#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.
01:17Do it that way!
01:20Yay 1, 0, 1.
01:22Go!
01:24Go!
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 to Pokhara to paraglide with friends.
02:03Pokhara Tower, Yeti 691, descending through 12,500 feet.
02:10Captain Kamal Casey is the senior officer and the pilot monitoring instruments on today's flight.
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 skies and
02:39he 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 Katewada. She's flown more than 6,000 hours.
02:58Captain Katewada has a very special history.
03:02Her husband, he was a pilot with the same company. He was a first officer on the Twin Otter and
03:09he did crash and he died some years earlier.
03:13Katewada decided to take up flying to honor his spirit so she become a pilot.
03:208,500 feet.
03:22While Captain Katewada is an experienced commercial pilot, she has only 186 hours on the ATR-72.
03:40The ATR-72 is a turboprop twin-engine aircraft. It'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.
04:34Sonu Jaiswal is live streaming from the cabin.
04:36The plan is to go paragliding in the Himalayan foothills with my buddies!
04:453-1-0.
04:48Captain Katewada 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 Airlines 691 in sight, report final, runway 1-2.
05:28Call you on final for runway 1-2.
05:31Yeti 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, standby.
05:53Disconnect.
05:55Captain Katewada disconnects the autopilot, then begins the first of two crucial turns to line up with the runway.
06:12Okay, flaps 30.
06:15Flaps 30.
06:18Continue descent.
06:20Okay.
06:25One minute from touchdown, the pilots run through the pre-landing checklist.
06:30Okay, landing gear.
06:31Down three green.
06:33Flaps?
06:3430.
06:39In the cabin, Sonu J-Swell continues live streaming.
06:44We'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.
07:08There'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.
07:21Add power.
07:24Captain Katewada 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 Katewada pushes the throttles to the limit.
08:05There's no torque.
08:07There's no torque.
08:07Okay, give it to me.
08:09The more senior captain takes control.
08:1980-6-9-1.
08:23200.
08:2580-6-9-1.
08:26Flight 691 is stalling.
08:36While Sonu Jaiswal live streams the unfolding disaster.
08:45What'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.
09:55The bodies of 71 of the 72 passengers and crew are eventually found and identified, including both pilots.
10:08This was the deadliest crash involving Nepali airlines ever.
10:15What could have caused a commercial airliner to drop out of the sky just seconds before landing?
10:30When 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 gorge.
10:56And the rest of the parts were at the side of the river.
11:04Under the supervision of Nepali investigators, the wreckage, along with the black boxes and central processing card from the plane's
11:13computer, 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.
11:50And 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.
12:31It's gone viral.
12:38A witness had filmed the plane during the final moment of the flight.
12:44It 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 have led to that and
13:12you 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 up with runway
13:33one two.
13:35And 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.
13:56Yeah.
13:59It 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 didn'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.
14:33I'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.
15:17Then I heard it.
15:21The explosion.
15:25The explosion.
15:26The explosion.
15:41The explosion.
15:43The explosion.
15:45fucked.
15:47much. Okay, thank you. So, do you know what happened? Not yet. In the early stages, you'd want
16:11to look at anything witnesses might have to say, anybody who might have seen, heard, or otherwise
16:16noticed the crash. The controller offers little insight into why the plane stall. Then a witness
16:24to the accident comes forward. There, that's where you saw the plane? He had the credibility because
16:33he was an engineer. And you said that you saw the propeller spitting just before the crash?
16:43When you see a propeller rotating, it means it moves very slow. Otherwise, you cannot see it moving.
16:51Thank you. The slow rotation of the propellers could indicate there was a problem with the engines that
16:59drive them. Quick update. Sounds like engine failure. Yeah. We need to talk to the French about their
17:09engine analysis. Hello.
17:20Nepali investigators now joined the team from France to examine the wreckage of Yeti flight 691.
17:28Engines are badly damaged. Can't tell if they failed in flight.
17:37Most of the engines were consumed by fire, so they couldn't learn definitively whether they were
17:42producing power. Look at that prop. Investigators notice something telling on a propeller hub. Looks feathered.
18:09When 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,
18:22but nothing is going to happen. It's actually stuck in a feathered position.
18:40This one moves freely, but it could have moved on impact. This one is stuck too.
18:53So two of them were in the feathered position when they hit the ground.
19:01Normally, propellers are feathered on the ground after shutdown. That prevents them from spinning
19:07in the wind and damaging the engine. There is, however, one exception. An automatic feathering unit
19:15will feather that propeller immediately as soon as an engine failure is detected,
19:19perhaps faster than the pilot can do it. Were the props feathered automatically in flight
19:28due to engine failure? Investigators download the data from Flight 691's multifunction computer
19:34to find out. The multifunction computer stores information about the automatic feathering unit
19:41in its memory. They're going to be able to learn whether the auto feather unit feathered one engine or both
19:50engines.
20:00It never activated. If you learn that the auto feather system didn't feather the propellers, that immediately raises the question,
20:10who or what did?
20:14Were the propellers feathered manually? Investigators consider a crucial piece of
20:20wreckage recovered from the scene. The central control pedestal. The central pedestal is located between the pilots.
20:29And here you have the power levers. And here you have the power levers, you have the flaps lever, and
20:34you have the condition levers, which controls the propellers.
20:39The flaps are stuck at 30. That's where they should be for landing. Condition levers are moving freely.
20:50It doesn't tell us much. Hmm. Look at this.
21:04Witness mark. You're looking for witness marks, the marks that one aircraft component makes against another at the time of
21:13impact.
21:14And those marks will suggest, in the case of the central control pedestal, where the controls were positioned at impact.
21:24The witness mark suggests that the pilots could have put the left lever in the feathered position.
21:32Maybe some other debris caused the witness mark. There's no witness mark for the right condition lever.
21:42Were the propellers feathered by the pilots? Or 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 whether the propellers were feathered, and if so, when.
22:18Wow.
22:21The torque and propeller speed drop at the same moment when the engine's at idle.
22:28They find evidence that the pilots feathered the props one minute before the crash.
22:35When the propellers are feathered, the torque drops, and the propeller's RPM speed drops.
22:43That's what the witness was able to see when he reported spotting the individual propeller blades.
22:49How did they make that mistake?
22:57What was going on in the pilot's mind?
23:01What was going on in the cockpit?
23:04What's happening?
23:18Pick it up 24 minutes into the flight.
23:21Right before the propellers were feathered.
23:25Investigators listened to the cockpit voice recording from Yeti Airlines Flight 691 to 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 descent.
23:53Okay.
23:55Stop.
23:55Stop.
23:56Where are we at here?
23:58Time is 10-56-35.
24:06According to the FDR, the flaps did not move to 30 at this point.
24:13But this is when the props were feathered.
24:19The FDR shows that when the pilot flying commanded flaps 30, the flaps didn't move.
24:26But at the same moment, the prop RPM decreased and torque went to zero.
24:32The pilot has pretty obviously feathered the engines instead of moving the flaps.
24:46They must have mixed up the flap levers with the condition levers.
24:51And Captain Casey was the pilot monitoring.
24:56How could a captain make that mistake?
25:04In most airline accidents, pilot error is a factor.
25:09That can be because of inadequate training, experience.
25:14It can be because of too little rest.
25:19But there can also be other factors impairing their decisions.
25:23Here you go.
25:29The team reviews results from 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, both pilot schedules were within guidelines, suggesting adequate rest.
26:01And their medical certificates are current.
26:05They conclude that something other than impaired judgment caused the pilots to feather the props by mistake.
26:13At this point, you'd have to wonder what might have been going on in the cockpit that would lead him
26:17to be distracted into setting the propellers to feather instead of setting the flaps for landing.
26:25Did the location of the condition levers on the pedestal play a part in the captain's error?
26:32They examine an ATR-72 pedestal.
26:37I reach over for the flaps, but I put my hand on the condition lever instead.
26:49The flap lever and the condition lever are very close together on the pedestal.
26:55I want to move the flaps to the 30-degree position.
27:00But instead, I 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.
27:27Right.
27:41Oh, that feels a lot less natural.
27:57And much easier to mix up.
28:03Okay.
28:04Flaps 30.
28:06Flaps 30.
28:09Continue to sense.
28:13The pilot monitoring moved the condition levers instead of the flap lever.
28:18That should be impossible, but it has happened before.
28:23I once asked for flaps and 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 that 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?
29:04Okay, visual, visual.
29:07Okay.
29:08Visual.
29:09Visual.
29:10Visual.
29:11Okay.
29:20Visual.
29:23Visual.
29:23You 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, so why is he doing that?
29:55When you're giving instruction, that's an added mental stress, it's an added cognitive load.
30:01It's very distracting.
30:03Let's start from the top.
30:06Poker Tower, Yeti Airline 691.
30:10Yeti Airline 691.
30:14Tower, Yeti 691, descending through 12,500 feet.
30:20Roger, Yeti 691, 12,500 feet.
30:25Expect to land on runway 30.
30:28Runway 30, Yeti 691.
30:33They discover that flight 691 was initially cleared to land on a different runway, runway 30.
30:41But eight minutes later, there's a change of plan.
30:44If traffic permits, let's land on runway 12.
30:49Then you'll be approved for runway 12 without any instructor pilot supervision.
30:53Okay, runway 12.
30:57Not only is he monitoring the flight, he's approving her to land at Pokhra'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 Pokhra International Airport.
31:23But why runway 12?
31:28You'll be approved to land in both directions.
31:31Copy that.
31:38Okay, stop it.
31:40So Captain Khatawada is cleared for runway 30.
31:45And Captain Casey decides much later in the game, he's approving her for runway 12.
31:52Captain Khatawada had landed on runway 30, but never 12.
31:59Runway 30 is a straight-in approach.
32:06In runway 12, you follow a narrow track next to the mountains, and you turn left twice to line up
32:13with the runway.
32:14So Captain Casey put Captain Khatawada on a more difficult landing.
32:25Runway 12 was a challenging approach for a pilot with just 185 hours on the 8th year.
32:32Did Captain Casey properly prepare Captain Khatawada for the difficult approach to runway 12?
32:41The best way to prepare a pilot for such an approach would be to do a proper briefing.
32:48Maybe they have photos, videos, simulator training if available.
32:56Investigators 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 on 12.
33:13I've got Captain Casey's flight history.
33:17Was Captain Casey even qualified to train others for landing on runway 12?
33:23Turns 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.
33:45I 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.
34:36A visual landing can increase the workload because they have to make tiny adjustments
34:41all the way through the pattern.
34:45Let'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.
35:13Okay, 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, then you're good to go manual.
35:34Hold on.
35:36Captain Casey is so focused on pointing out landmarks outside the cockpit,
35:41he's not paying attention to what's happening inside the cockpit.
35:47It's normal to let the less experienced pilot fly the aircraft
35:51and the most experienced pilot do the analysis.
35:56Okay, flaps 30.
35:58Flaps 30.
36:04Continue to sense.
36:05Okay.
36:11He probably didn't even look down to see what vever he was moving.
36:16But 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?
36:53Nepali 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.
37:12Down three green.
37:14Flaps?
37:1430.
37:15Wait.
37:17Captain Kariwata said the flaps are at 30, but according to the FDR, they're still set at 15.
37:25Neither pilot checked the flap settings.
37:30If Captain Casey saw that the flaps were not at 30,
37:34he may have realized he had moved the wrong lever.
37:37Power management?
37:39Take off.
37:40TLU?
37:41Low speed.
37:42Icing.
37:43AOA?
37:44Check.
37:45External lights on?
37:46On.
37:47Complete.
37:50They rushed it.
37:53The before landing checklist was done very fast.
37:57Like bam, bam, bam, bam, bam.
37:59And I don't any of them looked at the flap setting.
38:02They just answered by memory.
38:05And with the props feathered, there 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.
38:29An aural and visual ELEC warning alerts the pilots that they're losing electrical power.
38:36What is this?
38:37Huh?
38:39ELEC is on cap.
38:42The ELEC light comes on to warn the pilots,
38:45hey, you've got a big electrical problem.
38:48Check.
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.
39:06Check.
39:07Would you pull out a quick reference handbook and start working along electrical failure procedure?
39:13Or would you recognize, hey, I'm landing in less than 60 seconds.
39:17Let's just bring the plane in and deal with the problem on the ground.
39:21We just continue, right?
39:23Yes.
39:24Continue 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 lever and doesn't notice that the propellers are 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?
40:22Seconds from the runway, Captain KC realizes there's an issue with the engines.
40:27There's no power.
40:28There's no power.
40:31Add power.
40:35Even though the pilots see the engines are at idle, they are still unaware that the propellers are feathered.
40:41There's no power. No power.
40:43Add power.
40:47There's no torque.
40:48There's no torque.
40:48Okay, give it to me.
40:51In desperation, Captain KC takes control of the plane.
40:55You're landing, sir.
40:57No power.
40:58Torque indication zero.
41:01200.
41:048691.
41:06What's happening?
41:21He decided to fly the plane rather than try to diagnose the problem.
41:35One single glance around the cockpit could have told him that he had feathered the propellers.
41:48The final report of the Nepali Accident Investigation Commission concludes that the most probable cause
41:54of the accident was the inadvertent movement of both condition levers to the feathered position in flight.
42:03What strikes me about this is that it was a very normal situation.
42:08The 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.
42:25Before landing checklist.
42:26Combined with a high workload and a lack of appropriate training all contributed to the crash.
42:36After the accident, Yeti Airlines tests the approach in the simulator with their pilots.
42:43Most of our pilots were not able to land on runway 12.
42:47Either they were high on approach or they were fast on speed.
42:55Yeti Airlines stops flying into runway 12 until they are able to establish a safe visual procedure and retrain their
43:04pilots.
43:06The commission recommends that the Civil Aviation Authority of Nepal ensures that a stabilized flight path is approved
43:13before allowing commercial operations at a new airport.
43:20After the accident, the victims of Yeti Air Flight 691 are mourned by a nation.
43:27And fellow pilots remember their colleagues.
43:33Captain Kamal Casey, I just want to remember him when he was alive and he was there with us.
43:44Captain Khatibada, I respected her a lot.
43:50She will be remembered as an elder sister.
43:53And there is going to be always a void in the airlines that she is not there anymore.
44:32Captain Khatibada, I respected her a lot.
44:33Known schools were very passionate about, one of the bestks.
44:40That's why I did not interessante the comunque paypal cigarettes at alliała.
44:42Okah.
44:42We go?
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