#video #Mayday S26E08 Episode 8 Engsub
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00:02While a passenger live-streams an approach into Pokhara Airport in Nepal...
00:07The plan is to go paragliding with my buddies!
00:15Add power!
00:18Yeti Flight 691 falls from the sky.
00:24What's happening?
00:3072 people are killed.
00:34This was the deadliest crash involving Nepali Airlines ever.
00:43Eyewitness video gives investigators their first lead.
00:47That's at least an 80-degree left bank.
00:53When they analyze the flight data...
00:56Wow!
00:57They're shocked to discover the engines weren't generating power.
01:02No power!
01:03Torque indication zero!
01:05There should have been warning lights.
01:07Why didn't they figure it out?
01:09You start to question what was going on in the cockpit.
01:12Do not know if they knew about it.
01:13One!
01:14Two!
01:18Three!
01:20One!
01:22One!
01:23Two!
01:23Two!
01:24One!
01:24Two!
01:25Two!
01:26Two!
01:27Two!
01:28One!
01:28Two!
01:34One!
01:38Yeti Airlines Flight 691 flies south of the Himalayan mountains in Nepal.
01:49There are 68 passengers on board, including Sonu Jaiswal, a tourist from India, heading
01:57to Pokhara to paraglide with friends.
02:03Pokhara, Yeti 691, descending through 12,500 feet.
02:10Captain Kamal Casey is the senior officer and the pilot monitoring instruments on today's
02:16flight.
02:17Roger, Yeti 691, 12,500 feet.
02:22He's also a veteran of more than 21,000 flying hours.
02:29We had absolutely the utmost respect for Captain Kamal Casey, as he was a veteran in the Nepalese
02:38skies.
02:38And he was quite a humble and knowledgeable guy as well.
02:44It's very clear, we'll be good for visual landing.
02:49Flying the plane from the left-hand seat is Captain Anju Katawada.
02:54She's flown more than 6,000 hours.
02:59Captain Katawada has a very special history.
03:02Her husband, he was a pilot with the same company.
03:05He was a first officer on the twin motor and it crashed and he died some years earlier.
03:12Katawada decided to take up flying to honor his spirit.
03:17So she become a pilot.
03:208,500 feet.
03:22While Captain Katawada is an experienced commercial pilot, she has only 186 hours on the ATR-72.
03:40The ATR-72 is a turboprop twin-engine aircraft.
03:46It's a high-wing aircraft.
03:49It's a very stable, predictable and logical aircraft.
03:53And it's very good to fly here in the mountains and hilly regions of Nepal.
04:02Today's flight is a short 25-minute hop from Kathmandu to the tourist city of Pokhara.
04:13Yeti 691, expect to land on 1-2.
04:17Broadway 1-2, Yeti 691.
04:2115 miles from the airport, Yeti flight 691 is cleared for the approach.
04:29Hey everyone, exciting times as we're headed to Pokhara's new airport.
04:33Sonu Jaiswal is live streaming from the cabin.
04:37The plan is to go paragliding in the Himalayan foothills with my buddies.
04:463, 1, 0.
04:48Captain Katawada programs a heading for the approach to runway 1-2.
04:57You are in between the runway and the mountains.
05:01So you need to be very, very precise with your handling skills of the aircraft.
05:10Okay, visual, visual.
05:12Okay, visual.
05:14The pilots monitor their position carefully, keeping the plane clear of the mountains.
05:23Yeti Airline 691 in sight, report final runway 1-2.
05:28Call you on final for runway 1-2, Yeti Airlines 691.
05:36Gear down.
05:40Less than two minutes from the airport, the pilots configure the plane for landing.
05:46Okay, from here you can go manual.
05:49Okay, stand by.
05:53Okay.
05:54Disconnect.
05:56Captain Katawada disconnects the autopilot, then begins the first of two crucial turns to line up with the runway.
06:12Okay, flaps 30.
06:15Flaps 30.
06:16Flaps 30.
06:18Continue descent.
06:20Okay.
06:24One minute from touchdown, the pilots run through the pre-landing checklist.
06:29Okay, landing gear.
06:31Down three green.
06:33Flaps?
06:3430.
06:38In the cabin, Sonu Jaiswal continues live streaming.
06:43We're getting pretty close now.
06:48As the flight gets closer to the ground, the landing seems trouble-free.
06:59But seconds from the runway, Captain KC realizes there's a critical problem with the engines.
07:06There's no power.
07:09There's no power.
07:12When there's no power, that means they have very limited time at that altitude.
07:18They need to react quickly.
07:21Not power.
07:24Captain Katawada tries to power up, but the engines aren't producing any thrust.
07:31400 feet above the ground, the pilots face a critical situation.
07:40In the tower, the controller doesn't know that Flight 691 is in any trouble.
07:45Yeti 691, runway 12.
07:49Clear to land.
07:51There's no power.
07:52No power.
07:53Add power.
07:58Captain Katawada pushes the throttles to the limit.
08:05There's no torque.
08:06Okay, give it to me.
08:09The more senior captain takes control.
08:1980691.
08:23200.
08:2580691.
08:26Flight 691 is stalling.
08:36While Sonu Jaiswal live streams the unfolding disaster.
08:44What's happening?
08:59What's happening?
09:21Yeti Flight 691 has crashed in one of the worst possible places.
09:27The Shethi River runs near to the airport through a huge gorge.
09:33That's where the plane crashed.
09:38The plane was completely destroyed in the impact.
09:43There was a huge flame burning.
09:48There was no possibility to find any survivor.
09:56The bodies of 71 of the 72 passengers and crew are eventually found and identified, including
10:04both pilots.
10:07One of the two pilots.
10:15What could have caused a commercial airliner to drop out of the sky just seconds before landing?
10:30Yeti Flight 691.
10:31When investigators arrive at the crash site of Yeti Flight 691, they face a devastating scene.
10:41The wreckage was scattered all over the place.
10:46The first impact was before the river, where the parts of the left wing was detached.
10:52Some parts were located on the bottom of the river, the rest of the parts were at the side of
10:57the river.
11:05Under the supervision of Nepali investigators, the wreckage, along with the black boxes and
11:11central processing card from the plane's computer, are sent for analysis to labs in France and Singapore.
11:20It's really not uncommon in an accident investigation to have to send something out for closer investigation.
11:35Nepali investigators wonder about Flight 691's orientation when it hit the ground.
11:42Looks like this is from the first point of impact.
11:47That's a flap from the left wing and an aileron tip.
11:53So the left wing must have hit the ground first.
12:00The plane crashes wing down.
12:02What that suggests to investigators is that the plane crashed out of control.
12:08You would never intend to have it be that way.
12:10You'd always try and level it out and crash as close to a regular attitude as you can.
12:16Maybe the plane stalled.
12:20You may be right.
12:22Check this out.
12:30It's gone viral.
12:38A witness had filmed the plane during the final moment of the flight.
12:43It appears that the left wing lost lift and dipped severely.
12:50That's at least an 80 degree left bank.
12:59It sure looks like a stall to me.
13:06When you see evidence that looks like a stall, you immediately start questioning what could
13:11have led to that and you go back to what's going on during that approach.
13:23This is not an easy approach.
13:26They'd have to fly between the runway and the mountain and make two left turns before lining
13:32up with runway 12.
13:34And this is where the plane crashed.
13:38And just before the crash, they were beginning their final left turn.
13:43Did the pilots bank too far during one of the turns and stall?
13:50They would have had to go from zero to an 80 degree bank in a few seconds.
13:58It suggests there was a problem with the plane.
14:05You might want to focus and see if there's any smoking guns in the maintenance records.
14:09If there was anything wrong that somebody knew about, maybe they tried to fix it and it
14:14didn't get fixed.
14:17I've got maintenance records.
14:25Investigators go through the plane's records in search of any gaps in maintenance or inspections.
14:34I'm not seeing anything.
14:37Everything checks out.
14:40Maybe the controller knows something.
14:44Yeah.
14:46The air traffic controller may have heard something in their conversation with the pilots.
14:51Picked up something that isn't really evident from the tape.
14:58Did you have visual contact with the aircraft?
15:05Did you see or hear anything suggesting a problem with the plane?
15:10No, I was flying normally when I had visuals with it.
15:13It was just out of sight before the crash.
15:18Then I heard it.
15:22The explosion.
15:41Did the pilots say anything suggesting the problem with the plane?
15:45Nope.
15:46Not much.
15:49Not much.
15:50Okay.
15:53So, do you know what happened?
16:00Not yet.
16:08in the early stages you'd want to look at anything witnesses might have to say anybody
16:13who might have seen heard or otherwise noticed the crash the controller offers little insight
16:21into why the plane stall then a witness to the accident comes forward there that's where you
16:28saw the plane he had the credibility because he was an engineer and you said that you saw the
16:37propeller spinning just before the crash when you see a propeller rotating it means it was very slow
16:48otherwise you cannot see it moving okay thank you the slow rotation of the propellers could indicate
16:57there was a problem with the engines that drive them quick update sounds like engine failure
17:07we need to talk to the french about their engine analysis
17:16hello
17:20nepali investigators now join the team from france
17:23to examine the wreckage of yeti flight 691 engines are badly damaged can't tell if they
17:32failed in flight most of the engines were consumed by fire so they couldn't learn definitively whether
17:42they were producing power
17:47look at that prop
17:51investigators notice something telling on a propeller hub
17:59looks feathered
18:08when propellers are feathered their edges face forward and cannot produce thrust
18:16it's like putting your car in neutral position you can push on the gas as much as you want but
18:22nothing
18:23is going to happen
18:28it's actually stuck in a feathered position
18:32okay
18:40this one moves freely but it could have moved on impact
18:49this one is stuck too
18:54so two of them were in the feathered position when they hit the ground
19:01normally propellers are feathered on the ground after shutdown
19:05that prevents them from spinning in the wind and damaging the engine
19:10there is however one exception
19:12an automatic feathering unit will feather that
19:15propeller immediately as soon as an engine failure is detected
19:19perhaps faster than the pilot can do it
19:24were the props feathered automatically in flight due to engine failure
19:30investigators download the data from flight 691's multifunction computer to find out
19:35the multifunction computer stores information about the automatic feathering unit in its memory
19:44they're going to be able to learn whether the auto feather unit feathered one engine or both engines
20:00it never activated
20:04if you learn that the auto feather system didn't feather the propellers
20:08that immediately raises the question who or what did
20:14were the propellers feathered manually
20:17investigators consider a crucial piece of wreckage recovered from the scene
20:22the central control pedestal
20:25the central pedestal is located between the pilots
20:29and here you have the power levers
20:32you have the flaps lever
20:33and you have the condition levers
20:35which controls the propellers
20:39flaps are stuck at 30
20:41that's where they should be for landing
20:47condition levers are moving freely
20:51doesn't tell us much
20:55look at this
21:04witness mark
21:05witness mark
21:07you're looking for witness marks
21:09the marks that one aircraft component makes against another
21:12at the time of impact
21:13and those marks will suggest
21:17in the case of the central control pedestal
21:19where the controls were positioned at impact
21:24the witness mark suggests
21:26that the pilots could have put the left lever
21:29in the feathered position
21:32maybe some other debris caused the witness mark
21:35there's no witness mark for the right condition lever
21:42were the propellers feathered by the pilots
21:44or did the witness marks occur on impact
21:49we're going to need the flight data recorder download to settle this
21:57the flight data recorder doesn't record the propeller blade angle
22:01but it does record certain parameters that let investigators infer
22:06whether the propellers were feathered
22:08and if so when
22:18wow
22:21the torque and propeller speed drop at the same moment
22:25one of the engines at idle
22:28they find evidence that the pilots feathered the props
22:32one minute before the crash
22:35when the propellers are feathered
22:37the torque drops
22:39and the propeller's rpm speed drops
22:43that's what the witness was able to see
22:45when he reported
22:47spotting the individual propeller blades
22:49how did they make that mistake
22:58what was going on in the pilot's mind
23:02what was going on in the cockpit
23:04what's happening
23:18pick it up 24 minutes into the flight
23:20right before the propellers were feathered
23:25investigators listen to the cockpit voice recording
23:28from Yeti Airlines flight 691
23:31to understand why the pilots feathered their propellers
23:34when they did
23:35okay from here you can go manual
23:37okay stand by
23:42disconnect
23:45okay flaps 30
23:48flaps 30
23:51continue to sense
23:53okay
23:54stop
23:56where are we at here
23:59time is 10 56 35
24:06according to the FDR
24:09the flaps did not move to 30 at this point
24:12but this is
24:14when the props were feathered
24:19the FDR shows
24:20that when the pilot flying
24:22commanded flaps 30
24:23the flaps didn't move
24:25but at the same moment
24:27the prop rpm decreased
24:29and torque went to zero
24:32the pilot has pretty obviously
24:35feathered the engines
24:36instead of moving the flaps
24:46they must have mixed up the flap levers
24:48with the condition levers
24:51and captain casey was the pilot monitoring
24:56how could a captain make that mistake
25:04in most airline accidents
25:06pilot error is a factor
25:08that can be because of inadequate training
25:12experience
25:14it can be because of
25:16too little rest
25:18but there can also be other factors
25:21impairing their decisions
25:23here you go
25:29the team reviews results
25:31from the pilot's toxicology tests
25:36nothing on captain katiwata
25:44same with captain casey
25:49maybe they weren't adequately rested
25:54according to the airline's records
25:56both pilot schedules were within guidelines
25:59suggesting adequate rest
26:01and their medical certificates are current
26:05they conclude that something other
26:07than impaired judgment
26:08caused the pilots to feather the props
26:11by mistake
26:12at this point you'd have to wonder
26:14what might have been going on
26:15in the cockpit
26:16that would lead him to be distracted
26:19into setting the propellers to feather
26:21instead of setting the flaps for landing
26:25did the location of the condition levers
26:28on the pedestal
26:29play a part in the captain's error
26:32they examine an ATR 72 pedestal
26:37I reach over for the flaps
26:41but I put my hand on the condition lever instead
26:49the flap lever and the condition levers are very close together on the pedestal
26:55I want to move the flaps to the 30 degree position
27:03I move the condition lever to feathered
27:10the flap and condition levers have the same range of motion and stop in similar positions
27:18it's not a stretch that they could have mixed up the levers
27:22and don't forget captain casey was where I'm sitting
27:28right
27:28muscle memory is very important for a pilot
27:36because you can do sequences
27:38without being conscious about it
27:40but when you move
27:42to another seat on the other side
27:44suddenly that flow is disturbed
27:46because now you have to use the opposite hand
27:52oh that feels a lot less natural
27:57and much easier to mix up
28:03okay flaps 30
28:06flaps 30
28:09continue descents
28:13the pilot monitoring move the condition levers instead of the flap lever
28:17that should be impossible but it has happened before
28:23I once asked for flaps
28:25and the pilot monitoring selected the gear down
28:29and those levers are far apart
28:34still it's hard to imagine looking at these levers
28:38that you'd get them confused
28:41true
28:48maybe he wasn't looking at them
28:54why would an experienced captain not check which levers he was moving
29:05okay visual visual
29:06okay visual
29:09investigators return to the voice recording of yeti airlines flight 691
29:14to determine if the captain's attention was elsewhere when he selected the wrong levers
29:19okay make sure you stay between the mountains and the runway
29:23they revisit the moment just before the propellers were feathered
29:27keep your power nose up
29:30keep visual with the tower
29:31don't go too far
29:33okay copy that
29:37okay stop for a second
29:41he's giving her a lot of instructions
29:45maybe that's the distraction
29:48but she's a very experienced pilot
29:51so why is he doing that
29:54when you're giving instruction that's an added mental stress
29:58it's an added cognitive load
29:59it's very distracting
30:03let's start from the top
30:06poker tower
30:07yeti airline 691
30:10yeti airline 691
30:14tower
30:15yeti 691
30:16descending through 12,500 feet
30:24expect to land on runway 30
30:27runway 30
30:29yeti 691
30:33they discover that flight 691 was initially cleared to land on a different runway
30:39runway 30
30:40but eight minutes later there's a change of plan
30:44if traffic permits
30:46let's land on runway 12
30:49then you'll be approved for runway 12 without any instructor pilot supervision
30:53okay
30:54runway 12
30:57not only is he monitoring the flight
30:59he's approving her to land at Pohra's new airport
31:05investigators discover captain casey was instructing pilots on how to land on both runways at the new airport
31:14i flew with captain kamal casey just two days before for my route qualification into Pohra international airport
31:23but why runway 12
31:28you'll be approved to land in both directions
31:30copy that
31:38okay
31:38okay
31:39stop it
31:39so captain khatawada
31:42is cleared for runway 30
31:45and captain kc decides much later in the game
31:48he's approving her for runway 12
31:53captain khatawada had landed on runway 30
31:56but never won two
31:58runway 30 is a straight-in approach
32:06and runway 12
32:07you follow a narrow track next to the mountains
32:10and you turn left twice to line up with the runway
32:14so captain casey put captain khatawada on a more difficult landing
32:25runway 12
32:26runway 12 was a challenging approach for a pilot with just 185 hours on the air
32:32did captain casey properly prepare captain khatawada for the difficult approach to runway 12
32:42the best way to prepare a pilot for such an approach would be to do a proper briefing
32:47maybe they have photos
32:50maybe they have photos videos simulator training if available
32:55investigators examine captain khatawada's training records
33:02she spent no time in the simulator training on runway 12
33:06what about a formal briefing
33:09there's no documentation related to training
33:11on runway 12
33:13i've got captain casey's flight history
33:17was captain casey even qualified to train others for landing on runway 12
33:22turns out he had only landed on 12 twice
33:28a bit of experience but not enough
33:35because of his low experience and also khatawada's low experience on the aircraft
33:40i find that a bit strange
33:44i wonder if it's even possible to do a stabilized visual landing using that approach
33:59a stabilized visual approach is one that's conducted with the runway in sight
34:05at a normal rate of descent with landing flaps and landing gear down
34:10at the proper airspeed and with all checklists completed by a certain point
34:17there's just over one mile between the completion of the last turn and the runway
34:25that's going to give you just over 30 seconds from lining up to landing it's very tight
34:37official landing can increase the workload because they have to make tiny adjustments all the way
34:42through the pattern let's see how they handle the workload
34:49okay make sure you stay between the mountains and the runway
34:52to understand how the pilots dealt with the final approach to runway 12
34:58investigators return to the cvr
35:00keep your power nose up
35:03keep visual with the tower
35:06don't go too far
35:07okay copy that
35:09remember you need to make an early turn here
35:14okay a beam tower
35:16gear down
35:17gear down
35:24can i fly it manually
35:26wait
35:27wait not yet keep going straight
35:30after flaps 30
35:32then you're good to go manual
35:34hold on
35:36captain casey is so focused on pointing out landmarks outside the cockpit
35:40he's not paying attention to what's happening inside the cockpit
35:47it's normal to let the less experienced pilot fly the aircraft and the most experienced pilot do the analysis
35:56okay flaps 30
35:58flaps 30
35:59flaps 30
36:04continue descent
36:05okay
36:11you probably didn't even look down to see what lever he was moving
36:15but there was still an opportunity to catch the mistake when they do the landing checklist
36:25the before landing checklist was an opportunity for him to look down at that control pedestal
36:31and see that he had moved the condition levers into feather
36:35i'm almost certain they could have recovered right up until the last few seconds
36:41did the pilots failure to follow their checklist ultimately determine their fate
36:53napole investigators continue listening to the cvr of flight 691
36:58to learn whether the pilots followed the proper procedures before landing
37:03before landing checklist
37:09okay
37:10landing gear
37:11down three green
37:13flaps
37:1430
37:17captain kariwata said the flaps are at 30 but according to the fdr they're still set at 15
37:25neither pilot check the flap settings
37:30if captain casey saw that the flaps were not at 30 he may have realized he had moved the wrong
37:36lever
37:37power management takeoff tlu
37:41low speed icing a away
37:44check
37:45sternal lights on
37:46on
37:47complete
37:50they rushed it
37:53the before landing checklist was done very fast
37:56like bam bam bam bam bam bam
37:58and i don't any of them looked at the flap setting
38:02they just answered by memory
38:04oh
38:05and with the props feathered
38:08there should have been warning lights
38:11why didn't they figure it out
38:23when the propellers are feathered they're no longer providing power to the generators
38:30an aural and visual
38:31an aural and visual elec warning alerts the pilots that they're losing electrical power
38:36what is this
38:37what is this
38:38elec is on cap
38:42the elec light comes on to warn the pilots hey you've got a big electrical problem
38:48check
38:49checked
38:49check
38:51someone clicked off the warning
38:53they clicked off the warning without figuring out why it even came on
39:00it's hard to tell why captain kamal kc responded checked to the electrical light
39:05check
39:07would you pull out a quick reference handbook and start working a long electrical failure procedure
39:12or would you recognize hey i'm landing in less than 60 seconds let's just bring the plane in
39:18and deal with the problem on the ground
39:21we just continue right yes continue turn
39:30what's that click about
39:37FDR data shows this is where the flaps goes to 30
39:41so he notices the flap is not set at 30 and corrects it
39:51and with so much workload all he sees is the flap leader and doesn't notice that the propellers
39:56are feathered
39:59when your workload increases you get tunnel vision and you see less
40:05that makes it very difficult because now you only focus on one thing
40:11okay but why doesn't he figure it out when the engines have dropped to idle
40:21seconds from the runway captain casey realizes there's an issue with the engines
40:27there's no power
40:28there's no power
40:31add power
40:34even though the pilots see the engines are at idle
40:38they are still unaware that the propellers are feathered
40:41there's no power no power
40:43add power
40:46there's no torque
40:48okay give it to me
40:51in desperation captain casey takes control of the plane
40:55you're landing sir
40:56no power torque indication zero
40:59no power
40:59two hundred
41:038691
41:06what's happening
41:27what's happening
41:35one seeing a glance around the cockpit could have told him that he had feathered the propellers
41:48the final report of the napoli accident investigation commission concludes that
41:53the most probable cause of the accident was the inadvertent movement of both condition
41:58levers to the feathered position in flight what strikes me about this is that it was a very
42:06normal situation the only thing that went between success and failure was the slip of a hand
42:18the proximity to terrain and sharp turn required to land on runway 12 before landing checklist
42:26combined with a high workload and a lack of appropriate training all contributed to the
42:33crash after the accident Yeti Airlines tests the approach in the simulator with their pilots
42:42most of our pilots were not able to land on runway 12 either they were high on approach or they
42:50were
42:51fast on speed Yeti Airlines stops flying into runway 12 until they are able to establish a safe visual
43:02procedure and retrain their pilots the Commission recommends that the Civil Aviation Authority of
43:09Nepal ensures that a stabilized flight path is approved before allowing commercial operations at
43:16a new airport after the accident the victims of Yeti air flight 691 are mourned by a nation and fellow
43:28pilots
43:28remember their colleagues oh captain come on Casey I just want to remember him when he was alive and he
43:40was there with us
43:45cabin khati water I respected her a lot she will be remembered as an elder sister and there is going
43:55to
43:55be always a void in the airlines that she is not there anymore
44:28so
44:37you
44:38you
44:38you
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