Air Emergency (2003–…): Season 16, Episode 9 - Deadly Solution - full transcript
NARRATOR: An Airbus
A320 en route to Singapore
disappears while
flying over the Java Sea.
JOHN: It crossed my mind
that what could have caused it
is an act of
terrorism, sabotage,
something extreme
happening to the aircraft.
NARRATOR: For days, a massive
search and rescue effort
turns up nothing.
EMMANUEL: A crash
at sea is challenging.
It's difficult to locate
because you usually don't have
the full flight path down
to the surface of the ocean.
NARRATOR: What they find
paints a confounding picture
of the final minutes of flight.
RAY: The plane started to bank.
EMMANUEL: We were very
surprised by this action.
RAY: What are they doing?
NARRATOR: The
investigation uncovers
a single tragic misunderstanding
that claimed the
lives of 162 people.
Flight attendant:
LADIES AND GENTLEMEN,
WE ARE STARTING OUR APPROACH.
Pilot: WE LOST BOTH ENGINES!
Flight attendant:
PUT THE MASK OVER YOUR NOSE.
EMERGENCY DESCENT.
Pilot: MAYDAY, MAYDAY.
Flight attendant:
BRACE FOR IMPACT!
Controller: I THINK I LOST ONE.
Man: INVESTIGATION STARTING
INTO THIS TRAGEDY...
Man: HE'S GONNA CRASH!
*
NARRATOR: AirAsia Flight 8501
cruises high above the Java Sea
north of Indonesia.
It's a few days after Christmas,
and many of the 156 passengers
aboard the Airbus A320
are on holiday.
The pilot in command is
53-year-old Captain Iriyanto.
He's highly experienced,
with more than
20,000 hours in the air.
His first officer is French
national Remi Emmanuel Plesel.
He is 46 with about
2,000 flight hours,
much of it on the Airbus.
JOHN: On this particular
leg, it was the first officer
that was
manipulating the controls.
The captain was in
command of the flight
but was performing the
duties of the pilot monitoring,
or the non-flying pilot.
NARRATOR:
Today's flight originated
in the Indonesian city
of Surabaya. It's heading across
the Java Sea to Singapore.
Total flight time is
expected to be two hours.
*
FO. PLESEL: It
looks like weather ahead.
CPT. IRIYANTO: No. I
don't like the looks of that.
NARRATOR: Twenty-two
minutes into the flight,
the pilots notice bad
weather ahead on their radar.
FO. PLESEL: Anti-ice?
CPT. IRIYANTO: Anti-ice on.
JOHN: The crew would
definitely be taking care
to avoid
penetrating these thunderstorms
because it contains possibly
extreme turbulence, hail,
lightning, everything
that the air crew don't want
to expose themselves
and the passengers to.
[Phone rings]
NARRATOR: The captain
instructs the flight attendant
to prepare the
cabin for turbulence.
FLIGHT ATTENDANT:
Ladies and gentlemen,
please return to your
seats and fasten seat belts.
*
NARRATOR:
Khairunnisa Haidar Fauzi
is one of four flight attendants
helping to look
after the passengers
as they cruise at 32,000 feet.
*
As an additional
precaution, the captain decides
to increase altitude, to
go above the storm clouds
in their path.
CPT. IRIYANTO: I'm gonna
radio for a higher cruise,
get around that weather.
FO. PLESEL: Good idea.
AUTOMATION: [Alarm]
NARRATOR: But before the captain
can contact air traffic control,
he gets a fault warning
from the flight computer.
FO. PLESEL: ECAM actions?
NARRATOR: The plane's
sophisticated computers
give the pilots
step-by-step instructions
on how to fix the issue.
CPT. IRIYANTO: FAC 1 off and on.
FAC 2 off and on.
[Beep]
CPT. IRIYANTO: Warning cleared.
NARRATOR: Computers control most
of the Airbus A320's systems.
JOHN: There are basically seven
computers that fly the aircraft,
and they add a lot
of helpful features
that take workload
away from the pilot.
NARRATOR: Pilots are trained
to follow the instructions
given by the
aircraft's computers.
AUTOMATION: [Alarm]
NARRATOR: A few minutes later,
the warning sounds again.
CPT. IRIYANTO:
Same. FAC 1 off and on.
NARRATOR: After
addressing the fault warning,
the captain radios
air traffic control
to request the
higher flight level.
CPT. IRIYANTO: Okay. So
Jakarta air traffic control,
AirAsia 8501,
request climb to 38,000.
NARRATOR: The Jakarta
air traffic controller
has had an uneventful night.
He soon clears
the pilots to climb,
but to a slightly lower altitude
than the 38,000 feet requested.
AIR TRAFFIC CONTROLLER: AirAsia
8501, you are cleared to 3-4-0.
NARRATOR: After
permitting them to climb,
the controller
waits for confirmation.
AUTOMATION: [Alarm]
NARRATOR: But the pilots are
distracted by a third alarm.
CPT. IRIYANTO: Here we go again.
FO. PLESEL: ECAM actions.
CPT. IRIYANTO: FAC 1 off and on.
NARRATOR: The
controller hasn't heard back,
so he repeats his message.
AIR TRAFFIC CONTROLLER: AirAsia
8501, you are cleared to 3-4-0.
JOHN: It's very annoying
and very time consuming
to deal with this
recurring problem.
CPT. IRIYANTO:
[Sighs] Enough of this.
FO. PLESEL: ECAM actions.
*
NARRATOR: The controller
still hasn't heard confirmation
from the pilots.
AIR TRAFFIC CONTROLLER:
AirAsia 8501, do you read me?
Please acknowledge.
*
AUTOMATION: [Alarm]
NARRATOR:
But in the cockpit, the fault
warnings have escalated.
AIR TRAFFIC CONTROLLER:
AirAsia 8501, do you read me?
Please acknowledge.
NARRATOR: In the cabin,
passengers have no idea
their pilots are struggling to
maintain control of the plane.
*
*
The pilots now notice that the
plane is rolling sharply left.
CPT. IRIYANTO:
Level. Okay. Level.
NARRATOR: Something is going
terribly wrong with Flight 8501.
The first officer is struggling.
CPT. IRIYANTO: Level!
NARRATOR: But soon the
plane is rolling again.
CPT. IRIYANTO: Level!
FO. PLESEL: I'm trying.
NARRATOR: The pilots
can't seem to regain control.
FO. PLESEL: It's not responding.
AIR TRAFFIC CONTROLLER:
AirAsia 8501, please confirm.
You are climbing to
flight level 3-4-0.
NARRATOR: The controller
still hasn't heard confirmation
from the pilots when
the plane starts to climb
towards 34,000 feet
and then continues
climbing steeply even higher.
*
[Passengers screaming]
JOHN: No airline passenger
would have ever
experienced something like this
under normal
circumstances before.
It would have been a very
violent, shocking maneuver.
CPT. IRIYANTO: Pull down!
FO. PLESEL: It's not correcting.
NARRATOR: The plane seems to
have taken on a life of its own.
It climbs higher and higher as
the pilots fight to level off.
Then, inexplicably,
the plane starts to drop.
JOHN: That would certainly cause
near panic in some people.
Other people would be waiting
for the pilots to quote fix it.
CPT. IRIYANTO: Altitude!
FO. PLESEL: I see it!
NARRATOR: Flight 8501 is
plummeting from the sky,
speeding toward the ocean below.
JOHN: The rate of descent
here was very, very high.
NARRATOR: It seems
the pilots can do nothing
to save their plane.
CPT. IRIYANTO: Pull!
FO. PLESEL: It's not correcting.
What's going on? Max power.
CPT. IRIYANTO: Slowly.
[Passengers screaming]
*
NARRATOR: Forty-three minutes
into what should have been
a normal two-hour flight...
FO. PLESEL: Ugh!
NARRATOR: AirAsia Flight
8501 disappears from radar.
CPT. IRIYANTO: Pull!
FO. PLESEL: I'm trying!
CPT. IRIYANTO: Pull!
FO. PLESEL:
It's not correcting! Ugh.
*
*
NARRATOR: News quickly spreads
of the mysterious disappearance
of a commercial
flight to Singapore.
*
JOHN: The loss of AirAsia 8501
was a classic case of a flight
degenerating from mundane,
normal cruise conditions
to the loss of the aircraft in
a span of just twenty minutes.
NARRATOR: Within hours,
relatives of the 162 passengers
and crew are demanding answers.
How could an
airplane just disappear?
TONY (Archive): We don't
want to speculate right now
because the plane has
been missing for twelve hours,
and there's a deep
sense of depression.
NARRATOR: All the authorities
know is that the plane vanished
from radar
somewhere over the Java Sea.
Speculation runs wild
about what could have
brought the airliner down.
JOHN: It crossed my mind
that what could have caused it
is an act of
terrorism, sabotage,
something extreme
happening to the aircraft.
But it was very difficult to
come up with a clear picture
on the first news reports
as to what had taken place.
NARRATOR: It's
been only a few months
since Malaysia
Airlines Flight 370 disappeared
in eerily similar circumstances,
vanishing from radar
without sending any mayday call.
Search and rescue
vessels are dispatched,
but combing the vast and choppy
sea between Sumatra and Borneo
is a mammoth task.
An international team of
air safety investigators
flies in to join the
local experts in Jakarta.
Ray Nurcahyo is an
air crash investigator
with the Indonesian National
Transportation Safety Committee.
RAY: The air traffic control
radar data is our main source
to detect the
location of the aircraft.
NARRATOR:
They begin by interviewing
the air traffic controller.
RAY: So can you
tell me what happened?
EMMANUEL: They were
the ones who could tell us
a little bit more
about what had happened.
They had seen the
plane trajectory,
the plane flight path.
NARRATOR: They learn that the
plane was flying towards an area
of bad weather.
JOHN: When you start
out in an investigation,
you look at everything.
In this case, there
were weather considerations.
RAY: And then?
AIR TRAFFIC
CONTROLLER: Then they
started losing altitude fast.
*
NARRATOR:
And then it disappeared
from radar at 24,000 feet.
RAY: Thank you very much.
EMMANUEL: How could this plane
being in cruising altitude
suddenly climb and fall with
a very high rate of descent?
NARRATOR: Could the
aircraft have lost engine power
in a violent storm?
RAY: The weather might be
involved in the accident.
So we tried to get more
information on the weather data.
*
RAY: Can I get the weather
overlay for this map, please?
NARRATOR: Investigators
examine detailed weather charts
from the day of the accident.
RAY: There were
thunderstorms here and here.
RAY: It's quite a large
red color, so I assumed
there has been a bad
condition on that area.
JOHN: It was monsoon season,
and so there's a
lot of thunderstorms.
They can do damage
to the airplane that --
it's something that you
learn early as a pilot,
and it's something that
you adhere to very strongly.
You do not fly
through thunderstorms.
NARRATOR: Then they
start mapping the flight track
to see if the plane
could have entered the storms.
RAY: They were at
cruising altitude.
Then here they
asked for deviation.
They made it here and
then they started to drop.
They almost flew into the first
storm but then just missed it.
NARRATOR: Bad weather, the
first possible explanation
for the disappearance of Flight
8501, proves to be a dead end.
RAY: This is the spot
they were last seen on radar.
NARRATOR: Based on Flight
8501's last radar coordinates,
investigators have at least
narrowed down the search area.
Dozens of rescue vessels and
aircraft from multiple countries
scour the target area.
EMMANUEL: A crash
at sea is challenging.
It's difficult to locate
because you usually don't have
the full flight path down
to the surface of the ocean.
NARRATOR: The Indonesian
president decides to address
a nation in mourning.
PRES. WIDODO (Archive,
translated): To all the families
of the passengers and
crew, I share my loss with you
in this tragedy.
And we all pray.
NARRATOR: Two days into
the search, the first pieces
of wreckage are recovered
from the Karimata Strait
in the Java Sea.
RAY: The main wreckage was
found not far from the point
that we predicted
based on the ATC radar.
*
NARRATOR: Soon
searchers are finding bodies.
Among the first is
that of flight attendant
Khairunnisa Haidar Fauzi.
In a moving tribute,
hundreds attend her funeral.
Funerals for many more follow.
Of the 162 passengers and
crew, there are no survivors.
*
As the wreckage is
brought in for examination,
investigators can see that the
task ahead of them is daunting.
Why would a highly
sophisticated airliner,
flying at cruising altitude,
suddenly fall from the sky?
EMMANUEL: We had a lot of
little pieces everywhere.
My first reaction was
it's not gonna be easy.
*
*
RAY: Is it all like this?
EMMANUEL: A crash
at sea is challenging
because usually the main
interesting parts are underwater
and that's a little
bit difficult to get them.
NARRATOR: With much of
the plane still missing
at the bottom of the sea,
investigators study debris
found floating on the surface.
To see if the plane exploded,
they look for distinctive
smaller pieces with burnt edges.
*
JOHN: The debris that was
recovered did not exhibit any
telltale signs of having been
subject to a bomb explosion.
RAY: This plane didn't blow up.
NARRATOR: The pieces of AirAsia
8501 are large and clean.
EMMANUEL: We could eliminate
a possible in-flight break up.
NARRATOR: It's a step forward,
but unless they can find
the black boxes, the
mystery of AirAsia Flight 8501
may never be solved.
The flight recorders offer
the only hope of figuring out
what was
happening in the cockpit.
The search for them
goes into high gear.
RAY: The black box search team,
assisted by Singapore, France,
the UK and China, we
utilized side scan sonar
and underwater unmanned camera.
NARRATOR: All
black boxes are equipped
with an electronic beacon that
transmits a signal under water.
Ship-based sonar
systems can detect the signal
and help guide searchers
towards the black boxes.
EMMANUEL: When we get
this signal, we are in a range
of about two
thousand meters from them.
So this helps us narrow
it down to where they are
and then the divers then
have to try to find them.
NARRATOR: But weather
complicates the search.
EMMANUEL: The depth
was about forty meters,
and the sea was rough.
And we couldn't go
every day we wanted to go.
So we had to adapt our
strategy to the weather.
NARRATOR: After a two-week
search, they finally succeed.
RAY: The black boxes were found,
first on 12th of January,
the flight data recorder.
And the following day we found
the cockpit voice recorder
around the same area.
EMMANUEL: We were relieved
to get the boxes 'cause
this was a real major
step towards the explanation
of what had happened.
*
NARRATOR: Investigators
start by listening
to the cockpit voice recording.
It should reveal pilot
conversations and other sounds
from inside the
cockpit of Flight 8501.
RAY: Okay, let's start when
they ask permission to climb.
Play recording.
CPT. IRIYANTO: Jakarta air
traffic control, AirAsia 8501
request climb to
38,000 to clear storm clouds.
EMMANUEL: Up to that
point the flight was normal.
It was uneventful.
RAY: Continue recording.
NARRATOR: Almost immediately,
investigators make a discovery.
[Beeping]
FO. PLESEL: ECAM actions?
CPT. IRIYANTO: FAC 1 off
and on. FAC 2 off and on.
Warning cleared.
RAY: They were dealing
with some kind of warning.
Play recording.
AUTOMATION: [Alarm]
FO. PLESEL: ECAM actions?
CPT. IRIYANTO: Same.
RAY: Okay. The
warning came back.
JOHN: They were getting
continual fault warnings through
what's called an ECAM system,
Electronic Central
Aircraft Monitoring system.
RAY: Play recording.
AUTOMATION: [Alarm]
CPT. IRIYANTO: Here we go again.
FO. PLESEL: ECAM actions?
CPT. IRIYANTO: FAC 1 off
and on. FAC 2 off and on.
It's cleared.
EMMANUEL: At this point, the
crew's behavior was standard,
was normal. They were quiet.
They were communicating
on what checklists to apply.
AIR TRAFFIC CONTROLLER: AirAsia
8501, you are cleared to 3-4-0.
RAY: Okay, stop. We
know from the controller
that he never heard
back from them again. Play.
AUTOMATION: [Alarm]
CPT. IRIYANTO:
There it is again.
FO. PLESEL: ECAM actions?
NARRATOR: Then the recording
reveals something surprising.
CPT. IRIYANTO: No.
I've got a better idea.
NARRATOR: The captain appears to
have done something different,
and then there's a new warning.
RAY: Hold recording. Now
the autopilot has disengaged.
JOHN:
An unexpected disengagement
of the auto-throttle
and auto-thrust system results
in a pretty loud warning.
This is a very serious
concern to the investigators.
AUTOMATION: [Alarm]
FO. PLESEL: What was that?
CPT. IRIYANTO: Okay,
let's see what we have.
AUTOMATION: [Alarm]
FO. PLESEL: Master caution? Why?
CPT. IRIYANTO: Checking...
Level. Level.
NARRATOR: Investigators now hear
yet another cockpit warning.
RAY: Stall warning.
JOHN: The airplane would
have warnings to tell the pilot
that they were getting
close to an aerodynamic stall.
CPT. IRIYANTO: Pull! Slowly!
FO. PLESEL: What's going on?
CPT. IRIYANTO: Pull!
NARRATOR: An
aerodynamic stall occurs
when the angle between the
wings and the oncoming air
gets too steep.
The amount of air flowing
over the wings is reduced.
The aircraft loses lift
and can no longer stay aloft.
JOHN: It's a highly uncommon
event to have an Airbus stall,
particularly in cruise, because
it is protected from stalling.
JOHN:
Normally the computer won't
allow the aircraft to stall.
It won't allow the wings
to go at too high an angle
to the airflow and
stall the aircraft.
NARRATOR:
What caused this technically
advanced plane to stall?
RAY: The autopilot disconnects.
The aircraft stalls.
They struggle to
recover. It makes no sense.
NARRATOR: Only the
FDR data can reveal what
was happening with the aircraft
the moment the crisis hit.
*
Until that data is
ready for analysis,
the deadly midair
stall remains a mystery.
RAY: What were you
guys struggling with?
JOHN: One of the questions
that the investigators
would have faced is:
Why and how did an aircraft that
is supposed to be stall-proof
end up stalling?
CPT. IRIYANTO:
Pull down. Slowly!
*
NARRATOR: The flight data
recorder should provide answers,
but it needs to be flushed of
saltwater before it can be read.
In the meantime, investigators
pull the plane's maintenance
records to look for clues.
They soon make a discovery.
The aircraft seems to
have an issue with its RTLU.
EMMANUEL: RTLU is the
Rudder Travel Limit Unit.
The plane had had a
history of RTLU failures.
NARRATOR: The
Rudder Travel Limit Unit
is a computerized component
that prevents the rudder
on the tail from deflecting
too far in either direction
when the plane is
traveling at high speed.
If the flight
computer detects any problems
with its rudder limiter, it
sends a warning to the cockpit.
Records show the aircraft's
Rudder Travel Limit Unit
had been malfunctioning
for almost a year.
RAY: Twenty-three reports
of the exact same failure.
JOHN: The RTLU failures
on this particular airframe
had become
increasingly frequent.
There were eleven in
the last couple of months
and twenty-three in
the preceding period,
which is highly unusual.
RAY: That seems like a lot
of failures with the RTLU.
NARRATOR:
Could these be connected
to the mystery warnings
the pilots were experiencing? It
could be a major breakthrough.
RAY: Three days
before the crash there were
two exact same failures.
Why was this happening?
NARRATOR: After each
failure, maintenance workers
reset the RTLU.
ERTATA [Translated]:
As long as the reset resulted
in the computer to prompt pass,
maintenance personnel doesn't
have to investigate further.
RAY: They just kept resetting it
and then putting
it back in service.
NARRATOR: But they
never found a permanent fix.
JOHN: They were returning the
airplane to service after reset,
and from a legal standpoint
it did clear the problem.
But obviously whatever
the fault was, they hadn't
found it, because the
problem continued to reoccur.
NARRATOR: The aircraft
seemed to operate perfectly
despite the warnings.
Even the day before the crash,
the plane had successfully flown
from Surabaya to Kuala Lumpur.
RAY: Have we got the unit?
NARRATOR: The plane's
RTLU is among the wreckage
that's been
recovered from the Java Sea.
*
RAY: Let's send it
back to the manufacturer
and see if they
can find something.
NARRATOR: The unit is
sent to France for analysis.
*
Finally, investigators get to
examine a key piece of evidence,
the flight data recorder.
If they can download
all the flight data,
it should provide
a detailed picture
of exactly what was
happening with the electrical
and mechanical control
systems on the aircraft.
RAY: After the
black box recovered,
they transferred
to our laboratory.
EMMANUEL:
We worked with the Indonesian
investigation authority
in extracting the data, which
requires a lot of precautions,
since the flight
recorders had been immersed.
*
RAY: Move it down
too a little bit.
NARRATOR: On examination,
they discover the data board
has been damaged by
the impact of the crash.
It's uncertain whether the
information they desperately
need will be retrievable.
*
The download begins.
RAY: Even though the condition
of the black box was damaged,
we managed to
recover all of the data.
NARRATOR: Success.
RAY: Okay, so let's start
with those chime warnings.
So here's the first warning.
It clearly was the RTLU.
They do the fix, simply
resetting the entire system.
AUTOMATION: [Alarm]
JOHN: The procedure to reset the
system was much like your PC,
rebooting the PC. They
only had to turn the system off
and turn it back on again.
CPT. IRIYANTO: FAC 2 off and on.
RAY: Two more times
the RTLU warning goes off,
and each time they
did the right thing.
Then it went off
on a fourth time.
Then suddenly
there was a glitch.
What did they do different?
NARRATOR: After the fourth
time, the warnings change.
There is now a fault with the
aircraft's two main computers,
known as the flight
augmentation computers.
RAY: Put the new
data up on that screen.
*
Something caused both computers
to fail at the same time.
NARRATOR: But
nothing in the data shows
what the crew did differently
after the last warning.
What does come to light is that,
when the autopilot disengaged,
the rudder moved slightly.
RAY: Now let's see. The plane
started to bank to the left.
EMMANUEL: The
electrical interruption
on the flight control computers
created a rudder movement
of about two
degrees to the left.
JOHN: Two degrees
does not sound like a lot,
but at the speed
they were flying
it's exactly what caused
them to roll left 54 degrees.
JOHN: That's almost
twice the normal bank
that you would
feel in an airliner.
RAY: Now look at this.
It took them nine seconds
to do anything about the bank.
NARRATOR: Despite
the steep bank angle,
it seems the crew was slow
to react and level the plane.
EMMANUEL: During
the first nine seconds,
there was no crew
inputs on the controls
following this roll that
reached fifty-four degrees.
NARRATOR: Then the first
officer suddenly reacts,
pulling hard to the
right, then left again
and just as suddenly
he starts to pull up.
RAY: All they had to
do was steady the plane.
What were they doing?
NARRATOR: The FDR
data shows that the plane
climbed steeper and steeper
until they reach a
remarkable 45-degree pitch up.
RAY: Then it stalled.
NARRATOR: Investigators
know that the captain
did something
different, something that led
to a computer glitch causing
the autopilot to disconnect
and the plane to bank sharply.
But they don't know what he did.
JOHN:
The single event of autopilot
auto throttle disengagement
sends the investigators in
two different directions --
one, what caused it? Two,
how did the crew handle it?
As investigators struggle
to answer puzzling questions
about Flight
8501 and its crew...
[Phone rings]
RAY: Hello? NTSC.
NARRATOR: They get
an important new lead.
RAY: Wait, wait.
Slow down. What happened?
*
NARRATOR: A mysterious
action by the captain
to solve a routine
error appears to have set off
a deadly sequence of events.
Investigators are still trying
to understand what happened
when they receive
some new information.
RAY: Start from the
beginning. Where was he?
EMMANUEL: Three days before the
accident, on the 25th December,
this same
captain was about to fly
from Indonesia to Kuala Lumpur
when he had an RTLU malfunction.
He asked for an
engineer to come to the cockpit
and try to fix that.
ENGINEER: RTLU problem again?
CPT. IRIYANTO: Yeah, it
just keeps coming back.
NARRATOR: The maintenance
engineer rebooted the system.
[Alarm sounds]
But the problem came back.
ENGINEER: I've got an idea.
NARRATOR: He then
pulled the circuit breakers
for the main computer.
JOHN: Maintenance on the
ground has a very specific list
of circuit breakers
that says you can utilize
pulling these circuit
breakers to reset computers
within the airplane.
NARRATOR: As the captain
watched, the problem was fixed.
ENGINEER: Problem solved.
CPT. IRIYANTO: And can I do the
same thing if it happens again?
ENGINEER: Yeah, just do
what the ECAM tells you to do.
RAY: Don't tell me he
tried to do that in the air.
NARRATOR: Investigators
think that they now know
what the captain did that led
to the crisis in the cockpit.
RAY: Begin simulation.
NARRATOR: To see if they're
right, they decide to simulate
the cockpit
warnings heard in-flight.
RAY: Okay, so let's
start with the RTLU warnings.
AUTOMATION: [Alarm]
RAY: FAC 1 off. FAC 2 off. Good.
AUTOMATION: [Alarm]
CPT. IRIYANTO: Enough of this.
NARRATOR:
After the fourth RTLU warning,
he takes a new approach.
FO. PLESEL: ECAM actions?
CPT. IRIYANTO: No.
I've got a better idea.
NARRATOR: Investigators
believe the captain
pulled two
critical circuit breakers.
RAY: Captain pulls
circuit breaker one.
*
NARRATOR: The
result is immediate.
AUTOMATION: [Alarm]
RAY: And there goes the
autopilot disconnect warning.
NARRATOR: Investigators can
now be certain of one thing.
RAY: This had to be what he did.
JOHN: He was perhaps copying
what he'd seen the
ground engineer do,
but of course the
consequences in flight
to disabling critical
systems are quite different.
JOHN: The
captain wrongly assumed
that if it worked on the
ground it'll work in flight.
ERTATA [Translated]:
The circuit breaker,
which is part of the
flight augmentation computer,
is something that should
never be pulled out in the air.
NARRATOR: Pulling
the circuit breakers
has devastating consequences
the captain didn't anticipate.
JOHN: Unfortunately, he was
not pulling circuit breakers
that affected only the
rudder limiter system,
but ones that also disabled the
flight augmentation computer,
which tripped the autopilot,
the auto throttle and
all the normal mode protections
that the aircraft had.
NARRATOR: The
plane begins to roll.
Over the next nine seconds,
it rolls fifty-four degrees,
yet no one does
anything to stop it.
What took them so long to react?
RAY: The first officer would
have been looking here and here
when the autopilot
warning was disconnected,
and the captain was
still standing behind
the first officer's seat.
FO. PLESEL: What was that?
NARRATOR: It's
likely that neither pilot
was looking at the
attitude indicator
that showed the
plane was banking.
RAY: That's why it
took them nine seconds
to notice what this
gauge here was telling them.
NARRATOR: As the
plane started to roll,
the first officer was
focused on the fault warnings.
He didn't notice that
the plane was banking
until the captain
sat back down again.
[Alarm sounds]
CPT. IRIYANTO: Oh my God.
FO. PLESEL: Oh!
NARRATOR: Despite losing
control of these systems,
the high-tech plane
did have the capacity
to get back on course.
After the initial roll,
why didn't the first officer
just steady the plane
and reengage the autopilot?
Investigators have
to try to understand
what was going on
inside the pilots' heads.
JOHN: The co-pilot's
movement of the stick
to its extreme
rightmost position
resulted in a very
violent roll to the right,
two to three times what would
be programmed as the maximum
for an Airbus normally.
NARRATOR: In an
attempt to understand
the first officer's
actions, investigators study
how the human
brain behaves in flight.
A sense of balance is
maintained by liquid levels
in the ear canals.
When that shifts violently,
the brain can get mixed
signals that affect balance.
The FDR data shows how dramatic
the plane's movements were.
RAY: So the plane rolled
fifty-four degrees left,
and he pulled back almost
level in just two seconds.
That would
scramble anybody's gyros.
Maybe that was the confusion?
JOHN:
As soon as the first officer
had leveled the aircraft,
the fluid in his ear canals
keeps spinning to the right.
The aircraft is level,
but there's a very
strong illusion from the ears
that you're
turning to the right.
RAY: He pushes the plane all
the way to the left. But why?
CPT. IRIYANTO: Level.
FO. PLESEL: I am! I am!
JOHN: The natural response
would be to roll the aircraft
back to where it came from into
the fifty-four degree of bank,
which was what they
thought the level was.
RAY: And then he
pulls it as hard as he can,
and the plane starts climbing.
JOHN: This is a massive input.
The airplane would
pitch up very quickly.
FO. PLESEL: What's going on?
RAY: He was completely baffled.
JOHN: His vertigo may
have led him to believe
that the aircraft
was pitching down.
So he's actually recovering
from an imaginary pitch down.
RAY: He was disoriented.
JOHN: With all the
alarms that were going off,
with the rapid
left-right-left rolls
and with the generally
deteriorating situation,
I think the crew had started
to lose their spatial awareness
completely.
NARRATOR: Investigators
finally understand
what must have been going
on with the first officer's
confused state of mind.
But if the first officer
wasn't operating
the controls correctly,
why didn't the
captain take the one step
that could have saved the
lives of everyone on board?
*
Investigators study
the captain's behavior
during the roll.
CPT. IRIYANTO: Pull down!
NARRATOR: They know
from the recordings that
he was trying to
help right the plane.
CPT. IRIYANTO: Pull down.
FO. PLESEL: I'm
trying. It's not responding.
NARRATOR: He wants his first
officer to stop climbing up
and push the nose down.
CPT. IRIYANTO: Pull down!
NARRATOR: But his
command is confusing.
RAY: It's either you
pull up or you push down.
JOHN: When one
thinks that the co-pilot
is holding a side stick,
pull means pull it back,
which means go up. And
down means push it forward.
So pull down is a
contradictory command.
EMMANUEL: In that case
the captain should have said:
"Nose down. Nose down."
NARRATOR: The first
officer continues pulling back
on his side stick
until the very end.
JOHN: The input of
the first officer...
CPT. IRIYANTO: Pull down!
JOHN: Was the
exact wrong thing to do.
FO. PLESEL: What's going on?
NARRATOR: He clearly
didn't understand the command.
So why didn't the captain take
full control of the airplane?
RAY: He tried to take
over here and over here.
CPT. IRIYANTO: Pull!
FO. PLESEL: It's not correcting.
JOHN: There is a button
on top of the side stick
that can let you
take full control
to lock the other pilot out...
CPT. IRIYANTO: Pull!
JOHN: ... so that you
know what's going on.
NARRATOR: The data
shows that the captain
did push the take control
button, but only briefly.
He didn't push it long
enough to take over the plane.
FO. PLESEL: It's not responding.
RAY: But at the end
he never took control.
NARRATOR: It meant that
both pilots were trying to fly
at the same time.
RAY: Both pilots started
controlling the aircraft.
When that happened, control of
the aircraft become ineffective.
NARRATOR: If he'd
spoken three simple words,
the plane could have been saved.
JOHN: The training is,
you say, "I have control,"
and the other pilot
stops making inputs.
In this case,
that wasn't happening.
*
NARRATOR: Investigators
now know that pilot error
led to a spatially
disoriented first officer.
The captain, who
could have helped
by communicating more clearly
or taking over the plane,
did neither. Investigators
can never be certain why.
The case is building to a close
when they get another piece
of information. The results
of the RTLU analysis are in.
*
It was a series of
warnings from that unit
that triggered the
events that led to the crash.
[Alarm sounds]
FO. PLESEL: ECAM actions?
JOHN: The failure
the crew had experienced
with the rudder limiter system
was actually a negligible
failure. It was a nuisance.
And the
procedures to reset it...
CPT. IRIYANTO: FAC 1 off and on.
JOHN: ... were simple.
CPT. IRIYANTO: FAC 2 off
and on. Warning cleared.
NARRATOR: All the
captain had to do
was keep on following
the ECAM's instructions.
EMMANUEL: The plane had
had a history of RTLU failures
throughout the year, and this
failure had never been fixed.
NARRATOR: Microscopic
examination of the unit's
electronic
module finally reveals
the cause of those
repetitive failures.
EMMANUEL: We found out
that there was a crack
in the soldering joint
on the electronic module,
which caused the RTLU to
work from time to time only.
And had the correct maintenance
task been applied...
ENGINEER: Problem solved.
EMMANUEL: ... the
RTLU electronic module
would have been removed.
JOHN: The airplane should have
been sent for troubleshooting,
and you could have
broken the chain of events.
NARRATOR: For
investigators, discovering
that such a minute
fault sparked events
that led to the death
of all 162 people on board
makes this all the more tragic.
As they prepare
their final report,
it's clear that the
crash of Flight 8501
has exposed a series
of serious problems.
*
The final report calls for
improved maintenance protocols
to help eliminate
minor recurring problems,
like the RTLU fault, before they
lead to a major catastrophe.
JOHN: When you start
having four, five, six, eight,
ten recurring
problems, it's saying
that the traditional
methods are not working
and that you need to do much
more heavy-duty diagnostics
until they find the problem.
CPT. IRIYANTO: Pull! Pull down.
RAY: And the other lesson
we take from the accident
was the
communication between pilots
to make sure that
communication was well
to avoid the different
interpretation of the command.
JOHN: This is a case
that the industry learned
some very hard lessons,
but the thing most importantly
is that the industry
implements those lessons
so that we don't
have another one.
A320 en route to Singapore
disappears while
flying over the Java Sea.
JOHN: It crossed my mind
that what could have caused it
is an act of
terrorism, sabotage,
something extreme
happening to the aircraft.
NARRATOR: For days, a massive
search and rescue effort
turns up nothing.
EMMANUEL: A crash
at sea is challenging.
It's difficult to locate
because you usually don't have
the full flight path down
to the surface of the ocean.
NARRATOR: What they find
paints a confounding picture
of the final minutes of flight.
RAY: The plane started to bank.
EMMANUEL: We were very
surprised by this action.
RAY: What are they doing?
NARRATOR: The
investigation uncovers
a single tragic misunderstanding
that claimed the
lives of 162 people.
Flight attendant:
LADIES AND GENTLEMEN,
WE ARE STARTING OUR APPROACH.
Pilot: WE LOST BOTH ENGINES!
Flight attendant:
PUT THE MASK OVER YOUR NOSE.
EMERGENCY DESCENT.
Pilot: MAYDAY, MAYDAY.
Flight attendant:
BRACE FOR IMPACT!
Controller: I THINK I LOST ONE.
Man: INVESTIGATION STARTING
INTO THIS TRAGEDY...
Man: HE'S GONNA CRASH!
*
NARRATOR: AirAsia Flight 8501
cruises high above the Java Sea
north of Indonesia.
It's a few days after Christmas,
and many of the 156 passengers
aboard the Airbus A320
are on holiday.
The pilot in command is
53-year-old Captain Iriyanto.
He's highly experienced,
with more than
20,000 hours in the air.
His first officer is French
national Remi Emmanuel Plesel.
He is 46 with about
2,000 flight hours,
much of it on the Airbus.
JOHN: On this particular
leg, it was the first officer
that was
manipulating the controls.
The captain was in
command of the flight
but was performing the
duties of the pilot monitoring,
or the non-flying pilot.
NARRATOR:
Today's flight originated
in the Indonesian city
of Surabaya. It's heading across
the Java Sea to Singapore.
Total flight time is
expected to be two hours.
*
FO. PLESEL: It
looks like weather ahead.
CPT. IRIYANTO: No. I
don't like the looks of that.
NARRATOR: Twenty-two
minutes into the flight,
the pilots notice bad
weather ahead on their radar.
FO. PLESEL: Anti-ice?
CPT. IRIYANTO: Anti-ice on.
JOHN: The crew would
definitely be taking care
to avoid
penetrating these thunderstorms
because it contains possibly
extreme turbulence, hail,
lightning, everything
that the air crew don't want
to expose themselves
and the passengers to.
[Phone rings]
NARRATOR: The captain
instructs the flight attendant
to prepare the
cabin for turbulence.
FLIGHT ATTENDANT:
Ladies and gentlemen,
please return to your
seats and fasten seat belts.
*
NARRATOR:
Khairunnisa Haidar Fauzi
is one of four flight attendants
helping to look
after the passengers
as they cruise at 32,000 feet.
*
As an additional
precaution, the captain decides
to increase altitude, to
go above the storm clouds
in their path.
CPT. IRIYANTO: I'm gonna
radio for a higher cruise,
get around that weather.
FO. PLESEL: Good idea.
AUTOMATION: [Alarm]
NARRATOR: But before the captain
can contact air traffic control,
he gets a fault warning
from the flight computer.
FO. PLESEL: ECAM actions?
NARRATOR: The plane's
sophisticated computers
give the pilots
step-by-step instructions
on how to fix the issue.
CPT. IRIYANTO: FAC 1 off and on.
FAC 2 off and on.
[Beep]
CPT. IRIYANTO: Warning cleared.
NARRATOR: Computers control most
of the Airbus A320's systems.
JOHN: There are basically seven
computers that fly the aircraft,
and they add a lot
of helpful features
that take workload
away from the pilot.
NARRATOR: Pilots are trained
to follow the instructions
given by the
aircraft's computers.
AUTOMATION: [Alarm]
NARRATOR: A few minutes later,
the warning sounds again.
CPT. IRIYANTO:
Same. FAC 1 off and on.
NARRATOR: After
addressing the fault warning,
the captain radios
air traffic control
to request the
higher flight level.
CPT. IRIYANTO: Okay. So
Jakarta air traffic control,
AirAsia 8501,
request climb to 38,000.
NARRATOR: The Jakarta
air traffic controller
has had an uneventful night.
He soon clears
the pilots to climb,
but to a slightly lower altitude
than the 38,000 feet requested.
AIR TRAFFIC CONTROLLER: AirAsia
8501, you are cleared to 3-4-0.
NARRATOR: After
permitting them to climb,
the controller
waits for confirmation.
AUTOMATION: [Alarm]
NARRATOR: But the pilots are
distracted by a third alarm.
CPT. IRIYANTO: Here we go again.
FO. PLESEL: ECAM actions.
CPT. IRIYANTO: FAC 1 off and on.
NARRATOR: The
controller hasn't heard back,
so he repeats his message.
AIR TRAFFIC CONTROLLER: AirAsia
8501, you are cleared to 3-4-0.
JOHN: It's very annoying
and very time consuming
to deal with this
recurring problem.
CPT. IRIYANTO:
[Sighs] Enough of this.
FO. PLESEL: ECAM actions.
*
NARRATOR: The controller
still hasn't heard confirmation
from the pilots.
AIR TRAFFIC CONTROLLER:
AirAsia 8501, do you read me?
Please acknowledge.
*
AUTOMATION: [Alarm]
NARRATOR:
But in the cockpit, the fault
warnings have escalated.
AIR TRAFFIC CONTROLLER:
AirAsia 8501, do you read me?
Please acknowledge.
NARRATOR: In the cabin,
passengers have no idea
their pilots are struggling to
maintain control of the plane.
*
*
The pilots now notice that the
plane is rolling sharply left.
CPT. IRIYANTO:
Level. Okay. Level.
NARRATOR: Something is going
terribly wrong with Flight 8501.
The first officer is struggling.
CPT. IRIYANTO: Level!
NARRATOR: But soon the
plane is rolling again.
CPT. IRIYANTO: Level!
FO. PLESEL: I'm trying.
NARRATOR: The pilots
can't seem to regain control.
FO. PLESEL: It's not responding.
AIR TRAFFIC CONTROLLER:
AirAsia 8501, please confirm.
You are climbing to
flight level 3-4-0.
NARRATOR: The controller
still hasn't heard confirmation
from the pilots when
the plane starts to climb
towards 34,000 feet
and then continues
climbing steeply even higher.
*
[Passengers screaming]
JOHN: No airline passenger
would have ever
experienced something like this
under normal
circumstances before.
It would have been a very
violent, shocking maneuver.
CPT. IRIYANTO: Pull down!
FO. PLESEL: It's not correcting.
NARRATOR: The plane seems to
have taken on a life of its own.
It climbs higher and higher as
the pilots fight to level off.
Then, inexplicably,
the plane starts to drop.
JOHN: That would certainly cause
near panic in some people.
Other people would be waiting
for the pilots to quote fix it.
CPT. IRIYANTO: Altitude!
FO. PLESEL: I see it!
NARRATOR: Flight 8501 is
plummeting from the sky,
speeding toward the ocean below.
JOHN: The rate of descent
here was very, very high.
NARRATOR: It seems
the pilots can do nothing
to save their plane.
CPT. IRIYANTO: Pull!
FO. PLESEL: It's not correcting.
What's going on? Max power.
CPT. IRIYANTO: Slowly.
[Passengers screaming]
*
NARRATOR: Forty-three minutes
into what should have been
a normal two-hour flight...
FO. PLESEL: Ugh!
NARRATOR: AirAsia Flight
8501 disappears from radar.
CPT. IRIYANTO: Pull!
FO. PLESEL: I'm trying!
CPT. IRIYANTO: Pull!
FO. PLESEL:
It's not correcting! Ugh.
*
*
NARRATOR: News quickly spreads
of the mysterious disappearance
of a commercial
flight to Singapore.
*
JOHN: The loss of AirAsia 8501
was a classic case of a flight
degenerating from mundane,
normal cruise conditions
to the loss of the aircraft in
a span of just twenty minutes.
NARRATOR: Within hours,
relatives of the 162 passengers
and crew are demanding answers.
How could an
airplane just disappear?
TONY (Archive): We don't
want to speculate right now
because the plane has
been missing for twelve hours,
and there's a deep
sense of depression.
NARRATOR: All the authorities
know is that the plane vanished
from radar
somewhere over the Java Sea.
Speculation runs wild
about what could have
brought the airliner down.
JOHN: It crossed my mind
that what could have caused it
is an act of
terrorism, sabotage,
something extreme
happening to the aircraft.
But it was very difficult to
come up with a clear picture
on the first news reports
as to what had taken place.
NARRATOR: It's
been only a few months
since Malaysia
Airlines Flight 370 disappeared
in eerily similar circumstances,
vanishing from radar
without sending any mayday call.
Search and rescue
vessels are dispatched,
but combing the vast and choppy
sea between Sumatra and Borneo
is a mammoth task.
An international team of
air safety investigators
flies in to join the
local experts in Jakarta.
Ray Nurcahyo is an
air crash investigator
with the Indonesian National
Transportation Safety Committee.
RAY: The air traffic control
radar data is our main source
to detect the
location of the aircraft.
NARRATOR:
They begin by interviewing
the air traffic controller.
RAY: So can you
tell me what happened?
EMMANUEL: They were
the ones who could tell us
a little bit more
about what had happened.
They had seen the
plane trajectory,
the plane flight path.
NARRATOR: They learn that the
plane was flying towards an area
of bad weather.
JOHN: When you start
out in an investigation,
you look at everything.
In this case, there
were weather considerations.
RAY: And then?
AIR TRAFFIC
CONTROLLER: Then they
started losing altitude fast.
*
NARRATOR:
And then it disappeared
from radar at 24,000 feet.
RAY: Thank you very much.
EMMANUEL: How could this plane
being in cruising altitude
suddenly climb and fall with
a very high rate of descent?
NARRATOR: Could the
aircraft have lost engine power
in a violent storm?
RAY: The weather might be
involved in the accident.
So we tried to get more
information on the weather data.
*
RAY: Can I get the weather
overlay for this map, please?
NARRATOR: Investigators
examine detailed weather charts
from the day of the accident.
RAY: There were
thunderstorms here and here.
RAY: It's quite a large
red color, so I assumed
there has been a bad
condition on that area.
JOHN: It was monsoon season,
and so there's a
lot of thunderstorms.
They can do damage
to the airplane that --
it's something that you
learn early as a pilot,
and it's something that
you adhere to very strongly.
You do not fly
through thunderstorms.
NARRATOR: Then they
start mapping the flight track
to see if the plane
could have entered the storms.
RAY: They were at
cruising altitude.
Then here they
asked for deviation.
They made it here and
then they started to drop.
They almost flew into the first
storm but then just missed it.
NARRATOR: Bad weather, the
first possible explanation
for the disappearance of Flight
8501, proves to be a dead end.
RAY: This is the spot
they were last seen on radar.
NARRATOR: Based on Flight
8501's last radar coordinates,
investigators have at least
narrowed down the search area.
Dozens of rescue vessels and
aircraft from multiple countries
scour the target area.
EMMANUEL: A crash
at sea is challenging.
It's difficult to locate
because you usually don't have
the full flight path down
to the surface of the ocean.
NARRATOR: The Indonesian
president decides to address
a nation in mourning.
PRES. WIDODO (Archive,
translated): To all the families
of the passengers and
crew, I share my loss with you
in this tragedy.
And we all pray.
NARRATOR: Two days into
the search, the first pieces
of wreckage are recovered
from the Karimata Strait
in the Java Sea.
RAY: The main wreckage was
found not far from the point
that we predicted
based on the ATC radar.
*
NARRATOR: Soon
searchers are finding bodies.
Among the first is
that of flight attendant
Khairunnisa Haidar Fauzi.
In a moving tribute,
hundreds attend her funeral.
Funerals for many more follow.
Of the 162 passengers and
crew, there are no survivors.
*
As the wreckage is
brought in for examination,
investigators can see that the
task ahead of them is daunting.
Why would a highly
sophisticated airliner,
flying at cruising altitude,
suddenly fall from the sky?
EMMANUEL: We had a lot of
little pieces everywhere.
My first reaction was
it's not gonna be easy.
*
*
RAY: Is it all like this?
EMMANUEL: A crash
at sea is challenging
because usually the main
interesting parts are underwater
and that's a little
bit difficult to get them.
NARRATOR: With much of
the plane still missing
at the bottom of the sea,
investigators study debris
found floating on the surface.
To see if the plane exploded,
they look for distinctive
smaller pieces with burnt edges.
*
JOHN: The debris that was
recovered did not exhibit any
telltale signs of having been
subject to a bomb explosion.
RAY: This plane didn't blow up.
NARRATOR: The pieces of AirAsia
8501 are large and clean.
EMMANUEL: We could eliminate
a possible in-flight break up.
NARRATOR: It's a step forward,
but unless they can find
the black boxes, the
mystery of AirAsia Flight 8501
may never be solved.
The flight recorders offer
the only hope of figuring out
what was
happening in the cockpit.
The search for them
goes into high gear.
RAY: The black box search team,
assisted by Singapore, France,
the UK and China, we
utilized side scan sonar
and underwater unmanned camera.
NARRATOR: All
black boxes are equipped
with an electronic beacon that
transmits a signal under water.
Ship-based sonar
systems can detect the signal
and help guide searchers
towards the black boxes.
EMMANUEL: When we get
this signal, we are in a range
of about two
thousand meters from them.
So this helps us narrow
it down to where they are
and then the divers then
have to try to find them.
NARRATOR: But weather
complicates the search.
EMMANUEL: The depth
was about forty meters,
and the sea was rough.
And we couldn't go
every day we wanted to go.
So we had to adapt our
strategy to the weather.
NARRATOR: After a two-week
search, they finally succeed.
RAY: The black boxes were found,
first on 12th of January,
the flight data recorder.
And the following day we found
the cockpit voice recorder
around the same area.
EMMANUEL: We were relieved
to get the boxes 'cause
this was a real major
step towards the explanation
of what had happened.
*
NARRATOR: Investigators
start by listening
to the cockpit voice recording.
It should reveal pilot
conversations and other sounds
from inside the
cockpit of Flight 8501.
RAY: Okay, let's start when
they ask permission to climb.
Play recording.
CPT. IRIYANTO: Jakarta air
traffic control, AirAsia 8501
request climb to
38,000 to clear storm clouds.
EMMANUEL: Up to that
point the flight was normal.
It was uneventful.
RAY: Continue recording.
NARRATOR: Almost immediately,
investigators make a discovery.
[Beeping]
FO. PLESEL: ECAM actions?
CPT. IRIYANTO: FAC 1 off
and on. FAC 2 off and on.
Warning cleared.
RAY: They were dealing
with some kind of warning.
Play recording.
AUTOMATION: [Alarm]
FO. PLESEL: ECAM actions?
CPT. IRIYANTO: Same.
RAY: Okay. The
warning came back.
JOHN: They were getting
continual fault warnings through
what's called an ECAM system,
Electronic Central
Aircraft Monitoring system.
RAY: Play recording.
AUTOMATION: [Alarm]
CPT. IRIYANTO: Here we go again.
FO. PLESEL: ECAM actions?
CPT. IRIYANTO: FAC 1 off
and on. FAC 2 off and on.
It's cleared.
EMMANUEL: At this point, the
crew's behavior was standard,
was normal. They were quiet.
They were communicating
on what checklists to apply.
AIR TRAFFIC CONTROLLER: AirAsia
8501, you are cleared to 3-4-0.
RAY: Okay, stop. We
know from the controller
that he never heard
back from them again. Play.
AUTOMATION: [Alarm]
CPT. IRIYANTO:
There it is again.
FO. PLESEL: ECAM actions?
NARRATOR: Then the recording
reveals something surprising.
CPT. IRIYANTO: No.
I've got a better idea.
NARRATOR: The captain appears to
have done something different,
and then there's a new warning.
RAY: Hold recording. Now
the autopilot has disengaged.
JOHN:
An unexpected disengagement
of the auto-throttle
and auto-thrust system results
in a pretty loud warning.
This is a very serious
concern to the investigators.
AUTOMATION: [Alarm]
FO. PLESEL: What was that?
CPT. IRIYANTO: Okay,
let's see what we have.
AUTOMATION: [Alarm]
FO. PLESEL: Master caution? Why?
CPT. IRIYANTO: Checking...
Level. Level.
NARRATOR: Investigators now hear
yet another cockpit warning.
RAY: Stall warning.
JOHN: The airplane would
have warnings to tell the pilot
that they were getting
close to an aerodynamic stall.
CPT. IRIYANTO: Pull! Slowly!
FO. PLESEL: What's going on?
CPT. IRIYANTO: Pull!
NARRATOR: An
aerodynamic stall occurs
when the angle between the
wings and the oncoming air
gets too steep.
The amount of air flowing
over the wings is reduced.
The aircraft loses lift
and can no longer stay aloft.
JOHN: It's a highly uncommon
event to have an Airbus stall,
particularly in cruise, because
it is protected from stalling.
JOHN:
Normally the computer won't
allow the aircraft to stall.
It won't allow the wings
to go at too high an angle
to the airflow and
stall the aircraft.
NARRATOR:
What caused this technically
advanced plane to stall?
RAY: The autopilot disconnects.
The aircraft stalls.
They struggle to
recover. It makes no sense.
NARRATOR: Only the
FDR data can reveal what
was happening with the aircraft
the moment the crisis hit.
*
Until that data is
ready for analysis,
the deadly midair
stall remains a mystery.
RAY: What were you
guys struggling with?
JOHN: One of the questions
that the investigators
would have faced is:
Why and how did an aircraft that
is supposed to be stall-proof
end up stalling?
CPT. IRIYANTO:
Pull down. Slowly!
*
NARRATOR: The flight data
recorder should provide answers,
but it needs to be flushed of
saltwater before it can be read.
In the meantime, investigators
pull the plane's maintenance
records to look for clues.
They soon make a discovery.
The aircraft seems to
have an issue with its RTLU.
EMMANUEL: RTLU is the
Rudder Travel Limit Unit.
The plane had had a
history of RTLU failures.
NARRATOR: The
Rudder Travel Limit Unit
is a computerized component
that prevents the rudder
on the tail from deflecting
too far in either direction
when the plane is
traveling at high speed.
If the flight
computer detects any problems
with its rudder limiter, it
sends a warning to the cockpit.
Records show the aircraft's
Rudder Travel Limit Unit
had been malfunctioning
for almost a year.
RAY: Twenty-three reports
of the exact same failure.
JOHN: The RTLU failures
on this particular airframe
had become
increasingly frequent.
There were eleven in
the last couple of months
and twenty-three in
the preceding period,
which is highly unusual.
RAY: That seems like a lot
of failures with the RTLU.
NARRATOR:
Could these be connected
to the mystery warnings
the pilots were experiencing? It
could be a major breakthrough.
RAY: Three days
before the crash there were
two exact same failures.
Why was this happening?
NARRATOR: After each
failure, maintenance workers
reset the RTLU.
ERTATA [Translated]:
As long as the reset resulted
in the computer to prompt pass,
maintenance personnel doesn't
have to investigate further.
RAY: They just kept resetting it
and then putting
it back in service.
NARRATOR: But they
never found a permanent fix.
JOHN: They were returning the
airplane to service after reset,
and from a legal standpoint
it did clear the problem.
But obviously whatever
the fault was, they hadn't
found it, because the
problem continued to reoccur.
NARRATOR: The aircraft
seemed to operate perfectly
despite the warnings.
Even the day before the crash,
the plane had successfully flown
from Surabaya to Kuala Lumpur.
RAY: Have we got the unit?
NARRATOR: The plane's
RTLU is among the wreckage
that's been
recovered from the Java Sea.
*
RAY: Let's send it
back to the manufacturer
and see if they
can find something.
NARRATOR: The unit is
sent to France for analysis.
*
Finally, investigators get to
examine a key piece of evidence,
the flight data recorder.
If they can download
all the flight data,
it should provide
a detailed picture
of exactly what was
happening with the electrical
and mechanical control
systems on the aircraft.
RAY: After the
black box recovered,
they transferred
to our laboratory.
EMMANUEL:
We worked with the Indonesian
investigation authority
in extracting the data, which
requires a lot of precautions,
since the flight
recorders had been immersed.
*
RAY: Move it down
too a little bit.
NARRATOR: On examination,
they discover the data board
has been damaged by
the impact of the crash.
It's uncertain whether the
information they desperately
need will be retrievable.
*
The download begins.
RAY: Even though the condition
of the black box was damaged,
we managed to
recover all of the data.
NARRATOR: Success.
RAY: Okay, so let's start
with those chime warnings.
So here's the first warning.
It clearly was the RTLU.
They do the fix, simply
resetting the entire system.
AUTOMATION: [Alarm]
JOHN: The procedure to reset the
system was much like your PC,
rebooting the PC. They
only had to turn the system off
and turn it back on again.
CPT. IRIYANTO: FAC 2 off and on.
RAY: Two more times
the RTLU warning goes off,
and each time they
did the right thing.
Then it went off
on a fourth time.
Then suddenly
there was a glitch.
What did they do different?
NARRATOR: After the fourth
time, the warnings change.
There is now a fault with the
aircraft's two main computers,
known as the flight
augmentation computers.
RAY: Put the new
data up on that screen.
*
Something caused both computers
to fail at the same time.
NARRATOR: But
nothing in the data shows
what the crew did differently
after the last warning.
What does come to light is that,
when the autopilot disengaged,
the rudder moved slightly.
RAY: Now let's see. The plane
started to bank to the left.
EMMANUEL: The
electrical interruption
on the flight control computers
created a rudder movement
of about two
degrees to the left.
JOHN: Two degrees
does not sound like a lot,
but at the speed
they were flying
it's exactly what caused
them to roll left 54 degrees.
JOHN: That's almost
twice the normal bank
that you would
feel in an airliner.
RAY: Now look at this.
It took them nine seconds
to do anything about the bank.
NARRATOR: Despite
the steep bank angle,
it seems the crew was slow
to react and level the plane.
EMMANUEL: During
the first nine seconds,
there was no crew
inputs on the controls
following this roll that
reached fifty-four degrees.
NARRATOR: Then the first
officer suddenly reacts,
pulling hard to the
right, then left again
and just as suddenly
he starts to pull up.
RAY: All they had to
do was steady the plane.
What were they doing?
NARRATOR: The FDR
data shows that the plane
climbed steeper and steeper
until they reach a
remarkable 45-degree pitch up.
RAY: Then it stalled.
NARRATOR: Investigators
know that the captain
did something
different, something that led
to a computer glitch causing
the autopilot to disconnect
and the plane to bank sharply.
But they don't know what he did.
JOHN:
The single event of autopilot
auto throttle disengagement
sends the investigators in
two different directions --
one, what caused it? Two,
how did the crew handle it?
As investigators struggle
to answer puzzling questions
about Flight
8501 and its crew...
[Phone rings]
RAY: Hello? NTSC.
NARRATOR: They get
an important new lead.
RAY: Wait, wait.
Slow down. What happened?
*
NARRATOR: A mysterious
action by the captain
to solve a routine
error appears to have set off
a deadly sequence of events.
Investigators are still trying
to understand what happened
when they receive
some new information.
RAY: Start from the
beginning. Where was he?
EMMANUEL: Three days before the
accident, on the 25th December,
this same
captain was about to fly
from Indonesia to Kuala Lumpur
when he had an RTLU malfunction.
He asked for an
engineer to come to the cockpit
and try to fix that.
ENGINEER: RTLU problem again?
CPT. IRIYANTO: Yeah, it
just keeps coming back.
NARRATOR: The maintenance
engineer rebooted the system.
[Alarm sounds]
But the problem came back.
ENGINEER: I've got an idea.
NARRATOR: He then
pulled the circuit breakers
for the main computer.
JOHN: Maintenance on the
ground has a very specific list
of circuit breakers
that says you can utilize
pulling these circuit
breakers to reset computers
within the airplane.
NARRATOR: As the captain
watched, the problem was fixed.
ENGINEER: Problem solved.
CPT. IRIYANTO: And can I do the
same thing if it happens again?
ENGINEER: Yeah, just do
what the ECAM tells you to do.
RAY: Don't tell me he
tried to do that in the air.
NARRATOR: Investigators
think that they now know
what the captain did that led
to the crisis in the cockpit.
RAY: Begin simulation.
NARRATOR: To see if they're
right, they decide to simulate
the cockpit
warnings heard in-flight.
RAY: Okay, so let's
start with the RTLU warnings.
AUTOMATION: [Alarm]
RAY: FAC 1 off. FAC 2 off. Good.
AUTOMATION: [Alarm]
CPT. IRIYANTO: Enough of this.
NARRATOR:
After the fourth RTLU warning,
he takes a new approach.
FO. PLESEL: ECAM actions?
CPT. IRIYANTO: No.
I've got a better idea.
NARRATOR: Investigators
believe the captain
pulled two
critical circuit breakers.
RAY: Captain pulls
circuit breaker one.
*
NARRATOR: The
result is immediate.
AUTOMATION: [Alarm]
RAY: And there goes the
autopilot disconnect warning.
NARRATOR: Investigators can
now be certain of one thing.
RAY: This had to be what he did.
JOHN: He was perhaps copying
what he'd seen the
ground engineer do,
but of course the
consequences in flight
to disabling critical
systems are quite different.
JOHN: The
captain wrongly assumed
that if it worked on the
ground it'll work in flight.
ERTATA [Translated]:
The circuit breaker,
which is part of the
flight augmentation computer,
is something that should
never be pulled out in the air.
NARRATOR: Pulling
the circuit breakers
has devastating consequences
the captain didn't anticipate.
JOHN: Unfortunately, he was
not pulling circuit breakers
that affected only the
rudder limiter system,
but ones that also disabled the
flight augmentation computer,
which tripped the autopilot,
the auto throttle and
all the normal mode protections
that the aircraft had.
NARRATOR: The
plane begins to roll.
Over the next nine seconds,
it rolls fifty-four degrees,
yet no one does
anything to stop it.
What took them so long to react?
RAY: The first officer would
have been looking here and here
when the autopilot
warning was disconnected,
and the captain was
still standing behind
the first officer's seat.
FO. PLESEL: What was that?
NARRATOR: It's
likely that neither pilot
was looking at the
attitude indicator
that showed the
plane was banking.
RAY: That's why it
took them nine seconds
to notice what this
gauge here was telling them.
NARRATOR: As the
plane started to roll,
the first officer was
focused on the fault warnings.
He didn't notice that
the plane was banking
until the captain
sat back down again.
[Alarm sounds]
CPT. IRIYANTO: Oh my God.
FO. PLESEL: Oh!
NARRATOR: Despite losing
control of these systems,
the high-tech plane
did have the capacity
to get back on course.
After the initial roll,
why didn't the first officer
just steady the plane
and reengage the autopilot?
Investigators have
to try to understand
what was going on
inside the pilots' heads.
JOHN: The co-pilot's
movement of the stick
to its extreme
rightmost position
resulted in a very
violent roll to the right,
two to three times what would
be programmed as the maximum
for an Airbus normally.
NARRATOR: In an
attempt to understand
the first officer's
actions, investigators study
how the human
brain behaves in flight.
A sense of balance is
maintained by liquid levels
in the ear canals.
When that shifts violently,
the brain can get mixed
signals that affect balance.
The FDR data shows how dramatic
the plane's movements were.
RAY: So the plane rolled
fifty-four degrees left,
and he pulled back almost
level in just two seconds.
That would
scramble anybody's gyros.
Maybe that was the confusion?
JOHN:
As soon as the first officer
had leveled the aircraft,
the fluid in his ear canals
keeps spinning to the right.
The aircraft is level,
but there's a very
strong illusion from the ears
that you're
turning to the right.
RAY: He pushes the plane all
the way to the left. But why?
CPT. IRIYANTO: Level.
FO. PLESEL: I am! I am!
JOHN: The natural response
would be to roll the aircraft
back to where it came from into
the fifty-four degree of bank,
which was what they
thought the level was.
RAY: And then he
pulls it as hard as he can,
and the plane starts climbing.
JOHN: This is a massive input.
The airplane would
pitch up very quickly.
FO. PLESEL: What's going on?
RAY: He was completely baffled.
JOHN: His vertigo may
have led him to believe
that the aircraft
was pitching down.
So he's actually recovering
from an imaginary pitch down.
RAY: He was disoriented.
JOHN: With all the
alarms that were going off,
with the rapid
left-right-left rolls
and with the generally
deteriorating situation,
I think the crew had started
to lose their spatial awareness
completely.
NARRATOR: Investigators
finally understand
what must have been going
on with the first officer's
confused state of mind.
But if the first officer
wasn't operating
the controls correctly,
why didn't the
captain take the one step
that could have saved the
lives of everyone on board?
*
Investigators study
the captain's behavior
during the roll.
CPT. IRIYANTO: Pull down!
NARRATOR: They know
from the recordings that
he was trying to
help right the plane.
CPT. IRIYANTO: Pull down.
FO. PLESEL: I'm
trying. It's not responding.
NARRATOR: He wants his first
officer to stop climbing up
and push the nose down.
CPT. IRIYANTO: Pull down!
NARRATOR: But his
command is confusing.
RAY: It's either you
pull up or you push down.
JOHN: When one
thinks that the co-pilot
is holding a side stick,
pull means pull it back,
which means go up. And
down means push it forward.
So pull down is a
contradictory command.
EMMANUEL: In that case
the captain should have said:
"Nose down. Nose down."
NARRATOR: The first
officer continues pulling back
on his side stick
until the very end.
JOHN: The input of
the first officer...
CPT. IRIYANTO: Pull down!
JOHN: Was the
exact wrong thing to do.
FO. PLESEL: What's going on?
NARRATOR: He clearly
didn't understand the command.
So why didn't the captain take
full control of the airplane?
RAY: He tried to take
over here and over here.
CPT. IRIYANTO: Pull!
FO. PLESEL: It's not correcting.
JOHN: There is a button
on top of the side stick
that can let you
take full control
to lock the other pilot out...
CPT. IRIYANTO: Pull!
JOHN: ... so that you
know what's going on.
NARRATOR: The data
shows that the captain
did push the take control
button, but only briefly.
He didn't push it long
enough to take over the plane.
FO. PLESEL: It's not responding.
RAY: But at the end
he never took control.
NARRATOR: It meant that
both pilots were trying to fly
at the same time.
RAY: Both pilots started
controlling the aircraft.
When that happened, control of
the aircraft become ineffective.
NARRATOR: If he'd
spoken three simple words,
the plane could have been saved.
JOHN: The training is,
you say, "I have control,"
and the other pilot
stops making inputs.
In this case,
that wasn't happening.
*
NARRATOR: Investigators
now know that pilot error
led to a spatially
disoriented first officer.
The captain, who
could have helped
by communicating more clearly
or taking over the plane,
did neither. Investigators
can never be certain why.
The case is building to a close
when they get another piece
of information. The results
of the RTLU analysis are in.
*
It was a series of
warnings from that unit
that triggered the
events that led to the crash.
[Alarm sounds]
FO. PLESEL: ECAM actions?
JOHN: The failure
the crew had experienced
with the rudder limiter system
was actually a negligible
failure. It was a nuisance.
And the
procedures to reset it...
CPT. IRIYANTO: FAC 1 off and on.
JOHN: ... were simple.
CPT. IRIYANTO: FAC 2 off
and on. Warning cleared.
NARRATOR: All the
captain had to do
was keep on following
the ECAM's instructions.
EMMANUEL: The plane had
had a history of RTLU failures
throughout the year, and this
failure had never been fixed.
NARRATOR: Microscopic
examination of the unit's
electronic
module finally reveals
the cause of those
repetitive failures.
EMMANUEL: We found out
that there was a crack
in the soldering joint
on the electronic module,
which caused the RTLU to
work from time to time only.
And had the correct maintenance
task been applied...
ENGINEER: Problem solved.
EMMANUEL: ... the
RTLU electronic module
would have been removed.
JOHN: The airplane should have
been sent for troubleshooting,
and you could have
broken the chain of events.
NARRATOR: For
investigators, discovering
that such a minute
fault sparked events
that led to the death
of all 162 people on board
makes this all the more tragic.
As they prepare
their final report,
it's clear that the
crash of Flight 8501
has exposed a series
of serious problems.
*
The final report calls for
improved maintenance protocols
to help eliminate
minor recurring problems,
like the RTLU fault, before they
lead to a major catastrophe.
JOHN: When you start
having four, five, six, eight,
ten recurring
problems, it's saying
that the traditional
methods are not working
and that you need to do much
more heavy-duty diagnostics
until they find the problem.
CPT. IRIYANTO: Pull! Pull down.
RAY: And the other lesson
we take from the accident
was the
communication between pilots
to make sure that
communication was well
to avoid the different
interpretation of the command.
JOHN: This is a case
that the industry learned
some very hard lessons,
but the thing most importantly
is that the industry
implements those lessons
so that we don't
have another one.