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00:02The plane came flying out of the bottom of the cloud at 4,000 feet per minute.
00:06Pull up! Pull up!
00:07Nuremberg Air Service Flight 108 breaks apart while the pilots attempt to land at Dusseldorf Airport in Germany.
00:17All passengers and crew are killed.
00:21Because of the size of the accident site, we use the grid to identify the positions of every part of
00:29the wreckage.
00:31Investigators reconstruct the plane to determine what happened.
00:36There must be a thousand pieces in here.
00:41Over here!
00:42They uncover evidence of a one-in-a-million failure that should not have brought the plane down.
00:47The pilots had no chance to control the aircraft in a proper way.
00:54I think under these circumstances, there was nothing they could have done.
01:00BD, BD!
01:04Pull up!
01:07There was a motion before we put in danger at 8 Rhodes.
01:10If you go on...
01:23It is an hour before sunrise at Hanover Airport in West Germany.
01:31Nuremberg Air Service Flight 108 prepares for the first flight sinon.
01:41of the day in the cockpit is 36 year old captain ralph borstorff how's the weather looking and 28
01:50year old first officer sybil hailman they each have 2 500 flying hours should be clear sailing
01:59both of them would be fairly typical what you would see in commuter operations people starting
02:05their careers and getting ready to move up the weather forecast predicts calm skies with only
02:12a slim chance of thunderstorms near their destination might get a bit rough on landing
02:17because of some turbulence and a chance thunderstorm but it's unlikely just 10 sounds good
02:26a 10 percent chance of thundershowers it's 10 chance you want to know about it but it's not
02:31something you're going to put too much thought into before flight 108 can depart snow and ice
02:39that accumulated overnight are removed this flight was a full flight had 19 passengers on board all
02:48those being business people it's a 40 minute flight from hanover to dusseldorf a major business hub on
02:56the rhine river we started the route in 1987 about six months before this flight and we had very weak
03:05train connections between the east and western parts of germany so from the very very beginning
03:11we had full airplanes flight 108 leaves hanover at 7 15 a.m 15 minutes behind schedule flaps
03:28retracted the pilots are flying a fairchild swear engine metroliner 3 it's a powerful turboprop plane
03:37designed for short commuter flights the metro 3 airliner is a perfect scaled down airliner it
03:44hauls 19 people fast fuel efficiently all the creature comforts of a bigger airline
03:49from the very beginning i was impressed by the airplane it was extremely well designed it was
03:57flexible it was fast they could pressurization so everything a pilot likes the airplane had
04:07it takes 10 minutes for flight 108 to reach its cruising altitude of 14 000 feet
04:16it will stay at that altitude for only 15 minutes
04:22well no rest for the wicked without the descent checklist will you
04:29regional flying is generally an hour and a half or less
04:32um leading to increased workload for the time that you are in the air
04:39check the radar the captain notices some weather on the radar thunderstorm could be rolling in after
04:48all maybe doesn't look particularly bad i'll check the atis
04:57atis continuously broadcasts updated weather conditions at the destination airport
05:03gusting 24 visibility 10 sky condition broken clouds at 1500 feet
05:12nothing but a thunderstorm we should be fine
05:16okay we'll continue with the approach their expectation was that the weather was getting
05:22better and any thunder showers hadn't really materialized good morning this is your captain
05:28speaking we have begun our descent into dusseldorf please ensure your seatbelts are fastened
05:33it should be landing in about 15 minutes
05:4430 miles from the airport
05:47dusseldorf good morning requesting to send to 3000 nfd 108
05:52first officer hailman contacts the dusseldorf approach controller for landing instructions
05:58nfd 108 good morning to you you are cleared to 3000 feet and currently number three to land
06:06copy to send to 3000 number three to land
06:10an atc gives us a indication of where we are on the order for landing it helps us set up
06:15it helps
06:15us get ready it helps us know when you're going to start putting flaps and gear down three minutes later
06:24localize your life flight one zero eight lines up with the runway's center line
06:36establish on the localizer
06:40the first officer checks on the weather
06:45looks like a thunderstorm has moved right in front of us
06:51it might be trouble
06:55thunderstorms have to be treated with respect i mean they can produce hail they can produce
06:58downdraft tailwinds overpowering what the airplane is capable of doing
07:05the captain decides to maneuver around the storm
07:14the problem was it's a big thunderstorm in the approach sector of dusseldorf
07:20they shouldn't fly through thunderstorms
07:25in the dusseldorf control center nfd 108 please switch to tower control frequency 118 decimal 30
07:33the approach controller hands over flight 108 to the tower
07:38nfd 108 confirm switch to tower control frequency 118 decimal 30 bye
07:49moments later flight 108 disappears from radar
07:59seven miles northeast of dusseldorf airport a maintenance worker at a sewage treatment plant
08:06hears the sound of an approaching airplane
08:10flight 108 breaks out of the clouds in a steep dive
08:14500 400 400 300 pull up
08:23the plane pulls up just in time
08:28the plane came flying out of the bottom of the cloud at 4 000 feet per minute the g-force
08:32it would
08:32have taken to overcome that to pull the airplane nose back up uh it was violent
08:37the sound of the engines recedes into the distance
08:42that flight would have been sheer terror
08:45sheer terror for the people in the back sheer terror up front you know you went from having a
08:48visual reference to thinking you're good to all of a sudden you're back in the cloud again
08:53a minute later the plane returns this time flight 108 spirals out of control
09:03and breaks up no no no it's a horrifying sight i can't even imagine what the person watching that
09:10would be thinking two minutes before dawn flight 108 slams into an open field on the banks of the ruhr
09:18river
09:26the wreckage is scattered over a wide area first responders make their way to the crash site
09:36all 19 passengers and both pilots are dead the metroliner itself is broken into thousands of pieces
09:46you're seeing that parts are distributed throughout the area you'll start collecting all the parts
09:53mapping where they are and trying to put this puzzle back together again
10:04investigators from germany's air accident investigation unit or f us begin mapping the
10:11wreckage of the wreckage of flight 108 to determine what caused the accident
10:16the first step was to identify the positions of every part of the wreckage and because of the
10:25size of the accident site we use the grid and we were able to get the information where every piece
10:33was at the accident site much of the plane along with its black boxes are badly
10:42damaged the recorders in this aircraft aren't the new digital type of recorders which record 300 400
10:49parameters this was the old foil style recorders you had altitude airspeed you had heading some
10:58information at g loads you didn't have the data we have today by a long shot the black boxes and
11:05the
11:05debris are sent to a warehouse where investigators begin their analysis once the parts are recovered
11:14taken to a facility you could then clean where the fractures where the separations are you can look
11:21look at where a part broke apart the wings the engines the tail sections separated from the aircraft
11:33investigators try to confirm witness statements that the plane broke up before it crashed
11:41this piece looks compressed this piece looks compressed like it came from a high energy impact
11:48but this piece is intact what that indicates is this intact piece of wreckage did not go to the
11:58accident site with the rest of the airplane for sure an inflate breakup the team is now convinced
12:05that flight 108 broke up before hitting the ground the question is what led to that is there any evidence
12:14of a
12:14pre-existing failure that would have led to the accident
12:19hey can you uh bring that piece over to the table
12:23did a design flaw or some kind of failure create a fatigue crack causing the wings to break off before
12:31impact
12:33even though the airplane is fairly new you don't rule out anything was there a flaw in manufacturing was
12:40there a full drilled where it shouldn't have been drilled was there some other issue that would cause a
12:45crack to start growing very early in aircraft's life well this doesn't look like a fatigue crack at all
12:54it can only mean one thing overload fracture
13:04overload fractures can occur because the airplanes exceeded speed limits uh flight control inputs are
13:11severe uh severe turbulence can cause overload and sometimes you have a combination of all three coming
13:18together hey can you get the lights what pushed this plane past its structural limits investigators examined
13:27the plane's flight path for clues
13:34nothing unusual here
13:38the flight path from departure in route to arrival for landing seemed normal
13:46what happened to this part the end of the flight
13:53oh look at that they discovered that the pilots flew an erratic flight path before the plane crashed
14:02that would certainly cause a structural overload agreed the crew was on approach and now suddenly goes
14:13through some very tight maneuvers and you piece that together put the wreckage you found and where it was found
14:21and that gives you a much better idea of what led to the accident
14:27investigators speak to the controller who oversaw the approach of flight 108 to determine what
14:33what might have caused the unusual flight path tell me about the night of the crash
14:39uh there was thunderstorm activity from about 7 40 until just after 8 a.m
14:49did your other flights run into any trouble they reported moderate icing and turbulence but
14:56everyone else landed without incident okay no go-arounds no missed approaches no okay no
15:06uh but about six miles out a 737 got hit by lightning
15:16so we just experienced a lightning strike at 3 000 feet six miles final no immediate issues
15:24lufthansa 1354 dusseldorf approach roger let me know if you require further assistance
15:30typically when we're concerned about thunderstorms in the airport vicinity
15:34it's not much about the lightning it's more about the winds and the wind shears that can be powerful
15:38enough to push the airplane into the ground since airplanes are made of aluminium which conducts
15:44electricity most lightning strikes flow over the skin of the fuselage and safely exit through the tail
15:51i remember one occurrence of flying the aircraft got hit by lightning there was a sudden flash outside
15:57the fuselage you could hear it and the airplane kept on going and there was no associated damage to
16:06the aircraft and we continued on did you report the lightning strike to flight 108 yes nfd 108 the
16:14preceding landing experienced a lightning strike about six miles final dieseldorf approach we copy and are
16:22looking outside nfd 108
16:26for flight crews it is not abnormal to deal with thunderstorms and to deal with the probability
16:32of some lightning this flight was very very usual okay thank you for your time if it wasn't the weather
16:42that caused the pilots to push the plane past its structural limit what did
16:51will flight 108's black boxes provide clues as to why the plane broke up mid-flight
17:00it's not looking good how so
17:07flight data recording and the cockpit voice recording both stopped two minutes before the plane crashed
17:13at the exact same time that the plane started flying erratically a total power failure
17:22the cdr and fdr get their power from two separate sources so the fact that both these recorders
17:29stopped at the same time indicates whatever happened affected both electrical systems not just the one
17:36the metro liner's electrical system is powered by two generators in the event of a power failure
17:43two batteries act as a backup system
17:48but if it was a total power failure that means the backup system filled as well
17:55how's that even possible
17:58from the perspective and the explanations coming from the manufacturer the possibility of a total
18:04electrical loss was very low but during the course of the investigation we understood
18:10more and more that it could be that the flight crews had a total electrical loss
18:17investigators consider the effects of a total power failure
18:21they would have lost most of their instruments well except their vertical speed indicator the altitude
18:28and the third attitude indicator
18:32our metro liners have been installed with a third independent uh artificial horizon it used bleed air
18:42coming from the engine and as long as the engine was running the artificial horizon was working as well
18:48totally independent from electricity the standby non-electrical artificial horizon could have been used by the crew
18:56to help keep the aircraft level and straight
19:03and then the complexity of this accident gets into why didn't the crew effectively use that standby
19:10but even with limited instruments who's to say they could have even seen them
19:14oh good point the lights that illuminated the instruments may not have been working
19:19huh
19:22you need those instruments and if you can't see them then you don't know if you're up or down
19:25you're flying blind at this point
19:39to confirm the unlikely finding of a total electrical failure the team examines light bulbs from flight 108's instrument panel
19:50if the light bulb was on when the plane hit the ground the hot and pliable filament inside would be
19:56stretched
19:58but if the light was off the cold brittle filament
20:03would break upon impact
20:07all these filaments are broken
20:11the outcome was that we found no bulb which was under electrical power during the impact of the aircraft
20:23investigators now have conclusive evidence of a sudden total power failure
20:31but what could have caused it
20:34the controller did tell us that another plane got struck by lightning
20:40maybe this one did too
20:43a lightning strike outside of the aircraft could lead to a problem with the electrical system
20:49inside of the aircraft if the electrical field of a lightning strike is very very high
20:56could be induced into the aircraft
21:01investigators search for evidence of lightning striking the fuselage of flight 108
21:10there must be a thousand pieces in here
21:14it's a painstaking process lightning could have struck anywhere
21:19lightning marks on the skin would look like a circle you'll see the paint burned you may see some
21:26localized melting of the metal in that particular area
21:35over here
21:40what do you got
21:42i found it
21:45huh once you've found a piece of metal the lightning strike
21:48it's like okay where does it go on the airplane what's in the proximity of this is it
21:54next to the electronics is it next to hydraulics where is this lightning strike occurring
22:01the only way to determine where the mystery piece comes from is to reconstruct sections of the airplane
22:10at the time of this accident uh reconstructions were fairly typical mainly didn't have as much data as we
22:18now so reconstructing it made sense
22:30i think i've got it investigators match the piece of the plane to the left side of the fuselage
22:36forward of the wing this is where the lightning struck
22:41but could a lightning strike in front of the left wing actually cause a total electrical failure
22:49there are power system lines running right behind where the lightning struck
22:54can't be a coincidence
22:57is it possible that that lightning strike entered the electrical wires on the other side
23:03and therefore led to the loss of electrical power so that would have been the real focus
23:08the investigation at this point
23:16investigators examine what remains of flight 108's electrical wiring in search of evidence that
23:23the lightning strike jumped from the fuselage to the electrical system
23:29you would look for the insulation material the outsides and burned away
23:35is there melting inside the wires evans that somehow electrical energy got through the installation barrier
23:42into the wiring uh and then was starting actually melting the wires locally
23:49how odd those signs of arcing
23:57we checked the wiring we checked the electronic components available from the wreckage for some
24:03indication for electrical overload
24:13finding a lightning damage to the wiring not yet it's very possible once the lightning gets into the fuselage
24:21you may not see any direct impact in that area it flows into the aircraft and so even wiring as
24:30close by may appear to be unaffected but now this high energy has gotten into the airplane
24:36and the question is where does it go maybe i can find something in here
24:42after we found no evidence for damage in the wiring based on the lightning strike we had to do a
24:51deeper
24:52investigation within the investigation within the systems and that means we had to look for damages in the avionic components
25:02the team now focuses on even smaller components of the electrical system
25:08the diodes
25:10let's check this out
25:15a diode is an electrical component that allows current to flow in one direction only preventing reverse
25:23current flow that could damage circuits or create malfunctions
25:30if the diode is working properly there should be resistance to high current flow
25:35current flow in one direction and not the other
25:42only 50 ohms almost nothing now the reverse
25:55also 50 ohms
25:58but investigators discover low resistance to current flow in both directions it's shorted
26:11the outcome of our investigation of the diets was that all diodes um were open in both directions
26:18that means the diets were shorted the question now was why
26:25we decided to take these to a manufacturer and to ask them to do a deeper investigation
26:35results are in to better understand why the diodes shorted they examine test results provided by the manufacturer
26:43oh that's interesting looks like cracks in the center of the diode
26:55once you've seen that a diode has failed then you can do tests and research on a good diode to
27:01see
27:01how much energy you would take basically to fry that diode
27:06voltage tests are done to determine if the cracks in the diodes were the result of a lightning strike
27:12or something else
27:15a thousand volts
27:23a lightning bolt can carry hundreds of millions of volts more than enough energy to crack the diode
27:30it must have been lightning
27:33the damage of the diodes uh only can be produced by high voltage
27:41could it be possible that high voltage would be produced within the aircraft and the answer was
27:49you know it could be only produced by the lightning strike
27:56basically the lightning hit the aircraft flowed through the system it impacted the diodes which fried
28:04them cracked them took them offline and that shut down the electrical systems on the aircraft
28:12the odds of lightning taking out an entire electrical system are next to impossible and yet that's what happened
28:23but this doesn't explain why the crew flew into the thunderstorm in the first place
28:28okay
28:31the primary rule is if you see a thunderstorm no matter what its size you avoid it
28:39you go around you divert you hold you do whatever you can you do not want to fly through a
28:45thunderstorm
28:46uh
28:53investigators examine nuremberg air services flight operations manual to understand why the pilots of
29:00flight 108 ended up in a thunderstorm i don't get it it clearly states flights in or near thunderstorm
29:07should be absolutely avoided so why didn't they do the sensible thing and go around the storm
29:14at that time they had several possibilities one possibility was just to prepare if they would fly
29:22through the thunderstorm what could happen what they have to do what they have to prepare
29:27another possibility could have been just to divert to another airport let's have a listen
29:34to what the pilots were saying about the storm check the radar
29:43thunderstorm could be rolling in after all halfway through the flight the crew learns
29:48there's adverse weather ahead maybe doesn't look particularly bad I'll check the eaters the crew
30:01checks Dusseldorf Airport's weather service information Bravo and 070 but there's no
30:07indication of a thunderstorm once they got the latest their expectation bias was that the weather
30:13was getting better broken clouds at 1,500 feet nothing but a thunderstorm we should be fine
30:21the captain considers the information and makes his decision okay continue with the approach
30:32they just assume best-case scenario and don't do a proper briefing as professional pilots we always
30:38brief each other based off the worst conditions you never know if that 10 probability of thunderstorms
30:42actually happens and if it does happen and it's too late you don't have time to brief it
30:5311 minutes later the situation becomes more critical proceeding landing experience a lightning strike about six miles final if I
31:03were the crew and I were on approach and
31:04pursuing traffic in front of me where to get struck by lightning at that point I would initiate a missed
31:08approach go around and hold somewhere and figure out what we're going to do because the weather at that point
31:13is moving on to the approach
31:14probably you need to take that pretty seriously but that's not what the pilots do
31:18but that's not what the pilots do
31:19Dusseldorf approach we copy and are looking outside
31:22nfd108
31:28hey did you hear what happened to walter last weekend yeah not surprised
31:33hold on they should be talking about deviating or go around here not someone's weekend
31:40they should have been deciding where they were going to go and what they were going to do instead
31:43of going down this rabbit hole they just thought the other person's comfortable with it will continue
31:46going if they're comfortable uncomfortable investigators continue listening to the cvr as the pilots prepare
32:08for landing
32:10you're left of the center line what you're left of the center line you need to turn right
32:16the captain started deviating to the left apparently without telling the first officer of his plan
32:21i don't want to go in there i'm trying to get around it we're too close to the runway you
32:24can't change
32:25course now
32:28sounds like the captain is trying to deviate around the storm and the first officer isn't on the same page
32:34it's a bad idea to try and re-intercept the approach when you're already unstabilized
32:38it's just a bad idea you just do a go around
32:47okay i hear you
32:52again no discussion of their options
32:56there's some tension in the cockpit there's some issue between the captain and the first officer we
33:03don't know exactly what it was but clearly this was not conducive to the crew working together
33:12to determine what was the best course of action so now the captain turns the plane directly into the
33:21thunderstorm
33:24hold on tight here it comes
33:33neither crew knew what the other one was doing they hadn't briefed for the uh weather that they
33:37didn't have the plane set up for flying around in the vicinity of thunderstorms and they just kept going
33:49why wasn't this crew on the same page
33:56his understanding of the investigation team at that time was the communication between
34:02both pilots was not in a way as it should be
34:07what'd you find well investigators examine personnel records for insight into the pilot's working
34:16relationship
34:19the captain had a total of 2473 flight hours but only 277 hours in the metro three
34:31that's not a lot of experience on type no it's not
34:35the foo had basically the same number of flight hours but over 1300 hours in the metro
34:50investigators discover that the first officer had much more experience on the metro liner than the
34:56captain with the crew having such an imbalance in time the first officer is going to feel like
35:02they could be the captain that they got passed over for the upgrade they have more experience on the
35:06routes they have more experience on the plane more experience with the airline even in this case
35:12she probably didn't trust his handling of the aircraft that's never good in a cockpit
35:20did the pilots imbalance in experience make it difficult for them to cope with the lightning strike
35:31so they start making their descent here
35:35investigators examine how the pilots of flight 108 flew the plane as they entered the thunderstorm
35:41and then a minute before they lose power they start ascending again why would that happen
35:49let's hear what happens here
36:00okay glide alive
36:04quarter flaps
36:09selected
36:11three minutes from the airport the captain begins configuring the aircraft for landing
36:16and half flaps
36:22half flaps please
36:24as they descend towards the runway the captain rushes his flap settings
36:30the plane is now climbing instead of descending
36:33the captain requested the next flap setting half flaps the airplane then ballooned up climbed an altitude 400 feet
36:44i'm not sure that was so good
36:46the captain trims the plane's nose down to counteract the increase in altitude
36:52in response to the 400 foot climb the captain trims the airplane rather than just putting a few
36:58bits of electric trim in he holds the electric trim uh pitching the nose down quite substantially
37:03he then adds even more nose down trim
37:11we're still slightly high
37:20okay descending
37:24with all that trim the captain has added the plane is in a nose heavy position when the lightning strikes
37:41so now the captain loses the ability to recover
37:44mm-hmm
37:45when the lightning strike happens he loses electrical power so he may have a lot more heavier flight controls
37:52than he was prepared for
37:54and when the lightning strikes the instrument lighting fails
37:58making the instruments impossible to read
38:03there's no emergency procedure in the metroliner manual uh that tells you what to do if all your batteries fall
38:08offline
38:08uh you're a test pilot and at that point you use your pod experience
38:12one of the things to do was for the non-flying pilot to get a flashlight
38:16to illuminate the standby instrument to help the flying pilot out the flashlights weren't found we don't know if they're
38:25on the aircraft or not
38:26the power failure cuts off their ability to see and to communicate with each other they couldn't hear each other
38:33we've lost electrical power
38:40you've got a crew that can't communicate because you've lost the intercom system
38:43you've got a headset on and the metro is a very noisy cockpit so you can't hear the other person
38:47and what they're saying to you
38:48if they couldn't see their instruments or hear one another could the pilots still fly their plane
38:56they have aileron and rudder controls which aren't electrical
39:00the engines are still running the runaway is about seven miles away
39:07they should have been able to use the controls they did have to land the plane
39:12so they still had control over the ailerons over the rudder it was difficult but technically still
39:17flyable but without the ability to see their instruments they'd have no way of knowing where they were
39:34they're not going to be able to be able to control the aircraft in a proper way because the light
39:40for the
39:40third artificial horizon was not there and they had no visual ground contact and i think under these
39:48circumstances it's nearly impossible to control the aircraft
39:56investigators finally understand how a lightning strike caused a fatal crash
40:09you're left at the center line what it starts with a poorly functioning crew
40:14you're left of the center line you need to turn right
40:17i don't want to go in there i'm trying to get around it we're too close to the runway you
40:20can't
40:20change course now okay i hear you instead of giving him the advice or the two crew mentality that
40:29we're not where we should be we shouldn't be here the first officer chose to go the other route which
40:33was shut down and only make the minimum calls which were deviation calls half flaps please
40:43the pilots decide to fly their nose heavy aircraft into a thunderstorm
40:52a powerful lightning strike we've lost electrical power causes a total power failure we have nothing
41:02and the disoriented crew where are we i can't tell loses control of the plane
41:12500 400 300 pull up pull up pull up
41:21after you've been struck by lightning uh you got winds that are gusting all over the place starts to
41:25become a pretty violent situation pretty quick the combination of turbulence and the pilot's blind
41:32actions lasting more than a minute sends the plane into extreme turns and banks
41:40are we banking can't tell what's the airspeed don't worry about the speed just pull you think you can
41:45trust your senses but you can't you don't know if you're banking to the left you don't if you're
41:48banking to the right you can't tell if you've got a nose low or a nose high uh you can
41:53think you do you
41:54think you trust it at the end of the day your gut instinct will be wrong the plane is so
41:59overloaded
42:00with the g-forces in these turns it broke up yeah
42:16pull up pull up i'm crying you're looking at a g-load that literally ripped the engine pylon
42:23off the wing that literally broke the wings bar the strongest part of the airplane broke it like
42:27a toothpick that way exceeded what the aircraft manufacturer ever designed that airplane to go
42:49the main conclusion of the report by germany's air accident investigation unit is clear
42:55the crew flew into a thunderstorm even though they could have flown around it
43:02you have two fairly experienced pilots that they never ever should have been in that situation
43:07there were red flags throughout if anything can be learned from this one you got to speak up on
43:12a two-crew airplane you can't let the other person take you to the scene of the crash
43:16in their recommendations the fus reiterates the need for training
43:21and manuals that clearly describe how to operate in and near thunderstorms
43:27this is a very different crew than we see today who are well trained on copied resource management
43:34who work together as a crew and the systems change for the better and the airplanes are much better
43:42as for nuremberg air service the company soon replaced the remaining metrolinas in its fleet
43:49i made myself one of the last flight with the metroliner i had some tears in my eyes because i
43:54think it was
43:55on the aircraft's fault
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