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00:00Scorched wreckage is all that's left of a small commuter plane in Illinois.
00:07It was really a molten mess.
00:09Come on, climb!
00:10Climb!
00:11An Airbus A300 veers fatefully off course.
00:14Stop!
00:16It was the biggest human loss in Indonesian history.
00:20Two jumbo jets collide.
00:23583 people.
00:25Some of aviation's worst disasters.
00:28Is that Asia 0152?
00:30Say again?
00:31Were they all caused by a fatal misunderstanding?
00:35Yeah.
00:36Hang here.
00:37Who the hell's answering her?
00:38Investigators are stunned by what they uncover.
00:41Whoa, whoa, whoa.
00:43The controller advised him to stay put.
00:46That idiot's coming.
00:48Oh, Christ.
00:49What the hell?
00:50Get off, get off, get off!
00:54Me, me, me!
00:58Oh, Matt.
00:59Over to 65
01:00Oh, God.
01:01Yes!
01:02Up.
01:03Yes!
01:04Over to 65
01:05Nearly 11 million people take to the skies every day.
01:08Nearly 11 million people take to the skies every day.
01:24Their lives depend on the clear communications between skilled pilots and air traffic controllers.
01:31Controllers and pilots work together to correct each other's errors, especially errors of misunderstanding.
01:38Most of the time it works. Occasionally something slips through the cracks.
01:45United Express Flight 5925 is minutes away from its final destination, Quincy Airport in Illinois.
01:54Checks complete.
01:56Captain Kate Gathje is at the controls of a Beechcraft 1900C, a commuter plane carrying 10 passengers.
02:05What's the winds down there?
02:07It's been a long day, but the landing at Quincy Airport should be routine.
02:11Windsor 060 at 8, 12 miles visibility.
02:17Quincy is one of thousands of airports without a control tower.
02:21That means there are no controllers to direct traffic.
02:25Pilots must communicate directly with each other during takeoff and landing.
02:29At an airport like Quincy that is non-towered, you cannot be too vigilant when you're flying an airplane.
02:35You have to have a situational awareness to realize what's probably going to be coming next and where other aircraft are.
02:42Look at that sunset, man.
02:45That's gorgeous.
02:4730 miles from the airport, the United Express pilots check in on their open frequency used by all pilots at the airport.
02:54About 30 miles from the north of the field, inbound from landing runway 13 at Quincy.
03:01Any traffic in the area, please advise.
03:03There are three intersecting runways at Quincy.
03:09Most planes take off and land on runway 13, or runway number 4.
03:14As flight 5925 closes in, a small turboprop plane radios in on the frequency.
03:22King Air 1127.
03:24Delta is taxiing out.
03:26Take off on runway 4.
03:29The King Air A90 is taxiing out towards runway 4.
03:34Just 90 seconds before flight 5925 expects to touch down, the King Air plane is in position at the start of the runway and holding.
03:45King Air 1127.
03:48Delta holding short of runway 4.
03:50Be taken the runway for departure.
03:55Position hold is when an aircraft pulls onto the end of the runway, turns, points down the runway, prepared for takeoff, and holds its position.
04:04On final approach, the United Express pilots make another radio call on the frequency.
04:10Five mile final for runway 13 Quincy.
04:15You're down.
04:18As the commuter plane descends,
04:22500.
04:23an automated voice in the cockpit gives the pilots their altitude.
04:27On short final for runway 13.
04:29400.
04:29The captain checks to make sure that King Air is planning to stay put while she lands.
04:36The aircraft is going to hold in position on runway 4, or you guys are going to take off.
04:40500.
04:417, 6, 4, 6, Juliet.
04:42Holding for departure on runway 4.
04:44200.
04:45King Air.
04:47Okay, we'll get through your intersection in just a second, sir.
04:51We appreciate that.
04:53Finals are complete.
04:56Flight 5925 touches down at Quincy Airport.
05:00Max reverse?
05:02Oh, Christ.
05:03What the hell?
05:04But the King Air plane is headed towards them.
05:11We heard this explosion that rattled the walls and the windows shut.
05:17I ran for the door, and as I came outside, what I saw looked like a mushroom cloud.
05:22Paul Walker rushes towards burning wreckage on the runway.
05:33Open the door!
05:37But the first officer is struggling to get the door open.
05:42Please!
05:43Someone help!
05:45Open the door!
05:47There are no firefighters at the tiny airport to help with the rescue.
05:52People in there, we have to get inside that plane!
05:55I was literally their last hope.
06:05I grabbed the handle and attempted to open the door.
06:08When I wiggled the handle a little bit, somebody on the inside wiggled it the other way.
06:22I can't get it open!
06:25Help!
06:25As he hears desperate cries from inside, Walker suddenly realizes...
06:30Oh, God!
06:31It's you!
06:32Hide in there, Kate!
06:33He knows the flight's captain.
06:36Please help!
06:38The fact that you actually know somebody in that situation at that time just added more to it.
06:43There was no doubt in my mind I was going to get that door open.
06:49But the door remains jammed.
06:53Oh, God!
06:55I'm sorry, Kate!
06:56I'm going to get help!
06:58Leaving the airplane was one of the more difficult things I've ever done in my life.
07:02There's no escape from the burning wreckage of Flight 5925.
07:08Police!
07:09Police!
07:09Four pilots and ten passengers are killed in one of the worst runway collisions in North American history.
07:26By morning, a team of investigators from the National Transportation Safety Board is on site at Quincy Airport.
07:36How did this happen?
07:39How did the faults come into play that caused these airplanes to collide at the intersection of two runways?
07:46Analysis of the conversations between the pilots of the two flights is a key factor in the investigation.
07:56What was the crew saying?
07:57What were they thinking?
07:59The smaller twin turboprop aircraft, the King Air, doesn't have a cockpit voice recorder, or CVR.
08:05But the recorder of commuter flight United Express 5925 is recovered from the crash site.
08:15About 30 miles to the north of the field, inbound for landing runway 13 at Quincy.
08:20So far so good?
08:22Investigators study the conversations between pilots at Quincy Airport moments before the crash.
08:28Inbound for landing runway 13 at Quincy.
08:30Any traffic in the area, please advise.
08:35As the Beach 1900 approached Quincy, it made all the required radio calls.
08:40The pilots of United Express give other pilots at Quincy Airport the chance to advise if they're going to use the runway.
08:47But the CVR recording from United Express reveals that the radio calls from the King Air A-90 are more problematic.
08:57The pilot is slow to reply to Captain Gathji.
09:00King Air 1127, Delta's taxiing out.
09:06Take off on runway 4.
09:11They're using 4.
09:12But although the reply from the flight is delayed, it confirms for investigators that the pilots of United Express were aware of the King Air.
09:25King Air 1127, holding short of runway 4.
09:29Take in the runway for departure.
09:31Less than two minutes before the accident, the King Air pilot reports that they're holding short of the runway.
09:39It's a radio call that United Express takes care to double check.
09:44The aircraft are going to hold the position on runway 4.
09:46You guys are going to take off.
09:49But investigators are stunned when they listen to the response.
09:527-6-4-6-Juliet, holding for departure on runway 4.
09:57Who the hell's answering her?
10:01That's not the King Air.
10:04Quincy.
10:05Any other traffic, please?
10:07Investigators make a stunning discovery, listening to the cockpit voice recorder of United Express 5925.
10:15They hear a radio call from a third plane on the runway, a Cherokee.
10:19There was no reason for the pilot of the Cherokee, who's not on the active runway, who's not going to take off, to have made that call.
10:29The misunderstanding is further complicated by the pilot of the Cherokee.
10:34He did not use his type of airplane.
10:38If he had said Cherokee, that would have served as a clarifying point.
10:42Juliet holding for departure on runway 4, behind on the King Air.
10:47But proper identification isn't the only problem with the radio transmission.
10:54When investigators listen closer to the tapes, they discover that the altitude countdown obscures the radio transmission coming from the pilot.
11:03Holding for departure on runway 4, behind on the King Air.
11:07There was a mechanical device in that Beech 1900 that, at the appointed time, said 200.
11:16Marker on runway 4, behind on the King Air.
11:20And that masked the word behind the King Air.
11:26The pilots of United Express think it's the King Air telling them they're holding at the runway.
11:31OK, we'll get through the intersection in just a second, sir.
11:36We appreciate that.
11:38But King Air isn't holding.
11:40It's moved out onto the runway as the United Express flight makes its final approach.
11:48Unfortunately for the commuter aircraft crew, they believed they were now safe to land because the King Air would hold for them.
11:54Oh, Christ.
11:55But investigators wonder why weren't the pilots of King Air aware of the impending danger when the United Express pilots had been perfectly clear.
12:12When investigators look at who was in the King Air cockpit, their suspicions grow.
12:17It's a training flight.
12:21One pilot is a student.
12:24The teacher, Neil Reinwald, is experienced.
12:28He had been an Air Force Reserve pilot.
12:30He had been a pilot for Transworld Airlines.
12:34His resume looked tremendous.
12:37But a closer look at Reinwald's records reveals problems in his flight history.
12:42We found out that he failed a check ride.
12:47He was given another check, and he failed that.
12:52And they removed him from a pilot position to flight engineer, which is a non-flying pilot.
12:59This guy's skills were slipping.
13:02And on the day of the fatal crash, witnesses say he seemed in a hurry to get home.
13:08OK, Laura.
13:10Let's go home.
13:10Did a pilot in a rush cost the lives of 14 people?
13:17I think impatience was part of the problem.
13:22Get there-itis, that's a term we use a lot.
13:26Student pilot Laura Brooks was handling radio calls from the King Air.
13:31King Air 1127, Delta's taxiing out, take off on runway 4.
13:38Her instructor may have been preoccupied with his flight lesson, unaware of the commuter plane approaching from his left.
13:46Whether they were engaged in conversation about the aircraft, we don't know.
13:52But there was no announcement of takeoff, which is unusual.
13:55What exactly was happening in the cockpit of the King Air in the seconds before the accident remains a mystery.
14:05Finals are complete.
14:07Investigators conclude that impatience or a momentary distraction led the pilots to head out onto the runway.
14:13Office for departure at 1.424, 9,000 Gat.
14:18When Captain Gat-G fatally misunderstands the radio call of a third airplane, it causes a horrific tragedy.
14:25Oh, Christ.
14:26The collision was certainly avoidable.
14:29It was preventable several times.
14:31But as the airplanes got closer and closer together, timing ran out.
14:45The NTSB rules that the crew of United Express 5925 acted appropriately during their approach and landing.
14:53In the wake of the accident, training is improved to emphasize the importance of clear communication, especially at airports with no tower.
15:05There have been a lot of basic changes since the Quincy accident.
15:09I think they've worked.
15:10We haven't had an accident like this since.
15:12However, we can't rest on our laurels.
15:14Safety is paramount in all communications, on the ground and in the air.
15:26Misunderstandings between pilots and air traffic controllers are rare.
15:31The second that people are not understanding a language or having any kind of miscommunication, everything else kind of goes out the window.
15:41What?
15:41Is that what happened to a commercial plane that crashed in an Indonesian jungle?
15:46No, no, no, no, no!
15:55Garuda Flight 152 is heading towards the city of Medan, with 234 people on board.
16:04Let's stay on autopilot as long as we can.
16:06Yes, sir.
16:08Captain Rachmo Wiogo commands the Airbus A300.
16:12He's been flying in Indonesia for nearly 20 years.
16:15He's extremely familiar with the flight path.
16:21Today, the approach to Medan is more challenging than usual.
16:26Forest fires in Sumatra have blanketed Southeast Asia with smoke.
16:30It's wreaking havoc on air traffic.
16:35Smoke is limiting visibility to a degree that would make the descent and the approach really quite difficult.
16:42As flight 152 descends through 10,000 feet, it plows through thick smoke.
16:49Smoke, you hear below 10,000.
16:52The pilot would never have been able to get any external visual cues.
17:00If there is smoke all the way down to the ground, the controller knows the pilot is going to encounter problems.
17:19They're going to need all the help they can get, and the controlling should be very accurate.
17:26The captain adjusts the power to his engines.
17:30For PADI 152, turn left heading 240 to intercept runway 05.
17:39The one always lacks behind a bit, so keep an eye on it for me.
17:42Okay.
17:42The pilots follow the controller's instructions to turn left.
18:08They're one turn from lining up with the runway.
18:14Indonesia 152, turn right heading 046.
18:18Turn right heading 046, Indonesia 152.
18:23Flight 152 is on final approach.
18:26The runway should be in sight now.
18:30But when the plane nears the ground, it's nowhere near the airport.
18:36What?
18:38Climb!
18:45Climb!
18:53No!
18:55No!
18:56No!
18:57No!
18:57No!
18:57No!
18:58Let's go!
18:59No!
19:02No!
19:04No!
19:07No!
19:07Everyone on board is dead.
19:12It's the worst aviation accident in Indonesia's history.
19:19Air crash investigators are under pressure to explain the disaster.
19:26Rob Carter of the UK's Air Accident Investigations Branch assists at the scene.
19:32One of the things that seemed so strange was where the impact point was.
19:37It was nowhere near where we would expect the aircraft to be for the proper sort of approach into the airport.
19:46The debris field tells investigators that the plane was flying away from the airport,
19:51the opposite direction they should have been flying.
19:57Indonesian authorities look to air traffic control at Medan Airport for answers.
20:03They approached from the southeast. I was trying to bring them in this way.
20:06A left turn, then a right turn that gets them into runway 05.
20:12When they interview the controller that handled the flight,
20:15he tells investigators he suspects the captain somehow misinterpreted his instructions.
20:21He didn't understand which way to turn. He made a left turn here instead.
20:26Investigators are baffled.
20:28Why did the pilots of the flight make a wrong turn on final approach to an airport they knew extremely well?
20:34The ATC gave instruction Indonesia 152 to turn right onto heading 046.
20:42But the aircraft turned to the left.
20:45At that state, we do not have any clue at all.
20:54Investigators must figure out why Garuda Flight 152 veered off course and crashed into the jungle.
21:00They look to recordings of communications between air traffic controllers and pilots for answers.
21:11At first, they seem completely normal.
21:14Indonesia 152, descend to 3,000 feet for runway 05.
21:20But then they hear something problematic.
21:25Murpati 152, turn left heading 240 to intercept runway 05 from the right to side.
21:32The controller uses the wrong call sign.
21:37Yeah, Murpati 152.
21:39Now he's got Garuda 152.
21:41Instead of Garuda 152, he said Murpati 152.
21:48But the controller quickly corrects his mistake.
21:53Indonesia 152, do you read?
21:56Indonesia 152, say again.
22:00It appears as if the misunderstanding is cleared up.
22:03Okay, turn left heading 240, 235 now to intercept runway 05.
22:11Left heading 235.
22:14Roger, left heading 235, Indonesia 152.
22:19After a brief moment of confusion, the flight is exactly where it's supposed to be.
22:24That puts them about here, right on course.
22:28One more right turn, and he's lined up with the runway.
22:36Indonesia 152, turn right heading 046.
22:41There it is, clear as day.
22:43Turn right heading 046, Indonesia 152.
22:47How the flight made a wrong turn in the final few moments still can't be explained.
22:52It's in the exact opposite direction they were told.
22:58Why?
23:02Investigators wonder if the pilot thought he was heading towards the airport.
23:09They turn their attention to the airport's approach charts to learn more.
23:13The charts lay out what the normal approach is, and the pilots normally expect to fly that.
23:22Investigators discover that Garuda 152 wasn't on the standard approach.
23:27The standard approach to Maidan is from the left side, which involves making a final left turn to line up with the runway.
23:36But the Garuda captain had been instructed to approach from the right side of the runway.
23:41It required something he wasn't used to, a right turn before landing.
23:46The controller took them in a direction, which was not what they would have expected according to the approach charts.
23:55But there shouldn't really have been a problem with that.
23:59Controllers are supposed to confirm the approach path with pilots as they head towards the airport.
24:04How could he not have known which approach he was flying?
24:11Then investigators get their first big break.
24:14After searching for more than three weeks, the plane's voice and data recorders are recovered from the dense Indonesian forest.
24:22Let's start with turn number one.
24:26Here.
24:27They listened to the recordings to see if the pilots had all the information they needed for the correct approach.
24:36For PADI 152, turn left heading 240 to intercept runway 05 from the right side.
24:43Number one, always...
24:43That's behind a bit, so keep an eye on it for me.
24:46Okay.
24:46When investigators listened to the cockpit voice recorder, they realized what they thought was a harmless call sign mix-up actually had massive consequences.
24:59Because the controller used the wrong call sign.
25:02For PADI 152, turn left heading 240 to intercept runway 05 from the right side.
25:08So keep an eye on it for me.
25:10The pilots ignored the transmission and missed the direction to approach the runway from the right side.
25:16Indonesia 152, do you read?
25:20Indonesia 152, say again.
25:24When the controller repeats the approach instructions, he leaves out a critical detail.
25:30Turn left heading 240, 235 now to intercept runway 05.
25:37You didn't repeat which side they're approaching.
25:39The mix-up means the crew of flight 152 never hear a critical instruction to approach the runway from the right side instead of the usual left.
25:52Controllers didn't make it clear enough to the pilots that this was not going to be the standard pattern.
26:00He should have made it clear.
26:01You're not going to come in from the left-hand side of the runway.
26:05You're going to come in from the right-hand side.
26:09The captain, unable to see the ground through the smoke from the forest fires, dials in a left turn out of habit.
26:18Turning away from the airport towards mountains.
26:21In the confusion over the turn, no one notices that the Airbus is dropping dangerously close to the ground.
26:32What?
26:36Come on, climb!
26:38Come on!
26:38Pull up! Pull up!
26:44No! No! No! No! No!
26:47No! No! No!
26:48No! No! No!
26:49No! No! No!
26:50No! No! No! No!
26:51God damn it!
26:55Investigators conclude that a misunderstanding between the pilots of Garuda-152 and controllers led to the tragedy.
27:03We must understand that aviation involves people.
27:08People are fallible.
27:09pilots and air traffic controllers are trained to use very specific language when communicating
27:21with each other whether it's a regular day or a busy one
27:24everyone has an interest in safety so everyone that is involved wants to make sure that they
27:32are on the same page with their pilots no air traffic controller wants to be the person that
27:36said something wrong or did something wrong or contributed to an unsafe situation look at it
27:42that idiot's coming is that what happened when two airplanes collide on the holiday island of
27:48tenerife the spanish island of tenerife it's a tranquil getaway off the african coast sunjet 282
28:00proceed directly to runway backtrack and hold but today los rodeos airport is busier than it's
28:07ever been VA 783 hold short of the runway and standby for taxi clearance dozens of flights have been
28:17diverted here after a terrorist bombing in nearby las palmas it's a single runway airport the single
28:24parallel taxiway and because of the terrorist event in the region they had much more traffic
28:31than i'm certain that they would normally see sterling airliners are log jammed at the airport
28:37controllers are under pressure they were dealing with aircraft that had been delayed for a good part
28:45of the day or now there was a sense of urgency to get them out and safely on their way tenerife is
28:53known for its constantly changing weather can't see anything out there and now a thick fog is rolling
29:01visibility went down to almost zero clipper 1736 you are clear to start controllers direct pan-am flight
29:111736 with 378 passengers to taxi onto the runway behind KLM 4805 clipper 1736 clear taxi into the runway
29:23following the 747 from KLM clipper 1736 to expedite the departures of both KLM and pan-am they taxi both on
29:37the runway at the same time to put them in a position where they would be ready for a departure the pan-am
29:43jet is instructed to follow KLM 4805 along the single runway then make an exit off the taxiway so it can get
29:52in behind the KLM plane Robert Bragg is the first officer of the pan-am jumbo jet follow KLM down a runway
30:02backtrack make an exit to get around back of KLM so that's what we were doing at the end of the
30:11runway make 180 and report ready the pan-am pilots listen to the tower controller tell the KLM crew ahead
30:20of them what to do after departure you are clear to the Papa beacon climb to and maintain flight level
30:2790 right turn after takeoff Roger clear to the Papa beacon flight level 90 right turn up we are now at
30:35takeoff okay stand back for takeoff I will call you and we're still taxing down the runway clipper 1736
30:45Papa alpha 1736 report runway clear okay we'll report when we're clear thank you
30:54then just a few yards from their turnoff first officer Bragg sees something disturbing I think it's moving
31:06now looked up and there he was coming down the runway look at him that idiot's coming
31:13he had lifted off the runway I could see his rotating beacon underneath get off get off get off
31:29get off get off get off and then I ducked and set a real quick pair
31:35try to help he misses us
31:39open my eyes and
32:02and it looked like somebody had taken a big knife and just cut the whole top of the airplane off
32:09first officer Robert Bragg is one of 61 people who survived the collision
32:17the runway at Tenerife is the site of the deadliest aviation accident of all time
32:23583 people with only a few getting out on Pan Am
32:30this was something that we really had not contemplated when we started building bigger airplanes
32:35nobody ever thought what if we lost two of them in a collision on the ground
32:38this was a nightmare beyond all expectation
32:42the next morning air crash investigators from Spain the Netherlands and the United States are on the scene
32:53they face a huge task untangling the chain of events that led to this catastrophic runway collision
32:59voice recorders in this case were vital you had two airworthy aircraft coming together on the runway
33:08so the events leading up to that you know were key
33:14with the flight's black boxes on the way to the lab for analysis investigators turn their immediate
33:21attention to air traffic control
33:23they analyze recordings of the controllers directions to the pilots
33:28where were the aircraft on the runways and what was being said along their path down the runway
33:35get off get off get off
33:42502 when investigators play the tapes clipper one seven three six leave the runway
33:50three one out to your left
33:54they notice the controller is struggling to make himself clear to the Pan Am pilots
33:59I'm sorry say again please leave the runway the third one to your left
34:05okay taxi down the runway and leave the runway at the first intersection on the left is that correct
34:11negative the third one sir one two three the third one third
34:20there seemed to be some confusion as to which exit they were supposed to take
34:25we have kind of a linguistic problem here because these were Spaniards who speak Spanish as their native language
34:30attempting to speak in aviation English to an American crew and to a KLM Dutch crew
34:35he's on an active runway
34:36investigators discover that although the controller was giving clear instructions
34:41linguistic differences were complicating communications with the Pan Am pilots
34:46but it's not enough to explain the crash
34:50they now turn to communications between the KLM flight and controllers
35:00you are clear to the Papa beacon
35:02climb two and maintain the flight level nine or zero
35:05right turn after takeoff
35:07sounds fine
35:09Roger clear to Papa beacon
35:11flight level nine zero right turn out
35:13we are now at takeoff
35:14takeoff
35:15okay
35:17stand by for takeoff I will call you
35:21they don't find anything
35:23he's telling the tower he's in takeoff position
35:26but he's been told to wait for takeoff clearance
35:31so why does he start his takeoff role
35:34the pilots took off before they were cleared
35:37investigators are mystified
35:40flight level nine zero right turn out
35:44we are now at takeoff
35:45they hope clues left on the cockpit voice recorders of the KLM flight
35:49are enough to finally solve the mystery of the worst air disaster the world has ever seen
35:55the big question then was how could this happen
36:01an aviation disaster without precedent has investigators stumped
36:06what led the captain of a jumbo jet to believe that he had permission to takeoff
36:15it just seems so alien for the crew to make that mistake
36:21these are the best in the business
36:25investigators turn to the KLM cockpit voice recording for answers
36:30perhaps something said between Captain Van Zanten and the other pilots can explain his decision
36:35to start down the runway
36:40we landed here at 1.38
36:42yes I know that
36:43but we have to start from 7 o'clock that's when we checked in
36:46the time limit is 10 hours of flying with an amplitude of 13 hours
36:50that's the fun stopover
36:52the recording reveals that the captain seems stressed about work hours
36:57if the crew exceeds their duty time they'll be forced to cancel the flight
37:01and that means probably 30-40 thousand dollars of hotel rooms for the outbound passengers
37:08for you they're not going to be able to carry back that night
37:11flight delays left the pilots only two hours to get their passengers to Las Palmas
37:17pick up another load of passengers and get back in the air heading towards Amsterdam
37:21if I mess this up I could actually lose my license
37:26we certainly wouldn't want that
37:28a disturbing question confronts investigators
37:32did the KLM pilots rush to get off the ground
37:36half hour to taxi
37:38half hour to get there
37:40an hour to swap passengers and get back in the air
37:42it's tight
37:44it was obvious that time was an important factor in the KLM captain's decision making
37:54he wasn't going to waste any time once he got to the end of the runway
37:59KLM is ready for takeoff waiting for ATC clearance
38:02so he requests ATC clearance we're about a minute from the collision
38:08when the first officer asked for the clearance
38:11he was asking for the air traffic control clearance completely separate from the clearance
38:14to actually roll this 500-600 thousand pound monster down the runway
38:19you are clear to the Papa Beacon
38:21climb 2 and maintain flight level 90
38:24right turn after takeoff
38:26what investigators hear next answers many of the questions plaguing this investigation
38:32yes
38:34Roger clear to the Papa Beacon let's go
38:36flight level 90 right turn out we are now at takeoff
38:39okay
38:41whoa whoa whoa what just happened there
38:44play that again please
38:46investigators discover a misunderstanding that may explain why the pilots thought they were clear to takeoff
38:53the controller provides the pilots with the instructions what to do after takeoff
38:59you are clear to the Papa Beacon
39:01climb 2 and maintain flight level 90 right turn after takeoff
39:06but the captain reacts as if he's actually being cleared for departure
39:11yes
39:13they get a clearance from air traffic control that contains the word takeoff
39:17and that confirms for them that everything is the way it should be
39:21when in fact everything was not
39:23let's go take trust
39:24the KLM pilots throttle up and start down the runway
39:28it's a deadly decision caused by a simple misunderstanding in communications
39:34flight level 90 right turn out we are now at takeoff
39:38investigators now know what the Dutch first officer meant by at takeoff
39:42he's reporting that he's actually taking off not that he's ready to take off
39:48unfortunately in this case it meant they were taking off from the KLM perspective and for the air traffic control perspective they were hearing we are at takeoff position
40:00but for investigators there's something about the radio exchange that still doesn't make sense
40:08according to the tower transcripts the controller advised him to stay put
40:13okay
40:16stand by for takeoff I will call you
40:19why would he ignore them
40:22why didn't the KLM crew follow that clear instruction to stand by
40:27then they hear another critical moment on the KLM tape
40:31we are now at takeoff
40:33okay
40:35that's what he heard
40:39it's a stunning discovery
40:43flight level 90 right turn out we are now at takeoff
40:49okay
40:51two separate warnings to stay put were never heard in the KLM cockpit
40:58the tower and the Pan Am flight both made their critical calls at the exact same moment
41:03okay
41:05okay
41:06and we're still taxing down the runway
41:07stand by for takeoff
41:08I will call you
41:09clipper 1736
41:11the simultaneous transmissions produced a four-second squeal in the KLM cockpit
41:16we are now at takeoff
41:18okay
41:20we are now at takeoff
41:22okay
41:24the crew heard only one word
41:25okay
41:27unfortunately this happened during that pause after the controller says okay for KLM they had no opportunity to hear it
41:32the controller staying standby for takeoff nor were they able to hear the Pan Am crew reporting that they were still on the runway
41:42after a series of miscommunications the world's deadliest airline accident is now all but inevitable
41:48I think he's moving
41:50I think he's moving
41:54look at it
41:56that idiot's coming
42:01oh damn it
42:02oh damn it
42:11get off get off get off get off get off get off get off
42:14oh
42:24Van Santen should not have moved without explicit clearance
42:27you learn that in probably the first or second lesson in aviation
42:32do not take off unless you get a clearance
42:35clearance the accident in Tenerife leads to changes in the way controllers use
42:41language around the world and colors don't use the word takeoff unless they
42:46actually mean and intend for the aircraft to be doing just that taking
42:51off instead they will substitute the word after departure turn right heading
42:56040 or something to that effect like to and maintain flight level niner zero
43:01right turn after takeoff we humans think that we can communicate with great
43:06precision and we are absolutely wrong if you deviate from standard phraseology
43:11you end up with a situation like Tenerife air safety investigators are expanding
43:17their efforts to prevent tiny human misunderstandings from triggering air
43:21disasters Indonesia 152 say again our next jump is improperly utilizing the
43:29electronics where we're passing instructions and clearances with a much
43:33much higher degree of fidelity than we can possibly do my voice holding for
43:38departure at one way for two hundred yeah in air when you look back 40 or 50
43:43years we didn't even understand why we were having these accidents we didn't
43:48realize about communications and all of these things has taken us now to the
43:52point where we are almost at zero we're so close we can taste it