- 2 日前
Air Crash Investigation S25E04 - Second Thoughts - Luxair Flight 9642
カテゴリ
😹
面白系トランスクリプション
00:01Descending into heavy fog above Luxembourg.
00:05What the hell is that?
00:07Something goes disastrously wrong on Luxair flight 9642.
00:12The airplane was impossible to recover.
00:1720 of the 22 people on board are killed.
00:21A lot of people died that day.
00:23It was an accident, it was hard to understand.
00:25I can't find anything wrong with either engine.
00:28But when investigators analyze unusual sounds from the cockpit...
00:34It's a match?
00:36They hear the pilots do something which should be impossible.
00:40It's not supposed to happen.
00:42There's supposed to be things that prevent it from happening.
00:44So it's not as foolproof as we thought.
01:14It's just before 10 in the morning at Luxembourg's International Airport.
01:19A layer of fog blankets the runway, preventing planes from landing.
01:25Cargo Lux 778. Maintain runway heading until Lutax. Then use zone navigation.
01:32Luxair 403. Enter Decurch hold flight level 60. I will vect you later for ILS approach.
01:40Controllers are busy putting planes into a holding pattern while waiting for the fog to clear.
01:46Luxair 4452. Enter Decurch hold flight level 90. QNH is 1023.
01:53Luxair 8362. Descend level 80 to enter Decurch hold. Current RVR is 250.
02:02There are three planes circling 16 miles north of the airport at a position known as Decurch.
02:10In a situation with low visibility, lots of holding, lots of aircraft having different requirements.
02:18The level of stress is fairly high. Focus is really important.
02:23You've got to concentrate on everything that you're doing.
02:28Luxair 9642. Enter Decurch hold flight level 90.
02:32It will be vectors later for ILS approach on runway 24.
02:36That's all understood. Luxair 9642.
02:41One of the planes being directed to the holding pattern is Luxair flight 9642.
02:47The plane is a Fokker 50 turboprop heading to Luxembourg from Berlin.
02:53The Fokker 50 was a great performing aircraft overall.
02:57As a commuter airplane to be flown in Europe, we flew the aircraft day and night in all weather conditions.
03:05There are 19 passengers on the flight. Most are German business officials traveling to Luxembourg.
03:14The first officer on this morning's flight is 32-year-old John Arendt.
03:19I'll brief the folks.
03:22Ladies and gentlemen, good morning.
03:24Unfortunately, the fog in Luxembourg is so dense that at the moment we cannot land.
03:30So we'll have to wait a little bit for an improvement.
03:33We will proceed to a holding pattern while we wait for the weather to clear.
03:38We'll keep you updated as soon as we have some news.
03:43The captain is 26-year-old Claude Perkus.
03:47And Luxair 9642 is reducing speed to 160.
03:55Roger, 9642.
03:58The crew navigates towards the holding area north of the airport.
04:03What time can we hold till? How much fuel do we need?
04:09Uh... 550... 700.
04:12No, we'll need 850 when we leave the hold.
04:16No, we need fuel to reach till our alternate plus 20 minutes reserve, so we'll still need 600 kilos.
04:23Yes, but I want to keep...
04:24Luxair 9642. Descend to 3,000 feet on 1023. Turn left heading 130.
04:32Before they reach the holding point, the crew receives instructions to turn towards the airport and begin descent.
04:41Is that for us?
04:43Yes.
04:45Descend to 3,000 feet and say again the heading.
04:48130.
04:50130.
04:51Left heading 130.
04:53Luxair 9642.
04:55What kind of crap is that?
04:57The new instruction takes the crew by surprise.
05:02If you suddenly get startled that you are now number one and turning left and descending for your approach as
05:11number one, this can put you in a situation which would add to your workload.
05:17Let's see RVR now.
05:19I don't know. Should we check with dispatch?
05:22Yes.
05:24RVR is runway visual range.
05:27It's the minimum visibility on the runway required by a landing aircraft.
05:32For the Luxair Fokker, that distance is 300 meters or 984 feet.
05:39If the runway visual range is below 300 meters, you are not allowed to start the approach or to land
05:46the aircraft.
05:48Dispatch, 9642. What's the current RVR?
05:51Uh, 275.
05:54275 meters. What do we do now?
05:57I don't know.
06:00If they don't have that visibility, they go around and probably get vectored for another approach unless the RVR is
06:06too low, then they're going to be vectored to the holding pattern that decars.
06:11So, are we holding or is this for an approach?
06:13It's for an approach.
06:15Luxair 9642.
06:16Turn right heading 220. Cleared for approach.
06:249642.
06:27Tell them if at echo we don't have 300 meters, we'll do a go around and enter the hold.
06:32The pilots come up with a compromise. They'll continue their approach, but if runway visibility doesn't improve, they'll abort and
06:41join the holding pattern.
06:44We need 300 meters for the approach.
06:479642, copied. Continue your approach. I'll keep you advised.
06:54Passengers still believe they're headed for an extended hold.
07:02Speed's 95, 105, 109.
07:08Landing altitude?
07:10275 meters. Set.
07:14The flight is now only five miles from the runway, and there's no word that visibility has improved. Captain Pukis
07:22makes his decision.
07:23Okay, we'll do a go around. Missed approach. Ground idle stop off.
07:32Luxair 9642. RVR is 300 meters.
07:36But before the crew can execute a go around, the controller issues a last minute update to runway conditions.
07:459642 continuing approach.
07:49The visibility now meets the Fokker's minimum requirements. The crew's plans have changed again.
07:57Things change rather quickly for a flight crew when they're doing an approach, which requires really precise coordination among the
08:04crew members to make sure that everything goes smoothly and that they're stabilized on the approach.
08:10Four miles from the airport, flight 9642 is at an altitude of 1500 feet.
08:19Flaps?
08:21Uh, we are flapsed in.
08:259642, you are cleared to land. Wind 180 degrees, 5 knots.
08:33Uh, gear down?
08:35Yeah.
08:36Cleared to land, 9642.
08:41The flight is now two minutes from landing in Luxembourg.
08:52What the hell is that?
08:56Something has gone wrong with the engines.
09:00What the hell is that?
09:03Oh.
09:06Now at less than 500 feet, flight 9642 plummets towards the ground.
09:13Brain. Brain.
09:15Oh.
09:17Pull, pull, pull, pull, pull, pull, pull, pull, pull!
09:21The airplane suddenly went into a rapid and uncontrollable descent in a very low altitude,
09:29which was impossible to recover.
09:31It was impossible to recover.
09:459-6-4-2 Luxembourg.
09:49Luxair 9-6-4-2 Luxembourg.
09:53Luxair 9-6-4-2 Luxembourg. Do you read?
10:01We have a possible crash of a Fokker F-50 on final approach to runway 27. Please stand by.
10:13The wreckage is located two miles east of the airfield.
10:19Of the 22 people on board, only two survived the crash, including Captain Perkis.
10:26This is Luxembourg's deadliest aviation disaster.
10:32This accident is serious because it was a loss of life. A lot of people died that day.
10:37And it was an accident that was hard to understand.
10:42Investigators will need to examine the wreckage of flight 9642 to determine why a landing at a modern, well-equipped
10:50airport went so terribly wrong.
10:58The tail hits here, the left wing scrapes some trees, and then the plane skids across the road.
11:07The wreckage tells investigators that flight 9642 hit the ground in a nose-up position.
11:15The initial hypothesis would be that, in fact, they were trying to avoid the ground when the aircraft hit the
11:21ground.
11:22Engine failure, wind shear, mechanical issue.
11:27The debris pattern leaves investigators with a few obvious possibilities.
11:34Aircrafts don't crash short of runways. Do they have false indications?
11:38Were the engines running? So there are lots of things you have to initially think about.
11:43As they gather wreckage from the accident site, investigators wonder if the controller can provide any insight into the flight's
11:51final minutes.
11:53Anything unusual? Out of the ordinary?
11:56The whole day was out of the ordinary.
11:59The controller explains that the weather prevented planes from landing, forcing them into a hole.
12:08And that includes flight 9642?
12:10At first, yes.
12:15Luxair 9642, enter Decurch hold, flight level 90.
12:20But before they reach the hold, the weather cleared.
12:24Luxair 9642, descend to 3,000 feet on 1023, turn left heading 130.
12:32He also states that because of its position, flight 9642 was the first plane directed to the airport when the
12:40weather began to clear.
12:43They needed 300 meters of visibility to land, which we got at 10.05.
12:48So I cleared them to land.
12:51Even though they were heading for the holding pattern, the controller saw an opportunity.
12:55They were in an ideal position to the final approach fix at also the Luxembourg airport.
13:03And then?
13:05That's the last we spoke.
13:07No emergency call?
13:09No. Nothing.
13:13The controller can't explain why the Fokker ended up hitting the ground two miles from the airport.
13:22From air traffic control standpoint, there was nothing in the communication between the aircraft and air traffic to indicate that
13:30there was any problem whatsoever with the aircraft at all.
13:34Only Captain Puckers can answer why the Fokker went down short of the runway.
13:38But he's been hospitalized and is in a coma.
13:42Investigators will need to piece together the final minutes of the flight without him.
13:46With the captain not being available, the objective evidence, the physical evidence, talks to you.
13:54They begin by studying the engine components for any signs of failure.
14:01They look like they're in pretty good shape.
14:04Engines normally hold the aircraft in the air and they fly towards the runway.
14:10So I would suggest something happened to the engines that they didn't make it to the runway in the first
14:16place.
14:19No fire. No damage to any components.
14:22The rotors are fine. Fuel lines are intact.
14:25Intake is clear. Pumps and PCUs all check out.
14:29I can't find anything wrong with either engine.
14:33The state of the engines is puzzling.
14:36If both were in good working order, what could have caused the flight to fall from the sky just short
14:42of the runway?
14:46This is where they're turned for the approach.
14:51Investigators use Luxembourg's radar data to recreate Flight 9642's flight path.
14:57Seven minutes to impact.
14:59They're at 9,000 feet when they're cleared for the approach.
15:02Now, he descends even more steeply and at 7,000 feet per minute.
15:08They're only four miles away from the runway.
15:11Fifteen seconds later, they hit the ground.
15:16Here's the glide slope.
15:20Whoa.
15:22When investigators compare the plane's descent with the recommended descent, they see that the flight was 300 feet too high
15:31throughout the final stages of its approach.
15:35That explains why they were in such a hurry to lose altitude.
15:40300 feet above the glide slope, this is a real problem because you now try to descend the aircraft, slow
15:49down the aircraft and configure everything at the same time, which is nearly impossible.
15:56Why did the pilots allow their plane to get into such a difficult situation?
16:01Not a good idea to be rushing under approach at all, especially in low RVR.
16:05Dangerous, actually.
16:12Heavy fog.
16:14It'll be a hard landing.
16:15The team listens to Flight 9642's Cockpit Voice Recording, or CVR, for clues that can explain the pilot's dangerous predicament.
16:26Okay, they know the weather's going to be an issue.
16:29I'll call dispatch.
16:31Dispatch.
16:32Dispatch, good morning.
16:339-6-4-2.
16:359-6-4-2, good morning.
16:37How's the weather at the moment?
16:39RVR is 2-5-0 at the moment.
16:42If it doesn't get better, you will be diverted to Saarbrookan.
16:45Okay, thank you.
16:47Oh no, I will not go to Saarbrookan.
16:51I'm with you.
16:52Wind 110, 4 knots, expect ILS approach. Runway 27, transition level 6-0.
17:00He does not want to divert.
17:08Luxair 9-6-4-2, enter decurge hold, flight level 9-0.
17:14You're being directed into the holding pattern.
17:18That's all understood, Luxair 9-6-4-2.
17:23No, we need fuel to reach to our alternate plus 20 minutes reserved, so we'll still need 600 kilos.
17:30Okay, good.
17:31They want to make sure there's enough fuel to reach their alternate.
17:35Yes, but I want to keep...
17:37Luxair 9-6-4-2, descend to 3,000 feet on 1023, turn left heading 130.
17:44And then they're hit with a new plan.
17:54Is that for us?
17:55Yes.
17:58The recording reveals that the pilots were surprised by the instruction to begin their approach.
18:04What kind of crap is that?
18:08They were not happy about the change of plans.
18:14The sudden change meant that instead of proceeding to the hold,
18:17the pilots quickly initiated a left turn and began a steady descent towards the runway,
18:24all while configuring their plane for landing.
18:28So the crew were forced to rush themselves down to the final approach fix.
18:36The rushed approach now becomes the focus of the investigation.
18:43Luxair 9-6-4-2, turn right heading 220, cleared for approach.
18:48Okay, they're starting their approach.
18:52For a low visibility approach, properly briefed and performed,
18:57it's very structured, organized and standardized,
19:01so each pilot knows exactly which task they have to do at which time.
19:07Should we switch the seatbelt sign on?
19:09Yes. Yes, not a bad idea.
19:14Localizer captured.
19:17Check.
19:18Missed approach heading.
19:20They're not running a checklist.
19:22They're just throwing out random steps.
19:25Over the next few minutes, investigators hear several clear indications
19:30that the pilots are improvising this unexpected approach.
19:34You must be fully established, which means gear down, flaps extended,
19:40landing checklist completed, speed and altitude all at the correct spot.
19:45Are we at the beacon yet?
19:47You should have it dialed in by now.
19:50I can use the DME instead.
19:52Yeah, yeah, yeah.
19:54Even basic steps, such as configuring the navigation system, aren't performed.
20:00Flying an aircraft is about a precise following of certain steps at certain times.
20:08It's starting on an approach involving all the crew members.
20:11It's about detailed planning.
20:16They're skipping steps and improvising the procedures.
20:20The change of plans caught them by surprise.
20:32They're racing against the clock.
20:37They started to rush themselves in a quite high workload environment,
20:41trying to get the airplane down and doing the approach briefing all at once,
20:48which was quite tricky to achieve.
20:51Did the rushed approach result in the pilots being too high as they neared the runway?
20:58They're getting closer and closer to the airport.
21:01At three and a half miles out, they should be at 2,500 feet, but they're at 3,000 instead.
21:14Flaps?
21:15We are flapsed in.
21:189642, you are clear to land.
21:21Instead of managing their altitude and speed, they're rushing to get their plane properly configured.
21:28Speed and altitude control is actually important for every approach,
21:33but especially for a low visibility approach,
21:36where you have to be established much earlier than on a normal approach.
21:42So why all the confusion?
21:44It can't just be the last minute approach.
21:46I don't think they thought they'd be able to land.
21:48Have a look.
21:52RVR.
21:53RVR.
21:54RVR.
21:56The cockpit recording makes it clear to investigators
21:59that the crew didn't think they'd have the required visibility to make the landing.
22:05Let's see RVR now.
22:07I don't know. Should we check with dispatch?
22:10Yes.
22:12They're told they have a visual range of 275 meters,
22:15but they need 300 minimum to land.
22:17You're not sure how to proceed.
22:21Tell them if at echo we don't have 300 meters, we'll do a go around and enter the hold.
22:29Their plan is to do a go around if the visibility hasn't increased by the time they get to the
22:34outer marker here.
22:36The auto marker can be seen as a decision or a cutoff point.
22:41Once you pass the auto marker, the RVR must be at the required minimum.
22:48But as soon as they get to the outer marker, they get the magic words...
22:52300 meters.
22:56Luxair 9642. RVR is 300 meters. You are clear to land. Wind 180 degrees, 5 knots.
23:03But they're too high and need to lose altitude fast.
23:08The CVR explains why the pilots ended up above their target altitude.
23:13They were rushed into the approach and fixated on the poor runway visibility.
23:20Okay. So how does that lead to a crash 35 seconds later?
23:279642, you are clear to land.
23:30Uh, gear down?
23:32Yeah.
23:33Clear to land, 9642.
23:39And done.
23:42What the hell was that?
23:45Oh, .
23:46Terrain. Terrain.
23:50What just happened?
23:53In the last few seconds of the CVR recording, there was a loud noise.
23:58Crew was startled by this.
24:00What happened in those last 20 seconds?
24:03And what was that noise we heard?
24:12What was that noise we heard?
24:18What the hell was that?
24:20Investigators hope the Flight Data Recorder, or FDR, can solve the mystery of what went wrong in Flight 9642's final
24:29seconds.
24:30Okay, cruising along at 3,000 feet and 160 knots.
24:35Then they start to descend, go flaps 10, and accelerate rapidly towards the ground.
24:41Let's see what the engines were doing.
24:45What's happening here?
24:48Turbine RPMs drop.
24:50The torque drops down to zero.
24:53Looks like he's gone down below flight idle into ground mode.
24:59Ground mode changes the angle of the propellers so they can move the plane forward while it's on the ground.
25:05It's never used in the air.
25:09But then, turbine RPM spikes, fuel flow and torque increase.
25:16All while the altitude starts to plunge.
25:20Could they have gone into beta mode?
25:25Beta mode is basically reverse thrust.
25:28The propellers are positioned to move air forward instead of back.
25:32It's used to help stop the plane after it touches down.
25:38If you would put the power levers into beta mode in the air, this could lead to loss of control
25:45where recovery might not be possible.
25:49Did the pilots of flight 9642 put their engines into reverse?
25:53And if so, why?
25:55Can we hear the last 20 seconds of that CVR again?
26:00And done.
26:03What the hell is that?
26:06Oh, ****.
26:07Terrain, terrain.
26:14It's the propellers going into reverse.
26:17Investigators now have an explanation for the deafening sound on the CVR.
26:23This is almost like hitting the brakes.
26:26The aircraft would immediately dive into a rapid and uncontrollable descent.
26:32How could the engines end up going into ground mode and then into reverse, beta mode?
26:39How's that even possible?
26:42The turboprop airplane, like the F-50, it had a lot of safety features that would prevent the propeller from
26:51going into beta range in flight.
26:54Before a plane can be put into reverse mode, the thrust levers must first pass through ground mode.
27:01A lock prevents this from happening.
27:04Pilots can switch the lock off in flight to prepare for landing.
27:11Ground idle stop off.
27:14First officer Arendt performed that step as part of his descent and approach checklist.
27:20With the lock disabled, pilots can lift the ground range selector and move the thrust levers to ground mode after
27:27landing to help slow the plane.
27:30But instead, the data reveals that the engines went into ground mode 25 seconds before the plane crashed.
27:42Did they do it on purpose?
27:45The question is, how did they get there?
27:47Did the crew select it? Did they do it deliberately?
27:50Was it something bad that happened?
27:52The safety defenses didn't work?
27:54These are all things that have to be looked at.
27:57Okay, we're recording.
28:00Let's start with the taxi lights.
28:04To find out if the crew intentionally put the plane into ground mode before they were on the ground, they
28:11record a number of different sounds in the cockpit of another Fokker 50.
28:20Every switch has a sound attached to it.
28:24Okay, let's try flaps to 10.
28:35And now the ground range selector.
28:46And that does it.
28:48And this can be forensically analyzed and filtered out.
28:55You compare that to what you find from the cockpit voice recorder.
28:59These three sounds were picked up on the CVR.
29:02Let's start with this.
29:06We were able to confirm that this sound is the taxi lights being switched on.
29:19Test recording confirms that's the flap handle being moved to flaps 10 position.
29:28Then there's this.
29:34We compared it to the sound recorded on the test plane.
29:37It's a match?
29:39The audio analysis confirms that Captain Pukkes deliberately lifted the ground range selector and moved his throttle to ground mode
29:47while the plane was making its approach to the airport.
29:51The key element found in the sound spectrum study was that the power lever was in fact moved below the
29:57flight idle gate.
29:57And this was something that meant the pilot had to do it.
30:03Okay.
30:04So we know he did this on purpose.
30:07Why?
30:10There is no maneuver or procedure asking the pilots to actually lift the ground range selector in flight and pull
30:19the power levers below flight idle.
30:22It's a prohibited non-standard procedure and should never be done by the pilots.
30:29What could have prompted the pilots to put their engines into ground mode?
30:35He's five miles away from the airport when he decides to land, but he's 300 feet above the glide slope
30:41and his speed is 165 knots.
30:43If he wants to get down to the glide slope, he needs to descend rapidly, but his speed is already
30:48quite fast.
30:49So instead, he slams on the brakes.
30:54Once the power levers are in ground idle, this will produce extra drag on the propellers, reducing the speed and
31:03also allowing the aircraft to descend at the same time.
31:08Luxair 9642, RVR is 300 meters.
31:13Investigators believe that when the crew is told that runway visibility has improved, Captain Pukas moved his engines to ground
31:21mode to quickly reduce speed and lose altitude.
31:28Not sure that'll do it.
31:319642, continuing approach.
31:35Flaps?
31:37They should have made a better decision and go around, reposition and fly a proper approach or divert to the
31:44alternate and not forcing it in.
31:46Okay, we can explain putting the engines into ground mode.
31:51But reverse?
31:55What the hell is that?
32:00What the hell is that?
32:03Oh, .
32:09So the lock is only released when the plane is on the ground.
32:14Investigators know the pilots of Luxair Flight 9642 put their plane into ground mode before landing.
32:22But it doesn't explain why the throttles were moved further back to reverse while they were still hundreds of feet
32:29in the air.
32:30Should be impossible to do.
32:32To get to that range in flight, it's not supposed to happen.
32:36There's supposed to be two things that prevent it from happening.
32:40An electrical lock prevents the power levers from being moved into reverse in flight.
32:47Once the plane is on the ground and the wheels are spinning at at least 20 miles an hour, a
32:52signal is sent to an electrical switch that releases the flight idle stop and allows the throttles to move to
32:59the reverse position.
33:01This system is only meant to be used on the ground and that's why they have a lot of protections
33:04to make that only the possibility that it's going to happen.
33:09Could the lock have somehow failed?
33:13The mechanical stop is installed so that the pilots can, under no circumstances, physically move the power levers beyond ground
33:23idle.
33:23So no reverse thrust possible.
33:29Investigators study the components that make up the locking system.
33:33The anti-skid system checks out, the wheel speed relays are fine and there's nothing wrong with the lock switch.
33:42Investigators also check the anti-skid sensors which measure wheel speed, the computer that receives those signals and the switch
33:51controlling the lock.
33:54Everything seemed to check out normally.
33:57It shouldn't unlock unless the wheels are spinning.
34:00So what went wrong?
34:03Investigators scrutinize the electrical lock system that should have prevented flight 9642 from going into reverse.
34:11Anything in the maintenance record?
34:13There's this.
34:15They discover an incident that happened 14 years earlier.
34:22Power lever setting below flight idle possible in flight.
34:28Huh.
34:30In 1988, the flight idle stop disengaged inadvertently on another Fokker 50.
34:38So it's not as foolproof as we thought.
34:42The system design was actually well designed by Fokker, but they knew the system had a problem.
34:49When the landing gear is lowered, an electrical pulse could be sent to activate the plane's anti-skid control unit.
34:57That sends out a false indication that the plane is on the ground, just enough to unlock the flight idle
35:04stop.
35:07This particular pulse in the anti-skid control unit could in fact allow the power levers to go back into
35:12the beta range.
35:14At the time, Fokker said the chance of an inadvertent unlocking due to the glitch was extremely unlikely.
35:25These three conditions must be met for the stop to unlock.
35:30Gear down, the left and right gear locks releasing at precisely the same instant, and the power levers below flight
35:37idle.
35:39A lot of components had to line up in very great precision to make it happen.
35:43The perfect storm of bad things happening together.
35:46Could they have triggered the glitch?
35:49Investigators returned to the voice recording and flight data to determine if a short-lived electrical anomaly allowed the engines
35:57to go into reverse while in flight.
36:01We know from the sound analysis, the click that we heard on the CVR is the ground range selector being
36:06lifted.
36:10Approximately 30 seconds before impact, the captain moves his power levers below flight idle.
36:16Okay, so condition one is met.
36:20The first officer lowers the landing gear 13 seconds later and they unlock at the exact same time.
36:26Now that the conditions to trigger the glitch have been met, for the next 16 seconds, the levers can be
36:32moved to reverse.
36:34The aircraft thinks it's on the ground and it will go into reverse in flight.
36:42And just three seconds later, the propellers go into reverse.
36:45That's it.
36:52Ground idle stop off.
36:55They believe that in an effort to lose altitude quickly, the pilots of flight 9642 unknowingly triggered the electrical anomaly
37:04that allowed them to put their engines into reverse.
37:09The sequence of events begins with the captain moving the throttles to ground mode to reduce speed and altitude.
37:18Not sure that'll do it.
37:209642, continuing approach.
37:23The maneuver doesn't have the desired effect.
37:25The plane is still too high.
37:31Flaps?
37:32Flaps?
37:32We are flapsed in.
37:35The crew extends the flaps to reduce speed even further.
37:40Then…
37:42Gear down?
37:44Yeah.
37:44As Captain Pukas keeps his throttles pulled as far back as they can go, the first officer lowers the landing
37:51gear, unaware it will trigger the conditions to unlock reverse.
37:59What the hell is that?
38:01What the hell is that?
38:03There will be a loud bang, a O-ball, everybody will hear that in the cockpit and in the cabin.
38:09There will be an immense increase in tracks, so you will literally feel your body shifting and shaking.
38:22Captain Pukas doesn't even realize what's happened.
38:25Pum, pum, pum, pum, pum, pum!
38:32Once the landing gear was selected by the first officer, suddenly both engines went into full reverse.
38:40It was too late to recover.
38:4325 seconds after the throttle is inadvertently moved to reverse, the plane crashes, resulting in 20 deaths.
38:54If Fokker knew about this anomaly in 1988, why didn't they just fix it?
39:02Investigators examine reports to explain why Flight 9642 was allowed to fly, despite the aircraft manufacturer knowing about a potential
39:11glitch.
39:12They said the probability of this happening was so low that no immediate action was required.
39:21It's a very short duration power-up, so therefore the timing has to be very precise, and the likelihood of
39:28it to happen was low, there's no doubt about it, but certainly it was not zero.
39:34They eventually came up with a modification and issued this service bulletin about it a few years later.
39:40The manufacturer of the skid control unit had issued a service bulletin suggesting a simple fix that would prevent the
39:48erroneous signal from being sent.
39:53To modify the anti-skid control unit to the newer version that would not provide this power-up pulse, one
39:59nearly had to add a few diodes and a capacitor, so it wasn't a complicated fix, it wasn't difficult to
40:04do, it wasn't expensive.
40:06But the notification was issued as a service bulletin, not an airworthiness directive, which would have made the fix mandatory.
40:16If an aircraft manufacturer is making a modification to an aircraft, it gives out a service bulletin.
40:22You don't need to do it.
40:24An airworthiness directive is a state hazardous to the safety of the operation of the aircraft.
40:30That might even ground the whole world fleet of the aircraft till it's modified.
40:37Luxair never performed the suggested 1992 modification to its fleet of Fokker aircraft.
40:45If it had come as an airworthiness directive, they would have complied, no doubt about that, and the problem would
40:49have been fixed.
40:52The accident didn't happen here. It happens here. When they accepted an approach they weren't prepared for.
41:01How much fuel will we need?
41:05Uh...
41:07550...
41:07We need 850 when we leave the hole.
41:10No, we need fuel to reach till our alternate plus 20 minutes reserved, so we'll still need 600 kilos.
41:17Yes, but I want to keep...
41:19Luxair 9642, descend at 3000 feet on 1023, turn left heading 130.
41:25Is that for us?
41:26Yes.
41:29Investigators believe that the main cause of the crash of Flight 9642 was the crew's decision to accept the approach
41:36instruction rather than join a holding pattern.
41:40Left heading 130, Luxair 9642.
41:46What kind of crap is that?
41:49At the time they got their first heading for the intercept for the localizer for the runway, they should have
41:55said, no, we are not ready for the approach.
41:59Had they simply rejected the approach when the controller gave them those initial headaches and descent down to 3000 feet,
42:06the controller would have said that's fine.
42:09Here, they still don't have the visibility they need to land. They're too high and too fast and still aren't
42:16properly configured. If ever there was a case for a go around.
42:249642, continuing approach.
42:28The investigators also fault the crew for not executing a missed approach when they had so much going against them.
42:37Once the crew was surprised by the ATC clearance to start the approach as number one, a lot of events
42:46started putting the pilots in a kind of a tunnel vision or into a continuation bias, focusing only on the
42:54approach and the landing without considering any other options.
42:59To prevent the plane from being put into reverse in the air, the team also recommends that the modification to
43:06the skid control box, which stops any erroneous signal, be made mandatory for all Fokker 50 airplanes.
43:14Luxair makes the modification to its entire fleet of Fokker aircraft.
43:20The accident, in fact, proves the fact it was that serious and should have been addressed.
43:26Captain Pukas was charged with involuntary manslaughter. He was fined and sentenced to three and a half years probation.
43:36The lessons we have learned from this tragic Luxair accident is always stick to standard operating procedures, stick to the
43:46aircraft's limitations, be aware of operational bulletins.
43:52Unfortunately, most of these things were not done by the Luxair crew and this led to this tragic accident.
コメント