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00:02El aeropuerto de la zona de la zona de 4,000 pies per minuto.
00:06¡Pullo! ¡Pullo!
00:07Nuremberg Air Service Flight 108
00:09breaks apart while the pilots
00:12attempt to land at Dusseldorf Airport
00:14in Germany.
00:16All passengers
00:18and crew are killed.
00:21Because of
00:22the size of the accident site
00:24we use the grid to identify
00:26the positions
00:27of every part of the wreckage.
00:31Investigators
00:32reconstruct the plane to determine
00:34what happened.
00:36There must be a thousand pieces in here.
00:41Over here.
00:42They uncover evidence of a
00:43one-in-a-million failure that should
00:46not have brought the plane down.
00:48The pilots had no
00:50chance to control
00:51the aircraft in a proper way.
00:54I think under these circumstances
00:55there was nothing they could have done.
01:23It's an hour before sunrise
01:25at Hanover Airport
01:27in West Germany.
01:31Nuremberg Air Service Flight 108
01:33prepares for the first flight of the day.
01:42In the cockpit is 36-year-old
01:45Captain Ralph Borstorff.
01:47How's the weather looking?
01:49And 28-year-old
01:51First Officer
01:52Sybil Hale-man.
01:53They each have
01:542,500
01:54flying hours.
01:56Should we clear sailing?
01:59Both of them would be fairly typical.
02:02What you would see
02:03in commuter operations,
02:04people starting their careers
02:06and getting ready to move up.
02:08The weather forecast
02:09predicts calm skies
02:11with only a slim chance
02:13of thunderstorms
02:14near their destination.
02:16Might get a bit rough
02:17on landing
02:17because of some turbulence
02:19and a chance of thunderstorms,
02:20but it's unlikely.
02:21Just 10%.
02:22Sounds good.
02:26A 10% chance
02:27of thundershowers.
02:29It's a 10% chance
02:30you want to know about it,
02:31but it's not something
02:31you're going to put
02:32too much thought into.
02:34Before Flight 108
02:36can depart,
02:37snow and ice
02:39that accumulated overnight
02:40are removed.
02:44This flight was a full flight.
02:46It had 19 passengers on board,
02:48all of those being business people.
02:50It's a 40-minute flight
02:52from Hanover to Dusseldorf,
02:54a major business hub
02:56on the Rhine River.
02:58We started the route
02:59in 1987,
03:01about six months
03:02before this flight.
03:03We had very weak
03:05train connections
03:06between the east
03:07and western parts
03:08of Germany.
03:09So from the very,
03:10very beginning
03:11we had full airplanes.
03:14Flight 108
03:15leaves Hanover
03:16at 7.15 a.m.,
03:1915 minutes
03:20behind schedule.
03:22Flaps.
03:28Retracted.
03:30The pilots are flying
03:31a Fairchild
03:32Swear engine
03:33Metroliner 3.
03:35It's a powerful
03:36turboprop plane
03:37designed for short
03:38commuter flights.
03:40The Metrol3 airliner
03:41is a perfect
03:42scaled-down airliner.
03:43It hauls 19 people
03:44fast,
03:45fuel-efficiently.
03:46All the creature comforts
03:47of a bigger airline.
03:49From the very beginning,
03:51I was impressed
03:52by the airplane.
03:54It was
03:54extremely well-designed.
03:57It was flexible.
03:58It was fast.
04:00They could pressurization.
04:01So everything
04:02a pilot likes,
04:03the airplane has.
04:07It takes 10 minutes
04:09for flight 108
04:10to reach its cruising
04:12altitude of 14,000 feet.
04:16It will stay at that
04:18altitude for only 15 minutes.
04:22Well,
04:23no rest for the wicked.
04:25We'll have the descent
04:26checklist, will you?
04:29Regional flying
04:30is generally
04:31an hour and a half
04:32or less,
04:33leading to increased
04:34workload
04:35for the time
04:36that you are in the air.
04:39Check the radar.
04:41The captain
04:42notices some weather
04:44on the radar.
04:46Thunderstorm
04:47could be rolling
04:47in after all.
04:49Maybe.
04:50Doesn't look
04:50particularly bad.
04:52I'll check the ATIS.
04:57ATIS
04:58continuously broadcasts
05:00updated weather conditions
05:01at the destination airport.
05:03At 1-2
05:03dusting 2-4
05:04visibility
05:0510
05:06sky condition
05:07broken clouds
05:08at 1,500 feet.
05:11Nothing about a thunderstorm.
05:13We should be fine.
05:15Okay.
05:17We'll continue
05:18with the approach.
05:20Their expectation
05:21was that the weather
05:22was getting better
05:22and that any
05:23thinner showers
05:23hadn't really materialized.
05:26Good morning.
05:27This is your captain
05:27speaking.
05:28We have begun
05:29our descent
05:30into Dusseldorf.
05:31Please ensure
05:32your seatbelts are fastened.
05:33Should be landing
05:34in about 15 minutes.
05:4430 miles
05:45from the airport.
05:47Dusseldorf,
05:48good morning.
05:49Requesting to send
05:49to 3000
05:50NFD-108.
05:52First officer
05:53Hailman
05:54contacts the
05:54Dusseldorf approach
05:55controller
05:56for landing instructions.
05:58NFD-108,
05:59good morning to you.
06:00You are cleared
06:01to 3000 feet
06:02and currently
06:03number three to land.
06:06Copy
06:07to send to 3000,
06:08number three to land.
06:10When ATC gives us
06:11an indication
06:12of where we are
06:13on the order
06:13for landing,
06:14it helps us set up,
06:15it helps us get ready,
06:16it helps us know
06:16when you're going to
06:17start putting flaps
06:18and gear down.
06:20Three minutes later,
06:24Localizer
06:24Live
06:27Flight
06:27108
06:28lines up
06:29with the runway's
06:30centerline.
06:36Establish
06:37on the localizer.
06:40The first officer
06:41checks on the weather.
06:45Looks like
06:46a thunderstorm
06:46has moved
06:47right in front of us.
06:50Might be trouble.
06:55Thunderstorms
06:55have to be treated
06:56with respect.
06:56I mean,
06:57they can produce hail,
06:57they can produce
06:58downdrafts,
06:59tailwinds,
07:00overpowering
07:01what the airplane
07:01is capable of doing.
07:05The captain
07:05decides to maneuver
07:07around the storm.
07:14The problem was
07:15it's a big
07:16thunderstorm
07:17in the approach
07:18sector
07:18of Düsseldorf.
07:20They shouldn't
07:21fly through
07:21thunderstorms.
07:24In the
07:25Düsseldorf
07:25control center,
07:27NFD-108,
07:28please switch
07:29to tower control,
07:30frequency
07:30118.30.
07:33The approach
07:34controller
07:34hands over
07:35flight 108
07:36to the tower.
07:39NFD-108,
07:40confirm switch
07:41to tower control,
07:42frequency
07:42118.30.
07:44Bye.
07:49moments later,
07:51flight 108
07:53disappears from radar.
07:59Seven miles northeast
08:01of Düsseldorf airport,
08:03a maintenance worker
08:04at a sewage treatment plant
08:06hears the sound
08:07of an approaching airplane.
08:10flight 108
08:11breaks out of the clouds
08:13in a steep dive.
08:15500,
08:16400,
08:18300,
08:19pull up!
08:23The plane
08:24pulls up
08:25just in time.
08:28The plane
08:29came flying
08:29out of the bottom
08:30of the cloud
08:30at 4,000 feet per minute.
08:31The G-force
08:32it would have taken
08:32to overcome that,
08:33to pull the airplane
08:34nose back up,
08:35but it was violent.
08:37The sound
08:38of the engines
08:38recedes
08:39into the distance.
08:42That flight
08:43would have been
08:43sheer terror.
08:45Sheer terror
08:45for the people
08:46in the back,
08:46sheer terror up front.
08:47You know,
08:48you went from
08:48having a visual reference
08:49to thinking you're good
08:50to all of a sudden
08:50you're back
08:51in the cloud again.
08:53A minute later,
08:55the plane returns.
08:57This time,
08:58Flight 108
08:59spirals out of control
09:02and breaks up.
09:04No, no, no!
09:06It's a horrifying sight.
09:08I can't even imagine
09:09what the person
09:09watching that
09:10would be thinking.
09:11Two minutes
09:12before dawn,
09:13Flight 108
09:14slams into an open field
09:16on the banks
09:17of the Ruhr River.
09:26The wreckage
09:27is scattered
09:28over a wide area.
09:31First responders
09:33make their way
09:33to the crash site.
09:35All 19 passengers
09:37and both pilots
09:39are dead.
09:40The Metroliner
09:42itself is broken
09:43into thousands
09:44of pieces.
09:46You're seeing
09:47that parts
09:49are distributed
09:50throughout the area.
09:52You'll start
09:52collecting all the parts,
09:53mapping where they are,
09:55and trying to put
09:56this puzzle
09:57back together again.
10:04Investigators
10:05from Germany's
10:06Air Accident
10:07Investigation Unit,
10:08or FUS,
10:10begin mapping
10:11the wreckage
10:11of Flight 108
10:13to determine
10:14what caused
10:15the accident.
10:16The first step
10:17was to identify
10:19the positions
10:20of every part
10:22of the wreckage.
10:24And because
10:24of the size
10:25of the accident site,
10:27we used the grids
10:28and we were able
10:29to get the information
10:31where every piece
10:33was at the accident site.
10:37Much of the plane,
10:38along with its black boxes,
10:40are badly damaged.
10:43The recorders
10:44in this aircraft
10:45aren't the new
10:46digital type
10:47recorders,
10:48which record
10:49300, 400 parameters.
10:50This was the old
10:52foil-style recorders.
10:53You had altitude,
10:55airspeed,
10:56you had heading,
10:57some information,
10:58you had G-loads.
10:59You didn't have
11:00the data we have today
11:01by a long shot.
11:03The black boxes
11:05and the debris
11:06are sent to a warehouse
11:07where investigators
11:08begin their analysis.
11:12Once the parts
11:13are recovered,
11:14taken to a facility,
11:16you can then clean
11:17where the fractures,
11:18where the separations are.
11:20You can look at
11:21where a part broke,
11:23a part.
11:25The wings,
11:27the engines,
11:28the tail sections,
11:29separated from the aircraft.
11:33Investigators
11:34try to confirm
11:35witness statements
11:36that the plane
11:37broke up
11:37before it crashed.
11:41This piece
11:42looks compressed,
11:43like it came
11:44from a high-energy impact.
11:48But this piece
11:49is intact.
11:52What that indicates
11:53is this intact piece
11:55of wreckage
11:56did not go
11:57to the accident site
11:58with the rest
11:59of the airplane.
12:01For sure
12:02an in-flight breakup.
12:04The team
12:04is now convinced
12:05that flight 108
12:07broke up
12:08before hitting the ground.
12:10The question is
12:11what led to that?
12:13Is there any evidence
12:14of a pre-existing failure
12:15that would have led
12:16to the accident?
12:19Hey,
12:19can you bring
12:20that piece
12:21over to the table?
12:23Did a design flaw
12:25or some kind of failure
12:27create a fatigue crack,
12:28causing the wings
12:29to break off
12:30before impact?
12:33Even though
12:34the airplane
12:35is fairly new,
12:36you don't rule out anything.
12:37Was there a flaw
12:38in manufacturing?
12:40Was there a full drill
12:41where it shouldn't
12:42have been drilled?
12:42Was there some other issue
12:44that would cause
12:45a crack
12:45to start growing
12:47very early
12:48in the aircraft's life?
12:49Well, this doesn't look
12:50like a fatigue crack at all.
12:54It can only mean
12:56one thing.
12:58Overload fracture.
13:01Yeah.
13:04Overload fractures
13:05can occur
13:06because the airplane's
13:07exceeded speed limits,
13:09flight control inputs
13:10are severe,
13:12severe turbulence
13:13can cause overload,
13:14and sometimes
13:16you have a combination
13:16of all three
13:17coming together.
13:19Hey,
13:20can you get the lights?
13:22What pushed this plane
13:23past its structural limits?
13:26Investigators examined
13:27the plane's flight path
13:28for clues.
13:34Nothing unusual here.
13:38The flight path
13:39from departure
13:40en route
13:42to arrival
13:43for landing
13:43seemed normal.
13:46What happened
13:47to this part,
13:47the end of the flight?
13:53Oh,
13:54look at that.
13:56They discover
13:57that the pilots
13:58flew an erratic
13:59flight path
14:00before the plane crashed.
14:02That would certainly
14:04cause a structural
14:05overload.
14:06Agreed.
14:08The crew
14:09was on approach
14:10and now suddenly
14:12goes through
14:13some very tight
14:14maneuvers
14:15and you piece
14:17that together
14:17with the wreckage
14:19you found
14:19and where it was found
14:21and that gives you
14:22a much better idea
14:23of what led
14:25to the accident.
14:27Investigators
14:28speak to the controller
14:29who oversaw
14:30the approach
14:31of flight 108
14:32to determine
14:33what might have
14:34caused
14:34the unusual
14:35flight path.
14:37Tell me about
14:38the night
14:38of the crash.
14:40There was
14:41thunderstorm activity
14:43from about
14:447.40
14:45until just
14:46after 8 a.m.
14:47Mm-hmm.
14:49Did your other flights
14:50run into any trouble?
14:52They reported
14:53moderate icing
14:54and turbulence
14:55but everyone else
14:57landed with that incident.
14:58Okay.
14:59No go-arounds?
15:01No missed approaches?
15:02No.
15:03Okay.
15:04No.
15:06But about
15:07six miles out
15:08a 7.37
15:08got hit by lightning.
15:14Dusseldorf approach
15:15Lufthansa 1354.
15:17We just experienced
15:18a lightning strike
15:19at 3,000 feet
15:20six miles final.
15:23No immediate issues.
15:24Lufthansa 1354
15:26Dusseldorf approach.
15:27Roger.
15:27Let me know
15:28if you require
15:28further assistance.
15:31Typically
15:31when we're concerned
15:32about thunderstorms
15:33in the airport vicinity
15:34it's not much
15:35about the lightning
15:35it's more about
15:36the winds
15:36and the wind shears
15:37that can be powerful
15:38enough to push
15:39the airplane
15:39into the ground.
15:39Since airplanes
15:41are made of aluminium
15:42which conducts electricity
15:44most lightning strikes
15:46flow over the skin
15:47of the fuselage
15:48and safely exit
15:49through the tail.
15:51I remember
15:51one occurrence
15:52of flying
15:53the aircraft
15:53got hit by lightning
15:54there was a sudden flash
15:56outside the fuselage
15:58you could hear it
16:00and
16:02the airplane
16:03kept on going
16:04and there was no
16:05associated damage
16:06to the aircraft
16:07and we continued on.
16:09Did you report
16:10the lightning strike
16:10to flight 108?
16:11Yes.
16:13NFD 108
16:14the preceding landing
16:15experienced a lightning strike
16:17about six miles final.
16:19Dusseldorf approach
16:20we copy
16:21and are looking outside
16:22NFD 108.
16:26For flight crews
16:27it is not abnormal
16:29to deal with thunderstorms
16:30and to deal with
16:31the probability
16:32of some lightning
16:33this flight was
16:34very very usual.
16:36Okay.
16:37Great.
16:39Thank you for your time.
16:40If it wasn't the weather
16:42that caused the pilots
16:43to push the plane
16:44past its structural limit
16:46what did?
16:51Will flight 108's
16:53black boxes
16:54provide clues
16:55as to why the plane
16:56broke up
16:57mid-flight?
17:00It's not looking good.
17:02How so?
17:07Flight data recording
17:08and the cockpit voice recording
17:10both stopped
17:11two minutes
17:11before the plane crashed
17:13at the exact same time
17:15that the plane
17:16started flying erratically.
17:19A total power failure?
17:22The CVR and the FDR
17:24get their power
17:25from two separate sources
17:27so the fact
17:28that both these
17:29recorders stopped
17:30at the same time
17:31indicates
17:31whatever happened
17:32affected both
17:34electrical systems
17:35not just the one.
17:37The Metroliner's
17:38electrical system
17:39is powered
17:40by two generators.
17:41In the event
17:42of a power failure
17:43two batteries
17:44act as a backup system.
17:48But if it was
17:50a total power failure
17:51that means
17:52the backup system
17:53failed as well.
17:55How is that even possible?
17:58From the perspective
17:59and the explanations
18:00coming from the manufacturer
18:02the possibility
18:03of a total electrical loss
18:05was very low.
18:07But during the course
18:08of the investigation
18:09we understood
18:10more and more
18:11that it could be
18:12that the flight crews
18:13had a total electrical loss.
18:17Investigators consider
18:18the effects
18:19of a total power failure.
18:21They would have lost
18:22most of their instruments.
18:24Well except
18:24their vertical speed indicator
18:27the altitude
18:28and the third
18:29attitude indicator.
18:32Our Metroliner's
18:34have been installed
18:35with a third
18:36independent
18:38artificial horizon.
18:40It used bleed air
18:42coming from the engine
18:43and as long as
18:44the engine was running
18:45the artificial horizon
18:46was working as well.
18:48Totally independent
18:49from electricity.
18:51The standby
18:53non-electrical
18:54artificial horizon
18:55could have been used
18:56by the crew
18:56to help keep
18:58the aircraft level
18:59and straight.
19:03and then the complexity
19:04of this accident
19:05gets into
19:06why didn't the crew
19:07effectively use
19:08that standby.
19:10But even with
19:10limited instruments
19:11who's to say
19:12they could have
19:13even seen them?
19:14Oh good point.
19:16The lights that
19:17illuminated the instruments
19:17may not have been working.
19:19Huh.
19:22You need those instruments
19:23and if you can't see them
19:24then you don't know
19:25if you're up or down.
19:25You're flying blind
19:26at this point.
19:39To confirm
19:41the unlikely finding
19:42of a total electrical failure
19:44the team examines
19:45light bulbs
19:46from Flight 108's
19:48instrument panel.
19:50If the light bulb
19:51was on
19:52when the plane
19:52hit the ground
19:53the hot
19:54and pliable filament
19:55inside would be stretched.
19:58But if the light
19:59was off
20:00the cold
20:01brittle filament
20:02would break
20:04upon impact.
20:07All these filaments
20:08are broken.
20:11The outcome was
20:13that we found
20:15no bulb
20:16which was
20:17under electrical power
20:19during the impact
20:20of the aircraft.
20:23investigators
20:24now have
20:25conclusive evidence
20:26of a sudden
20:27total power failure.
20:31But what could
20:32have caused it?
20:34The controller
20:35did tell us
20:36that another plane
20:38got struck
20:38by lightning.
20:40Maybe this one
20:41did too.
20:43A lightning strike
20:45outside of the aircraft
20:46could lead to
20:47a problem
20:48with the electrical
20:49system
20:49inside of the aircraft.
20:51If the electrical
20:52field
20:52of a lightning
20:53strike
20:54is very
20:55very high
20:55could be
20:57induced
20:57into the aircraft.
21:02Investigators
21:02search for
21:03evidence
21:03of lightning
21:04striking the
21:05fuselage
21:06of Flight 108.
21:10There must be
21:11a thousand pieces
21:12in here.
21:14It's a
21:15painstaking process.
21:17Lightning
21:17could have
21:18struck anywhere.
21:19lightning marks
21:20on the skin
21:21would look like
21:22a circle.
21:23You'll see
21:23the paint
21:24burned.
21:25You may see
21:26some localized
21:26melting of the
21:27metal in that
21:28particular area.
21:35Over here.
21:40What do you got?
21:42I found it.
21:46Once you've found
21:47a piece of metal
21:47to lightning strike,
21:48it's like,
21:49okay,
21:49where does it go
21:50on the airplane?
21:51What's in the
21:51proximity of this?
21:52Is it next to
21:54the electronics?
21:56Is it next to
21:57hydraulics?
21:57Where is this
21:58lightning strike
21:59occurring?
22:01The only way
22:02to determine
22:02where the mystery
22:03piece comes from
22:04is to reconstruct
22:06sections of the
22:07airplane.
22:11At the time
22:12of this accident,
22:14reconstructions
22:14were fairly
22:15typical.
22:16Mainly,
22:16didn't have as
22:17much data
22:18as we have
22:18now.
22:19So,
22:20reconstructing
22:21it made
22:21sense.
22:30I think
22:31I've got it.
22:32Investigators
22:33match the
22:33piece of the
22:34plane to the
22:34left side of
22:35the fuselage
22:36forward of the
22:37wing.
22:37This is
22:38where the
22:39lightning
22:39struck.
22:41But could
22:42a lightning
22:43strike in
22:44front of the
22:44left wing
22:45actually cause
22:46a total
22:46electrical
22:47failure?
22:49There are
22:50power system
22:51lines running
22:51right behind
22:52where the
22:52lightning
22:53struck.
22:54Can't be a
22:55coincidence.
22:57Is it
22:57possible that
22:58that lightning
22:59strike entered
23:00the electrical
23:01wires on the
23:02other side
23:02and therefore
23:04led to the
23:05loss of
23:05electrical
23:05power?
23:06So,
23:06that would
23:07have been
23:07the real
23:07focus of
23:08the
23:08investigation
23:09at this
23:09point.
23:16Investigators
23:17examine what
23:17remains of
23:18Flight 108's
23:20electrical wiring
23:21in search of
23:22evidence that
23:23the lightning
23:23strike jumped
23:24from the
23:24fuselage to
23:25the electrical
23:26system.
23:29You would
23:30look for
23:30the
23:31insulation
23:32material on
23:33the
23:33outside
23:34and burned
23:34away.
23:35Is there
23:35melting inside
23:36the wires?
23:37Evidence that
23:37somehow
23:38electrical energy
23:40got through the
23:41insulation barrier
23:42into the
23:43wiring and
23:45then was
23:46starting to
23:46actually melting
23:47the wires
23:48locally.
23:48How odd.
23:51No signs
23:52of arcing.
23:57We checked
23:57the wiring,
23:58we checked
23:59the electronic
23:59components
24:00available from
24:01the wreckage
24:02for some
24:03indication for
24:04electrical
24:05overload.
24:13Finding
24:13any lightning
24:14damage to
24:14the wiring?
24:15Not yet.
24:17It's very
24:17possible once
24:18the lightning
24:18gets into
24:19the fuselage
24:20you may not
24:21see any
24:22direct impact
24:24in that
24:24area.
24:25It flows
24:26into the
24:27aircraft and
24:28so even
24:29wiring that's
24:30close by may
24:31appear to be
24:31unaffected but
24:33now this high
24:34energy has
24:34gotten into
24:35the airplane
24:36and the
24:37question is
24:37where does
24:37it go?
24:38Maybe I can
24:39find something
24:40in here.
24:42After we
24:43found no
24:44evidence for
24:45damage in
24:46the wiring
24:47based on
24:48the lightning
24:48strike we
24:50had to do
24:51a deeper
24:51investigation
24:52within the
24:53systems and
24:54that means
24:54we had to
24:56look for
24:56damages in
24:58the avionic
24:59components.
25:02The team
25:03now focuses
25:03on even
25:04smaller components
25:05of the
25:06electrical
25:06system
25:07the diodes.
25:10Let's
25:11check this
25:11out.
25:15A diode is
25:17an electrical
25:17component that
25:19allows current
25:19to flow in one
25:20direction only
25:21preventing reverse
25:23current flow that
25:24could damage
25:24circuits or
25:26create
25:26malfunctions.
25:30if the diode is
25:31working properly
25:32there should be
25:33resistance to
25:34high current
25:35flow in one
25:36direction and
25:37not the other.
25:42only 50 ohms
25:43almost nothing
25:45now the
25:46reverse
25:55also 50 ohms
25:58but investigators
26:00discover low
26:01resistance to
26:02current flow in
26:03both directions.
26:04It's shorted.
26:11The outcome of
26:11our investigation
26:12of the diodes
26:13was that all
26:14diodes were
26:16open in both
26:17directions.
26:18That means
26:19the diodes
26:20were shorted.
26:21The question
26:22now was
26:23why?
26:25We decided
26:26to take
26:27these to a
26:28manufacturer and
26:29ask them
26:30to do a
26:31deeper
26:31investigation.
26:35Results
26:36are in.
26:37To better
26:37understand why
26:38the diodes
26:39shorted they
26:40examined test
26:41results provided
26:42by the
26:42manufacturer.
26:46Oh that's
26:47interesting.
26:49Looks like
26:49cracks in the
26:50center of the
26:50diode.
26:54Once you've
26:55seen that a
26:56diode has
26:57failed then
26:58you can do
26:58tests and
26:59research on a
27:00good diode to
27:01see how much
27:02energy it
27:02would take
27:03basically to
27:04fry that
27:04diode.
27:07Voltage
27:07tests are
27:08done to
27:08determine if
27:09the cracks in
27:10the diodes were
27:11the result of a
27:11lightning strike
27:12or something
27:13else.
27:15A thousand
27:16volts.
27:18Investigators
27:19learn that when
27:19more than a
27:20thousand volts
27:21are applied to
27:22a working diode
27:23it will crack.
27:24A lightning
27:25bolt can carry
27:26hundreds of
27:26millions of
27:27volts, more
27:28than enough
27:28energy to
27:29crack the
27:29diode.
27:31It must
27:31have been
27:32lightning.
27:33The damage
27:34of the
27:34diodes only
27:36can be
27:37produced by
27:39high voltage.
27:41Could it be
27:43possible that
27:44high voltage
27:45would be
27:45produced within
27:46the aircraft?
27:47And the
27:48answer was
27:49no, it
27:50could be only
27:51produced by
27:52the lightning
27:53strike.
27:56Basically, the
27:57lightning hit the
27:58aircraft, flowed
27:59through the
28:00system, it
28:01impacted the
28:02diodes, which
28:04fried them, cracked
28:05them, took them
28:06offline, and that
28:07shut down the
28:08electrical systems
28:09on the aircraft.
28:12The odds of
28:14lightning taking out
28:15an entire
28:15electrical system
28:16are next to
28:18impossible.
28:19And yet, that's
28:20what happened.
28:23But this
28:24doesn't explain
28:25why the crew
28:26flew into the
28:26thunderstorm in
28:27the first place.
28:29Okay.
28:31The primary
28:33rule is, if you
28:34see a
28:35thunderstorm, no
28:36matter what its
28:37size, you
28:37avoid it.
28:38You go
28:40around, you
28:41divert, you
28:42hold, you do
28:43whatever you
28:43can.
28:44You do not
28:45want to fly
28:45through a
28:45thunderstorm.
28:53Investigators
28:54examine Nuremberg
28:55Air Service's
28:56flight operations
28:57manual to
28:58understand why
28:59the pilots of
29:00flight 108
29:01ended up in a
29:02thunderstorm.
29:04I don't get
29:04it.
29:05It clearly
29:06states flights
29:06in or near
29:07thunderstorms
29:07should be
29:08absolutely avoided.
29:09So why didn't
29:10they do the
29:11sensible thing
29:12and go around
29:13the storm?
29:14At that
29:15time, they
29:15had several
29:16possibilities.
29:18One possibility
29:19was just to
29:20prepare if they
29:21would fly through
29:22the thunderstorm,
29:23what could
29:24happen, what
29:25they have to
29:25do, what
29:26they have to
29:26prepare.
29:27Another
29:27possibility could
29:28have been just
29:30to divert to
29:31another airport.
29:33Let's have a
29:34listen to what
29:34the pilots were
29:34saying about
29:35the storm.
29:41Check the
29:41radar.
29:43Thunderstorm
29:44could be
29:44rolling in
29:45after all.
29:46Halfway
29:46through the
29:47flight, the
29:47crew learns
29:48there's adverse
29:49weather ahead.
29:51Maybe.
29:54Doesn't look
29:54particularly bad.
29:58I'll check the
29:59ATIS.
30:00The crew
30:01checks Dusseldorf
30:02Airport's weather
30:03service.
30:04Information
30:05Bravo at
30:06070.
30:07But there's no
30:07indication of a
30:08thunderstorm.
30:10Once they got
30:10the ATIS, their
30:11expectation bias was
30:12that the weather
30:13was getting
30:13better.
30:14Broken clouds
30:14at 1,500 feet.
30:17Nothing but a
30:18thunderstorm.
30:19We should be
30:19fine.
30:21The captain
30:22considers the
30:23information and
30:24makes his
30:24decision.
30:26Okay.
30:28We'll continue
30:29with the
30:29approach.
30:32They just
30:33assume best
30:34case scenario
30:34and don't do a
30:35proper briefing.
30:36As professional
30:37pilots, we always
30:38brief each other
30:39based off the
30:39worst conditions.
30:40You never know
30:40if that 10%
30:41probability of
30:42thunderstorms
30:42actually happens
30:43and if it does
30:44happen and it's
30:45too late, you
30:46don't have time
30:46to brief it.
30:51NFD-108.
30:53Eleven minutes
30:54later, the
30:54situation becomes
30:55more critical.
30:57Proceeding landing
30:58experienced a
30:59lightning strike about
31:00six miles final.
31:02If I were the crew
31:03and I were on
31:04approach and
31:04pursuing traffic in
31:05front of me were
31:06to get struck by
31:06lightning, at that
31:07point I would
31:08initiate a missed
31:08approach, go around
31:09and hold somewhere
31:10and figure out what
31:11we're going to do
31:11because the weather
31:12at that point is
31:13moving on to the
31:13approach path and
31:14you need to take
31:14that pretty seriously.
31:15But that's not
31:16what the pilots do.
31:19Dusseldorf approach,
31:19we copy and are
31:20looking outside.
31:22NFD-108.
31:33Hold on, they
31:35should be talking
31:36about deviating or
31:37go around here, not
31:38someone's weekend.
31:40They should have
31:40been deciding where
31:41they were going to go
31:42and what they were
31:42going to do instead
31:43of going down this
31:44rabbit hole.
31:44They just thought
31:45the other person's
31:45comfortable with it
31:46and will continue
31:46going if they're
31:47comfortable, I'm
31:48comfortable.
31:49Investigators
31:50continue listening to
31:51the CVR as the
31:53pilots prepare for
31:54landing.
32:10You're left of the
32:10center line.
32:11What?
32:13You're left of the
32:14center line, you
32:15need to turn right.
32:16The captain started
32:17deviating to the left
32:18apparently without
32:19telling the first
32:20officer of his plan.
32:21I don't want to go in
32:22there, I'm trying to
32:22get around it.
32:23We're too close to the
32:24runway, you can't
32:24change course now.
32:28Sounds like the
32:29captain is trying to
32:29deviate around the
32:30storm.
32:31And the first
32:32officer isn't on the
32:33same page.
32:34It's a bad idea to
32:35try and re-intercept
32:36the approach when
32:37you're already
32:37unstabilized, it's
32:38just a bad idea,
32:39you just do a go
32:39around.
32:40Oh.
32:41Huh.
32:48Okay, I hear
32:52again, no discussion of
32:54their options.
32:55There's some tension in
32:58the cockpit, there's
32:59some issue between the
33:01captain and the first
33:02officer, we don't know
33:04exactly what it was, but
33:07clearly this was not
33:09conducive to the crew
33:11working together to
33:13determine what was the
33:14best course of action.
33:16So now, the captain
33:18turns the plane directly
33:20into the thunderstorm.
33:24Hold on tight, here it
33:25comes.
33:26Mm-hmm.
33:33Neither crew knew what
33:34the other one was doing.
33:35They hadn't briefed for
33:36the weather, they didn't
33:37have the plane set up for
33:38flying around in the
33:39vicinity of
33:40thunderstorms, and they
33:41just kept going.
33:49Why wasn't this crew on
33:50the same page?
33:56The understanding of the
33:58investigation team at that
34:00time was the communication
34:01between both pilots was not
34:03in a way as it should be.
34:07What'd you find?
34:09Well, investigators examine
34:12personnel records for
34:14insight into the pilot's
34:15working relationship.
34:19The captain had a total
34:21of 2,473 flight hours, but
34:25only 277 hours in the
34:29Metro 3.
34:30That's not a lot of
34:31experience on type.
34:33No, it's not.
34:35The EFO had basically the
34:39same number of flight
34:41hours, but over 1,300
34:46hours in the Metro.
34:50Investigators discover that
34:52the first officer had much
34:53more experience on the
34:55Metro liner than the
34:56captain.
34:57Oh.
34:58With the crew having such an
35:00imbalance in time, the first
35:01officer is going to feel like
35:02they could be the captain
35:03that they got passed over
35:04for the upgrade.
35:05They have more experience on
35:06the routes.
35:06They have more experience on
35:07the plane.
35:08More experience with the
35:09airline, even in this case.
35:12She probably didn't trust
35:14his handling of the
35:14aircraft.
35:16That's never good in a
35:17cockpit.
35:20Did the pilot's imbalance
35:22in experience make it
35:24difficult for them to cope
35:25with a lightning strike.
35:31So they start making their
35:33descent here.
35:35Investigators examine how
35:37the pilots of flight 1-0-8
35:39flew the plane as they
35:40entered the thunderstorm.
35:42And then, a minute before
35:43they lose power, they start
35:44ascending again.
35:46Why would that happen?
35:49Let's hear what happens
35:50here.
36:01Okay, glide alive.
36:04Quarter flaps.
36:09Selected.
36:11Three minutes from the
36:12airport, the captain begins
36:14configuring the aircraft for
36:16landing.
36:17And half flaps.
36:22Half flaps, please.
36:23As they descend towards the
36:26runway, the captain rushes
36:28his flap settings.
36:30The plane is now climbing
36:32instead of descending.
36:34The captain requested the
36:36next flap setting, half
36:37flaps.
36:38The airplane then ballooned
36:41up, climbed an altitude
36:42400 feet.
36:44I'm not sure that was so
36:45good.
36:46The captain trims the
36:48plane's nose down to
36:50counteract the increase in
36:51altitude.
36:52In response to the 400
36:54foot climb, the captain
36:55trims the airplane.
36:56Rather than just putting a
36:57few bits of electric trim in,
36:59he holds the electric trim,
37:00pitching the nose down
37:01quite substantially.
37:03He then adds even more
37:05nose down trim.
37:11We're still slightly high.
37:19Okay, descending.
37:24With all that trim the captain
37:25has added, the plane is in a
37:27nose-heavy position when the
37:29lightning strikes.
37:41So now the captain loses the
37:43ability to recover.
37:44Mm-hmm.
37:46When the lightning strike
37:47happens, he loses electrical
37:48power, so he may have a lot
37:50more heavier flight controls
37:52than he was prepared for.
37:55And when the lightning strikes,
37:57the instrument lighting fails,
37:59making the instruments
38:00impossible to read.
38:02There's no emergency
38:04procedure in the Metroliner
38:05manual that tells you what
38:07to do if all your batteries
38:08fall offline.
38:09You're a test pilot, and at
38:10that point you use your
38:11pilot experience.
38:12One of the things to do was
38:14for the non-flying pilot to
38:15get a flashlight to illuminate
38:18the standby instrument to help
38:20the flying pilot out.
38:21The flashlights weren't found.
38:24We don't know if they were
38:25on the aircraft or not.
38:26The power failure cuts off
38:28their ability to see and to
38:30communicate with each other.
38:31They couldn't hear each
38:32other.
38:34We've lost electrical power.
38:38We have nothing!
38:40You've got a crew that can't
38:41communicate because you've
38:42lost the intercom system.
38:43You've got a headset on, and
38:44the Metro's a very noisy
38:45cockpit, so you can't hear the
38:46other person and what they're
38:47saying to you.
38:48If they couldn't see their
38:50instruments or hear what
38:51one another, could the pilots
38:53still fly their plane?
38:56They have aileron and rudder
38:58controls, which aren't
38:59electrical.
39:00The engines are still
39:01running.
39:03The runaway is about seven
39:05miles away.
39:07They should have been able to
39:08use the controls they did have
39:10to land the plane.
39:12They still had control over
39:14the ailerons, over the
39:15rudder.
39:15It was difficult, but
39:16technically still flyable.
39:18But without the ability to see
39:19their instruments, they'd have
39:21no way of knowing where they
39:22were.
39:27Seconds later, flight
39:28108 is diving towards the
39:31ground.
39:34The pilots had no chance to
39:36control the aircraft in a proper
39:39way because the light for the
39:40third artificial horizon was not
39:43there, and they had no visual
39:46ground contact.
39:47And I think under these circumstances, it's
39:50nearly impossible to control the
39:52aircraft.
39:56Investigators finally understand how a
39:58lightning strike caused a fatal crash.
40:09You're left of the center line.
40:11What?
40:12It starts with a poorly functioning crew.
40:14You're left of the center line.
40:16You need to turn right.
40:17I don't want to go in there.
40:18I'm trying to get around it.
40:19We're too close to the runway.
40:20You can't change course now.
40:22Okay.
40:23I hear you.
40:25Instead of giving him the advice
40:27or the two crew mentality that we're
40:29not where we should be, we shouldn't be
40:30here, the first officer chose to go the
40:33other route, which was shut down and
40:34only make the minimum calls, which were
40:35deviation calls.
40:37Half laps, please.
40:43The pilots decide to fly their nose-heavy
40:46aircraft into a thunderstorm.
40:52A powerful lightning strike.
40:54We've lost electrical power.
40:57Causes a total power failure.
41:00We have nothing!
41:01And the disoriented crew.
41:04Where are we?
41:05I can't tell.
41:06Loses control of the plane.
41:11500.
41:13400.
41:15300.
41:16Pull up, pull up, pull up.
41:21After you've been struck by lightning,
41:23you've got winds that are gusting all
41:24over the place.
41:25It starts to become a pretty violent
41:26situation pretty quick.
41:28The combination of turbulence and the
41:31pilot's blind actions lasting more than a
41:33minute sends the plane into extreme
41:36turns and banks.
41:40Are we banking?
41:41Can't tell.
41:42What's the airspeed?
41:43Don't worry about the speed, just pull.
41:44You think you can trust your senses, but
41:46you can't.
41:46You don't know if you're banking to the
41:48left, you don't know if you're banking to
41:49the right.
41:49You can't tell if you've got a nose low or a nose
41:51high.
41:52You can think you do.
41:53You can think you trust it.
41:55At the end of the day, your gut instinct
41:56will be wrong.
41:57The plane is so overloaded with the G-forces in
42:01these turns.
42:03It broke up.
42:06Yeah.
42:16Pull up, pull up!
42:17I'm crying!
42:20You're looking at a G-load that literally ripped
42:22the engine pylon off the wing, that literally
42:24broke the wing spar, the strongest part of the
42:26airplane, broke it like a toothpick that way
42:29exceeded what the aircraft manufacturer ever
42:31designed that airplane to go through.
42:49The main conclusion of the report by Germany's Air
42:52Accident Investigation Unit is clear.
42:55The crew flew into a thunderstorm, even though they
42:59could have flown around it.
43:02You have two fairly experienced pilots that they
43:04never, ever should have been in that situation.
43:07There were red flags throughout.
43:09If anything can be learned from this one, you've got
43:11to speak up on a two-crew airplane, you can't let the
43:13other person take you to the scene of the crash.
43:16In their recommendations, the FUS reiterates the need
43:20for training and manuals that clearly describe how to
43:24operate in and near thunderstorms.
43:27This is a very different crew than we see today, who are
43:32well-trained in cockpit resource management, who work
43:35together as a crew.
43:36And the systems change for the better, and the airplanes are
43:40much better.
43:42As for Nuremberg Air Service, the company soon replaced the
43:46remaining Metrolinas in its fleet.
43:48I made myself one of the last flights with the Metroliner.
43:52I had some tears in my eyes because I think it was not the
43:55aircraft's fault.
43:56The End
43:57너
43:58en
44:00en
44:01en
44:02en
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