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  • 6/20/2025

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00:00The landing is the most dangerous part of any flight.
00:06Have you seen the runway?
00:07No.
00:09Both pilots did not adhere to standard operating procedures.
00:12It was hazardous behavior.
00:19Investigations confirm that when pilots ignore the rule book
00:26the consequences can be deadly.
00:31Why would they do this?
00:36I have ground contact. We're continuing on.
00:39Free flights end in tragedy.
00:41Instinct can let the pilot down.
00:44When flight crews improvise on final approach.
01:00Up.
01:0113102 Avenue.
01:03I'm on my side.
01:04I'm on my side.
01:05I'm on my side.
01:06I'm on my side.
01:07I'm on my side.
01:08Crossair flight 3597 cruises at 27,000 feet en route from Berlin to Zurich.
01:23Captain Hans Ulrich Lutz is in command.
01:29He's been with the airline for more than 22 years.
01:32So, tell me about the runway and the conditions.
01:36Uh, overcast with light snowfall.
01:39Visibility 3,000 meters.
01:40First officer Stefan Lehrer is a newcomer to the airline.
01:44He's had a pilot's license for only a year and a half.
01:48There are 28 passengers on board the Avro 146 airliner.
01:53It's due to land in less than half an hour.
01:55According to the latest information, we'll be using runway 14.
02:00What kind of approach?
02:02Uh, ILS approach.
02:04Okay.
02:06An ILS, or instrument landing system approach, employs radio signals beamed from the airport to guide pilots to the runway.
02:17In Zurich, it's now snowing. Visibility is deteriorating.
02:22Zurich approach. Crossair 3597.
02:26Please confirm the approach in use is the ILS 14.
02:30Crossair 3597. You're identified.
02:33It will be a VOR DME. Approach runway 28.
02:38Oh, hell. What next?
02:41The captain is annoyed because the landing plan has changed.
02:44Damn.
02:46To reduce noise over neighboring towns, runway 14 shuts down at 10pm.
02:52But the alternate runway, runway 28, is not equipped for ILS landings.
02:58It employs a less accurate navigational system that makes landing more complicated.
03:04A VHF radio beacon sends information to the aircraft about its distance from the runway
03:11and whether it's left or right of it.
03:14But it provides no guidance on the plane's altitude.
03:17He would always prefer an ILS approach because he gets guidance on the approach slope.
03:27Nearing Zurich, the plane enters dense cloud.
03:31Flaps 3-3.
03:35Flaps 3-3 selected.
03:40Do we have ground contact?
03:41Yes.
03:42With the ground now visible, the captain expects to see the runway within seconds.
03:55Crossair 3597 cleared to land runway 28.
03:58Runway 28.
04:032-4, the minimum.
04:052-4.
04:06The flight has hit decision height, 2400 feet above sea level.
04:11Decision height is the minimum height you can descend before you need to see the runway and continue the approach visually.
04:18or you have to make a decision to go around.
04:24I have ground contact, we're continuing on.
04:30500.
04:32They continue descending.
04:34300.
04:35But they still can't see the runway.
04:38Think go around?
04:41Go around!
04:42Go around!
04:43Go around!
04:44Go around!
05:06Crossair 3597.
05:07This is Zurich Tower.
05:08Do you copy?
05:09We have a possible emergency in Approach Sector East.
05:10I repeat, Approach Sector East.
05:12Crossair Flight 3597 has crashed northeast of Zurich, near the village of Basserdorf.
05:30Over here!
05:3224 of the 33 people on board are dead.
05:35Including Captain Lutz and First Officer Stefan Lehrer.
05:41A team from Switzerland's Aircraft Accident Investigation Bureau arrives at the crash site.
05:494 kilometers and 50 meters from the runway.
05:52The location of the wreckage so far from the airport raises their interest.
05:56The aircraft was not where he was intended to be.
05:59He collided with a hill east of runway 28, so obviously he was too low.
06:05And the first question was, why was this aircraft too low?
06:11Investigators wonder if the crew received proper guidance during the descent to Zurich Airport.
06:17Crossair 3597, continue speed reduction to final approach speed.
06:24I was covering the Approach West position on the night of the accident.
06:26Could the air traffic controller have misdirected the plane?
06:31She was relatively young, and let's say she didn't have that much experience.
06:36The team scrutinizes control tower transcripts.
06:42They find no indication that the controller gave the crew flawed instructions.
06:46Focus turns to the captain.
06:51Gear down.
06:53He has the final say on any landing.
06:55The pilot can always say no.
06:58He can always reject the clearance.
07:00If he thinks that landing is probably not possible,
07:04he is free to reject an Approach Clearance and ask for a different one.
07:07With reduced visibility at Zurich, the team questions why the captain didn't ask to come in on the original Approach to Runway 14.
07:18Approach course.
07:20He could have made an instrument guided or ILS Approach.
07:23It would have been much easier to fly ALIS Approach in this kind of weather.
07:28A pilot experimenter.
07:31For an experienced pilot, this was a really basic mistake.
07:34Basic.
07:36178 in court.
07:38Investigators hope they'll find answers in the cockpit voice recording.
07:42Six miles is checked.
07:44100 above.
07:46Final moments before the accident.
07:49I have ground contact.
07:50We're continuing on.
07:52The crew sounds confident that the runway will soon come into view.
07:58But they crashed two and a half miles short of their destination.
08:04300.
08:06300.
08:08The team wonders if the plane's distance measuring equipment, or DME, was malfunctioning.
08:14The DME is supposed to indicate a plane's distance from the airport.
08:20Six miles is checked.
08:22Yes.
08:24Investigators compare the time Lutz checked his distance with radar data showing the aircraft's location.
08:30They confirm his reading was accurate.
08:33So, we knew that the pilots had an indication for the distance available at that time.
08:39But if his distance instrument was functioning...
08:46Why did Flight 3597 come down short of the airport?
08:55Investigators find a clue in the CVR transcripts.
08:58I don't see anything after six miles.
09:02Do we have ground contact?
09:05They discover that neither pilot checked their distance after the six-mile reading.
09:10Yes.
09:12Captain Lutz wasn't monitoring the vital instrument during the final minutes of his approach.
09:17Instead, he was preoccupied with looking for the lights of the runway.
09:20The pilot flying is supposed to keep his eyes on the instruments because all the information he needs is there.
09:30He only switches to flying by sight when the non-flying pilot says,
09:35runway in sight.
09:37If Lutz had checked his instruments, he would have known how far from the runway he actually was.
09:43Ignoring his instruments and without a visual fix on the runway, Captain Lutz began his descent to Zurich airport.
09:54It's alarming behavior.
09:56But investigators know there was a safeguard that could have prevented the disaster.
09:592-4 at the minimum.
10:042-4.
10:06Aircraft making non-precision approaches into Zurich are supposed to level off and stay at 2,400 feet until they have the runway in sight.
10:20But the recovered flight data recorder reveals Captain Lutz sped right through 2,400 feet.
10:39I have ground contact. We're continuing on.
10:42He claimed to have the ground in sight, but could he see the runway?
10:50No. He couldn't see the runway because there was a hill between him and the runway.
10:56And at that altitude, there's no way he could see it.
11:01The conclusion, Captain Lutz clearly ignored the minimum descent altitude and then slammed into a hill.
11:08Whether there is flat terrain or hills, minimums are set accordingly.
11:14And in no way you can just pass the minimums, whether there's hills or not.
11:172-4 at the minimum.
11:262-4.
11:28The pilot was improvising.
11:29We're continuing on.
11:31In the midst of a difficult landing.
11:33Investigators want to know why.
11:38Investigators dig into Captain Hans Ulrich Lutz's flying record.
11:43Years of flying and flying hours don't say anything about competence.
11:57The record reveals he repeatedly failed exams regarding navigational systems.
12:01I personally do pilot assessments and he would never have gone through my assessment with a positive recommendation.
12:11Hell, what next?
12:15Captain Lutz broke from procedure while landing on November the 24th, 2001.
12:19I have ground contact, we're continuing on.
12:25That cost 24 people their lives.
12:28Instinct can let the pilot down.
12:40He shouldn't have to work on instinct.
12:42It should be thought through, considered safety action based on design, experience and policies and procedures.
12:53Landing procedures are designed to minimize danger.
12:57So when pilots improvise, they put everyone on board at risk.
13:01Trigana Air Service Flight 267 takes off on an afternoon flight from Sentani Airport in Papua Province, Indonesia.
13:10Landing gear up.
13:11Landing gear up.
13:13Landing gear is up.
13:15Captain Hassan Udin and First Officer Arya Din are at the controls of the ATR-42 aircraft.
13:2449 passengers are on board.
13:29The 40-minute flight will take them from Sentani to a remote airport at Oxybil.
13:37Water?
13:42The trip is so short.
13:46We'll call Oxybil.
13:48The captain is already preparing for the descent to their destination.
13:52Oxybil, Trigana 267.
13:54Trigana 267, Oxybil, copy.
13:56We are beginning our approach for elected descent from 11,500 feet.
14:01Confirmed descent from 11,500.
14:04Let me know when you are positioned over Oxybil.
14:07Oxybil is a small airport situated in a valley.
14:11The mountains surrounding it reach as high as 11,000 feet.
14:15It lacks the advanced landing systems available at bigger airports.
14:19Pilots must keep the runway in sight during approach.
14:23Cabin crew, prepare for landing.
14:29In preparation, please straighten your seat back and store your tray.
14:34I'll be coming around to collect any garbage you may have.
14:36Typically, the flights of a commuter aircraft would be an hour or less.
14:39So the typical duty day for a pilot might include four or more takeoffs and landings.
14:45Flap 15.
14:47It's challenging in the sense of taking off and landing are the most risky parts of any aircraft flight.
14:52Just before 3pm, the plane begins its final descent.
15:07Five minutes later, the air traffic controller at Oxybil realizes flight 267 is not reporting from the next location.
15:21Trigonna 267, Oxybil, do you copy?
15:27Trigonna 267, Oxybil, do you copy?
15:35One of the common things that happens when an airplane doesn't land at an airport for some reason is they may divert to another airfield.
15:43Hey, this is Oxybil. We've lost contact with flight 267.
15:47Have you heard from the pilots?
15:52You haven't?
15:54We might have a problem here.
15:59News of the plane's disappearance quickly spreads.
16:02A team of investigators from Indonesia's National Transportation Committee, the KNKT, monitors the situation.
16:10My first impression was that something wrong had happened.
16:17Not looking good.
16:21The following day, a search plane flying out of Oxybil Airport sees smoke billowing from nearby Tango Mountain.
16:28It's the wreckage of flight 267, 10 miles northwest of Oxybil Airport, and off course from where it was supposed to be.
16:39How do they end up over there?
16:42Two days after flight 267 disappeared from radar, a search team finds the wreckage, 8,300 feet up the rugged Tango Mountain.
16:56Go ahead, Oxybil.
17:02Jakarta, we'll reach the crash site. No survivors.
17:07Okay. Once you catch your breath, the number one priority is to find the black boxes.
17:15Okay.
17:17KNKT investigators need to find out why flight 267 slammed into a mountain 10 miles west of the usual approach path.
17:24Blue's the flight path in the approach chart. Here's where they crashed.
17:31I'd like to know more about the terrain around here.
17:34The team uses special software to generate a topographical map for the area.
17:40It shows the pilots were flying a treacherous route.
17:46They were surrounded by mountains as high as 9,000 feet.
17:50Why didn't they fly above them?
17:53Investigators hope flight 267's black boxes recovered from the crash site will provide answers.
18:04Certainly there would have been something in the flight data recorder that may have given an indication that some system on the aircraft wasn't operating as it should have.
18:13But when they try to retrieve the data, they discover the recorder wasn't working at the time of the crash.
18:23Useless.
18:26That leaves the cockpit voice recorder as the team's next hope to piece together the events leading up to the crash.
18:35The recording contains two hours of audio and includes two previous trips they made.
18:48I'll call down and let them know we're coming.
18:51Investigators listen to an earlier descent into Oxville.
18:57Confirmed descent from 11,500. Let me know when you are positioned over Oxville.
19:02Uh, Oxville.
19:04We won't be over the airport. We're going to fly direct to our left base leg to runway 11.
19:09Copy that.
19:11Left base leg. That's not what it says in the charts.
19:14They took a shortcut?
19:15The official approach directs aircraft to fly over the airport and then circle back and land.
19:25But on this earlier flight, the pilots flew directly to runway 11 without looping around.
19:36Did the pilots repeat that shortcut just before they crashed?
19:40Let's skip ahead to the accident flight.
19:43Confirmed descent from 11,500. Let me know when you are positioned over Oxville.
19:49Oxville, we're flying direct to a left base leg to runway 11.
19:55Copy that.
19:57So they take the same shortcut for the accident flight?
20:03They plan for the family?
20:05Investigators listen closely for any signs of potential danger.
20:09Yeah, looking forward to some time off.
20:11We've been very busy.
20:15But it's what they don't hear that raises their interest.
20:19They're not doing their approach briefing and checklist.
20:22Briefings and checklists give the flight crew a better understanding of their environment.
20:27Not doing that makes it less likely that the pilot will remember to do certain things or to take certain precautions.
20:34Flask 15, gear down.
20:35Listening to the final moments before the crash, investigators make another surprising discovery.
20:44That's it?
20:45Normally at the last second of the flight, the pilot will have been screaming or do something.
20:59It happened so fast.
21:00Sounds like they didn't even see the mountain.
21:02Investigators suspect that clouds might have obscured the pilot's view of the mountain.
21:17The team scrutinizes weather data recorded less than an hour before the crash.
21:23Oxabill was covered by dense clouds.
21:25You've got a cloud base of 8,000 feet.
21:26They're not doing their approach briefing.
21:27The pilot's decision to continue their approach despite so much cloud cover surprises investigators.
21:41Gear down.
21:42The visual approach is not allowed to be done in a cloudy condition.
21:48Instead of following approved landing procedures.
21:51The base of the clouds was 8,000 feet.
21:54The pilots improvised, hoping they would eventually see the runway.
21:58They were descending, expecting to drop out of the clouds at any minute.
22:05Instead, they crash into a mountain at 8,300 feet.
22:13But even if the pilots couldn't see the mountain, the plane's warning system should have detected it.
22:22When a plane is in close proximity to terrain, or about to hit an object,
22:27there's a warning system that warns the pilot when the plane is very close to terrain.
22:40So why didn't that system activate?
22:45We need to check their warning system.
22:48Investigators want to know why flight 267's ground proximity warning system didn't alert the pilots that they were about to fly into a mountain.
22:58The warning system uses GPS and a terrain database to monitor an aircraft's height above the surrounding terrain.
23:10If the plane comes too close to the ground, the system will warn the flight crew with audio messages.
23:17Terrain, terrain, pull up!
23:19Telling the pilots to take immediate action.
23:22Were there any warnings going off in the cockpit?
23:24No, there's nothing in the transcript.
23:28Was the aircraft's warning system functioning properly?
23:33The team studies the terrain data it uses.
23:37This area is not very well mapped.
23:39Some of the Papua area was very rough data.
23:45The precision of the data was not as close to the actual conditions.
23:52Did the pilots fly into a mountain whose elevation was not properly recorded in the terrain database?
23:58Investigators interview Tregana pilots who regularly fly in the Oxaville area to find out if the system gives adequate terrain warnings.
24:10And what do you normally do when you keep getting these false warnings?
24:15They learn the system does provide warnings.
24:19But an excessive number turn out to be false alarms due to the poor quality of terrain data.
24:24If you're flying within a mountainous area, it can give you false warnings or unnecessary warnings.
24:31Imagine you are trying to land in a small airport in the middle of the valley.
24:35You can see the airport in front of you in visual conditions and then the system starts giving a warning.
24:41Terrain, terrain, pull up!
24:42You think, well I can see the airport in front of me, I can see the terrain behind it.
24:47That warning is annoying.
24:50Okay, thank you.
24:53They just pulled a breaker to get rid of the false warnings.
24:56Terrain, terrain, pull up!
24:59Terrain, terrain.
25:01Apparently it's common practice.
25:03Are you kidding me?
25:06Did flight 267 not get terrain warnings because the pilots deliberately shut down the system?
25:13Terrain, terrain, terrain.
25:15Yeah, yeah, yeah.
25:17The KNKT examines the captain's employment records and finds that he not only made a habit of pulling the circuit breaker,
25:25but also that the company was well aware of it.
25:28It says here that they scheduled the briefing with him to address it.
25:32Based on this information, we assume that that day, on the accident day, the captain also inactivated the system.
25:43Terrain, terrain, pull up!
25:45Terrain, terrain.
25:46I got this.
25:47Pull up!
25:48Terrain, terrain.
25:50Investigators now believe the pilots intentionally disabled their warning system on an earlier flight that day, and then never reset it.
25:58If the system was active, I'm sure that the accident would have been avoided, because the last seconds of the flight before the impact, the system will scream, pull up, pull up.
26:14Terrain, terrain, terrain.
26:15Terrain, terrain.
26:16I got this.
26:17I got this.
26:18I got this.
26:19I got this.
26:20I got this.
26:21I got this.
26:22I got this.
26:23I got this.
26:24I got this.
26:26I got this.
26:27I got this.
26:28I got this.
26:29I got this.
26:31I got this.
26:32I got this.
26:33I got this.
26:34I got this.
26:35I have this.
26:36ättxième, in my.
26:37Subma operate in hours by taking shortcuts and turning off vital warning systems.
26:39The practice results in the death of forty-nine passengers.
26:45passengers. No landing is routine. Overconfident pilots who improvise can be caught off guard
26:52with disastrous results. On a rainy summer evening, TransAsia flight
27:00222 is in a holding pattern, 3,100 feet above the Taiwan Strait.
27:08The pilot flying is Captain Li Yi Liang. Heading 240. He's a former military pilot with 22 years
27:17of commercial experience. TransAsia 222, heading 240. TransAsia 222, heading 240, approved.
27:28First Officer Qiyong Quanxing is monitoring the plane's instruments. He's been in the job
27:32for just two and a half years. There are 54 passengers on board the ATR-72, a popular
27:39short-haul aircraft.
27:46Flight 222 departed from Kaohsiung City, the second largest city in Taiwan. It's headed for
27:53Magong in the Pengu Archipelago, a popular Taiwanese vacation spot. But bad weather is delaying
28:04arrival.
28:05Excuse me. How long before we land?
28:18The flight skirts the edge of Typhoon Matbo, a Category 2 storm passing through the region.
28:24There was a typhoon just passing through Taiwan area and moving into China. But there was
28:30thunderstorm, heavy rain and very strong wind.
28:35TransAsia 222, request runway 20.
28:39VOR.
28:41TransAsia 222, roger. Fly heading 02360, radar vector. VOR approach.
28:50The plane's distance measuring equipment, the DME, will tell the crew how far they are from
28:55the runway.
28:56Javon crew, prepare for landing.
29:00Speed check.
29:02Flapped.
29:03Flop 15 set.
29:05TransAsia 222, clear to land.
29:19Flops 30, gear down.
29:22500.
29:24500
29:28Um, 300
29:36Set altitude 300
29:39Altitude set 300
29:43200
29:51The captain reduces the plane's altitude
29:54They are now less than 30 seconds from the ground
29:59Have you seen the runway?
30:11No
30:12No, no, sir
30:15Okay, okay
30:18Trans Asia Flight 222 is in jeopardy
30:30Oh, my God.
31:00Flight 222 crashes into the village of Zizi,
31:07less than a mile from the airport where it was scheduled to land.
31:14Of the 58 people on board, 48 are dead, including both pilots.
31:20Investigators from Taiwan's Aviation Safety Council
31:32begin mapping the crash site.
31:38In the beginning, we do not understand why the aircraft
31:42while flying into a residential area instead of landing on the runway.
31:50They determine the plane was not lined up with the runway on its descent.
31:55This is the heading they should have been on.
31:59Why were they so far off course?
32:01The team wonders if Typhoon Matmo contributed to the accident.
32:07Typhoon Matmo, probably just a medium-sized typhoon.
32:11But even that, they will bring a lot of water and, of course, strong wind.
32:18The investigation takes a close look at weather data.
32:23Wind speed 11 knots, gusting to 21 knots,
32:27but within the operational limits of the aircraft.
32:30It's enough to push the commuter plane off course,
32:33but not enough to bring it down.
32:35What about the visibility?
32:42I've got images from the airport at that time.
32:46It's starting to be more than just rain.
32:48That's a serious storm.
32:52The visibility decrees very quickly, just after 7 o'clock.
32:57A minimum range of clear visibility is required for pilots to attempt a landing.
33:05The team estimates that visibility was so limited,
33:09the Trans-Asia crew would have had difficulty seeing the runway.
33:12Visibility was decreasing from 1,600 feet to 1,800 feet,
33:20all the way down to 500 feet because of the heavy rain.
33:23Visibility can't be more than a couple of hundred meters.
33:27The pilots made a critical mistake by attempting to land in such poor conditions.
33:32But why Flight 222 crashed so far from Margong Airport remains a mystery.
33:38How did you end up way over here?
33:44I've got the data already now.
33:47Investigators scan the recovered flight data recorder,
33:50looking for anything unusual.
33:52Wait a minute.
33:54One minute before impact, they were at 200 feet?
34:00What was the minimum descent altitude?
34:04According to the rules of the Margong approach,
34:07pilots must not fly below a preset minimum descent altitude, or MDA,
34:13until they can see the runway.
34:17If they can't see it, they are to do what's called a missed approach.
34:21Have you seen the runway?
34:23They abort the landing, go around and try to land again.
34:27No.
34:29Or they divert to a different airport entirely.
34:31It says the minimum descent altitude was 330 feet.
34:37Take a look at this.
34:39Wang can see that the aircraft drops to 200 feet,
34:43well below the minimum altitude.
34:45It holds there for almost 14 seconds.
34:48The weather data suggests that at their position,
34:51the pilots wouldn't have been able to see the runway.
34:53If the visibility was so bad, why did they ignore the MDA?
34:57Why would they do this?
35:01We need to hear what was going on in that cockpit.
35:05Investigators turn to the cockpit voice recording.
35:09Ready?
35:11Let's start near the end, just before the landing.
35:13Transasia 222, request heading 2-4-0.
35:23Before landing checklist.
35:25Gear down.
35:27Flaps 30.
35:28Control auto.
35:29Takeoff lights on.
35:30Icing lights off.
35:32Runway 2-0.
35:33Clearance received.
35:34Before landing checklist complete.
35:37Wind 2-9-0.
35:39Wait, stop.
35:40Was that their before landing checklist?
35:45Pilots are supposed to acknowledge each item on a checklist
35:48with a standardized call and response communication.
35:52Let's keep going.
35:54But that's not what happens.
35:56Both pilots did not adhere to standard operating procedures.
35:59Puts the aircraft and the people around them at risk.
36:02Ready?
36:03Gear down.
36:04Investigators then hear the pilots break another rule
36:07while executing their landing.
36:09200.
36:10Hold it there.
36:14They knew the minimum descent altitude was 330 feet.
36:19But the captain seemed to just ignore that, too.
36:22Maybe they can see the runway after all.
36:24Let's find out.
36:29Have you seen the runway?
36:32No, sir.
36:34When they descend to 200 feet,
36:37they are still looking for the runway.
36:39No?
36:39No?
36:40No, sir.
36:41Okay.
36:42Okay.
36:43They cannot see the runway.
36:46But they decide to just descend the aircraft,
36:51try to find the runway.
36:52When they descend to 72 feet,
36:57they are still looking for the runway.
36:58Another 13 seconds pass before the pilots take any action.
37:05Go around!
37:06Go around!
37:06Go around!
37:14Why did the crew of Flight 222 ignore the rules on such a demanding approach?
37:20Investigators continue to search Flight 222's cockpit voice recording for clues.
37:318 miles from airport for VOR runway 20.
37:35Why did they wait so long to do anything?
37:37I want to hear it again, from the beginning.
37:44Anti-skid test?
37:46Check.
37:47Stand by.
37:49After start checklist complete.
37:50What they hear next is disturbing.
37:53Sir, do we preset next altitude 3, 4, 0 or 400?
37:57Time and again, the pilots struggle with basic procedures.
38:02Huh?
38:03Everything from checklists to setting altitude.
38:06Preset next altitude 400.
38:08It's always surprising when you have a recording that indicates
38:12that pilots are violating standard procedures.
38:14The recording then reveals why the crew was struggling.
38:21I'm so tired.
38:23Sir, are we holding here?
38:26Yes.
38:29Okay.
38:30Right orbit or left orbit?
38:34In the CVR, we clearly heard the pilot was yawning
38:37and saying that he was tired.
38:40Investigators look at the flight crew's work schedule before the accident.
38:44It shows that over the past 90 days,
38:49the captain flew 278 hours.
38:53The first officer, 264.
38:56Over the past three months,
38:58they flew an average of six flights a day.
39:03When an airline increases the frequency of flights,
39:05you may get into a situation where people are more fatigued,
39:08where people are flying beyond what is reasonable.
39:11Investigators determined TransAsia management
39:15was overworking their pilots.
39:19The discovery raises more questions.
39:22How common was it for pilots to ignore standard operating procedures?
39:28Okay, gentlemen, whenever you're strapped in,
39:30we'll start the simulation.
39:31And did TransAsia's management practices affect their pilots in other ways?
39:41They ask a group of the company's ATR-72 pilots
39:45to fly the route from Kaohsiung to Magong in a simulator,
39:49with the added challenge of a nearby typhoon.
39:51Pilot after pilot fails to follow the proper procedures.
40:00This was not a one-off sort of thing happening just in this flight,
40:04but this was something that was systemic within the airline,
40:07because it shows that this sort of behavior was normal.
40:11This sort of behavior was acceptable.
40:13Okay, we're done here.
40:15Just about every single one of them ignored standard operating procedures.
40:18We educate all the pilots.
40:24We have to do things according to the procedures.
40:27I was surprised that there were still pilots doing something by their own way.
40:34Ladies and gentlemen, we're about to begin our approach to Magong Airport.
40:38Investigators finally understand what led to the crash of Flight 222.
40:43Two overworked and fatigued pilots improvised their landing during a worsening storm.
40:58Assuming the runway would eventually appear ahead of them through the rain.
41:02Have you seen the runway?
41:03They dropped so low.
41:07No.
41:07They clipped the trees and sealed their fate.
41:10Door up!
41:11Door up!
41:12Up!
41:12Up!
41:28In their final report,
41:34investigators call on TransAsia to fully review its safety management system
41:39and pilot training program.
41:42Three flight crews improvised during hazardous landings.
41:47Relying on instinct rather than the rule book,
41:50they made mistakes that caused tragedy.
41:54The ability for a person to make a mistake is there.
41:59Training and process and procedure and regulation
42:02and lessons that we've learned are all things that exist
42:05to allow us to kind of mitigate and deal with those human errors should they occur.