Air Emergency (2003–…): Season 7, Episode 6 - Ditch the Plane - full transcript
The aircraft, TS-LBB, took off from Bari, Italy, as Flight 1153 at 2:32 p.m. local time, on its return leg to Djerba, Tunisia. At about 3:15 p.m., the pilot alerted the Palermo Punta Raisi airport to technical problems and requested permission for an emergency landing. The right engine stopped at 3:25 p.m., at which point the pilot apparently realized he wouldn't reach Palermo. The left engine cut out at 3:35 p.m. Two minutes later, the aircraft disappeared from Palermo's radar and radio contact was lost.
High above the Mediterranean,
two pilot struggle with a stalled engine.
45 miles from land,
the pilots make a difficult decision:
Prepare the ditch
Passengers are forced
to make live or death decisions on their own.
Do not inflate your vest.
The accident will tear families apart
set in motion a massive rescue effort at sea.
and trigger a multinational investigation...
...to discover why both engines
of one of the world's most popular planes
stopped in mid-flight.
Air Crash Investigation
Season 07, Edition 06
This is a true story.
It is based on official reports
and eyewitness accounts
DITCH THE PLANE
August the 6th, 2005
Bari, Italy
An ancient port town on the Adriatic Sea
where the past meets the present.
Just North of this historic city
Bari Internat'l Airport serves 10 major airlines
and more than a 1,5 million passengers each year.
One of those carriers
is Tunisia’s Tuninter Airlines.
Captain شفيق الغربي
is a pilot with Tuninter.
Today, he is in command of Flight 1153.
The 45 year old Tunisian is
a military trained pilot
with a flawless flight record.
Gharbi's copilot is 28-year-old علي كبيّر الأسود
How much fuel?
400 kg
2700 total?
Captain Gharbi and his copilot
flew from Tunis to Bari this morning
to collect 34 Italian passengers.
Now, they are going to fly them to Djerba,
a Tunisian resort island.
Among the passengers is 31-year-old police officer
Lucas Squicciarini
His girlfriend Paula is travelling with him.
Our first choice was not Djerba,
it was Cape Verde.
The thing with Cape Verde is
that it was a period of terrorist activities.
The flight would have left
from either Rome or Milan.
Since there are two large airports,
Paula was afraid that there would be an attack
so we chose not to go to Cape Verde.
It was my first trip with Paula.
We met the previous winter.
We had plans to marry the following year.
You take your belt,
pull at the loose end of the strap
to release your seat-belt.
Ladies and gentlemen,
your life vests are located beneath your seats.
To inflate the vest pull firmly on the cord
only when you are leaving the aircraft
If you need to refill the vest,
blow into the mouth-tubes.
Roger that, cleared for take off.
Final trip for departure.
The crew is flying a French made ATR 72.
The small turbo prop is perfect for short flights.
It doesn't need a lot of maintenance
or guzzle a lot of fuel.
Just after 2:30 PM,
the plane takes off.
49 minutes after take off,
Flight 1153 is 400 mile away from its destination,
Djerba.
So, we started chatting with other passengers.
We were all excited
We talked about the vacation.
Then, 75 miles from the nearest land
and 23,000 ft above the sea...
...the right engine stops working.
We've lost engine number 2.
Let's get to 17,000 ft.
TUI-1153 request 17,000 ft
Captain Gharbi begins an emergency descend.
When you have a single engine flame out
it will descend to a lower altitude,
the air is thicker,
the propeller is more efficient.
Under current conditions, the ATR 72 can best fly
on one engine at an altitude of 17,000 ft.
The crew struggles to restart the right engine.
But then, less than two minutes
after the first engine quits...
Stop, stop,
engine number 1 has flamed out
...both of the engines have stopped.
The engine shut off
Our first thought was of a terrorist attack,
since there were so many at the time
We tried to figure out what was happening,
so we looked towards the cockpit
to see if someone was trying to sabotage the plane
The plane is now falling to the sea at 800 ft/min
(14.6 km/hr)
TUI 1153
We've lost both engines,
request immediate landing at Palermo
The crew still hopes to reach an airport,
but they have 70 miles of ocean to cross
before they are over land.
Crews are trained for almost anything
There is a checklist for them to follow
to solve most problems
including what to do when both engines die.
Fuel supply
Check
The pilots don't know
why their engines have stopped.
The only clue they are getting
is a low fuel feed warning
a LO PR warning light tells the pilot that
there is a low fuel pressure to the engine
That can be a mechanical problem
or that can be a contamination problem.
The crew follows the steps of the manufacturer
to relight their dead engines.
Fuel supply, check
Power lever flight idle,
START button
Engine RELIGHT
Negative
Get Chokry
The Captain asks the cabin crew to bring
the on board engineer Harbaoui to the cockpit
Palermo approach
this is TUI 1153
We've lost both engines,
Request immediate landing.
The closest airport is in Palermo,
on the Italian island of Sicily.
TUI 1153, Palermo
Affirmative
you are cleared for landing.
Palermo approach,
What is our distance to the airport?
Your distance to Palermo
is now 48 nautical miles.
An ATR 72 will fall from the sky
at a predictable rate:
1 ft down for every 16 ft forward
48 nautical miles is further
than the plane can glide.
I think we are not going to make it
If they can't restart their engines soon
they will be forced to ditch in the sea.
Ditching at sea
is a very difficult decision to make
because it is the hardest thing to do,
you have swells, waves, wind.
Is anybody going to see you?
How long can the plane float for?
Landing a passenger plane on water
is extremely dangerous.
In 1996,
an Ethiopian Airlines pilot was forced to
bring his 767 down on the Indian Ocean
The ditching was recorded by a tourist
on a nearby beach.
50 people survived
but 125 people died.
The crew of this small plane doesn't usually
include an engineer.
When there is one on board,
he usually travels in the cabin.
I remember this person looked at the stewardess
and shook his head as if saying:
No. after the second engine has shut off.
That gesture showed,
there was nothing left to do
The crew has tried all it can
They are running out of time and options.
Flight engineer Chokry Harbaoui has joined
in the struggle to get the engines started.
You have run the checklist?
Yes
The Captain hopes the engineer will know something
that isn't covered by the checklist.
Attempt to restart the engines,
right engine first.
Fuel supply:
Check
Engines 2 START POWER button:
ON
Engine relight:
Negative
Palermo approach, here TUI 1153
any closer airport where we can land?
Negative, 1153,
Palermo airport
is the closest airport in your position
We are not going to make it
Prepare the ditch.
Oh, My God
The Captain has decided to land the plane at sea.
I will let you imagine the panic on board
People where screaming and crying
Please, stay calm
There were people in the front seats
that had a baby girl.
She had been playing and was so excited
She now sees the panic in her mother's face,
it made me feel so sad.
TUI-1153, what is your fuel load?
Cockpit fuel quantity: 1800 kg
Captain Gharbi's fuel gauge
shows that he has plenty of fuel,
but for some reason,
neither engine will restart
Just 10 minutes after the trouble began,
the plane is 7000 ft above the ocean and falling.
Outside, it is completely silent
but in the cabin...
...there is panic
Please, remain in your seats
with your seat-belts fastened
My first instinct was to undo my seat-belts
to prevent getting trapped when we hit the water
I didn't want to be trapped in my seat
and go down in a horrible way.
but secondly, I put on my life jacket
and quickly blew it up
I did this to soften the blow of the impact
Do not inflate your vests
until you have left the plane
A plane, ditching at sea
will more than likely fill with water.
That is why safety procedures call for
passengers to only inflate their life vests
once they have cleared the plane,
otherwise they could become trapped
inside the flooded fuselage and drown.
In the Ethiopian Airlines crash,
many passengers ignored this advice
and drowned
after surviving the initial impact.
Negative
The dead engines are not
the only problem confronting the crew
Many of their instruments
get their power from the engines
Without the engines,
some vital gauges are dead.
On a two engine flame out
you go on your standby instruments,
which is, you have an attitude indicator
you have an altimeter
The crew continues to try
to restart their engines,
but it has become clear
that they have run out of time.
Confirm distance, please
Your distance is now 20 miles.
Boats, I see boats
Choosing to ditch near a ship or a vessel
is not in any checklist
It is just good airman-ship,
because the rescue can start immediately
and increases you chances of survival.
Flame out approach, this is TUI 1153
We can't make it to the airport
We see two boats on the left side,
we are going there
If you can, please call
Captain Gharbi turns his plane towards the boats
Can you send helicopters or something similar?
Emergency, all marine units, aircraft in distress
20 nautical miles off Palermo
Even before the plane hits the water,
rescuers are on their way
Although it is a rare manoeuvre
there is also a checklist
for ditching a plane in the water
Before ditching,
the crew ensures all landing gear is retracted
to help the plane land more smoothly.
Landing gear lever up
When pilots ditch,
they want their airplane
is streamlined as possible
so that it glides across the water when it hits.
Pilots must not only monitor the systems
on the plane
they also have to assess conditions at sea.
They don't want to hit a wave head on.
If you hit perpendicular to the waves
or the swells with the aircraft
it is like hitting concrete:
the plane will break up.
Passengers can see what is coming.
I was hanging on tight
to the seat in front of me,
and through the window,
I could see the impact was imminent.
The crew is 700 ft above the sea.
You are with me, honey
Careful
Chokry, ready?
Here we go
At a speed of 145 mph,
the plane collides with the sea.
Squicciarini:
I lost consciousness.
I woke up in the water
I was 2 or 3 meters under water
I came up to the surface,
wearing only my pants
I had lost my life jacket and clothes
on impact
I got to the surface and grabbed on to a bag
I was in shock,
I was surrounded by everything
My thoughts were constantly with Paula
I thought I was going to die,
because I was spitting blood
I felt my lungs filling with blood
Captain Gharbi survives
but has been seriously injured
Co-pilot Ali Kebaier Al-Aswad has also survived
But Flight engineer Chokry Harbaoui is killed.
No one aboard the nearby boats saw Flight 1153
crash into the sea.
The plane has broken into three pieces.
The tail-section and much of the fuselage sink
to the bottom of the sea,
but the larger section, containing the two wings,
stays afloat.
It becomes a life raft for survivors
But not all of the passengers have survived;
many haven't made it out of the plane
and to the surface.
Helicopter pilot Stefano Burigana
is one of the first to arrive at the scene.
The bridge control asked if we were aware
of a ditched aircraft out of the coast of Palermo
and if we were able
to help them to locate the airplane.
When we approached the airplane
we could see the wings floating.
There were several people in the water
around the aircraft.
All floating and
everybody with their jacket inflated.
Burigana spots Lucas Squicciarini floating,
away from the main wreckage
There was one man without his jacket
and he was at a far distance from the airplane.
I decided to go over him
and throw one of our life jackets to him
Within the hour,
the crash site is teeming with rescuers.
They search for survivors
from the water and from the air.
23 people are pulled from the Mediterranean Sea,
but 16 have died in the crash,
including Paula Di Ciaola.
My relatives told me a couple of days later,
while I was still at the hospital
I had no reaction,
Paula was gone.
I reacted when I got home
When I got home and went to the cemetery,
I realized what was happening.
That is where I got really down.
It is quite likely that none of those who died
ever had a chance to swim to safety.
Their serious injuries would have prevented them
from escaping after the plane hit the water.
In this accident, most of the survivors
were seated in the rear of the plane,
most of those who died, up front.
Those sections, along with some valuable clues
are now at the bottom of the sea.
The one section that didn't sink
is towed to the port in Palermo
and taken to a nearby hangar.
a team of agents
from Italy's National Flight Safety Agency
the ANSV,
begin looking for leads.
Their job: Find out why the engines
stopped in mid-flight
We need to collect as
much evidence as possible
in order to fulfil 2 main answers:
What happened
and why have it happened?
They are led by chief ANSV investigator
Vincenzo Pennetta.
I arrived in Palermo the day after the accident
on the 7th in the morning
A flight engineer by training,
Pennetta has led several aircrash investigations.
The engines and central fuselage
have been recovered,
the rest of the plane lies
somewhere off the Sicilian Coast.
The main challenge of the investigation
was the fact that the FDR and the CVR
and also the front fuselage
were 1,500 meters under the sea.
While the Italian Navy conducts
a deep water search for the rest of the wreck
and the crucial black boxes,
Italian investigators are given some assistance
by the plane's European manufacturer
ATR's Giuseppe Caldarelli is here to find out
if there is a flaw with the company's plane.
Any time there is an accident and
even if one person die is for me a big accident.
Worldwide,
hundred's of ATR 72's cross the skies each day.
Those aircraft have a very sound structure
and robust systems
and are very cost-efficient.
Together,
Pennetta and Caldarelli set out to find
why both engines on such an advanced airplane
died in mid-flight...
...before it happens again.
Captain Gharbi, how are you?
I am getting better, thank you
Investigators want to know what happened
in the cockpit when the engines died.
Without the CVR,
they must rely on the recollections of
surviving passengers and crew members.
The main cause could be a lack of fuel
But according to Captain شفيق الغربي
lack of fuel was not the problem.
What were your fuel readings?
The fuel quantity indicator said 1800 kg of fuel
What is your fuel load?
Cockpit fuel quantity 1800 kg
Was there any warning
that you were low on fuel?
There was definitively no low fuel warning
just a low feed pressure light.
The absence of a low fuel warning and the
presence of a low feed pressure warning
is a major clue.
This set of alarms usually indicates
that there is a problem
in feeding the engine with fuel.
Since the gauges indicated
that there was fuel on board
that did not get to the engines,
Giuseppe Caldarelli looks for flaws
in the fallen plane's fuel delivery system.
Four years earlier,
an Airbus operated by AirTransat developed a
leak in the fuel line that feeds the right engine.
Over time, the plane leaked all of its fuel
and both engines failed
The pilots were forced to glide their plane
to an emergency landing.
That incident has a lot of similarities
to the Tuninter crash
Giuseppe Caldarelli's team looks for breaks
or blockages in the fuel lines
and evidence that the fuel-pumps malfunctioned
and stopped fuel float to the engines.
While Caldarelli waits for technicians
to complete tests on pumps and lines,
Pennetta decides to start a new line of enquiry.
He explores the possibility that the on board fuel
was somehow contaminated
Fuel contamination can derive
from 4 or 5 different sources.
Kerosine-based jet fuel is very delicate.
If stored or transferred improperly,
it can be polluted with water, sand or fungus
even sticky residue
from the hoses of refuelling tankers.
Any of these could prevent the fuel
from properly igniting
and could have caused the engines to shut down.
The plane last took on fuel in Bari.
Samples from the tanker that supplied it
are taken for testing.
Pennetta needs to prove that
one of these contaminants got into its fuel,
prevented combustion
and caused both engines to fail
Sediments can be transferred
from the tanker truck to the aircraft
So, the fuel feeder can be clogged,
and so, the engine can have some problem.
Technicians remove the truck's fuel filters
to look for evidence of contamination.
Hoses and couplings are swabbed for sticky residue
or colonies of micro organisms
and submitted for testing
at an Italian Airforce Laboratory.
The fuel is filtered for minute particles,
suspended in the fluid...
...and carefully examined for impurities.
The truck's filters are also inspected
for residue or sediment from the tanks.
Meanwhile, in Palermo,
Caldarelli and his technicians have completed
tests on Flight 1153's fuel lines and pumps.
The tests are thorough,
the results conclusive.
The fuel feed-line were okay
No leak
If the fuel delivery system was working,
and the two pilots remember having ample fuel,
then why had the engines failed?
When test results from the Bari fuel tanker
come in
they too are conclusive.
The fuel filters, hose couplings
and tanker fuel at Bari Airport are clean
So, fuel contamination as a source
of a double engine flame out was excluded.
At this point, the investigators still don't know
what caused the downing of Tuninter Flight 1153.
But something has been eating up Pennetta.
If the plane was filled with fuel
and since the fuel is stored in the wings,
why did the wing-section float?
The floating of the wing indicates
that the weight of the wing was not so high.
We have been told by ATR
that if the amount of fuel in the wing was
around 2000 kg were on the fuel tanks
the wings wouldn't be able to float.
Pennetta suspects the plane didn't have
as much fuel as the pilots thought
but he doesn't know how that could be.
Two weeks into the investigation,
Pennetta gets an important lead in the case
After two weeks of the event,
we received some technical documentation
from the aircraft operator.
According to the logs,
Captain Gharbi flew the same aircraft
the day before the accident.
After that flight,
he reported a problem with his fuel gauge.
When he left the aircraft the day before,
he reported that the right FQI
was out of service,
so it need to be replaced.
The fuel quantity indicator or FQI is a gauge
that tells pilots how much fuel is left on board.
The lights on the FQI were malfunctioning.
Captain Gharbi made a note of this
in the maintenance log.
You were able to see that
the FQI was changed the day before the event.
The maintenance log raises the possibility
that the FQI was not the right one for the plane.
It doesn't seem to have the right model number
Tuninter flies two models of ATR aircraft:
The ATR 42...
...and the larger ATR 72.
The FQI's for each plane look identical,
except for a different model number
at the top of each unit.
The ATR-72 should have a model number 2500
but according to the logs,
mechanics installed unit 2250 instead.
Tuninter's maintenance logs offer a valuable clue.
But for Pennetta,
there is no definitive proof
that the wrong FQI was installed on the plane.
It could have been a mismatch
in that aircraft documentation,
so we need to prove that.
There is only one way to know for certain
whether the ATR 72 has the right FQI.
Go and find it at the bottom of the sea.
We need to recover the wreckage of that aircraft
to see physically what was the FQI installed
on the aircraft.
Not until three weeks after the crash,
the investigators recover wreckage from the sea.
The data from the black boxes
confirms what the pilots have been saying.
There was no warning of low fuel,
so, there appeared to be enough fuel
to make the flight.
The black boxes cannot solve this mystery.
Investigators hope
that the tail and front-section can.
They are hold
aboard the naval vessel from the sea.
The moment the cockpit is hold in,
Pennetta is there.
There is only one thing
he wants to see inside.
So, when the wreckage was recovered
from the sea and put on the ship deck
I realized that the FQI for an ATR 42
was installed.
It was like we found the smoking gun.
The wrong FQI was installed on Flight 1153.
Pennetta finally has the break
he has been looking for.
The ATR's FQI collects data
from sensors in the fuel tanks
and calculates how much fuel is in the tanks.
But since the fuel tanks on the 42 and the 72
are at different size,
FQIs can't be swapped between them.
Technicians conduct refuelling tests
with the wrong FQI installed on an ATR 72...
...and the results are chilling.
The results show
that if you install an FQI type '42'
on an ATR-72 aircraft
if I have no fuel in the tanks,
with zero fuel,
the FQI show me 1800 kg.
Precisely the amount of fuel that the Captain
reported having when his engines flamed out.
Investigators conclude:
At 23,000 ft above the Mediterranean,
the wrong FQI let the crew to believe
that they had ample fuel...
...when their tanks were actually empty.
The engines could not possibly
have been restarted.
With hundreds of ATR 42s and ATR 72s still flying,
the implications are stark.
Could there be other planes flying
with the wrong gauge?
The first recommendation was
to mandate all operators
that use the ATR 42 and 72 aircraft in their fleet
to check whether the right FQI
was installed on the aircraft.
Pennetta and Caldarelli have uncovered the error
that caused both engines to quit in mid-air.
But the case isn't closed:
Standard flight-procedures should have uncovered
the error before take off
and prevented the disaster.
Captain Gharbi's aircraft went in for repairs
in Tunisia the night before the crash.
The FQI indicated 790 kg of fuel in the tank.
After the new FQI was installed,
it showed that there was almost 4 x as much fuel:
3,100 kg.
The following morning, Captain Gharbi noticed
that the fuel-levels has gone up.
He assumed the fuel had been added.
But when fuel is added to an aircraft,
a refuelling slip must be left in the cockpit.
Where is the refuelling slip?
The pilot asks to the flight dispatcher,
where the refuelling slip was
but the flight dispatcher was not able to find it.
I'll give it to you when you get back from Djerba
There was no refuelling slip,
because the plane hadn't been refuelled.
In spite of regulations,
the captain left without that vital piece of paper
There are some standard regulations
requiring the pilot to take off
only when he is sure about the quantity of fuel.
With the wrong fuel indicator on board,
and less fuel than he believed
Captain Gharbi makes it to Bari, Italy,
and tops off his plane
for the next leg of the trip to Djerba.
How much fuel we are added?
400 kg
2700 in total?
Believing he has 2700 kg of fuel on board,
Captain Gharbi begins his flight to Djerba.
If the correct FQI had been installed,
the Captain would have known
that he had only 540 kg,
not nearly enough to make the crossing.
Pennetta's investigation comes to a close.
He draws up his final report.
His colleague, Giuseppe Caldarelli
voices a bold view
Even with no fuel and dead engines,
Flight 1153 could have made it to land.
The aircraft was in a position
that allowed to reach Palermo.
Caldarelli wonders
if the pilots did everything they could have
to get the plane safely to Palermo.
Investigators get some unexpected answers
by having seasoned pilots fly the same flight
with the exact same problems.
We are now in big trouble,
because the 2nd engine has gone off.
Pennetti's investigation into the crash of TUI1153
has uncovered the events to the accident.
Now, he and Caldarelli
need to resolve one question
Did mistakes, made by the pilots,
cost people their lives?
Prepare the ditch!
Caldarelli and his team studied the specifications
and draw a surprising conclusion.
Flight 1153 could have been able
to glide to Palermo.
According to manufacturer data,
an ATR is able to glide 3 miles
for every 1000 ft of descend.
This is a downward slope of 6.31%
With the help of a tailwind that day,
Flight 1153 was able to glide 70 miles to Palermo
The crew might have been able to make it.
So, what had the pilots done wrong?
To answer that question,
Pennetta and Caldarelli recreate Flight 1153
in the flight simulator
at the ATR facility in France.
Test pilots try to glide an ATR 72 for 70 miles
from the altitude
at which Flight 1153 lost its 2nd engine.
The simulation was requested
to see the range of the aircraft,
starting from the 2nd engine flame out
When engines flame out,
you have to be very aware
of the configuration of the aircraft
in order to keep as much as possible the altitude
and distance to fly before the crash.
With both engines out,
the priority is to keep the plane
gliding as far as necessary.
To do that,
pilots can change the angle
of their windmilling propellers.
You will have the maximum glide performance
when you minimize the drag.
It is very important to feather the propellers
in order to reduce the drag.
Feathering the props involves
changing their angle against the wind.
The manoeuvre reduces drag.
When you want to feather the propellers in flight,
you first have to reduce the power lever to idle,
and put the condition lever
back to feather position.
The crew did not feather their props
when their engines quit.
The windmilling propellers created enormous drag.
If the crew had feathered their props,
they may have been able to glide further.
By the time Captain Gharbi's 2nd engine flamed out
he was just below 22,000 ft.
To further reduce drag at that altitude,
the plane should be slowed to a 158 mph,
the ATR 72's ideal gliding speed.
Surprisingly, to glide as far as possible,
a pilot doesn't want to fly as fast as possible.
The faster a plane flies,
the more the airflow pushes against it,
creating resistance.
Every plane has an optimal speed
to achieve the furthest glide.
The crew continue flying up to 55 mph faster
than their optimal gliding speed.
That added to the drag on the plane
and reduced the distance they could glide.
By feathering his props and reducing his speed,
a simulator pilot in France
was able to get as far as Palermo.
Flight 1153 hit the water 26 miles from shore,
well short of
what the plane was capable of achieving.
The simulation confirmed that
the crew might have been able to make it to land.
It was theoretically possible to reach the coast
but it was also very difficult
to reach that result.
Simulator pilots had one big advantage
over the crew of Flight 1153
They weren't in a life or dead situation,
and they knew they had to glide, instead.
But Captain Gharbi didn't know he was out of fuel.
He didn't think he need to glide to Palermo
Gharbi focused on restarting the engines instead,
feathering the props
isn't part of that procedure.
If the Captain had known he was out of fuel
he might have acted to maximize glide instead.
Once he realized that his engines wouldn't start,
his focus was on try to find a place
to ditch the plane.
He also had to content with a lack of instruments
as well as radio interruptions.
Most importantly,
Captain Gharbi had the lives of his 34 passengers
to consider.
Of course,
it is much easier to cope with
that situation on the simulator
because if you do it wrong,
if you crash the aircraft,
you have the magic button:
RESET
Everything is okay again
and that is very different in the real life,
with the passengers behind them.
The simulation highlights the importance of
proper training to deal with unlikely situations
such as a twin engine flame out.
In aviation it is a very rare event.
Vincenzo Pennetta's report urges airlines
to train their pilots how to ditch
without engine power.
Better pilot-training is just one
of 17 safety recommendations in the report.
Perhaps the most important:
That ATR redesigned the FQI.
In order to prevent a FQI type 42
on a 72 aircraft and vice versa
To prevent mechanics
from installing the incorrect part,
Pennetta believes that the only answer
is to design the FQIs
so that they only fit
on the plane they are meant for.
Nine man faced charges of criminal negligence
for the downing of Flight 1153,
including the Tuninter mechanic
who installed the wrong FQI
and Captain Gharbi.
I'll give it to you
when you get back from Djerba.
There is no single cause of the accident
This accident,
like many other aircraft accidents,
was determined by a series of action,
a series of events, linked one to another
This is unheard of.
I would have accepted the engine breaking
or a window shattering
but to have people died,
because of a lack of fuel?
The crash of flight 1153 was caused
by a series of grave errors,
on the ground and in the air.
but the FDR does show that the crew's last move
before hitting the water was absolutely perfect.
According to the evidences of the FDR
and also statement by the crew that survived
the aircraft touched the sea first
with the rear part of the aircraft
at an attitude
which is compatible with the optimal attitude,
which is 9 degrees.
Captain Gharbi raised the plane's nose up
to 9 degrees at the last possible moment.
So, instead of ploughing into the sea
his plane glided along the surface of the water.
The manoeuvre likely saved lives by allowing
more passengers to escape the ruined aircraft.
His flying may have prevented this accident
from becoming an even greater tragedy.
Narrator:
Jonathan Aris
Subtitles
Rein Croonen
two pilot struggle with a stalled engine.
45 miles from land,
the pilots make a difficult decision:
Prepare the ditch
Passengers are forced
to make live or death decisions on their own.
Do not inflate your vest.
The accident will tear families apart
set in motion a massive rescue effort at sea.
and trigger a multinational investigation...
...to discover why both engines
of one of the world's most popular planes
stopped in mid-flight.
Air Crash Investigation
Season 07, Edition 06
This is a true story.
It is based on official reports
and eyewitness accounts
DITCH THE PLANE
August the 6th, 2005
Bari, Italy
An ancient port town on the Adriatic Sea
where the past meets the present.
Just North of this historic city
Bari Internat'l Airport serves 10 major airlines
and more than a 1,5 million passengers each year.
One of those carriers
is Tunisia’s Tuninter Airlines.
Captain شفيق الغربي
is a pilot with Tuninter.
Today, he is in command of Flight 1153.
The 45 year old Tunisian is
a military trained pilot
with a flawless flight record.
Gharbi's copilot is 28-year-old علي كبيّر الأسود
How much fuel?
400 kg
2700 total?
Captain Gharbi and his copilot
flew from Tunis to Bari this morning
to collect 34 Italian passengers.
Now, they are going to fly them to Djerba,
a Tunisian resort island.
Among the passengers is 31-year-old police officer
Lucas Squicciarini
His girlfriend Paula is travelling with him.
Our first choice was not Djerba,
it was Cape Verde.
The thing with Cape Verde is
that it was a period of terrorist activities.
The flight would have left
from either Rome or Milan.
Since there are two large airports,
Paula was afraid that there would be an attack
so we chose not to go to Cape Verde.
It was my first trip with Paula.
We met the previous winter.
We had plans to marry the following year.
You take your belt,
pull at the loose end of the strap
to release your seat-belt.
Ladies and gentlemen,
your life vests are located beneath your seats.
To inflate the vest pull firmly on the cord
only when you are leaving the aircraft
If you need to refill the vest,
blow into the mouth-tubes.
Roger that, cleared for take off.
Final trip for departure.
The crew is flying a French made ATR 72.
The small turbo prop is perfect for short flights.
It doesn't need a lot of maintenance
or guzzle a lot of fuel.
Just after 2:30 PM,
the plane takes off.
49 minutes after take off,
Flight 1153 is 400 mile away from its destination,
Djerba.
So, we started chatting with other passengers.
We were all excited
We talked about the vacation.
Then, 75 miles from the nearest land
and 23,000 ft above the sea...
...the right engine stops working.
We've lost engine number 2.
Let's get to 17,000 ft.
TUI-1153 request 17,000 ft
Captain Gharbi begins an emergency descend.
When you have a single engine flame out
it will descend to a lower altitude,
the air is thicker,
the propeller is more efficient.
Under current conditions, the ATR 72 can best fly
on one engine at an altitude of 17,000 ft.
The crew struggles to restart the right engine.
But then, less than two minutes
after the first engine quits...
Stop, stop,
engine number 1 has flamed out
...both of the engines have stopped.
The engine shut off
Our first thought was of a terrorist attack,
since there were so many at the time
We tried to figure out what was happening,
so we looked towards the cockpit
to see if someone was trying to sabotage the plane
The plane is now falling to the sea at 800 ft/min
(14.6 km/hr)
TUI 1153
We've lost both engines,
request immediate landing at Palermo
The crew still hopes to reach an airport,
but they have 70 miles of ocean to cross
before they are over land.
Crews are trained for almost anything
There is a checklist for them to follow
to solve most problems
including what to do when both engines die.
Fuel supply
Check
The pilots don't know
why their engines have stopped.
The only clue they are getting
is a low fuel feed warning
a LO PR warning light tells the pilot that
there is a low fuel pressure to the engine
That can be a mechanical problem
or that can be a contamination problem.
The crew follows the steps of the manufacturer
to relight their dead engines.
Fuel supply, check
Power lever flight idle,
START button
Engine RELIGHT
Negative
Get Chokry
The Captain asks the cabin crew to bring
the on board engineer Harbaoui to the cockpit
Palermo approach
this is TUI 1153
We've lost both engines,
Request immediate landing.
The closest airport is in Palermo,
on the Italian island of Sicily.
TUI 1153, Palermo
Affirmative
you are cleared for landing.
Palermo approach,
What is our distance to the airport?
Your distance to Palermo
is now 48 nautical miles.
An ATR 72 will fall from the sky
at a predictable rate:
1 ft down for every 16 ft forward
48 nautical miles is further
than the plane can glide.
I think we are not going to make it
If they can't restart their engines soon
they will be forced to ditch in the sea.
Ditching at sea
is a very difficult decision to make
because it is the hardest thing to do,
you have swells, waves, wind.
Is anybody going to see you?
How long can the plane float for?
Landing a passenger plane on water
is extremely dangerous.
In 1996,
an Ethiopian Airlines pilot was forced to
bring his 767 down on the Indian Ocean
The ditching was recorded by a tourist
on a nearby beach.
50 people survived
but 125 people died.
The crew of this small plane doesn't usually
include an engineer.
When there is one on board,
he usually travels in the cabin.
I remember this person looked at the stewardess
and shook his head as if saying:
No. after the second engine has shut off.
That gesture showed,
there was nothing left to do
The crew has tried all it can
They are running out of time and options.
Flight engineer Chokry Harbaoui has joined
in the struggle to get the engines started.
You have run the checklist?
Yes
The Captain hopes the engineer will know something
that isn't covered by the checklist.
Attempt to restart the engines,
right engine first.
Fuel supply:
Check
Engines 2 START POWER button:
ON
Engine relight:
Negative
Palermo approach, here TUI 1153
any closer airport where we can land?
Negative, 1153,
Palermo airport
is the closest airport in your position
We are not going to make it
Prepare the ditch.
Oh, My God
The Captain has decided to land the plane at sea.
I will let you imagine the panic on board
People where screaming and crying
Please, stay calm
There were people in the front seats
that had a baby girl.
She had been playing and was so excited
She now sees the panic in her mother's face,
it made me feel so sad.
TUI-1153, what is your fuel load?
Cockpit fuel quantity: 1800 kg
Captain Gharbi's fuel gauge
shows that he has plenty of fuel,
but for some reason,
neither engine will restart
Just 10 minutes after the trouble began,
the plane is 7000 ft above the ocean and falling.
Outside, it is completely silent
but in the cabin...
...there is panic
Please, remain in your seats
with your seat-belts fastened
My first instinct was to undo my seat-belts
to prevent getting trapped when we hit the water
I didn't want to be trapped in my seat
and go down in a horrible way.
but secondly, I put on my life jacket
and quickly blew it up
I did this to soften the blow of the impact
Do not inflate your vests
until you have left the plane
A plane, ditching at sea
will more than likely fill with water.
That is why safety procedures call for
passengers to only inflate their life vests
once they have cleared the plane,
otherwise they could become trapped
inside the flooded fuselage and drown.
In the Ethiopian Airlines crash,
many passengers ignored this advice
and drowned
after surviving the initial impact.
Negative
The dead engines are not
the only problem confronting the crew
Many of their instruments
get their power from the engines
Without the engines,
some vital gauges are dead.
On a two engine flame out
you go on your standby instruments,
which is, you have an attitude indicator
you have an altimeter
The crew continues to try
to restart their engines,
but it has become clear
that they have run out of time.
Confirm distance, please
Your distance is now 20 miles.
Boats, I see boats
Choosing to ditch near a ship or a vessel
is not in any checklist
It is just good airman-ship,
because the rescue can start immediately
and increases you chances of survival.
Flame out approach, this is TUI 1153
We can't make it to the airport
We see two boats on the left side,
we are going there
If you can, please call
Captain Gharbi turns his plane towards the boats
Can you send helicopters or something similar?
Emergency, all marine units, aircraft in distress
20 nautical miles off Palermo
Even before the plane hits the water,
rescuers are on their way
Although it is a rare manoeuvre
there is also a checklist
for ditching a plane in the water
Before ditching,
the crew ensures all landing gear is retracted
to help the plane land more smoothly.
Landing gear lever up
When pilots ditch,
they want their airplane
is streamlined as possible
so that it glides across the water when it hits.
Pilots must not only monitor the systems
on the plane
they also have to assess conditions at sea.
They don't want to hit a wave head on.
If you hit perpendicular to the waves
or the swells with the aircraft
it is like hitting concrete:
the plane will break up.
Passengers can see what is coming.
I was hanging on tight
to the seat in front of me,
and through the window,
I could see the impact was imminent.
The crew is 700 ft above the sea.
You are with me, honey
Careful
Chokry, ready?
Here we go
At a speed of 145 mph,
the plane collides with the sea.
Squicciarini:
I lost consciousness.
I woke up in the water
I was 2 or 3 meters under water
I came up to the surface,
wearing only my pants
I had lost my life jacket and clothes
on impact
I got to the surface and grabbed on to a bag
I was in shock,
I was surrounded by everything
My thoughts were constantly with Paula
I thought I was going to die,
because I was spitting blood
I felt my lungs filling with blood
Captain Gharbi survives
but has been seriously injured
Co-pilot Ali Kebaier Al-Aswad has also survived
But Flight engineer Chokry Harbaoui is killed.
No one aboard the nearby boats saw Flight 1153
crash into the sea.
The plane has broken into three pieces.
The tail-section and much of the fuselage sink
to the bottom of the sea,
but the larger section, containing the two wings,
stays afloat.
It becomes a life raft for survivors
But not all of the passengers have survived;
many haven't made it out of the plane
and to the surface.
Helicopter pilot Stefano Burigana
is one of the first to arrive at the scene.
The bridge control asked if we were aware
of a ditched aircraft out of the coast of Palermo
and if we were able
to help them to locate the airplane.
When we approached the airplane
we could see the wings floating.
There were several people in the water
around the aircraft.
All floating and
everybody with their jacket inflated.
Burigana spots Lucas Squicciarini floating,
away from the main wreckage
There was one man without his jacket
and he was at a far distance from the airplane.
I decided to go over him
and throw one of our life jackets to him
Within the hour,
the crash site is teeming with rescuers.
They search for survivors
from the water and from the air.
23 people are pulled from the Mediterranean Sea,
but 16 have died in the crash,
including Paula Di Ciaola.
My relatives told me a couple of days later,
while I was still at the hospital
I had no reaction,
Paula was gone.
I reacted when I got home
When I got home and went to the cemetery,
I realized what was happening.
That is where I got really down.
It is quite likely that none of those who died
ever had a chance to swim to safety.
Their serious injuries would have prevented them
from escaping after the plane hit the water.
In this accident, most of the survivors
were seated in the rear of the plane,
most of those who died, up front.
Those sections, along with some valuable clues
are now at the bottom of the sea.
The one section that didn't sink
is towed to the port in Palermo
and taken to a nearby hangar.
a team of agents
from Italy's National Flight Safety Agency
the ANSV,
begin looking for leads.
Their job: Find out why the engines
stopped in mid-flight
We need to collect as
much evidence as possible
in order to fulfil 2 main answers:
What happened
and why have it happened?
They are led by chief ANSV investigator
Vincenzo Pennetta.
I arrived in Palermo the day after the accident
on the 7th in the morning
A flight engineer by training,
Pennetta has led several aircrash investigations.
The engines and central fuselage
have been recovered,
the rest of the plane lies
somewhere off the Sicilian Coast.
The main challenge of the investigation
was the fact that the FDR and the CVR
and also the front fuselage
were 1,500 meters under the sea.
While the Italian Navy conducts
a deep water search for the rest of the wreck
and the crucial black boxes,
Italian investigators are given some assistance
by the plane's European manufacturer
ATR's Giuseppe Caldarelli is here to find out
if there is a flaw with the company's plane.
Any time there is an accident and
even if one person die is for me a big accident.
Worldwide,
hundred's of ATR 72's cross the skies each day.
Those aircraft have a very sound structure
and robust systems
and are very cost-efficient.
Together,
Pennetta and Caldarelli set out to find
why both engines on such an advanced airplane
died in mid-flight...
...before it happens again.
Captain Gharbi, how are you?
I am getting better, thank you
Investigators want to know what happened
in the cockpit when the engines died.
Without the CVR,
they must rely on the recollections of
surviving passengers and crew members.
The main cause could be a lack of fuel
But according to Captain شفيق الغربي
lack of fuel was not the problem.
What were your fuel readings?
The fuel quantity indicator said 1800 kg of fuel
What is your fuel load?
Cockpit fuel quantity 1800 kg
Was there any warning
that you were low on fuel?
There was definitively no low fuel warning
just a low feed pressure light.
The absence of a low fuel warning and the
presence of a low feed pressure warning
is a major clue.
This set of alarms usually indicates
that there is a problem
in feeding the engine with fuel.
Since the gauges indicated
that there was fuel on board
that did not get to the engines,
Giuseppe Caldarelli looks for flaws
in the fallen plane's fuel delivery system.
Four years earlier,
an Airbus operated by AirTransat developed a
leak in the fuel line that feeds the right engine.
Over time, the plane leaked all of its fuel
and both engines failed
The pilots were forced to glide their plane
to an emergency landing.
That incident has a lot of similarities
to the Tuninter crash
Giuseppe Caldarelli's team looks for breaks
or blockages in the fuel lines
and evidence that the fuel-pumps malfunctioned
and stopped fuel float to the engines.
While Caldarelli waits for technicians
to complete tests on pumps and lines,
Pennetta decides to start a new line of enquiry.
He explores the possibility that the on board fuel
was somehow contaminated
Fuel contamination can derive
from 4 or 5 different sources.
Kerosine-based jet fuel is very delicate.
If stored or transferred improperly,
it can be polluted with water, sand or fungus
even sticky residue
from the hoses of refuelling tankers.
Any of these could prevent the fuel
from properly igniting
and could have caused the engines to shut down.
The plane last took on fuel in Bari.
Samples from the tanker that supplied it
are taken for testing.
Pennetta needs to prove that
one of these contaminants got into its fuel,
prevented combustion
and caused both engines to fail
Sediments can be transferred
from the tanker truck to the aircraft
So, the fuel feeder can be clogged,
and so, the engine can have some problem.
Technicians remove the truck's fuel filters
to look for evidence of contamination.
Hoses and couplings are swabbed for sticky residue
or colonies of micro organisms
and submitted for testing
at an Italian Airforce Laboratory.
The fuel is filtered for minute particles,
suspended in the fluid...
...and carefully examined for impurities.
The truck's filters are also inspected
for residue or sediment from the tanks.
Meanwhile, in Palermo,
Caldarelli and his technicians have completed
tests on Flight 1153's fuel lines and pumps.
The tests are thorough,
the results conclusive.
The fuel feed-line were okay
No leak
If the fuel delivery system was working,
and the two pilots remember having ample fuel,
then why had the engines failed?
When test results from the Bari fuel tanker
come in
they too are conclusive.
The fuel filters, hose couplings
and tanker fuel at Bari Airport are clean
So, fuel contamination as a source
of a double engine flame out was excluded.
At this point, the investigators still don't know
what caused the downing of Tuninter Flight 1153.
But something has been eating up Pennetta.
If the plane was filled with fuel
and since the fuel is stored in the wings,
why did the wing-section float?
The floating of the wing indicates
that the weight of the wing was not so high.
We have been told by ATR
that if the amount of fuel in the wing was
around 2000 kg were on the fuel tanks
the wings wouldn't be able to float.
Pennetta suspects the plane didn't have
as much fuel as the pilots thought
but he doesn't know how that could be.
Two weeks into the investigation,
Pennetta gets an important lead in the case
After two weeks of the event,
we received some technical documentation
from the aircraft operator.
According to the logs,
Captain Gharbi flew the same aircraft
the day before the accident.
After that flight,
he reported a problem with his fuel gauge.
When he left the aircraft the day before,
he reported that the right FQI
was out of service,
so it need to be replaced.
The fuel quantity indicator or FQI is a gauge
that tells pilots how much fuel is left on board.
The lights on the FQI were malfunctioning.
Captain Gharbi made a note of this
in the maintenance log.
You were able to see that
the FQI was changed the day before the event.
The maintenance log raises the possibility
that the FQI was not the right one for the plane.
It doesn't seem to have the right model number
Tuninter flies two models of ATR aircraft:
The ATR 42...
...and the larger ATR 72.
The FQI's for each plane look identical,
except for a different model number
at the top of each unit.
The ATR-72 should have a model number 2500
but according to the logs,
mechanics installed unit 2250 instead.
Tuninter's maintenance logs offer a valuable clue.
But for Pennetta,
there is no definitive proof
that the wrong FQI was installed on the plane.
It could have been a mismatch
in that aircraft documentation,
so we need to prove that.
There is only one way to know for certain
whether the ATR 72 has the right FQI.
Go and find it at the bottom of the sea.
We need to recover the wreckage of that aircraft
to see physically what was the FQI installed
on the aircraft.
Not until three weeks after the crash,
the investigators recover wreckage from the sea.
The data from the black boxes
confirms what the pilots have been saying.
There was no warning of low fuel,
so, there appeared to be enough fuel
to make the flight.
The black boxes cannot solve this mystery.
Investigators hope
that the tail and front-section can.
They are hold
aboard the naval vessel from the sea.
The moment the cockpit is hold in,
Pennetta is there.
There is only one thing
he wants to see inside.
So, when the wreckage was recovered
from the sea and put on the ship deck
I realized that the FQI for an ATR 42
was installed.
It was like we found the smoking gun.
The wrong FQI was installed on Flight 1153.
Pennetta finally has the break
he has been looking for.
The ATR's FQI collects data
from sensors in the fuel tanks
and calculates how much fuel is in the tanks.
But since the fuel tanks on the 42 and the 72
are at different size,
FQIs can't be swapped between them.
Technicians conduct refuelling tests
with the wrong FQI installed on an ATR 72...
...and the results are chilling.
The results show
that if you install an FQI type '42'
on an ATR-72 aircraft
if I have no fuel in the tanks,
with zero fuel,
the FQI show me 1800 kg.
Precisely the amount of fuel that the Captain
reported having when his engines flamed out.
Investigators conclude:
At 23,000 ft above the Mediterranean,
the wrong FQI let the crew to believe
that they had ample fuel...
...when their tanks were actually empty.
The engines could not possibly
have been restarted.
With hundreds of ATR 42s and ATR 72s still flying,
the implications are stark.
Could there be other planes flying
with the wrong gauge?
The first recommendation was
to mandate all operators
that use the ATR 42 and 72 aircraft in their fleet
to check whether the right FQI
was installed on the aircraft.
Pennetta and Caldarelli have uncovered the error
that caused both engines to quit in mid-air.
But the case isn't closed:
Standard flight-procedures should have uncovered
the error before take off
and prevented the disaster.
Captain Gharbi's aircraft went in for repairs
in Tunisia the night before the crash.
The FQI indicated 790 kg of fuel in the tank.
After the new FQI was installed,
it showed that there was almost 4 x as much fuel:
3,100 kg.
The following morning, Captain Gharbi noticed
that the fuel-levels has gone up.
He assumed the fuel had been added.
But when fuel is added to an aircraft,
a refuelling slip must be left in the cockpit.
Where is the refuelling slip?
The pilot asks to the flight dispatcher,
where the refuelling slip was
but the flight dispatcher was not able to find it.
I'll give it to you when you get back from Djerba
There was no refuelling slip,
because the plane hadn't been refuelled.
In spite of regulations,
the captain left without that vital piece of paper
There are some standard regulations
requiring the pilot to take off
only when he is sure about the quantity of fuel.
With the wrong fuel indicator on board,
and less fuel than he believed
Captain Gharbi makes it to Bari, Italy,
and tops off his plane
for the next leg of the trip to Djerba.
How much fuel we are added?
400 kg
2700 in total?
Believing he has 2700 kg of fuel on board,
Captain Gharbi begins his flight to Djerba.
If the correct FQI had been installed,
the Captain would have known
that he had only 540 kg,
not nearly enough to make the crossing.
Pennetta's investigation comes to a close.
He draws up his final report.
His colleague, Giuseppe Caldarelli
voices a bold view
Even with no fuel and dead engines,
Flight 1153 could have made it to land.
The aircraft was in a position
that allowed to reach Palermo.
Caldarelli wonders
if the pilots did everything they could have
to get the plane safely to Palermo.
Investigators get some unexpected answers
by having seasoned pilots fly the same flight
with the exact same problems.
We are now in big trouble,
because the 2nd engine has gone off.
Pennetti's investigation into the crash of TUI1153
has uncovered the events to the accident.
Now, he and Caldarelli
need to resolve one question
Did mistakes, made by the pilots,
cost people their lives?
Prepare the ditch!
Caldarelli and his team studied the specifications
and draw a surprising conclusion.
Flight 1153 could have been able
to glide to Palermo.
According to manufacturer data,
an ATR is able to glide 3 miles
for every 1000 ft of descend.
This is a downward slope of 6.31%
With the help of a tailwind that day,
Flight 1153 was able to glide 70 miles to Palermo
The crew might have been able to make it.
So, what had the pilots done wrong?
To answer that question,
Pennetta and Caldarelli recreate Flight 1153
in the flight simulator
at the ATR facility in France.
Test pilots try to glide an ATR 72 for 70 miles
from the altitude
at which Flight 1153 lost its 2nd engine.
The simulation was requested
to see the range of the aircraft,
starting from the 2nd engine flame out
When engines flame out,
you have to be very aware
of the configuration of the aircraft
in order to keep as much as possible the altitude
and distance to fly before the crash.
With both engines out,
the priority is to keep the plane
gliding as far as necessary.
To do that,
pilots can change the angle
of their windmilling propellers.
You will have the maximum glide performance
when you minimize the drag.
It is very important to feather the propellers
in order to reduce the drag.
Feathering the props involves
changing their angle against the wind.
The manoeuvre reduces drag.
When you want to feather the propellers in flight,
you first have to reduce the power lever to idle,
and put the condition lever
back to feather position.
The crew did not feather their props
when their engines quit.
The windmilling propellers created enormous drag.
If the crew had feathered their props,
they may have been able to glide further.
By the time Captain Gharbi's 2nd engine flamed out
he was just below 22,000 ft.
To further reduce drag at that altitude,
the plane should be slowed to a 158 mph,
the ATR 72's ideal gliding speed.
Surprisingly, to glide as far as possible,
a pilot doesn't want to fly as fast as possible.
The faster a plane flies,
the more the airflow pushes against it,
creating resistance.
Every plane has an optimal speed
to achieve the furthest glide.
The crew continue flying up to 55 mph faster
than their optimal gliding speed.
That added to the drag on the plane
and reduced the distance they could glide.
By feathering his props and reducing his speed,
a simulator pilot in France
was able to get as far as Palermo.
Flight 1153 hit the water 26 miles from shore,
well short of
what the plane was capable of achieving.
The simulation confirmed that
the crew might have been able to make it to land.
It was theoretically possible to reach the coast
but it was also very difficult
to reach that result.
Simulator pilots had one big advantage
over the crew of Flight 1153
They weren't in a life or dead situation,
and they knew they had to glide, instead.
But Captain Gharbi didn't know he was out of fuel.
He didn't think he need to glide to Palermo
Gharbi focused on restarting the engines instead,
feathering the props
isn't part of that procedure.
If the Captain had known he was out of fuel
he might have acted to maximize glide instead.
Once he realized that his engines wouldn't start,
his focus was on try to find a place
to ditch the plane.
He also had to content with a lack of instruments
as well as radio interruptions.
Most importantly,
Captain Gharbi had the lives of his 34 passengers
to consider.
Of course,
it is much easier to cope with
that situation on the simulator
because if you do it wrong,
if you crash the aircraft,
you have the magic button:
RESET
Everything is okay again
and that is very different in the real life,
with the passengers behind them.
The simulation highlights the importance of
proper training to deal with unlikely situations
such as a twin engine flame out.
In aviation it is a very rare event.
Vincenzo Pennetta's report urges airlines
to train their pilots how to ditch
without engine power.
Better pilot-training is just one
of 17 safety recommendations in the report.
Perhaps the most important:
That ATR redesigned the FQI.
In order to prevent a FQI type 42
on a 72 aircraft and vice versa
To prevent mechanics
from installing the incorrect part,
Pennetta believes that the only answer
is to design the FQIs
so that they only fit
on the plane they are meant for.
Nine man faced charges of criminal negligence
for the downing of Flight 1153,
including the Tuninter mechanic
who installed the wrong FQI
and Captain Gharbi.
I'll give it to you
when you get back from Djerba.
There is no single cause of the accident
This accident,
like many other aircraft accidents,
was determined by a series of action,
a series of events, linked one to another
This is unheard of.
I would have accepted the engine breaking
or a window shattering
but to have people died,
because of a lack of fuel?
The crash of flight 1153 was caused
by a series of grave errors,
on the ground and in the air.
but the FDR does show that the crew's last move
before hitting the water was absolutely perfect.
According to the evidences of the FDR
and also statement by the crew that survived
the aircraft touched the sea first
with the rear part of the aircraft
at an attitude
which is compatible with the optimal attitude,
which is 9 degrees.
Captain Gharbi raised the plane's nose up
to 9 degrees at the last possible moment.
So, instead of ploughing into the sea
his plane glided along the surface of the water.
The manoeuvre likely saved lives by allowing
more passengers to escape the ruined aircraft.
His flying may have prevented this accident
from becoming an even greater tragedy.
Narrator:
Jonathan Aris
Subtitles
Rein Croonen