- 6 days ago
Air Crash Investigation Series S21E08 Caught in a Jam
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00:00Descending through thick clouds...
00:08Ansett New Zealand Flight 703 slams into a hill.
00:14It was just an almighty crash. Horrendous sound.
00:18Ansett 703, do you read?
00:20Those lucky enough to survive the crash find themselves stranded...
00:24There's no signals at all and they're off radar.
00:26...and facing the possibility of freezing to death.
00:30Opithymia would have been a major problem.
00:33Once investigators finish piecing together the clues...
00:36There it is, clear as day.
00:38It was obvious that there was a malfunction.
00:40...their findings lead to an unprecedented charge of manslaughter.
00:44This accident should not have happened.
00:48D-Day, D-Day.
00:49The
01:06It's nine in the morning, as ANSET New Zealand Flight 703 cruises towards the city of Palmerston North, New Zealand.
01:23Best approach heading is set. We're on heading 250.
01:29At the controls is 40-year-old Captain Gary Sotheren, a six-year ANSET veteran with almost 8,000 flying hours.
01:39ANSET 703 established inbound.
01:4333-year-old First Officer Barry Brown has more than 6,000 hours.
01:49Will do at 10 miles, ANSET 703.
01:51That was a fairly standard sort of commuter flight, and these two pilots were very, very qualified to fly this plane.
02:00There are 18 passengers on board the short flight.
02:14William McGrory is flying to his company's head office for an early morning meeting.
02:20I was working for a plumbing company. I was based in Auckland, and they were based in Palmerston North.
02:27Do you race?
02:30Oh, no. Never wants to race in my life. Pass the tone, though.
02:34Are you headed home?
02:35And then the hostess sat down in the seat in front of me on the armrest and started chatting.
02:43She was talking about her life, and I was telling her what I was up to, and she was great.
02:47Just full of life, full of beans, and had her life planned.
02:51I'm trying to save enough to buy a house.
02:53She was from Christchurch, and I believe that's where she was going to buy her house.
02:57She was really excited about that.
03:00Captain Southern again, we are beginning our approach to Palmerston North.
03:03We should have you on the ground right around 9.30.
03:05The pilots are flying a Dash 8-100 series, a 40-seat regional airliner known for its short take-off and landing capability.
03:15And course bar is active.
03:18Check.
03:18Flight 703 left Auckland for the one-hour flight to Palmerston North.
03:24It's a 250-mile journey south to a region with notoriously unpredictable weather.
03:32There was low clouds around the Palmerston North area.
03:36So, I mean, it wouldn't have been a great day to fly because of the lack of visibility.
03:42As we were on approach...
03:45Hang on a minute.
03:47And she looked out the window and looked a bit concerned.
03:56She looked on the other side as well, and she said...
03:58I don't think their landing gear's down on the right side.
04:01Can you check your window?
04:02The landing gear on the Dash 8 is located in the engine's housing on the wings.
04:10Because the wings are on top of the airplane, when the landing gear is extended, it's clearly visible from the cabin.
04:16No cut to the landing gear at all.
04:19We were looking straight out under the wing, pretty much.
04:22So, yeah, you would see it all right.
04:24I could tell that it wasn't extended.
04:26Excuse me.
04:26Karen Gallagher alerts the pilots.
04:34I'll keep an eye on the airplane while you're doing that.
04:36Yeah, OK.
04:38In the cockpit, Captain Sotheran and his first officer are already troubleshooting the problem.
04:43The right landing gear isn't down.
04:46I guess you guys know that.
04:48Yeah, we know.
04:52Alternate gear extension.
04:54Approach and landing checklist, pressurization.
04:56When the gear doesn't go down normally, every airplane has a checklist to have a backup system.
05:02That's required by design.
05:04Dash 8 is no exception.
05:05It should not be a big deal.
05:07We're good.
05:13We have everything under control.
05:17There's a standard procedure that they're running through.
05:21She came back and sat down again on the armrest and said they're just doing a manual reset and they'll have the wheel down in no time.
05:28She wasn't stressed or not alarmed at all.
05:30As flight 703 nears Palmerston North, the pilots follow the procedure for lowering landing gear manually.
05:40Airspeed below 140 knots.
05:42It's 140.
05:46Karen was sitting right there in front of me and the next minute...
05:49And then I'll have a few days off, so I'll probably head down to...
05:51There was just an almighty crash, just horrendous sound, and then the sound stopped.
06:00And we must have lifted off the ground.
06:07Another crash, and then we seemed to be sliding.
06:12So it's just horrible, horrible noise.
06:14All the metal and all the things flying around inside the plane.
06:18Eventually, we came to a stop.
06:28And there was just this strange silence of no more grinding and metal and things happening around me.
06:35The impact fractured a vertebra in McRory's back.
06:40But the rush of adrenaline keeps him from feeling the pain.
06:44I guess it just flicked into survival mode and didn't really matter what was wrong with me.
06:48Just, I was alive.
06:50To get out of this plane, that was probably the only single thing that was on my mind at the time.
06:54I saw a hole in front of me on the right-hand side and saw that as an opportunity to get out.
07:03William McRory has survived the crash of ANSET Flight 703, but now fears the possibility of a fire.
07:10I assumed that we had crash-landed on the tarmac without the wheel down.
07:18And any minute now, all the fire engines would be screaming up to us to spray all the foam on and make sure we didn't catch fire.
07:26McRory suddenly realizes he's nowhere near the airport and has no idea where he is.
07:33I just looked back and thought, hell, we're in a paddock somewhere in the hills.
07:37And that's when I went back to the plane because there was people starting to come out through the holes in the sides.
07:45And I went back to assist.
07:50There were some people pretty badly injured.
07:53Some of the passengers were still unconscious.
07:56Up in the cockpit, the two pilots had survived but were pretty badly injured.
08:02Passengers still trapped in the wreckage are in urgent need of medical help.
08:06Have!
08:08ANSET 703, ANSET 703, this is Palmiston Tower. Do you read?
08:12In the airport's tower, controller Tony Chapman tries to contact ANSET Flight 703.
08:18I don't know where they are. There's no signals at all and they're off radar.
08:23Well, the emergency services were ready to go.
08:25There's firefighters at Palmiston North Airport.
08:27but they didn't know where the plane was exactly to make matters worse it's
08:33extremely cold and windy survivors need to find a way to keep warm until help
08:39arrives not for hell we need some we need some gear to get everyone warm there
08:44must be blankets or maybe there's some bags at the back we know we can just get
08:48some jerseys or jumpers or shirts or whatever just to get people warm but
08:53there was nothing nothing at all to keep us warm we're out in front of the nose now which was facing
09:01back the way we came I saw my little briefcase so I grabbed that and opened it up knowing full well
09:09that my phone was in there 1995 not many New Zealanders would have had cell phones at all so
09:14it's pretty amazing that he had one and then saw it and it was still working I rang 111 they said what
09:23emergency do you need an ambulance fire or police and I said send the whole bloody lot we've got a
09:30plane crash send everything and she immediately changed her tone and said just hang up and we'll
09:36get back to you you're looking for a white twin engine prop plane we're flying west along Manawatu
09:44Gorge heading towards the airport flight 703 last reported being on final approach for runway 25
09:51the plane could now be anywhere in a 150 square mile area everyone was huddled together to try and
10:01keep warm as the shock was really setting in at this stage hypothermia would have been a concern for
10:06the passengers who had survived the ones that were injured in particular the last thing you want is
10:11to be exposed to the cold for the survivors of anset 703 time is running out anset New Zealand flight 703 has
10:23crashed somewhere in the hills around Palmerston North passenger William McRory anxiously waits for
10:29the emergency operator to call back did he say where they were okay did you get a number the operator has
10:39notified Palmerston North's tower of McCrory's call perfect thank you what a witness called in said he saw the crash
10:50they had been told hello that I saw the crash and they didn't know that I was actually in the crash at the
11:03time so I straightened them up on that pretty quickly we missed it no I was on the bloody thing
11:09William whatever happens do not hang up the phone you have to stay on the phone with me okay okay the
11:17person from the control tower said we need to know where you are can you give us some descriptions of
11:22of what's around you we're on a hill it could be a farm it's freezing cold the passengers who had
11:30survived of course would be going into shock and it was very cold for them and that could have had
11:36unfortunate consequences okay do whatever you can to keep everybody warm survivors build a makeshift
11:42shelter from the wreckage to protect themselves from the howling winter wind it had been snowing the
11:48day before so the cold was all there it was just a probably a better day all right I'll see what we
11:54can find can you see if you can find some kind of landmark anything that can help them find where we are
12:03how long is your battery going to last about an hour okay good don't hang up the passenger who'd come to
12:12help me said I'll have a look around so he went off up the hill and he'd gone quite a distance in
12:20quite a while really and he came back some time later and he said there's a big holding pen for
12:26sheep up the hill further we're next to a very large sheep holding pen wood maybe 30 meters long okay William
12:37some of the rescuers who were listening to this conversation what someone recognized it and knew
12:42where to go looks like they're near the Buckley stock out up by whole block Road one of them knew that
12:49the only holding pen of that size anywhere around the area was so-and-so's farm with the location of
12:58the crash roughly pinpointed rescuers make their way to the scene one rescue helicopter pilot described it
13:05as flying in the inside of the milk bottle to give you an idea of flying up in the cloud
13:10you can hear a helicopter that's good William getting closer
13:20there it is
13:24I remember the helicopter coming up through the cloud and and I saw its lights hidden for us it's
13:38just incredible I'll never forget that feeling I've seen those lights and the sound of a helicopter okay
13:45and that's when the adrenaline stopped pumping and I started feeling the pain and the cold and the
14:04misery that everyone else was carrying through
14:08Flight 703 has crashed into a hill 10 miles from the airport at Palmerston North
14:1315 passengers and both pilots have survived
14:16Tragically three passengers and flight attendant Karen Gallagher are killed
14:22we were very very lucky that 17 of us survived I think so sadly for those that did lose their lives
14:29the hostess and the others that died on that day was so unnecessary
14:35investigators from New Zealand's Transport Accident Investigation Commission the TAIC are quickly on the scene
14:52at the time it was massive news there's not many plane crashes in New Zealand and particularly
15:00in this case because there were so many survivors
15:07definitely hit more than once
15:09because the plane was manufactured in Canada
15:12Larry Vance from the Canadian Transport Safety Board
15:15is sent to New Zealand to assist with the investigation
15:20it was a main fuselage piece
15:23that was basically intact
15:25there was a separated tail there was a separated left wing
15:28they were spread out over the rolling hills
15:31the land was sloped so it was pretty strewn about
15:35right here the nose wheel hits first
15:42the marks on the ground tell investigators that the plane's forward landing gear wheels hit the ground first
15:49the fact that the nose wheel hit first and then the rest of the aircraft followed told us that the aircraft was flying somewhat level
15:56it wasn't going nose first into the ground
16:01the most critical clue is the one that's missing
16:07the ground where the right landing gear should have touched down is undisturbed
16:16what we saw from ground markings it was entirely consistent with the fact that the right landing gear was not extended
16:23the marks on the ground show that flight 703 was flying level when the forward landing gear hit the ground
16:29but the right main landing gear was not extended
16:40in the cockpit investigators find evidence that the pilots attempted to lower the landing gear
16:44we saw that the landing gear selector was down
16:51we saw that the emergency landing gear selector was being used
16:59so we knew they were dealing with a landing gear problem simply by looking in the cockpit
17:03landing data altimeters tanks belt smoking
17:07ASB below 140 knots
17:09it's 140
17:10landing gear selected down
17:12yeah
17:13landing gear alternate release door fully open
17:16which it is
17:18the alternate method should have lowered the gear
17:21for some reason the plane hit the ground less than a minute later
17:25yeah
17:26we had two main questions
17:28the first one was why did the landing gear not extend
17:32and the second one was why did the pilots fly the aircraft into the ground
17:41investigators need to examine the wreckage of anset 703
17:45to determine why the pilots were unable to get their landing gear down
17:50but the muddy terrain is presenting a challenge
17:52it was virtually impossible to get equipment onto that site
17:57it would just slip and they would get stuck and slide down hills and so on
18:03Vance comes up with a solution
18:06they had a huge helicopter owned by Russians
18:09what we suggested to them that they do is get a big long cable
18:13and put the cable through the fuselage
18:15the ribs were in good enough condition
18:17that they would basically hold the weight of that fuselage
18:22they brought that helicopter in on a 200 foot long line
18:26and they lifted that fuselage out all in one piece
18:34with all the wreckage in a hangar
18:36investigators are able to examine the right landing gear
18:39to understand why it didn't come down
18:41right landing gear doesn't come down
18:44right landing gear doesn't come down
18:47start the ultimate procedure
18:49and then slim into a hill
18:51eight and a half miles from the runway
18:54first question is what went wrong with that gear
18:57what we were thinking is there's really only a couple of things
19:01that can keep that gear from extending
19:03it's hard to tell why it didn't come down
19:06Vance is joined by Jim Donnelly
19:07a maintenance engineer from de Havilland
19:10the Dash 8's manufacturer
19:12it was obvious that there was a malfunction of the right main landing gear to extend
19:17so we needed to look at
19:19what may have influenced the
19:22the landing gear system operation
19:24when the landing gear is up
19:27a latch holds a roller on the gears leg in the retracted position
19:32when pilots lower the gear
19:33an actuator moves the up lock latch to release the roller
19:38allowing the landing gear to extend
19:41this is probably where the problem was
19:44well when we got to the hangar we could actually have a better look
19:51we had better lighting and more controlled climate
19:55and everything pointed to the right main landing gear up lock actuator
19:59and the up lock actuator latch
20:03latch
20:05latch is definitely showing signs of wear
20:09when we visually examined the up lock latch
20:13really didn't notice a great deal
20:16however you could feel
20:18a very slight detent on the latch itself where the roller sat
20:23over time the roller wore a small groove into the right side latch
20:30it was enough to prevent it from sliding into the down position
20:35it was similar to what you would find if you got your car stuck on ice and you started spinning your tire
20:42and the tire would wear itself down a little bit of a dip down into the ice
20:47and once you get one of those of course it's awfully hard to get out of
20:51here's another
20:56landing gear fail sticksed in
20:59yeah
21:02it definitely was an issue
21:05investigators dig through the Dash 8's history
21:07the issue with the up lock actuator wear
21:08the issue with the up lock actuator wear was well documented on early model Dash 8's
21:18a number of operators experienced it
21:21the ANSET fleet sure he did share problems
21:26both are Dash 8's by the looks of it
21:30ANSET New Zealand's Dash 8's had been experiencing landing gear failures for years
21:37there were incidents of the landing gear either not lowering or lowering very slowly
21:47the problem became so widespread that de Havilland offered airlines a modified up lock mechanism
21:53designed to overcome the problem
21:55it was found that a change of material would be of benefit to prevent these issues and it would be a harder material
22:06something that didn't have the same wear properties
22:10just the left side
22:12gotcha
22:14thanks for that
22:16they replaced the mechanism on the left side
22:19but we're waiting on pads for the right
22:22ANSET only replaced the left up lock actuator because that is where they experienced the majority of their issues
22:32but all of these gear problems were easily dealt with
22:36in every case the pilots use the alternate method to lower the gear
22:40they all landed safely
22:42if the gear didn't lower normally
22:46pilots could pull a handle in the cockpit
22:49that manually disengage the latch
22:51so that the gear can drop into position
22:53the alternate system is 100% reliable
22:59there has never been an issue with the
23:02alternate landing gear extension system
23:04failing to lower a landing gear
23:07but evidence from the cockpit wreckage reveals the first officer didn't pull the handle hard enough to release the landing gear
23:14we saw that the handle that is normally pulled
23:20was partially pulled
23:23failing to lower the landing gear is unusual
23:26but it doesn't explain why the pilots of ANSET flight 703
23:31slammed into a hill just a few miles from the airport
23:34investigators need to know what was happening inside the cockpit
23:40you're looking to see who's actually flying the airplane
23:43who's monitoring the altitude
23:45who's doing the call outs
23:47this is what investigators have to look at
23:49the pilots of ANSET flight 703 have suffered severe head trauma
23:55and are unable to be interviewed
23:57it's a major setback
23:58not below 4600 to start off with
24:01not below 3,009 miles
24:04investigators now depend on the cockpit voice recorder
24:07to uncover the cause of the crash
24:12ANSET 703
24:14stop descent at 6,000 feet
24:16for the VOR DME
24:18approach runway 25
24:20stop descent 6,000 for approach 25
24:24ANSET 703
24:25the approach to runway 25 at Palmerston North
24:29involves making a right turn 14 miles from the airport
24:33and approaching the runway from the east
24:36everything seemed to be pretty well nominal
24:39until they got on final approach
24:43not below 4600 to start off with
24:45not below 3,009 miles
24:48not below 2,500 at 7 miles
24:51and 1,600 at 5 miles
24:53because of the steep terrain surrounding the airport
24:58the pilots need to hit prescribed altitudes at specified distances from the airport
25:04and it's right on the limits
25:06so we've got to stick to that
25:083,009
25:102,500 at 7
25:121,600 at 5
25:14they knew their minimums
25:16the recording shows that the pilots knew their minimum altitudes throughout the descent
25:21not on our flags
25:25not on our flags
25:27missed approach heading is
25:29sit
25:33we're on heading 250
25:35check
25:39ANSET 703
25:41established inbound
25:43flight 703 makes the final turn
25:46and reports flying on a heading towards the airport
25:49ANSET 703 roger
25:51contact Palmerston Tower at 10 miles
25:53will do at 10 miles
25:55ANSET 703
25:57also in second place
25:59okay
26:01they knew their minimums
26:03they're 13 miles out
26:05known course
26:06and in
26:08two and a half minutes
26:10they'll hit the ground
26:13gear down
26:19say again
26:24gear down
26:26yep
26:27selected
26:30selected
26:34and on profile
26:36hang on
26:37fraction low
26:39check
26:43flaps 15
26:46oh crap
26:49oh look at that
26:51what's that?
26:53sounds like they just noticed the gear isn't down and locked
26:56yeah that's not good
26:58okay so uh...
26:59she's not locked
27:01alternate uh... landing gear?
27:03seem to be on top of it
27:05alternate extension
27:06do you want to grab the QRH?
27:08yep
27:09Captain Sotheran instructs his first officer to run through the alternate procedure
27:13which is set out in the plane's quick reference handbook
27:16checklist is designed to make sure the gear doesn't come down so ultimately it will come down and then you can land
27:24whip through that one
27:25see if we can get it out of the way before it's too late
27:28yeah living and a half miles out
27:31gonna have to move it to get that gear down
27:37I'll keep an eye on the airplane while you're doing that
27:40yeah okay
27:41good separation of duties
27:46Captain Fleiss
27:48on the FO
27:49rose the checklist
27:50the right landing gears are down
27:52I guess you guys know that
27:54it's uh...
27:55Karen Gallagher
27:57yeah we know
27:59thank you
28:02alternate gear extension
28:04approach landing checklist pressurization
28:06just skip down to the actual applicable stuff
28:09when the captain asked the first officer to skip over those steps
28:12he had the authority under answer to do so
28:14and so this is something that's again not unusual
28:17was not breaking a rule
28:18but the crew is rushing
28:20rushing to get this checklist done
28:21which they needed to do if they wanted to land the airplane
28:24yeah uh... landing data
28:27altimeters
28:28tanks uh... belt smoking
28:30airspeed below 140 knots
28:32it's 140
28:34landing gear selected down
28:36yeah
28:38and the gear alternate release door
28:40open
28:41the first officer would open a door in the ceiling
28:44and that exposes the handle
28:47you pull it until you can't pull it anymore
28:50and the landing gear drops
28:52and then it free falls to the down and lock position
28:56so far so good
28:58few more steps
28:59the gear be down and locked with
29:01about four and a half minutes to spare
29:02and set seven zero three establish finals upon us to north
29:08and set seven zero three that's understood
29:11and insert this handle
29:15and set handle
29:18till
29:20first officer brown is struggling with the procedure
29:24if there was any chance that the landing gear would not go down to the lock position
29:30there's a hand pump down in the floor that you open another door on the floor you put a handle in and make a selection
29:36and you start pumping
29:38and operate until the main gear locks
29:42you missed a step
29:44he's fussing with the pump handle he hasn't even pulled the gear release yet
29:47oh
29:49yeah
29:51and operate until the main gear locks
29:54you're supposed to pull the handle
29:55oh
29:56it's actually got that after that
29:59oh
30:01it's actually got that after that
30:11yeah
30:12it's pulled
30:13they pulled it
30:15but not all the way
30:16that's why the gear was still up when they hit
30:19the plane is only a few hundred feet from the ground
30:22but the pilots still haven't lowered the right landing gear
30:27hurray hurray
30:29pull up
30:31hurray hurray
30:33pull up
30:36could one missed step on a checklist have doomed the passengers and crew of flight 703
30:47alternate landing gear alternate extension
30:49you want to grab the qrh
30:51yep
30:53i'll keep an eye on the airplane what are you doing there
30:56yeah okay
30:58investigators struggle to understand how two experienced pilots failed to notice they were flying dangerously low
31:04the captain clearly said
31:06and i'll keep an eye on the airplane
31:10doesn't sound like he did that
31:12there are two people in the cockpit
31:13the captain was to fly the airplane
31:16but now he's involved in the checklist
31:18oh yeah
31:20and operate until the main gear locks
31:22you're supposed to pull the handle
31:24the voice recording has revealed that instead of monitoring the airplane as he said he would
31:29the captain was helping his first officer with the landing gear checklist
31:34in any emergency somebody has to fly the airplane and keep the airplane where it needs to be
31:39let's see the approach profile
31:40the flight data shows exactly when flight 703 began to stray from its planned descent path
31:48they're approaching their minimum altitude when the gear hangs up
31:51and they keep descending
31:58fast
32:00the data shows that flight 703 kept dropping lower and lower until it was almost 1400 feet too low
32:06and the aircraft started to descend quite quickly down below what would be a desirable glide path
32:13and the captain didn't notice that
32:15he was paying more attention to what the co-pilot was doing because the co-pilot was struggling trying to get the landing gear sequence right
32:22they should have been descending at about 580 feet per minute
32:30instead they were descending at around 1200 feet per minute
32:35why is that?
32:39the captain should have put some more power to the engines and adjusted the nose attitude to decrease his rate of descent
32:43that's what should have been happening
32:46that's what should have been happening
32:48okay, right here
32:50the engines are cut back to flight idle
32:53course bar is active, check
32:57going down to 4600 now
32:59Captain Sotheran brought his engines to flight idle to aid his descent
33:04and then left them in that position for more than a minute
33:10during that time flight 703 descended below the recommended altitude
33:16the captain eventually increased engine power
33:21but not enough
33:23and flaps 15
33:25and up to 33%
33:27and back to flight idle
33:2910%
33:31not giving it a lot of power
33:37he allowed the airplane to get way below the profile
33:40he didn't notice that because again he was busy, he was distracted
33:43the co-pilot didn't notice because he's trying to deal with his checklist
33:47so nobody noticed the airplane went descending below profile
33:51but there is a device on the Dash 8 that should have warned the pilots that they were rapidly approaching the ground
33:58the ground proximity warning system or GPWS
34:03the system uses radio signals to measure the distance from the ground and the plane's closing speed
34:10if the plane is getting too close to the ground or descending too quickly
34:14a warning sounds advising the pilots to pull up
34:22okay, let's listen to what they heard in the cockpit
34:24investigators listen for the warning sounds from the GPWS
34:29you're supposed to pull the handle
34:31it's actually got that after that
34:33it's pulled
34:36it's pulled
34:37it's pulled
34:41there it is, clear as day
34:43it's pulled
34:45it's pulled
34:47it's pulled
34:49there it is, clear as day
34:51it's pulled up
34:534.5 seconds before impact
34:55not a lot of time to rear
34:56the voice recording reveals that the warning system didn't give the pilots much time to pull up and save the plane
35:09it was quite obvious to us that they had made an attempt to start an immediate climb away
35:16terrain, terrain, pull up
35:19they had started to put on power
35:22they had obviously brought the nose up from the aircraft's previous nose down attitude
35:26computer simulations show that the GPWS on the Dash 8 should have provided a warning well before Flight 703 hit the hill
35:3817 seconds, that's more like it
35:42the pilots would have had ample time to avoid a collision
35:45had it been 17 seconds I suspect the airplane would have cleared the hill
35:49it would have been a scary moment but they would have cleared the hill
35:52there's a big difference between 17 seconds and 4.5 seconds
35:58and 4.5 seconds
36:01sure is
36:03a 4.5 second warning before you hit the hill isn't
36:08particularly helpful
36:10the team now wonders why the crew of Flight 703 got a late warning from their GPWS
36:15investigators have recovered the GPWS computer from the wreckage of ANSET Flight 703
36:36we didn't know if there was anything wrong with that system but we knew it warranted looking at first
36:44looking at further
36:51this checks out, no problems at all
36:54the unit appears to be in good working order
36:57investigators know the GPWS didn't warn the pilots until it was too late
37:04did something interfere with the altimeter that feeds the unit altitude data
37:09what do we know about this?
37:13the issue was brought up about the nearby telecommunications tower and whether or not that had
37:20any potential for interference with the operation of the airplane
37:24what do you got?
37:26it's a radio transmission tower
37:28signals are in the 800 to 900 megahertz range
37:32those frequencies wouldn't affect the radio altimeter
37:44the main reason that we ruled out the telecommunications tower very quickly was that it was not in the same frequency range at all that's used by the GPWS
37:51two entirely different frequencies
38:07it's been painted
38:08to prevent any disruption to reception
38:11the antenna for the radio altimeter is marked with the words
38:15do not paint
38:17it appears ANSET ignored that
38:21the GPWS antenna
38:24sends and receives radio altimeter signals
38:27as the aircraft passes over the ground
38:28it was painted
38:31it shouldn't have been painted
38:33we had no idea
38:35what this meant to the operation of the system
38:38the non-metallic paint used would not inhibit radio signals
38:43that's not it
38:46they're running out of leads
38:48it's got to be the software
38:50investigators determine that a software glitch prevented the GPWS from getting accurate altitude readings
38:57as the plane descended faster than normal over unusually hilly terrain
39:03we concluded that probably the radio altimeter missed a beat or two
39:08as they were approaching the undulating terrain
39:11that it just dropped out for whatever one or two hits
39:15enough to cause it to give only a four or five second warning
39:21landing gear alternate release door open
39:23which it is
39:26but the failed GPWS doesn't answer the investigation's most pressing question
39:31why didn't the pilots discontinue their approach while they struggled with their gear
39:35clear now to assess the landing gear issue here
39:40twelve miles out
39:42that only gives them about five minutes to get the gear down and land
39:49why not go around and buy some time?
39:51good question
39:53time is your friend
39:55and if you don't have enough time it's your enemy
39:58so you want to make sure you give yourself time
39:59because these procedures do take time to lower the gear
40:01question is why did it continue?
40:04investigators now realize that the entire sequence of events put in motion by the failed gear
40:10could have been prevented if the pilots had taken one simple action
40:15I've ordered all of this by just going around
40:19oh crap
40:24yeah look at that
40:26I don't want that
40:28yeah that's not good
40:30okay so uh
40:31she's not locked
40:33alternate uh landing gear
40:35alternate extension
40:36you want to grab the QRH
40:38yeah
40:39just whip through that one
40:47see if we can get it out of the way before it's too late
40:50the team believes Captain Sotheran's decision to continue the approach while trying to lower the gear
40:56was a tragic mistake
40:58when this landing gear did not come down
41:01the pilots should have stopped their approach right away
41:03they should have said we're going to go somewhere
41:04and hold
41:06and we're going to get the landing gear down
41:08oh
41:09yeah
41:10and operate until the main gear
41:12blocks
41:13you're supposed to pull the handle
41:16but instead Captain Sotheran made the decision to continue his approach to Palmerston North
41:22in human factors terms it's called continuation bias
41:27continuation bias means you've got a plan to do something
41:30other things come up to show you that plan may not be as good as you hoped
41:34but you don't accept those other things
41:37his resolve to continue the approach proves deadly
41:41hooray hooray
41:42pull up
41:44up
41:46up
41:48up
41:50up
41:52up
41:54up
41:56up
41:57up
42:00in their final report
42:02investigators fault Captain Sotheran
42:04for not making proper power adjustments
42:06for losing track of his altitude
42:08for not focusing on flying the airplane
42:11and for continuing the approach while troubleshooting the landing gear
42:15you're dead to yourselves
42:18a landing gear issue should not cause an airplane accident
42:24flight crews are trained to overcome this type of emergency
42:29this accident was about the performance of the pilots
42:33this accident should not have happened
42:36and said New Zealand revised its operations manual following the accident
42:41pilots are now instructed to discontinue their approach and resolve any abnormal situations before attempting to land
42:46what I learned from this accident was
42:49what I learned from this accident was give yourself time
42:51it's not a critical emergency
42:53it's something you can do in an organized way but you need time
42:56but you need time
42:58in the year 2000
42:59in an unprecedented move Captain Sotheran is charged with manslaughter for operating an aircraft in a careless manner
43:07after a six-week trial
43:08after a six-week trial six years after the accident a jury finds him not guilty
43:14it was a grueling trial for the captain he never flew for inset again and had to leave the country to resume his flying career
43:22to this day William McGrory bears no ill will towards the crew of anset flight 703
43:28yes there was part of the era but I did not at any time blame the pilots for the crash
43:34it's a whole host of things on the day that came together like the perfect storm
43:39at the time after the crash I learned to appreciate life in general
43:45and I often have to pinch myself and say hey smell the roses
43:49tell people you love them again
43:52and remember that one instant you can be here the next instant you can be dead
43:56so it's been good for me in that respect that it makes you appreciate what you have got
44:02so it's been good for you
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