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00:00A late-night flight in Russia
00:08ends in a harrowing crash.
00:14The flying control surfaces, the fusillage, the engines, totally destroyed.
00:21Investigators search for a mechanical explanation for the crash.
00:25A split in engine balance makes it more difficult to fly,
00:27but it shouldn't cause a crash.
00:31But when they dig deeper...
00:33It doesn't make sense.
00:34What do they call hell broke loose?
00:36They make a shocking discovery.
00:38Just do it on yourself, okay?
00:40Take it!
00:41Take it!
00:42Why isn't Captain helping him?
00:448-2-1, is everything okay with the crew?
00:51D-D-D-D!
00:55Oh, stop!
00:57It's the middle of the night in Russia.
01:17A passenger jet is 45 minutes from touching down in Perm, a city in central Russia.
01:28There are 82 passengers on board.
01:31Most of them are Russian.
01:3343-year-old first officer, Rustim Alabirdin, is the pilot flying tonight.
01:42The captain, Rodion Medvedev, 34, is monitoring the instruments and radio communications.
01:53The two have only flown together twice before.
01:56Did you see the latest schedule?
02:00Not yet.
02:01How is it?
02:03It's ridiculous.
02:04They think we're machines.
02:06Aeroflot Nord is a regional airline and a subsidiary of Russia's state-owned airline, Aeroflot.
02:13Regional airlines sprouted up between 1991 and 1995.
02:21One of them was Aeroflot Nord.
02:25The reputation of the company was fairly strong.
02:27Blight 821 lifts off from Moscow just after one in the morning.
02:39The plane is making a two-hour journey to Perm and then returning to the Russian capital.
02:45Captain Medvedev and first officer, Alabirdin, are flying a 16-year-old American-built Boeing 737.
03:02The twin-engine plane has clocked almost 45,000 flying hours.
03:10Aeroflot Nord leased the plane in March 2008 to expand its fleet.
03:15The demand within Russia was on the way up, so the industry needed to get aircraft in.
03:26And the supply for aircraft, obviously, was to come from the west.
03:30Perm is a small international airport.
03:34It has a single tower operating 24 hours a day.
03:38And one long runway running northeast to southwest.
03:45The plan for flight 821 is to approach from the west, turn right, and land on runway 21.
03:56Good evening.
04:06Good morning.
04:07Good morning.
04:09This is your captain speaking.
04:11We've begun our descent into Perm and should have you on the ground in 20 minutes.
04:15And the local time is 4.50 p.m. a.m. and the temperature is 7 degrees.
04:24Flight 821 are clear to continue to set to 8,800 feet.
04:29Follow Bravo approach pattern.
04:30The Perm air traffic controller reroutes flight 821 to keep the runway clear for another plane's takeoff.
04:38What's this now?
04:43Why the changing direction?
04:44I don't know.
04:48Aeroflot 821, we are changing the approach due to impending takeoff of Lutenza 319.
04:53821, okay, understood.
04:58Could have told us sooner.
04:59Flight 821 must now wait for permission to land.
05:08What's the weather like?
05:11Light one, visibility 10 kilometers.
05:16Aeroflot 821, turn right, descend to 6,800 feet.
05:21Aeroflot 821, turn right, descend to 6,800 feet.
05:51How low must we descend?
05:54The captain wants to know at what altitude they should begin their final right turn to the runway.
06:00821, descend to 2,000 feet.
06:03Surface wind 050 degrees out, 10 knots.
06:06The wind is 9 knots.
06:09Increase your speed.
06:11Right, of course.
06:13891, 821, confirming base turn and descending to 2,000 feet.
06:18The crew now prepares for landing.
06:23Flips 30.
06:25Sit.
06:33The first officer notices the plane is veering left, so he brings it back on course.
06:38In the tower, the controller sees that flight 821 is now climbing instead of descending.
06:54Aeroflot 821, according to my data, you are climbing.
06:58Can you confirm?
06:59Damn it.
07:00The first officer adjusts the pitch of the plane to resume the descent.
07:07We can confirm and we're descending now.
07:13But now the controller sees flight 821 has flown past the approach path.
07:18He instructs the crew to loop around and restart their landing.
07:25Aeroflot North 821, restart your final approach.
07:28Turn right heading 360, descend to 2,000 feet.
07:33But the plane keeps going straight.
07:37821, descend to 2,000 feet.
07:40Turn right heading 360.
07:42Follow my instructions strictly.
07:44Flight 821 continues to ignore the instruction to turn right.
07:50And then his radar shows the plane banking left and veering off course.
08:01In the cockpit, it's now chaos.
08:35The plane has crashed onto the Trans-Siberian Railway on the outskirts of Perth, Russia.
08:55It had nearly eight tons of fuel on board.
09:01Local firefighters and rescue workers rushed to the crash site.
09:05Sunrise reveals the extent of the damage to Aeroflot Nord Flight 821.
09:17Nothing is left but charred wreckage.
09:21All 88 people on board die in the accident.
09:26Their distraught relatives gather outside the Aeroflot Nord offices.
09:31They hope an investigation into the cause of the tragic accident will explain why their family and friends died.
09:41Russian authorities labor around the clock to clear the wreckage of Aeroflot Nord Flight 821 from the crash site on the Trans-Siberian Railway.
09:57They need to get the trains running again.
10:05Be careful with this. Bring it over here.
10:07Meanwhile, Russian investigators from the Interstate Aviation Committee, the IAC, will work to find the cause of this tragic accident.
10:17Photos of flight 821's crash site offer up clues about the orientation and pitch of the plane when it hit the ground.
10:26The flying control surfaces, the fuselage, the engines, totally destroyed.
10:38And it flew past the approach line.
10:43We need to find out why.
10:45Russian investigators need to understand what could have provoked a catastrophic loss of control just minutes before landing.
10:53It was raining.
10:57Let's track down the weather charts.
11:01Thank you for making trip from Washington.
11:04I hope we can help.
11:05American investigators from the National Transportation Safety Board join the team.
11:12Bob Benzon is among them.
11:15We were invited because the Boeing was a manufacturer in the United States.
11:23The first priority is checking the weather conditions at the time of the crash.
11:31Visibility was 6.2 miles.
11:35Some cloud cover, light rain, and hardly any wind.
11:41Hardly challenging conditions for commercial pilots.
11:44I agree.
11:44One of the things we eliminated rather early in the investigation was the problem with the weather.
11:55What about the flight recorders?
11:57On the plane to France.
11:59They're in rough shape.
12:00The cockpit voice recorder and the flight data recorder were so badly damaged in the fire
12:06that they had to be sent to a specialized facility in France to retrieve the data.
12:12It could take weeks for results to return.
12:16In the meantime, the Russian investigators briefed the Americans on their progress.
12:20We found no evidence of the mechanical failure in the engines.
12:26What about an in-flight fire or a breakup?
12:29The plane first hit these trees on the left embankment.
12:35And all the debris was confined in the immediate area.
12:40There's no scorching on the trees.
12:43No breakup prior to crash.
12:45The fire started on the ground.
12:46After scouring through the wreckage and examining the impact details,
12:55investigators are certain Flight 821 was intact before it crashed.
13:05With no clues to work with,
13:08the investigators wonder if Flight 821's air traffic controller
13:12can shed any light on the crash.
13:17I keep playing it over and over in my mind.
13:19It doesn't make sense.
13:20What happened when the plane made its approach?
13:22Let me show you.
13:26Here.
13:27The plane started climbing, but it should have been descending.
13:31They were going to miss the approach line,
13:33so I told them to turn right and redo the approach.
13:35Aeroflot Nord 821, restart your final approach.
13:39Turn right heading 360, descend to 2,000 feet.
13:43Aeroflot 821, can we continue our approach?
13:46They wanted to keep the planned approach,
13:48but I said no.
13:51821 understood and followed my instructions strictly
13:54and had to give the instructions three times.
13:58And still, they didn't turn.
13:59They seemed confused.
14:01What he tells investigators next is revealing.
14:06821, is everything okay with the crew?
14:09Aeroflot 821 affirmative.
14:12The ground controller suspected something.
14:15He asked, are you okay, guys?
14:17Is it anything wrong in your cockpit?
14:20And they ensured him, no, is everything perfect?
14:24Once the captain confirmed everything was okay,
14:26they still failed to turn.
14:28And then?
14:32Aeroflot 821, please come in.
14:43They confirmed the instructions?
14:46Yes.
14:47Several times, they said they knew where to go and what to do.
14:51821, confirming the ascending to 2,000 feet
14:54and turning right, heading 360.
14:56The controller deepens the mystery.
15:00Why didn't the crew do what the controller asked?
15:04What was really going on in the cockpit
15:06in the moments before this horrible crash?
15:09With the crash of Aeroflot Nord 821 still a mystery,
15:20investigators need to find out if the 737 was mechanically sound
15:25when it took off from Moscow.
15:26When the Soviet Union split up,
15:33a lot of the resources that the Russian aviation industry had
15:38were in short supply.
15:40Spare parts were in short supply.
15:43The skill of the engineers maintaining the aircraft was reduced.
15:48And the aircraft were being operated on a shoestring.
15:55In Russia, tracking down records can be complicated by bureaucratic roadblocks.
16:01Great. We got them.
16:06Let's see what they can tell us.
16:09Good. They go back to when the plane went into service.
16:12But the team is lucky.
16:14A safety and certification company, Bureau Veritas,
16:18regularly inspected the Boeing 737
16:21and kept detailed records going back years.
16:24When this aircraft went down, the rudder system became an object of interest.
16:36Remember the design flaw in the 737's rudder
16:38that we discovered in the 1990s?
16:40It caused multiple accidents before it was caught.
16:45In 1994, US Air Flight 427 was approaching Pittsburgh
16:49when a rudder hardover caused the aircraft to nosedive
16:57and slam into nearby woods.
17:02All 132 people on board that 737 were killed.
17:08It was not an isolated incident.
17:12A rudder hardover was something that occurred
17:14because of a mismatch between hydraulic pressure on the rudder
17:17on the 737, which caused the rudder to move in one direction,
17:22which could not be reversed with the rudder pedals.
17:26Boeing decided to redesign the actuator of the rudder system
17:30to prevent these rudder hardovers.
17:34Have a look.
17:38Can we fix this one?
17:40But we never can be perfectly sure that the fix is in.
17:43The team now considers whether a frozen rudder caused Flight 821 to nosedive into the ground.
17:53They hunt through the maintenance records for any mention of the rudder.
17:57Wait, I've got a work order here.
18:01It's in 2005 for replacing the rudder PCU.
18:05The rudder PCU.
18:08It's in much.
18:10They took a look at the power control unit for the rudder
18:14and found that the aeroplane had the new system fitted
18:17and then the investigation moved on from there.
18:20With confirmation that the rudder's control unit was in fact replaced.
18:24Okay.
18:26Let's see if we can find some airline maintenance locks.
18:31Investigators now wonder if Aeroflot Nord,
18:35which leased the 737 only six months previously,
18:39kept up with its maintenance.
18:43Here.
18:44Suddenly, a new clue appears.
18:48A month before the crash,
18:50the right engine started producing 20% more thrust than the left.
18:56And that's enough to throw the engine balance way off.
18:59Investigators learned that during Flight 821
19:03the engines were producing asymmetrical thrust.
19:06When one engine is producing more power than the other,
19:12the aeroplane will rotate or yaw.
19:17An aircraft flying out of balance
19:20is sort of skidding sideways through the air.
19:24To balance right engine with the left,
19:27the thrust levers need to be staggered.
19:30Like this.
19:33That's a big split.
19:34Makes it very difficult to fly the aircraft
19:39and manipulate the throttles when they're split.
19:45Investigators discover that just the day before the crash,
19:49different pilots who flew the same plane
19:51were so concerned about the problem.
19:53They took photographs to show how far
19:56the thrust levers needed to be staggered.
19:59It's a crucial lead.
20:00A split in engine balance makes it more difficult to fly,
20:05but it shouldn't cause a crash.
20:07The autothrottle can correct it most of the time.
20:10But did these pilots know about the mismatch?
20:15Take a look.
20:17The crash day.
20:19And it's signed by now, Captain.
20:20Investigators now know there was a problem with the mismatched engines,
20:25and they know the pilots were aware of it.
20:28The question is,
20:30did they know how to fly the plane with imbalanced engines?
20:34The airline insists both pilots was very experienced.
20:37Still looking for leads in the case of Flight 821,
20:42the team shifts the focus to the pilots.
20:45Yet the controller said the crew seemed confused
20:49when he asked them to redo their approach.
20:50Captain had over 3,900 flying hours.
20:561,400 of these at night.
21:00That's not a ton, but it's enough.
21:03Wait.
21:05Two-thirds of his hours were in the cockpit of the Tupolev 134.
21:10The 2-134?
21:12Built in Russia,
21:14the Tupolev 134 was one of the most widely used jets
21:18in the former Soviet bloc.
21:20But it required twice as many crew members to fly them
21:24as a modern Western jet like a Boeing or Airbus.
21:28Russian aircraft were operated on a four-crew basis,
21:32and now you were asking the pilots to operate solely on their own,
21:38with no engineer, no navigator,
21:39demanding more skill and knowledge from the two pilots.
21:44The placement of the engines on the Tupolev is also different.
21:49The engines are close together at the rear of the plane.
21:54Mismatched engines require minimal adjustment
21:58since the thrust is all coming from the back.
22:01When you add power, the aeroplane just accelerates ahead.
22:06It doesn't pitch up, the nose doesn't come up.
22:09Flying the 737, it's very different from flying the Tupolev.
22:13A Boeing 737's engines are spaced apart, slung beneath the wings.
22:19With a mismatch in engine power, the stronger side pushes the wing up
22:24and requires the pilot's constant correction of control surfaces to maintain balance.
22:29The only way it can counteract an asymmetric thrust is to provide bank, a small amount of bank,
22:39in the opposite direction to try and maintain the aircraft's track.
22:43With this discovery, investigators now take a hard look at how much the pilots knew about flying the 737.
22:53The first officer had almost 9,000 flying hours.
22:57While investigators discovered that the first officer had 9,000 flying hours, the captain had much less, only 3,900 hours.
23:08Less than 1,200 of which were on the 737.
23:11That's low for a captain. We need to find out if his training made up for it.
23:19The captain had gone to Flight Training International in Denver, Colorado.
23:24Every pilot's training should be fully documented.
23:29But when Captain Medvedev's training records arrive, investigators are shocked.
23:43There's almost nothing here.
23:46All the paperwork surrounding that training had pretty much disappeared.
23:51It's a crucial development that changes the course of the investigation.
24:04Investigators delve into the training records for the captain of Flight 821.
24:09They need to know if he was properly trained to fly a 737.
24:14Especially one with mismatched engines.
24:21The captain's English language skills were limited.
24:24Which begs the question, how much training did he understand?
24:29All the technical manuals were written in English.
24:32And all their operating procedures were written in English.
24:34The interaction with the flight computers.
24:37So it really is quite a difficult task to get that level of understanding in a very short period of time.
24:43Medvedev got his training certification for the 737 on September 10th, 2006.
24:50But then went back to flying the Tupolev.
24:52He didn't get into the 737 again until January 9th, 2007.
25:03Investigators learned that Captain Medvedev did not do a refresher course before returning to the 737.
25:09He had a four-month break away from his knowledge and he had to have been forgetting things left and right.
25:18Hardly a proficient 737 pilot.
25:22Hardly.
25:24Investigators now know that Captain Medvedev's training on the Boeing 737 was woefully inadequate.
25:30The team knows first officer Al-Aberdin had much more flying experience than the captain.
25:43Okay, tomorrow we'll try the air. Take care.
25:45What they now need to find out is if the first officer was any better equipped to fly the 737.
25:51I am from IAC. I have a quick question for you.
25:56Investigators wonder how the first officer performed during his 737 training.
26:02He had plenty of experience on Antonov II.
26:06An Antonov II is a huge propeller biplane with a single engine designed mainly for agricultural and forestry purposes.
26:17Antonov II looks like Cessna. Very simple aircraft.
26:25They don't have equipment to fly in clouds or flight at night on Antonov II.
26:31All this is based on daytime and good weather condition experience.
26:36737 simulator proved to be a real challenge for him.
26:48Investigators learned that one thing the first officer especially struggled with was flying with thrust asymmetry.
26:55Check the speed-space. You are banking. Bank angle, bank angle.
27:08This is the third time. Bank angle.
27:10The team now knows first officer Al-Aberdin needed much more training for flying with unbalanced engines.
27:15engines the copilot his situation is even more dramatic than the captain's the instructor said
27:24that he cannot fly the asymmetrical thrust he wasn't ready even to be the copilot on this plane
27:30investigators are astonished by the extent of the first officer's shortcomings on the 737
27:42Medvedev was simply too green to captain the 737 we can't tell how much of the English training he
27:49even retained first officer had even more failings it was a mistake to put them together in the carpet
27:57the team determined that the airline should never have paired a new captain with such an unproven
28:06first officer but they still don't know if the crews lack of training and experience played any
28:14role in the crash specialists in France have finally extracted the data from the badly damaged flight
28:25recorder of Aeroflot Nord 821 okay now we can see what the plane was doing let's pull up the
28:34parameters up to now the investigators only know what the controller told them about 821's path
28:40leading up to the crash the recorded flight data will tell them much more they focus in on the engine
28:50thrust parameters the first few hours of data provide few clues as to the cause of the crash looks like
28:59the auto throttle is on the auto throttle controls the engines power setting automatically instead of the
29:06pilot controlling it manually it's staggering the thrust levers and matching the engines okay bring out the
29:16last three minutes of the flight isolate this section the whole hell broke loose the pitch and roll data
29:35paint a harrowing picture
29:46the investigation team continues to study the flight data to better understand what happened
30:07on board Aeroflot Nord flight 821 they have learned the first hour and a half of the flight was
30:15uneventful but when 821 starts the approach things go terribly wrong okay let's break this down
30:25the plane comes down to 6800 feet everything seems fine until this the right engine is operating at 61%
30:41but the left is near 40 as the plane banks deeply to the right the auto throttle can't handle such a large
30:51split in engine power so it disengages now the first officer has to manage the massive stagger in the thrust
31:02levers himself the thing he couldn't do in training that required a lot more flying skill you had to
31:12compensate for the fact that the engine power was mismatched or you had to very carefully move the
31:19throttles in a way that kept the power balanced and the crew wasn't very good at doing either one of those things
31:25what investigators discover next is even more puzzling
31:33the first officer now disengages the autopilot as the first officer begins the final bright turn towards
31:42the runway he performs a series of actions that disengage the autopilot he turns the yoke right pushes it forward and
31:53engages the stabilizer trim in sequence just like hitting the brakes when you're in cruise control this
32:01signals to the autopilot that the pilot wants to take manual control even if he doesn't in most instances
32:12an autopilot is somewhat difficult to disengage but this man managed to do that by accidentally trimming when
32:18he should not have the mismatched engines are now forcing the plane to bank left and climb when it
32:27should be turning right and descending take a look at that no one has an input for 20 25 seconds
32:42investigators are astounded to discover that even though the autopilot is now off neither pilot makes
32:51any changes to throttle to pitch or roll for a full 25 seconds what is this no one flying the plane if a
33:02pilot isn't aware that the autopilot is enough then he can get himself into a lot of trouble by by not
33:08noticing airspeed changes by not noticing subtle turns by not keeping track of his altitude the team now
33:22knows more of the technical details that contributed to flight 821's crash but why things spiraled out of
33:30control in the cockpit is still unknown finally investigators get the cockpit voice recorder that captured the
33:42last 30 minutes of flight they hope it will provide the answers they need are you guys ready let's hear now
33:54what's going on what's going on in that plane
33:59flaps 30 flaps 30 yeah do what you have to do come on
34:06set just do it on yourself okay hold it 504 a.m. the first officer has to call up the flaps twice before
34:19the captain even response why the captain commands his first officer to do it all himself
34:26it's essential that these two crew members work together the non-flying pilot would be operating the
34:37radio but monitoring the progress of the aircraft as well and monitoring the performance of the other
34:43pilot investigators compare the flight data with the cockpit voice recorder timeline here it's clear
34:51there's a problem with the thrust with the autothrottle disengaged the mismatched engines cause the plane to
34:57veer left the first officer notices the aircraft banking he now makes the series of inputs that forces the autopilot to
35:07disconnect this causes the aircraft to climb and continue banking left instead of descending to
35:16the right the first officer doesn't know why the banking he wants captain to take over
35:35he needs to bank right but he's banking left instead he's confused the captain is looking at the 737
36:04adi but confuses it with an eastern style adi like on the tupolev the adi or attitude director indicator is the
36:16instrument that displays an aircraft's orientation relative to the horizon and the western adi the
36:24airplane symbol remains fixed aligned with the actual airplane so as you bank the aircraft the horizon
36:33will tilt to show the same view as you would see if you looked out the window the adi in older planes from
36:41eastern block countries worked just the opposite the horizon is fixed and the airplane symbol moves
36:48it's a huge difference the captain didn't know which way he was really banking exactly and he made the bad situation worse
37:00bank angle bank angle the captain was suddenly given control of the aircraft i think he looked down and
37:08didn't realize the situation and started to bank it hard to the left the co-pilot said no no don't do that but it was too far gone
37:17he may have reverted back to interpreting the instruments he was used to when he was flying
37:31the tupolev or the antonov it was just a case of not being able to interpret the western adi
37:39but one last mystery remains why was the captain so unwilling to take charge until the last second
37:46what was his problem
37:52the team investigating the crash of flight 821 has determined that pilot error led to the tragic accident
37:59that killed 88 people
38:04the first officer couldn't handle the mismatched engines but the captain refused to take control of the situation
38:14take it take it take what i can't do it either the most shocking part for me it was a captain's
38:22reaction to pilot back him help me take it take it what pilot and command reaction take what what i can do
38:32with this how your pilot instruments in front of you in order to better understand the psychological state
38:42of the pilots investigators have analyzed the pitch of their voices they wonder if stress played a role in the
38:50crash the first officer was alert but didn't get distressed until the last few seconds let's take a look at the captain now
39:00the analysis reveals that the captain was at a high level of stress throughout the entire flight
39:08yet you know it tries to take control of the plane
39:10then investigators get a break in the case from the air accidents investigative branch in the united kingdom
39:26right before takeoff a passenger send a text to a friend she thought captain was wrong
39:33good evening ladies and gentlemen this is your captain speaking i'd like to welcome you on board
39:47their offload north flight eight nine one eight to one our flying time to perm will be 20 hours
39:56two hours and 30 minutes i'll talk to you again before we reach our destination until then sit back and
40:03enjoy the flight i think the captain sounds drunk investigators learned that just prior to takeoff a
40:11passenger sent a text to her friend in the united kingdom the passenger said she was scared because the
40:18captain sounded totally drunk let's cue the captain announcements investigators listen to the cvr once again
40:31but this time with a horrifying new perspective good evening good morning
40:42he's confused play it again good evening good morning this is your captain speaking we've begun our
40:52descent into palm and should have you on the ground in 20 hours after 20 minutes
40:58the local time is 4 50 pm am and the temperature is seven degrees i'd say he's drunk
41:15the recording substantiates the passenger's text but the investigators still need hard evidence
41:21finally finally the captain's muscle tissue has been tested for traces of alcohol
41:33the analysis confirms that there was alcohol in his system before the crash
41:43he was drunk they found that the commander had raised levels of alcohol which would have been in
41:51his body in his body before he took off those levels impaired his judgment and his ability to react
42:00accordingly in a stressful situation where the aircraft in effect was out of control
42:04the malfeasance
42:10the malfeasance
42:27neglect irresponsibility and incompetence that was demonstrated
42:31unilaterally in this it's just unbelievable
42:46the most shocking part of this entire
42:49event was the fact that an airline could allow itself to either evolve or maybe even devolve
42:56into such a multi-faceted situation how could they allow themselves to do this and it killed 88 people
43:09in its final report the investigative team recommends a complete overhaul of the russian aviation system
43:17the whole system needed to be looked at and strengthened in terms of the regulations
43:22and how they train russian pilots three years after the crash aeroflot sold aeroflot nord
43:32it now operates as a separate airline called nord davia
43:38aeroflot does have quite a good safety record and i assume that they're working on
43:44the situation and have done a a good job the accident rates way down over what it used to be
43:50so hopefully uh things are moving in the proper direction