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Air Crash Investigation - Season 26 - Episode 04: Divided in Crisis (Air Algérie 6289)
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00:02Controllers in Islamabad watch as Air Blue Flight 202 head straight towards a massive hill.
00:09He's not turning.
00:14They issue urgent warnings.
00:17Turn left immediately.
00:18But fail to prevent a disaster.
00:20You're going down!
00:30It's the worst accident in Pakistan's aviation history.
00:36When investigators listen to the CVR, they hear the pilots realize they're in danger.
00:42Terrain, sir!
00:45Took steps to avoid it.
00:47Turning left.
00:49But were unable to save the lives of 152 people.
00:54Why aren't we turning left?
00:56The crew knew what they had to do.
01:00They had reported that they were doing what they were supposed to do.
01:04And yet, the aircraft continued to fly in the wrong direction.
01:10BD, BD!
01:14Oh, fuck!
01:17I need a one-zero gravity.
01:18I need a one-zero gravity.
01:19I need a one-zero gravity.
01:34Air Blue Flight 202 begins its early morning descent towards Islamabad, Pakistan.
01:46There are 146 passengers and six crew on board the Airbus A321.
01:57Air Blue 202, expect arrival to ILS runway 30, followed by circling approach to land runway 12.
02:05Understood.
02:05It'll be ILS down to Minima and then left downwind.
02:10okay
02:13captain pervez chowdhury is one of the airlines most experienced pilots
02:20najam koreshi is a former air blue pilot who flew with captain chowdhury
02:26captain chowdhury had a lifetime of experience flying with the pakistan international airline
02:31he had a very successful carrier and he was pretty much approaching the end of his carrier
02:45first officer syed ahmed has less commercial experience he's a former f-16 fighter pilot
02:52and squadron leader in pakistan's air force air blue two zero two clear to three nine hundred for
03:00ILS two three zero clear to descend to three nine hundred
03:11he had about three hundred hours on the time so just brain-new learning the differences
03:15between the a force line and the commercial line
03:20pakistan's capital Islamabad is a city of more than eight hundred thousand people it's surrounded
03:27by the himalayan foothills to the north and northeast
03:34the mountainous terrain means the only approach to Islamabad's runway is from the south due to the
03:42wind direction today planes are landing on runway one two they must circle the airport and make a visual
03:49approach to the other end of the runway
03:54it is always safer to land with a headwind as compared to a tailwind
03:59when the winds change beyond a certain limit the air traffic controller will switch the runways
04:05that will ensure the plane lands in a headwind
04:11thick clouds envelop the airport making landings difficult
04:16China southern is going around and diverting back to Urumqi
04:20China southern confirming diverting back to Urumqi
04:24attention all landing aircraft
04:27China southern is diverting due to weather
04:31if at any point you lose sight of the airfield
04:35you should abandon the approach completely and carry out the missed approach procedure
04:44flight 202 is now less than 10 minutes from landing
04:54you're down
05:04the plane reaches the minimum altitude to which the pilots can descend without the runway in sight
05:12as soon as you see the runway
05:14you turn right
05:15and then after that you're supposed to keep the runway in sight
05:19commencing right turn
05:21heading 352
05:25call it in
05:28air blue
05:29air blue
05:29air blue
05:29air blue
05:30air blue
05:30air blue
05:33heading 352. Air blue 202 confirming at 2500 turning right heading 352.
05:46Captain Chowdhury initiates the first turn of the circling approach. Air blue 202
05:53continue on the circle for landing on runway 12. Caution low clouds and
05:58visibility maintain visual with the airport. Even in the poor weather it's up
06:05to the pilots to decide whether they should continue the approach or not
06:09depending whether they have it on the inside. The controller expects to see the
06:18lights of the Airbus as it flies past the airfield.
06:33He's approaching the no-fly zone north of the airfield. Instruct him to turn left immediately.
06:41Flight 202 is much further north than expected and needs to turn left for the
06:47approach to runway 1-2. Air blue 202 turn left heading 180.
06:56Confirm he has visual with the ground. If not instruct him to climb and execute a missed approach.
07:02Air blue 202 confirm you have airfield in sight.
07:07The controllers had radar. They could see what the aircraft was doing.
07:11They could see that the aircraft was not doing what the procedure said they should be doing.
07:19Ask again.
07:21Air blue 202, please confirm you have visual with the ground.
07:33Air blue 202, visual with the ground.
07:37Air blue 202, visual with the ground.
07:38He's confirming visual.
07:41He's not turning.
07:45Controllers can see that flight 202 is rapidly approaching the hills north of the airport.
07:56In the cockpit, the pilots are struggling to turn their plane away from the mountains ahead.
08:04Air blue 202, visual with the aircraft.
08:04Air 12.
08:05Air bring to the ground.
08:21Air bring to the ground.
08:23sir instruct him to turn left immediately
08:30the controllers can't believe what they're seeing here's a guy with 25 000
08:36hours and he's flying directly towards a mountain
08:41in the cabin passengers have become aware that something's not right
08:51they're approaching the 5 000 foot magala hills terrain
08:56ahead pull up sir we are going down we're going down
09:02the message from radar turn left immediately
09:21flight 202 has crashed into the magala hills seven miles from the airport
09:30the wreckage lies at an altitude of nearly 3 000 feet it will be difficult for rescuers to reach
09:36the site we couldn't get access to it with a car or a truck even with helicopters there was no
09:48place
09:48to set down so the only way to get to the accident site was with a long slow climb
09:58it takes more than half an hour for rescuers and volunteers to make their way up the steep hill
10:04to the crash site in hopes of finding survivors
10:17when crews do reach the site they find a scene of complete devastation
10:33a hundred and fifty two people died in the saxon it's the worst accident in pakistan's aviation history
10:45why did a modern airplane fly into well-known mountains north of the airport in islamabad
11:00investigators arrive at the accident site to study the wreckage of air blue flight 202
11:09when an aircraft flies into mountains there are really two areas that we're looking at in terms of
11:15the root cause one is a sudden and unexpected loss of control the other would be the aircraft has
11:25actually stayed in control of the pilots and still somehow been flown into a mountain
11:34an analysis of the engines shows that they were fully functional at the time of impact
11:39and capable of producing maximum thrust
11:46okay good work everyone start heading back down
11:51right so the stabilizer was set at 3.5 degrees nose up
11:56landing gear was down engines at climb power
12:00so configured for landing but climbing at full power
12:06an examination of the electrical and mechanical components that we could find
12:12there was no obvious damage or mechanical failure
12:16they were trying to land here
12:20but then they slam into the margala hills seven miles north of the runway
12:27how did they get so far off course
12:33for an approach that was supposed to be a very tight approach because of the existence of the hills
12:40that is extraordinary
12:43they were approaching from the southeast for landing here on runway one two
12:56scattered clouds rain
13:00visibility was at 3.5 kilometers
13:04challenging conditions
13:08could the cloudy conditions have been a factor in the accident
13:14when an aircraft flies into high ground one thing that is almost certainly a factor is poor visibility
13:23low cloud fog call it what you will
13:28visibility would have been an issue but you don't need to see the margala hills to know that they're there
13:39so
13:40everyone knows towards the north east of the runway there are mountains they're clearly marked on the maps
13:45terrain ahead
13:47so we're going down
13:48pull up
13:51pull up
13:52pull up
13:57can the controller explain why the crew of flight 202 couldn't avoid the mountains
14:04radar control
14:05radar control informed him he'd be doing the circling approach to runway one two
14:09a blue 202 expect arrival at ILS three zero followed by circling approach to land runway one two
14:17and he understood the approach
14:19yes sir he did
14:22understood
14:23it'll be ILS down to minima
14:26and then left downwind
14:30and then
14:31that's when I assume control
14:34as he began the right turn to the circling approach
14:41the circling approach involves four carefully timed turns
14:46the first to the right
14:48followed by a left turn that takes the plane parallel to the runway
14:53the two final turns lined the plane up for the landing on runway one two
14:59pilots must keep the runway in sight for the duration of this approach
15:07after about a minute i expected to see him fly by
15:13but he never did
15:16i asked the crew if they had the runway in sight and they confirmed that they did
15:21air blue two zero two please confirm you have visual with the ground
15:28air blue two zero two visual with the ground
15:32but he kept flying further and further away from the airport directly towards the hills
15:40after breathing off from the approach they are supposed to turn after 30 seconds
15:45instead they kept going for almost two minutes
15:49we tried to stop him several times
15:54it was too late message from radar turn left immediately
16:08we couldn't prevent
16:13what happened
16:20it's all here on the radar track
16:29crew knew what they had to do
16:32they reported that they were doing what they were supposed to do
16:37and yet the aircraft continued to fly in the wrong direction
16:42terrain ahead
16:47how could the pilots have ended up so dangerously off course
16:58investigators look into the background of flight 202's pilots
17:03to determine if the approach into islamabad was mishandled
17:09captain had years of experience with major airlines
17:15captain chowdhury has been flying for more than 40 years
17:20he has accumulated more than 25 000 flying hours throughout his career
17:25but only about 1 000 of those were on the airbus
17:33the first officer however is a whole different story
17:38first officer syed ahmed had far fewer hours than the captain
17:44the former fighter pilot had recently joined the airline
17:47and had accumulated only 286 hours on airbus a320 airplanes
17:56two very different pilots
17:59one during the end of his career with thousands of hours of experience
18:04and the other just starting off his commercial career
18:08but neither of them had a ton of experience with the airbus a321
18:16did the pilots lack of experience on this type of plane play a role in the accident
18:25experience is generally considered to be an asset
18:29the only potential downside is that of course if you've got a lot of experience of one particular thing
18:36it actually might be more difficult to learn how to operate this new type of aircraft
18:49okay so they're supposed to perform their approach within this area
18:53anything beyond this is outside the airport's 4.3 mile protection zone
19:00okay let's see his track
19:04investigators examine flight 202's radar track to see how the pilots set up their approach
19:11all right
19:13so they make their first turn here
19:19and then head straight out of the protection zone
19:25and this left turn takes them directly into the marhala hills
19:32the radar track shows that the pilots flew closer and closer to the mountains surrounding islamabad
19:39wouldn't they have gotten a warning that they're approaching the hills
19:48yes sir it should have sounded 60 seconds before impact
19:57the enhanced ground proximity warning system looks downward to see the height that you're at above ground
20:06but it also looks ahead to see any terrain that you're flying towards
20:14if they got a warning
20:17why didn't they try to pull up or turn to avoid it
20:25did the pilots of flight 202 get any warning of an impending collision
20:32the crew would have been given pictures on their navigation display of the approaching terrain
20:38and they would have been given oral warnings so since they flew directly into the terrain
20:46has the enhanced ground proximity warning system completely failed
21:01don't leave me in suspense so they get any ground proximity warnings
21:07they sure did
21:15the cockpit data shows that in the final minute of the flight the crew got 21 separate warnings about
21:22the rising terrain ahead
21:29okay so that answers that
21:34over 21 times we saw terrain terrain pull up terrain ahead pull up there's no way that the captain missed
21:42that warning the enhanced ground proximity warning system was working properly terrain ahead
21:50if the warning system was operating why would the pilots ignore it and allow the accident to happen
21:57if you hear a full terrain pull up warning from the gpws the reaction should be immediate it should be
22:06to
22:06apply full power pull the nose of the aircraft up get it moving away from the ground and that should
22:11be done
22:12before any questions are asked
22:19why didn't the crew of air blue flight 202 act on terrain warnings and steer their plane away from the
22:27mountains islamabad air blue 202 investigators listen to the cockpit voice recording what are current conditions
22:35please they focus on how the crew set up for landing it will be runway one two yes invisibility scrap
22:58the weather was marginal and marginal weather makes you nervous because you don't know whether you're going to be able
23:05to see anything at all
23:07and the captain clearly was nervous about this approach
23:13did the captain proceed with an approach he wasn't comfortable with
23:18set waypoints for runway one two radial zero two six five miles of beam
23:39the circling approach is by definition a visual approach
23:45it didn't make any sense for the captain
23:47to be entering waypoints into the flight management system
23:51the circling approach is by definition a visual approach so there is no way that any pilot would normally do
23:58this
24:01then just two miles from the airport the pilots of air blue flight 202 hear of a flight landing ahead
24:09of them
24:09be advised that a tia 737 has landed on runway one two safely
24:17commencing right turn heading three five two
24:23that could have caused the pilot to say hey if they can get in we can get in too
24:29stop so he starts his turn later than usual half a mile from the runway
24:42instead of breaking off early they had to continue on because of the low visibility and low ceilings
24:48and they did not break off to the right until the last possible point which was at the end of
24:52the runway
24:54concerned with poor visibility captain chowdhury makes a baffling decision
25:00switch into nav mode for managed approach to runway one two
25:05there he goes switching to nav mode he can't be visual
25:11carrying out the circling approach using the autopilot to navigate is a violation of procedures
25:20as soon as you select the nav mode the plane starts to fly the pre-programmed waypoints
25:27and at this point captain chowdhury's normal flying the visual approach okay sir
25:36but are you visual
25:40i have a visual
25:44chowdhury insists he can see the runway but investigators are certain he could not
25:51they can't see the airfield any longer because they've just got to the far side of it
25:55there is no airfield in sight
25:59so instead of turning left to fly parallel with the runway
26:06he keeps flying in this direction moving further and further from the airport
26:12sir we're reaching higher ground
26:16terrain ahead
26:18terrain ahead sir there's terrain ahead
26:22sir turn left
26:25terrain ahead
26:28it should be turning terrain ahead
26:31as the captain struggles to turn away from the hills
26:34the rain the head controllers become concerned air blue 202 confirm you have airfield in sight
26:42what should i tell him sir
26:45tell them tell them
26:49the crew doesn't reply straight away probably because the first officer knows full well that no
26:55they don't have visual contact with the airfield but he waits for his captain to tell him what to say
27:00air blue 202 please confirm you have visual with the ground
27:04terrain ahead
27:06air blue 202 visual with the ground
27:11in the end the crew tells air traffic control that they are in visual contact with the ground
27:18now that's not untrue but it's not the same thing as being visual with the airfield
27:24it feels more like a reply designed to get air traffic control off their backs
27:27terrain
27:28sir we are approaching terrain ahead
27:30yes i know we are turning left
27:33pull up pull up sir
27:37the captain says he's turning left but he keeps flying directly towards the hills
27:48investigators are unable to explain why captain chowdhury could not alter his course and steer away from the
27:58mountains
27:59turn left
28:02the final minute of the cvr reveals a picture of chaos
28:06terrain and confusion
28:08pull up pull up sir sir pull up
28:14they're applying power trying to climb
28:19marine
28:19sir pull up sir
28:24investigators hear first officer ahmed pleading with his captain to pull up
28:28terrain ahead why aren't we turning left
28:32pull up
28:35terrain ahead pull up terrain sir
28:56terrain ahead
29:01all they had to do was turn away from those hills
29:09despite reacting to the terrain warnings the pilots could not steer their plane away from the mountains
29:18i think they knew what was happening
29:21i think they knew that they had to turn left for some reason the aircraft didn't turn left
29:27will flight 202's flight data recorder explain why captain chowdhury didn't
29:34or couldn't turn and avoid the mountains can we see the altitude please
29:41the minimum altitude is 2500 feet
29:46investigators can see that chowdhury dialed in an altitude below what's permitted
29:53there's only one reason it would drop below that
30:07there's no earthly reason for doing it because the minimums are there for a very good reason
30:13the only reason why they ever break the minimums is because they can't see the ground properly and
30:18they want to get closer to it can we see the flight path
30:25you see he's way off course in heavy fog and has clearly lost visual
30:33let's see the autopilot modes
30:38so he asks the automation to take over
30:46more than four miles off course captain chowdhury makes his biggest error
30:51by switching modes on his autopilot
30:56the captain switched from heading mode to nav mode
31:00and the aircraft turned left to heading of 300
31:07towards the mountain
31:11the airbus now makes a left turn towards a predetermined waypoint
31:16bringing the flight dangerously close to the mountains
31:21he's approaching the no-fly zone north of the airfield
31:26from this point on air traffic control continued to urge the flight to turn left
31:31because they knew they were in the vicinity of the high mountainous terrain terrain
31:35ahead
31:38avenue 202 turn left heading 180
31:40marine
31:41why aren't we turning left
31:43pull up
31:46can we see what he's selecting
31:51he's dialing in a left turn
31:59captain chowdhury
32:00uses his heading knob to turn the plane sharply left away from the hills
32:08but the plane it keeps flying in the same direction
32:11it's not turning
32:24he's still in nav
32:28investigators realized the captain forgot that his plane was in navigation mode
32:33and not heading mode which is required to turn the aircraft
32:38if the aircraft is flying in nav mode it will keep on flying on its predetermined course
32:45whether or not the crew change the heading select
32:51why aren't we turning left
32:55captain chowdhury doesn't realize that his inputs are futile
33:02in order to get from nav mode into heading mode
33:05you pull the knob out and that engages heading mode
33:09he forgot to pull it out
33:12he realizes his error and pulls the knob here at 40 seconds before impact
33:26ah
33:28when captain chowdhury tries to correct his error he only makes a bad situation worse
33:36sir turn left
33:37oh why is it turning left
33:45captain chowdhury has dialed in so many left turns
33:49that his last input is now to the plane's right
33:53the airbus takes the shortest route to get to that heading
33:58directly towards the margala hills
34:05he's in heading mode for the rest of the flight
34:13the investigation saw that the captain was so reliant on the automation that
34:16he was trying to turn the aircraft to the left
34:20asking why the aircraft wasn't turning to the left but he didn't even use his side stick and actually
34:26turn the aircraft to the left manually
34:27why aren't we turning left
34:30the rain
34:31the head
34:31investigators now know why captain chowdhury was unable to turn left and avoid the mountains
34:37but one question remains
34:39why didn't the first officer recognize the mistakes and do something to correct them
34:45so we're going down
34:52100 knots
34:54check
34:54investigators find a possible explanation for the first officer's puzzling behavior
35:00v1 at the very start of flight 202 rotate
35:07as it took off for islamabad
35:11the flight starts with the pilots working efficiently as a crew
35:15positive rate
35:17gear up
35:23gear up
35:27the takeoff from karachi is textbook
35:33from initial pushback startup and all of it to take off everything seemed normal
35:42we are clear to climb to flight
35:44explain to me why that is blue but the other symbols are white
35:50the pilot's cordial relationship soon changes
35:56sir
35:57there on your display why is that symbol blue but the others are white
36:02you should know why that is
36:05i believe it's because the flight plan defers from the current route
36:09oh that's wrong it's because it's the one being navigated towards basic
36:15do you know how to modify this point
36:19from the main menu oh you don't need to return to the main menu you can do it on the
36:24screen
36:26what did they teach you in that so-called training of yours
36:31captain chowdhury is heard quizzing and berating his first officer
36:37this wasn't normal behavior it seems it was only really for the purpose of
36:42putting his first officer in his place making sure he knew who was in charge and to do as he
36:50was told
36:52what's he doing
36:55if you don't know how to use the flight management system
36:59then what use are you in the cockpit you might as well go back and help the girls serve tea
37:07yes
37:18what about maximum thrust available for climb can you at least tell me what that is
37:23this has been going on for nearly an hour now torture
37:30radio ahead to islamabad for the weather
37:34do you know how to use the radio yes
37:40captain chowdhury is a very experienced pilot
37:42he should know that this is not how we behave on the flight deck of an airliner
38:02investigators wonder why captain chowdhury would act so aggressively towards his first officer
38:09he was recently treated for diabetes and hypertension but deemed fit to fly
38:18anything pilots who flew with him said he was demanding sometimes difficult
38:24but nothing at this level
38:27maybe it had more to do with him
38:31could the first officer's background have affected his captain's attitude towards him
38:41in pakistan there has been a hidden rivalry between air force pilots
38:46and the people who are in the commercial side already
38:50they feel that actually force guys they are taking away their opportunities
38:58investigators believe that the captain's abusive behavior might explain one of the mysteries of this
39:04tragedy why first officer ahmed never took control of the plane
39:11all the first officer had to do was to take manual control of the aircraft
39:15and fly it away from the mountain
39:20investigators scrutinize first officer ahmed's actions leading up to the crash of flight 202
39:26his first officer tells the captain to pull up three times and return left twice but he never says he's
39:35taking control
39:41if i was the first officer i'll take over the control pull back on the side stick to create the
39:47max performance maneuver applied to
39:49guthrush and keep climbing till i'm clear of the hills
39:54the team believes the captain's behavior earlier in the flight explains why the first officer allowed him to mishandle the
40:02approach
40:03if you don't know how to use the flight management system then what use are you in the cockpit
40:12we have the captain's behavior which was so overbearing so autocratic
40:18so nasty that it served to completely shatter the self-confidence of the first officer
40:25first officer ahmed allows procedures to be set aside switch into nav mode for marriage approach to runway one
40:35two okay
40:38sir and then fails to take control when his captain flies the plane directly towards the mountains
40:47he was so worn down by the captain's harsh behavior that he just couldn't stand up to him he became
40:53a bystander
40:59the first officer clearly knows that what they're doing is wrong he knows that his captain
41:04is disoriented that the aircraft is on a collision course with a mountain
41:10and yet somehow he doesn't have it in him to intervene
41:16terrain ahead pull up sir we are going down
41:21sir we're going down three and a half minutes after the start of the approach
41:27we're going down the airbus slams into the hills
41:32killing everyone on board
41:41this is one of the most extraordinary accidents i've seen
41:48there were no technical factors in this accident
41:53there was nothing wrong with the aircraft there was nothing wrong with the engines
41:59it was all a matter of human misjudgment and human error
42:10if he doesn't try the approach in nav mode there's no accident
42:16all the warning signs were there telling them what to do
42:22it should have been easy to recover very if he hadn't taken his first officer out of the picture
42:31different outcome absolutely incredible
42:42it's hard to believe that somebody of his experience
42:46would make so many errors and mishandling of the aircraft say it i just it just defies logic
42:58the final report into the crash of airblue flight 202 makes several recommendations to pakistani airlines
43:07including better briefings on the circling approach procedures and better crew management training
43:16this accident shows the cockpit management in the atmosphere in the cockpit that's set by the captain
43:21is just as important as an operating aircraft and operating engines
43:26and in 2018 the airport in islamabad is replaced with a more modern airport with two runways that are
43:34well away from the hills that claim the lives of the 152 people on board flight 202
43:44as i learned more i really felt extremely bad
43:52i felt very sad about that loss
43:58it was a preventable accident
44:01it was a preventable accident
44:01you
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