- 6/10/2025
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00:01A passenger plane prepares to land at Amsterdam Airport.
00:05Runway in sight.
00:07When suddenly...
00:11Steer! Steer! Steer!
00:13Disaster strikes.
00:22Investigators face intense pressure to find out why.
00:26When something happens at the airfield, it has more attention from the public.
00:32But finding answers proves to be difficult.
00:35There was nothing that indicated that they were in a very desperate situation.
00:39Careful examination of the evidence...
00:41There's nothing wrong here, the gauge is working fine.
00:44...only deepens the mystery.
00:46Why the heck did they decide to turn back?
00:48Can investigators uncover what really doomed Flight 433?
00:53There's a piece still missing.
00:59D-D-D-D!
01:03Oh!
01:04End of tape!
01:06Three-D-1, zero-perative, three-yard, three-yard, four-pack, nine-lot2, one-lot2, one-lot, one-lot!
01:10Now, zero-perated, one-lot2.
01:11It's Easter Monday, 1994, at Amsterdam's Schiphol Airport.
01:27Set, Torque.
01:29My controls.
01:31KLM City Hopper Flight 433 is on its way from Amsterdam to Cardiff, Wales.
01:38Torque set.
01:41Flying time is an hour and 20 minutes.
01:51V1, rotate.
01:56The plane is a Saab 340B, a dual turboprop designed for short regional flights.
02:03The Saab 340B was a fairly popular commuter airliner back in the 1990s when it was introduced and in production.
02:11It was in use all over the world, and Europe and North America in particular.
02:14The captain on Flight 433 is 37-year-old Gerrit Levaert.
02:24The first officer, Paul Stassen, is 34.
02:27Both pilots have been flying commuter flights with KLM for more than two years.
02:36Today's flight from Amsterdam's Schiphol Airport crosses over the North Sea and England to Cardiff.
02:42It's a popular route for KLM City Hopper.
02:47Fred Bergisch flew it often as a pilot when he was with the airline.
02:52It's three, four times a day, that routing, to Cardiff and Bristol.
02:58It's profitable.
02:59It's good.
02:59There are 21 passengers in the cabin.
03:06Most are heading home after the Easter long weekend.
03:10It was nice that you came. Thank you.
03:13My mother didn't want to fly on her own, so I went to get her.
03:17Marika Jenkins is a Dutch-born social worker living in Wales.
03:22She flew to Amsterdam to pick up her mother and take her to Cardiff.
03:26We managed to have a bit of a family reunion that Easter weekend before we flew back.
03:40Look out ahead of us. Can you see that?
03:43Oh, yeah.
03:45Captain Levaert spots thunderclouds ahead.
03:49He wants to get above them.
03:52That's control for flight level 200.
03:54Amsterdam, KLM 433.
03:58Go ahead, 423.
04:00Is flight level 200 available?
04:05Climb to 200. You are re-cleared. Flight level 200.
04:10Amsterdam Air Traffic Control OKs the climb to 20,000 feet.
04:17Thank you, sir. Climbing flight level 200, KLM 433.
04:21The captain decided to be on top of the weather, which is a good decision, of course.
04:28You want the passenger comfort.
04:31Avoid turbulence. Avoid storms.
04:34And that is what they did.
04:38Has the airline asked you to become an instructor?
04:39No, not yet. You need a lot of experience to get there.
04:44It's a big responsibility.
04:52Right engine oil pressure.
04:53Check. Take action.
04:55Copy. Taking action.
04:57In response to the alarm, First Officer Stassen consults the engine oil pressure warning checklist.
05:04There are several reasons where oil pressure could drop in an engine.
05:07Primarily due to leaks or some sort of damaging event in the engine system.
05:12Emergency checklist for engine and propeller oil pressure low.
05:17The checklist tells him to monitor the warning light and the oil pressure gauges.
05:22If the warning light is on or the gauge is below 30, then you can continue.
05:29But if you have both, then shut down the engine.
05:32That's not the case.
05:35This is so strange.
05:40There are a variety of warnings that may come up in a cockpit.
05:43Some of them are quite serious, where the pilots would have to immediately institute some emergency procedures.
05:50Others, such as this, they have the time to take out a checklist and go step by step through that checklist
05:55to make sure the problem isn't serious.
05:58What do we have now?
05:59So the light is on, but we're above 30 PSI.
06:02So, continue normal operation?
06:05Yes.
06:07The crew completes the checklist and decides it's safe to keep flying.
06:19This isn't as bad as I thought.
06:22In the cabin, passengers are unaware of any issues in the cockpit.
06:26It was pretty relaxed.
06:30It was a small plane flying to Cardiff.
06:37Okay, we're not climbing anymore.
06:43Approaching 17,000 feet, Captain Leivart notices a problem with his plane's performance.
06:50No.
06:50It's not climbing as quickly as it should be.
06:54You need to return to Amsterdam, make a pan call, request to maintain flight level 160, tell them we have a technical issue.
07:04A pan call, or the pilot saying pan, pan, pan, means there is an unusual situation.
07:10Not a critical situation, not an emergency situation yet.
07:13But it's something where it's indicating to the air traffic control, please pay attention to us, we need extra help.
07:18Amsterdam KLM 433, pan, pan, pan, pan, pan, pan, pan, pan, we have an engine problem and we'd like to maintain 160 for return to Schiphol.
07:29That's copied, sir.
07:30You may turn right, heading to Schiphol.
07:32The controller grants the pilot's requests.
07:36We have a pan from KLM 433, now returning to Schiphol.
07:39At the airport, emergency vehicles are put on standby.
07:52Less than 15 minutes after takeoff, KLM flight 433 is heading back to Amsterdam.
08:01You trained for it.
08:03They decided to return to Schiphol, which was a good decision.
08:07Descending 7-0.
08:11Check, set, okay.
08:151,500 feet per minute.
08:17Now descending towards the airport.
08:19Staying steady now?
08:21The crew keeps a close eye on their problem engine.
08:25Yes, but it's sensible to turn by.
08:29You should tell the passengers.
08:31They must deliver the bad news.
08:34I'll, uh, say calmly that, as a precaution, we're heading back.
08:41Yeah?
08:43Ladies and gentlemen, this is your first officer.
08:46We have a slight problem with the right engine.
08:49And for safety, we are returning to Amsterdam.
08:52Sorry for the inconvenience.
08:54That's not something you really want to hear.
08:59Oh, well.
09:00They know what they're doing.
09:02And I remember saying to my men,
09:04hmm, don't sit comfortably after somebody tells you that one engine's not working.
09:10KLM 433, can you give me any details?
09:12The controller wants to know more about the engine problem.
09:17KLM 433, situation's under control.
09:20We have an engine oil pressure problem in engine number two.
09:23Yes, okay, we can bring you in for zero six.
09:26You're a number one.
09:27There was nothing coming out of the communication with the pilots.
09:30It indicated that they were in a very desperate situation,
09:33that the aircraft was about to lose control or anything like that.
09:35This was, if you can call it this, a normal emergency.
09:47I was hoping to get home by four.
09:57Runway in sight.
09:59Okay, 423.
10:01The pilots are focused on the landing.
10:03Wind is 280 degrees, 8 knots.
10:09Flaps 20.
10:11Flaps 20.
10:14Outer marker.
10:15Check.
10:17KLM 433 is just 500 feet above the ground.
10:24Watch your speed.
10:26The plane has slowed to a dangerously low speed.
10:30I'm on it.
10:33A sudden bank to the right takes the passengers by surprise.
10:38As it veered.
10:39I remember saying to my mother,
10:42well, I actually swore.
10:45Rick, don't swear.
10:51You want to come in straight.
10:52And if you have a bank close to the ground,
10:55it's always a problem.
10:58The captain struggles to level his plane.
11:03Going around.
11:04Set torque.
11:05Flaps 7.
11:06Gear up.
11:07Captain Leivart attempts a go-around.
11:09Ah!
11:10The plane veered quite sharply to the right.
11:15And at that point,
11:16things were clear that they were in right.
11:20Flight 433 is beyond recovery.
11:27Steer!
11:28Steer!
11:29Steer!
11:30Garrett!
11:31Garrett!
11:31Garrett!
11:32Garrett!
11:32Garrett!
11:32Crash, crash, crash.
11:52Runway 06, emergency runway 06.
11:55KLM Cityhopper 433 has crashed next to Amsterdam's Schiphol Airport.
12:12Marika Jenkins and her mother have somehow survived.
12:17I remember it being very, very quiet.
12:21So all the stuff that you imagine might happen,
12:26which is people screaming and being panicked,
12:31it wasn't.
12:34Mom.
12:36You're okay.
12:39Let's get out.
12:41I said to my member,
12:42so I'm going to undo your seatbelt
12:44because we have to get out.
12:46And she said, but nobody's told us that we can.
12:49And I said, I don't think nobody is.
12:51So I'm going to do it.
12:54People near the runway watching planes land rush to help.
13:04KLM Flight 433 has crashed in a field next to the runway.
13:10Emergency vehicles can't get through the thick mud.
13:14Rescuers and passengers must trudge to safety on foot.
13:17And with the help of a local farmer's tractor.
13:24First responders and a handful of civilians
13:27lead the survivors away from the smouldering wreckage.
13:31I need to rest.
13:33I just wanted to sit there and have a cigarette.
13:35That's all I wanted to do.
13:38That's odd, isn't it?
13:39It's odd to think that those are the thoughts you have.
13:43And because I had my handbag,
13:46I rolled a cigarette.
13:49And somebody came up towards me and said,
13:52should you be doing that, lad?
13:54After what just happened, I'll do what I want.
13:57And he said, but you're covered in kerosene.
13:59And I said, well, if I was meant to die today,
14:01I think I would have died today.
14:03I'm having a cigarette, whatever happens.
14:04Marika and her mother are lucky to be alive.
14:17Not everyone is so fortunate.
14:18Of the 24 people on board,
14:21two passengers and the captain are dead.
14:26Eight passengers and the first officer are seriously injured.
14:30While emergency workers secure the accident site,
14:35investigators from the Netherlands Aviation Safety Board
14:37begin the search for clues.
14:45Karst Bermkes is among the first on the scene.
14:48When we got to the accident site,
14:50it was that the aircraft crashed about 500 meters
14:55on the southeast side of the runway.
15:00How is it possible an aircraft landed next to the runway?
15:04Not miles away, just outside the airport.
15:09Investigators managed to recover the plane's black boxes.
15:12But it will take some time to process the flight and voice data.
15:22Investigators are eager to hear
15:23what the air traffic controller has to say about the crash.
15:26Ben Groenendijk is the investigator on the case.
15:32We go to the tower and approach
15:35and we get the first information.
15:39When the crash happened within eyesight,
15:42we also get his report of what he saw.
15:45They issued a pan call.
15:46We're coming back to the airport.
15:48We got information from ATC, air traffic control,
15:52that the pilot returned from a flight to Cardiff.
16:02Amsterdam KLM 433, pan, pan, pan, pan, pan, pan.
16:07We have an engine problem
16:09and we'd like to maintain 160 for return to Schiphol.
16:12That's copy, sir.
16:13You may turn right, heading to Schiphol.
16:16Did they tell you what the problem was?
16:22Yeah.
16:23They said it had to do with the oil pressure.
16:26KLM 433, can you give me any details?
16:29KLM 433, situation's under control.
16:32We have an engine oil pressure problem in engine number two.
16:36This was at a fairly high altitude.
16:38They had plenty of opportunity to diagnose the problem
16:40and to maneuver the aircraft expertly with one engine.
16:44They were trained to do that
16:46and that's not an unusual situation.
16:49I gave them some wind info
16:50just before they were supposed to land.
16:53Next thing I knew, they were going around.
16:56Going around.
16:58Set torque flap seven, gear up.
17:01Pilots conduct a go-around
17:03if their landing becomes unstable.
17:06They increase the power,
17:08they gain altitude,
17:09they circle around
17:10and they try a second time for that landing.
17:12How do you know they were attempting a go-around?
17:15I could see that their gear was up.
17:18To help reduce drag,
17:20pilots retract the landing gear for a go-around.
17:24They had veered off to the right of the runway.
17:29Some type of flight control issue.
17:30A malfunction of the rudder,
17:36ailerons or other control surfaces
17:38could explain why the plane banked so violently
17:40at the last moment.
17:43Right before the aircraft is about to touch down,
17:45within a few hundred feet of the ground,
17:47any sort of controllability issue...
17:49Steer! Steer!
17:50The potential for danger is much, much higher
17:53than if the same problem happened at altitude.
17:55The potential for danger is much higher
17:56than if the plane is about to touch down.
17:57They have a problem with their oil pressure.
17:58They have a problem with their oil pressure,
17:59and then lost control of the airplane
18:00when they tried to land.
18:02Okay, let's focus on the engine and flight controls.
18:04Investigators face difficult questions
18:08in their search for a cause,
18:09but already the plane is about to touch down.
18:10They have a problem with their oil pressure,
18:11and then lost control of the airplane
18:13when they tried to land.
18:14Okay, let's focus on the engine and flight controls.
18:19Investigators face difficult questions
18:21in their search for a cause,
18:23but already the public is demanding answers.
18:26When something happens at an airfield,
18:30it has more attention from the public.
18:33We try not to jump into conclusions,
18:37and we just stay blank and start an investigation.
18:46In a hangar at Schiphol Airport,
18:48the Netherlands Aviation Safety Board investigators
18:50scour the wreckage for clues
18:52to explain the crash of Flight 433.
18:56They need to know if the plane suffered
18:58a flight control malfunction.
19:00We want to exclude all possible factors
19:04that could have contributed to the accident.
19:08Let's start with the rudder.
19:12Investigators know the plane veered to the right
19:14during the landing attempt,
19:16but they don't know why.
19:21In the air, pilots move the rudder left and right
19:24to control the plane's yaw,
19:26or horizontal rotation.
19:28It's a critical control surface
19:30for helping them line up with the runway.
19:38Investigators wonder if the rudder malfunctioned
19:40just before landing.
19:50They need to examine the rudder locking device.
19:53It's used to lock the rudder in place
19:55to prevent it moving in a heavy wind
19:57while on the ground.
20:03Did the rudder lock somehow engage in flight,
20:06causing a catastrophic loss of control?
20:09Can I take a look?
20:12A rudder lock, if it would be still on,
20:14would certainly degrade the authority of the rudder.
20:18So you check that.
20:21They study the rudder components.
20:23They look for any sign of a malfunction in the gust lock system.
20:29There's nothing wrong with it.
20:30The lock is fine.
20:32We didn't find anything wrong with the gust lock.
20:38Further analysis reveals that all of the plane's other flight control surfaces
20:41were also working properly.
20:42Flaps 20.
20:43Flaps 20.
20:44The cause of the deadly disaster lies somewhere else.
20:54KLM 433, can you give me any details?
21:03Investigators know that the KLM pilots reported an oil pressure problem.
21:08KLM 433, situation's under control.
21:11We have an engine oil pressure problem in engine number two.
21:17They need to know what that problem was,
21:20and if it contributed to the crash.
21:24You could have a seizure of an engine,
21:27or overheating, because the oil is not there.
21:32Well, turbines are moving.
21:35There's no evidence that the engine's overheated or seized,
21:39due to a lack of oil.
21:41Any damages from the impact.
21:46Not from oil pressure.
21:48There's no evidence of any oil pressure issues at all.
21:51It seems the pilots reported a problem that didn't exist.
21:55We checked, of course, the rest of the engine,
21:58for a thorough investigation,
21:59and we didn't find any other malfunctions on the engine.
22:02Why would they report a problem if they didn't have one?
22:06What were they looking at?
22:08Investigators now wonder.
22:11Did the cockpit instruments somehow malfunction?
22:16And mislead the pilots?
22:19Right engine oil pressure.
22:21Check. Take action.
22:23Copy. Taking action.
22:25So, the next step is that you look in all the systems
22:29to see if there were any malfunctions that could explain
22:35why there wasn't lower oil pressure.
22:38Yeah.
22:39Are we ready?
22:41Testing the oil pressure gauges and warning systems
22:44from the Saab 340 should tell investigators
22:47if the KLM pilots were getting accurate oil pressure readings.
22:51There's nothing wrong here. The gauge is working fine.
22:54They find no malfunction in the oil pressure gauge.
23:00Hold on.
23:02That shouldn't happen.
23:05But the warning light is another matter.
23:09OK, let's do it again.
23:15OK.
23:16Hmm.
23:17Hmm.
23:19That's strange.
23:21It's giving an intermittent warning.
23:24It's another surprising discovery.
23:27The oil pressure warning light sometimes activates
23:30even when the pressure is normal.
23:34Digging deeper, they examine the switch that controls the warning light.
23:38We suspected the oil pressure switch, so we looked into that.
23:51Ah, OK.
23:53There's a short circuit in the switch.
23:57The oil pressure switch, it had a malfunction.
24:00It had a short.
24:01Now they understand what the pilots were seeing.
24:06A false warning.
24:08Has the airline asked you to become an instructor?
24:11No, not yet.
24:13You need a lot of experience to get there.
24:15It's a big responsibility.
24:21Right engine, oil pressure.
24:22An electrical short in the oil pressure switch caused the warning light to come on when it shouldn't have.
24:29The oil pressure warning itself was false, and the engine was operating normally.
24:37So, they were seeing a false warning.
24:40But that doesn't explain the accident.
24:43The discovery raises as many questions as it answers.
24:47A false warning alone shouldn't lead to a crash.
24:50Take action.
24:53Copy. Taking action.
24:55Pilots are trained to use checklists to make sure they're not thrown off by harmless circuitry malfunctions.
25:02The checklist in this aircraft was designed in such a way that it gave the crew the opportunity
25:08to diagnose the problem as being one of a warning system issue, not a propeller and not an engine issue.
25:14Let's see if there's an update on the first officer.
25:27The captain of Flight 433 was killed in the accident.
25:31Hi, it's Cass.
25:34Any news?
25:36But the first officer survived.
25:38And investigators hope he can explain exactly how the crew responded to the false alarm.
25:43That's always very important.
25:46You want to have the first impressions of the surviving crew.
25:49But the reality that it's not always possible.
25:54So, nothing at all?
25:58Okay, thanks.
25:59The impact has left the first officer with severe amnesia.
26:05He remembers nothing from the flight.
26:08Investigators will need to look elsewhere for answers.
26:12Crash investigators in Amsterdam are finally able to listen to the cockpit voice recording from KLM 433.
26:26They hope it will tell them why the pilots turned around and why their landing at Schiphol went so terribly wrong.
26:33If you don't have the information from the crew, then the recordings become more important.
26:43So, we were very, very interested in what was recorded on the cockpit voice recorder.
26:49Okay, let's hear it.
26:51To give us specific clues of what actually happened during the flight.
26:56Has the airline asked you to become an instructor?
26:59No, not yet.
27:01You need a lot of experience to get there.
27:03It's a big responsibility.
27:05Here's the warning.
27:07Right engine oil pressure.
27:09Let's see how they handle it.
27:12Check, take action.
27:14Copy, taking action.
27:16Investigators know that if the pilots follow the steps in their checklist correctly, they should be able to solve the problem.
27:22The procedures that are in the emergency checklist help the pilots to determine whether or not it's a false warning or a real warning.
27:29Emergency checklist for propeller and engine oil pressure low.
27:34Engine oil and prop oil checked.
27:37So far, so good.
27:39The pilots seem to be following the correct procedure.
27:41If the warning light is on, or the gauge is below 30, then you can continue.
27:50But if you have both, then shut down the engine.
27:53Okay, stop it there.
27:55So, let's get this straight.
28:11If the warning light comes on and the oil pressure is below 30 psi, then you shut down the engine.
28:25On the SOP 340, the warning system and the oil measuring system are two separate systems.
28:30And if there is a confusion between the two, let's say there's a warning light, but the oil pressure is above a certain level.
28:38The guidance on the emergency checklist is to continue normal operations.
28:44What do we have now?
28:46So, the light is on, but we're above 30 psi.
28:49So, continue normal operation.
28:52We'll wait, stop it there.
29:00So, they had the warning light, but the oil pressure was above 30 psi, so they could have kept flying.
29:12The recording reveals that not only was it safe for the pilots to continue their flight, they knew it was safe.
29:19Why the heck did they decide to turn back?
29:21Well, it's up to the captain to make a decision whether he continues or go back, but there was no reason to go back.
29:39Fast forward to the end of the checklist and let's see if they say anything else about it.
29:46Okay, we're not climbing anymore.
29:48Ah.
29:49No.
29:50That must be why they turned back.
29:53We get to return to Amsterdam.
29:55Make a pan call, request maintain flight level 160.
29:59Tell them we have a technical issue.
30:01Amsterdam, KLM 433, pan pan, pan pan, pan pan.
30:06I always say stop it there.
30:08Not climbing.
30:10Investigators are stumped.
30:13All the evidence shows that the engines were working normally.
30:16The only problem was a false alarm.
30:19So why would the plane have trouble climbing?
30:25The engines are fine.
30:27Why are they not climbing?
30:30The mystery of flight 433 is proving difficult to solve.
30:35But for the media and the public at large, answers can't come soon enough.
30:40The month afterwards, the problems came because there must have been a pilot from the company who phoned the press and said, I know for sure that's pilot error.
30:54The problem is that everybody is jumping into conclusions that we have to prove it.
31:01There's a piece still missing.
31:06We're going to need the flight data.
31:10Investigators hope the data recorder will provide the answers they need to solve the mystery of flight 433.
31:18OK, let's see what we've got.
31:19Investigators now turn to the flight data recorder from KLM flight 433.
31:32It contains reams of information about the aircraft's performance.
31:39The flight data recorder came out of the accident in good condition.
31:43So I had the data and could make graphs of the data.
31:48Just these ones for now.
31:50But can the data reveal why flight 433 had trouble climbing and why it crashed?
32:00Here's where they got the warning.
32:03Bring up the oil pressure data.
32:11That's plenty of pressure.
32:13The data shows oil pressure never dipped below a safe level.
32:17It did not prevent the plane from climbing.
32:27It's staying steady now?
32:29Yes, but it's sensible to turn back.
32:35Investigators remain in the dark.
32:38Until...
32:40What's going on here?
32:42They spot something unexpected.
32:44Right side engine thrust.
32:45It's dropping.
32:52It's a major discovery.
32:54It suggests pilot error may have caused the deadly disaster.
33:01Right here.
33:03Right after the alarm goes off, he actually pulls the power back.
33:05Right engine oil pressure.
33:06Check.
33:07Take action.
33:08Copy.
33:09Taking action.
33:10When the warning happened, he started to pull back on the power lever.
33:11And nobody knew why.
33:12All the way to idle.
33:13All the way to idle.
33:15Each of two power levers controls one of the two power levers controls one of the two power levers.
33:17Right engine oil pressure.
33:18Right engine oil pressure.
33:19Check.
33:20Take action.
33:21Check.
33:22Take action.
33:23About four hours riskers and crew many units.
33:24All the way to idle.
33:25Like one of the remoteanın says.
33:26Each of the two power levers controls one of the two engines.
33:33idle
33:40each of two power levers controls one of the two engines the data shows that when
33:47the first officer started the emergency checklist the captain reduced the right
33:51hand engine power to idle it doesn't say anything about reducing power the
34:03captain may have been trying to protect what he thought was a damaged engine by
34:07powering back but reducing engine power is not part of the emergency checklist
34:13my first reaction was he might do it to save the engine just for the moment but
34:20you would expect when they got to the proper conclusion eventually to continue
34:25normal operation that you would use the engine again and look he keeps it in
34:30idle for the remainder of the flight well no wonder they couldn't climb
34:40okay we're not climbing anymore no if you don't use one of the two engines at that
34:48altitude they will not climb very much so the false alarm goes off he reduces power
34:58to the right engine that causes the oil pressure to actually drop this is so
35:03strange it's decreasing Garrett
35:11and that's why they thought they had a problem with the engine as in a car if you lose your gas pedal
35:19then the rpm will get lower the pilots decide to turn back even though they don't have a
35:29problem it's staying steady now yes but it's sensible to turn back the oil pressure system the engine
35:39and the propeller these are all working just fine there is a key question investigators now need to answer
35:47did having an idle engine cause this accident let's see the data from the final approach
35:55they wonder how having the right engine at idle affected the landing
36:01okay so at this point they're too slow
36:06watch your speed on it
36:19the captain advances power to the left engine to regain speed but since the right engine isn't
36:32producing thrust the left engine pushes the aircraft to the right and they veer to the right of the runway
36:40now at this point there's no way they're going to make the landing so they have no choice but
36:58to attempt to go around his decision to make a core out is a good decision if you're not sure from a safe
37:05landing make it go around going around set torque flap seven gear up but when the captain pushes the
37:13left engine to maximum power it sends the plane into a catastrophic right turn
37:23then you have a situation where you have a differential thrust going on pulling the aircraft
37:28toward the side of the idling engine
37:31oh steer steer steer steer steer it get it get it
37:37what a blunder
37:48his engine he had flight idle it was still working
37:54so just one little push to the handle
37:59and he was out of the problems
38:03even though investigators have discovered serious piloting errors should all the blame lay there
38:16okay so just how qualified were these guys
38:21Dutch investigators dig into the training records of both pilots of KLM flight 433
38:32flight hours check rides rest times I mean these all look good
38:38there's got to be something missing what else do we have both pilots appear to have been fit to fly
38:46both pilots had their certificate there's no question that they were qualified
38:51but a document from the captain's days as a first officer reveals two failed flight tests
38:58okay this is from when he was training to be a first officer and he passed eventually
39:05training records show captain levard struggled with exactly the kind of problem he faced on the day of the accident
39:23the loss of the accident the loss of an engine he failed one engine out test twice
39:32it's an important discovery
39:34the records reveal that the captain failed tests simulating the kind of engine loss he thought he was facing when landing at skippo
39:50damn it we looked into the training and we found that the crew especially the captain had some difficulties with one engine in operative during flight and the only other time they tested him was the crew of the captain had some difficulties with one engine in operative during flight
40:01and the only other time they tested him was november 92 and he barely passed
40:08the records show the captain earned a standard minus the bare minimum required of him
40:16after the fact it's clear that there were some things missed when it comes to the training and operations of these kinds of aircraft
40:26investigators finally understand the sequence of events that brought down KLM Cityhopper flight 433
40:33the captain was primed to do this and the first officer didn't question his decisions and neither of them understood the danger they were in
40:45when
40:52when a short circuit causes a false warning
40:55right engine oil pressure check take action
40:58taking action
40:59the captain starts reducing right engine power before his first officer has a chance to read the checklist
41:06his premature action fools them both into thinking they have an engine problem when they don't
41:13there was information that was available to both pilots but somehow or another they were not communicating that information to each other in a way that allowed them to make good decisions
41:22emergency checklist for engine and propeller oil pressure low
41:27and once they put that right hand engine to idle
41:30they blocked it out of their minds as an option
41:34the right power lever remained in the position of flight to idle
41:39and they didn't discuss the consequences of that
41:42runway in sight
41:44ok 423
41:46as the pilots get closer to the runway
41:49watch your speed
41:50come on it
41:51the problems they created for themselves begin to snowball
41:55things became more unstable
41:58things got into a situation where they were less in control of what was going on
42:02going around
42:04set torque
42:06flap 7
42:07gear up
42:09attempting a go around using just one engine is the final mistake
42:14you can see it on the flight data
42:16you see the power levers coming up
42:18then they lost it
42:19steer
42:20steer
42:21steer
42:22steer it
42:23get it
42:24get it
42:25get it
42:26get it
42:35what started as a minor electrical problem turned into a cascading series of pilot errors
42:41but the Netherlands aviation safety board determines that the cause of those errors goes beyond the cockpit
42:47most of the time the pilot makes an error is because it's becoming very complicated
42:54in this case it was not complicated so it must be his thinking somewhere went wrong
43:02that's why the training has to be improved that they take it more seriously
43:08many of the investigators recommendations are aimed squarely at the airline
43:15the final report calls on KLM to review pilot testing techniques establish cockpit management training
43:23and improve guidance on flying with an idle engine
43:27it's easy to blame the pilots especially when in this case one person didn't survive and the other person has no memory of it
43:38but this is more of a system situation
43:40one of the takeaways is what can be learned here so that all parts of the system the flight crews the operating manuals the manufacturers the airlines what role do they all play and how could those roles change to prevent this in the future or to make it much less likely to happen
43:54much less likely to happen
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44:01
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