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On 6 November 2002, the pilots of Luxair Flight 9642 accidentally set the propellers into reverse pitch while attempting to land at Luxembourg Findel Airport in heavy fog. The aircraft loses control and crashes into a field short of the airport. 20 of the 22 people on board are killed.
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00:00Descending into heavy fog above Luxembourg.
00:05What the hell is that?
00:07Something goes disastrously wrong on Luxair flight 9642.
00:12The airplane was impossible to recover.
00:1720 of the 22 people on board are killed.
00:21A lot of people died that day.
00:23It was an accident that was hard to understand.
00:25I can't find anything wrong with either engine.
00:28But when investigators analyze unusual sounds from the cockpit...
00:33It's a match?
00:35Mm-hmm.
00:36...they hear the pilots do something which should be impossible.
00:39It's not supposed to happen.
00:41There's supposed to be things that prevent it from happening.
00:43So it's not as foolproof as we thought.
00:50D-D, D-D!
00:52It's just before 10 in the morning at Luxembourg's International Airport.
01:04A layer of fog blankets the runway, preventing planes from landing.
01:21Cargo Lux 778, maintain runway heading until Lutax, then you zone navigation.
01:28Luxair 403, enter D-Kurch hold flight level 60.
01:32I will vect you later for ILS approach.
01:34Controllers are busy putting planes into a holding pattern while waiting for the fog to clear.
01:40Luxair 4452, enter D-Kurch hold flight level 90.
01:44Q&H is 1023.
01:49Luxair 8362, descend level 80 to enter D-Kurch hold.
01:54Current RVR is 250.
01:58There are three planes circling 16 miles north of the airport at a position known as D-Kirch.
02:05In a situation with low visibility, lots of holding, lots of aircraft having different requirements,
02:14the level of stress is fairly high.
02:16Focus is really important.
02:18You've got to concentrate on everything that you're doing.
02:22Luxair 9642, enter D-Kurch hold flight level 90.
02:27It will be vectors later for ILS approach on runway 24.
02:31That's all understood, Luxair 9642.
02:34One of the planes being directed to the holding pattern is Luxair flight 9642.
02:41The plane is a Fokker 50 turboprop heading to Luxembourg from Berlin.
02:46The Fokker 50 was a great performing aircraft overall.
02:51As a commuter airplane to be flown in Europe, we flew the aircraft day and night in all weather conditions.
02:57There are 19 passengers on the flight.
03:01Most are German business officials travelling to Luxembourg.
03:06The first officer on this morning's flight is 32-year-old John Arendt.
03:11I'll brief the folks.
03:13Ladies and gentlemen, good morning.
03:16Unfortunately, the fog in Luxembourg is so dense that at the moment we cannot land.
03:22So we'll have to wait a little bit for an improvement.
03:25We will proceed to a holding pattern while we wait for the weather to clear.
03:29We'll keep you updated as soon as we have some news.
03:32The captain is 26-year-old Claude Perkis.
03:39And Luxair 9642 is reducing speed to 160.
03:46Roger, 9642.
03:49The crew navigates towards the holding area north of the airport.
03:54What time can we hold till?
03:56How much fuel will we need?
03:58Uh, 550, 700.
04:03No, we'll need 850 when we leave the hold.
04:06No, we need fuel to reach till our alternate plus 20 minutes reserve, so we'll still need 600 kilos.
04:12Yes, but I want to keep...
04:14Luxair 9642, descend to 3,000 feet on 1023, turn left heading 130.
04:21Before they reach the holding point, the crew receives instructions to turn towards the airport and begin descent.
04:29Is that for us?
04:32Yes.
04:33Uh, descend to 3,000 feet and say again the heading.
04:37130.
04:39Left heading 130, Luxair 9642.
04:44What kind of crap is that?
04:46The new instruction takes the crew by surprise.
04:51If you suddenly get startled that you are now number one and turning left and descending for your approach as number one,
05:00this can put you in a situation which would add to your workload.
05:04Let's see if we are now.
05:07I don't know, should we check with dispatch?
05:09Yes.
05:10RVR is runway visual range.
05:14It's the minimum visibility on the runway required by a landing aircraft.
05:19For the Luxair Fokker, that distance is 300 meters or 984 feet.
05:26If the runway visual range is below 300 meters, you are not allowed to start the approach or to land the aircraft.
05:33Dispatch 9642, what's the current RVR?
05:37Uh, 275.
05:40275 meters.
05:42What do we do now?
05:43I don't know.
05:45If they don't have that visibility, they go around and probably get vectored for another approach.
05:51Unless the RVR is too low, then they are going to be vectored to the holding pattern that decurs.
05:56So, are we holding or is this for an approach?
05:59It's for an approach.
06:00Luxair 9642, turn right heading 220, cleared for approach.
06:05Right heading 220 and cleared for approach, 9642.
06:11Tell them if at echo we don't have 300 meters, we'll do a go around and enter the hold.
06:16The pilots come up with a compromise.
06:20They'll continue their approach.
06:22But if runway visibility doesn't improve, they'll abort and join the holding pattern.
06:27We need 300 meters for the approach.
06:309642, copied.
06:33Continue your approach.
06:34I'll keep you advised.
06:36Passengers still believe they're headed for an extended hold.
06:40Speeds 95, 105, 109.
06:51Landing altitude?
06:53275 meters.
06:54Set.
06:55The flight is now only five miles from the runway, and there's no word that visibility has improved.
07:03Captain Pukis makes his decision.
07:05Okay, we'll do a go around.
07:07Missed approach.
07:08Ground idle stop off.
07:11Luxair 9642, RVR is 300 meters.
07:19But before the crew can execute a go around, the controller issues a last minute update to runway conditions.
07:259642 continuing approach.
07:30The visibility now meets the Fokker's minimum requirements.
07:34The crew's plans have changed again.
07:36Things change rather quickly for a flight crew when they're doing an approach, which requires really precise coordination among the crew members to make sure that everything goes smoothly and that they're stabilized on the approach.
07:50Four miles from the airport.
07:53Flight 9642 is at an altitude of 1500 feet.
07:57Flaps?
07:58Uh, we are flapsed in.
08:039642, you are cleared to land.
08:04Wind 180 degrees, five knots.
08:05Uh, gear down?
08:06Yeah.
08:07Cleared to land, 9642.
08:08The flight is now two minutes from landing in Luxembourg.
08:10What the hell is that?
08:11Something has gone wrong with the engines.
08:15Oh.
08:16Phone.
08:17F***.
08:18Phone.
08:19F***.
08:20F***.
08:21Phone.
08:22Phone.
08:23Phone.
08:24What the hell is that?
08:35Something has gone wrong with the engines.
08:45Now, at less than 500 feet, flight 9642 plummets towards the ground.
08:52The airplane suddenly went into a rapid and uncontrollable descent in a very low altitude,
09:06which was impossible to recover.
09:229-6-4-2 Luxembourg.
09:25Luxair, 9-6-4-2 Luxembourg.
09:30Luxair, 9-6-4-2 Luxembourg. Do you read?
09:37We have a possible crash of a Fokker F-50 on final approach to runway 27. Please stand by.
09:49The wreckage is located two miles east of the airfield.
09:55Of the 22 people on board, only two survived the crash, including Captain Perkis.
10:02This is Luxembourg's deadliest aviation disaster.
10:07This accident is serious because it was a loss of life. A lot of people died that day.
10:12And it was an accident that was hard to understand.
10:16Investigators will need to examine the wreckage of flight 9642
10:21to determine why a landing at a modern, well-equipped airport went so terribly wrong.
10:28The tail hits here. The left wing scrapes some trees, and then the plane skids across the road.
10:40The wreckage tells investigators that flight 9642 hit the ground in a nose-up position.
10:47The initial hypothesis would be that, in fact, they were trying to avoid the ground when the aircraft hit the ground.
10:54Engine failure, wind shear, mechanical issue.
11:00The debris pattern leaves investigators with a few obvious possibilities.
11:06Aircrafts don't crash short of runways. Do they have false indications?
11:10Were the engines running? So there are lots of things you have to initially think about.
11:15As they gather wreckage from the accident site, investigators wonder if the controller can provide any insight into the flight's final minutes.
11:23Anything unusual? Out of the ordinary?
11:27The whole day was out of the ordinary.
11:30The controller explains that the weather prevented planes from landing, forcing them into a hole.
11:36And that includes flight 9642?
11:41At first, yes.
11:42Luxair 9642, enter Decurch hold, flight level 90.
11:51But before they reach the hold, the weather cleared.
11:54Luxair 9642, descend to 3,000 feet on 1023, turn left heading 130.
12:01He also states that because of its position, flight 9642 was the first plane directed to the airport when the weather began to clear.
12:13They needed 300 meters of visibility to land, which we got at 10.05.
12:18So I cleared them to land.
12:20Even though they were heading for the holding pattern, the controller saw an opportunity.
12:24They were in an ideal position to the final approach fix at also the Luxembourg airport.
12:31And then?
12:33What's the last we spoke?
12:35No emergency call.
12:37No. Nothing.
12:39The controller can't explain why the Fokker ended up hitting the ground two miles from the airport.
12:50From air traffic control standpoint, there was nothing in the communication between the aircraft and air traffic to indicate that there was any problem whatsoever with the aircraft at all.
13:01Only Captain Pukas can answer why the Fokker went down short of the runway.
13:06But he's been hospitalized and is in a coma.
13:09Investigators will need to piece together the final minutes of the flight without him.
13:14With the captain not being available, the objective evidence, the physical evidence, talks to you.
13:20They begin by studying the engine components for any signs of failure.
13:27They look like they're in pretty good shape.
13:30Engines normally hold the aircraft in the air, and they fly towards the runway.
13:36So I would suggest something happened to the engines that they didn't make it to the runway in the first place.
13:45No fire. No damage to any components.
13:48The rotors are fine. Fuel lines are intact.
13:51Intake is clear. Pumps and PCUs all check out.
13:54I can't find anything wrong with either engine.
13:58The state of the engines is puzzling.
14:01If both were in good working order, what could have caused the flight to fall from the sky just short of the runway?
14:10This is where they're turned for the approach.
14:14Investigators use Luxembourg's radar data to recreate Flight 9642's flight path.
14:21Seven minutes to impact.
14:23They're at 9,000 feet when they're cleared for the approach.
14:26Now, he descends even more steeply, and at 7,000 feet per minute.
14:32They're only four miles away from the runway.
14:3415 seconds later, they hit the ground.
14:40Here's the glide slope.
14:44Whoa.
14:45When investigators compare the plane's descent with the recommended descent, they see that the flight was 300 feet too high throughout the final stages of its approach.
14:58That explains why they were in such a hurry to lose altitude.
15:01300 feet above the glide slope, this is a real problem, because you now try to descend the aircraft, slow down the aircraft, and configure everything at the same time, which is nearly impossible.
15:16Why did the pilots allow their plane to get into such a difficult situation?
15:23Not a good idea to be rushing on an approach at all, especially in low RVR.
15:27Dangerous, actually.
15:33It'll be fog. It'll be a hard landing.
15:35The team listens to flight 9642's cockpit voice recording, or CVR, for clues that can explain the pilot's dangerous predicament.
15:47Okay, they know the weather's gonna be an issue.
15:50I'll call dispatch.
15:52Dispatch, good morning.
15:549642.
15:569642, good morning.
15:58How's the weather at the moment?
16:00RVR is 250 at the moment.
16:01If it doesn't get better, you will be diverted to Sarbrookan.
16:05Okay, thank you.
16:07Oh no, I will not go to Sarbrookan.
16:10I'm with you.
16:12With 110, 4 knots, expect ILS approach.
16:16Runway 27, transition level 6, 0.
16:19He does not want to divert.
16:20Luxair 9-642, enter Decurch hold, flight level 9-0.
16:31They're being directed into the holding pattern.
16:35That's all understood, Luxair 9-642.
16:40No, we need fuel to reach to our alternate plus 20 minutes reserve, so we'll still need 600 kilos.
16:46Okay, good.
16:49They want to make sure there's enough fuel to reach their alternate.
16:53Yes, but I want to keep...
16:54Luxair 9-642, descend to 3,000 feet on 1023, turn left heading 130.
17:01And then they're hit with a new plan.
17:07Is that for us?
17:08Yes.
17:09The recording reveals that the pilots were surprised by the instruction to begin their approach.
17:21What kind of crap is that?
17:23They were not happy about the change of plans.
17:26The sudden change meant that instead of proceeding to the hold, the pilots quickly initiated a left turn and began a steady descent towards the runway, all while configuring their plane for landing.
17:42So the crew were forced to rush themselves down to the final approach fix.
17:52The rushed approach now becomes the focus of the investigation.
17:58Luxair 9-642, turn right heading 220, cleared for approach.
18:02Okay, they're starting their approach.
18:06For a low visibility approach, properly briefed and performed, it's very structured, organized and standardized.
18:15So each pilot knows exactly which task they have to do at which time.
18:20Should we switch the seatbelt sign on?
18:22Yes.
18:23Yes.
18:24Not a bad idea.
18:28Localizer captured.
18:30Check.
18:32Missed approach heading.
18:34They're not running a checklist.
18:36They're just throwing out random steps.
18:39Over the next few minutes, investigators hear several clear indications that the pilots are improvising this unexpected approach.
18:47You must be fully established, which means gear down, flaps extended, landing checklist completed, speed and altitude, all at the correct spot.
18:57Are we at the beacon yet?
18:59You should have it dialed in by now.
19:01I can use a DME instead.
19:04Yeah, yeah, yeah.
19:06Even basic steps, such as configuring the navigation system, aren't performed.
19:12Flying an aircraft is about a precise following of certain steps at certain times.
19:19It's starting on an approach involving all the crew members.
19:23It's about detailed planning.
19:28They're skipping steps and improvising the procedures.
19:31The change of plans caught them by surprise.
19:42They're racing against the clock.
19:47They started to rush themselves in a quite high workload environment, trying to get the airplane down and doing the approach briefing all at once, which was quite tricky to achieve.
20:01Did the rushed approach result in the pilots being too high as they neared the runway?
20:06They're getting closer and closer to the airport.
20:10At three and a half miles out, they should be at 2,500 feet, but they're at 3,000 instead.
20:23Flaps?
20:24Uh, we are flapsed in.
20:279642, you are cleared to land.
20:30Instead of managing their altitude and speed, they're rushing to get their plane properly configured.
20:36Speed and altitude control is actually important for every approach, but especially for a low visibility approach, where you have to be established much earlier than on a normal approach.
20:48So why all the confusion? It can't just be the last minute approach.
20:53I don't think they thought they'd be able to land. Have a look.
20:58RVR, RVR, RVR.
21:02The cockpit recording makes it clear to investigators that the crew didn't think they'd have the required visibility to make the landing.
21:10Let's see RVR now.
21:14I don't know. Should we check with dispatch?
21:16Yes.
21:18They're told they have a visual range of 275 meters, but they need 300 minimum to land.
21:24You're not sure how to proceed.
21:25Tell them if at echo we don't have 300 meters, we'll do a go around and enter the hole.
21:34Their plan is to do a go around if the visibility hasn't increased by the time they get to the outer marker here.
21:41The auto marker can be seen as a decision or a cut-off point.
21:47Once you pass the auto marker, the RVR must be at the required minimum.
21:51But as soon as they get to the outer marker, they get the magic words...
21:56300 meters.
22:00Luxair 9642. RVR is 300 meters.
22:04You are clear to land. Wind 180 degrees, 5 knots.
22:08But they're too high and need to lose altitude fast.
22:12The CVR explains why the pilots ended up above their target altitude.
22:16They were rushed into the approach and fixated on the poor runway visibility.
22:23Okay.
22:25So how does that lead to a crash 35 seconds later?
22:299642, you are clear to land.
22:33Uh, gear down?
22:35Yeah.
22:37Clear to land, 9642.
22:38And done.
22:40What the hell is that?
22:42Oh, .
22:44Terrain. Terrain.
22:46What just happened?
22:48In the last few seconds of the CVR recording, there was a loud noise.
22:51The crew was startled by this.
22:52What happened in those last 20 seconds?
22:53And what was that noise we heard?
22:54What the hell is that?
22:58Investigators hope the flight data recorder, or FDR, can solve the mystery of what went wrong in flight knowledge.
23:01In the last few seconds of the CVR recording, there was a loud noise.
23:02The crew was startled by this.
23:03What happened in those last 20 seconds?
23:05And what was that noise we heard?
23:06What the hell is that?
23:07What the hell is that?
23:08What the hell is that?
23:10What the hell is that noise?
23:14Investigators hope the flight data recorder, or FDR, can solve the mystery of what went wrong in flight 9642's final seconds.
23:31Okay, cruising along at 3,000 feet and 160 knots.
23:35Then they start to descend, go flaps 10,
23:38and accelerate rapidly towards the ground.
23:41Let's see what the engines were doing.
23:45What's happening here?
23:47Turbine RPMs drop.
23:50The torque drops down to zero.
23:52Looks like he's gone down below flight idle into ground mode.
23:55Ground mode changes the angle of the propellers
24:01so they can move the plane forward while it's on the ground.
24:04It's never used in the air.
24:08But then, turbine RPM spikes, fuel flow and torque increase.
24:15All while the altitude starts to plunge.
24:18Could they have gone into beta mode?
24:20Beta mode is basically reverse thrust.
24:26The propellers are positioned to move air forward instead of back.
24:31It's used to help stop the plane after it touches down.
24:36If you would put the power levers into beta mode in the air,
24:41this could lead to loss of control where recovery might not be possible.
24:46Did the pilots of flight 9642 put their engines into reverse?
24:50And if so, why?
24:52Can we hear the last 20 seconds of that CVR again?
24:57And done.
24:59What the hell is that?
25:03Terrain, terrain.
25:10It's the propellers going into reverse.
25:12Investigators now have an explanation for the deafening sound on the CVR.
25:19This is almost like hitting the brakes.
25:21The aircraft would immediately dive into a rapid and uncontrollable descent.
25:28How could the engines end up going into ground mode
25:31and then into reverse beta mode?
25:34How's that even possible?
25:35The turboprop airplane, like the F-50,
25:40it had a lot of safety features
25:43that would prevent the propeller from going into beta range in flight.
25:49Before a plane can be put into reverse mode,
25:52the thrust levers must first pass through ground mode.
25:56A lock prevents this from happening.
25:59Pilots can switch the lock off in flight to prepare for landing.
26:02Ground idle stop off.
26:08First officer Arendt performed that step
26:10as part of his descent and approach checklist.
26:14With the lock disabled,
26:15pilots can lift the ground range selector
26:18and move the thrust levers to ground mode
26:20after landing to help slow the plane.
26:23But instead,
26:25the data reveals that the engines went into ground mode
26:2825 seconds before the plane crashed.
26:30Did they do it on purpose?
26:38The question is, how did they get there?
26:40Did the crew select it?
26:41Did they do it deliberately?
26:43Was it something bad that happened?
26:44The safety defenses didn't work?
26:46These are all things that have to be looked at.
26:49Okay, we're recording.
26:52Let's start with the taxi lights.
26:54To find out if the crew intentionally
26:59put the plane into ground mode
27:00before they were on the ground,
27:02they record a number of different sounds
27:04in the cockpit of another Fokker 50.
27:11Every switch has a sound attached to it.
27:14Okay, let's try flaps to 10.
27:25And now the ground range selector.
27:28And that does it.
27:38And this can be forensically analyzed and filtered out.
27:45You compare that to what you find
27:46from the cockpit voice recorder.
27:48These three sounds were picked up on the CVR.
27:51Let's start with this.
27:55We were able to confirm that this sound
27:57is the taxi lights being switched on.
28:08Test recording confirms that's the flap handle
28:10being moved to flaps 10 position.
28:12Then there's this.
28:22We compared it to the sound recorded on the test plane.
28:25It's a match?
28:26Mm-hmm.
28:27The audio analysis confirms
28:29that Captain Pukes deliberately lifted
28:31the ground range selector
28:33and moved his throttle to ground mode
28:35while the plane was making its approach to the airport.
28:38The key element found in the sound spectrum study
28:41was the power lever was in fact
28:43moved below the flight idle gate.
28:45And this was something that meant
28:46the pilot had to do it.
28:49Okay.
28:51So we know he did this on purpose.
28:54Why?
28:57There is no maneuver or procedure
29:00asking the pilots
29:01to actually lift the ground range selector in flight
29:05and pull the power levers below flight idle.
29:08It's a prohibited non-standard procedure
29:11and should never be done by the pilots.
29:15What could have prompted the pilots
29:17to put their engines into ground mode?
29:21He's five miles away from the airport
29:23when he decides to land,
29:24but he's 300 feet above the glide slope
29:26and his speed is 165 knots.
29:28If he wants to get down to the glide slope,
29:30he needs to descend rapidly,
29:32but his speed is already quite fast.
29:34So instead, he slams on the brakes.
29:39Once the power levers are in ground idle,
29:42this will produce extra drag on the propellers,
29:45reducing the speed
29:47and also allowing the aircraft to descend
29:49at the same time.
29:52Deluxe Air 9642, RVR is 300 meters.
29:57Investigators believe that when the crew is told
29:59that runway visibility has improved,
30:02Captain Pukas moved his engines to ground mode
30:04to quickly reduce speed and lose altitude.
30:12Not sure that'll do it.
30:149642, continuing approach.
30:18Flaps?
30:18They should have made a better decision
30:22and go around, reposition,
30:24and fly a proper approach
30:25or divert to the alternate
30:27and not forcing it in.
30:29Okay.
30:30We can explain putting the engines into ground mode.
30:33But reverse?
30:37What the hell is that?
30:45Oh, f***.
30:46So the lock is only released
30:53when the plane is on the ground.
30:56Investigators know
30:57the pilots of Luxair Flight 9642
30:59put their plane into ground mode
31:02before landing.
31:04But it doesn't explain
31:05why the throttles were moved further back
31:07to reverse
31:08while they were still hundreds of feet in the air.
31:11Should be impossible to do.
31:13To get to that range in flight,
31:15it's not supposed to happen.
31:17There's supposed to be two things
31:18that prevent it from happening.
31:21An electrical lock
31:22prevents the power levers
31:24from being moved into reverse in flight.
31:27Once the plane is on the ground
31:28and the wheels are spinning
31:30at at least 20 miles an hour,
31:32a signal is sent
31:33to an electrical switch
31:34that releases the flight idle stop
31:36and allows the throttles
31:38to move to the reverse position.
31:39This system is only meant
31:42to be used on the ground
31:43and that's why they have
31:43a lot of protections
31:44to make that only the possibility
31:46that's going to happen.
31:48Could the lock have somehow failed?
31:52The mechanical stop is installed
31:54so that the pilots can
31:56under no circumstances
31:58physically move the power levers
32:00beyond ground idle.
32:02So no reverse thrust possible.
32:08Investigators study the components
32:09that make up the locking system.
32:12The anti-skid system checks out.
32:14The wheel speed relays are fine
32:16and there's nothing wrong
32:17with the lock switch.
32:20Investigators also check
32:22the anti-skid sensors
32:23which measure wheel speed,
32:25the computer that receives those signals
32:27and the switch controlling the lock.
32:32Everything seemed
32:32to check out normally.
32:34It shouldn't unlock
32:36unless the wheels are spinning.
32:38So what went wrong?
32:40Investigators scrutinize
32:42the electrical lock system
32:43that should have prevented
32:44flight 9642 from going into reverse.
32:48Anything in the maintenance record?
32:49There's this.
32:52They discover an incident
32:53that happened 14 years earlier.
32:57Power lever setting
33:00below flight idle
33:02possible in flight.
33:04Huh.
33:05In 1988,
33:07the flight idle stop
33:09disengaged inadvertently
33:10on another Fokker 50.
33:14So it's not as foolproof
33:15as we thought.
33:17The system design
33:18was actually well designed
33:20by Fokker
33:21but they knew
33:22the system had a problem.
33:24When the landing gear
33:26is lowered,
33:27an electrical pulse
33:28could be sent
33:29to activate
33:30the plane's
33:30anti-skid control unit.
33:32That sends out
33:33a false indication
33:34that the plane
33:35is on the ground,
33:37just enough
33:37to unlock
33:38the flight idle stop.
33:41This particular pulse
33:42in the anti-skid control unit
33:44could in fact allow
33:45the power lever
33:45to go back
33:46into the beta range.
33:48At the time,
33:49Fokker said
33:50the chance
33:51of an inadvertent unlocking
33:52due to the glitch
33:53was extremely unlikely.
33:55These three conditions
34:00must be met
34:01for the stop
34:02to unlock.
34:03Gear down,
34:05the left and right
34:05gear locks
34:06releasing at precisely
34:07the same instant,
34:08and the power levers
34:09below flight idle.
34:10A lot of components
34:13had to line up
34:13in very great precision
34:15to make it happen,
34:16the perfect storm
34:17of bad things
34:18happening together.
34:19Could they have
34:20triggered the glitch?
34:22Investigators
34:23returned to the
34:23voice recording
34:24and flight data
34:25to determine
34:26if a short-lived
34:27electrical anomaly
34:28allowed the engines
34:30to go into reverse
34:31while in flight.
34:32We know from
34:34the sound analysis
34:35the click
34:35that we heard
34:36on the CVR
34:36is the ground
34:37range selector
34:38being lifted.
34:42Approximately
34:4330 seconds
34:43before impact,
34:45the captain
34:45moves his power
34:46levers below
34:46flight idle.
34:47Okay,
34:48so condition
34:49one is met.
34:52The first officer
34:53lowers the landing
34:54gear 13 seconds
34:55later and they
34:55unlock at the
34:56exact same time.
34:58Now that the
34:58conditions to trigger
34:59the glitch
34:59have been met,
35:00for the next
35:0016 seconds,
35:02the levers
35:02can be moved
35:03to reverse.
35:05The aircraft
35:06thinks it's
35:07on the ground
35:08and it will
35:09go into reverse
35:10in flight.
35:12And just
35:13three seconds
35:14later,
35:14the propellers
35:15go into reverse.
35:16That's it.
35:23Ground idle
35:23stop off.
35:25They believe
35:26that in an effort
35:27to lose altitude
35:28quickly,
35:29the pilots
35:29of flight
35:309642
35:31unknowingly
35:32triggered the
35:33electrical anomaly
35:34that allowed
35:34them to put
35:35their engines
35:36into reverse.
35:38The sequence
35:39of events
35:40begins with
35:40the captain
35:41moving the
35:41throttles to
35:42ground mode
35:43to reduce
35:43speed and
35:44altitude.
35:47Not sure
35:47that'll do it.
35:499642,
35:50continuing approach.
35:51the maneuver
35:52the maneuver
35:52doesn't have
35:53the desired
35:54effect.
35:54The plane
35:55is still
35:55too high.
36:00Flaps?
36:00We are
36:01flapsed in.
36:03The crew
36:04extends the
36:04flaps to
36:05reduce speed
36:06even further.
36:07Then...
36:08gear down?
36:12Yeah.
36:12As Captain
36:13Pukas keeps
36:14his throttles
36:14pulled as far
36:15back as they
36:16can go,
36:17the first
36:18officer lowers
36:18the landing
36:19gear,
36:20unaware it
36:21will trigger
36:21the conditions
36:22to unlock
36:23reverse.
36:23There will be
36:31a loud bang,
36:32a O-ball,
36:33everybody will
36:33hear that in
36:34the cockpit
36:35and in the
36:35cabin.
36:36There will be
36:36an immense
36:38increase in
36:39tracks,
36:39so you will
36:40literally feel
36:41your body
36:41shifting and
36:42shaking.
36:48Captain
36:49Pukas doesn't
36:50even realize
36:51what's happened.
36:52Pop,
36:52pop,
36:52pop,
36:53pop,
36:53pop!
36:58Once the
36:59landing gear
37:00was selected
37:00by the
37:01first officer,
37:02suddenly both
37:03engines went
37:04into full
37:05reverse.
37:05It was too
37:06late to
37:07recover.
37:0825 seconds
37:10after the
37:10throttle is
37:11inadvertently
37:11moved to
37:12reverse,
37:13the plane
37:13crashes,
37:14resulting in
37:1520 deaths.
37:19If Fokker
37:20knew about
37:21this anomaly
37:21in 1988,
37:22why didn't
37:22they just
37:23fix it?
37:27Investigators
37:27examine reports
37:28to explain why
37:29Flight 9642
37:31was allowed to
37:32fly, despite the
37:33aircraft manufacturer
37:34knowing about a
37:35potential glitch.
37:37They said the
37:38probability of this
37:39happening was so
37:39low that no
37:41immediate action
37:42was required.
37:42it's a very short
37:46duration power-up, so
37:48therefore the timing has
37:50to be very precise, and
37:51the likelihood of it
37:52happened was low, there's no
37:53doubt about it, but
37:54certainly it was not
37:55zero.
37:57They eventually came up
37:58with a modification and
37:59issued this service
38:00bulletin about it a few
38:01years later.
38:02The manufacturer of the
38:05skid control unit had
38:07issued a service
38:08bulletin suggesting a
38:09simple fix that would
38:10prevent the erroneous
38:11signal from being
38:12sent.
38:16To modify the
38:17anti-skid control unit to
38:18the newer version that
38:19would not provide this
38:20power-up pulse, one
38:21nearly had to add a few
38:23diodes and a capacitor, so
38:24it wasn't a complicated
38:25fix, wasn't difficult to do,
38:26it wasn't expensive.
38:26But the notification was
38:30issued as a service
38:31bulletin, not an air
38:33worthiness directive, which
38:34would have made the fix
38:35mandatory.
38:37If an aircraft
38:38manufacturer is making
38:40a modification to an
38:41aircraft, it gives out a
38:42service bulletin.
38:43You don't need to do it.
38:45An air worthiness
38:46directive is a state
38:48hazardous to the safety of
38:49the operation of the
38:51aircraft.
38:51That might even ground the
38:53whole world fleet of the
38:55aircraft till it's
38:56modified.
38:58Luxair never performed
39:00the suggested 1992
39:01modification to its fleet
39:03of Fokker aircraft.
39:05If it had come as an
39:06air worthiness directive,
39:07they would have
39:07complied, no doubt about
39:08that, and the problem
39:10would have been fixed.
39:13The accident didn't
39:14happen here.
39:15It happens here.
39:17When they accepted an
39:18approach they weren't
39:19prepared for.
39:21How much fuel will we
39:22need?
39:23Uh, five, five,
39:26fifty, we need eight
39:28fifty when we leave the
39:29hole.
39:30No, we need fuel to
39:31reach till our alternate
39:33plus twenty minutes
39:34reserve, so we'll still
39:35need six hundred kilos.
39:36Yes, but I want to keep...
39:38Luxair 9642, descend to
39:40three thousand feet on
39:41one zero two three, turn
39:42left heading one three
39:43zero.
39:44Is that for us?
39:45Yes.
39:48Investigators believe that
39:49the main cause of the crash
39:50flight 9642 was the crew's
39:53decision to accept the
39:55approach instruction rather
39:56than join a holding
39:57pattern.
39:59Left heading one three
40:00zero, Luxair 9642.
40:04What kind of crap is that?
40:07At the time they got the
40:08first heading for the
40:09intercept for the localizer
40:11for the runway, they should
40:13have said, no, we are not
40:14ready for the approach.
40:15Had they simply rejected
40:18the approach when the
40:20controller gave them those
40:20initial headaches and
40:21descent down to three
40:22thousand feet, the
40:24controller would have said
40:25that's fine.
40:26Here, they still don't have
40:28the visibility they need to
40:29land.
40:30They're too high and too
40:31fast and still aren't
40:33properly configured.
40:35If ever there was a case
40:37for a go around.
40:419642, continuing approach.
40:43The investigators also
40:46fault the crew for not
40:48executing a missed
40:49approach when they had so
40:50much going against them.
40:53Once the crew was
40:54surprised by the ATC
40:56clearance to start the
40:57approach as number one, a
41:00lot of events started
41:02putting the pilots in a
41:04kind of a tunnel vision or
41:06into a continuation bias,
41:08focusing only on the
41:09approach and the landing
41:10without considering any other
41:12options.
41:14To prevent the plane from
41:16being put into reverse in
41:17the air, the team also
41:19recommends that the
41:20modification to the skid
41:21control box, which stops
41:23any erroneous signal, be
41:25made mandatory for all
41:26Fokker 50 airplanes.
41:29Luxair makes the
41:30modification to its entire
41:31fleet of Fokker
41:32aircraft.
41:34The accident, in fact,
41:35proves the fact it was
41:37that serious and should have
41:38been addressed.
41:38Captain Pukkers was charged
41:41with involuntary manslaughter.
41:44He was fined and sentenced
41:46to three and a half years
41:47probation.
41:50The lessons we have learned
41:51from this tragic Luxair
41:53accident is always stick to
41:56standard operating procedures,
41:57stick to the aircraft's
42:00limitations, be aware of
42:02operational bulletins.
42:03Unfortunately, most of
42:06these things were not done
42:08by the Luxair crew, and
42:10this led to this tragic
42:11accident.
42:12The end.
42:12The end.