02in this flight crew
41:03set in motion
41:04a sequence of events
41:06that led to the crash.
41:09As an investigator,
41:11all of these accidents
41:12I've worked,
41:13it's very clear
41:14there is never
41:15a single cause.
41:17It's always a chain
41:18of events.
41:20So, should I remain
41:22on this heading?
41:23Yep.
41:25A deadly combination
41:27of poor pilot performance
41:30and spatial disorientation
41:33contributed to the accident.
41:35to it.
41:35All the risk factors
41:38were present.
41:39There was distraction,
41:40there was reduced
41:41outside visibility,
41:43and there was confusion.
41:48But in the end,
41:49investigators conclude
41:50that one major mistake
41:52triggered the entire tragedy.
41:54N1, OK, command.
41:58So, should I remain
42:00on this heading?
42:01Yep.
42:06It was the crew's failure
42:08to ensure the autopilot
42:10was turned on.
42:11that ultimately led
42:22to the death
42:23of 114 people.
42:27We're flashing!
42:32Oh!
42:32In the aftermath
42:40of Flight 507's crash,
42:43Cameroon's Commission
42:44of Inquiry
42:45makes a series
42:47of recommendations,
42:48including the regular
42:49update of safety manuals
42:51related to cockpit procedure
42:52and crew responsibility.
42:56They made changes
42:57to the standard
42:59operating procedures
42:59about who's responsible
43:01for engaging the autopilot.
43:03And that was very key.
43:05And improved pilot training
43:07with a focus
43:08on upset recovery.
43:10One technology
43:11that Boeing has
43:13tested and developed
43:15and is looking at
43:16putting into its airplanes
43:17is a roll recovery arrow
43:19so that if you're
43:20at an unusual angle
43:20of bank,
43:21the attitude display
43:22will actually show you
43:24which direction
43:24you need to roll
43:25the airplane
43:25and provide an accompanying aural.
43:30In the end,
43:31you have to look
43:32at training
43:33crew make-up
43:34all adding
43:35into all the links
43:36of chain,
43:37the chain that caused
43:38this to happen
43:39this night.
43:41Let's see what
43:42this storm is doing.
43:43And those who are not
43:44familiar with
43:45accident investigation
43:46think that all the answers
43:47are at the crash site,
43:48it's rarely
43:49at the crash site.
43:51And that's exactly
43:52what happens.
43:54Rotate.
43:54EARING
44:04EARING
44:04EARING
44:04EARING
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