- 4 hours ago
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00:01Just minutes after taking off from Lima...
00:03We declare an emergency.
00:05The pilots of Aero Peru Flight 603
00:08get mixed messages from their plane.
00:11I cut the engines, but the speed is increasing.
00:15Having erroneous airspeed indications
00:17now puts into your brain,
00:18am I climbing, am I not climbing?
00:20They seek assistance from the ground.
00:23Can you tell us our altitude, please?
00:24You're at 9,700 feet according to my radar.
00:28But nothing makes sense.
00:30We're in the water. Pull up!
00:34All 70 people on board are killed.
00:38Investigators compare the cockpit voice recording...
00:41We will maintain 10,000 feet.
00:43Set it.
00:4410,000 feet.
00:45...with the flight data recorder...
00:47Captain doesn't realize how close they are to the water.
00:49...and suspect a single faulty sensor
00:51prevented the crew from averting disaster.
00:54It violates the laws of physics.
00:57Airplanes just don't do that.
01:00VD, VD.
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03:03night on the dots what precision like the Suez let's go
03:18the crew is extremely professional they accomplished their checklists and
03:22procedures as what would be expected and they were basically an on-time machine
03:44flight 603 will fly out to the Pacific Ocean before heading south to Santiago the aircraft
03:52is a four-year-old Boeing 757 200 the Boeing 757 is a long narrow-bodied aircraft twin
04:01engine it's simple in its design simple instrumentation and just an overall
04:07comfortable airplane to fly the passengers settle in for the three-and-a-half-hour flight
04:19in the cockpit the first officer spots a potential problem the ultimate is a stop
04:35the pilots also get a wind shear warning the wind shear is an alert that we're entering
04:43into an environment of undesirable winds that could be highly critical in the safety of the aircraft
04:50those type of winds are just very uncommon in that area and we're not forecasted at night at all
04:58flight 603 climbs into the thick clouds above Lima the pilots lose sight of the ground the speed they
05:09now discover another instrument isn't working yeah right flying in the clouds at night without knowing
05:18how fast they're going or their height above the ground the pilots face a potentially dangerous situation
05:26am i climbing am i not climbing am i near mountainous terrain which is very close to the coastal line
05:33of Peru
05:35tower aero peru 603 flight 603 updates the tower controller aero peru 603 tower go ahead
05:43we have no altimeter and no airspeed declaring an emergency
05:52when a pilot declares an emergency with air traffic control the controller is going to give that
05:57aircraft priority handling roger change frequency to 119.7 for further instruction from radar control
06:05switching to 119.7
06:12before contacting radar control the captain takes over from the first officer
06:17okay i have control the captain may decide to take over the flying role and tell the first officer
06:25to talk on the radio and work procedures lima 603 we request vectors for ils runway 15
06:33the pilots request directions for a return to the airport roger we suggest a right turn heading 330
06:41it was a good call to ask air traffic control give us vectors we're so busy up here dealing with
06:46everything else you can certainly help us out if you tell us which direction to turn and guide us back
06:51towards the airport turn right heading 330 a heading of 330 will take the plane north to a position where
07:01it can then make the turn back to Lima but two and a half minutes later aero peru 603 you're
07:10showing level
07:119200 what is your heading now the radar controller notices that flight 603 hasn't turned back towards the
07:22airport
07:23heading 205 we're heading away from the shore affirmative
07:30we will maintain 10,000 feet said it 10,000 feet the captain decides to fly further out to sea
07:37before returning to Lima
07:40they go out over the ocean which is one of the best decisions to possibly do they don't now have
07:46to worry about
07:47other aircraft in the andes mountains in the cabin passengers are unaware of what's happening in the cockpit
08:00safely away from shore according to the radar you're crossing radial 230 from Lima distance west southwest
08:10is 37 miles flight 603 finally starts turning north to begin the approach to Lima and needs to begin its
08:19descent to the airport
08:20I'll try to the same with the power cut
08:30he was going to descend at idle thrust which is a good way to descend it's nice and steady in
08:35a 757
08:36and keeps the airspeed under good control
08:46I cut the engines but speed is increasing even with power to the engines cut the airspeed indicators show that
08:54the plane is accelerating
08:58can you tell us the speed please
08:59I have 320
09:02we have 350
09:06they'll need to use a different strategy to descend
09:12getting to the lower altitude hopefully getting into some clearer areas to see the coastal line could give
09:18them more comfort for a safe landing take the speed brakes out
09:25that is another great way of slowing the aircraft and getting better control of the airspeed
09:34but deploying the speed brakes has the opposite effect
09:41over speed
09:42a new warning tells them they're flying far too fast
09:47the airplane's above its maximum allowable airspeed
09:50it's in danger of breaking apart if they don't do something right now
09:59but I have the speed brakes out and all the power is cut this can be right
10:04what more possibly can be confusing and going wrong right now
10:11seconds later they get a contradictory warning that the planes flying far too slow
10:19the stick shaker indicates to pilots that if the airplane gets any slower it's going to be in a stall
10:25condition
10:28are they going too fast or too slow the pilots must decide which alarm to react to
10:42the captain decides to increase the speed by pitching the nose down silencing the stall warning
10:53but they're not out of danger yet
10:58with conflicting warnings and no reliable airspeed or altitude readings the pilots of flight 603 urgently need help
11:09is there any plane that can take off to rescue us
11:15at this point it was a totally out of the box thought by the first officer to ask for this
11:24type of assistance
11:25which would have given them a visual reference right next to them with altitude airspeed
11:31also communications and we have somebody alongside of us holding our hand to the airport
11:38the plane is now 50 miles from Lima's airport
11:43aero peru 603 you are heading 270 10,000 feet
11:48while they wait for a rescue plane the captain attempts to join the approach path to the runway
11:55I'll try to intercept the ILS and then the scent
11:59Lima aero peru 603 we will try to intercept the ILS
12:03Roger aero peru 603
12:05they think they're flying at a nice safe altitude
12:08and they think that they pretty much have airspeed under control
12:11they probably thought they were in a pretty darn good position
12:17soon after the radar controller provides an update on the escort flight
12:22aero peru 603 there is a 707 about to take off
12:28starting to move now
12:33it seems to be flying well
12:38can you tell us our altitude please
12:40you're at 9700 feet according to my radar
12:519700 feet but we're getting a terrain warning
12:55pull up pull up if he's telling you to pull up
12:59we're here in the water pull up
13:08we're running over
13:2029 minutes after taking off
13:23flight 603 crashes into the pacific ocean
13:2648 miles from Lima Peru
13:36within hours a navy aircraft discovers debris from flight 603
13:44the accident occurred at night and the wave conditions were very high
13:49so the first few ships that went out to look for the wreckage really struggled to find it
13:55heavy fog also hampers recovery efforts
14:14by the end of the first day the bodies of only 13 of the 70 people on board are recovered
14:21there are no signs of survivors
14:27those who haven't been found are believed to be inside the fuselage on the seabed
14:45it's up to air crash investigators from Peru's accident investigation board to find out why a plane last observed flying
14:54nearly 10,000 feet above the sea suddenly crashed into it
15:04we have the military radar
15:05with the underwater wreckage still beyond reach investigators get their first lead from the Peruvian military
15:15any coastal nation will have military radar that's constantly scanning for any approaching aircraft
15:21so by querying the Peruvian military radar we were able to get some data about the altitude and position of
15:30the accident flight
15:31so after taking off they follow the approved flight plan over the ocean and then they start heading north
15:38yeah they're headed back towards lima
15:43the flight climbs to 13,000 feet and then it starts to descend
15:49and now
15:52in the last seven minutes
15:54the flight has a series of erratic climbs and descents before it crashes
15:59it appears they lost control
16:06it becomes just a roller coaster ride of altitudes because they don't have control
16:16what could have caused the pilots to lose control
16:21when you start putting an investigation together you start putting the what-ifs on the table
16:27what if this failed what if that failed what if this went wrong what if the crew made a mistake
16:33pre-takeoff seems okay
16:35investigators scrutinize the communications between air traffic control and the pilots
16:40look at this the crew reported problems with airspeed and altitude readings only two and a half minutes into the
16:46flight
16:48aero peru 603 tower go ahead
16:52we have no altimeters and no airspeed
17:00faulty air data
17:03sounds like an issue with the pitostatic system
17:08the pitostatic system uses tubes and sensors mounted on the plane which measure air pressure to calculate airspeed and altitude
17:19wasn't there a recent crash involving the pitostatic system
17:28only eight months earlier another boeing 757 crashed soon after taking off from puerto plata in the dominican republic
17:37the cause was a blocked pitot tube
17:41some investigators were wondering if we had a similar situation to what we had in bergen air
17:46wasn't entirely the same but it still involved blockage or covering parts of the pitostatic system
17:54maybe that's what happened here
18:06nearly two weeks since aero peru flight 603 crashed into the ocean
18:11a u.s navy ship helps the peruvian navy to track the pings from the boeing 757's two black boxes
18:19the wreckage is finally located at a depth of 680 feet
18:28using remotely operated vehicles investigators finally get their first view of the wreckage site
18:37the records is very concentrated the plane was intact when he hit the water
18:49the fact that all the major pieces of the airplane are in one concentrated area
18:54really gives the investigators a much clearer picture of how the airplane came down
19:00so they either came down in a flat spin or it came down nose first
19:04which is a very unusual accident
19:09there
19:10the black boxes are also located
19:15they're very very critical to get both recorders
19:18first you want to know how the airplane was behaving and then secondly what was going on in the cockpit
19:24between the crew members of the airplane
19:29they are packed in seawater and sent to washington
19:32where the ntsb the national transportation safety board
19:36will process their invaluable data
19:45that's it keep moving that way
19:49the team also searches for evidence of some kind of blockage of the pitot tubes and static ports
19:56there keep going
19:59they focus on a section of the left fuselage where the static ports are located
20:04okay now moving
20:10that's it
20:12the static ports were blocked
20:16they can see that the ports are covered
20:22when we saw that those static ports were covered
20:25it was case closed
20:27drop the curtains
20:28we knew exactly what happened in this accident
20:32how did such a critical device
20:35which determines airspeed and altitude
20:37get covered up and blocked
20:42make sure you tag everything
20:45investigators survey the recovered wreckage of aero peru flight 603
20:50to find out what is covering the static ports
20:56look at that
21:00looks like silver tape
21:02same color as the fuselage
21:09pliers
21:30why were the ports covered with tape
21:33and by whom
21:39it wasn't our job to assign blame or liability
21:43but we wanted to understand the procedure
21:45to make sure that important step of removing the tape
21:48would never get overlooked again
21:54so let's check the last block entry
21:56okay
21:58investigators check maintenance records
22:00to understand why the ports were taped over
22:05interesting
22:06hey
22:08bird strike
22:12during the plane's last landing before the accident
22:16the right engine was struck by birds
22:20they replaced the turbine blades
22:22the hydraulic pump was repaired
22:24and they polished the lower front of the 757
22:29exactly where the static ports are located
22:32did maintenance personnel follow the correct procedures for polishing the 757
22:38when you're performing work on the airplane such as polishing and washing it
22:43it's important not to get any debris into the ports
22:46because when you take off temperatures go down they may freeze in place
22:51which could cause severe instrument problems to the airplane
22:56according to the maintenance manual they're supposed to cover the static ports
23:00so whoever polished the plane covered the static ports with tape and didn't remove it
23:07so why wasn't the tape removed after the area was polished
23:12if you look at the maintenance process on an airplane and cleaning and polishing an airplane is maintenance
23:20there's multiple steps multiple people and multiple looks
23:24the whole purpose of that is to make sure that nothing is missed
23:30were the static ports inspected as part of flight 603's line check
23:37it was a crazy night
23:39investigators interview the line mechanic
23:42to determine if the static ports were inspected after the work was done
23:46the line chief usually does it but he was sick
23:51so
23:53I did it
24:03so
24:04I guess you didn't see the tape then
24:10aluminum tape is pretty common
24:13and if you take it and just spread it over those ports
24:16it blends in perfectly
24:18and it makes it very easy for somebody to miss it
24:23was he adequately trained
24:25I would say the answer to that is no
24:30did you see either pilot do a pre-flight check
24:34yes
24:35the captain
24:38you know if he checked them
24:43couldn't tell you
24:46if I had a new person on my crew
24:48I would tell them to watch the captain
24:50see what he's doing
24:52and it becomes routine for mechanics to watch what the flight crew does
24:57okay
24:58thank you for your time
25:01there's at least one if not two line checks that are done by
25:05supervisors of the line maintenance
25:07and then one of the crew members would do a walk around as they are obligated to do always
25:13so there are several levels where things should have been detected but weren't in this flight
25:23so
25:24both the line mechanic and the pilot missed
25:29investigators now know
25:31that despite all the safety checks that were meant to be performed
25:34no one spotted the silver tape covering the static ports
25:38so we know what caused the faulty air speeds and altitudes
25:42but faulty air data alone doesn't cause a plane to crash
25:46so what did
25:55investigators turned to the cockpit voice recorder from aero peru flight 603
26:01there you go
26:02thank you
26:02to determine how the pilots dealt with faulty air speed and altitude data
26:07pick it up from the takeoff
26:30the plane is barely off the ground when the pilots identify the first problem
26:35the altimeters are stuck
26:37the captain's altimeter
26:39the captain's altimeter
26:40the first officer's altimeter
26:41the standby altimeter
26:43all three sources
26:45were different
26:46and they were all wrong
26:50keep V2 plus 10
26:51V2 plus 10
26:53it's quickly followed by a second issue
26:56the speed
26:58the air speed is also stuck
27:01yeah right
27:02hold on
27:07they were only at 200 feet above the ground
27:09and they already knew that there are problems with altitude and air speed
27:14in three different places in the cockpit they're seeing unreliable air speed and altitude
27:21according to the FDR they're still climbing
27:23let's see how they handle that faulty data
27:29what's going on?
27:30we're not climbing
27:31I'm climbing
27:34investigators hear the captain continue to rely on the faulty data on his altimeter
27:39climb, climb, climb
27:41I am climbing
27:43despite what the first officer tells him
27:46the captain is looking at his altimeter and saying what he sees right in front of him
27:52it's very hard to ignore this false data
27:55the air speed and altitude readings are like a magnet drawing your eye and attention
28:00again and again
28:01climb, climb
28:02I am climbing
28:03so in this initial moments of the climb
28:06it seems like the first officer was more in touch with what the airplane was really doing
28:11what else do the pilots do to handle the situation?
28:13keep playing
28:16let's go to basic instruments
28:19but within a minute the captain stops focusing on the faulty instruments
28:25he decides to use the pitch and power procedure
28:27that's good
28:29very quickly on the captain says basic instruments
28:32I believe he means the pitch and power procedure
28:39the pitch and power procedure requires reducing the pitch angle of the aircraft to 2 degrees nose up
28:46and the throttles to 55%
28:48this should result in level flight
28:52by flying with set pitch and power and ignoring the unreliable air speed and altitude
28:58gives the crew time to sort out what's going on
29:02and think through what might be causing the unreliable indications
29:07then they declare the emergency
29:09pick it up after that
29:10let's see if they did the procedure properly
29:17switching 2, 1, 19.7
29:21auto throttle has its connected
29:23auto throttle has disconnected
29:25but instead of checking his attitude indicator and engine gauges
29:29let's see, read that
29:32the captain focuses on the crew alerting screen
29:35which is displaying more alerts
29:39rudder ratio and max speed trim
29:41the rudder ratio and max speed trim warnings
29:45were just the result of the unreliable air speed and altitude indications in the cockpit
29:49they shouldn't have been the primary focus of the crew
29:54they're getting distracted by false alerts
29:57they ignore the pitching power procedure
30:01we're flying without speed
30:03soon after
30:04speed is zero
30:07all air speed indicators at zero
30:13investigators hear the pilots turning their attention back to the erroneous air speed and altitude readings
30:20the tape on the static ports meant that the air speed and altitude were always wrong
30:27and they were always changing as the airplane climbed and descended
30:32we will maintain 10,000 feet
30:35set it, 10,000 feet
30:37but at no point did they disregard the unreliable air speed and altitude
30:43they looked at them constantly
30:4512,000 feet
30:46the crew never switched their mindset to just using pitch and power
30:53they climbed for several more minutes
30:56but if they were climbing, how did the crew end up hitting the ocean?
31:01they can't keep climbing forever
31:04we have problems reading our instruments
31:06investigators continue listening to the cockpit voice recorder of Aero Peru Flight 603
31:12to determine how the crew carried out the return to Lima with faulty instrument data
31:18set the approach please
31:19I did, I did
31:20then let's go
31:24the captain, he knew he had to, to get down to Lima Airport
31:28I'll try to descend with the power cut
31:31and the way to do that was to reduce the power
31:36no sooner do the pilots cut the power than they face another problem
31:41the speed is increasing
31:44why is the speed so high?
31:46is it the real speed?
31:48that's what worries me, I don't think so
31:52they think they're speeding up
31:54but they can only be slowing down
32:01the pilots don't know whether to believe the faulty airspeed indicator
32:06that's showing they're going too fast
32:08after having pulled their thrust levers back to idle
32:12that'd be totally confusing for the captain
32:15he'd be saying this can't be happening
32:17it's impossible, it violates the laws of physics of aircraft
32:21but the captain's thought process is overtaken by what happens next
32:27overspeed
32:30the faulty airspeed data
32:32is now triggering the overspeed warning
32:35an overspeed warning gets your attention very quickly
32:40and you want to react to it
32:42but this is the time when he should have been questioning
32:45whether that was correct
32:49the first officer makes a split second decision
32:53take the speed brakes out
32:57and now
33:00with the power cut
33:01and the speed brakes out
33:04slows the plane down to the point of stalling
33:07the erroneous overspeed data
33:09leads the pilots to reduce their speed
33:12which puts their plane into a stall
33:26the crew instinctively lowered the nose and increased their actual airspeed
33:31those are the steps that will keep you from stalling the airplane
33:37responding to the stall warning was the right move
33:41but after that
33:45they head further out to sea instead of towards Lima
33:50why would they do that?
33:56shortly after the stall warning ends
34:00a new warning tells them they are dangerously close to terrain
34:06the captain doesn't realize how close they are to the water
34:10on the 757 a radio altimeter measures the plane's altitude when below 2500 feet
34:16and sounds the ground proximity warning when the plane drops too close to the terrain
34:22the ground proximity warning system is separate from the pitostatic system
34:26it was telling them the truth
34:29too low terrain
34:31too low terrain
34:33and now we've induced a terrifying alert of
34:37I'm about to hit a mountain
34:39the pilots thought they were near a mountain
34:41when they were actually approaching the surface of the ocean
34:44too low terrain
34:48let's go left
34:49too low terrain
34:58radar shows you're turning left you're heading to the west
35:03alternative we're heading 250
35:05we're heading out to sea because we have a low terrain warning
35:09too low terrain
35:12he knew that the water
35:15the ocean is to the left
35:17and that's going to be my safe environment
35:19think rate
35:21think rate
35:22no sooner do they deal with the terrain warning
35:25than the pilots are confronted by an alert telling them they are descending too rapidly
35:30think rate
35:32think rate
35:33let's climb let's go up
35:35too low terrain
35:40now going up was the right call
35:42they were descending at 3,000 feet per minute
35:44they climbed to 4,000 feet and they stay there for
35:49approximately one minute
35:56so what led to the final plunge into the sea?
36:00let's go back to lima
36:01i'll try to intercept the ILS
36:03and then the set
36:05after 25 harrowing minutes the captain initiates a turn back to lima
36:11lima aero peru 603 we will try to intercept the ILS
36:16can you tell us our altitude?
36:18is our altitude?
36:199,700 feet
36:21roger aero peru 603 you are showing level at 9,700
36:28but when the terrain warning activates investigators know the plane was below 2,500 feet
36:36they both had the wrong altitude
36:40investigators discover the controller was also providing flight 603 with incorrect altitude information
36:49the assumption was the controllers can tell us our altitude but the flaw in that is that that altitude is
36:55actually being sent to the controller from the aircraft itself
36:59if the information on board the aircraft is incorrect then the information that's being sent to the radar is also
37:06going to be incorrect
37:09investigators speak to the controller to understand why he relayed the faulty readings back to flight 603
37:17so it looks like you were providing the crew with altitude data
37:20yes they said they didn't have any altimeters so I told them what I was seeing on my radar screen
37:27were you using SSR in mode C?
37:30yes that's right
37:31your radar's altitude is coming from the plane's transponder
37:38when the controller confirmed the altitudes for the pilots I think it gave them a false sense of hope that
37:45at least one of our problems has been solved
37:47the altitude problem when in fact that was tragically incorrect
37:57but even with the faulty altitude readings could the pilots still have landed their planes safely?
38:11pick it up during their final descent
38:13pick it up during their final descent
38:13to determine if the pilots had any other options to save their plane
38:18investigators listen to the final moments of Aero Peru flight 603
38:24it seems to be flying well
38:27can you tell us our altitude?
38:28you're at 9700 feet according to my radar
38:32too low, terrain
38:33too low, terrain
38:359700 feet but we're getting a terrain warning
38:38too low, terrain
38:39the crew can't understand the conflicting information
38:43too low, terrain
38:44but there was a way for the pilots to determine their actual altitude and save the plane
38:50too low, terrain
38:56too low, terrain
38:58too low, terrain
38:58when the ground proximity warning system activated in the cockpit
39:01the crew could have referred to the radio altimeter
39:05and that would have given them the truth data about how high they were above the ground
39:09too low, terrain
39:14too low, terrain
39:25terrain
39:26we're hitting the water
39:28up, terrain
39:30when an aircraft
39:31has its wing touch the water
39:34in a bank attitude
39:36the situation is hopeless
39:39pull up, terrain
39:40pull up, terrain
39:42pull up, terrain
39:44terrain
39:46pull up, terrain
39:47the pilots try to get the plane back in the air
39:50pull up
39:53but the plane banks left
39:55and falls back towards the sea
39:57we're running over
40:00terrain
40:03terrain
40:03terrain
40:04terrain
40:11they really had no idea how low they were
40:14and all those alarms fall so real just
40:17made matters worse
40:29the situation in the cockpit was so confusing
40:35it was hard for either crew member to understand which cautions and warnings were true and important
40:41and there didn't seem to be a good balance between the two crew members in sorting that out
40:48for investigators there's one final unanswered question
40:53were the pilots properly prepared to handle an emergency like this?
40:58they examine the quick reference handbook which provides guidance in emergency situations
41:04as well as Aero Peru's training procedures
41:14not one single word on how to handle erroneous air data
41:21the lack of training worked against them
41:26a big takeaway from this accident was that flight crews need to be better trained to get to pitch and
41:32power in the event of unreliable air speed and altitude
41:40investigators needed only two months to solve the mystery of flight 603
41:45they now know that blocked static ports
41:49the ultimate resistance
41:50the ultimate resistance
41:51created faulty air data readings
41:55over speed
41:56and those faulty readings created so much confusion in the cockpit
42:01but I have the speed brakes out
42:03and all the power is cut
42:04that can be right
42:05that the overwhelmed crew was unable to separate the false alarms from the true ones
42:14they really needed to develop a laser focus on just flying the airplane
42:19but they never got there
42:22the captain's failure to react to the ground proximity warnings in time
42:27he's telling you to pull up
42:29we're hitting the water
42:31pull up
42:34contributed to the death of 70 people
42:53there's nothing highly technical about tape
42:56but boy did it start a chain of events
43:02the investigations report outlines a number of recommendations
43:07but chief among them is for more training to ensure crews know how to deal with inaccurate air data
43:15and implementing the use of eye-catching static port covers while a plane is being maintained
43:23remember it's the simple things
43:26that cause problems
43:28and we need to keep that in everybody's mind
43:31attention to detail
43:33if you perform that detail
43:35whatever it is
43:37you're not going to get
43:39problems
43:43this accident was one of the pillars of safety procedures
43:51our training changed
43:53our pre-flight procedures changed
43:55our attention to details changed
43:58and it still lives to this day
44:05our interest was 1 c.m.
44:27the sea for the sea for the stars
44:28we sebenars
44:28and we are going to get some details
44:28and we'll see you tomorrow
44:28next week
44:29we will see the stormes, next week
44:29of the sea
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