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Air Crash Investigation S23E02 Mixed Signals
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00:00It's the worst aviation disaster in Portuguese history.
00:04144 people are killed.
00:07The scope of the devastation was remarkable.
00:11The wreckage provides little evidence.
00:14They're way too damaged to test.
00:17Air traffic control offers no insight.
00:20Were they advised to use the ILS?
00:22Yes.
00:23Only the final seconds of Independent Air Flight 1851.
00:28Pull up.
00:30They had seven seconds until impact.
00:33Reveal the whole story.
00:36They don't say anything?
00:38I've never encountered anything like this before.
00:42And I never encountered anything like this afterwards.
00:45To say it was unique would be an understatement.
00:49Mayday, mayday.
00:53Pull up.
00:54Independent Air Flight 1851 cruises above the Atlantic Ocean.
01:16There are 137 tourists on board the American charter flight.
01:28Santa Maria, Independent Air 1851, requesting that report.
01:33Less than 30 minutes before landing, the crew prepares for descent.
01:371851, wind 260, 14 knots.
01:4634-year-old flight engineer Jorge Gonzalez checks the weather ahead.
01:52He's a U.S. Air Force veteran with a sterling reputation.
01:5541-year-old captain Leon James Doherty is also from the military and has been flying jetliners for almost a decade.
02:05Let's request descent.
02:08Santa Maria Control, Independent Air 1851 would like to descend.
02:1336-year-old First Officer, Sammy Adcock, just started with Independent Air two weeks ago.
02:21Independent Air 1851, clear to descent to flight level 4-0.
02:27Clear to flight level 4-0, Independent Air 1851.
02:31The crew was a balanced crew.
02:41They had flown together for about a week or ten days and they were doing fine.
02:48They're flying a four-engine Boeing 707.
02:52The long-range, narrow-bodied jetliner has dominated passenger travel for more than three decades.
03:01It wasn't a modern jet at the time, it was 21 years old, but it was well-maintained within all the safety regulations.
03:15Today's flight from Bergamo, Italy, will refuel at Santa Maria, an island in the remote Azores,
03:21before continuing to its final destination, Punta Cana, in the Dominican Republic.
03:27Santa Maria was a popular destination for refueling because of its location in the Atlantic.
03:36It's a small island with a large mountain in the center.
03:42That mountain is called Pico Alto.
03:45At almost 2,000 feet, Pico Alto, or high peak,
03:50is the highest point of a mountain range stretching across Santa Maria.
03:54Pico Alto.
04:12You close the door.
04:14It's a jungle out there.
04:19Are you finished with those?
04:20Yeah.
04:22Thanks.
04:25What's your passing level? Independent air 1851.
04:30Passing flight level 220.
04:3460 miles from the airport, the first officer tunes in to the frequency for Santa Maria Airport.
04:43Good afternoon, Santa Maria Tower.
04:47Today, a trainee in the tower is guiding in the flight with the help of a supervisor.
04:53Independent air 1851, passing flight level 200 to flight level 40.
05:01Independent 1851, roger.
05:07In 1989, I would describe the Santa Maria Air Traffic Control Facility as being very unsophisticated, very small.
05:15The airport is also not equipped with radar.
05:18There were only three scheduled airline flights per day.
05:21It doesn't justify the cost of air traffic control radar, which is very challenging for air traffic control.
05:30You're cleared 3,000 feet on Q&H 1027.
05:37Runway will be one-niner.
05:38The controller is relying solely on position reports from the pilot, so they have to be meticulous about protecting the airspace and documenting the altitude that the aircraft is at.
06:04Is that what they said?
06:07Is that what they said? 1027 on the millibars?
06:09Yep.
06:11Just over 13 minutes from the airport, the crew readies the plane for landing.
06:16Seatbelts and shoulder harness.
06:35Secured.
06:45We're having fun now.
06:47Hey, hey.
06:49On that day, the weather in Santa Maria was fine.
06:52There was just some cloud cover in the vicinity of Pico Alto.
06:57That is very common.
06:58Switching off autopilot.
07:04The captain takes control of the aircraft.
07:11The captain would likely be hand-flying the airplane to get comfortable controlling it.
07:20That ain't looking too hot out there.
07:23Yeah, we'll get down below.
07:24Depends on what level those are.
07:26There's cloud cover ahead.
07:29If conditions get worse, the crew will have to make the approach using only their instruments for reference.
07:37Okay, I'm going to go ahead and put the ILS in on my side.
07:40Okay.
07:41ILS, or instrument landing system, is a navigation system that provides vertical and horizontal guidance to the runway.
07:50That means that he can fly in clouds until he gets on to final approach.
07:55It's always better to have help.
07:5935 miles from the airport, the coastline of Santa Maria comes into view.
08:06When approaching from the east, you will see some big cliffs, some green, a lot of green.
08:11Where's the airport?
08:16It's on the other side of the island.
08:22As they approach the island, an alert in the cockpit tells the pilots that they are 500 feet above their selected altitude.
08:30400 to go.
08:32Don't know if we're going to get visual or not here.
08:34Starting to pass through the layers.
08:47As they cross the coast of Santa Maria, weather conditions worsen.
08:52The winds can be pretty severe around the Pico Alto, and this can present a challenge for the pilots to maintain control of their aircraft.
09:02I can't keep this damn thing level.
09:13I can't keep this damn thing level.
09:13Just two minutes from the airport, flight 1851 is seen flying very low overhead.
09:43Pull up.
09:46Pull up.
09:47Hurry, hurry.
09:49Pull up.
09:51The equipment is telling the crew they are in a potentially dangerous situation.
09:55Just four and a half miles from the Santa Maria airport in the Azores, Portuguese firefighters and civilians discover a horrific scene of devastation.
10:13Independent air flight 1851 has crashed into the island's highest mountain.
10:18The jet hit Pico Alto very near the top of the mountain.
10:25The accident site was a bit of a chaotic scene.
10:30The wreckage was thrown all over the mountain.
10:33There were some small fires.
10:36It was a very steep terrain.
10:39It was very difficult for rescuers to work there.
10:43It soon becomes clear that all 144 passengers and crew have been killed.
10:49It was a big challenge for the locals mostly to deal with that.
10:55Santa Maria has only 5,000 people living there.
10:59And in a flash, they became the scenario of the worst air disaster to occur in Portugal.
11:04Rescuers work through the night.
11:09By daybreak, the Portuguese Civil Aviation Authority, known as the DGAC, arrives at the crash site.
11:17They are soon joined by American representatives from the NTSB, the National Transportation Safety Board.
11:26The terrain that we traversed was very challenging.
11:30There was a lot of personal effects.
11:33People were dressed for vacation.
11:35There were children whose dolls I could see in the trees.
11:38The scope of the devastation, it was remarkable.
11:43Investigators need to get a better perspective if they are to understand why Flight 1851 crashed into a mountain so close to Santa Maria's airport.
11:51The overhead view revealed to us just how concentrated the wreckage was on the side of the mountain where the airplane struck it.
12:02That was something I had not seen before.
12:12So, this is the flight path.
12:15The plane impacts the east side of Pico Alto.
12:18Correct.
12:23Investigators examine the wreckage pattern for clues as to how Flight 1851 was flying before impact.
12:30They're all concentrated right here, sending debris over the mountain ridge.
12:40Scars on the ridge give investigators their first clues.
12:44Looks like low-angle, high-velocity.
12:48It must have been flying level.
12:50Seafit?
12:52Looks like it.
12:54They quickly recognize this incident to be a controlled flight into terrain, or Seafit.
13:01If one looks at Seafit accidents, there are really two types.
13:04One where an airplane descends prematurely, the other where it hits the side of a mountain.
13:11They must have known about the mountains.
13:14What was the altitude where they hit?
13:171,795 feet.
13:19And Pico Alto, what does the Jeppesen shark show?
13:28It's listed as 1,936 feet.
13:32Pico Alto is clearly identified on the Santa Maria approach chart.
13:36So, they struck the mountain 140 feet below what was listed on their chart.
13:46What were they doing so low?
13:49The possibilities were, one, the crew was off course.
13:53Two, there was an altitude error.
13:55It was our job to find out which of those would explain the accident.
14:01What's the minimum sector altitude?
14:033,000 feet.
14:04The minimum sector altitude is at least 1,000 feet above all terrain within 25 miles of the airport.
14:16There's plenty of room.
14:19According to the company's operations manual, there should be at least two Jeppesen charts on board the plane at all times.
14:25They had to have known.
14:27Yeah.
14:28This was the question.
14:29I mean, why did these guys descend so low when they knew by the charts that the minimum altitude was 3,000 feet and there was a mountain there?
14:40So, this was the last flight of the day?
14:44Yes, it was.
14:47What was the minimum sector altitude you gave them?
14:49The team turns to the air traffic controller for insight into why the aircraft was flying below 3,000 feet.
15:023,000 feet.
15:04You're sure?
15:06Yeah, I even made a note of it on my flight strip.
15:08He was perfectly calm.
15:14He had a normal behavior.
15:16He thought he had done a good job.
15:20Were you the only controller on duty at the time?
15:23My supervisor was also there.
15:25It was such a slow airport.
15:27It was certainly not unusual for a supervisor to provide on-the-job training for an air traffic trainee.
15:32What was the weather like?
15:42Fairly good at the airport.
15:43No rain or strong winds.
15:47Visibility was unlimited.
15:51However, the top of Piqualto was in cloud.
15:55And winds can be unpredictable up there.
15:58The weather was okay.
16:00The focus for the investigators was on how the cloud layer affected the pilot's ability to see and avoid the top of the mountain.
16:11Were they advised to use the ILS?
16:14Yes.
16:18Expect ILS approach.
16:21Runway 19er report reaching 3,000.
16:24The investigator learns that the pilots did encounter cloud cover near Pico Alto.
16:32But they shouldn't have had a problem using their instruments to get them to the runway.
16:38Did the crew report any mechanical issues?
16:41No, not to me anyway.
16:47Thank you for your time.
16:48I couldn't find anything that explains what happened from his part.
16:56So if the controller gave them the proper clearance, why are they so low?
17:03What if there was an issue with the plane that they didn't report?
17:05The team must now consider if a mechanical issue that wasn't reported to the controller prevented the crew from maintaining a safe altitude above the mountain.
17:17It was possible.
17:19We couldn't rule this out until we looked more closely at the evidence that something very quickly happened, something catastrophic, just before impact.
17:27Is this everything?
17:38So far.
17:40Investigators are looking for clues in the wreckage of Flight 1851 to explain why it descended below minimum altitude and crashed into a mountain on Santa Maria Island.
17:53Could a malfunctioning engine have forced the aircraft below the minimum safe altitude?
18:06It says here the jet had less than 45,000 hours in the air with seven service bulletins over the last six years.
18:15Any issues?
18:17No.
18:18In 1983, Agent 2 had suffered turbine failure.
18:23It looks like it was repaired.
18:26It was full of wood and dirt.
18:28A quick examination provides an answer.
18:31There's nothing wrong with these engines.
18:33Engines that are generating power at impact, if they hit a field of trees, will ingest part of the vegetation into the engines and that will bring the engine fan blades to a stop.
18:48And that's what happened here.
18:49Engines that are not turning, that are not working, won't do that.
18:55What about the altimeter?
19:01If the altimeters were malfunctioning, the crew might have believed they were flying higher than they actually were.
19:07Hi.
19:13Look, way too damaged to test.
19:15What are the service records, sir?
19:19They were last calibrated four months ago.
19:22No problems.
19:24It's another dead end.
19:28Maybe the altitude alert survived.
19:32Let's take a look.
19:32The altitude alert warns the crew with an audio alert when they're approaching a preset altitude.
19:48Hang on.
19:49Is this it?
19:53Yeah, that's it.
19:56Doesn't look too bad.
20:02Yeah, check this out.
20:05Diltimeter alert's set to 2,000.
20:08Investigators discover the altitude alert was set for 2,000 feet, not the required altitude of 3,000 feet.
20:16I remember this shocked all of us.
20:19We just couldn't believe it, how that could happen.
20:23Why would the altimeter alert be set to 2,000 when the controller gave them a clearance of 3,000?
20:29Maybe the controller remembered wrong.
20:33Let's check the tapes.
20:37ATC recordings gives you what's exchanged during the different phases of the flight.
20:42So you can confirm, absolutely, what was said, either contacting the plane or inside the ATC.
20:51Good afternoon, Santa Maria Tower.
20:55Will the air traffic control audio recording confirm what the trainee told investigators?
21:03Independent 1851, roger.
21:05You're clear to 3,000 feet on Q&H 1027.
21:12Runway 19er.
21:14Expect Isla's approach.
21:18Runway 19er.
21:19Report reaching 3,000.
21:23Stop there.
21:26He said it.
21:28Twice.
21:28The control tower recording confirms that the controller gave a 3,000-foot clearance.
21:35Listening to the clearance did not explain the 1,000-foot error due to the altimeter alert.
21:43We needed to listen to the CDR.
21:46Take it from the point where they first contact the controller.
21:53Investigators now listen to the cockpit conversation
21:55to determine why the crew descended below the 3,000-foot minimum sector altitude given by the controller.
22:04Good afternoon, Santa Maria Tower.
22:06Independent air 1851, passing flight level 200 to flight level 40.
22:14That's the first officer.
22:19Independent 1851, roger.
22:21You're clear to 3,000 feet on Q&H 1027.
22:29Clear to 2,000.
22:32Did the first officer just say 2,000?
22:35Go back, play it again.
22:40Clear to 2,000.
22:42Investigators wonder why the first officer misheard the altitude clearance as 2,000 feet
22:50instead of 3,000 feet.
22:54Maybe he heard 2,000, 3,000, and mistook it for 2,000.
23:03It's possible.
23:04It looked to us that perhaps the word 3 never was listened by the first officer.
23:13So the first officer only listened, you're clear, 2,000.
23:19Not 2,000, 3,000, but 2,000.
23:22So he never heard the word 3.
23:24The CVR recorded the first officer reading back an incorrect clearance.
23:33It was very puzzling to us when we heard the CVR why the crew did not act.
23:38It was clear that that wasn't given much credence.
23:40The controller should have corrected him, too, but doesn't.
23:46Why?
23:47And that's an important part of this accident investigation.
23:50We couldn't figure out why the air traffic controller did not correct the first officer.
23:57Hang on a second.
24:02The first officer's read back of 2,000 feet isn't in the controller's transcript.
24:07So he never heard it?
24:09How is that possible?
24:11We couldn't figure out how they could miss each other.
24:13It was inexplicable.
24:19All right, so the first officer mishears the altitude.
24:22He reads it back to the controller as 2,000 at 1356.59.
24:28Investigators compare the conversations between the controller and the first officer of Flight 1851
24:33to better understand why there was miscommunication between them.
24:38What does the controller say next?
24:41Well, he repeats the clearance by saying expect ILS approach, runway one niner, report reaching 3,000.
24:48That's it?
24:48Hang on.
25:00Hang on.
25:00They're talking at the same time.
25:10Yeah.
25:11They cancelled each other out.
25:12It's a troubling realization.
25:17An overlap of communication between the tower and the pilot.
25:21Passing flight level 2,000 for flight level 4,000.
25:28We're clear to 3,000 feet on QNH 1027, runway one niner.
25:35We're clear to 2,000 feet on QNH 1027, runway one niner, report reaching 3,000.
25:46It was stunning.
25:48We were stunned to finally understand how the two transmissions overlapped perfectly to cancel each other out.
25:58I was an investigator for over 30 years at the NTSB.
26:02I've never encountered anything like this before, and I never encountered anything like this afterwards.
26:07They're both talking at the same time.
26:09They're both pushing their PTTs.
26:10Pilots and controllers use a push-to-talk, or PTT, button.
26:22When it's pressed, the radio transmits but cannot receive.
26:27To think that so many people died because of a simple error, that was just, that's sad.
26:33That's hard to deal with as an investigator.
26:40So the controller doesn't hear it, but he should still insist the first officer read it back or repeat it.
26:47There are some readbacks in air traffic control that you simply have to get back every single time, and altitude is one of them.
26:54The trainee controller did not request an altitude readback, and the supervisor didn't notice, and that was unfortunate.
27:03What about the supervisor?
27:05Good question.
27:06According to the controller, she was there.
27:15Maybe she was busy with other things.
27:19Possible.
27:21Investigators wonder if the supervisor monitoring the trainee during the approach clearance was somehow distracted.
27:31Check this out.
27:33According to the phone record, she took a call during her shift.
27:36You don't want to take a phone call during something important like a descent clearance because they have to give them a course to follow
27:47and an altitude to maintain really important stuff that you cannot possibly miss.
27:55Something doesn't line up.
27:56The plane's altimeter alert was incorrectly set to 2,000 feet.
28:08Even at that altitude, they would have cleared the ridge by some 200 feet.
28:14Yeah.
28:14We still had to explain why the airplane struck the mountain 200 or so feet, even further below the altitude that they were trying to maintain.
28:26Something had to explain that.
28:28What else affects altitude?
28:31QNH.
28:32QNH is a pressure setting, pilot's input, so their altimeter measures the proper height above sea level.
28:44It can change with weather conditions.
28:46If the altimeter is set to a higher QNH than it's actual, the aircraft will actually be lower than what the altimeter is telling the pilots.
28:57It says here they were given a QNH of 1019 at 144 p.m.
29:05Then they were given a reading of 1027 at 156 p.m.
29:12Okay.
29:14So it changed 8 millibars in 12 minutes.
29:22Could that be right?
29:24I'll check the weather reports.
29:27For an 8 millibar change to occur in 12 minutes would be something that may occur during a hurricane or something like that.
29:36I don't see anything that would make that possible.
29:38So how much would they drop with an 8 millibar increase?
29:45Investigators calculate the change in altitude between the two QNH values.
29:51That QNH brought them at least 200 feet below 2,000.
29:55Right into the mountain.
29:57The team concludes that an incorrect altimeter setting put the flight on a collision course with Pico Alto.
30:04When you're close to the ground, in restricted visibility conditions, an accurate altimeter setting is everything that will protect the airplane from a CFIT accident.
30:20Thanks for talking with me again.
30:22Yeah, of course.
30:23Uh, just one follow-up question here.
30:26What was the pressure setting you gave them?
30:30Investigators conduct a second interview with the controller to understand why he gave two very different QNH settings to the pilots.
30:381019 was on the Met report.
30:4412 minutes later, when you gave them a 3,000-foot clearance, you said,
30:49QNH 1027.
30:59I asked the controller directly about the QNH he had given to the plane,
31:05and, uh, and, uh, and, uh, and he couldn't explain why he had given that QNH at all.
31:10In my view, it's just, he didn't notice he was giving the wrong information.
31:15Sorry, I don't know where I got that second number.
31:29For that QNH to change so rapidly, it should have been noticed by both the air traffic trainee and their supervisor and the pilots as well.
31:37I'm surprised that the pilots didn't reach out and say,
31:43hey, can you repeat that QNH again?
31:54After the first officer gets the minimum descent altitude wrong,
31:59he questions the QNH.
32:01Is that what they said?
32:031027 on the millibars?
32:04Yep.
32:07He was right to question it.
32:09But the captain just dismisses it.
32:12And the first officer just accepts it.
32:16Because of the different experience levels,
32:20because of the prominence and assertiveness with which the captain said it,
32:24shut off any discussion, when, in fact, there should have been.
32:26Makes you wonder what else these guys missed.
32:37Yeah, let's play the tape.
32:44Investigators returned to the cockpit voice recording
32:46to learn how the crew of Independent Air Flight 1851
32:51allowed so many errors to accumulate on approach to Santa Maria.
32:55Ultimators, set and cross-checked.
33:03Set and cross-checked.
33:05Seatbelts and shoulder harness.
33:11Secured.
33:13We're having fun now.
33:14Hey, hey!
33:17That's it?
33:19Stop the tape.
33:19They discover the pilots missed important steps on the checklist.
33:27They don't even mention the minimum descent altitude.
33:31Or pico alto, here.
33:32They hear a briefing that doesn't include reference
33:41to the navigation charts that were available to the pilots.
33:47Had they done the approach briefing
33:48and reviewed the information
33:50and articulated the information as required,
33:53it's highly unlikely, in my opinion,
33:56that they would have struck the mountain.
34:00Another unfortunate error.
34:02There were a couple of things
34:05in the performance of the captain
34:07that were questionable.
34:10He didn't try to understand
34:12what was the real Q&H that was given.
34:16Then, he didn't insist in a complete checklist.
34:22Let's hear what comes next.
34:27It ain't looking too hot out there.
34:29Yeah, we'll get down below.
34:30Depends on what level those are.
34:33Okay, I'm going to go ahead
34:34and put the ILS in on my side.
34:36Okay.
34:43After 2,000...
34:45Yeah, we'll get below these clouds.
34:49Stop.
34:50Right there.
34:512,000 again.
34:52The captain says nothing and descends to 2,000.
34:58Why?
35:00The captain was ultimately responsible
35:02as the pilot in command,
35:03but each crew member failed in that respect.
35:07Play the tape.
35:101,000 to go.
35:121 to go.
35:13Wow, look.
35:14There's the island.
35:22Stop it.
35:24Who is that?
35:27Investigators hear an unknown female
35:29speaking in the cockpit
35:30on approach into Santa Maria.
35:35She appears twice over 16 minutes,
35:38starting when they begin their descent.
35:40The flight attendant, maybe.
35:43But what is she doing there?
35:45I don't know.
35:46That's not what I call a sterile cockpit.
35:49And the captain lets it happen.
35:52The captain violated the sterile cockpit rule,
35:56which bans non-essential conversation
35:58in the cockpit below 10,000 feet.
36:08I believe that violating the sterile cockpit rule
36:11was consistent with the way they fooled the approach.
36:14They weren't sitting on the edge of their seats.
36:16They were far too relaxed.
36:18There is no place like Santa Maria.
36:22Is it nice?
36:23Yeah.
36:25To have a beer.
36:27See you on the ground?
36:28Ignoring standard procedures.
36:35Distractions.
36:36The list keeps growing.
36:40Starting to pass through the layers.
36:47Can't keep the damn thing level.
36:52Help you?
36:53Nope.
36:57Pull out.
36:58Pull out.
37:01Pull out.
37:04Pull out.
37:13They don't say anything?
37:18When the GPWS went off,
37:20there was no response from the crew.
37:22There was not even a,
37:23what's that?
37:24What's going on?
37:25There was nothing.
37:25They don't say anything.
37:28Or do they do anything?
37:41So this is the plane's descent approaching Santa Maria.
37:47Investigators examined the flight data
37:49to determine how the pilots responded
37:52to the ground proximity warning.
37:53So they're descending at about 2,500 feet per minute.
38:00They level off here.
38:04And the GPWS goes off here.
38:07And they crash about seven seconds later.
38:11No reaction.
38:14No change in altitude.
38:15The data shows there were no inputs from the pilots
38:20to recover the aircraft.
38:21It's like they ignored the alarm.
38:24When the GPWS goes on,
38:27you apply maximum power,
38:30climb at the maximum rate,
38:33and get the heck out of there.
38:35Seven seconds.
38:37They had seven seconds from the first warning
38:39until impact.
38:43They could have climbed over the mountain in that time
38:47had they done what they should have done.
38:49And they didn't do that.
38:50And we couldn't figure that out.
38:53Pull up.
38:54Why didn't the crew respond to the warning?
39:00Surely the crew was trained to respond
39:02to the ground proximity warning.
39:05Investigators closely examined
39:07the training manuals for independent air.
39:15You are not going to believe this.
39:18The simulators were programmed
39:20with different approach speeds
39:21and flap settings in the accident aircraft.
39:26What does that mean?
39:27It means that the GPWS
39:29would go off during normal approaches.
39:31Independent air rented time
39:37on another company's 707 simulator.
39:40It was configured differently
39:41from the accident aircraft.
39:43Flaps 40.
39:47Pull up.
39:49Sir?
39:50Pull up.
39:52By training the crew to ignore the GPWS
40:00in the simulators,
40:01they gave the crew the message
40:03to ignore the GPWS in the airplane.
40:07I can't believe how many things went wrong.
40:15Investigators conclude
40:16that by avoiding any one of the minor errors,
40:19flight 1851 would have cleared Pico Alto,
40:23preventing the deaths of 144 people.
40:25It all starts with the first officer
40:29mishearing the minimum sector altitude.
40:32Independent 1851, roger.
40:35You're cleared to 3,000 feet.
40:38Cleared to 2,000.
40:43Make it three.
40:44If the first officer had referred to his charts...
40:49Roger.
40:51Good catch.
40:52...the altitude alert would have been set
40:54at the proper elevation...
40:56...and the aircraft would have cleared the mountain
41:01by more than 1,000 feet.
41:06Same result if the air traffic controller
41:07had asked for a re-back.
41:10Independent air 1851.
41:11Uh, you're cleared to 3,000.
41:15I say again, report reaching 3,000.
41:17Over.
41:21Or if the captain kept a sterile cockpit.
41:25Uh, after 2,000...
41:28Yeah, we'll get below these clouds.
41:31Wow, look.
41:34There's the island.
41:35It should be 3,000, not 2,000.
41:39It's time to return to the cabin.
41:41You cannot be unattentive,
41:47especially in the last, uh, period of the flight.
41:51Even with all those mistakes,
41:52the trainee controller had given them
41:54the proper altimeter setting.
41:56You're cleared to 3,000 on Q&H 1027.
42:02Uh, correction.
42:051019.
42:06Flight 1851 with a clear Pico Alto by 200 feet.
42:14Whoa.
42:19We're close.
42:23Finally, the GPWS.
42:26Pull up.
42:27If the crew had the proper GPWS training...
42:31Go around.
42:34...they would have had one last chance
42:36to avoid hitting the mountain.
42:38They might have made it.
42:46I have never seen an accident
42:50where these many factors happen
42:53where any one of which,
42:55had they not been there,
42:57we wouldn't have had an accident.
43:00In the wake of the crash,
43:02the NTSB recommends a careful review
43:05of airline training programs
43:07with a focus on international operations
43:09and safety,
43:11especially those related to the GPWS response.
43:17The major lesson was that airlines
43:20need to train their crews better
43:22to improve aviation safety.
43:27Independent Air later settled
43:29with the victims' families
43:30for 34 million U.S. dollars,
43:33before a compensation case ever went to trial.
43:36Independent Air went out of business in 1990.
43:43In the aviation business,
43:45there is no room at all for complacency.
43:47The longer we do a job,
43:48the more complacent we tend to get.
43:51After a while,
43:52some of the things we do,
43:53even if they're unsafe,
43:54start to appear to be safe
43:55and, unfortunately,
43:57we can have an accident
43:58like the one that we witnessed here.
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