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On 5 May 2007, Kenya Airways Flight 507 crashes during a thunderstorm shortly after takeoff from Douala International Airport in Cameroon, killing all 114 people on board. The pilots suffered spatial disorientation after their failure to engage the autopilot resulted in an excessive bank.
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00:01Now that is fast.
00:071,000 feet and climbing.
00:09A brand new 737 takes off during an intense storm.
00:13They should be there by now.
00:15And then mysteriously falls from the sky over West Africa.
00:22Those who operate these type of aircraft, they have the same question.
00:25What happened? What happened in Cameroon?
00:27Investigators scour the crash site for clues.
00:33The ground. Over there.
00:36This was the toughest accident scene I've been on in my career.
00:41But look at this.
00:43When the investigators review the flight data...
00:46Hold on! We're crashing!
00:49...they discover there was an inexplicable fight for control in the cockpit.
00:54Left! Left! Left correction!
01:00Who flies like that?
01:04Me, me, me, me!
01:05I'm heading 107 yards, thank you.
01:08I am heading 107 yards, thank you.
01:09I'm heading 107 yards, thank you.
01:10107 yards, thank you.
01:11I'm heading 107 yards, thank you.
01:131,000 feet, 1,000 feet, 1,000 feet.
01:14We have to go…
01:15...and then go.
01:17In Douala, Cameroon, Kenya Airways Flight 507 is almost an hour behind schedule.
01:35Ladies and gentlemen, we are going to wait for the weather conditions to improve before we take off.
01:42A severe storm must pass before the pilots can depart.
01:47There are 108 impatient passengers on board.
01:55Many need to catch connecting flights.
02:00Flight 507 began in Abidjan earlier in the day.
02:07It's now bound for Nairobi, Kenya.
02:10507 was a very common flight for our Kenya Airways, particularly last decade.
02:15The amount of traffic from East Africa to West Africa has really increased, partially because there's much more business going on.
02:21The Boeing 737NG, recently acquired by Kenya Airways, is the newest generation of twin-engine commercial jets.
02:31This was a new era of aviation in Africa, where airlines, and particularly the bigger ones, invest in brand-new aircraft.
02:40Captain Francis Wanwia is in command of tonight's flight.
02:55He's an experienced pilot with more than 8,000 hours in the cockpit.
02:59Andrew Kirou is his first officer.
03:07The young pilot joined Kenya Airways a year ago.
03:11Let's see what this storm is doing.
03:15The pilots use the 737's on-board weather radar to monitor the storm.
03:20Looks like there might be a way around it.
03:26Now that the storm has moved off the end of the runway, Captain Wanwia believes he can fly past it.
03:34It's quite common that the weather may be a factor in delay in Africa because of its severity.
03:38So it's not, in that respect, a surprise for the operator to find this kind of weather at that time of the night.
03:45Tower, Kenya 507.
03:47Looks like there's a break in the weather.
03:50Requesting start-up.
03:53Okay, 507. Start-up approved.
03:57Start-up checklist. Quickly, please.
04:02Generator's on.
04:05A few minutes before midnight, flight 507 is finally ready for take-off.
04:12Okay. Request taxi clearance.
04:17Kenya 507. Requesting taxi clearance.
04:22Taxi runway 12, Kenya 507.
04:26Taxi runway 12.
04:29Kenya 507.
04:30Put on the wipers.
04:45Put on the wipers.
04:49Right is clear.
04:50The crew taxis to the runway.
04:59There's one flight ahead of them.
05:01Royal Air Morroc, flight 287.
05:06Royal Air Morroc, 287.
05:08In position.
05:09Runway 12.
05:10Latest weather, please.
05:11Visibility 800 meters.
05:14Will come.
05:16Rain moderate thunderstorms.
05:18All right.
05:20287.
05:21Question takeoff.
05:22The Royal Air Morroc, flight, departs without incident.
05:35Wait till we line up.
05:38Okay.
05:39Usually, things happen quickly, though.
05:42Captain Wanwia double-checks the storm's position.
05:57Let's have a look.
05:58And confirms the route around the lingering storm cell.
06:03Tower.
06:04Kenya 507.
06:06After departure, we would like to maintain a heading slightly left of the runway due to weather ahead.
06:13Right.
06:14Ah.
06:15Sorry.
06:16Slightly right.
06:18Just after the aircraft took off, the plan was to make a small turn to the right to avoid the most active weather cells that they saw on the weather radar in front of them.
06:26Approved.
06:29Okay.
06:31All done.
06:34Ladies and gentlemen, a kind reminder to ensure your seatbelts are well-fastened for takeoff.
06:41Caban crew to your seats.
06:53Okay.
06:55Takeoff thrust is set.
06:56Speed building on both.
06:59Check.
07:0080 knots.
07:02Check.
07:04V1.
07:05Rotate.
07:08Just after midnight, Kenya Airways flight 507 finally departs for Nairobi.
07:17Gear up.
07:19Okay.
07:19Okay.
07:19Okay.
07:19Okay.
07:261,000 feet and climbing.
07:33Heading select.
07:35Selected.
07:36Check.
07:36The 737 starts turning right to avoid the storm.
07:45Anyone?
07:46Okay, come on.
07:48So, should I remain on this heading?
07:51Yep.
07:512,400 feet and climbing.
07:582,400 feet and climbing.
08:02Now we're getting into it.
08:04Bank angle.
08:17Bank angle.
08:17Bank angle.
08:18Bank angle.
08:18Suddenly, the 737 rolls dangerously to the right.
08:22The captain fights to level the plane.
08:30Bank angle.
08:31Bank angle.
08:32But it continues banking further and further right.
08:35Bank angle.
08:36Bank angle.
08:40Bank angle.
08:44Bank angle.
08:46Bank angle.
08:46Bank angle.
08:48Despite the pilot's efforts, they keep rolling.
08:58Bank angle.
08:58We're crashing.
09:00Now we are crashing.
09:01Left.
09:02Left.
09:02Bank angle.
09:03Bank angle.
09:04Left direction.
09:04Jump.
09:05Marine.
09:05Marine.
09:06Bank angle.
09:07Bank angle.
09:08Bank angle.
09:08Up.
09:08Up.
09:09Up.
09:09Pull.
09:10Up.
09:10Up.
09:11Up.
09:11Up.
09:12Up.
09:12Up.
09:13Up.
09:13Up.
09:14Up.
09:14Up.
09:15Up.
09:15Up.
09:16Up.
09:29Five hours later, the controller in Douala is ending his shift.
09:39Doula Tower.
09:39No reason I can think of. They should be there by now.
09:48Kenya Airways Flight 507 should have landed in Nairobi 45 minutes ago, but the plane has still not arrived.
09:56Sure.
09:58And no one even knows where to start looking for it.
10:02Kenya Airways Flight 507 was due in Nairobi at 6.15 a.m. local time.
10:14But it never arrived.
10:18By morning, news of the missing 737 has spread.
10:25Families and friends of the passengers want to know where their loved ones are.
10:32Engelbert Zawar-Etundi worked for Cameroon's Civil Aviation Authority.
10:42When I first heard that an aircraft was missing, I immediately thought we were going to have a catastrophe on our hands.
10:56Two days later, search teams finally locate the wreckage of Kenya 507.
11:02It's three and a half miles southeast of Douala Airport.
11:08The 737 has crashed into a mangrove swamp and is submerged in mud and water.
11:17There are no survivors.
11:19As a nation, we are united in grief.
11:30It's a tragic turn of events.
11:33Victims, friends and family are demanding answers from the Cameroonian government.
11:38But the government has a problem.
11:40Cameroon did not have an agency in charge of air accident investigations.
11:54Investigators from several countries descend on Cameroon.
11:57Since the Boeing 737 is manufactured in the United States, Dennis Jones from the U.S. National Transportation Safety Board, the NTSB, joins the investigation.
12:13The fact that it was a relatively new airplane at the time certainly made it a little bit more compelling.
12:21But all around the world, those who operate these type of aircraft, they have the same question.
12:26What happened?
12:26What happened in Cameroon?
12:30It's all from the tail.
12:34Looks like everything else is down in there.
12:38I saw a lot of debris from the tail section.
12:41We were not able to see the wreckage itself because we were in a swamp.
12:46And that was another challenge throughout the whole process.
12:50A technical advisor for Boeing, Mark Smith, also joins the team of investigators.
13:04This was the toughest accident scene I've been on in my career at Boeing.
13:10We're standing there looking around at the devastation, the destruction.
13:13So we have to, as a team, start working on what happened to it, where are the various pieces.
13:22A key piece of evidence is quickly found.
13:26The 737's flight data recorder.
13:30Well, looks pretty good, considering.
13:36The FDR is sent to Canada's Transportation Safety Board to be downloaded.
13:43While searchers continue looking for the cockpit voice recorder,
13:52investigators try to determine what caused the plane to crash so soon after takeoff.
13:59The airport is only three and a half miles away.
14:04They can't have been in here in more than two minutes.
14:08We really didn't have a clue.
14:11You're looking for explanations.
14:13We were able to start doing a lot of on-scene examination documentation,
14:18trying to get an idea how it impacted the ground.
14:23The layout of the wreckage tells investigators how the plane was flying on impact.
14:33Completely obliterated.
14:36So I haven't found the most of it.
14:38Looks like it came in hard and fast.
14:40When you have a high-speed impact like that in a nose-dine attitude,
14:46you usually get extensive fragmentation of aircraft.
14:51Well, actually, what we're trying to do is estimate, if we can,
14:54an angle and maybe even a speed of impact to try and get a feel for what happened,
14:59because once again, we don't yet have the FDR data.
15:02How deep does this go?
15:09More than 15 feet.
15:12Well, it definitely hit nose first.
15:15And hard.
15:16So, was there some kind of loss of control that took place?
15:21That was what was kind of foremost on my mind.
15:25While they wait for the flight data,
15:31investigators turned to the controller on duty that night to help fill in some blanks.
15:38What can you tell me about that night?
15:41The first thing is that they delayed their takeoff.
15:45Really?
15:46How come?
15:47There was a storm coming in from the east.
15:56Power, 507.
15:59We are going to wait for the storm to pass.
16:01Cancelling starter.
16:05Roger, 507.
16:06Cancelling starter.
16:08The storm could last all night, but visibility should improve.
16:10The airplane was on the tarmac, loaded, ready to go, waiting for the weather to clear,
16:17and then they would take off.
16:21But 20 minutes later, they decide to take off.
16:24Why?
16:25It cleared a bit.
16:26And they were going to try to get around it.
16:34Tower, Kenya 507.
16:37Looks like there's a break in the weather.
16:39Requesting start-up.
16:42Okay, 507.
16:44Start-up approved.
16:47The controller explains how the crew planned to fly to the right of the storm.
16:55Is it possible the crew misjudged the storm's size and strength?
17:03NTSB investigator Bill Bramble also joins the team.
17:07They had a cell eight miles off the end of the runway,
17:11so the crew was using their own radar to decide how to maneuver around the cell.
17:18Here's a meteorological report from that night.
17:25Thunderstorm and rain over the airport with winds gusting up to 20 knots.
17:28But it was starting to clear.
17:32Investigators wonder if the wind and rain were still severe enough to bring down a 737.
17:38He asked permission from the controller to go around the storm.
17:43To the right.
17:46Maybe the storm was worse than he thought.
17:50There was a weather delay for several flights.
17:53KQ-507 was one of four flights that were delayed on the ground for about an hour.
18:02Investigators need to speak to other pilots who took off from Douala that night.
18:07How intense was the storm once they were in the air?
18:10I will speak to one of the pilots tomorrow.
18:19Investigators interview a pilot who departed immediately after Kenya Airways Flight 507.
18:27They need to find out if he had any difficulty avoiding the storm.
18:31The flight crews solely depended on their own onboard systems to understand what they were getting into.
18:39There was no assistance from the ATC.
18:43So, no problems at all.
18:46Not even mild turbulence.
18:49He said the weather was smooth after they took off.
18:52They did the same thing too.
18:54They took off and turned to the right to circumnavigate the weather.
18:57Okay.
18:58Thank you for your time.
18:59Investigators conclude the pilots could have maneuvered around the storm on their flight path.
19:05Just sit.
19:08With weather ruled out, the team wonders if there was a mechanical issue with a brand new 737.
19:16This was important because it was the first for the 800 series.
19:21And if there's an accident and it's not immediately understood what the problem is,
19:25it's really important to get to the bottom of it.
19:29Technicians in Canada have been able to extract the FDR data.
19:37Let's see what we've got.
19:38They read the data out, altitude, airspeed, bank angle, pitch attitude, those sorts of things.
19:47Once you plot those out, you can start seeing what occurred.
19:52Any malfunction warnings during the flight would provide an important clue.
20:00There might have been some kind of mechanical issue that might have popped up.
20:04No warnings.
20:05They find no signs of any system failure.
20:09The data showed us the airplane was behaving as we would expect it to.
20:15It was a perfectly airworthy aircraft.
20:18There's no question about it.
20:19As the team continues looking through the data...
20:23But look at this.
20:25...they discover that just over a minute into the flight, a different kind of alert did go off.
20:32Bank angle alert at an altitude of 2,800 feet.
20:35For investigators, this is their first real clue about what happened to flight 507.
20:45Any roll exceeding 35 degrees is considered extreme.
20:52Once reaching that angle, a warning alerts pilots of danger.
20:57Rotate.
20:58When investigators review the pilot's inputs after takeoff, they make a critical discovery.
21:07Get up.
21:08Okay.
21:10He was turning left from the moment they left the ground.
21:15That information showed us that right after takeoff, the aircraft started to roll to the right a little bit, and the pilot corrected it.
21:24And then he keeps making corrections to the left.
21:27Looks like he's trying to keep the plane level.
21:31But what caused the slow roll to the right in the first place?
21:41Bingo.
21:42It's the way the flaps are rigged.
21:45Give it a slight right roll.
21:47The aircraft had a tendency to roll to the right.
21:52The flaps increase a plane's lift at slower speeds.
21:57On this particular airplane, the left flap provided slightly more lift than the right one.
22:04It's similar to driving down the freeway in your car and just letting go of the wheel.
22:12If I was to do that, then it'll start to drift off one way or another.
22:16That's the way the airplane was slowly and naturally banking it.
22:19This discovery explains why the captain kept his control column turned to the left immediately after takeoff.
22:33Well, that's weird.
22:34But it doesn't explain an even more puzzling element of the flight data.
22:40Look at this.
22:42The captain's control wheel input seemed to stop.
22:45It's like he just let go of it.
22:47Six degrees right, he does nothing.
22:50Eleven degrees.
22:52Fifteen degrees.
22:53Twenty degrees.
22:55Thirty degrees and still nothing.
22:57As the plane's bank angle approached thirty-five degrees, neither pilot took action to stop the increasingly dangerous roll.
23:09Until the bank angle warning sounded.
23:15And then he does this.
23:17Right, left, right again, left again.
23:21In the last moments of the flight, we noticed an erratic movement of the control column that didn't make any sense.
23:35For sixteen seconds after the bank angle warning, the aircraft continued its dangerous roll.
23:44The airplane just continues to roll right up to 110 degrees of bank.
23:53The crew didn't recover it before an impact.
23:58The data paints a baffling picture of the one and a half minute flight.
24:08Who flies like that?
24:09That was puzzling to us.
24:16So it really highlighted that we needed more information, we needed more data.
24:21And that data is the CVR.
24:22The CVR is what tells us the conversation, what might they have been looking at.
24:29But after weeks of searching the crash site, there's still no sign of the cockpit voice recorder.
24:39It's been more than a month since the crash of Kenya Airways Flight 507.
24:47And the cockpit voice recorder has still not been found.
24:53We spent days scouring the site, up track, down track, everywhere, looking for the CVR, trying to find it.
25:03The team now uses a tracking device to scan the swamp for a signal from the box.
25:16Five weeks after the crash, the cockpit voice recorder is finally recovered.
25:20That was a very, very exciting time for everyone involved with the recovery, as well as the investigation group itself for having that information.
25:32Okay, let's start on the ground.
25:35Started.
25:38Investigators hope the recording will explain why the pilots let their plane bank so dangerously to the right.
25:44They hope the recording will also explain how they ended up spiraling into a swamp.
26:07Okay, this is where he stops making any inputs.
26:19Selected, check.
26:21N1, okay, command.
26:24That's the call to activate the autopilot.
26:30So, should I remain on this heading?
26:33Yep.
26:37After calling for the autopilot to be engaged, Captain Wamweer released the control column, trusting the autopilot to fly the plane.
26:48But there's a problem.
26:50The autopilot didn't come on.
26:53He thought the 737 was flying itself?
26:57There was nobody flying the control, so nothing was controlling the airplane.
27:01The discovery changes the course of the entire investigation.
27:08N1, okay, command.
27:12Why didn't the autopilot come on?
27:15The captain calls for the autopilot to be engaged.
27:20But the first officer does not respond.
27:22The procedure should be for the first officer to push the button and say, the autopilot engaged.
27:28Okay, command.
27:32So, should I remain on this heading?
27:34Yep.
27:37Investigators believe the first officer was so focused on inputting the route around the storm that he failed to engage the autopilot.
27:492,400 feet and climbing.
27:51Now we're getting into it.
27:58Meanwhile, the captain assumed the autopilot was engaged and controlling the pre-selected right turn.
28:06Bank angle, bank angle.
28:10The pilots only noticed a problem when the bank angle warning went off.
28:15Bank angle, bank angle.
28:17It's pretty clear the captain expected the autopilot to be engaged and it didn't get engaged.
28:23And then neither crew member picked up the fact that it wasn't engaged.
28:27We're crashing!
28:29No, we are crashing!
28:30Left!
28:31Left!
28:32Left direction!
28:34Go!
28:34Go!
28:34Go!
28:34Go!
28:34Go!
28:34Go!
28:34Go!
28:34Go!
28:34Go!
28:35Go!
28:35Go!
28:36Go!
28:37Go!
28:39Go!
28:40Go!
28:41Go!
28:42Go!
28:43Go!
28:44Go!
28:45Go!
28:46Go!
28:46Go!
28:47Go!
28:51Why did neither crew member take the critical step of engaging the autopilot?
28:58Standard operating procedures provide a safety net for crews, but if crews don't adhere to the standard operating procedures, they lose that protection.
29:07They comb through Kenya Airways procedures to see who has responsibility for activating the autopilot.
29:15Anything?
29:16From what I can tell, it's not really clear who was supposed to do it.
29:22All it specifies is turn on when above minimum altitude for engagement.
29:27It's not very helpful.
29:29It wasn't really clear.
29:30It wasn't really clear in the standard operating procedures of when the autopilot does come on,
29:36who's responsible for doing that and what the response should be to that.
29:39No!
29:40Oh!
29:41Bank angle!
29:42Bank angle!
29:43Bank angle!
29:44Bank angle!
29:46Recovering from a 35-degree bank is not a complicated procedure.
29:57The bank angle warning is designed to give pilots enough time to react.
30:03But for some reason, this crew wasn't able to do that.
30:10The team digs into their records.
30:13This is what we have on one way.
30:19Lots of experience.
30:2116 years as a pilot, most of those on the 737.
30:25Let's see what this storm is doing.
30:27The captain had been a flight attendant for Kenya Airways years and years ago,
30:32and then went to flight school and got his ratings and transitioned into the role of pilot.
30:40Wait.
30:41Look at this.
30:44But the captain's training records reveal serious shortcomings.
30:48Inadequate knowledge of systems and procedures, insufficient flight discipline, poor cockpit scans.
30:56Below standard.
30:58Yikes.
31:00Get up.
31:00We discovered the captain had a history of training difficulties and lack of systems knowledge for autoflight systems and so forth.
31:11So he had some red flags in his history.
31:13The first officer's report isn't any better.
31:19Feel to monitor autopilot when engaged.
31:23V1.
31:25Rotate.
31:26The first officer was young and fairly inexperienced.
31:29He only had a little over 800 hours of flight time.
31:32And he had had some training feedback that involved things like you need to be more proactive about calling out deviations and so forth.
31:43Not an A-level crew.
31:44Not an A-level crew.
31:44Not an A-level crew.
31:50Not an A-level crew.
31:52Not an A-level crew.
31:53That's right.
31:53That's right.
31:54did a lack of skills in the cockpit
31:58doom the 108 passengers on board the flight.
32:14Investigators need to determine if pilot error
32:16caused the horrific crash of Kenya Airways Flight 507.
32:24Okay, Allah, he's definitely surprised.
32:32Then, 22 degrees to the right, 20 left, 45 right,
32:41then 11 to the left.
32:44That's not helping.
32:47Oh, the bank can't go, the bank can't go.
32:51When the bank warning came on,
32:54and the aircraft was on a right roll,
32:56the first response was the captain turned it further to the right
33:01and which aggravated the situation.
33:04Now the bank angle is approaching 50 degrees.
33:09As the situation grew worse
33:13after the bank angle warning and the confusion amongst the crew,
33:18the autopilot does engage,
33:20and the captain pushed that button.
33:24The team discovers that when the captain finally realized
33:28as the autopilot was not engaged, he activated it.
33:38But when it didn't immediately level the plane,
33:41the captain turned the control column erratically,
33:44an action which overrode the autopilot.
33:46We're crashing!
33:48Yeah, we are crashing!
33:49Bank angle.
33:51Then, yes, we are crashing.
33:54Left, left.
33:57Left correction.
34:00So now one's trying to turn left
34:02while the other turns to the right.
34:06They're fighting each other's inputs.
34:08Left, left, left, left correction.
34:13Jump.
34:16Bank angle.
34:17Bank angle.
34:25I don't get it.
34:28It should have been a simple recovery.
34:30The back and forth was trying to do corrective actions,
34:35but it didn't seem like it was correcting anything.
34:40He's already banked over to the right,
34:4234, 35 degrees.
34:44Why would he row further?
34:46Well, that's the question we have to answer right there.
34:51Investigators use a Boeing simulator
34:53to recreate the final stages of the flight.
34:57From the simulator,
34:58you can literally put yourself in the driver's seat
35:00and reconstruct the flight
35:02and be there at the pilot
35:03to be able to determine whether we can recover.
35:08Can we give it a 50-degree right bank, please?
35:14Activate the autopilot, please.
35:21Exactly what it's supposed to do.
35:22The roll is slowing.
35:26And the inputs we discussed.
35:30Right, left, right.
35:33Jeez.
35:34There goes the autopilot.
35:35Bank angle's increasing again.
35:40Bank angle.
35:41Bank angle.
35:42The simulation shows that if the captain had given the autopilot
35:46enough time to take control,
35:49the 737 would have returned to a relatively safe bank angle.
35:54But his erratic inputs prevented that from happening.
35:59If only he'd done nothing.
36:00It was determined that recovery was still an option
36:05just a few seconds before impact, really.
36:10Investigators are puzzled.
36:12Why wasn't the experienced captain
36:15able to execute such a straightforward recovery?
36:19Was there something here that we were missing
36:21in the investigation that may have confused the crew?
36:25So, we started looking harder at the possibility
36:29of spatial disorientation.
36:33From the simulator?
36:35Yeah.
36:36Just darkness outside.
36:39No reference at all.
36:41It was a completely black view out the windshield.
36:47If you look up out the windshield,
36:49you have no ground reference
36:50that could immediately have helped you
36:53straighten the airplane out.
36:55Hold on!
36:56Bank angle.
36:57Bank angle.
36:57Bank angle.
36:59Spatial disorientation is an inability
37:01to distinguish up from down,
37:03left from right.
37:04Bank angle.
37:06It has been known to hinder judgment
37:09and delay response times.
37:11Bank angle.
37:12Bank angle.
37:12We're crashing!
37:14Yeah, we are crashing!
37:15Left!
37:16Left!
37:17Left direction!
37:19Bank angle.
37:19Only the first officer
37:21seemed to assess the situation correctly.
37:24What are you doing?
37:25Bank angle.
37:26Bank.
37:26First thing he says is,
37:28yeah, we are crashing.
37:30It took him 10 seconds to speak up.
37:35Bank angle.
37:36Bank angle.
37:42Bank angle.
37:43When the bank angle alert went off,
37:46there wasn't much discussion
37:48about what was happening.
37:49until the captain said,
37:51we're crashing.
37:52Yeah, we are crashing.
37:54And the first officer didn't say anything
37:57until he said that.
37:58Left direction!
38:00The team listens to the recording
38:06of the first leg of the flight
38:07from Abidjan to Douala.
38:10They are looking for clues
38:11as to why the first officer
38:13remained silent.
38:14Let's hear it.
38:17What is wrong with you?
38:20What they hear shocks them.
38:26When investigators listen
38:28to the cockpit voice recording
38:29of the first leg of Kenya Airways
38:31flight 507...
38:33Sorry, did you say an altitude
38:35of 14,000 feet?
38:37Yes.
38:38Don't be so stupid.
38:39Write it down if you care to remember.
38:41Wow.
38:43They're stunned
38:44by how the captain
38:45treated his first officer.
38:48It was pretty bad.
38:50The captain was
38:51sort of browbeating
38:51the first officer.
38:53There were words like
38:54stupid,
38:55shut up,
38:56stuff like that
38:57that you wouldn't expect to hear
38:59in a professional crew environment.
39:00What is wrong with you?
39:04Did you not hear the instruction?
39:06Heading 2-3-0.
39:09Understand?
39:12The first officer
39:13seemed to kind of shut down.
39:16Heading 2-3-0.
39:19Understand?
39:22He was,
39:23at a certain point,
39:24sort of reduced to responding
39:26with these sort of
39:27monosyllabic grunts.
39:28Investigators suspect
39:33this might explain
39:34why the first officer
39:35took so long
39:36to speak up.
39:42The captain's behavior
39:44toward the first officer
39:45on the first flight
39:46likely caused him
39:48to adopt
39:49sort of a passive role.
39:51You need both pilots
39:52actively engaged
39:53in checking each other
39:54and catching errors.
39:55and if one pilot
39:57adopts a passive role,
39:59they're going to be
39:59less effective.
40:02Sorry, heightened ego.
40:05Captain Wanwia's
40:07treatment of his
40:08first officer
40:08leads investigators
40:10to examine
40:11his professional history
40:12more closely.
40:13Tell me more information.
40:15We spent a lot of time
40:16going to pilot records,
40:18interviewing other
40:19flight crew members.
40:21Are they ready?
40:21They quickly learned
40:23that the captain's
40:24shortcomings
40:25were not limited
40:25to his flying abilities.
40:28He had a lot
40:29of concerning things
40:30in his training files
40:32about being overbearing,
40:34being authoritarian,
40:36in terms of how he dealt
40:37with other crew members.
40:41So,
40:42we have a young,
40:43reserved first officer
40:44and an overbearing captain.
40:46This accident
40:48is kind of a throwback
40:49to those early days
40:50where we were focused
40:51on the issues
40:52of overly assertive,
40:53authoritarian,
40:54overbearing captains
40:55and submissive,
40:57inadequately assertive
40:59junior first officers.
41:00A lethal combination.
41:04Investigators conclude
41:06the bad pairing
41:07in this flight crew
41:08set in motion
41:09a sequence of events
41:10that led to the crash.
41:11As an investigator,
41:15all of these accidents
41:16I've worked,
41:18it's very clear
41:19there is never
41:20a single cause.
41:22It's always
41:22a chain of events.
41:24So,
41:25should I remain
41:26on this heading?
41:27Yep.
41:30A deadly combination
41:32of poor pilot performance
41:34and spatial disorientation
41:37contributed to the accident.
41:39to it.
41:41All the risk factors
41:42were present.
41:43There was distraction,
41:45there was reduced
41:45outside visibility,
41:47and there was confusion.
41:52But in the end,
41:54investigators conclude
41:55that one major mistake
41:56triggered the entire tragedy.
42:00N1.
42:01Okay, command.
42:03So,
42:04should I remain
42:04on this heading?
42:05Yep.
42:09It was the crew's failure
42:12to ensure
42:13the autopilot
42:14was turned on.
42:17Oh!
42:18Bank angle.
42:19Bank angle.
42:25That ultimately
42:26led to the death
42:27of 114 people.
42:31We're crashing!
42:32Bank angle.
42:36Bank!
42:37In the aftermath
42:44of Flight 507's crash,
42:48Cameroon's Commission
42:49of Inquiry
42:49makes a series
42:51of recommendations,
42:53including the regular update
42:54of safety manuals
42:55related to cockpit procedure
42:57and crew responsibility.
43:00They made changes
43:02to the standard
43:03operating procedures
43:04about who's responsible
43:05for engaging your autopilot,
43:07and that was very key.
43:09And improved pilot training
43:12with a focus
43:12on upset recovery.
43:14One technology
43:15that Boeing
43:16has tested
43:18and developed
43:20and is looking
43:20at putting
43:21into its airplanes
43:21is a roll recovery arrow,
43:23so that if you're
43:24at an unusual angle
43:25of bank,
43:26the attitude display
43:27will actually show you
43:28which direction
43:29you need to roll
43:29the airplane
43:30and provide it
43:30an accompanying aural.
43:31In the end,
43:36you have to look
43:36at training,
43:38crew makeup,
43:39all adding
43:40into all the links
43:41of chain,
43:42the chain that caused
43:43this to happen
43:43this night.
43:45Let's see what
43:46this storm is doing.
43:48When those who are not
43:49familiar with
43:49accident investigation
43:50think that all the answers
43:51are at the crash site,
43:53it's rarely
43:53at the crash site.
43:55And that's exactly
43:56what happens.
43:58Rotate.
43:58Rotate.
43:59Rotate.
44:00Rotate.
44:01Rotate.
44:02Rotate.
44:03Rotate.
44:04Rotate.
44:05Rotate.
44:06Rotate.
44:07Rotate.
44:08Rotate.
44:09Rotate.
44:10Rotate.
44:11Rotate.
44:12Rotate.
44:13Rotate.
44:14Rotate.
44:15Rotate.
44:16Rotate.
44:17Rotate.
44:18Rotate.
44:19Rotate.
44:20Rotate.
44:21Rotate.
44:22Rotate.
44:23Rotate.
44:24Rotate.
44:25Rotate.
44:26Rotate.