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Air Crash Investigation Series S20E03 Katmandu Descent
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00:00On a challenging descent in the Himalayas...
00:05Landing on runway 02. Questions or concerns?
00:08No questions, no concerns, Commander.
00:10A passenger jet collides with the side of a mountain.
00:14Attack!
00:15No, no, no, no!
00:18It really was a shocking moment.
00:21But when their most vital piece of evidence doesn't deliver...
00:27This is it.
00:30...investigators scramble for answers.
00:35Could be weather.
00:37Loss of thrust.
00:38Intruder in the cockpit.
00:40But the accidental discovery of a valuable clue...
00:43Could it be?
00:44...points to the origins of what went wrong.
00:47Come on, come on, come on!
00:48That was the eureka moment in this investigation.
00:53Me day, me day.
00:57Oh, fuck.
01:00Oh, fuck.
01:01No, no, no.
01:02Go ahead and get up.
01:03Oh, fuck.
01:04No, no, no, no.
01:05No, no, no, no, no, no, no, no, no, no, no, no, no, no, no.
01:07Pakistan International Airlines Flight 268 is en route to Kathmandu, the capital of Nepal.
01:27The two-and-a-half-hour flight from Karachi is one of the few that flies to the Nepali capital,
01:33situated 4,600 feet above sea level.
01:37Landlocked between China and India, Nepal is home to eight of the world's ten tallest peaks,
01:44including the mighty Everest.
01:47Kathmandu is a favourite destination for travellers to the Himalayas,
01:51many of whom are making their way to Nepal for the start of the popular trekking season.
01:57Could I have a tea, please?
01:59Among them are Mick Hardwick and his friend Dave Harries,
02:03both mountaineering instructors back home in Britain.
02:07Thank you for climbing to the Alps.
02:10There were certainly very, very good climbers in a variety of different disciplines in alpine work,
02:15really at the top of the tree.
02:18They're on their way to climb Annapurna, the tenth highest mountain in the world.
02:25Annapurna was certainly an ambitious programme, but it wasn't foolhardy.
02:28It was well thought out and well planned.
02:30It would have been a huge moment for them.
02:33It would have been a trip of a lifetime.
02:36In the distance, they get their first look at the Himalayas.
02:41Have a look at that.
02:45Finally.
02:46On the flight deck, Captain Iftikhar Janjua is in command.
02:55He's a former officer in the Pakistani Air Force,
02:58who's now a senior pilot instructor with the airline.
03:01Captain Mohamed Hussain flew around the world with Captain Janjua on many different flights.
03:08I knew him for a period of about five years.
03:12He had no airs about him, you know, he was quite a simple person.
03:15He was a family man.
03:17He never smoked.
03:18He didn't drink.
03:19That way he was a straight guy.
03:20I don't like the look of the clouds ahead.
03:26The first officer is Hassan Akhtar, a junior pilot with the airline,
03:31with almost 1,500 hours flying the Airbus A300.
03:35How about we divert around them?
03:38Yes, Commander. Agreed.
03:40It's nearing the end of monsoon season.
03:43Large storms are still frequent along the route.
03:46Kathmandu, Pakistan 268.
03:47We are 10 to 15 miles right of the track to avoid a build-up en route.
03:52To avoid the storm, Captain Janjua notifies Kathmandu air traffic control
03:57of his change to Flight 268's approach.
04:00Roger, 10 to 15 miles right of track. Copied.
04:06Could get bumpy. Let's keep them seated.
04:09Agreed, Commander.
04:12Fast and seatbelt sign is on.
04:14We're about to begin our descent into Kathmandu.
04:16We are entering an area of turbulence,
04:18and I request all of you to remain seated.
04:21The descent until it was quite scary,
04:23because the plane seems to be descending forever.
04:26You sort of lose track of where you actually are.
04:28We're expecting it to be a little choppy.
04:31Well, here comes the mountains.
04:34Then you're on the runway,
04:35and it's always a relief when the plane comes to a halt.
04:40I'll take over from here, Akhtar.
04:46Yes, Commander.
04:48I have control.
04:49You have control?
04:51The first officer hands over control of the aircraft to the captain.
04:58Flight 268 leaves its cruising altitude
05:01as it begins the approach into Kathmandu.
05:03In 1992, Kathmandu Airport doesn't use radar to track its planes.
05:14Every movement, planned or otherwise,
05:16must be accurately reported by the flight crew.
05:20In the absence of radar,
05:22it requires good communication
05:23between the aircraft and the air traffic controller.
05:25They have to communicate very carefully.
05:27Pakistan 268, approaching overhead.
05:31Simran 150.
05:33Pakistan 268, descent to 11,500.
05:36No delay expected.
05:38Roger, sir.
05:39Down to 11,500.
05:41The problem with Kathmandu is
05:43that you have a range of mountains to the south
05:46that you have to get over,
05:47and then you have to drop down quite steeply
05:50in order to be able to land at the threshold of the runway.
05:55There is a danger of arriving at the threshold
05:56too fast or even a little bit high.
06:00The mountains surrounding Kathmandu
06:02require pilots to make what's known as a stepped approach.
06:06Pilots must descend to a series of lower altitudes
06:09at certain distances from the airport.
06:14We can expect descent clearance by 16 miles.
06:17Descent angle is steep,
06:18so we need to be at flaps 15 by 16 miles.
06:22Landing on runway 02,
06:24watch for stray animal and birds.
06:25Questions or concerns?
06:27No questions, no concerns, Commander.
06:29Pakistan 268, report 16 miles,
06:32wind 180, expect Sierra approach.
06:35Roger, call you at 16 miles,
06:36expecting Sierra approach.
06:38Sierra approach, Commander.
06:39Here it is.
06:44Watch my levels.
06:45The details of the stepped approach
06:46are laid out on a chart for the pilots.
06:49The approach chart is designed
06:51to keep you clear of terrain,
06:53so you have to follow the approach chart.
06:57As flight 268 begins its final approach
07:00towards Kathmandu,
07:02passengers and crew prepare for landing.
07:04Oh, sun and blue skies will be nice.
07:10Alpha Charlie Hotel,
07:11surface wind 200, 05.
07:15Pakistan 268 is at 16 miles,
07:1811,500.
07:2016 miles from the airport,
07:22the pilots report their altitude
07:23as 11,500 feet.
07:26Roger, Pakistan 268.
07:28Report 10 miles.
07:30Roger, call you at 10 miles,
07:31Pakistan 268.
07:32The crew works its way
07:35through the steps towards Kathmandu,
07:37approaching from the south.
07:43They should be touching down
07:44in about six minutes.
07:49Alpha Charlie Hotel,
07:50continue to taxiway number two.
07:55Pakistan 268 is at 10 miles.
07:58Report your level.
08:02We crossed out of the 8,500.
08:06200 now.
08:08Roger, clear for final.
08:10Report four miles, runway 02.
08:13We'll call you at four miles,
08:14Pakistan 268.
08:15Clear for final, runway 02.
08:17Runway 02.
08:20Flight 268 is now less than 10 miles
08:23from the runway.
08:23Air traffic control waits
08:34for the flight crew's
08:35next position report.
08:45Three minutes go by.
08:47Flight 268 should have reported
08:58that they've reached
08:58the next step by now.
09:03Pakistan 268, report position.
09:07Pakistan 268, report position.
09:13Pakistan 268, tower.
09:14Pakistan 268, this is tower.
09:20As the minutes tick by,
09:24air traffic controllers come
09:26to a horrifying realization.
09:31Flight 268 is missing
09:33somewhere in the Himalayas.
09:39It doesn't take much time
09:40for Kathmandu air traffic controllers
09:42to get word
09:43that PIA flight 268
09:47has crashed somewhere
09:48in the Himalayas.
09:51Within hours,
09:53the plane's wreckage
09:55is found on the side
09:57of a mountain.
09:59The flight was carrying
10:01more than 20 tons of fuel.
10:05And the plane is completely
10:07consumed by fire.
10:08all 167 people on board
10:13have died.
10:16Tonight, investigators
10:17refuse to speculate
10:18on possible causes
10:19of the crash.
10:20So dangerous are the conditions...
10:22We're all back in North Wales
10:24and the news filter
10:25threw into the office.
10:26We just sort of
10:27stared in disbelief, really.
10:30We could believe it.
10:31You hear of these things happening,
10:32but when it happens to
10:33people you've been in contact
10:34on a daily basis
10:36year in, year out
10:37and worked with them
10:38on the cliffs
10:39and the crags.
10:40It's just disbelief.
10:43As the flames die down,
10:45Nepal faces
10:45a chilling reality.
10:48A passenger jet
10:49has crashed
10:49near the Kathmandu runway
10:51for the second time
10:52in two months.
10:56The first was
10:57a Thai Airways Airbus
10:58with 113 people on board.
11:04Canadian accident
11:08investigator Dave McNair
11:09is already in Nepal
11:11leading the Thai Airways
11:12investigation.
11:13There hadn't been
11:14an accident in Kathmandu
11:15for many, many years.
11:16There was the one accident
11:17that happened back in July
11:18and then a second accident
11:20of a major aircraft
11:21at the same place
11:22and really was
11:23a shocking moment.
11:25Yeah.
11:26Within hours,
11:28the Nepalese government
11:29launches an investigation
11:30into the crash
11:31of Flight 268.
11:33We need to get there
11:34as soon as the weather clears.
11:35Already stretched thin
11:36by the Thai Airways investigation,
11:38the Nepalese
11:39ask British investigators
11:40for help.
11:42Thanks for coming, Andrew.
11:44Andrew Robinson
11:45from Britain's
11:46Air Accidents
11:46Investigation Branch
11:47is one of the investigators
11:49assigned to the case.
11:50Let's see what
11:51we're dealing with here.
11:53My role in the investigation
11:54was to look at
11:55the engineering aspects
11:56of the accident.
11:58So I would be looking
11:59at the site,
12:00the wreckage distribution,
12:02the wreckage itself,
12:03the components within it
12:04and trying to work out
12:06what the impact attitude was,
12:08whether all the aircraft
12:09was present at the impact site,
12:11that sort of thing.
12:13Kathmandu Airport
12:14is the main hub
12:15of Nepal's tourist industry.
12:18The pressure is on the team
12:20to figure out
12:21what caused this accident
12:22as quickly as possible.
12:25We wanted to find out,
12:26obviously,
12:27if there was something wrong
12:28with Kathmandu Airport
12:29or procedures involved
12:31in approaching
12:32or landing at it.
12:33So, yes,
12:35there was a huge concern
12:36within the aviating community.
12:40The Nepalese government
12:41deploys the military
12:42to help investigators
12:43get to the remote crash site,
12:45which is more than 7,000 feet
12:47above sea level.
12:49I was part of the team
12:50to go up there
12:51to look at the initial
12:51wreckage survey.
12:54It was quite of a perilous drive
12:56to get there.
12:57We got to the base camp,
12:59and then we had to walk
13:00about two kilometers up a path
13:02to get to the site.
13:03It was an emotional walk
13:05because as we're walking up,
13:07people are bringing
13:08the remains down.
13:12When we first encountered
13:14the wreckage site,
13:16you couldn't even recognize
13:17an airplane
13:18except for the tail.
13:20And, of course,
13:21you could see
13:21some of the souvenirs
13:22that people had
13:23were lying on the ground.
13:24A little child's sock was there.
13:26So, you know,
13:26that's related to the people
13:27who were on the airplane.
13:29But in this case,
13:30it was just the aircraft
13:31was just totally destroyed.
13:32It was just
13:33complete obliteration
13:34of the aircraft.
13:36The team begins
13:37examining the wreckage.
13:40But conditions
13:41are treacherous.
13:42The aircraft had crashed
13:44into the side of a mountain,
13:45about 150 feet from the top.
13:48And getting about
13:49on the site
13:49to inspect it
13:50was actually quite difficult
13:51because the average slope
13:52was about 45 degrees.
13:55Investigators quickly conclude
13:56that it's too dangerous
13:57to examine the wreckage
13:59on site.
14:00The actual workers
14:01were Nepalese
14:02who had to deal
14:03with some steep slopes
14:04and had to work
14:05very, very carefully
14:05to make sure
14:06nobody was injured
14:07on the site.
14:07As the investigation
14:11gets underway,
14:12one thing is obvious.
14:14Flight 268's final altitude.
14:16This is the location
14:17of the crash site,
14:19nine miles south
14:20of the airport.
14:22The aircraft collided
14:23with the mountain
14:24at an elevation
14:27of 7,280 feet.
14:31Investigators plot
14:33the location
14:33and altitude
14:34of the crash site.
14:35just below the summit.
14:38Where should they be?
14:39Can you pass me
14:40that approach truck, please?
14:43At 10 miles out,
14:46he should have been
14:47at 8,200 feet.
14:53How do you hit a mountain
14:54you're supposed to clear
14:55by 1,000 feet?
14:57You know it hit the mountain,
14:58there's no doubt about that,
14:59but you don't know why
15:00it was as low as it was
15:01when it hit the mountain.
15:02As yet more mystery
15:05swirls around Flight 268,
15:08a makeshift morgue
15:09is set up
15:10outside the airport.
15:12The people of Kathmandu
15:13must come to terms
15:14with a second tragedy
15:15in as many months,
15:17and pressure builds
15:19to find out
15:19why that happened.
15:25Nepalese soldiers
15:26have retrieved
15:26the aircraft's black boxes
15:28from the wreckage
15:29of PIA Flight 268.
15:31Put that over there, please.
15:32The Digital Flight Data Recorder,
15:35or DFDR,
15:36contains information
15:37about critical aircraft
15:38operations and performance.
15:41They look pretty banged up.
15:43The cockpit voice recorder
15:44records conversations
15:45between the pilots.
15:47They'll both be sent to France,
15:49where the data
15:50will be downloaded
15:51and analyzed.
15:53Flight recorders
15:53are extremely vital
15:54for investigations.
15:56The most important part
15:57is it really brings you
15:58closer to understanding
16:00the entire reason
16:01for the accident.
16:05But until they get the data,
16:07investigators must look
16:08elsewhere for clues.
16:09They hope the air traffic
16:10controller can provide
16:11some insight.
16:13I've been running
16:13through every conversation
16:14we had
16:15and studying my notes.
16:16Does anything stand out?
16:19They had to deviate
16:20around some bad weather.
16:25Kathmandu, Pakistan 268.
16:26We are 10 to 15 miles
16:28right of the track
16:29to avoid a buildup en route.
16:31The controller tells
16:32investigators that
16:33the crew reported
16:34some storm clouds
16:35on the way to Kathmandu.
16:37It's usually very hazy
16:38in the Kathmandu Valley.
16:39In most conditions,
16:41when you've got mountains,
16:41you invariably have clouds.
16:44That's common
16:45this time of year.
16:47Anything else after that?
16:48Standard position reports
16:49by the book.
16:50Pakistan 268 is at 10 miles.
16:56Report your level.
16:57We crossed out of 8,500.
16:59200 now.
17:01Roger.
17:01Clear for final.
17:02Report 4 miles.
17:04Runway 02.
17:05We'll call you at 4 miles,
17:06Pakistan 268.
17:08He said he'd contact me
17:10when he got 4 miles out.
17:11But I never heard
17:13from him after that.
17:13OK, let's see
17:20what the wreckage
17:20can tell us.
17:21When an aircraft
17:22is destroyed,
17:23there are still things
17:24you can get
17:24from the accident site.
17:26Investigators consider
17:27the possibility
17:28the jet was flying
17:29out of control
17:30when it crashed.
17:31They scrutinized
17:32the crash site for clues.
17:34Look at this.
17:36The right wing
17:37impacts up here.
17:41A large scar
17:42shows Robinson
17:43precisely where the wings
17:44hit the side
17:45of the mountain.
17:49He also notices
17:50that just 1.3 meters
17:52below the impact scar,
17:53the top of a tree
17:54has been cut cleanly.
17:56The wing couldn't
17:57have cut that tree.
17:58So what did?
18:00The aircraft
18:01cut some tree branches.
18:02So you can actually
18:03use that to measure
18:04angles of impact.
18:05Then you can use
18:06other evidence
18:06to find out
18:07what happened
18:07to the airplane.
18:08What about
18:13the flaps?
18:20Fully extended.
18:22Exactly 1.3 meters
18:24below the wing.
18:26For the team,
18:27it's a critical clue.
18:28As the Airbus A300
18:32slows for landing,
18:34its wing flaps
18:35extend by as much
18:36as 25 degrees.
18:38Hanging below the wings,
18:39the extended flaps
18:41would shave the top
18:42of the tree
18:42as it slams
18:43into the mountain.
18:49Wings level,
18:50no pitch down,
18:51flaps extended.
18:52In other words,
18:54the exact landing
18:55configuration.
18:57This plane was
18:57absolutely not
18:58out of control.
19:01Flaps 10.
19:03Flaps 10.
19:05This is an indication
19:06that in fact the crew
19:07was deliberately
19:07flying it there.
19:09But what was
19:09abnormal was the fact
19:10the airplane was
19:11being flown too low.
19:13The question is
19:13why was that?
19:17To answer that question,
19:19the team creates
19:20a list of every
19:21conceivable scenario
19:22based on the evidence
19:23they've collected
19:24so far.
19:25Any thoughts?
19:28Loss of thrust?
19:33Clear for final
19:34runway zero two.
19:35Runway zero two.
19:39Loss of engine number one.
19:41We're losing number two
19:42as well.
19:43Investigators consider
19:44a loss of thrust
19:45in both engines.
19:47Okay, watch my altitude.
19:49Come on, come on,
19:49come on!
19:507800.
19:51Initiate restart.
19:52Either engine.
19:53And a rapid loss
19:54of altitude.
19:557500.
19:55We're not going to make it!
19:56Leading to the collision
19:57with the mountain.
20:05Robinson studies
20:06what's left
20:07of the plane's engines.
20:08only one way this got in so deep.
20:21The damage and debris inside
20:22tell Robinson
20:23the fan blades
20:24were spinning
20:24when they hit the ground.
20:29And further examination
20:30of the device
20:31that controls fuel flow
20:33shows they were
20:34at the lowest
20:35thrust setting,
20:36flight idle.
20:37That's precisely
20:39where they should be
20:40for an A300
20:41descending towards
20:42the runway.
20:45The thrust
20:46from the engines
20:47was symmetrical
20:48and at low power.
20:49There was no indication
20:51of loss of control,
20:52so that was dismissed.
20:53So we then had to sit down
20:57and think of reasons
20:58why the pilot
21:00might have been too low.
21:02With mechanical failure
21:03ruled out...
21:04Okay,
21:05not the engines.
21:06and the black box data
21:08still in Paris.
21:09What else?
21:10Investigators turned
21:11their attention
21:11to what was happening
21:13in the cockpit.
21:16Robert Bohr
21:17is an aviation psychologist
21:19who has studied
21:20the course
21:20of this investigation.
21:22Accident investigators
21:23will typically approach
21:25this kind of investigation
21:26as though
21:27they were detectives
21:28and they're going to raise
21:29a wide range of questions,
21:30hypotheses
21:31that they will want
21:32to test out.
21:33Okay,
21:34what about an intruder
21:36in the cockpit?
21:39Unlawful interference
21:40is something
21:41that's around us.
21:42It's everywhere.
21:43We spend our lives
21:44dealing with it
21:45every time we check in
21:46at the airport.
21:47So we know it's out there.
21:49The team now wonders,
21:51were the 167 people
21:53on board
21:53victims of a terrorist attack?
22:01Investigators are concerned
22:02an act of terrorism
22:03may have brought
22:04PIA Flight 268
22:05to a violent end
22:07in the Himalayas.
22:14Pakistan International Airlines
22:16has been on high alert
22:17for over a decade
22:19since one of its planes
22:20was hijacked
22:21for 13 days in 1981.
22:24As a result,
22:25the airline routinely
22:26places armed guards
22:28on high-risk routes.
22:32There were four air guards
22:33on this flight.
22:34They turned to the passenger
22:36manifest for more information.
22:38Here,
22:39here,
22:42here,
22:43and here.
22:45As often happened
22:46in Pakistan Airways flights,
22:47there were a number
22:48of security guards
22:49on board
22:49which would probably
22:51tend to suppress
22:53unlawful interference.
22:54The controller reported
22:57that the first officer's
22:58final radio call
22:59just 32 seconds
23:01before impact
23:02was calm
23:02and professional.
23:04I'll call you at four miles,
23:05Pakistan 268.
23:07No hint of a struggle.
23:09That helps us
23:10to understand
23:10that on the flight deck
23:11things were pretty normal.
23:13The crew were probably
23:14therefore not being
23:15interfered with
23:15by a hijacker.
23:16I think we can
23:19rule out an intruder.
23:21Now what?
23:23Could be weather?
23:26In Kathmandu,
23:27they're quite often
23:28build up some clouds
23:29and they can develop
23:30into thunderstorms
23:31or cumulonimbus-type clouds.
23:33And the suspicion was
23:34maybe there was
23:34some sort of cloud
23:35like that on the approach.
23:38This is everything
23:39from the time
23:40of the accident.
23:42Investigators examine
23:42weather conditions
23:43throughout the flight.
23:45The report was cloudy
23:47with a potential
23:48for storms.
23:52But because the crew
23:54had deviated
23:55around bad weather...
23:56Kathmandu,
23:57Pakistan 268.
23:58We are 10 to 15 miles
23:59right of track
24:00to avoid a build-up
24:01on route.
24:02It's unlikely
24:03they then flew
24:04into a thunderstorm.
24:09By now,
24:09the team has ruled out
24:11all possible external factors
24:13for this accident.
24:15Flaps were out.
24:16Engine spinning.
24:18No intruder.
24:19No serious weather
24:20on approach.
24:22They're left
24:22with only one conclusion.
24:25You must not have known
24:25that they were flying
24:26too low.
24:29Okay, for finals,
24:30runway 02.
24:31Runway 02.
24:33Next altitude
24:33is 6,800
24:34at 8 miles.
24:36Now crossing
24:37through 7,500,
24:397,400.
24:42That's happening!
24:43It's clear in this situation
24:48that the pilots
24:49have built up a picture
24:50of the outside world
24:52that is not true
24:53and accurate,
24:54which leads to the crash.
24:56However,
24:57we have to ask questions
24:58why that may be.
25:03Investigators look
25:04into two possibilities
25:05for the flight's
25:06dangerously low altitude.
25:08Either they ignored
25:10their chart
25:11and were doing
25:11a visual approach
25:12or they somehow
25:13misread the chart.
25:15Nothing else makes sense.
25:16We had no way
25:17of knowing
25:18why it was too low.
25:20So that became
25:21a matter of studying
25:22the data
25:23and having a general
25:24roundtable discussion.
25:26All right.
25:26Let's start with
25:27the visual approach.
25:29Roger, Pakistan 268.
25:31Report,
25:311,0 miles.
25:32Roger, call you
25:33at 1,0 miles,
25:34Pakistan 268.
25:35We can save some time
25:39by going visual.
25:40Watch my speed.
25:41We should soon
25:42see the runway.
25:43On a visual approach,
25:44pilots fly based
25:45almost entirely
25:46on what they can see.
25:48Yes, Commander.
25:49Visual to runway 0,2.
25:50Rather than
25:51a predetermined route.
25:52Flaps 10.
25:54Flaps 10.
25:56Flaps 15.
25:58Flaps 15.
26:00In many instances,
26:02visual landings
26:02are easier for pilots.
26:05Watch for the runway.
26:06But with a greater
26:07risk of human error.
26:09What's happening?
26:10No, no, no, no.
26:17It's possible,
26:18but almost total
26:21cloud coverage
26:22throughout the entire
26:23approach.
26:24Plus, they knew
26:25the terrain.
26:26The captain made
26:26this approach
26:27at least seven times.
26:28The first officer,
26:29five.
26:31Investigators conclude
26:32it's highly unlikely
26:33the flight crew
26:34attempted a visual
26:35approach in thick clouds.
26:38It's a complicated arrival.
26:40It requires a step down
26:41at various points
26:43toward the runway threshold.
26:45And perhaps
26:45most significantly,
26:47the meteorological conditions
26:48were not conducive
26:49to a visual approach.
26:51Pakistan 268,
26:52report 16 miles.
26:53The only theory left
26:54is that the pilots
26:55somehow misinterpreted
26:56their approach chart.
26:58Seattle approach,
26:58Commander.
26:59Here it is.
27:03Watch my levels.
27:05Everything was working,
27:06technically.
27:07It didn't appear
27:08to be any interference
27:09on the flight deck
27:10by anyone.
27:11And so the only conclusion
27:13that we can take from this
27:14is that for some reason,
27:15the pilots
27:16had clearly
27:17misinterpreted data.
27:18All right.
27:24Let's look at this.
27:26Investigators hope
27:27the flight's black box data,
27:29back from Paris,
27:30will help solve
27:31the mystery.
27:32They look at the plane's
27:34flight path
27:34as the crew
27:35prepares for landing.
27:36They started their descent.
27:37At 16 miles out,
27:39they're at 10,500 feet.
27:41Then down to 9,500
27:42at 13 miles.
27:448,200 at 10 miles.
27:47Then quickly down to 7,500
27:48until impact
27:49at 7,280.
27:51The data reveals
27:52an astonishing fact.
27:54So, 1,000 feet too low,
27:56right from the get-go.
28:00The approach to Kathmandu
28:02is one of the last places
28:03on Earth
28:03a pilot would risk
28:04flying too low.
28:13Wait a minute.
28:14There you go.
28:16Perfect match.
28:19They were flying the approach,
28:20but one step ahead.
28:24What the aircraft flew
28:25was pretty much
28:27what the chart said,
28:28except that
28:29the pilot had got
28:30one step ahead of himself.
28:32So he's flying
28:33the correct altitude
28:33for the next position,
28:36which was a sort of
28:37eureka moment, I think,
28:39in this investigation.
28:40He's adjusting his descent
28:44to hit the lower altitudes.
28:47It's no accident.
28:49We obviously started to wonder
28:51why this should be the case.
28:54Still working in the shadow
28:56of the Thai Airways crash
28:58just two months earlier.
28:59Are we ready?
29:00Let's hear it.
29:02Investigators now hope
29:03the Pakistan Airways cockpit
29:04voice recording
29:05will shed light
29:06on what happened
29:07in the cockpit
29:08in the lead-up
29:09to the fatal collision.
29:13But as the team
29:15begins listening
29:15to the CVR,
29:17they get a gut-wrenching shock.
29:19This is it.
29:34The cockpit voice recording
29:36of PIA Flight 268
29:38is playing the last thing
29:39investigators want to hear.
29:42Silence.
29:44But then...
29:45We are entering
29:46an area of turbulence
29:47and I request all of you
29:48to remain seated.
29:50The tape has recorded
29:51the announcements made
29:52to the cabin
29:53and conversations
29:54with controllers,
29:55but not the conversations
29:56between the two pilots.
29:59Okay.
30:00So nothing from the cockpit, Mike.
30:03It's a major setback.
30:07Back to the drawing board.
30:12Without the full cockpit
30:13voice recording,
30:15investigators need to find
30:16other ways of understanding
30:17why the pilots of Flight 268
30:20were flying a thousand feet
30:21too low
30:22at every step
30:23of their approach.
30:25We have to therefore
30:26build a picture
30:27of what might have been going on
30:28in their minds,
30:29in the relationship
30:30between the two pilots,
30:32and in their relationship
30:33between themselves,
30:35the physical environment,
30:36and air traffic control.
30:38What if the problem
30:39is the actual approach chart itself?
30:41To avoid the mountains
30:43surrounding Kathmandu,
30:44pilots follow an approach chart
30:46about the size
30:47of a large postcard.
30:49It provides the specific altitudes
30:51pilots must take
30:52at set distances
30:53from the airport.
30:55They study the same chart
30:57used by the flight crew.
30:58So is, let's say,
31:018,200 feet
31:03the right altitude
31:04for 10 miles
31:05or 8 miles?
31:07It's hard to say.
31:09Even harder
31:10when it's actual size.
31:12The operations team
31:13spent a lot of time
31:14looking at a chart
31:15that the crew
31:16had been using.
31:17They concluded
31:18that there was a large amount
31:19of information on it.
31:20It was a lot of clutter.
31:25Investigators need to know
31:26how the crew
31:27would have prepared themselves
31:28for the complicated approach.
31:30They examine
31:31the cockpit layout
31:32of an identical
31:33Pakistan International Airlines
31:35Airbus A300.
31:37There's no place
31:38to clip an approach chart here.
31:40Most aircraft
31:41have little clips
31:43on the control column
31:44to attach
31:44the approach plates to.
31:46Now this particular aircraft
31:47didn't.
31:48There is just here.
31:50Now only the captain
31:51can see it.
31:52And he'd have to keep
31:53turning his head.
31:54Unlikely they use that.
31:56More likely he put it here.
32:00The other clip
32:00is a full three feet away
32:02from either pilot.
32:03That's not much better.
32:05It's almost impossible to read.
32:07And that handle
32:07is blocking the descent profile.
32:09They learn that
32:10Pakistan International Airlines
32:11has only two places
32:13for pilots to clip their charts.
32:14Both positions
32:15make it very difficult
32:16to read a four inch
32:17wide piece of paper.
32:19It's difficult
32:20to make a quick reference
32:21if you're having to
32:21sort of look to the right
32:22or to the left
32:23for a chart.
32:26Could it be?
32:29Then, quite by accident,
32:31the investigators discover
32:32a key clue
32:33regarding the pilot's
32:34misreading
32:35of the approach chart.
32:37If you pick up the chart
32:39and happen to put your thumb
32:40over the 11,500 foot mark
32:43for 16 nautical mile marker,
32:45in that case,
32:48it might have guided his eye
32:49to the next height fix
32:51and he might have assumed
32:52that that was the correct height
32:53for the 16 mile marker point.
32:58This definitely makes it look
32:59like 10,500
33:00is the correct altitude
33:02at 16 miles.
33:03Robinson finally has a theory
33:05he can put to the test.
33:10Kathmandu Tower,
33:11good afternoon.
33:12Pakistan 268,
33:1325 miles at 11,500.
33:16Just a few minutes
33:17before impact,
33:18the first officer reports
33:19being 25 miles
33:21from the airport
33:21at the correct altitude
33:23of 11,500 feet.
33:26Pakistan 268,
33:27report 16 miles,
33:28wind 180,
33:30expect Sierra approach.
33:31Roger,
33:32call you at 16 miles,
33:33expecting Sierra approach.
33:35Sierra approach,
33:35Commander.
33:36But when the captain
33:37looks at the approach chart,
33:39his thumb may have obscured
33:41the correct next altitude.
33:43Here it is.
33:44Watch my levels.
33:45Now,
33:46instead of maintaining
33:4711,500 feet,
33:49Captain Janjua
33:50dials in the next altitude
33:51on the chart.
33:53Descending to 10,500.
33:55Oblivious that his plane's approach
33:57is now one step ahead.
34:01The crew has now
34:02made a fatal mistake.
34:04Unaware the airliner
34:05is now descending
34:06towards a violent collision
34:07with the side of a mountain.
34:10So,
34:12that's where it all started.
34:17Investigators now pursue
34:18the new theory
34:19that the pilots of Flight 268
34:21misread the altitudes
34:22on a cluttered approach chart.
34:25At 16 miles,
34:26they should be at 11,500.
34:28But they've descended
34:29to 10,500.
34:31The team has
34:32a surprising realization.
34:33But then they report
34:34being at 11,500.
34:37At the 16-mile mark,
34:43the first officer reports
34:44the altitude
34:44they should be at,
34:4511,500 feet.
34:47Pakistan 268
34:49is at 1,6 miles,
34:5011,500.
34:52Instead of 10,500,
34:54the lower altitude
34:55they're actually at.
34:59The investigators
35:00have uncovered
35:01a new mystery
35:02that goes right
35:03to the heart
35:04of what went
35:05so horribly wrong.
35:06Why did they descend
35:07to 10,500
35:08and then report
35:09being at 11,500?
35:16Andrew Robinson's team
35:17returns to the flight data,
35:19hoping to understand
35:20why the pilots
35:21of Flight 268
35:22misread
35:23and misreported
35:24their approach altitudes
35:25before the crash.
35:26a slat extension,
35:28a frequency change,
35:29and then flaps
35:30and landing gear.
35:31He was a busy guy.
35:34It's a fast
35:35and steep approach.
35:36And unless you're a pilot
35:37with considerable experience
35:38flying this route
35:39maybe several times
35:40in a week,
35:41it's going to be
35:41very testing.
35:43Descending to 10,500.
35:46Initiating descent.
35:46Investigators now believe
35:49that as the distracted
35:50flight crew
35:50approached 16 miles,
35:52Throttles to flight idle,
35:54slats 15.
35:54Their attention
35:55was consumed
35:56by the demands
35:57of the busy descent.
35:59Flats 10.
36:01Flats 10.
36:02Flats 15.
36:04Landing gear down.
36:05By now,
36:06the captain
36:06has already dialed
36:08the flight's descent
36:08a thousand feet too low.
36:10Gear down.
36:11Three green.
36:12We're at 16.
36:12Report our position.
36:13Pakistan 268.
36:16He's at 16 miles.
36:18Investigators think
36:19the first officer
36:20hastily misreports
36:21the altitude
36:21on the approach chart.
36:2311,500.
36:25Without double-checking
36:27his altimeter.
36:29Then,
36:30Captain Janjua
36:31is too busy
36:32to notice
36:32the discrepancy
36:33between the reported
36:34and actual altitudes.
36:36In quite a stressful environment
36:38such as the arrival
36:40at this airport,
36:41the build-up of pressure
36:43inside the pilot
36:44must be quite considerable.
36:46And their capacity
36:47to assimilate,
36:48take in information,
36:49read what's going on around
36:51is going to be severely taxed.
36:58Can we hear his next report, please?
37:02Pakistan 268.
37:03Is that 10 miles?
37:05Report your level.
37:06We've crossed out
37:07of 8,500.
37:08200 now.
37:09When he makes this report,
37:12he's at 8,100 feet.
37:17We've crossed out
37:18of 8,500.
37:21200 now.
37:24Roger.
37:24Clear for final.
37:25Report 4 miles.
37:27Runway.
37:27Both pilots
37:28seem to have made mistakes.
37:30But air traffic control
37:31could have caught them
37:32and sounded the alarm.
37:33Why did the air traffic controllers
37:37not speak up?
37:38Why did they not say anything?
37:44Investigators head
37:44to Kathmandu Airport
37:46to find out
37:47why air traffic controllers
37:48didn't warn
37:49Flight 268
37:50it was flying too low
37:51before it crashed.
37:54I did not know
37:55his exact position.
37:57So I had no way of knowing
37:58what the terrain below him was.
37:59In this case,
38:01without radar,
38:01it's really the responsibility
38:02of the crew
38:03to make sure
38:04of where they're flying
38:05in their approach.
38:06They also learned
38:07that pilots flying
38:08into Kathmandu
38:09often reported
38:10being at altitudes
38:11lower than the ones
38:12specified on the chart.
38:13When the mountaintops
38:15are covered in clouds,
38:16pilots will sometimes
38:17dip under them
38:18and fly over this valley instead.
38:22We crossed out
38:23of 8,500.
38:25200 now.
38:26If the pilots
38:27of Flight 268
38:29had detoured
38:29around the mountain,
38:318,200 feet
38:32would be a safe altitude.
38:34Radar coverage
38:35in this area
38:36was not well developed
38:37and therefore
38:38it was very much
38:39a procedural approach
38:40and not one
38:41that relied on
38:43inputs
38:43from the air traffic
38:44controllers themselves.
38:46They were recipients
38:47of information
38:48and not really
38:48guiding the aircraft in.
38:51It all starts
38:52with the initial
38:52misreading of the chart
38:53and spirals forward
38:54from there.
38:56Investigators believe
38:57they've finally developed
38:58an explanation
38:59for how the tragic
39:00accident unfolded.
39:05Seattle approach,
39:06commander.
39:07The first mistake
39:08is made before
39:09the 16-mile marker
39:10where the captain
39:11likely misreads
39:12the approach chart.
39:14Here it is.
39:15Watch my levels.
39:16And enters the altitude
39:17for the 13-mile marker
39:19one step ahead.
39:20Descending to 10,500.
39:23Land the gear down.
39:24Gear down.
39:28Tree green.
39:29We're at 16.
39:30Report our position.
39:31Then,
39:32likely distracted
39:32by the busy approach,
39:34the first officer
39:35misreports their altitude.
39:37Pakistan 268
39:38is at 16 miles.
39:40He reports
39:40where they should have been.
39:4211,500.
39:44Not where they actually are.
39:48Investigators believe
39:48that if the captain
39:49had caught
39:50and checked
39:51that discrepancy,
39:51the flight's outcome
39:52might have been
39:53completely different.
39:55At that point,
39:56there was scope
39:56to correct
39:58and get back on track.
40:00But the profile
40:02suggests that
40:03they thought
40:04they were on
40:04the correct altitude
40:05and everything
40:06stemmed from there.
40:08So they carried on
40:10being that
40:10one step ahead.
40:13Flight 268
40:14remains 1,000 feet
40:16below the recommended
40:17safe altitude
40:17for what's left
40:19of its fatal descent.
40:20We cross out
40:23of 8,500.
40:26200 now.
40:28Next altitude,
40:296,800
40:30at 8 miles.
40:32Now crossing
40:33through 7,500,
40:357,400.
40:39No, no, no, no, no!
40:44Three minutes
40:44after they first
40:45misread the chart,
40:46they impact the ground.
40:47What is quite striking
40:50is that it is
40:51a very difficult approach
40:52and in spite of that,
40:54the pilots
40:54are actually operating
40:55effectively
40:56but not safely.
40:58This is at the heart
40:59of crew resource management
41:00and that has failed
41:02in this accident.
41:06In the end,
41:07if the plane
41:07had been just
41:08a few hundred feet higher,
41:10it would have missed
41:11the mountain
41:11and 167 lives
41:13would have been spared.
41:14In the aftermath
41:17of the Flight 268 tragedy,
41:19investigators make
41:20a number of recommendations
41:21to prevent another accident
41:23due to a misread
41:24approach chart.
41:27Chief among them
41:28is simplifying
41:29the Sierra approach
41:30itself
41:30to make it
41:31less complex
41:32and challenging.
41:34They also recommend
41:35installing air traffic
41:36radar at Kathmandu
41:38and suggest
41:39Pakistan International Airlines
41:41install clips
41:42on the control columns
41:43of all its
41:44A300 airplanes.
41:47Minor things
41:48like provision
41:48of chart clips,
41:50installation of radar,
41:51it's a gradually
41:52improving picture
41:53and things hopefully
41:54still will continue
41:56to improve.
41:57A memorial
41:58to the victims
41:59of Flight 268
42:00stands at the foot
42:01of the mountain
42:02where it crashed.
42:04They're still remembered
42:04by people
42:05of my generation.
42:07They're still remembered
42:07as people
42:08who did a lot
42:09and would have done
42:10a lot more
42:10in the world
42:11of mountain training.
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