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00:00Es ist das Schlimmste Schlimmste in der Portugese historie.
00:07144 Menschen wurden getötet.
00:09Der Schauspiel des Devastations war unglaublich.
00:13Der Schauspiel zeigt wenig evidence.
00:16Sie sind sehr schrecklich zu testen.
00:19Der Kontrollverlust gibt keine Insight.
00:22Sie sollen die ILS benutzen?
00:24Ja.
00:25Only the final seconds of Independent Air Flight 1851.
00:30Pull up.
00:32They had seven seconds until impact.
00:34Reveal the whole story.
00:37They don't say anything?
00:39I've never encountered anything like this before.
00:42And I never encountered anything like this afterwards.
00:46To say it was unique would be an understatement.
00:55Independent Air Flight 1851 cruises above the Atlantic Ocean.
01:16There are 137 tourists on board the American charter flight.
01:27Santa Maria Independent Air 1851 requesting MET report.
01:32Less than 30 minutes before landing, the crew prepares for descent.
01:371851, wind 260, 14 knots.
01:4434-year-old flight engineer Jorge Gonzalez checks the weather ahead.
01:49He's a U.S. Air Force veteran with a sterling reputation.
01:5441-year-old Captain Leon James Doherty is also from the military
01:59and has been flying jetliners for almost a decade.
02:02Let's request a set.
02:04Santa Maria Control, Independent Air 1851 would like to descend.
02:1136-year-old First Officer Sammy Adcock
02:15just started with Independent Air two weeks ago.
02:18Independent Air 1851, clear to descent to flight level 40.
02:24Cleared to flight level 40, Independent Air 1851.
02:34The crew was a balanced crew.
02:37They had flown together for about a week or ten days and they were doing fine.
02:41They're flying a four-engine Boeing 707.
02:47The long-range, narrow-bodied jetliner has dominated passenger travel for more than three decades.
02:53It wasn't a modern jet at the time. It was 21 years old.
03:03But it was well maintained within all the safety regulations.
03:06Today's flight from Bergamo, Italy will refuel at Santa Maria, an island in the remote Azores,
03:16before continuing to its final destination, Punta Cana, in the Dominican Republic.
03:21Santa Maria was a popular destination for refueling because of its location in the Atlantic.
03:30It's a small island with a large mountain in the center.
03:35That mountain is called Pico Alto.
03:38At almost 2,000 feet, Pico Alto, or High Peak, is the highest point of a mountain range stretching across Santa Maria.
04:05Hey, close the door. It's a jungle out there.
04:11Are you finished with those?
04:12Yeah.
04:14Thanks.
04:15Thank you.
04:17What's your passing level? Independent Air 1851.
04:22Passing flight level 220.
04:2660 miles from the airport, the first officer tunes in to the frequency for Santa Maria Airport.
04:32Good afternoon, Santa Maria Tower.
04:38Today, a trainee in the tower is guiding in the flight with the help of a supervisor.
04:44Independent Air 1851, passing flight level 200 to flight level 40.
04:51Independent 1851, roger.
04:53In 1989, I would describe the Santa Maria Air Traffic Control Facility as being very unsophisticated, very small.
05:05The airport is also not equipped with radar.
05:08There were only three scheduled airline flights per day.
05:11It doesn't justify the cost of air traffic control radar, which is very challenging for air traffic control.
05:16You're cleared 3,000 feet on Q&H 1027. Runway will be one-niner.
05:31Expect Isla's approach. Runway one-niner, report reaching 3,000.
05:36The controller is relying solely on position reports from the pilot.
05:45So they have to be meticulous about protecting the airspace and documenting the altitude that the aircraft is at.
05:52Is that what they said? 1027 on the millibars? Yep.
05:57Just over 13 minutes from the airport, the crew readies the plane for landing.
06:20Seatbelts and shoulder harness.
06:28Secured.
06:32We're having fun now.
06:34Hey, hey.
06:36On that day, the weather in Santa Maria was fine.
06:39There was just some cloud cover in the vicinity of Pico Alto.
06:43That is very common.
06:47Switching off autopilot.
06:50The captain takes control of the aircraft.
06:52The captain would likely be hand-flying the airplane to get comfortable controlling it.
07:05That ain't looking too hot out there.
07:07Yeah, we'll get down below.
07:09Depends on what level those are.
07:11There's cloud cover ahead.
07:13If conditions get worse, the crew will have to make the approach using only their instruments for reference.
07:18Okay, I'm gonna go ahead and put the ILS in on my side.
07:23Okay.
07:25ILS, or instrument landing system, is a navigation system that provides vertical and horizontal guidance to the runway.
07:33That means that he can fly in clouds until he gets on to final approach.
07:39It's always better to have help.
07:4335 miles from the airport, the coastline of Santa Maria comes into view.
07:47When approaching from the east, you will see some big cliffs.
07:53Some green, a lot of green.
07:57Where's the airport?
07:58It's on the other side of the island.
08:04As they approach the island, an alert in the cockpit tells the pilots that they are 500 feet above their selected altitude.
08:10400 to go.
08:13Don't know if we're gonna get visual or not here.
08:26Starting to pass through the layers.
08:29As they cross the coast of Santa Maria, weather conditions worsen.
08:33The winds can be pretty severe around the Pico Alto, and this can present a challenge for the pilots to maintain control of their aircraft.
08:52Can't keep this damn thing level.
08:53Can't keep this damn thing level.
09:11Help you?
09:12No.
09:16Just two minutes from the airport, flight 1851 is seen flying very low overhead.
09:22Pull up.
09:24Pull up.
09:26Hurray, hurray.
09:28Pull up.
09:30The encapement is telling the crew they are in a potentially dangerous situation.
09:42Just four and a half miles from the Santa Maria airport in the Azores, Portuguese firefighters and civilians discover a horrific scene of devastation.
09:52Independent air flight 1851 has crashed into the island's highest mountain.
09:59The jet hit Pico Alto very near the top of the mountain.
10:05The accident site was a bit of a chaotic scene.
10:08The wreckage was thrown all over the mountain.
10:11There were some small fires.
10:13It was a very steep terrain.
10:14It was very difficult for rescuers to work there.
10:20It soon becomes clear that all 144 passengers and crew have been killed.
10:26It was a big challenge for the locals mostly to deal with that.
10:32Santa Maria has only 5,000 people living there.
10:35And in a flash, they became the scenario of the worst air disaster to occur in Portugal.
10:40Rescuers work through the night.
10:44By daybreak, the Portuguese Civil Aviation Authority, known as the DGAC, arrives at the crash site.
10:51They are soon joined by American representatives from the NTSB, the National Transportation Safety Board.
11:01The terrain that we traversed was very challenging.
11:05There was a lot of personal effects.
11:07People were dressed for vacation.
11:09There were children whose dolls I could see in the trees.
11:12The scope of the devastation, it was remarkable.
11:16Investigators need to get a better perspective if they are to understand why Flight 1851 crashed into a mountain so close to Santa Maria's Airport.
11:28The overhead view revealed to us just how concentrated the wreckage was on the side of the mountain where the airplane struck it.
11:35That was something I had not seen before.
11:45So, this is the flight path.
11:48The plane impacts the east side of Pico Alto.
11:54Correct.
11:56Investigators examined the wreckage pattern for clues as to how Flight 1851 was flying before impact.
12:03All concentrated right here.
12:08Sending debris over the mountain ridge.
12:12Scars on the ridge give investigators their first clues.
12:17Looks like low angle, high velocity.
12:20It must have been flying level.
12:22Seafit?
12:23Looks like it.
12:24They quickly recognize this incident to be a controlled flight into terrain, or Seafit.
12:32If one looks at Seafit accidents, there are really two types.
12:36One where an airplane descends prematurely.
12:39The other where it hits the side of a mountain.
12:42They must have known about the mountains.
12:43What was the altitude where they hit?
12:471,795 feet.
12:54And Pico Alto?
12:56What does the Jefferson shark show?
12:58It's listed as 1,936 feet.
13:01Pico Alto is clearly identified on the Santa Maria approach chart.
13:07So, they struck the mountain 140 feet below what was listed on their chart.
13:14What were they doing so low?
13:16The possibilities were, one, the crew was off course.
13:22Two, there was an altitude error.
13:25It was our job to find out which of those would explain the accident.
13:30What's the minimum sector altitude?
13:323,000 feet.
13:35The minimum sector altitude is at least 1,000 feet above all terrain within 25 miles of the airport.
13:43There's plenty of room.
13:46According to the company's operations manual, there should be at least two Jefferson charts on board the plane at all times.
13:52They had to have known.
13:54Yeah.
13:56This was the question.
13:57I mean, why did these guys descend so low when they knew by the charts that the minimum altitude was 3,000 feet and there was a mountain there?
14:08So, this was the last flight of the day?
14:12Yes, it was.
14:14What was the minimum sector altitude you gave them?
14:17The team turns to the air traffic controller for insight into why the aircraft was flying below 3,000 feet.
14:293,000 feet.
14:31You're sure?
14:33Yeah, I even made a note of it on my flight strip.
14:35He was perfectly calm. He had a normal behavior. He thought he had done a good job.
14:45Were you the only controller on duty at the time?
14:48My supervisor was also there.
14:49It was such a slow airport. It was certainly not unusual for a supervisor to provide on-the-job training for an air traffic trainee.
15:00What was the weather like?
15:01Fairly good at the airport. No rain or strong winds. Visibility was unlimited.
15:15However, the top of Piqualta was in cloud. And winds can be unpredictable up there.
15:22The weather was okay. The focus for the investigators was on how the cloud layer affected the pilot's ability to see and avoid the top of the mountain.
15:34Were they advised to use the ILS?
15:37Yes.
15:42Expect ILS approach. Runway 19, report reaching 3,000.
15:49The investigator learns that the pilots did encounter cloud cover near Pico Alto.
15:55But they shouldn't have had a problem using their instruments to get them to the runway.
16:00Did the crew report any mechanical issues?
16:03No. Not to me anyway.
16:09Thank you for your time.
16:11I couldn't find anything that explains what happened from his part.
16:18So if the controller gave them the proper clearance, why are they so low?
16:23What if there was an issue with the plane that they didn't report?
16:26The team must now consider if a mechanical issue that wasn't reported to the controller prevented the crew from maintaining a safe altitude above the mountain.
16:37It was possible. We couldn't rule this out until we looked more closely at the evidence.
16:42That something very quickly happened, something catastrophic, just before impact.
16:46Is this everything?
16:58So far.
17:00Investigators are looking for clues in the wreckage of Flight 1851
17:04to explain why it descended below minimum altitude and crashed into a mountain on Santa Maria Island.
17:16Let's start here.
17:18Could a malfunctioning engine have forced the aircraft below the minimum safe altitude?
17:23It says here the jet had less than 45,000 hours in the air with seven service bulletins over the last six years.
17:34Any issues?
17:36No.
17:381983, Agent 2 had suffered turbine failure.
17:42Looks like it was repaired.
17:43It's full of wood and dirt.
17:46A quick examination provides an answer.
17:49There's nothing wrong with these engines.
17:51Engines that are generating power at impact, if they hit a field of trees, will ingest part of the vegetation into the engines and that will bring the engine fan blades to a stop.
18:05And that's what happened here.
18:06Engines that are not turning, that are not working, won't do that.
18:12What about the altimeter?
18:18If the altimeters were malfunctioning, the crew might have believed they were flying higher than they actually were.
18:27Hi.
18:28Thank you.
18:30Look, way too damaged to test.
18:31What are the service records, sir?
18:32They were last calibrated four months ago.
18:39No problems.
18:41It's another dead end.
18:44Maybe the altitude alert survived.
18:47Let's take a look.
18:53The altitude alert warns the crew with an audio alert when they're approaching a preset altitude.
19:03Hang on.
19:07Is this it?
19:08Yeah, that's it.
19:11Doesn't look too bad.
19:17Yeah, check this out.
19:19The altitude alert is set to 2,000.
19:21Investigators discover the altitude alert was set for 2,000 feet, not the required altitude of 3,000 feet.
19:31I remember this shocked all of us.
19:33We just couldn't believe it, how that could happen.
19:35Why would the altimeter alert be set to 2,000 when the controller gave them a clearance of 3,000?
19:42Maybe the controller remembered wrong.
19:45Let's check the tapes.
19:47ATC recordings gives you what's exchanged during the different phases of the flight.
19:55So you can confirm absolutely what was said, either contacting the plane or inside the ATC.
20:01Good afternoon, Santa Maria Tower.
20:07Will the air traffic control audio recording confirm what the trainee told investigators?
20:13Independent 1851, roger.
20:18You're clear to 3,000 feet on QNH 1027.
20:23Runway 19, expect Isla's approach.
20:29Runway 19, report reaching 3,000.
20:32Stop there.
20:36He said it.
20:39Twice.
20:41The control tower recording confirms that the controller gave a 3,000-foot clearance.
20:45Listening to the clearance did not explain the 1,000-foot error due to the altimeter alert.
20:53We needed to listen to the CVR.
20:56Take it from the point where they first contact the controller.
20:59Investigators now listen to the cockpit conversation to determine why the crew descended below the 3,000-foot minimum sector altitude given by the controller.
21:12Good afternoon, Santa Maria Tower.
21:16Independent air 1851, passing flight level 200 to flight level 40.
21:23That's the first officer.
21:25Independent air 1851, roger.
21:31You're clear to 3,000 feet on QNH 1027.
21:38Clear to 2,000.
21:40Did the first officer just say 2,000?
21:43Go back, play it again.
21:48Clear to 2,000.
21:49Investigators wonder why the first officer misheard the altitude clearance as 2,000 feet instead of 3,000 feet.
22:02Maybe he heard 2,000 and mistook it for 2,000.
22:11It's possible.
22:13It looked to us that perhaps the word 3 never was listened by the first officer.
22:18So the first officer only listened, you're clear, 2,000.
22:24Not 2, 3,000, but 2,000.
22:28So he never heard the word 3.
22:31The CVR recorded the first officer reading back an incorrect clearance.
22:36It was very puzzling to us when we heard the CVR why the crew did not act.
22:44It was clear that that wasn't given much credence.
22:47The controller should have corrected him too, but doesn't.
22:50Why?
22:52And that's an important part of this accident investigation.
22:56We couldn't figure out why the air traffic controller did not correct the first officer.
23:01Hang on a second.
23:07The first officer's read back of 2,000 feet isn't in the controller's transcript.
23:11So he never heard it?
23:13How is that possible?
23:15We couldn't figure out how they could miss each other.
23:18It was, it was inexplicable.
23:20All right, so the first officer mishears the altitude.
23:26He reads it back to the controller as 2,000 at 1356.59.
23:31Investigators compare the conversations between the controller and the first officer of Flight 1851
23:38to better understand why there was miscommunication between them.
23:42What does the controller say next?
23:44Well, he repeats the clearance by saying,
23:46Expect ILS approach, runway one niner, report reaching 3,000.
23:51That's it?
24:01Hang on.
24:02Hang on.
24:11We were talking at the same time.
24:13Yeah.
24:14Canceled each other out.
24:16It's a troubling realization.
24:19An overlap of communication between the tower and the pilot.
24:25Passing flight level 2-0-0 for flight level 4-0.
24:29You're clear to 3,000 feet on QNH, 1027, runway one niner.
24:41We're clear to 3,000 feet.
24:44Runway one niner, report reaching 3,000.
24:47It was stunning.
24:49We were stunned.
24:51To finally understand how the two transmissions overlapped perfectly.
24:57To cancel each other out.
24:59I was an investigator for over 30 years at the NTSB.
25:02I've never encountered anything like this before, and I never encountered anything like this afterwards.
25:07They're both talking at the same time. They're both pushing their PTTs.
25:10That's right.
25:13Pilots and controllers use a push-to-talk or PTT button.
25:21When it's pressed, the radio transmits but cannot receive.
25:25To think that so many people died because of a simple error, that was just, that's sad.
25:32That's hard to deal with as an investigator.
25:34So the controller doesn't hear it, but he should still insist the first officer read it back or repeat it.
25:45There are some readbacks in air traffic control that you simply have to get back every single time.
25:51An altitude is one of them.
25:53The trainee controller did not request an altitude readback, and the supervisor didn't notice, and that was unfortunate.
26:00What about the supervisor?
26:01What about the supervisor?
26:03Good question.
26:09According to the controller, she was there.
26:12Maybe she was busy with other things?
26:15Possible.
26:18Investigators wonder if the supervisor monitoring the trainee during the approach clearance was somehow distracted.
26:26Check this out.
26:28According to the phone record, she took a call during her shift.
26:32You don't want to take a phone call during something important like a descent clearance because they have to give them a course to follow and an altitude to maintain.
26:45Really important stuff that you cannot possibly miss.
26:47Something doesn't line up.
26:52The plane's altimeter alert was incorrectly set to 2,000 feet.
27:01Even at that altitude, they would have cleared the ridge by some 200 feet.
27:06Yeah.
27:08We still had to explain why the airplane struck the mountain 200 or so feet even further below the altitude that they were trying to maintain.
27:21Something had to explain that.
27:22What else affects altitude?
27:25Q and H.
27:31Q and H is a pressure setting, pilot's input, so their altimeter measures the proper height above sea level.
27:38It can change with weather conditions.
27:40If the altimeter is set to a higher Q and H than it's actual, the aircraft will actually be lower than what the altimeter is telling the pilots.
27:49It says here they were given a Q and H of 1019 at 144 p.m.
27:58Then they were given a reading of 1027 at 156 p.m.
28:04Okay.
28:07So it changed 8 millibars in 12 minutes.
28:14Could that be right?
28:16I'll check the weather reports.
28:19For an 8 millibar change to occur in 12 minutes would be something that may occur during a hurricane or something like that.
28:27I don't see anything that would make that possible.
28:30So how much would they drop with an 8 millibar increase?
28:36Investigators calculate the change in altitude between the two Q and H values.
28:42That Q and H brought them at least 200 feet below 2,000.
28:46Right into the mountain.
28:49The team concludes that an incorrect altimeter setting put the flight on a collision course with Pico Alto.
28:54When you're close to the ground in restricted visibility conditions, an accurate altimeter setting is everything that will protect the airplane from a CFIT accident.
29:08Thanks for talking with me again.
29:11Yeah, of course.
29:13Just one full-off question here.
29:15What was the pressure setting you gave them?
29:17Investigators conduct a second interview with the controller to understand why he gave two very different Q and H settings to the pilots.
29:261019 was on the MET report.
29:3112 minutes later, when you gave them a 3,000 foot clearance, you said Q and H 1027.
29:40I asked the controller directly about the Q and H he had given to the plane, and he couldn't explain why he had given that Q and H at all.
29:57In my view, it's just he didn't notice he was giving the wrong information.
30:09Sorry, I don't know where I got that second number.
30:11For that Q and H to change so rapidly, it should have been noticed by both the air traffic tradee and their supervisor and the pilots as well.
30:26I'm surprised that the pilots didn't reach out and say, hey, can you repeat that Q and H again?
30:32After the first officer gets the minimum descent altitude wrong, he questions the Q and H.
30:47Is that what they said? 1027 on the millibars?
30:50Yep.
30:52He was right to question it.
30:54But the captain just dismisses it.
30:55Thank you.
30:57And the first officer just accepts it.
30:59Because of the different experience levels.
31:04Because of the prominence and assertiveness with which the captain said it.
31:08Shut off any discussion when, in fact, there should have been.
31:11Makes you wonder what else these guys missed.
31:25Yeah, let's play the tape.
31:26Investigators returned to the cockpit voice recording to learn how the crew of Independent Air Flight 1851 allowed so many errors to accumulate on approach to Santa Maria.
31:39Altimeters.
31:40Set and cross-checked.
31:41Set and cross-checked.
31:42Set and cross-checked.
31:43Seat belts and shoulder harness.
31:44Secured.
31:45We're having fun now.
31:46Hey, hey.
31:47That's it?
31:48Stop the tape.
31:49They discover the pilots missed important steps on the checklist.
31:52They don't even mention the minimum descent altitude.
31:53Or pico alto.
31:54Here.
31:55They hear a briefing.
31:56that doesn't include reference to the navigation charts that were available to the pilots.
31:57They don't even mention the minimum descent altitude.
31:58That's it?
31:59Stop the tape.
32:00They discover the pilots missed important steps on the checklist.
32:03They don't even mention the minimum descent altitude.
32:04Or pico alto.
32:05Here.
32:06They hear a briefing that doesn't include reference to the navigation charts that were available to the pilots.
32:11Had they done the approach briefing and reviewed the information and articulated the information as required,
32:18it's highly unlikely, in my opinion, that they would have struck the mountain.
32:26Another unfortunate error.
32:42There were a couple of things in the performance of the captain that were questionable.
32:49He didn't try to understand what was the real Q&H that was given.
32:56Then he didn't insist in a complete checklist.
33:00Let's hear what comes next.
33:03It ain't looking too hot out there.
33:08Yeah, we'll get down below.
33:10Depends on what level those are.
33:12Okay, I'm gonna go ahead and put the ILS in on my side.
33:15Okay.
33:16Uh, after 2,000, yeah, we'll get below these clouds.
33:28Stop.
33:29Right there, 2,000 again.
33:32When the captain says nothing and descends to 2,000, why?
33:38The captain is ultimately responsible as the pilot in command, but each crew member failed in that respect.
33:45Okay.
33:46Play the tape.
33:47Uh, 1,000 to go.
33:48One to go.
33:49Wow, look.
33:50There's the island.
33:52Stop it.
33:53Who is that?
33:54Investigators hear an unknown female speaking in the cockpit on approach into Santa Maria.
34:10She appears twice over 16 minutes, starting when they begin their descent.
34:18The flight attendant, maybe.
34:20But what is she doing there?
34:21I don't know.
34:22That's not what I call a sterile cockpit.
34:25And the captain lets it happen.
34:26The captain violated the sterile cockpit rule, which bans non-essential conversation in the cockpit below 10,000 feet.
34:40I believe that violating the sterile cockpit rule was consistent with the way they fooled the approach.
34:50They weren't sitting on the edge of their seats.
34:52They were far too relaxed.
34:54There is no place like Santa Maria.
34:57Is it nice?
34:59Yeah.
35:00To have a beer.
35:02See you on the ground.
35:08Ignoring standard procedures.
35:10Distractions.
35:11The list keeps growing.
35:15Starting to pass through the layers.
35:17You can't keep this damn thing level.
35:26Althea?
35:27No.
35:31Pull up.
35:33Pull up.
35:35Pull up.
35:38Pull up.
35:47They don't say anything.
35:51When the GPWS went off, there was no response from the crew.
35:55There was not even a, what's that?
35:57What's going on?
35:58It was nothing.
36:00They don't say anything, or do they do anything?
36:13Thank you.
36:14So, this is the plane's descent approaching Santa Maria.
36:19Investigators examined the flight data
36:21to determine how the pilots responded to the ground proximity warning.
36:28So, they're descending at about 2,500 feet per minute.
36:32They level off here,
36:35and the GPWS goes off here.
36:38And they crash about seven seconds later.
36:40No reaction.
36:44No change in altitude.
36:47The data shows there were no inputs from the pilots to recover the aircraft.
36:52It's like they ignored the alarm.
36:55When the GPWS goes on,
36:58you apply maximum power,
37:01climb at the maximum rate,
37:03and get the heck out of there.
37:06Seven seconds.
37:07They had seven seconds from the first warning
37:09until impact.
37:13They could have climbed over the mountain in that time
37:16had they done what they should have done,
37:19and they didn't do that,
37:20and we couldn't figure that out.
37:22Pull up.
37:23Why didn't the crew respond to the warning?
37:29Surely the crew was trained to respond to the ground proximity warning.
37:32Investigators closely examined the training manuals for independent air.
37:43You are not going to believe this.
37:46The simulators were programmed with different approach speeds
37:49and flap settings in the accident aircraft.
37:54What does that mean?
37:55It means that the GPWS would go off during normal approaches.
38:02Independent air rented time on another company's 707 simulator.
38:07It was configured differently from the accident aircraft.
38:11Flaps 40.
38:12Pull up.
38:16Sir?
38:18Pull up.
38:24By training the crew to ignore the GPWS in the simulators,
38:27they gave the crew the message
38:30to ignore the GPWS in the airplane.
38:33I can't believe how many things went wrong.
38:41Investigators conclude
38:42that by avoiding any one of the minor errors,
38:45flight 1851 would have cleared Pico Alto,
38:48preventing the deaths of 144 people.
38:52It all starts with the first officer
38:54mishearing the minimum sector altitude.
38:57Independent 1851, Roger.
39:00You're clear to 3,000 feet.
39:03Clear to 2,000.
39:08Make it 3.
39:10If the first officer had referred to his charts...
39:14Roger. Good catch.
39:17...the altitude alert would have been set
39:19at the proper elevation,
39:20and the aircraft would have cleared the mountain
39:25by more than 1,000 feet.
39:29Same result if the air traffic controller
39:31had asked for a re-back.
39:33Independent air 1851.
39:36Uh, you're clear to 3,000.
39:38I say again, report reaching 3,000.
39:41Over.
39:45Or if the captain kept a sterile cockpit.
39:48Uh, after 2,000...
39:51Yeah, we'll get below these clouds.
39:54Wow, look.
39:56There's the island.
39:58It should be 3,000, not 2,000.
39:59It's time to return to the cabin.
40:07You cannot be unattentive,
40:10especially in the last, uh, period of the flight.
40:13Even with all those mistakes,
40:14the trainee controller had given them
40:16the proper altimeter setting.
40:17You're clear to 3,000 on Q&H 1027.
40:24Uh, correction.
40:271019.
40:29Flight 1851 would have cleared Pico Alto
40:31by 200 feet.
40:32Well, we're close.
40:43Finally, the GPWS.
40:47Pull up.
40:48If the crew had the proper GPWS training...
40:52Go around!
40:54...they would have had one last chance
40:57to avoid hitting the mountain.
41:05They might have made it.
41:06I have never seen an accident
41:10with these many factors
41:12happen
41:13where any one of which,
41:15had they not been there,
41:16we wouldn't have had an accident.
41:20In the wake of the crash,
41:22the NTSB recommends a careful review
41:24of airline training programs
41:26with a focus on international operations
41:28and safety,
41:29especially those related to the GPWS response.
41:33The major lesson was that airlines
41:38need to train their crews better
41:40to improve aviation safety.
41:45Independent Air later settled
41:47with the victims' families
41:48for 34 million U.S. dollars
41:50before a compensation case
41:53ever went to trial.
41:56Independent Air went out of business
41:58in 1990.
42:00Any aviation business,
42:02there is no room at all
42:03for complacency.
42:05The longer we do a job,
42:06the more complacent we tend to get.
42:08After a while,
42:09some of the things we do,
42:10even if they're unsafe,
42:11start to appear to be safe.
42:13And unfortunately,
42:14we can have an accident
42:15like the one that we witnessed here.