- hace 2 días
On 5 May 2007, Kenya Airways Flight 507 crashes during a thunderstorm shortly after takeoff from Douala International Airport in Cameroon, killing all 114 people on board. The pilots suffered spatial disorientation after their failure to engage the autopilot resulted in an excessive bank.
Categoría
📺
TVTranscripción
00:00a brand-new 737 takes off during an intense storm they should be there by
00:10now and then mysteriously falls from the sky over West Africa those who operate
00:19these type of aircraft they have the same question what happened what happened in
00:22Cameroon investigators scour the crash site for clues the ground over there this was
00:33the toughest accident scene I've been on in my career but look at this when the
00:39investigators review the flight data they discover there was an inexplicable fight
00:47for control in the cockpit
00:55who flies like that
01:17in Douala Cameroon Kenya Airways flight 507 is almost an hour behind schedule
01:28ladies and gentlemen we are going to wait for the weather conditions to improve before we take off
01:36a severe storm must pass before the pilots can depart there are 108 impatient passengers
01:49on board many need to catch connecting flights flight 507 began in Abidjan earlier in the day
02:00it's now bound for Nairobi Kenya 507 was a very common flight for Kenya Airways particularly last decade
02:10the amount of traffic from East Africa to West Africa has really increased partially because
02:15there's much more business going on the Boeing 737 NG recently acquired by Kenya Airways is the
02:24newest generation of twin-engine commercial jets this was a new era of aviation in in Africa where
02:32airlines and particularly the bigger ones invest in brand new aircraft
02:46captain Francis Wanweir is in command of tonight's flight he's an experienced pilot with more than
02:53eight thousand hours in the cockpit
02:59Andrew Kirou is his first officer the young pilots joined Kenya Airways a year ago
03:06let's see what this storm is doing the pilots use the 737s onboard weather radar to monitor the storm
03:15looks like there might be a way around it
03:19now that the storm has moved off the end of the runway
03:24captain Wanweir believes he can fly past it
03:28it's quite common that the weather may be a factor in delay in Africa because of its severity
03:33so it's not in that respect a surprise for the operator to find this kind of weather at that time of the night
03:38tower Kenya 507 looks like there's a break in the weather requesting start-off
03:47okay 507 start-up approved start-up checklist quickly please
03:54uh generator's on a few minutes before midnight flight 507 is finally ready for takeoff
04:06okay request taxi clearance
04:10taxi runway 12 kenya 507
04:17taxi runway 12 kenya 507
04:20taxi runway 12 kenya 507
04:25car
04:46the crew taxis to the runway there's one flight ahead of them Royal Air
04:57Maroc flight 287 the Royal Air Maroc flight departs without incident
05:27wait till we line up okay usually things happen quickly though okay try to keep up
05:49captain when we are double-checks the storms position let's have a look and confirms the
05:55route around the lingering storm cell tower Kenya 507 after departure we would like to maintain a
06:04heading slightly left of runway due to weather ahead right so slightly right just after the
06:14aircraft took off the plan was to make a small turn to the right to avoid the most active weather
06:19shells that they saw on the weather radar in front of them okay all done ladies and gentlemen a kind
06:32reminder to ensure your seatbelts are well fastened for takeoff come and crew to your seats
06:37okay takeoff trust is set speed building on both check 80 knots check
06:58just after midnight Kenya Airways flight 507 finally departs for Nairobi get off okay
07:141,000 feet and climbing heading select selected check
07:32the 737 starts turning right to avoid the storm anyone okay come on so should I remain on this heading yep
07:512,400 feet and climbing
07:53now we're getting into it
08:00now we're getting into it
08:00suddenly the 737 rolls dangerously to the right
08:18the captain fights to level the plane
08:25but it continues banking further and further right
08:30despite the pilots efforts they keep rolling
08:46we're crashing yeah we are crashing
08:56left left left left direction
09:00to bring three
09:02thank you
09:03thank you
09:07Five hours later the controller in Douala is ending his shift
09:29Dula tower
09:39No reason I can think of they should be there by now
09:43Kenya Airways flight 507 should have landed in Nairobi 45 minutes ago
09:48But the plane has still not arrived
09:50Sure
09:52And no one even knows where to start looking for it
09:59Kenya Airways flight 507 was due in Nairobi at 6.15am local time
10:08But it never arrived
10:11By morning news of the missing 737 has spread
10:17Families and friends of the passengers want to know where their loved ones are
10:24Engelbert Zawa Etundi worked for Cameroon's Civil Aviation Authority
10:33When I first heard that an aircraft was missing
10:42I immediately thought we were going to have a catastrophe on our hands
10:46Two days later search teams finally locate the wreckage of Kenya 507
10:58It's three and a half miles southeast of Douala Airport
11:01The 737 has crashed into a mangrove swamp and is submerged in mud and water
11:09There are no survivors
11:18As a nation we are united in grief
11:24It's a tragic turn of events
11:28Victims, friends and family are demanding answers from the Cameroonian government
11:32But the government has a problem
11:39Cameroon did not have an agency in charge of air accident investigations
11:45Investigators from several countries descend on Cameroon
11:51Since the Boeing 737 is manufactured in the United States
12:01Dennis Jones from the US National Transportation Safety Board
12:07The NTSB joins the investigation
12:10The fact that it was a relatively new airplane at the time
12:14Certainly made it a little bit more compelling
12:16But all around the world
12:18Those who operate these type of aircraft
12:20They have the same question
12:21What happened?
12:22What happened in Cameroon?
12:26It's all from the tail
12:30Looks like everything else is down in there
12:33I saw a lot of debris from the town section
12:36We were not able to see the wreckage itself
12:39Because we were in a swamp
12:41And that was another challenge throughout the whole process
12:46A technical advisor for Boeing, Mark Smith, also joins the team of investigators
12:58This was the toughest accident scene I've been on in my career at Boeing
13:05We're standing there looking around at the devastation, the destruction
13:09So we have to, as a team, start working on what happened to, where are the various pieces
13:16A key piece of evidence is quickly found
13:21The 737's flight data recorder
13:24Well, looks pretty good, considering
13:28The FDR is sent to Canada's Transportation Safety Board to be downloaded
13:40While searchers continue looking for the cockpit voice recorder
13:46Investigators try to determine what caused the plane to crash so soon after takeoff
13:53The airport is only three and a half miles away
13:57They can't have been in here in more than two minutes
14:02We really didn't have a clue
14:05You're looking for explanations
14:08We were able to start doing a lot of on-scene examination documentation
14:13Trying to get an idea of how it impacted the ground
14:15The layout of the wreckage tells investigators how the plane was flying on impact
14:24Completely obliterated
14:31So I haven't found the most of it
14:33Looks like it came in hard and fast
14:36When you have a high-speed impact like that and a nose-dine attitude
14:41You usually get extensive fragmentation of aircraft
14:45Well, actually what we're trying to do is estimate, if we can, an angle
14:50And maybe even a speed of impact to try and get a feel for what happened
14:55Because once again, we don't yet have the FDR data
15:01How deep does this go?
15:04More than 15 feet
15:07Well, definitely hit nose first
15:10And hard
15:12So, was there some kind of loss of control that took place?
15:17That was what was kind of foremost on my mind
15:24While they wait for the flight data, investigators turned to the controller on duty that night
15:30To help fill in some blanks
15:33What can you tell me about that night?
15:36The first thing is that they delayed their takeoff
15:40Really? How come?
15:42There was a storm
15:44Coming in from the east
15:51Power, 507
15:54We are going to wait for the storm to pass
15:56Cancelling start-up
16:00Roger, 507
16:01Cancelling start-up
16:03The storm can last all night, but visibility should improve
16:06The airplane was on the tarmac loaded, ready to go, waiting for the weather to clear
16:12And then they would take off
16:16But, 20 minutes later, they decided to take off
16:19Why?
16:20It cleared a bit
16:22And they were going to try to get around it
16:24Tower
16:31Kenya, 507
16:33Looks like there's a break in the weather
16:35Requesting start-up
16:38Okay, 507
16:39Start-up approved
16:43The controller explains how the crew planned to fly to the right of the storm
16:47Is it possible the crew misjudged the storm's size and strength?
16:58NTSB investigator Bill Bramble also joins the team
17:03They had a cell eight miles off the end of the runway
17:07So the crew was using their own radar to decide how to maneuver around the cell
17:11Here's a meteorological report from that night
17:20Thunderstorm and rain over the airport with winds gusting up to 20 knots
17:24But it was starting to clear
17:27Investigators wonder if the wind and rain were still severe enough to bring down a 737
17:35He asked permission from the controller to go around the storm
17:39To the right
17:42Maybe the storm was worse than he thought
17:45There was a weather delay for several flights
17:49KQ507 was one of four flights that were delayed on the ground for about an hour
17:57Investigators need to speak to other pilots who took off from Douala that night
18:02How intense was the storm once they were in the air?
18:06I will speak to one of the pilots tomorrow
18:08Investigators interview a pilot who departed immediately after Kenya Airways Flight 507
18:22They need to find out if he had any difficulty avoiding the storm
18:26The flight crews solely depended on their own onboard systems to understand what they were getting into
18:37There was no assistance from the ATC
18:38So, no problems at all
18:42Not even mild turbulence
18:44He said the weather was smooth after they took off
18:48They did the same thing too
18:49They took off and turned to the right to circumnavigate the weather
18:52Okay
18:53Thank you for your time
18:55Investigators conclude the pilots could have maneuvered around the storm on their flight path
19:01Sit
19:02With weather ruled out
19:05The team wonders if there was a mechanical issue with the brand new 737
19:12This was important because it was the first for the 800 series
19:16And if there's an accident and it's not immediately understood what the problem is
19:20It's really important to get to the bottom of it
19:22Technicians in Canada have been able to extract the FDR data
19:31Let's see what we've got
19:34They read the data out
19:37Altitude, airspeed, bank angle, pitch attitude, those sorts of things
19:43Once you plot those out, you can start seeing what occurred
19:47Any malfunction warnings during the flight would provide an important clue
19:55There might have been some kind of mechanical issue that might have popped up
19:59No warnings
20:01They find no signs of any system failure
20:05The data showed us the airplane was behaving as we would expect it to
20:11It was a perfectly airworthy aircraft, there's no question about it
20:14As the team continues looking through the data
20:18But look at this
20:20They discover that just over a minute into the flight
20:24A different kind of alert did go off
20:27Bank angle over at an altitude of 2800 feet
20:31For investigators, this is their first real clue about what happened to flight 507
20:37Any role exceeding 35 degrees is considered extreme
20:46Once reaching that angle, a warning alerts pilots of danger
20:52Rotate
20:54When investigators review the pilot's inputs after takeoff, they make a critical discovery
21:01Get up
21:03Okay
21:05He was turning left from the moment they left the ground
21:11That information showed us that right after takeoff
21:14The aircraft started to roll to the right a little bit and the pilot corrected it
21:20And then he keeps making corrections to the left
21:23Looks like he's trying to keep the plane level
21:25But what caused the slow roll to the right in the first place?
21:36Bingo!
21:38That's the way the flaps are rigged
21:40Give it a slight right roll
21:42The aircraft had a tendency to roll to the right
21:45The flaps increase a plane's lift at slower speeds
21:51On this particular airplane, the left flap provided slightly more lift than the right one
21:58It's similar to driving down the freeway in your car
22:04And just letting go of the wheel
22:07If I was to do that, then it'll start to drift off one way or another
22:11That's the way the airplane was slowly and naturally banking it
22:17This discovery explains why the captain kept his control column turned to the left immediately after takeoff
22:28Well, that's weird
22:30But it doesn't explain an even more puzzling element of the flight data
22:33Look at this
22:36The captain's control wheel input seemed to stop
22:40Looks like he just let go of it
22:42Six degrees right, he does nothing
22:45Eleven degrees
22:47Fifteen degrees
22:49Twenty degrees
22:51Thirty degrees
22:53And still nothing
22:55As the plane's bank angle approached 35 degrees
22:56Neither pilot took action to stop the increasingly dangerous roll
23:03Bank angle, bank angle
23:05Until the bank angle warning sounded
23:08Bank angle
23:10And then he does this
23:12Right, left, right again, left again
23:16Bank angle
23:19In the last moments of the flight
23:22We noticed an erratic movement of the control column
23:25That didn't make any sense
23:31Bank angle, bank angle
23:33For sixteen seconds after the bank angle warning
23:37The aircraft continued its dangerous roll
23:42The airplane just continues to roll right
23:46Up to 110 degrees of bank
23:47The crew didn't recover it before impact
23:51Bank angle, bank angle
23:53The data paints a baffling picture of the one-and-a-half-minute flight
24:04Who flies like that?
24:08That was puzzling to us
24:11So it really highlighted that we need more information, we need more data
24:15And that data is the CVR
24:18The CVR is what tells us
24:20The conversation
24:22What might they have been looking at?
24:24But after weeks of searching the crash site
24:27There's still no sign of the cockpit voice recorder
24:35It's been more than a month since the crash of Kenya Airways Flight 507
24:40And the cockpit voice recorder has still not been found
24:48What is that?
24:50We spent days scouring the site
24:53Up track, down track, everywhere
24:56Looking for the CVR, trying to find it
24:58The team now uses a tracking device to scan the swamp for a signal from the box
25:01Five weeks after the crash, the cockpit voice recorder is finally recovered
25:15That was a very, very exciting time for everyone involved with the recovery
25:19As well as the investigation group itself for having that information
25:25Okay, let's start on the ground
25:30Started
25:32Investigators hope the recording will explain why the pilots let their plane bank so dangerously to the right
25:37Tower
25:38Tower
25:39Kenya 507
25:41Looks like there's a break in the weather
25:43Requesting startup
25:44Okay 507, startup approved
25:46Okay, request taxi clearance
25:48They hope the recording will also explain how they ended up spiralling into a swamp
25:511,000 feet ten climbing
25:531,000 feet ten climbing
25:551,000 feet ten climbing
25:571,000 feet ten climbing
25:581,000 feet ten climbing
26:001,000 feet ten climbing
26:021,000 feet ten climbing
26:031,000 feet ten climbing
26:051,000 feet ten climbing
26:07heading select okay this is where he stops making any inputs
26:14selected check n1 okay come on that's the call to activate the other pilot
26:26so should i remain on this heading yep
26:29after calling for the autopilot to be engaged captain wam weir released the control column
26:39trusting the autopilot to fly the plane
26:44but there's a problem the other pilot didn't come on he thought the 737 was flying itself
26:53there was nobody flying the control so nothing was controlling the airplane
26:57the discovery changes the course of the entire investigation n1 okay command
27:08why didn't the autopilot come on the captain calls for the autopilot to be engaged
27:15but the first officer does not respond the procedure should be for the first officer to push the button
27:21and say the autopilot engaged okay command so should i remain on his heading yep
27:32investigators believe the first officer was so focused on inputting the route around the storm
27:39that he failed to engage the autopilot
27:422 400 feet and climbing
27:51now we're getting into it meanwhile the captain assumed the autopilot was engaged and controlling
27:58the pre-selected right turn
27:59the pilots only noticed a problem when the bank angle warning went off
28:10bank angle
28:11bank angle
28:12it's pretty clear the captain expected the autopilot to be engaged and it didn't get engaged
28:18and then neither crew member picked up the fact that it wasn't engaged
28:22we're crashing we're crashing no we are crashing no we are crashing left left left
28:35why did neither crew member take the critical step of engaging the autopilot
28:54standard operating procedures provide a safety net for crews
28:57but if crews don't adhere to the standard operating procedures they lose that protection
29:01they comb through kenya airways procedures to see who has responsibility for activating the autopilot
29:11anything
29:14from what i can tell it's not really clear who was supposed to do it
29:18all it specifies is turn on when above minimum altitude for engagement it's not very helpful
29:24it wasn't really clear in the standard operating procedures of when the autopilot does come on who's
29:32responsible for doing that and what the response should be to that
29:41recovering from a 35 degree bank is not a complicated procedure
29:46the bank angle warning is designed to give pilots enough time to react
29:59but for some reason this crew wasn't able to do that
30:06the team digs into their records
30:08this is what we have on one way up lots of experience 16 years as a pilot most of those on the 737
30:20let's see what this storm is doing the captain had been a flight attendant for kenya airways years and
30:26years ago and then went to flight school and got his ratings and transitioned into the role of pilot
30:33it wait look at this but the captain's training records reveal serious shortcomings
30:45inadequate knowledge of systems and procedures insufficient flight discipline poor cockpit scans
30:52below standard yikes get up okay we discovered the captain had a history of training difficulties
31:02and lack of systems knowledge for auto flight systems and so forth so he had some red flags in his history
31:12the first officer's report isn't any better feel to monitor autopilot when engaged
31:19v1 rotate the first officer was young and fairly inexperienced he only had a little over 800
31:26hours of flight time and he had had some training feedback that involved things like you need to be
31:35more proactive about calling out deviations and so forth not an a-level crew
31:40we're crashing
31:51did a lack of skills in the cockpit doom the 108 passengers on board the flight
31:57flight
32:09investigators need to determine if pilot error caused the horrific crash of kenya airways flight 507
32:16of the flight to the flight
32:22okay alah he's definitely surprised
32:28then 22 degrees to the right
32:3220 left 45 right then 11 to the left that's not helping
32:40that's not helping out the flight to the left that's not helping out of the flight
32:47when the bank warning came on and the aircraft was on a right roll
32:52the first response was the captain turned it further to the right and which aggravated the situation
33:00now the bank angle is approaching 50 degrees
33:03as the situation grew worse after the bank angle warning and the confusion amongst the crew
33:14the autopilot does engage and captain pushed that button
33:20the team discovers that when the captain finally realized the autopilot was not engaged he activated it
33:33but when it didn't immediately level the plane the captain turned the control column
33:38erratically an action which overrode the autopilot we're crashing now we are crashing
33:46and yes we are crashing left left left correction
33:56so now one's trying to turn left while the other turns to the right
34:00they're fighting each other's inputs they're fighting each other's inputs left left left correction
34:20i don't get it
34:24it should have been a simple recovery
34:26the back and forth was trying to do corrective actions but it didn't seem like it was correcting
34:34anything he's already banked out to the right 34 35 degrees why would he row further well that's
34:43the question we have to answer right there investigators use a boeing simulator to recreate the final stages of the flight
34:51from the front of the simulator you can literally put yourself in the driver's seat
34:56and reconstruct the flight and be there at the pilot to be able to determine whether we can recover
35:04can we give it a 50 degree right bank please activate the autopilot please
35:16exactly what it's supposed to do the roll is slowing
35:21and the inputs we discussed
35:25right left right geez there goes the autopilot bank angles increasing again
35:38the simulation shows that if the captain had given the autopilot enough time to take control
35:43the 737 would have returned to a relatively safe bank angle but his erratic inputs prevented that from happening
35:55if only he'd done nothing
35:57it was determined that recovery was still an option just just a few seconds before impact really
36:04investigators are puzzled why wasn't the experienced captain able to execute such a straightforward recovery
36:15was there something here that we were missing in the investigation that may have confused the crew
36:21so we started looking harder at the possibility of spatial disorientation
36:26from the simulator yeah just darkness outside no reference at all
36:35it was a completely black view out the windshield if you look up out the windshield you have no ground
36:45reference that could immediately have helped you straighten the airplane out
36:49but hold on
36:54spatial disorientation is an inability to distinguish up from down
36:59left from right
37:02it has been known to hinder judgment and delay response times
37:06bank angle we're crashing yeah we are crashing left left left correction
37:15only the first officer seemed to assess the situation correctly
37:22first thing he says is yeah we are crashing it took him 10 seconds to speak up
37:36when the bank angle alert went off there wasn't much discussion about what was happening until the captain said
37:47we're crashing yeah we are crashing and the first officer didn't say anything until he said that
37:59the team listens to the recording of the first leg of the flight from abijan to dwala
38:06they are looking for clues as to why the first officer remains silent
38:12let's hear it what is wrong with you what they hear shocks them
38:22when investigators listen to the cockpit voice recording of the first leg of kenya airways flight 507
38:29sorry did you say an altitude of 14 000 feet
38:32yes yes don't be so stupid write it down if you care to remember wow they're stunned by how the
38:40captain treated his first officer it was pretty bad the captain was sort of brow beating the first
38:48officer there were words like stupid shut up stuff like that that you wouldn't expect to hear in a
38:55professional crew environment what is wrong with you did you not hear the instruction heading two three zero
39:04understand
39:08the first officer seemed to kind of shut down heading two three zero understand
39:15he was at a certain point sort of reduced to responding with these sort of monosyllabic grunts
39:27investigators suspect this might explain why the first officer took so long to speak up
39:32the captain's behavior toward the first officer on the first flight likely caused him to adopt sort of a
39:45passive role you need both pilots actively engaged in checking each other and catching errors and if one
39:52pilot adopts a passive role they're going to be less effective
39:58so heightened ego
40:01captain wamwea's treatment of his first officer leads investigators to examine his professional
40:07history more closely tell me more information we spent a lot of time going to pilot records
40:14interviewing other flight crew members
40:16whether they're ready they quickly learned that the captain's shortcomings were not limited to his
40:21flying abilities he had a lot of concerning things in his training files about being overbearing
40:30being authoritarian in terms of how he dealt with other crew members
40:36so we have a young reserved first officer and an overbearing captain
40:42this accident is kind of a throwback to those early days where we were focused on the issues of
40:48overly assertive authoritarian overbearing captains and submissive inadequately assertive junior first
40:55officers a lethal combination
41:00investigators conclude the bad pairing in this flight crew set in motion a sequence of events that led to the
41:06crash as an investigator all of these accidents i've worked it's very clear there is never a single cause
41:17it's always a chain of events so should i remain on this heading yup
41:26a deadly combination of poor pilot performance
41:29and spatial disorientation contributed to the accident all the risk factors were present there was
41:39distraction there was reduced outside visibility and there was confusion
41:48but in the end investigators conclude that one major mistake triggered the entire tragedy
41:54and one okay command so should i remain on this heading yup
42:07it was the crew's failure to ensure the autopilot was turned on
42:11that ultimately led to the death of a hundred and fourteen people
42:27we're blocking
42:28in the aftermath of flight 507's crash cameroon's commission of inquiry makes a series of
42:47recommendations including the regular update of safety manuals related to cockpit procedure
42:53and crew responsibility they made changes to the standard operating procedures about who's responsible
43:01for engaging your autopilot and that was very key and improved pilot training with a focus on upset
43:09recovery one technology that boeing has tested and developed and is looking at putting into its
43:16airplanes is a roll recovery arrow so that if you're at an unusual angle of bank the attitude display will
43:23actually show you which direction you need to roll the airplane and provide an accompanying aural
43:30in the end you have to look at training
43:33crew makeup all adding into all the links of chain the chain that caused this to happen this night
43:41let's see what this storm is doing when those who are not familiar with accident investigation think
43:46that all the answers are at the crash site it's rarely at the crash site
43:51and that's exactly what happens rotate
43:54rotate
43:58you
44:00you
44:02you
44:04you
44:06you
44:08you
44:10you
44:12you
Sé la primera persona en añadir un comentario