Skip to playerSkip to main contentSkip to footer
babycarseattips
  • 5 days ago

Category

📺
TV
Transcript
00:00On approach to a remote town in Indonesia's Papua province, a turboprop plane vanishes.
00:17We tried to think positively that there's a chance the aircraft ended up landing at a different airport with limited communication.
00:24Overseas a search is underway for an Indonesian plane carrying more than 50 people.
00:31A treacherous climb up a steep mountain leads to the worst possible news.
00:37We'll reach the crash site. No survivors.
00:41The number one priority is to find the black boxes.
00:45With no clues, investigators hope the damaged black boxes will solve this puzzling case.
00:52Can you turn that up?
00:58That's it.
01:22Sentani Airport in Papua Province, Indonesia.
01:28Sentani Airport in Papua Province, Indonesia.
01:38Trigana Air Service pilots Captain Hasanuddin and First Officer Arya Din are on a short layover before their fifth flight of the day.
01:42What do we got, like 20 minutes?
01:44About that, yeah.
01:45I think I'll get up and stretch my legs.
01:46Want anything from the terminal?
01:47I'm okay, thanks.
01:48The pilots have already flown four short flights today in Papua.
01:50This leg will take them to a remote airport in the Oxybill area.
01:52The pilots have already flown four short flights today in Papua.
01:54This leg will take them to a remote airport in the Oxybill area.
01:56Typically, the flights of a commuter aircraft would be an hour or less.
02:01So, the typical duty day for a pilot might include four or more take-offs and landings.
02:02It's challenging in the sense of taking off and landing are the most difficult times.
02:03The pilots have already flown four short flights today in Papua.
02:08The pilots have already flown four short flights today in Papua.
02:13This leg will take them to a remote airport in the Oxybill area.
02:17It's challenging in the sense of taking off and landing are the most risky parts of any aircraft flight.
02:33And doing so several times in a day could put different kinds of stresses on a pilot.
02:38Hello?
02:39Flight attendant Dita Amelia Cuniawan
02:43Good afternoon.
02:44Has been with Trigana Air Service for three years and knows many of the regulars who fly this route.
02:51Good to see you again.
02:5649 passengers will be making the short trip to Oxybill.
03:07Oxybill is a very remote area.
03:09So, most of the passengers would be local government officials, local businessmen.
03:15Very few tourists go to Oxybill.
03:18Do you want to stretch on the way back?
03:28No, I'm good for one more leg.
03:34All set, back there Dito.
03:35Good to go.
03:36Thank you Dito.
03:37Thank you Dito.
03:45At 2.22pm, flight 267 takes off.
03:53Landing gear up.
03:57Landing gear is up.
03:58Flap set to zero.
04:03Flap zero.
04:04The flight to Oxybill takes 40 minutes.
04:07The estimated arrival time is 3.04pm.
04:11We're at 2,000 feet.
04:12Want to turn on the autopilot?
04:13Autopilot engaged.
04:15We're at 2,000 feet.
04:16Want to turn on the autopilot?
04:21Autopilot engaged.
04:25The pilots are flying an ATR-42-300, a twin turboprop short-haul aircraft.
04:31The ATR-42 is a medium capacity commuter type aircraft.
04:37They're popular because they can get into smaller airports.
04:41Places where you can't really get an airplane that's a 737 or 747 size into and out of the airport.
04:53Minutes later, the plane reaches its cruising altitude of 11,500 feet.
04:58Water.
04:59The flight is so short.
05:00We'll call Oxybill.
05:01We'll call Oxybill.
05:02The captain is already preparing for the descent into Oxybill.
05:03Oxybill, Trogana 267.
05:04We'll call Oxybill.
05:05Oxybill, Trogana 267.
05:06Trogana 267, Oxybill copy.
05:07We are beginning our approach to the descent from 11,500 feet.
05:10Confirmed descent from 11,500 feet.
05:11Let me know when you are positioned over Oxybill.
05:12Oxybill is a small airport situated in a valley.
05:18Oxybil, Trigana 267.
05:20Trigana 267, Oxybil, copy.
05:23We are beginning our approach to elected descent from 11,500 feet.
05:28Confirmed descent from 11,500.
05:30Let me know when you are positioned over Oxybil.
05:34Oxybil is a small airport situated in a valley.
05:39The mountains surrounding it can reach 11,000 feet.
05:43Decreasing engine thrust.
05:52244 knots and dropping.
05:55Oxlable Airport is in a mountainous area.
05:58It sits in a valley.
06:00And on top of that, they have very limited navigational aids at that airport.
06:05Without the aid of advanced landing systems seen at bigger airports,
06:09pilots flying into Oxybil must keep the runway in sight during the approach.
06:19A visual approach, as the name implies,
06:22is an approach where the flight crew has to have the airport and the surrounding area in sight.
06:30Cabin crew, prepare for landing.
06:32In preparation, please straighten your seat back and store your tray.
06:38I'll be coming around to collect any garbage you may have.
06:46Big plans for the family?
06:48Yeah, looking forward to some time off.
06:51Yes, it's been very busy these past few weeks.
06:53Lab 16.
07:13Lab 16.
07:16Lab 16.
07:19Gear down.
07:49Confirm descent from 12,000.
07:51Report when you are positioned over Oxyville.
07:54Five minutes later, the air traffic controller at Oxyville
07:59realizes Flight 267 hasn't reported in as expected.
08:04Trigana 267, Oxyville, do you copy?
08:09Trigana 267, Oxyville, do you copy?
08:12One of the common things that happens
08:19when an airplane doesn't land at an airport for some reason
08:23is they may divert to another airfield.
08:25The crew landing the aircraft may have been too busy
08:28to call the airport before diverting to another airfield.
08:32Hey, this is Oxyville.
08:33We've lost contact with Flight 267.
08:35Have you heard from the pilots?
08:40You haven't?
08:43We might have a problem here.
08:49Word of the missing plane travels fast.
08:53Overseas, a search is underway for an Indonesian plane
08:56carrying more than 50 people.
08:57The flight lost contact today over a remote area of the country.
09:03As the news spreads,
09:05investigators with Indonesia's National Transportation Safety Committee,
09:09the KNKT, fear the worst.
09:12My first impression was
09:15that something wrong had happened.
09:19Not looking good.
09:23Well, maybe they just diverted and haven't checked in yet.
09:25We tried to keep thinking positively that there's a chance the aircraft suffered from some damage
09:32and ended up landing at a different airport with limited communication.
09:36A search and rescue team is assembled consisting of army soldiers and search and rescue personnel.
09:43They immediately began the search around Oxyville Airport
09:51because we learned from air traffic control
09:54that its last location was quite close to the airport.
10:01Flight 267 was only 15 miles from Oxyville Airport
10:05when it last checked in with air traffic control.
10:07But search efforts come up empty
10:11until a pilot flying out of Oxyville Airport
10:16spots smoke billowing from nearby Tango Mountain.
10:20We don't have a lot of information.
10:25We can only hope that the people on board have survived.
10:30The day after, a pilot reports seeing smoke in the mountains surrounding Oxyville, Indonesia.
10:46The crash site of Tragana Flight 267
10:51is located.
11:02Yeah.
11:05140 degrees, 29 minutes.
11:0951.18 seconds east.
11:13Okay, got it. Thank you.
11:16The wreckage is at approximately 8,300 feet
11:20on a ridge of Tango Mountain,
11:2310 nautical miles from Oxyville Airport.
11:30They went off course.
11:32How do they end up over there?
11:34We need to get eyes on that crash site.
11:38I'm going to send one of our guys up.
11:39Okay.
11:46A search and rescue team takes a KNKT investigator to the crash site.
11:58At over 4,000 feet above ground level,
12:01there are no roads, runways, or clearings.
12:05The only way to get to the crash site is on foot.
12:11To reach the area, the team had to walk for about four and five hours.
12:18They have to climb, and it's quite steep,
12:21with the dense vegetation.
12:24It's quite hard to get to the site.
12:30After climbing for five hours,
12:32the team finally reaches the crash site.
12:42A field of debris stretches through Tango's thick forest.
13:11PHONE RINGS
13:13PHONE RINGS
13:14Go ahead, Oxabel.
13:16Jakarta, we'll reach the crash site.
13:19No survivors.
13:23Okay.
13:25Once you catch your breath, the number one priority is to find the black boxes.
13:29Okay.
13:34Hey, guys.
13:36Check it out.
13:40We're looking for the FDR and the CVR.
13:44Because of the remote location,
13:48bringing much of the wreckage down from the mountain will be impossible.
13:52So the investigator at the scene must document as much as he can
13:57and send photos back to headquarters.
14:07While the search and rescue team retrieves the remains of the 54 people that died,
14:13the KNKT investigator tries to determine exactly how the plane hit the mountain.
14:23The trees surrounding the crash site provide an important clue.
14:27They are sheared off in a straight line, indicating the plane flew head-on into the mountain.
14:37That's right. There's no sign they pulled up.
14:41How could the crew have flown straight into a mountain that's so well known to pilots?
14:51The investigation team's top priority will be to figure out what was happening in the cockpit at the time of the crash.
14:57The plane's flight data recorder and cockpit voice recorder can be invaluable tools for the investigation.
15:13The damaged black boxes are shipped out for analysis.
15:31In the days that follow,
15:47family members mourn while they wait for the recovery of loved ones.
15:57Search and rescue, along with the local help,
16:02have been successful in retrieving the 54 bodies.
16:05They are desperate to know what caused the crash that killed everyone on the flight.
16:16It's up to KNKT investigators to figure that out.
16:20They first need to determine why the plane ended up off course.
16:24Blue's the flight path in the approach chart.
16:27In the approach chart.
16:30Here's where they crashed.
16:34Flight 267 crashed about 10 miles west of the approach path into Oxybil Airport.
16:42They went right
16:45and ended up here.
16:47I'd like to know more about the terrain around here.
16:49To determine the height of the terrain along the flight's path,
16:55investigators use special software that generates topographical data for the area.
17:04When we learned about the location of the crash,
17:08we had some difficulties.
17:10We realized it would be a challenge for us to identify the terrain height of the plane's debris.
17:15The topographical map reveals that the pilots were flying a treacherous route.
17:30They were surrounded by mountains as high as 9,000 feet.
17:36Why didn't they fly above them?
17:39Investigators wonder if there was a mechanical problem with the plane's debris.
17:44that caused it to plow into a mountain.
17:48Maybe the FDA can tell us.
17:52Certainly, there would have been something in the flight data recorder
17:56that may have given an indication that some system on the aircraft
18:00wasn't operating as it should have.
18:02When the recovered flight data arrives,
18:06Nakayo and Wobowo are eager to get their first look
18:09at how the plane was functioning at the time of the crash.
18:12Wait a minute.
18:16This doesn't make any sense.
18:21It says the plane was going east, not south.
18:26We were able to download this data that contained all the flight information.
18:38But the flight data we recovered didn't correlate with what might have happened on the day of the crash.
18:44And the time of day is wrong.
18:48So was the speed.
18:50The flight data was not from the day of the accident.
18:54Digging even deeper into the data,
18:59the investigators come to a disturbing realization.
19:02The recorder wasn't working at the time of the crash.
19:07Useless.
19:09We found that the FDR had been experiencing several problems since 2012.
19:16It has been installed to an aircraft and found fault and then offloaded,
19:22went to the shop for repair, back again to the aircraft.
19:26The malfunctioning FDR had no connection to the accident,
19:32making it much harder for Nakayo and Wobowo to figure out what caused it.
19:38Investigators still don't know why flight 267
19:42slammed into the side of a mountain.
19:45In the Indonesian province of Papua,
19:52the families of the 54 people on board Trigana Flight 267
19:57lay their loved ones to rest.
20:02Including flight attendant Dita Amelia Kuniawan.
20:06Overcome by grief, they want answers as to what happened.
20:16Authorities have released new pictures showing the wreckage
20:19from the Indonesian passenger plane that crashed in the country's
20:22remote eastern region over the weekend.
20:27KNKT investigators are facing intense pressure
20:30to determine why flight 267 crashed.
20:32Without recorded flight data,
20:37the plane's cockpit voice recorder is investigators' last hope
20:42to learn what was happening in the air at the time of the crash.
20:46They would be able to understand what was said to and from air traffic control,
20:51and they can also understand any kind of communication,
20:54formal or informal, that was taking place within the cockpit.
20:57That can be a huge indicator of something going wrong with that flight.
21:03Fortunately, the CVR data is successfully recovered.
21:08All right, we're ready?
21:10Okay, play it.
21:12The CVR contains two hours of audio,
21:16including from the two flights prior to the accident flight.
21:19I'll call down and let them know we're coming.
21:23Investigators first listen to the pilot's flight into Oxbyl
21:28from earlier in the day in the hopes of finding clues.
21:32Oxbyl, Trigana 267.
21:35Trigana 267, Oxbyl, copy.
21:37We're beginning our approach.
21:40We'd like to descend from 11,500 feet.
21:43Confirmed descent from 11,500.
21:46Let me know when you are positioned over Oxbyl.
21:48Uh, Oxbyl?
21:50We won't be over the airport.
21:52We're going to fly direct to our left base leg to runway 11.
21:55Copy that.
21:57Left base leg?
21:59That's not what it says in the charts.
22:01They took a shortcut?
22:02The CVR reveals that the pilots made an intentional deviation in their approach
22:07during their prior flight into Oxbyl.
22:11The official approach directs aircraft to fly over the airport
22:16and then circle back and land.
22:21But on the earlier flight, the pilots flew directly to runway 11
22:27without looping around.
22:32500 feet, landing flaps and propeller speed are set and confirmed.
22:45After flying the shorter approach,
22:48the pilots landed on the runway at Oxbyl
22:52without incident.
22:54Investigators wonder if the pilots tried to repeat that shorter approach a few hours later,
23:04but with a very different result.
23:07Let's skip ahead to the accident flight.
23:09We're at 2,000 feet.
23:12Want to turn on the autopilot?
23:15Autopilot engaged.
23:20Confirmed descent from 11,500.
23:22Let me know when you are positioned over Oxbyl.
23:25Oxbyl, we're flying direct to our left base leg to runway 11.
23:29Copy that.
23:31So they take the same shortcut for the accident flight.
23:34The last flight proceeds much like the crew's earlier flight into Oxbyl.
23:39Big plans with the family?
23:42Investigators listen closely for any signs of danger.
23:46Yeah, looking forward to some time off.
23:49Been very busy this past week.
23:52It's what they don't hear that raises questions.
23:56They're not doing their approach briefing and checklist.
24:00Briefings and checklists serve several functions.
24:03One of the key functions is to give the flight crew a better understanding of their environment.
24:08Not doing that makes it less likely that the pilot will remember to do certain things,
24:14or to take certain precautions, or to be aware of certain hazards that could be happening on that particular flight.
24:22The team now knows that the crew missed a crucial step on their approach.
24:28But can the recording reveal anything about how the plane was functioning mechanically just before the crash?
24:35Can you turn that up?
24:36Picking up anything with the engines?
24:46We tried to analyze the sound of the engine.
24:50Glass 15, gear down.
24:55Based on the frequency and amplitude of the sound of the propeller,
25:00we concluded that the engine and propeller were both in good shape.
25:04Nothing unusual.
25:05On the last phase of the flight, the CVR recorded that the condition in the cockpit was normal.
25:25While listening to the final moments of the crash, investigators make a baffling discovery.
25:30That's it?
25:31Normally, at the last second of the flight, the pilot would have been scream or do something.
25:46It happened so fast.
25:51Sounds like they didn't even see the mountain.
25:52Investigators have a theory about the crash of Trigana Flight 267.
25:54Transcription by CastingWords
26:24Transcription by CastingWords
26:54Transcription by CastingWords
27:24Transcription by CastingWords
27:54Transcription by CastingWords
28:23The visual approach is not allowed to be done in a cloudy condition.
28:28So when they're in a cloudy condition and they're unable to see the whole mountain,
28:33they should follow the procedures.
28:38But instead of following procedure...
28:43They knew the base of the clouds was 8,000 feet.
28:49They took a gamble that they would eventually catch sight of the runway.
28:53They were descending, expecting to drop out of the clouds at any minute.
29:01Instead, they crashed into a mountain at 8,300 feet.
29:23We still don't know why they didn't know they were in the path of a mountain.
29:31With modern aviation technology, even if the pilots didn't see the mountain, the plane should have.
29:37So why didn't they know they were heading straight into one?
29:43We need to check their warning system.
29:45When a plane is in close proximity to terrain, or about to hit an object,
29:55there's a warning system that warns the pilot when the plane is very close to terrain.
30:02The warning system uses GPS and a terrain database to monitor an aircraft's height above the surrounding terrain.
30:16If the plane comes too close to the ground, the system will warn the flight crew with audio messages.
30:22Terrain, terrain, terrain, pull up.
30:26So pilots know to increase their altitude.
30:29This is the profile of the mountain.
30:31This is our flight, descending through clouds, and the pilots can't see the ridge in front of them.
30:40Their proximity to the terrain would have activated the terrain caution here 60 seconds before impact.
30:50Now the pull-up warning should have gone off here 30 seconds before.
30:57Were there any warnings going off in the cockpit?
31:03No, there's nothing in the transcript.
31:07The absence of audible alerts leads investigators to wonder if the plane's warning system was working properly.
31:16The team knows the FDR wasn't properly maintained.
31:20Could the same be true for the warning system?
31:22We tried to dig deeper to see if the warning system had been properly installed in Tregona 267.
31:32Last maintenance was performed on August 14, two days before the crash.
31:39It appeared to be working normally.
31:40When we looked into the maintenance record, we did not find any significant mention of something broken in the warning system.
31:53With a faulty warning system ruled out, investigators now wonder if the terrain data used by the system was accurate.
32:07This area is not very well mapped.
32:12Some of the Papua area was very rough data.
32:17The precision of the data was not as close to the actual conditions.
32:24If you fly in a mountainous area, the database itself might not detect the fine details of the contour of the terrain around you.
32:35Did the lack of accurate terrain data mean the system wasn't able to warn pilots when they were too close to the mountainous terrain?
32:42The Tregona 267 investigators decide to speak with Tregona pilots who regularly fly in the Oxybil area to find out if they received terrain warnings.
32:57The pilots report that not only did the system provide warnings, it gave an excessive amount of false warnings due to the poor quality data.
33:06If you're flying within a mountainous area, it can give you false warning or unnecessary warnings.
33:13Was this area prone to false alarms?
33:16Imagine you are trying to land in a small airport in the middle of the valley.
33:21You can see the airport in front of you, you're in visual conditions, and then the system starts giving a warning.
33:27Terrain, terrain, pull up.
33:29You think, well, I can see the airport in front of me, I can see the terrain behind it.
33:32That warning is annoying.
33:37And what do you normally do when you keep getting these false warnings?
33:42Hold on.
33:44He says sometimes they deliberately pull the circuit breaker.
33:50Sorry, go on.
33:52It's an astonishing finding.
33:54It might have been because of spurious or inappropriate warnings by the system.
33:58That is, it's telling you that you're close to the ground when in fact you're not.
34:03This is what I like to call the boy who cried wolf syndrome.
34:07Terrain, terrain, pull up.
34:09You know, the other flights we've done, we've had no problem.
34:12Let's just turn this thing off.
34:14Terrain.
34:15Terrain.
34:17But if you pull the circuit breaker, you might forget that you've pulled it.
34:21And that's not good because if you're going into a valley when it's still cloudy, you still need your systems no matter how unreliable that is.
34:29Any warning you get if you don't have visual contact with the ground, you follow it.
34:35Okay, thank you.
34:39They just pulled the breaker to get rid of the false warnings.
34:44Apparently it's common practice.
34:47Are you kidding me?
34:48This revelation leads investigators to ask themselves a difficult question.
34:55Did flight 267 lack terrain warnings?
35:01Because the pilots intentionally turned the system off.
35:05Both the captain and the first officer were very experienced.
35:09In fact, I think these pilots are much more experienced than the average turboprop pilot.
35:18We reached cruising altitude to 11,500.
35:23Is it possible the pilots were overconfident because they had flown this route so often?
35:28We also asking questions to some pilots, particularly pilots that had experience flying with these two accident pilots.
35:44Will you excuse me?
35:47I now have a pilot on the line that says he's personally seen Captain Hasenun pulling the circuit breaker.
35:52We found some information that some co-pilots flying with the captain knew that the captain had the habit to inactivate the system.
36:07Decreasing engine thrust.
36:11Hooray! Hooray! Pull up!
36:13Hooray! Hooray!
36:16Overconfidence and complacency are two of the issues that are common in aviation.
36:19And what it leads to is certain equipment could be turned off because the pilots think that their experience in other aspects of flight will more than compensate.
36:29Hooray! Hooray!
36:31Yeah, yeah, yeah.
36:33When a flight crew operates deliberately with an aircraft that's not fully capable, they're increasing the risk of that flight.
36:40Looking through the captain's records, investigators discover that the airline knew about his habit of pulling the circuit breaker.
36:56Hmm.
36:57It says here the base scheduled the briefing with him to address it.
37:03Based on this information, we assume that that day, on the accident day, the captain also inactivate the system.
37:13Terrain, terrain, terrain, pull up!
37:18Terrain, terrain, pull up!
37:20Terrain, terrain, pull up!
37:22Investigators now believe that the pilots intentionally disabled their warning system on an earlier flight that day.
37:31And then never reset it.
37:34If the system was active, I'm sure that the accident would have been avoided.
37:39Because the last seconds of the flight before the impact, the system will scream, pull up, pull up.
37:47The pilot would have to take action to save the flight.
38:03No wreckage relating to the warning system is recovered from the crash site.
38:08Investigators can't know for sure if the circuit breaker had been pulled.
38:14But even if the pilots were overly confident they could make the approach without the aid of the warning system,
38:23there's still something else that doesn't add up.
38:27The pilots flew into this area all the time.
38:30Why were they flying so close to the mountains in the first place?
38:35Investigators are trying to determine why pilots who were very familiar with the Oxybil area would risk flying so close to the mountains below them.
38:49Can you pull up this approach chart?
38:50A diagram in the corner of the approach chart informs pilots about the safe minimum altitudes in areas surrounding the approach path.
39:12The approach chart says the minimum safe altitude in this area is 8,000 feet.
39:19Flight 267 crashed at 8,300 feet.
39:22They were adhering strictly to the information that was there in the approach chart, but the information was wrong.
39:31And that wrong information put them at risk for colliding with terrain.
39:34We're good to 8,000 feet.
39:44Investigators believe the pilots were aware of the minimum safe altitude published on the approach chart.
39:51It's the last piece of the puzzle.
39:54The crew thinks they're safe down to 8,000 feet.
40:07And on the accident day, the base of the clouds is 8,000 feet.
40:14It makes the pilots feel as long as they're in the clouds, they're safe.
40:17Decreasing engine thrusts.
40:27244 knots and dropping.
40:32Cabin crew prepare for landing.
40:36What struck me more than anything was that this was so very preventable.
40:40This was a controlled flight into terrain event.
40:42The investigation has uncovered a confluence of factors that led to the crash of flight 267.
40:51Big plans for the family?
40:53Yeah.
40:54Looking forward to some time off.
40:56It's been very busy these past few weeks.
40:59At the core, two pilots who had grown overconfident flying the route so many times before.
41:06terrain, terrain. Pull up terrain, terrain. Pull up terrain, terrain. Pull up terrain, terrain. Pull up terrain, terrain. Pull up terrain, terrain. Pull up terrain, terrain.
41:20Because the captain had a reputation for pulling the ground proximity warning system's circuit breaker.
41:26Investigators suspect he disabled the system on an earlier flight that day.
41:30day then on the last flight into oxy bill we're beginning our approach would
41:42like the descent from eleven thousand five hundred feet
41:47five hundred let me know when you are positioned or rock here down
41:53the pilots failed to do their approach briefing or safety checks and relied on faulty approach
42:02charts there are three key things that could have avoided this accident adherence to standardized
42:09procedures the use of warning systems and the use of cockpit resource management techniques
42:15which could be as simple as is there a checklist that should be used
42:23three very clear areas where any one of them would have prevented this accident none of them
42:45happened in the aftermath of flight 267 the KNKT makes a series of safety recommendations that
42:52will make the skies of Indonesia safer first of all the charts need needed to be updated it that's
43:01coming we also asked the airline operator to request the database for the warning system to be updated
43:08with a more accurate version up to now we noticed a significant drop in warning system violations
43:19also since the approach chart for oxy bill has been fixed we've seen a positive impact in terms of flight
43:29safety in Papua the lessons from this accident the insights from the investigation won't go away
43:41they'll be here decades from now I'm confident that the insights from this report will influence design of
43:49equipment will influence the design of procedures will influence the kind of hazards that flight crews will look out for in the future
43:56in the future