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00:01While a passenger livestreams an approach into Pokhara Airport in Nepal...
00:06The plan is to go paragliding with my buddies!
00:13Add power!
00:16Yeti Flight 691 falls from the sky.
00:22What's happening?
00:2872 people are killed.
00:31This was the deadliest crash involving Nepali Airlines ever.
00:40Eyewitness video gives investigators their first lead.
00:44That's at least an 80-degree left bank.
00:50When they analyze the flight data...
00:53Wow.
00:54They're shocked to discover the engines weren't generating power.
00:59No power! Torque indication zero!
01:01There should have been warning lights.
01:03Why didn't they figure it out?
01:05You start to question, what was going on in the cockpit?
01:09B-B-B-B-B!
01:13Oh!
01:14Alright, let's go!elim
01:17,1.0.2,1.2.1,0.3.2.1.0.2... Yeti
01:34Airlines Flight 691 flies south of the Himalayan mountains in Nepal.
01:43There are 68 passengers on board, including Sonu Jaiswal, a tourist from India, heading to Pokhara to paraglide with friends.
01:57Pokhara Tower, Yeti 691, descending through 12,500 feet.
02:04Captain Kamal Casey is the senior officer and the pilot monitoring instruments on today's flight.
02:10Roger, Yeti 691, 12,500 feet.
02:15He's also a veteran of more than 21,000 flying hours.
02:22We had absolutely the utmost respect for Captain Kamal Casey as he was a veteran in the Nipleese skies.
02:30And he was quite a humble and knowledgeable guy as well.
02:36It's very clear. We'll be good for visual landing.
02:41Flying the plane from the left-hand seat is Captain Anju Katiwada.
02:46She's flown more than 6,000 hours.
02:50Captain Katiwada has a very special history.
02:54Her husband, he was a pilot with the same company.
02:57He was a first officer on the three-note there, and he did crash, and he died some years earlier.
03:04Katiwada decided to take up flying to honor his spirit, so she'd become a pilot.
03:118,500 feet.
03:13While Captain Katiwada is an experienced commercial pilot, she has only 186 hours on the ATR-72.
03:30The ATR-72 is a turboprop twin-engine aircraft.
03:35It's a high-wing aircraft.
03:38It's a very stable, predictable, and logical aircraft.
03:42And it's very good to fly here in the mountains and hilly regions of Nepal.
03:51Today's flight is a short 25-minute hop from Kathmandu to the tourist city of Pokhara.
04:02Yeti 691, expect to land on 12.
04:06Railway 12, Yeti 691.
04:1015 miles from the airport, Yeti flight 691 is cleared for the approach.
04:17Hey, everyone. Exciting times as we're headed to Pokhara's new airport.
04:21Sonu Jaiswal is live-streaming from the cabin.
04:24The plan is to go paragliding in the Himalayan foothills with my buddies!
04:33Three, one, zero.
04:35Captain Katiwada programs a heading for the approach to runway 12.
04:44You are in between the runway and the mountains.
04:48So you need to be very, very precise with your handling skills of the aircraft.
05:00The pilots monitor their position carefully, keeping the plane clear of the mountains.
05:09Yeti Airlines 691 in sight. Report final. Runway 12.
05:14Call you on final for runway 12. Yeti Airlines 691.
05:21You're down.
05:25Less than two minutes from the airport, the pilots configure the plane for landing.
05:31Okay, from here you can go manual.
05:33Okay, stand by.
05:38Disconnect.
05:40Captain Katiwada disconnects the autopilot,
05:43then begins the first of two crucial turns to line up with the runway.
05:56Okay, flaps 30.
05:58Flaps 30.
06:01Continue descent.
06:03Okay.
06:08One minute from touchdown, the pilots run through the pre-landing checklist.
06:13Okay, landing gear.
06:14Down three green.
06:16Flaps?
06:1630.
06:21In the cabin, Sonu Jaiswal continues live streaming.
06:26We're getting pretty close now.
06:30As the flight gets closer to the ground, the landing seems trouble-free.
06:41But seconds from the runway, Captain KC realizes there's a critical problem with the engines.
07:04Captain Katiwada tries to power up, but the engines aren't producing any thrust.
07:12400 feet above the pilots face.
07:13400 feet above the ground, the pilots face a critical situation.
07:20In the tower, the controller doesn't know that flight 691 is in any trouble.
07:25Getty 691, runway 12.
07:28Clear to land.
07:30There's no power.
07:32No power.
07:33Add power.
07:37Captain Katiwada pushes the throttles to the limit.
07:44There's no torque.
07:45Okay, give it to me.
07:48The more senior captain takes control.
08:04Flight 691 is stalling, while Sonu Jaiswal live streams the unfolding disaster.
08:21What's happening?
08:30What's happening?
08:41What's happening?
08:56Yeti flight 691 has crashed in one of the worst possible places.
09:03The Shethi river runs near to the airport through a huge gauze.
09:09That's where the plane crashed.
09:13The plane was completely destroyed in the impact.
09:18There was a huge flame burning.
09:23There was no possibility to find any survivor.
09:30The bodies of 71 of the 72 passengers and crew are eventually found and identified, including both pilots.
09:49What could have caused a commercial airliner to drop out of the sky just seconds before landing?
10:03When investigators arrive at the crash site of Yeti flight 691, they face a devastating scene.
10:13The wreckage was scattered all over the place.
10:18The first impact was before the river, where the parts of the left wing was detached.
10:24Some parts were located on the bottom of the river guards.
10:27And the rest of the parts were at the side of the river.
10:35Under the supervision of Nepali investigators, the wreckage, along with the black boxes and central processing card from the plane's
10:44computer,
10:45are sent for analysis to labs in France and Singapore.
10:51It's really not uncommon in an accident investigation to have to send something out for closer investigation.
11:05Nepali investigators wonder about flight 691's orientation when it hit the ground.
11:12Looks like this is from the first point of impact.
11:16That's a flap from the left wing and an aileron tip.
11:22So the left wing must have hit the ground first.
11:29The plane crashes winged down.
11:31What that suggests to investigators is that the plane crashed out of control.
11:36You would never intend to have it be that way.
11:39You'd always try and level it out and crash as close to a regular attitude as you can.
11:44Maybe the plane's stalled.
11:48You may be right.
11:50Check this out.
11:58It's gone viral.
12:05A witness had filmed the plane during the final moment of the flight.
12:11It appears that the left wing lost lift and dipped severely.
12:17That's at least an 80 degree left bank.
12:25It sure looks like a stall to me.
12:32When you see evidence that looks like a stall, you immediately start questioning what could have led to that, and
12:38you go back to what's going on during that approach.
12:48Did the pilots bank too far during the flight?
12:49This is not an easy approach.
12:51They'd have to fly between the runway and the mountain and make two left turns before lining up with runway
12:58one-two.
13:00And this is where the plane crashed?
13:02And just before the crash, they were beginning their final left turn.
13:08Did the pilots bank too far during one of the turns and stall?
13:15They would have had to go from zero to an 80 degree bank in a few seconds.
13:20Yeah.
13:23It suggests there was a problem with the plane.
13:26Yeah.
13:29You might want to focus and see if there's any smoking guns in the maintenance records.
13:33If there was anything wrong that somebody knew about, maybe they tried to fix it and it didn't get fixed.
13:40I've got maintenance records.
13:48Investigators go through the plane's records, in search of any gaps in maintenance or inspections.
13:56I'm not seeing anything.
13:59Everything checks out.
14:02Maybe the controller knows something.
14:06Yeah.
14:08The air traffic controller may have heard something in their conversation with the pilots.
14:13Picked up something that isn't really evident from the tape.
14:19Did you have visual contact with the aircraft?
14:27Did you see or hear anything suggesting a problem with the plane?
14:31No, I was flying normally when I had visuals with it.
14:34It was just out of sight right before the crash.
14:39Then I heard it.
14:43Explosion.
15:01Did the pilots say anything suggesting the problem with the plane?
15:05Nope.
15:05No, I'm not sure.
15:09Okay.
15:12So, do you know what happened?
15:19Not yet.
15:27In the early stages, you'd want to look at anything witnesses might have to say, anybody who might have seen,
15:33heard, or otherwise noticed the crash.
15:37The controller offers little insight into why the plane stall.
15:41Then a witness to the accident comes forward.
15:44There?
15:45That's where you saw the plane?
15:49He had the propeller.
15:51He had the propeller because he was an engineer.
15:53And you said that you saw the propeller spinning just before the crash?
16:01When you see a propeller rotating, it means it moves very slow.
16:05Otherwise, you cannot see it moving.
16:10The slow rotation of the propellers could indicate there was a problem with the engines that drive them.
16:24In the early stages, you were in the air.
16:26So, do you think it would be a good thing?
16:26I don't know.
16:27I don't know.
16:31Well, I'm not sure.
16:35I think it's a good idea.
16:45I don't know.
16:46I don't know.
16:46if they failed in flight most of the engines were consumed by fire so they
16:55couldn't learn definitively whether they were producing power
17:01look at that pop investigators noticed something telling on a propeller hub
17:12looks feathered
17:22when propellers are feathered their edges face forward and cannot produce thrust
17:29it's like putting your car in neutral position you can push on the gas as much as you want
17:35but nothing is going to happen
17:41it's actually stuck in a feather position
17:52this one moves freely but it could have moved on impact
18:01this one is stuck too so two of them were in the feathered position when they hit the ground
18:12normally propellers are feathered on the ground after shutdown that prevents them from spinning in
18:18the wind and damaging the engine there is however one exception an automatic feathering unit will
18:25feather that propeller immediately as soon as an engine failure is detected perhaps faster than the
18:31pilot can do it were the props feathered automatically in flight due to engine failure investigators download
18:41the data from flight 691 multi-function computer to find out the multi-function computer stores information
18:53they're going to be able to learn whether the auto feathering unit feathered one engine or both engines
19:09it never activated
19:12if you learn that the auto feather system didn't feather the propellers that immediately raises the question
19:19who or what did
19:23were the propellers feathered manually investigators consider a crucial piece of wreckage recovered from
19:29the scene the central control pedestal the central pedestal is located between the pilots and here you have
19:38the power levers you have the flaps lever and the other condition levers which controls the propellers
19:46the flaps are stuck at 30 that's where they should be for landing
19:54condition levers are moving freely
19:57oh it doesn't tell us much
20:02hmm look at this
20:10witness mark
20:13you're looking for witness marks the marks that one aircraft component makes against another
20:18at the time of impact and those marks will suggest in the case of the central control pedestal
20:25where the controls were positioned at impact
20:30the witness mark suggests that the pilots could have put the left lever in the feathered position
20:37maybe some other debris caused the witness mark there's no witness mark for the right condition lever
20:47were the propellers feathered by the pilots or did the witness marks occur on impact
20:53we're gonna need the flight data recorder download to settle this
21:01the flight data recorder doesn't record the propeller blade angle but it does record certain parameters
21:08that let investigators infer whether the propellers were feathered and if so when
21:30they find evidence that the pilots feathered the props one minute before the crash
21:38when the propellers are feathered the torque drops and the propellers rpm speed
21:43drops that's what the witness was able to see when he reported spotting the individual propeller blades
21:59what was going on in the pilot's mind what was going on in the cockpit
22:05what's happening
22:17pick it up 24 minutes into the flight right before the propellers were feathered
22:25investigators listen to the cockpit voice recording from yeti airlines flight 691
22:30to understand why the pilots feathered their propellers when they did
22:34okay from here you can go manual okay stand by
22:41disconnect
22:44okay flaps 30
22:47flaps 30
22:49continue descent
22:51okay
22:52stop
22:53where are we at here
22:57time is 10 56 35
23:04according to the fdr
23:07the flaps did not move to 30 at this point but this is when the props were feathered
23:16the fdr shows that when the pilot flying commanded flaps 30 the flaps didn't move but at the same moment
23:25the prop rpm decreased and torque went to zero
23:29the pilot has pretty obviously feathered the engines instead of moving the flaps
23:42they must have mixed up the flap levers with the condition levers
23:47and captain casey was the pilot monitoring
23:52how could a captain make that mistake
24:00in most airline accidents pilot error is a factor that can be because of inadequate
24:07training experience it can be because of too little rest but there can also be other factors impairing their decisions
24:18here you go
24:24the team reviews results from the pilots toxicology tests
24:28the team reviews results from the pilots toxicology tests
24:31nothing on captain katiwata
24:38same with captain casey
24:43maybe they weren't adequately rested
24:48according to the airlines records both pilot schedules were within guidelines
24:52suggesting adequate rest
24:54and their medical certificates are current
24:58they conclude that something other than impaired judgment caused the pilots to feather the props by mistake
25:05at this point you'd have to wonder what might have been going on in the cockpit
25:09that would lead him to be distracted into setting the propellers to feather instead of setting the flaps for landing
25:18did the location of the condition levers on the pedestal play a part in the captain's error
25:24they examine an atr 72 pedestal
25:29i reach over for the flaps
25:32but i put my hand on the condition lever instead
25:40the flap lever and the condition levers are very close together on the pedestal
25:46i want to move the flaps to the 30 degree position
25:51but instead
25:54i move the condition lever
25:57to feathered
26:00the flap and condition levers have the same range of motion and stop in similar positions
26:08it's not a stretch that they could have mixed up the levers
26:12and don't forget captain casey was where i'm sitting
26:17right
26:23muscle memory is very important for a pilot because you can do sequences without being conscious about it
26:30but when you move to the other seat on the other side
26:33suddenly that flow is disturbed because now you have to use the opposite hand
26:41oh that feels a lot less natural
26:46and much easier to mix up
26:52okay flaps 30
26:54flaps 30
26:58continue to sense
27:01the pilot monitoring move the condition levers instead of the flap lever that should be impossible but it has happened
27:09before
27:11i once asked for flaps and the pilot monitoring selected the gear down
27:17and those layers are far apart
27:21still it's hard to imagine looking at these levers that you'd get them confused
27:27true
27:35maybe he wasn't looking at them
27:40why would an experienced captain not check which levers he was moving
27:50okay
27:51okay visual visual
27:52okay visual
27:54investigators return to the voice recording of yeti airlines flight 691
27:59to determine if the captain's attention was elsewhere when he selected the wrong levers
28:04okay make sure you stay between the mountains and the runway
28:07they revisit the moment just before the propellers were feathered
28:12keep your power nose up
28:14keep visual with the tower don't go too far
28:17okay copy that
28:21okay stop for a second
28:25he's giving her a lot of instructions
28:29maybe that's the distraction
28:32but she's a very experienced pilot so why is he doing that
28:38when you're giving instruction that's an added mental stress it's an added cognitive load
28:43it's very distracting
28:46let's start from the top
28:49poker tower
28:50yeti airline 691
28:53yeti airline 691
28:57tower yeti 691 descending through 12 500 feet
29:03roger yeti 691 12 500 feet
29:07expect to land on runway 30
29:09runway 30
29:11runway 30
29:12yeti 691
29:15they discover that flight 691 was initially cleared to land on a different runway runway 30
29:23but eight minutes later there's a change of plan
29:26if traffic permits let's land on runway 12
29:30then you'll be approved for runway 12 without any instructor pilot supervision
29:35okay runway 12
29:38not only is he monitoring the flight he's approving her to land at pohra's new airport
29:45investigators discover captain casey was instructing pilots on how to land on both runways at the new airport
29:54i flew with captain kamal casey just two days before for my root qualification into pohra international airport
30:03but why runway 12
30:08you'll be approved to land in both directions
30:11copy that
30:17okay stop it
30:19so captain katewada is cleared for runway 30
30:24and captain casey decides much later in the game he's approving her for runway 12
30:31captain katewada had landed on runway 30 but never won two
30:37runway 30 is a straight-in approach
30:43and runway 12 you follow a narrow track next to the mountains
30:48you turn left twice to line up with the runway
30:52so captain casey put captain katewada on a more difficult landing
31:02runway 12 was a challenging approach for a pilot with just 185 hours on the area
31:09did captain casey properly prepare captain katewada for the difficult approach to runway 12
31:18the best way to prepare a pilot for such an approach would be to do a proper briefing
31:24maybe they have photos video simulator training if available
31:32investigators examine captain katewada's training records
31:38she spent no time in the simulator training on runway went to what about a formal briefing
31:44there's no documentation related to training on one two
31:48i've got captain casey's flight history
31:52was captain casey even qualified to train others for landing on runway one two
31:58turns out he had only landed on one two twice
32:03a bit of experience but not enough
32:09because of his low experience and also
32:12catewada's low experience on the aircraft i find that a bit strange
32:19i wonder if it's even possible to do a stabilized visual landing using that approach
32:33a stabilized visual approach is one that's conducted with the runway in sight
32:38at a normal rate of descent with landing flaps and landing gear down at the proper airspeed
32:45and with all checklists completed by a certain point
32:50there's just over one mile between the completion of the last turn and the runway
32:57that's going to give you just over 30 seconds from lining up to landing it's very tight
33:08a visual landing can increase the workload because they have to make tiny adjustments all the way
33:14through the pattern let's see how they handle the workload
33:20okay make sure you stay between the mountains and the runway
33:24to understand how the pilots dealt with the final approach to runway one two investigators return to the cvr
33:31keep your power nose up keep visual with the tower
33:36don't go too far okay copy that remember you need to make an early turn here
33:44okay a beam tower gear down gear down
33:54can i fly it manually wait wait not yet keep going straight after flaps 30 then you're good to go
34:02manual
34:04hold on captain casey is so focused on pointing out landmarks outside the cockpit
34:10he's not paying attention to what's happening inside the cockpit
34:16it's normal to let the less experienced pilot flood aircraft and the most experienced pilot do the analysis
34:24okay flaps 30. flaps 30.
34:32continue descent okay
34:39he probably didn't even look down to see what lever he was moving
34:43but there was still an opportunity to catch the mistake when they do the landing checklist
34:52the before landing checklist was an opportunity for him to look down
34:56at that control pedestal and see that he had moved the condition levers into feather
35:02i'm almost certain they could have recovered right up until the last few seconds
35:08did the pilots failure to follow their checklist ultimately determine their fate
35:19nepali investigators continue listening to the cvr of flight 691 to learn whether the pilots
35:26followed the proper procedures before landing before landing checklist
35:34okay
35:35okay landing gear down three green
35:38flaps 30. wait
35:42captain kariwata said the flaps are at 30 but according to the fdr they're still set at 15.
35:49neither pilot checked the flap settings
35:54if captain kc saw that the flaps were not at 30 he may have realized he had moved the wrong
36:00lever
36:01power management take off tlu
36:05low speed icing aoa
36:07okay check external lights on on complete
36:13they rushed it
36:17the before landing checklist was done very fast like bam bam bam bam bam bam and i don't any of
36:23them looked at
36:23the flap setting they just answered by memory
36:28oh and with the props feathered there should have been warning lights why didn't they figure it out
36:45when the propellers are feathered they're no longer providing power to the generators
37:18an aural and visual
37:20it's hard to tell why captain kamal kc responded checked to the electrical light
37:26check
37:28would you pull out a quick reference handbook and start working along electrical failure procedure
37:32or would you recognize hey i'm landing in less than 60 seconds let's just bring the plane in and deal
37:39with the problem on the ground
37:41we just continue right yes continue turn
37:49what's that click about
37:56fdr data shows this is where the flaps goes to 30.
37:59so he notices the flap is not set at 30 and corrects it
38:10and with so much workload all he sees is the flap leader and doesn't notice that the propellers are feathered
38:17when your workload increases you get tunnel vision and you see less
38:23that makes it very difficult because now you only focus on one thing
38:29okay but why doesn't he figure it out when the engines have dropped to idle
38:39seconds from the runway captain casey realizes there's an issue with the engines
38:44there's no power there's no power
38:48add power
38:51even though the pilots see the engines are at idle they are still unaware that the propellers are feathered
38:57there's no power there's no power there's no torque okay give it to me
39:07in desperation captain casey takes control of the plane
39:11you're landing sir no power torque indication zero
39:19getty 691
39:21what's happening
39:35he decided to fly the plane rather than try to diagnose the problem
39:49one thing a glance around the cockpit could have told him that he had feathered the propellers
40:01the final report of the nepali accident investigation commission
40:05concludes that the most probable cause of the accident was the inadvertent movement of both condition
40:12levers to the feathered position in flight
40:17what strikes me about this is that it was a very normal situation
40:21the only thing that went between success and failure was the slip of a hand
40:30the proximity to terrain and sharp turn required to land on runway one two
40:37before landing checklist combined with a high workload and a lack of appropriate training all contributed to the crash
40:47after the accident yeti airlines tests the approach in the simulator with their pilots
40:54most of our pilots were not able to land on runway one two
40:58either they were high on approach or they were fast on speed
41:06yeti airlines stops flying into runway one two until they are able to establish a safe visual procedure
41:13and retrain their pilots the commission recommends that the civil aviation authority of nepal
41:20ensures that a stabilized flight path is approved before allowing commercial operations at a new airport
41:30after the accident the victims of yeti air flight 691 are mourned by a nation and fellow pilots remember their
41:39colleagues
41:42and they are able to establish a safe way for us
41:42for captain kamal casey i just want to remember him when he was alive and he was there with us
41:53captain khatiboda i respected her a lot
41:58she will be remembered as an elder sister and there is going to be always a void in the airlines
42:07that
42:08she is not there anymore
42:11you
42:12you
42:13you
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