- vor 10 Minuten
On 6 March 2003, the left engine of Air Algérie Flight 6289 fails during takeoff from Aguenar – Hadj Bey Akhamok Airport in Tamanrasset, Algeria. The aircraft enters a stall and crashes into a desert near the Trans-Sahara Highway, killing all but 1 of the 103 occupants on board.
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00:03As Air Al-Jarif Flight 6289 lifts off from Taman Rasset, Algeria,
00:10Air traffic controllers hear an explosion.
00:20The plane crashes into the desert.
00:23102 people are killed.
00:27Investigators examine engine debris found on the runway.
00:31Looks like there's a fatigue crack in the nozzle guideway.
00:34They know an engine failed, but not why the pilots couldn't recover.
00:39Pilots are expected to fly out of a situation either on takeoff or landing where they've lost an engine.
00:45The investigation reveals a crew that was struggling, not with the plane.
00:49Let go, take your hand away. I let go, I let go.
00:52But with each other.
00:53Which one of them is actually flying the plane?
00:57BD BD BD
01:18it's early afternoon in the middle of the sahara desert in algeria the crew of flight 6289
01:24readies for its upcoming journey at the remote tamaracid aguinar airport
01:34seatbelts seatbelts there are 97 passengers on board among them members of the local football
01:41team headed to a tournament and military personnel seatbelt seatbelts though there
01:47are some european nationals almost everyone on board is algerian
02:01another instrument transfer switches
02:06normal in the cockpit pre-flight checks are underway your damper
02:16on today's flight is operated by air algeri a state-owned national carrier air algeri is a
02:23publicly owned company that is owned by the country of algeria the country takes a lot of pride in
02:30this particular airline because it is the face name of the country as it goes all around the world
02:43the wind is calm temperature 23 q and h 1020 qfe 965. copied we'll call you back for engine start
02:5544 year old fatima yousfi is the first officer of this flight she is algeria's first female commercial
03:02pilot the female first officer was one of the first women to be hired at in an airline in algeria
03:11which would be a big deal in such a male-dominated field especially in that country
03:17as the first woman to pilot a boeing 747 trans-oceanic flight lynn ripple myer knows what it's like to
03:24blaze a trail
03:28aviation was then and still is in some cases of a boys club back in the beginning of when women
03:37were
03:38initially beginning in aviation here in the states maybe it's like it was for her that it was unusual
03:50time and i said 62 89 we request clearance for kardaya received we will call you back
04:01hey we've got some tamaracid football players back there oh tell them we're rooting for them this
04:07weekend 48 year old captain bualem benawicha has over 10 000 flying hours a thousand of those hours are on
04:15the boeing 737 the captain was highly experienced had been flying for over 20 years and then flown
04:22all kinds of aircraft from small aircraft to large jetliners 62 89 tamaracid start approved callback for
04:31taxi roger at 3 pm the pilots get clearance to start up the engines okay before start checklist fuel
04:43quantity 9800 kg pumps on flight 6289 is a boeing 737 200 an early generation of the popular twin engine
05:00jetliner the boeing 737 is one of the most common types of commercial airliners in the world and there
05:09are different variations of it the boeing 737 200 is a original version of the 737 so it's an older
05:18model
05:18and it's not as highly sophisticated in technology as current 737s
05:28flight 6289 will be departing from taman rasset with a scheduled stop in gardaia and then on to the capital
05:36algiers the total flying time is approximately three hours
05:47that is taxi air algeri 6289 6289 tamaracid taxi onto runway 02 and backtrack wind 030 at 10 knots
06:00and then backtracking 6289
06:06as they taxi to the runway passengers settle in for the journey
06:22we are ready
06:24we are ready 6289
06:276289 tamaracid cleared for takeoff runway 02 wind 330 at 12 knots
06:366289
06:46you have 90 knots 100 knots
07:026289
07:04v1 rotate
07:11but seconds after takeoff
07:14gear up
07:16a loud explosion rocks the airplane
07:24bismillah what's going on
07:26the pilots assess the situation
07:29let's go let go
07:30i let go i let go
07:34passengers sense something has gone wrong
07:38we have a small problem
07:40we have a small problem 6289
07:406289
07:42the 737 is approaching a stall
07:566289 are you in emergency
08:10the pilots make desperate attempts to recover the aircraft
08:15but their efforts are in vain
08:18the plane goes into a free fall
08:21the passengers brace themselves
08:32the plane bursts into flames and skids across the desert just outside tamaracid airport
08:41emergency response is immediately activated and firefighters rush to the scene
08:53the impact and fire that ensued afterwards made survival very unlikely for the passengers in the aircraft
09:02but then against all odds rescuers discover a survivor
09:07not within the wreckage but lying in the distant sand clinging to life
09:12a gentleman seated all the way in the back
09:15that didn't have a seat belt on so when the airplane crashed and broke apart he was thrown free
09:21he shows only faint signs of life as an ambulance rushes him to hospital in critical condition
09:29defying all expectations the man's condition soon stabilizes and he begins to recover
09:35this passenger's luck cannot be overstated in what was
09:38algeria's worst aviation accident at the time
09:43he is the sole survivor out of 103 passengers and crew
09:49while the country mourns the tragic loss of a football squad
09:54algerian and french families grieve their loved ones and soon demand answers
10:03the investigation into the crash of flight 6289 is conducted by a commission of inquiry established by the algerian ministry
10:13of transport
10:15they receive support from several international agencies including the ntsb america's national transportation safety board
10:24i was the u.s accredited representative for this accident to assist the algerians initially
10:29i wasn't going to travel to the scene however the u.s ambassador to algeria requested our assistance
10:38while algerian investigators await the arrival of their american colleagues they interview the taman rasset air traffic controller
10:48did the pilots indicate that there was an issue the first officer called only seconds after takeoff
10:59we have a small problem 6289
11:02pilots typically are hesitant to call mayday mayday or announce some type of emergency particularly if they
11:11really don't know what the situation and the critical nature of the situation is and what was the problem
11:19they didn't say but i heard something that sounded like an explosion seconds later the plane was falling
11:28out of the sky you said an explosion that's what it sounded like like a bomb
11:44so in 2003 algeria was not the safest place there was bombings and terrorist activities because they
11:51were coming out of 11 years of civil war
11:56when the plane fell was it in one piece yes it was investigators found the airplane intact there are
12:04no claims of responsibility by terrorists so it pretty much ruled out that there was some type of
12:10nefarious means to bring the aircraft down can you describe how the plane fell it was nose up and crashed
12:22near the threshold of runway 20. the controller and other witnesses saw that the airplane was struggling
12:30to climb had a nose high pitch attitude and then impact the ground eyewitnesses recall that the plane struggled
12:39to gain enough lift to remain airborne an indication it was in a stall
12:45one week after the incident algerian investigators are joined by a member of the ntsb
12:55air traffic controller and witnesses described seeing a storm and one witness remarked that the landing gear
13:01was down if the landing gear is still down while the aircraft is trying to climb it creates a lot
13:09of drag
13:09on that airplane it takes a lot of thrust and a lot of power to maintain the climb to overcome
13:15all that drag
13:16from the landing gear that would affect a plane's ability to climb but that alone wouldn't cause a
13:23stall that has to have been something else to the load sheets yes right here
13:30one of the big questions is about the aircraft weight because if you're too heavy you won't climb
13:35as well as if you're within the weight envelope investigators review the plane's load sheet
13:41to see if the plane was overweight before takeoff looks like the first officer made some corrections
13:47here while reviewing the load sheet the first officer notices the fuel weight is wrong and changes it
13:55from 8800 kilograms to the correct amount of 9800 kilograms
14:06so with those corrections the way to take off would have been 48 708 kilograms and the maximum weight
14:13allowed at takeoff would be 49 500 kilograms the first officer noticed that there was a thousand kilo
14:21difference and uh passenger count was a little bit off which didn't make a whole lot of difference in the
14:26overall weight and balance but did show that she was very attentive in her duties the aircraft weight
14:33was right up against the maximum takeoff weight even though it was heavy the aircraft weight shouldn't
14:38have affected the performance too much what mechanical failure i'll get the maintenance reports
14:48investigators make sure that the maintenance is clean and the aircraft has a clean bill of health prior to
14:53the flight it was up to date in its maintenance cycle no work deferred no technical exemptions the
15:04maintenance reports provide no leads maybe there was an environmental factor at play take a look at this
15:14the location of the location of the airport have something to do with the stall
15:20temperature is 23 degrees celsius so it's hot
15:24tamaraset is in a harsh desert climate and the high temperatures can affect the aircraft performance and climb
15:31and the airport sits at 4518 feet above sea level
15:35at this altitude the air is already thin if you factor in the heat it's high density altitude that
15:44affects the performance of the airplane so it's generating much less lift over the wings so it takes
15:49longer to get the airplane airborne so just a few pounds below max takeoff weight high elevation airport
15:57high temperature landing gear extended that could definitely cause a plane to stall
16:02but that doesn't explain the explosion right what are we missing
16:14investigators study the crash site of flight 6289 for evidence that could explain the explosion heard
16:21seconds after takeoff so the first point of impact is here
16:315396 feet from the takeoff point skidded through the airport perimeter fence across the road and came to rest
16:38here less than 300 feet outside of the airport
16:51plane's destroyed by the fire the main wreckage is practically in one piece except for the rear section
16:57and look at this debris this was on the runway right about here
17:04engine debris
17:08on the runway we found a large quantity of engine debris which is indicative of an engine shelling
17:13when a large quantity of engine blades are thrown out the back end of an engine
17:20it's an old adage in accident investigation what fails first falls first
17:27so if they find debris prior to finding the wreckage then they know that happened prior to the accident
17:33so one of the engines blew out that must have been the explosion the controller hurt
17:39what caused the engine failure we needed to get our eyes on those engines to determine which
17:46failed and why it failed investigators begin a visual inspection of the plane's engines
17:52starting with the right one take a look at the family
17:58heavy deformation
18:00it was definitely rotating at the time of impact
18:04on the right engine we showed that it was turning at impact we don't know what exactly what level of
18:09thrust it was rotating at
18:13if the right engine was operating on impact then did the left engine fail
18:23these turbine blades have far fewer deformations than the right engine looks like it was barely moving
18:29the hot section is completely torn apart
18:33in an engine's hot section fuel is ignited in a combustion chamber generating a powerful stream of hot air
18:41that spins the turbine blades
18:45the damage is evidence that the left engine failed
18:49we knew that the failure was in the hot section so we had to follow
18:52every lead that we could to determine where the failure occurred
19:02there's a bunch of blades missing from the hot section
19:05the missing pieces are most likely the debris that we found on the runway
19:10we found that the hot section was basically corncobbed as we say there was
19:15not many blades left in the hot section and there is metal all over the place what caused the blades
19:22to break
19:23let's get some of these parts out on the table and we wanted to further tear down the engine we
19:29wanted to look at the failures under the microscope we're going to look at the metallurgical aspects
19:33of the failure we wanted to look to see if there was a bird strike
19:37investigators begin by examining components from the hot section in search of pre-existing defects
19:46managed to remove the sediment from the nozzle vein
19:53nozzle guide vanes direct the hot air flow in the combustion chamber to the blades of the high
19:59pressure turbine causing them to spin
20:07interesting
20:21looks like there's a fatigue crack in the nozzle guide vein
20:26investigators find evidence of fatigue cracks in two of the left engine's nozzle guide vanes
20:33this type of cracking occurs over time and as the engine ages these cracks get slightly larger and
20:39and eventually they will fail and it will destroy the entire engine
20:45if this was a progressive failure why wasn't it caught earlier
20:51this type of cracking is typical of an older engine and it's a progressive failure
20:55so that gets us into the question of what was the maintenance history what was the inspection
20:59criteria that was used by the operator investigators look into the engine's repair history
21:08it looks like the left engine was completely overhauled four years ago
21:13when would have been the last time they looked at the nozzle guide veins
21:15during the hot section maintenance inspection which was last year any mention of cracking any work done
21:23on there either inspections of the hot section are meant to catch fatigue cracks
21:30so why weren't these found since this was an algerian registered aircraft it falls under the authority
21:36of the algerian civil aviation authority for oversight of the inspection not the fa which typically
21:43has more stringent requirements the crack formed at some point it was missed during the inspection last
21:50year it grew and grew until point of failure and then blew out at takeoff that explains why the engine
21:56failed
21:57not why the plane stalled pilots are expected to demonstrate their ability
22:03to fly out of a situation either on takeoff or landing where they've lost an engine
22:10investigators examine the crew's training records to determine if they knew how to handle a single engine
22:16failure on takeoff the first officer's last exercise in engine failure during takeoff was four months ago
22:24the captain's training was even more recent only two months before the crash they both should have
22:29known what to do in this situation they've got the airplane veering to the left there's no way they
22:38they didn't know that engine failed so what did they actually do
22:47investigators prepare to listen to the cockpit voice recorder from air algeri flight 6289
22:55it was very important for us to listen to the cvr to determine how the pilots dealt with this
22:59engine failure got it queued up to right before i take off
23:07v1 rotate
23:19they hear the sound of the engine failing five seconds after takeoff
23:25bismillah what's going on let go let go i let go i let go
23:35they transferred control in the middle of an emergency that didn't even sound like a proper
23:39transfer he just took the controls for another pilot to take control from the pilot who is flying the
23:48pilot needs to say i've got it taking control of the airplane without saying he was taking control
23:53made things worse for him and for the first officer the captain is the pilot monitoring he shouldn't be
23:59taking over he should be diagnosing the problem so to either of them identify a left engine failure
24:08after handing over control to the captain the first officer realizes they aren't properly
24:13configured to climb with only one engine get up or are we okay but there's no response from the captain
24:24we have a small problem 6289 6289
24:30just seconds after the engine failure the situation deteriorates as the plane begins to stall
24:42there are no attempts by the pilots to work together to identify or troubleshoot the problem
24:48let go take your hand away i let go i let go let go take your hand away let go
24:53don't think
24:55seconds later the ground proximity warning activates indicating the plane is getting dangerously close to the
25:03ground please take your hand away both pilots really didn't know what the other was doing didn't
25:10know what the other expected of them and may well have been working at cross purposes and as a result
25:16of that the team performance broke down don't think don't think
25:23it's going to be a good thing to do and it's going to be a good thing to do and
25:27i don't hear a single
25:28mention of engine failure and why was he telling her to let go so many times was she trying to
25:32take
25:33back control of the plane which one of them is actually flying the plane when all is said and done
25:38the pilots did not work together without more information from the flight data recorder we really
25:44don't know exactly what they did to control the airplane investigators turned to the flight data
25:50recorder or fdr from flight 6289 to determine how the pilots tried to recover from the loss of the
25:57left engine flight data recorders are important to investigators because it gives them information
26:03on how the pilots were operating the airplane and how they were managing the critical situation they
26:10were in not much here older plane older fdr it doesn't actually tell us how the pilots were handling
26:19the engine failure because we only had five parameters on the fdr we had to go to boeing and
26:26ask for a detailed aircraft performance analysis to determine what happened on this accident flight
26:35using the fdr's limited data boeing's performance study includes a reconstruction of engine operations
26:42and flight controls in the final moments of the flight
26:47so there is the left engine losing its thrust after it blows out that's odd the data from the fully
26:56functioning right engine shows something unexpected look at the thrust from the right engine yes it seems
27:04to be going up and down but we know it was working fine that can only mean one thing
27:13bismillah what's going on the team finds evidence of thrust being added to the right engine
27:21let's go let go and then pulled back i let go i let go when one engine fails what you
27:29need is maximum power
27:30on the other engine not reduce it so thrust is pulled down then back up then down then back up
27:40again
27:42we have a small problem we have a small problem 6289 6289 come at last
27:51let's go
27:54this is as if they were having some sort of a tug of war it shouldn't have been first officer
28:01did the
28:01right thing by increasing the power of the right engine what likely happened is that the captain
28:07wasn't fully aware of which engine had failed however the first officer knew that the the left
28:12engine had failed and was trying to push up the throttle on the right engine to keep them from stalling
28:21let's go take your hand away i let go i let go let's go take your hand away let's go
28:25i let go
28:26don't think don't think the captain's basically telling the first officer to get out of his way to
28:35leave him alone to let him be in charge of the airplane by himself which he was knowing that the
28:43left engine had failed the first officer might have been trying to help things out by increasing
28:47the power on the right engine please take your hand away
28:56the moment the captain reduced the thrust on the right engine and never returned it to takeoff thrust
29:02with the gear down it doomed the flight
29:07pilots should have been able to work together to recover the plane
29:11these planes are designed to fly with a team
29:14pilot flying pilot not flying both have very specific roles that they are trained to do but
29:22especially in emergencies they stay in their roles they help each other they work as a team
29:27and this crash could have been avoided if they would have done that
29:32why didn't the crew of air algeri flight 6289 work together to prevent the loss of 102 lives
29:42okay i'll queue it up to the pre-flight preparations
29:48investigators return to the cockpit voice recording of flight 6289
29:52to understand why there was a lack of coordination between the two pilots
29:59northern instrument transfer switches normal your damper on
30:08they listen as the first officer works through the pre-flight checklist they're surprised by what they
30:14don't hear
30:17where's the captain is she doing the flight preparation by herself
30:23authorization mode selector auto okay flight instruments
30:30we found that the first officer was actually in the cockpit by herself conducting most of the pre-flight
30:35work without the captain
30:40it's unusual for the captain not to be present during the pre-flight because there are responsibilities
30:46that the captain has to get his side of the airplane ready it's just inappropriate for the captain not to
30:52be in the cockpit during the pre-flight and it's actually kind of rude it's only after the first
31:00officer completes the pre-flight preparations that the captain enters the cockpit 1019 roger
31:09good afternoon captain how are we looking um good i completed the pre-flight checklist i tested your
31:16oxygen and everything is set to go good captain ben weisha is late leaving his responsibilities to the
31:26first officer when the captain showed up he was not in the mindset of getting brought up to speed or
31:32being part of the team of setting the cockpit up for the flight
31:39heading zero two zero altitude investigators then hear the pilots performing their before start
31:48checklist 280 you know i could have been on the team with those boys back there give me a break
31:55who's the third voice flight attendant
32:00the only male flight attendant is the chief flight attendant
32:06okay takeoff speeds as part of the checklist the first officer reviews the takeoff speeds
32:15v1 144 knots vr 146 not saying you were good enough to turn pro yeah i was a good footy
32:24blair
32:25you wanted a scout come watch me blair yeah they were scouting you to mow the pitch
32:30um v2 150 knots okay that's enough i understand can we go i got it i got it let's go
32:43so the captain is just carrying on a conversation with his friend
32:46while they're doing their before start checklist what is even worse is he cuts her off before they
32:50could even finish it one of the most important parts of the information that she was trying to
32:57give were the takeoff speeds and then there should have been a briefing of an engine failure departure
33:06at this airport that was a special departure that needed to be briefed it was ignored
33:13did the captain become more focused once they began to taxi
33:17roger taxing for runway at zero two what investigators find most shocking is what they hear next
33:30where are we eating tonight that place across from the hotel oh you always go back to the same place
33:37i like what i like we are now cheers plenty of good spots to eat they are completely distracted
33:45they're violating every sterile cockpit rule during critical phases of flight extraneous conversations
33:52and non-essential conversations between the crew members are prohibited not only is the captain
33:57dismissing the first officer he has this casual attitude about basic safety practices it's possible
34:04he was more interested in talking to the flight attendant than reviewing the briefing with the first
34:09officer it's possible that he had been through so many pre-flight takeoff briefings that at that time he
34:15felt it was unnecessary as a result of his dismissive attitude the captain is unprepared to properly respond
34:33when the crisis occurs shortly after takeoff
34:40had the pilots completed their pre-flight safety briefing
34:43their response to the engine failure might have been very different
34:53gear up
34:58engine failure left engine fly v2 plus 25
35:02lowering the nose to 12 degrees
35:08once the plane was stabilized the pilots could have returned safely to the airport
35:14engine failure is actually a relatively common occurrence every pilot needs to be prepared
35:19and trained so instead of letting the first officer fly the plane while he diagnoses the issue
35:25he tries to do everything himself and transferring control during an emergency situation
35:31there was never a positive transfer of control the captain just took the control yoke away from
35:37the first officer so he injected himself in the emergency
35:46let's go let go i let go i let go
35:49the captain took control at the worst possible time when he was out of the loop and by not assigning
35:56responsibility to her he gave himself the responsibility of doing two things at once
36:00diagnosing the nature of the engine problem and then flying the airplane
36:07please by trying to fly the plane and diagnose the problem on his own the captain took on too much
36:15it put the first officer in a very difficult position she's now in the supportive role the non-flying
36:23role waiting to be told what to do and he's not giving any helpful orders other than let go
36:33why would an experienced captain so brazenly dismiss his first officer's help
36:39risking the lives of everyone on board
36:46investigators look into the pilot's backgrounds in an attempt to understand why the captain took over
36:52from his first officer in the midst of an emergency so the captain actually had twice as many flying
36:58hours as the first officer the captain was both qualified as a captain on a 737 but also as a
37:05first
37:05officer on a 767 perhaps his attitude was that flying the 737 was not that big of a deal because
37:13i fly a 767 which is much more sophisticated and highly technical but she had more hours on the 737
37:22not only did she have more experience flying the 737 that's the only plane that she was flying
37:28i think there's a good chance that had she been left alone she would have flown the airplane out of
37:34the
37:34scenario that we saw in this accident the question is would he have reacted the same way if the first
37:40officer was a man in 2003 at the time of this crash here in the states female airline pilots only
37:49constituted less than six percent of the pilot population and it really hasn't changed that much
37:54in the 20 years since then the first officer was algeria's first female commercial airline pilot
38:03my friend male pilots in this part of the world aren't used to sharing a cockpit with women
38:12i think algeria is becoming fairly westernized but in some cultures there is the feeling that a man has
38:18be up in the cockpit in case anything goes wrong why did this captain take control from the first
38:24officer when she was doing an okay job at that point and i think you can't rule out the possibility
38:30that there may have been some uh gender stereotyping on his part that played a role in it sadly this
38:38accident was totally preventable
38:46of what led to the crash of flight 6289 v1 144 knots vr 146 knots you were good enough to
38:59turn pro
38:59after arriving late and allowing the flight attendant into the cockpit the captain interrupted a crucial
39:05pre-flight safety briefing um v2 150 knots okay that's enough i understand can we go i got it i
39:15got
39:15it let's go the captain demonstrated a lax attitude towards cockpit protocols
39:22fatigue cracks in a nozzle guide vane in the plane's left engine were reaching their braking point and when
39:29the guide vane failed it set off a chain reaction high speed metal fragments ripped the engine apart
39:39let's go let go i let go i let go when crisis struck the captain decided he needed to be
39:45the one to
39:46handle the controls and took over flying from his first officer before even identifying the problem
39:53the engine failure alone was not the cause of this accident engines fail and pilots are trained to
39:59handle those emergencies failing to retract the landing gear after the engine failure made recovery more
40:08difficult let go take your hand away i let go i let go let go take your hand away let
40:13go
40:21it was captain's assumption of patrol of the aircraft without properly identifying the nature of the
40:27emergency his failure to raise the landing gear and his lack of adherence to standard operating procedures
40:34that eventually doomed the flight as a result of this accident algeria's commission of inquiry makes
40:43several recommendations they recommend that air algeri along with other operators ensure that their crew
40:51resource management training programs emphasize the importance of handover procedures and task sharing
40:58in the cockpit but in the 1980s they had captains who were trying to fly a team airplane solo
41:07so a lot of training went into it to teach that your best resource is your team you support each
41:13other
41:13and work together and work together as a team for the safety of the airplane the fact that the captain
41:20insisted on taking over control of the airplane at that critical moment
41:25cost everybody on that airplane their lives
41:30i felt particularly affected when i saw that the accident was preventable and i think the investigators
41:37did the best job they could trying to discover why the crew made the errors that they did the next
41:42time
41:42that happens people won't die as a result of that for lynn rippelmeyer it's one more example of why the
41:50industry needs to continue evolving the airlines now are much more open to hiring women to not having gender
42:00bias realizing that women do have a lot to contribute to the industry and i think it's up to women
42:08now to
42:08step up to the plate and take the opportunities that the career offers they're amazing