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On 28 September 1992, Pakistan International Airlines Flight 268 crashes into a mountainside while on approach to Tribhuvan International Airport in Kathmandu, Nepal, killing all 167 people on board. The pilots had begun the descent too early after misreading the approach chart.
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00:00on a challenging descent in the Himalayas landing on runway 02 questions or concerns
00:12no questions no concerns commander a passenger jet collides with the side of a mountain
00:18it really was a shocking moment but when their most vital piece of evidence doesn't
00:29deliver this is it investigators scramble for answers could be weather loss of thrust intruder
00:45in the cockpit but the accidental discovery of a valuable clue could it be points to the origins
00:52of what went wrong come on come on come on that was the eureka moment in this investigation
00:59pakistan international airlines flight two
01:2968 is on route to Kathmandu the capital of Nepal the two and a half hour flight from Karachi is one
01:39of the few that flies to the Nepali capital situated 4600 feet above sea level landlocked between China
01:48and India Nepal is home to eight of the world's 10 tallest peaks including the mighty Everest Kathmandu is a
01:57favorite destination for travelers to the Himalayas many of whom are making their way to Nepal for the
02:04start of the popular trekking season could I have a tea please among them are Mick Hardwick and his
02:11friend Dave Harris both mountaineering instructors back home in Britain I climb with them to the Alps they were certainly very very good climbers in a variety of different disciplines in Alpine work really top of the tree they're on their way to climb Annapurna the 10th highest mountain in the world
02:21Annapurna was certainly an ambitious program but it wasn't foolhardy it was well thought out and well planned it would have been a huge moment for them it would have been a trip of a lifetime in the distance they get their first look at the Himalayas and it would have been a huge moment for them it would have been a trip of a lifetime
02:28in the distance they get their first look at the Himalayas have a look at that finally
02:31finally
02:58on the flight deck Captain Iftikhar Janjua is in command he's a former officer in the Pakistani Air Force who's now a senior pilot instructor with the airline
03:13Captain Mohammed Hussein flew around the world with Captain Janjua on many different flights
03:20I knew him for a period of about five years
03:24he had no ears about him you know he was quite a simple person
03:27he was a family man
03:29he never smoked he didn't drink
03:31that way he was a straight guy
03:33I don't like the look of the clouds ahead
03:38the first officer is Hassan Akhtar a junior pilot with the airline with almost 1500 hours flying the Airbus A300
03:47how about we divert around them
03:51yes commander agreed
03:53it's nearing the end of monsoon season
03:56large storms are still frequent along the route
03:59Kathmandu Pakistan 268
04:02we are 10 to 15 miles right of the track to avoid a build-up en route
04:06to avoid the storm Captain Janjua notifies Kathmandu air traffic control of his change to flight 268's approach
04:14Roger 10 to 15 miles right of track copied
04:18could get bumpy
04:21let's keep them seated
04:23agreed commander
04:24fasten seatbelt sign is on
04:28we're about to begin our descent into Kathmandu
04:31we are entering an area of turbulence and I request all of you to remain seated
04:35the descent it over is quite scary because the plane needs to be descending forever
04:41you sort of lose track of where you actually are
04:44we're expecting it to be a little choppy
04:46well here comes the mountains
04:49then you're on the runway and it's always a relief when the plane comes to a halt
04:56I'll take over from here actor
05:02yes commander
05:03I have control
05:05you have control
05:07the first officer hands over control of the aircraft to the captain
05:11flight 268 leaves its cruising altitude as it begins the approach into Kathmandu
05:20in 1992 Kathmandu airport doesn't use radar to track its planes
05:31every movement planned or otherwise must be accurately reported by the flight crew
05:37in the absolute radar it requires good communication between the aircraft near traffic controller
05:43they have to communicate very carefully
05:46Pakistan 268 approaching overhead
05:49Simrah 150
05:51Pakistan 268 descent to 11,500
05:54no delay expected
05:56Roger sir
05:58down to 11,500
06:00the problem with Kathmandu is you have a range of mountains to the south
06:05that you have to get over and then you have to drop down quite steeply
06:09in order to be able to land at the threshold of the runway
06:14there is a danger of arriving at the threshold too fast or even a little bit high
06:19the mountains surrounding Kathmandu require pilots to make what's known as a stepped approach
06:25pilots must descend to a series of lower altitudes at certain distances from the airport
06:31we can expect descent clearance by 16 miles
06:38descent angle is steep so we need to be at flaps 15 by 16 miles
06:42landing on runway 02
06:44watch for stray animal and birds
06:46questions or concerns
06:47no questions no concerns commander
06:49Pakistan 268 report 16 miles
06:52wind 180
06:54expect Sierra approach
06:56Roger call you at 16 miles expecting Sierra approach
06:59Sierra approach commander
07:04here it is
07:05watch my levels
07:06the details of the stepped approach are laid out on a chart for the pilots
07:10the approach chart is designed to keep you clear of terrain
07:14so you have to follow the approach chart
07:19as flight 268 begins its final approach towards Kathmandu
07:24passengers and crew prepare for landing
07:27the sun and blue sky is a bit nice
07:33Alpha Charlie Hotel surface wind 200-05
07:36Pakistan 268 is at 16 miles
07:4011,500
07:4216 miles from the airport
07:45the pilots report their altitude as 11,500 feet
07:48roger Pakistan 268
07:51roger
07:52Pakistan 268
07:53report 10 miles
07:54roger call you at 10 miles
07:55Pakistan 268
07:57the crew works its way through the steps towards Kathmandu
08:01approaching from the south
08:03they should be touching down in about 6 minutes
08:06they should be touching down in about 6 minutes
08:10Alpha Charlie Hotel continue to taxiway number 2
08:16Pakistan 268
08:19Pakistan 268 is at 10 miles
08:22report your level
08:24we crossed out of 8,500
08:30200 now
08:31roger
08:33clear for final
08:34report 4 miles
08:36runway 02
08:37runway 02
08:38we'll call you at 4 miles
08:40Pakistan 268
08:41clear for final
08:42runway 02
08:43runway 02
08:44flight 268
08:47flight 268 is now less than 10 miles from the runway
08:59air traffic control waits for the flight crew's next position report
09:04three minutes go by
09:11flight 268 should have reported that they've reached the next step by now
09:19Pakistan 268 report position
09:26Pakistan 268 report position
09:29Pakistan 268 report position
09:32Pakistan 268 report position
09:34Pakistan 268 report position
09:37Pakistan 268 tower
09:40Pakistan 268 this is tower
09:42Pakistan 268 this is tower
09:44As the minutes tick by, air traffic controllers come to a horrifying realisation.
10:00Flight 268 is missing somewhere in the Himalayas.
10:08It doesn't take much time for Kathmandu air traffic controllers to get word.
10:13The PIA flight 268 has crashed somewhere in the Himalayas.
10:22Within hours, the plane's wreckage is found on the side of a mountain.
10:30The flight was carrying more than 20 tonnes of fuel.
10:36And the plane is completely consumed by fire.
10:41All 167 people on board have died.
10:45Tonight, investigators refuse to speculate on possible causes of the crash.
10:49So dangerous are the conditions...
10:54We're all back in North Wales, and news filtered through into the office.
10:58We just sort of...
11:00...stared in disbelief, really.
11:01We couldn't believe it.
11:02You hear of these things happening, but when it happens to people you've been in contact with on a daily basis,
11:08year in, year out, and worked with on the cliffs and the crags, it's just disbelief.
11:14As the flames die down, Nepal faces a chilling reality.
11:19A passenger jet has crashed near the Kathmandu runway for the second time in two months.
11:29The first was a Thai Airways Airbus with 113 people on board.
11:40Canadian accident investigator Dave McNair is already in Nepal, leading the Thai Airways investigation.
11:46There hadn't been an accident in Kathmandu for many, many years.
11:49There was the one accident that happened back in July, and then a second accident of a major aircraft at the same place.
11:55And it really was a shocking moment.
11:58Yeah.
11:59Within hours, the Nepalese government launches an investigation into the crash of Flight 268.
12:06We need to get there as soon as the weather clears.
12:09Already stretched thin by the Thai Airways investigation, the Nepalese ask British investigators for help.
12:15Thanks for coming, Andrew.
12:18Andrew Robinson from Britain's Air Accidents Investigation Branch is one of the investigators assigned to the case.
12:25Let's see what we're dealing with here.
12:27My role in the investigation was to look at the engineering aspects of the accident.
12:33So I would be looking at the site, the wreckage distribution, the wreckage itself, the components within it,
12:40and trying to work out what the impact attitude was, whether all the aircraft was present at the impact site, that sort of thing.
12:48Kathmandu Airport is the main hub of Nepal's tourist industry.
12:54The pressure is on the team to figure out what caused this accident as quickly as possible.
13:01We wanted to find out obviously if there was something wrong with Kathmandu Airport or procedures involved in approaching or landing at it.
13:09So, yes, there was a huge concern within the aviating community.
13:16The Nepalese government deploys the military to help investigators get to the remote crash site, which is more than 7,000 feet above sea level.
13:26I was part of the team to go up there to look at the initial wreckage survey.
13:30It was quite of a perilous drive to get there.
13:34We got to the base camp, and then we had to walk about two kilometers up a path to get to the site.
13:40It was an emotional walk because as we're walking up, people are bringing the remains down.
13:46When we first encountered the wreckage site, you couldn't even recognize an airplane except for the tail.
13:58And, of course, you could see some of the souvenirs that people had were lying on the ground.
14:02A little child's sock was there.
14:04So, you know, that related to the people who were on the airplane.
14:07But in this case, it was just the aircraft was just totally destroyed.
14:11It was just complete obliteration of the aircraft.
14:15The team begins examining the wreckage.
14:19But conditions are treacherous.
14:21The aircraft had crashed into the side of a mountain about 150 feet from the top.
14:27And getting about on the site to inspect it was actually quite difficult because the average slope was about 45 degrees.
14:34Investigators quickly conclude that it's too dangerous to examine the wreckage on site.
14:40The actual workers were Nepalese who had to deal with some steep slopes
14:44and had to work very, very carefully to make sure nobody was injured on the site.
14:50As the investigation gets underway, one thing is obvious.
14:54Flight 268's final altitude.
14:57This is the location of the crash site, nine miles south of the airport.
15:01The aircraft collided with the mountain at an elevation of 7,280 feet.
15:10Investigators plot the location and altitude of the crash site.
15:16Just below the summit.
15:17Where should they be?
15:18Can you pass me that approach chart, please?
15:20At 10 miles out, he should have been at 8,200 feet.
15:23How do you hit a mountain you're supposed to clear by 1,000 feet?
15:38You know it hit the mountain, there's no doubt about that.
15:41But you don't know why it was as low as it was when it hit the mountain.
15:46As yet more mystery swirls around flight 268, a makeshift morgue is set up outside the airport.
15:55The people of Kathmandu must come to terms with a second tragedy in as many months.
16:01And pressure builds to find out why that happened.
16:08Nepalese soldiers have retrieved the aircraft's black boxes from the wreckage of PIA flight 268.
16:14Put that over there, please.
16:16The Digital Flight Data Recorder, or DFDR, contains information about critical aircraft operations and performance.
16:24They look pretty banged up.
16:27The cockpit voice recorder records conversations between the pilots.
16:31They'll both be sent to France, where the data will be downloaded and analyzed.
16:37Flight recorders are extremely vital for investigations.
16:40The most important part is it really brings you closer to understanding the entire reason for the accident.
16:47But until they get the data, investigators must look elsewhere for clues.
16:54They hope the air traffic controller can provide some insight.
16:58I've been running through every conversation we had and studying my notes.
17:02Does anything stand out?
17:04They had to deviate around some bad weather.
17:10Kathmandu, Pakistan 268.
17:12We are 10 to 15 miles right of the track to avoid a buildup en route.
17:17The controller tells investigators that the crew reported some storm clouds on the way to Kathmandu.
17:23It's usually very hazy in the Kathmandu Valley.
17:26In most conditions, when you've got mountains, you invariably have clouds.
17:30That's common this time of year.
17:33Anything else after that?
17:35Standard position reports by the book.
17:41Pakistan 268 is at 10 miles.
17:43Report your level.
17:44We crossed out of 8,500. 200 now.
17:48Roger.
17:49Clear for final.
17:50Report 4 miles.
17:51Runway 02.
17:52We'll call you at 4 miles, Pakistan 268.
17:56He said he'd contact me when he got 4 miles out.
17:59But I never heard from him after that.
18:07Okay.
18:08Let's see what the wreckage can tell us.
18:10When an aircraft is destroyed, there are still things you can get from the accident site.
18:14Investigators consider the possibility the jet was flying out of control when it crashed.
18:20They scrutinize the crash site for clues.
18:23Look at this.
18:25The right wing impacts up here.
18:29A large scar shows Robinson precisely where the wings hit the side of the mountain.
18:35He also notices that just 1.3 meters below the impact scar, the top of a tree has been cut cleanly.
18:46The wing couldn't have cut that tree.
18:48So what did?
18:49The aircraft cut some tree branches.
18:52So you can actually use that to measure angles of impact.
18:55Then you can use other evidence to find out what happened to the airplane.
18:58What about the flaps?
19:11Fully extended.
19:13Exactly 1.3 meters below the wing.
19:17For the team, it's a critical clue.
19:21As the Airbus A300 slows for landing, its wing flaps extend by as much as 25 degrees.
19:29Hanging below the wings, the extended flaps would shave the top of the tree as it slams into the mountain.
19:36Wings level, no pitch down, flaps extended.
19:45In other words, the exact landing configuration.
19:48This plane was absolutely not out of control.
19:51Flaps 10.
19:54Flaps 10.
19:57This is an indication that in fact the crew was deliberately flying it there.
20:01But what was abnormal was the fact the airplane was being flown too low.
20:06The question is, why was that?
20:11To answer that question, the team creates a list of every conceivable scenario based on the evidence they've collected so far.
20:19Any thoughts?
20:22Loss of thrust?
20:23Loss of engine number one.
20:36We're losing number two as well.
20:38Investigators consider a loss of thrust in both engines.
20:42Okay, watch my altitude.
20:44Come on, come on, come on!
20:457800.
20:46Initiate restart, either engine.
20:48And a rapid loss of altitude.
20:507500.
20:51Take it!
20:52Leading to the collision with the mountain.
21:01Robinson studies what's left of the plane's engines.
21:14Only one way this got in so deep.
21:16The damage and debris inside tell Robinson the fan blades were spinning when they hit the ground.
21:26And further examination of the device that controls fuel flow shows they were at the lowest thrust setting.
21:33Flight idle.
21:34That's precisely where they should be for an A300 descending towards the runway.
21:41The thrust from the engines was symmetrical and at low power.
21:47There was no indication of loss of control, so that was dismissed.
21:50So we then had to sit down and think of reasons why the pilot might have been too low.
22:00With mechanical failure ruled out.
22:02Okay.
22:03Not the engines.
22:04And the black box data still in Paris.
22:07What else?
22:08Investigators turned their attention to what was happening in the cockpit.
22:14Robert Bohr is an aviation psychologist who has studied the course of this investigation.
22:20Accident investigators will typically approach this kind of investigation as though they were detectives.
22:26And they're going to raise a wide range of questions, hypotheses that they will want to test out.
22:32Okay.
22:33What about an intruder in the cockpit?
22:36Unlawful interference is something that's around us.
22:41It's everywhere.
22:42We spend our lives dealing with it every time we check in at the airport.
22:47So we know it's out there.
22:49The team now wonders.
22:51Were the 167 people on board victims of a terrorist attack?
23:01Investigators are concerned an act of terrorism may have brought PIA Flight 268 to a violent end in the Himalayas.
23:12Pakistan International Airlines has been on high alert for over a decade since one of its planes was hijacked for 13 days in 1981.
23:25As a result, the airline routinely places armed guards on high-risk routes.
23:33There were four air guards on this flight.
23:36They turned to the passenger manifest for more information.
23:39Here, here, here, and here.
23:46As often happened in Pakistan Airways flights, there were a number of security guards on board,
23:52which would probably tend to suppress unlawful interference.
23:58The controller reported that the first officer's final radio call, just 32 seconds before impact, was calm and professional.
24:05We'll call you at four miles, Pakistan 268.
24:10No hint of a struggle.
24:12That helps us to understand that on the flight deck, things were pretty normal.
24:16The crew were probably, therefore, not being interfered with by a hijacker.
24:19I think we can rule out an intruder.
24:24Now what?
24:26Could be weather?
24:28In Kathmandu, they're quite often build up some clouds, and they can develop into thunderstorms or cumulonimbus-type clouds.
24:35And the suspicion was maybe there was some sort of cloud like that on the approach.
24:41This is everything from the time of the accident.
24:45Investigators examine weather conditions throughout the flight.
24:49The report was cloudy with a potential for storms.
24:53But because the crew had deviated around bad weather.
25:01Kathmandu, Pakistan 268.
25:03We are 10 to 15 miles right of track to avoid a build-up en route.
25:07It's unlikely they then flew into a thunderstorm.
25:10By now, the team has ruled out all possible external factors for this accident.
25:20Flaps were out.
25:22Engine's spinning.
25:24No intruder.
25:26No serious weather on approach.
25:28They're left with only one conclusion.
25:31They must not have known that they were flying too low.
25:35Okay, for finals, runway 02.
25:38Runway 02.
25:39Next altitude is 6800 at 8 miles.
25:42Now crossing through 7500.
25:457400.
25:49What's happening?
25:50No, no, no, no, no!
25:53It's clear in this situation that the pilots have built up a picture of the outside world that is not true and accurate.
26:02Which leads to the crash.
26:04However, we have to ask questions why that may be.
26:10Investigators look into two possibilities for the flight's dangerously low altitude.
26:16Either they ignored their chart and were doing a visual approach or they somehow misread the chart.
26:23Nothing else makes sense.
26:24We had no way of knowing why it was too low.
26:28So that became a matter of studying the data and having a general round table discussion.
26:33All right.
26:35Let's start with the visual approach.
26:37Roger.
26:38Pakistan 268.
26:40Report 1-0 miles.
26:41Roger.
26:42Call you at 1-0 miles.
26:43Pakistan 268.
26:45We can save some time by going visual.
26:49Watch my speed.
26:51We should soon see the runway.
26:53On a visual approach, pilots fly based almost entirely on what they can see.
26:58Yes, Commander.
26:59Visual to runway 02.
27:01Rather than a predetermined route.
27:03Flaps 10.
27:05Flaps 10.
27:07Flaps 15.
27:09Flaps 15.
27:10In many instances, visual landings are easier for pilots.
27:15Watch for the runway.
27:17But with a greater risk of human error.
27:20What's happening?
27:21No, no, no, no.
27:28It's possible, but almost total cloud coverage throughout the entire approach.
27:35Plus, they knew the terrain.
27:36The captain made this approach at least seven times.
27:40The first officer, five.
27:42Investigators conclude it's highly unlikely the flight crew attempted a visual approach in thick clouds.
27:49It's a complicated arrival.
27:52It requires a step down at various points toward the runway threshold.
27:56And perhaps most significantly, the meteorological conditions were not conducive to a visual approach.
28:03Pakistan 268, report 16 miles.
28:06The only theory left is that the pilots somehow misinterpreted their approach chart.
28:11Seattle approach, Commander.
28:15Here it is. Watch my levels.
28:18Everything was working technically.
28:20It didn't appear to be any interference on the flight deck by anyone.
28:24And so the only conclusion that we can take from this is that for some reason, the pilots had clearly misinterpreted data.
28:31All right. Let's look at this.
28:37Investigators hope the flight's black box data, back from Paris, will help solve the mystery.
28:45They look at the plane's flight path as the crew prepares for landing.
28:50They started their descent.
28:52At 16 miles out, they're at 10,500 feet.
28:55Then down to 9,500 at 13 miles.
28:598,200 at 10 miles.
29:01Then quickly down to 7,500 until impact at 7,280.
29:06The data reveals an astonishing fact.
29:09So, 1,000 feet too low, right from the get-go.
29:12The approach to Kathmandu is one of the last places on Earth a pilot would risk flying too low.
29:29Wait a minute.
29:31There you go. Perfect match.
29:35They were flying the approach, but one step ahead.
29:38What the aircraft flew was pretty much what the chart said, except that the pilot had got one step ahead of himself.
29:48So he's flying the correct altitude for the next position, which was a sort of eureka moment, I think, in this investigation.
29:56He's adjusting his descent to hit the lower altitudes.
30:03It's no accident.
30:06We obviously started to wonder why this should be the case.
30:10Still working in the shadow of the Thai Airways crash just two months earlier.
30:17Are we ready? Let's hear it.
30:20Investigators now hope the Pakistan Airways cockpit voice recording will shed light on what happened in the cockpit in the lead-up to the fatal collision.
30:28But as the team begins listening to the CVR, they get a gut-wrenching shock.
30:38This is it.
30:43This is it.
30:53The cockpit voice recording of PIA Flight 268 is playing the last thing investigators want to hear.
31:01Silence.
31:02Silence.
31:03Silence.
31:04Silence.
31:05Silence.
31:06Silence.
31:07Silence.
31:08Silence.
31:09Silence.
31:10Silence.
31:11Silence.
31:12The tape has recorded the announcements made to the cabin, and conversations with controllers, but not the conversations between the two pilots.
31:19Okay.
31:24So nothing from the cockpit Mike.
31:26Back to the drawing board.
31:33Without the full cockpit voice recording,
31:36investigators need to find other ways of understanding
31:38why the pilots of Flight 268 were flying 1,000 feet too low
31:43at every step of their approach.
31:46We have to therefore build a picture of what might have been going on
31:50in their minds, in the relationship between the two pilots,
31:53and in their relationship between themselves,
31:57the physical environment, and air traffic control.
32:00What if the problem is the actual approach chart itself?
32:04To avoid the mountains surrounding Kathmandu,
32:06pilots follow an approach chart about the size of a large postcard.
32:11It provides the specific altitudes pilots must take
32:15at set distances from the airport.
32:18They study the same chart used by the flight crew.
32:21So is, let's say, 8,200 feet the right altitude for 10 miles or 8 miles?
32:30It's hard to say.
32:32Even harder when it's actual size.
32:35The operations team spent a lot of time looking at a chart
32:39that the crew had been using.
32:41They concluded that there was a large amount of information on it.
32:44It was, um, it was a lot of clutter.
32:46Investigators need to know how the crew would have prepared themselves
32:52for the complicated approach.
32:54They examine the cockpit layout of an identical
32:57Pakistan International Airlines Airbus A300.
33:01There's no place to clip an approach chart here.
33:05Most aircraft have little clips on the control column
33:08to attach the approach plates to.
33:10Now, this particular aircraft didn't.
33:13There is just here.
33:15Now only the captain can see it.
33:17And he'd have to keep turning his head.
33:20Unlikely they use that.
33:22More likely he put it here.
33:25The other clip is a full three feet away from either pilot.
33:29That's not much better.
33:31It's almost impossible to read.
33:32And that handle is blocking the descent profile.
33:34They learn that Pakistan International Airlines
33:37has only two places for pilots to clip their charts.
33:41Both positions make it very difficult
33:42to read a four-inch-wide piece of paper.
33:45It's difficult to make a quick reference
33:47if you're having to sort of look to the right
33:49or to the left for a chart.
33:53Could it be?
33:56Then, quite by accident,
33:57the investigators discover a key clue
34:00regarding the pilot's misreading of the approach chart.
34:03If you pick up the chart
34:06and happen to put your thumb
34:08over the 11,500-foot mark
34:10for 16 nautical-mile marker,
34:13in that case,
34:15it might have guided his eye
34:17to the next height fix,
34:19and he might have assumed
34:20that that was the correct height
34:21for the 16-mile marker point.
34:26This definitely makes it look like
34:2810,500 is the correct altitude at 16 miles.
34:31Robinson finally has a theory
34:34he can put to the test.
34:39Kathmandu Tower, good afternoon.
34:41Pakistan 268,
34:4225 miles at 11,500.
34:45Just a few minutes before impact,
34:47the first officer reports
34:48being 25 miles from the airport,
34:51at the correct altitude of 11,500 feet.
34:55Pakistan 268, report 16 miles.
34:57Wind 180.
34:581-8-0, expect Sierra approach.
35:01Roger, call you at 16 miles,
35:03expecting Sierra approach.
35:04Sierra approach, Commander.
35:06But when the captain
35:07looks at the approach chart,
35:09his thumb may have obscured
35:10the correct next altitude.
35:13Here it is.
35:14Watch my levels.
35:15Now, instead of maintaining
35:1711,500 feet,
35:19Captain Janjua dials in
35:21the next altitude on the chart.
35:23Descending to 10,500.
35:25Oblivious that his plane's approach
35:28is now one step ahead.
35:31The crew has now made a fatal mistake.
35:34Unaware, the airliner is now descending
35:36towards a violent collision
35:38with the side of a mountain.
35:39So, that's where it all started.
35:48Investigators now pursue the new theory
35:50that the pilots of Flight 268
35:52misread the altitudes
35:54on a cluttered approach chart.
35:55At 16 miles,
35:58they should be at 11,500.
36:00But they've descended to 10,500.
36:03The team has a surprising realization.
36:05But then they report being at 11,500.
36:13At the 16-mile mark,
36:15the first officer reports
36:16the altitude they should be at,
36:1811,500 feet.
36:20Pakistan 268 is at 1-6 miles,
36:2311,500.
36:25Instead of 10,500,
36:27the lower altitude
36:28they're actually at.
36:29The investigators have uncovered
36:34a new mystery
36:35that goes right to the heart
36:37of what went so horribly wrong.
36:40Why did they descend to 10,500
36:41and then report being at 11,500?
36:49Andrew Robinson's team
36:51returns to the flight data,
36:52hoping to understand
36:54why the pilots of Flight 268
36:56misread and misreported
36:57their approach altitudes
36:59before the crash.
37:01A slat extension,
37:02a frequency change,
37:03and then flaps and landing gear.
37:06He was a busy guy.
37:08It's a fast and steep approach.
37:10And unless you're a pilot
37:11with considerable experience
37:13flying this route
37:13maybe several times in a week,
37:15it's going to be very testing.
37:18Descending to 10,500.
37:20Initiating descent.
37:22Investigators now believe
37:23that as the distracted flight crew
37:25approached 16 miles,
37:27throttles to flight idle,
37:29slats 15.
37:30Their attention was consumed
37:31by the demands
37:32of the busy descent.
37:34Flats 10.
37:36Flats 10.
37:37Flats 15.
37:40Landing gear down.
37:41By now,
37:42the captain has already
37:43dialed the flight's descent
37:44a thousand feet too low.
37:46Gear down.
37:47Three green.
37:47We're at 16.
37:48Report our position.
37:51Pakistan 268
37:52is at 16 miles.
37:53Investigators think
37:55the first officer
37:56hastily misreports
37:57the altitude
37:58on the approach chart.
38:0011,500.
38:02Without double-checking
38:03his altimeter.
38:05Then,
38:06Captain Janjua
38:07is too busy
38:08to notice the discrepancy
38:10between the reported
38:11and actual altitudes.
38:12In quite a stressful environment,
38:16such as the arrival
38:17at this airport,
38:19the build-up of pressure
38:20inside the pilot
38:22must be quite considerable.
38:23And their capacity
38:24to assimilate,
38:26take in information,
38:27read what's going on around,
38:29is going to be severely taxed.
38:31Can we hear his next report, please?
38:40Pakistan 268
38:41is at 10 miles.
38:43Report your level.
38:44We crossed out of 8,500.
38:47200 now.
38:49When he makes this report,
38:50he's at 8,100 feet.
38:56We crossed out of 8,500.
38:57200 now.
39:03Roger.
39:03Clear for final.
39:04Report 4 miles.
39:06Runway.
39:06Both pilots
39:07seem to have made mistakes.
39:09But air traffic control
39:10could have caught them
39:11and sounded the alarm.
39:14Why did the air traffic controllers
39:16not speak up?
39:17Why did they not say anything?
39:23Investigators head
39:24to Kathmandu Airport
39:25to find out
39:27why air traffic controllers
39:28didn't warn flight 268
39:30it was flying too low
39:31before it crashed.
39:34I did not know
39:35his exact position.
39:37So I had no way of knowing
39:38what the terrain below him was.
39:40In this case,
39:41without radar,
39:42it's really the responsibility
39:43of the crew
39:44to make sure
39:44of where they're flying
39:46in their approach.
39:47They also learned
39:48that pilots flying
39:49into Kathmandu
39:50often reported
39:51being at altitudes
39:52lower than the ones
39:53specified on the chart.
39:54When the mountaintops
39:56are covered in clouds,
39:57pilots will sometimes
39:58dip under them
39:59and fly over this valley instead.
40:04We crossed out of 8,500,
40:06200 now.
40:08If the pilots of flight 268
40:10had detoured around the mountain,
40:128,200 feet
40:14would be a safe altitude.
40:15Radar coverage in this area
40:18was not well developed
40:19and therefore
40:20it was very much
40:21a procedural approach
40:23and not one
40:24that relied on inputs
40:26from the air traffic
40:26controllers themselves.
40:28They were recipients
40:29of information
40:30and not really guiding
40:31the aircraft in.
40:33It all starts
40:35with the initial misreading
40:36of the chart
40:36and spirals forward
40:37from there.
40:39Investigators believe
40:40they've finally developed
40:41an explanation
40:42for how the tragic accident
40:43unfolded.
40:49The first mistake
40:51is made before
40:52the 16-mile marker
40:54where the captain
40:55likely misreads
40:56the approach chart
40:57and enters the altitude
41:01for the 13-mile marker
41:03one step ahead.
41:04descending to 10,500,
41:08landing gear down.
41:11Gear down.
41:12Free green.
41:13We're at 16.
41:14Report our position.
41:15Then,
41:16likely distracted
41:17by the busy approach,
41:18the first officer
41:19misreports their altitude.
41:21Box on 268
41:23is at 16 miles.
41:25He reports
41:25where they should have been.
41:2711,500.
41:29Not where they actually are.
41:30Investigators believe
41:34that if the captain
41:34had caught
41:35and checked
41:36that discrepancy,
41:37the flight's outcome
41:38might have been
41:38completely different.
41:40At that point,
41:41there was scope
41:42to correct
41:43and get back on track.
41:46But the profile
41:47suggests that
41:49they thought
41:50they were on
41:50the correct altitude
41:51and everything
41:52stemmed from there.
41:54So they carried on
41:56being that
41:56one step ahead.
41:59Flight 268
42:00remains 1,000 feet
42:02below the recommended
42:03safe altitude
42:04for what's left
42:05of its fatal descent.
42:08We cross out of
42:108,500.
42:13200 now.
42:15Next altitude,
42:166,800 at 8 miles.
42:19Now crossing through
42:207,500.
42:227,400.
42:26No, no, no, no, no!
42:27Three minutes after
42:32they first misread
42:33the chart,
42:34they impact the ground.
42:37What is quite striking
42:38is that it is
42:39a very difficult approach
42:40and in spite of that,
42:42the pilots are actually
42:43operating effectively,
42:45but not safely.
42:46This is at the heart
42:47of crew resource management
42:49and that has failed
42:51in this accident.
42:52In the end,
42:55if the plane had been
42:56just a few hundred
42:57feet higher,
42:58it would have missed
42:59the mountain
43:00and 167 lives
43:02would have been spared.
43:05In the aftermath
43:06of the Flight 268
43:07tragedy,
43:08investigators make
43:09a number of
43:10recommendations
43:10to prevent
43:11another accident
43:12due to a misread
43:13approach chart.
43:16Chief among them
43:17is simplifying
43:18the Sierra approach
43:19itself to make it
43:21less complex
43:22and challenging.
43:23They also recommend
43:25installing air traffic
43:26radar at Kathmandu
43:27and suggest
43:29Pakistan International
43:30Airlines install
43:32clips on the control
43:33columns of all
43:34its A300 airplanes.
43:37Minor things
43:38like provision
43:39of chart clips,
43:40installation of radar,
43:41it's a gradually
43:42improving picture
43:43and things hopefully
43:45still will continue
43:46to improve.
43:47A memorial
43:49to the victims
43:50of Flight 268
43:51stands at the foot
43:52of the mountain
43:53where it crashed.
43:54I still remember
43:55the people
43:56of my generation,
43:58I still remember
43:58there's people
43:59who did a lot
44:00and would have done
44:01a lot more
44:01in the world
44:02of mountain training.
44:03것으로
44:04the front
44:05of the mountain
44:05as far as
44:08as far as
44:09the
44:09of the mountain
44:10as far as
44:11a lax
44:12happening,
44:13there's a lot of
44:14巨大
44:15and the
44:16ц
44:16has been
44:17in the
44:17middle
44:18of the mountain
44:19the
44:19of the mountain
44:22of the mountain
44:22and the
44:22of the mountain
44:22of the mountain
44:25.
44:26There's a lot
44:26of
44:27mountain
44:28to the mountain
44:29where
44:29there's
44:30the mountain
44:31where
44:31there's