Air Crash Investigation S11E02 The Plane That Flew Too High

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Transcript

00:00Mayday, mayday!

00:30At Panama's Tocumen International Airport, West Caribbean Airways Flight 708 begins boarding

00:43two hours behind schedule.

00:48It's well past midnight.

00:50The 152 passengers on this charter flight are returning home to Martinique.

00:56They've been visiting the Panama Canal.

01:01Captain Omar Ospina has just flown in with his crew from Colombia.

01:06As he's behind schedule, he must turn the plane around quickly.

01:11But there are more unexpected delays.

01:14First officer David Muñoz informs the captain that the flight is overbooked.

01:19Even the jump seat in the cockpit is filled.

01:23Two of the flight attendants will stay in Panama because there's not enough room on

01:36board.

01:45Checking the weight of the aircraft and the length of the runway, Captain Ospina calculates

01:53that he can safely get airborne.

01:58Their flight path will take them through some heavy weather, something crews are accustomed

02:03to during hurricane season.

02:05OK, we're ready for takeoff.

02:07Request pushback clearance.

02:08Ground, West Caribbean Airways.

02:09708, request pushback clearance.

02:10Gate 28.

02:11West Caribbean 708.

02:12Cleared for pushback.

02:13Gate 28.

02:15Proceed to runway 21L.

02:16West Caribbean 708.

02:17Runway 21L.

02:18Cleared for takeoff.

02:19West Caribbean 708, cleared for pushback.

02:20Gate 28.

02:21West Caribbean 708, cleared for pushback.

02:22Gate 28.

02:23West Caribbean 708, cleared for pushback.

02:24Gate 28.

02:25West Caribbean 708, cleared for pushback.

02:26West Caribbean 708, cleared for pushback.

02:27West Caribbean 708, cleared for pushback.

02:28West Caribbean 708, cleared for pushback.

02:44V1, rotate.

02:57At one in the morning, flight 708 begins the journey to Martinique.

03:02They took off from Panama airport to Cuman airport with a heavy load for a long flight

03:09for that aircraft.

03:13The flight should take three hours.

03:16They climb up to 31,000 feet, their initial assigned flight level.

03:22They have a flight plan with a final cruise level of 330, 33,000 feet.

03:30The crew is flying an MD-80.

03:35The plane is easily recognizable by its two rear-mounted engines.

03:39The MD-82 aircraft is a very good aircraft.

03:43It's a model that was derived from the DC-9.

03:47They made it longer, more fuel efficient, and more modern instrumentation and avionics.

03:54Anti-ice on, please.

03:57As altitude increases and temperature drops, they activate the plane's anti-ice system.

04:07Half an hour into the flight, while cruising at 31,000 feet, the weather ahead is turning

04:11nasty.

04:15A low-intensity hurricane moving in from the Atlantic has been whipping up winds across

04:19the region.

04:24Request deviation left.

04:25Barranquilla, West 708, request deviation to the left to avoid formation.

04:31West Caribbean 708, cleared to deviate left.

04:40The kind of weather they were flying, it's common for pilots to deviate from their initial

04:45route to avoid this bad weather.

04:48Hey, this should get better soon.

04:5440 minutes into the flight, the plane has burned through thousands of pounds of fuel,

05:06allowing it to fly higher.

05:08In order to reduce weight, they had to climb to 31,000 feet, wait until the weight goes

05:13down, and then do a step climb up to 33,000 feet.

05:18Let's do 330.

05:19330.

05:20Barranquilla, West 708.

05:22Barranquilla, West 708, request level 330.

05:26708, cleared to level 330.

05:30The captain now begins the climb to their scheduled altitude of 33,000 feet.

05:47Turn off engine anti-icing.

05:52I can't accelerate.

06:06The captain notices that the engines don't seem to be responding.

06:11What about the bathroom?

06:15The crew isn't overly concerned.

06:21Almost a third of the way to Martinique, West Caribbean Flight 708 enters Venezuelan airspace.

06:34Is there cake and coffee for everybody?

06:37What are we expected to share?

06:43As the storm intensifies, First Officer Munoz worries about icing.

06:49Did I turn it on, Captain?

06:50Do we have ice?

07:02Put them on.

07:04Soon, the turbulence gets worse.

07:07Man, there's a lot of nasty weather.

07:10Put the fasten seatbelt sign on.

07:13Police! Stay in your seat!

07:15Soon, the turbulence gets worse.

07:18Man, there's a lot of nasty weather.

07:21Put the fasten seat belt sign on.

07:38Please, stay in your seat.

07:46I'm dimming the lights so the passengers don't stand up.

07:54Should we go down to level 310?

07:57Do it.

08:00Micatea...

08:01The Micatea air traffic control station in Venezuela isn't equipped with radar.

08:07Request descent to level 310.

08:10The controller depends on pilots to tell him where they are.

08:133-1-0.

08:15Captain Ospina turns off the autopilot.

08:18Give me 3-1-0.

08:20And the plane starts heading back down to 31,000 feet.

08:26The turbulence is getting even heavier.

08:30And then suddenly the stick shaker goes off.

08:33It's the most serious warning that a crew can get.

08:37The captain's control column starts to vibrate,

08:40warning him the plane is flying dangerously slowly.

08:44At close to 31,000 feet, the plane suddenly drops.

08:56It's a storm, captain!

08:58It's a storm!

09:00The plane is falling fast.

09:02The crew has only seconds to figure out why.

09:07What's 3-1-0, Will?

09:09To level down to level 2-4-0.

09:13Descending to 2-4-0.

09:15Do you have a problem or thwart?

09:17Affirmative. Tell him we've had a flame out on both engines.

09:20We've had a flame out on both engines.

09:22Confirm?

09:23We've had a flame out on both engines.

09:25Roger.

09:26Confirm radial and distance from Punto Cabello, if possible.

09:31The controller needs to know where they are.

09:35Negative! Negative!

09:36We're at 14,000 feet.

09:38We're about 4,000.

09:39And going down. The plane is uncontrollable.

09:41Keep your heads down! Stay down!

09:43Keep your heads down!

09:45Confirm people on board. Intention.

09:47And distance from that plane, if it's possible.

09:50152 people on board and the plane is uncontrollable.

09:53In just 30 seconds, the plane falls 9,000 feet.

09:58I understand 152 people on board.

10:01Affirmative!

10:03Acknowledge.

10:04What level you are crossing at this time, Whiskey?

10:07Charlie Whiskey.

10:15Whiskey. Charlie Whiskey. 7-0-8.

10:18Confirm position, if possible.

10:21Whiskey. Charlie Whiskey.

10:24Confirm position, if possible.

10:27Whiskey. Charlie Whiskey. 7-0-8.

10:30Confirm position, if possible.

10:36While flying almost 10 kilometres above the earth,

10:39West Caribbean 7-0-8 mysteriously drops from the sky.

10:44Air traffic control in Venezuela doesn't know its location,

10:48nor if anyone has survived.

10:55The morning after West Caribbean flight 7-0-8 goes missing,

11:00Venezuelan villagers report that a plane has crashed on a remote farm.

11:07Colonel Lawless Ramos is the lead air crash investigator

11:10for the Venezuelan government.

11:12She has never handled a crash this big.

11:16She's shocked by what she sees.

11:19All 160 people on board,

11:21most of them French citizens from Martinique, have died.

11:31It was a real shock for us,

11:33because it was our first really big accident.

11:36It was a real shock for us,

11:38because it was our first really big accident.

11:41It was a real shock for us,

11:43because it was our first really big accident.

11:46And it had the highest number of deaths for any crash in Venezuela.

11:50We felt a lot of pressure because of that.

11:56The scope of the investigation is daunting.

12:02Lawless Ramos knows the plane that has crashed

12:05is one of the safest planes in the world.

12:08There are more than 3,000 such planes flying every day.

12:15Investigating a crash where an aircraft so popular as the MD-80

12:19is a great responsibility

12:21because of the effects it could have on the rest of the fleet.

12:28The Colombian, Venezuelan and French press from Martinique

12:32all descend on the site demanding answers.

12:39The plane has crashed in a lawless area next to the Colombian border.

12:44Kidnappings are common.

12:49The Venezuelan army informs investigators

12:52that it can only protect them during daylight hours.

13:02Certainly our team, including myself,

13:04wasn't prepared for the emergency we faced.

13:09This accident was complex

13:11and it was very difficult to quickly figure out what had happened.

13:19After the victims have been removed,

13:21the investigators' first goal is to determine

13:24how much of the plane landed intact at the crash site.

13:28If it's all there, they can rule out a mid-air break-up.

13:33We could observe the four corners of the aircraft,

13:36the tail, a part of the cockpit, and some remains of the wings.

13:42And this suggested that there were no explosions

13:45or a collision that produced the accident.

13:56The plane was in a state of emergency

14:00Investigators question the Maiketía air traffic controller.

14:04They told me that they had a flame-out on both their engines.

14:07Do you have a problem on board?

14:09We've had a flame-out on both engines!

14:18When we learned that the crew had reported a flame-out in both engines,

14:22we immediately focused on the function of the airplane's engines.

14:29Yeah, I don't know.

14:32Yeah, I'm just getting up to speed now.

14:35Joe Sador is a senior investigator at the NTSB in Washington,

14:39specialising in foreign assignments.

14:42As soon as we're notified of an accident,

14:44we contact the manufacturer of both the airframe and the engine.

14:48Given the initial information of a dual-engine flame-out,

14:51this caused us to start getting as much information

14:54about the engines as possible.

14:59No sign of fire inside the engine.

15:02Laura Lise had her hands full with this accident.

15:05It was a remote location, there was four countries involved,

15:09and she didn't have a big staff.

15:13Let's see what we can find out about the weather they flew through.

15:17Colonel Ramos knows that severe storms can kill a plane's jet engines.

15:23In 1977, a DC-9 with similarly mounted rear engines

15:28experienced a flame-out while flying through a thunderstorm.

15:32Both engines were disabled.

15:34The plane fell 17,000 feet,

15:37slammed to the ground and erupted in flames.

15:46Investigators suspect that the engines of Flight 708

15:50may have flamed out either from heavy rain entering them

15:54or due to turbulent winds.

15:56One way to think of an engine flame-out

15:58is when you have a pilot light go out on your furnace at home.

16:02The engine is working properly with combustion going on internally

16:06and then the flame stops and the engine quits.

16:14If both engines flamed out,

16:16it would explain why the plane fell from the sky in one piece.

16:27But Colonel Ramos knows that her best chance of finding out

16:30exactly what happened to the engines lies with the plane's two black boxes.

16:35They could hold critical flight and voice data.

16:39But retrieving that data gets complicated by political concerns.

16:45The other difficulty with this investigation was the international aspect.

16:49This was a Columbia operator that took off from Panama,

16:53was overflying Venezuela and crashed on their soil.

16:58So from the Venezuelan standpoint,

17:01they had very little connection with the actual flight

17:04or the passengers on the aircraft.

17:07The Venezuelan government, deeply mistrustful of the United States,

17:11has the final say on who will examine the black boxes.

17:15Since this is a United States manufactured aircraft,

17:19we offered our facility to them to download both the FDR and CVR.

17:24But they requested that they be downloaded at the French facility of the BEA,

17:29our counterparts in Paris.

17:34The black boxes are sent to France for expert analysis.

17:39The French aviation authorities participated in the accident investigation

17:42because all the passengers were French citizens that lived in Martinique.

17:50In the meantime, investigators pursue another possible cause of engine failure.

17:55Contaminated fuel.

17:58They track down the fuel truck that filled the plane in Panama.

18:06It was important to test the fuel because it was a possible cause

18:09for why the engines had failed.

18:12The fuel was contaminated.

18:16We asked the Panamanian authorities to test the fuel for contaminants,

18:20but the results they obtained were negative.

18:25Hi. I hope I can be of some help.

18:28Joe Sador arrives from Washington with two engine experts.

18:33Once we were in Washington, we were asked to test the fuel.

18:36We were asked to test the fuel.

18:38We were asked to test the fuel.

18:40We were asked to test the fuel.

18:42Joe Sador arrives from Washington with two engine experts.

18:46Once we arrived on scene, that was one of the first things

18:49that we wanted to look at was the engines.

18:52So my engine investigator and the Pratt & Whitney investigator

18:56went to each engine and examined them thoroughly.

19:02What they find is surprising.

19:04Both engines exhibited indications of high-speed rotation at impact.

19:09The evidence indicated that both engines were operating at a very high power.

19:14The investigators give the engines a clean bill of health.

19:22When we obtained the analysts' results for the engines,

19:25we realized that they worked perfectly.

19:29Do you have a problem on board?

19:31Affirmative! Tell them we've had a flame-out on both engines!

19:34We've had a flame-out on both engines!

19:37Sure looks like those blades were turning when the plane hit the ground.

19:41And that the flame-out reported by the crew never happened.

19:47The main suspect in the crash of one of the most popular planes on Earth is ruled out.

19:53Investigators need another lead.

19:56It made us want to get that FDR and CVR data as quickly as possible.

20:02The team is now counting on the plane's two black boxes

20:05to shed light on the cause of the crash.

20:09They travel to France, where one of the boxes has been opened.

20:13When they listen to the plane's cockpit voice recorder,

20:16investigators are surprised by what they hear.

20:19It's a stall! It's a stall!

20:24After listening to the cockpit voice recordings,

20:27we realized that the plane had entered a stall.

20:31How did this plane stall at over 30,000 feet with two working engines?

20:37To create the lift needed to fly,

20:39a plane depends on a very fast-moving stream of air over the wings.

20:43An airplane stall is when the lift over the wings is reduced to the point

20:48that the lift cannot support the weight of the aircraft in the air.

21:01It's unusual for planes to stall at such a high altitude.

21:05Investigators hope the plane's second black box will reveal why that happened.

21:16When we opened the flight data recorder, even though it was really damaged,

21:20the conditions inside were good, and that was a huge relief.

21:24But for some reason, much of what's on the recorder is gibberish.

21:30Unfortunately, some of the data was not usable.

21:38And it was some very important data points that were not available,

21:42such as elevator position, rudder position, heading,

21:47and the most important parameter was that the plane was in a stall.

21:54Engine pressure ratios.

21:57It's a disappointing loss for Sador.

22:02We need those engine parameters.

22:04The engine pressure numbers would tell investigators

22:07how much power the engines were generating.

22:10They would paint a picture of how the airplane was flying in its final minutes.

22:17In Washington, the NTSB offers to help.

22:24Sophisticated software may be able to recapture some of the lost data.

22:29We wanted to work with what data we had to recover any engine data that we could.

22:36Meanwhile, investigators look for other clues about what may have caused the stall.

22:41That's quite a storm. Probably very heavy rain.

22:45They discover that the plane flew through freezing wet weather,

22:49capable of causing ice to form.

22:52Ice on the wings can cause a plane to stall.

22:56When ice accumulates on an airplane,

22:58it will have increased drag and increased weight and decreased lift.

23:03The MD-80 is equipped with an anti-icing system.

23:07When turned on, it blows hot air from the engines onto the wings,

23:12preventing ice from forming.

23:18Let's see what they did about the ice.

23:23Put on the fasten seatbelt sign.

23:26Man, that is a lot of nasty weather.

23:29As the plane rose to 33,000 feet,

23:32Captain Ospina made an unusual decision.

23:36Turn off engine anti-icing.

23:42A short while later, First Officer Munoz wants to know

23:45if the anti-icing system should be put back on.

23:49Did I turn it on, Captain?

23:51Yes.

23:56Pilots generally examine the outside metal windowsill

23:59to see whether ice is forming there.

24:04Put them on.

24:06It appears the captain saw ice.

24:09Since they were flying through cold and wet conditions,

24:13investigators don't know why the crew

24:15didn't simply turn on the anti-ice and leave it on.

24:19With the weather conditions they had,

24:22they should have been using the anti-ice systems

24:25during the entire flight.

24:29Investigators wonder if the crew made an error

24:32that allowed ice to build up on the plane's wings,

24:35causing it to storm and fall from the sky.

24:42Promising new evidence in the crash of West Caribbean Flight 708

24:46may help the investigative team to zero in

24:49on the cause of the disaster.

24:55The NTSB has managed to recover missing data

24:59about the MD-80's engines.

25:07This was very important for us because it allowed us to understand

25:10the operation of the engine throughout the flight.

25:14If there had been ice on the wings,

25:16the engines would have had to work harder

25:18to overcome the friction it creates.

25:21The engine power numbers would have gone up.

25:24Look at this.

25:26Engine power wasn't going up, it was actually going down.

25:30Therefore, that showed that there was no ice on the airframe.

25:35Ice didn't cause the storm.

25:39So what did?

25:43Investigators must determine why the engines

25:45weren't providing the power needed to keep the MD-80 in the air.

25:54The airline's troubled history of safety violations

25:57gives investigators a possible lead.

26:01It had been cited for flying overweight planes.

26:05Colombian authorities used to bring the aircraft to a scale

26:08they have at Bogota airport

26:10and compare against the manifest

26:12and in some occasions they found that the aircraft was heavier

26:16than what was reported.

26:20Did Flight 708 stall in mid-air because it was too heavy?

26:27During our visit to Panama, we observed that West Caribbean

26:30didn't have very rigorous control

26:32over the checking of passengers' luggage and their weight.

26:38If a plane is too heavy,

26:40it may not be able to fly at higher altitudes

26:43where the air is less dense.

26:49Pilots need to make these calculations carefully.

27:00The pilot knows at what altitude he can fly

27:02by studying the aircraft's performance tables

27:05and inputting the plane's weight and the temperature.

27:10What investigators don't know

27:12is whether Captain Ospina did the maths correctly.

27:18They now try to calculate whether Flight 708 was too heavy

27:21to avoid stalling at 33,000 feet.

27:25So we went back and looked at the number of passengers on board,

27:29the number of crew on board

27:31and the weight of the aircraft itself along with the baggage.

27:36They already tested the plane at its reported weight of 148,000 pounds.

27:42All right, let's add a few thousand pounds.

27:44We've got heavier luggage,

27:47mis-weighed cargo.

27:51Let's try 155,000 pounds.

27:55Investigators now make the calculations

27:57for a plane that's grossly overweight.

28:02They're in for a surprise.

28:05And even with a heavier aircraft at take-off,

28:08the aircraft could maintain level flight at 330.

28:13It's a setback for the investigation.

28:16We're missing something.

28:19Let's go back to the beginning.

28:25After much research,

28:27investigators still can't figure out what caused the plane to stall.

28:35Thanks.

28:38The answer has to do with how a plane distributes power.

28:47When it's turned on,

28:49the anti-icing system draws energy from the engines,

28:52reducing power for thrust.

28:54This decrease in thrust can affect the performance of the airplane

28:57depending on the weight and the altitude.

28:59So the performance study showed

29:01that the airplane was perfectly safe to fly at 33,000 feet with the anti-ice on.

29:05Anti-ice on, please.

29:07However, it could only fly as high as 31,900 feet with the anti-ice on.

29:14It was the anti-icing.

29:16Robbed them of the power they needed.

29:21They shouldn't have gone higher than 319.

29:24They shouldn't have gone higher than 319.

29:37We concluded that the aircraft was flown too high

29:40for its weight and the weather conditions it faced.

29:48The airspeed started to decelerate

29:50when the flight crew turned on the anti-ice system.

29:53This reduced the thrust of the engine.

29:56Investigators conclude the reduction in thrust led the plane to stall.

30:01Sir, we just got the final load sheet.

30:04They now assume that when Captain Ospina calculated his maximum cruise altitude,

30:09he failed to factor in the need for anti-icing.

30:13There are many factors you have to take into account when planning,

30:17and apparently they did not do it in this case.

30:20But if low thrust led to a stall, why didn't the crew notice?

30:25Part of the answer is that while the problem was developing,

30:28they weren't flying the plane.

30:32They had their autopilot on.

30:38The autopilot should not let a plane stall.

30:41Investigators wonder why this particular autopilot let that happen.

30:51While researching the autopilot on the MD-80,

30:54they discover a bulletin from the plane's manufacturer.

30:58It was sent to the airline three years earlier.

31:03Under some conditions, airspeed could decay to stall warning

31:07before the autopilot disconnects.

31:13In the bulletin issued by Boeing,

31:15it described another incident with an autopilot

31:18that was almost the exact same as what had happened with West Caribbean.

31:24The bulletin warned crews that if they set the autopilot to maintain the plane's altitude,

31:29they should keep a close eye on their airspeed.

31:32The operation bulletin warned that with the autopilot on,

31:36and at altitude, that a similar situation could occur,

31:40where the aircraft could maintain altitude and airspeed could decrease

31:45if the pilots were not monitoring the airspeed.

31:49So, in order to maintain altitude, as the speed goes down,

31:53the aircraft starts to pitch up, nose up altitude,

31:57increasing the angle of attack to have a better lift.

32:02But that has a problem, because you cannot exceed a certain angle

32:07because you can enter a stall condition.

32:12In this case, the autopilot led the aircraft into a condition

32:16that caused an excessive angle of attack.

32:18That generated the stall.

32:22As important as the bulletin was,

32:25there's no evidence that it ever reached West Caribbean's pilots.

32:31Investigators now have a deeper understanding of the events causing the stall.

32:36The crew were not monitoring their instruments,

32:39believing that the autopilot would maintain the correct speed.

32:43They were wrong.

32:46It was at this moment that the captain began to notice that something wasn't right.

32:50It can't accelerate.

32:52But what did that do?

32:54They were aware that they had a problem, but they didn't know why.

33:02The captain decided to descend to an altitude where the engines would perform better.

33:08And descending to 31,000 feet was the right choice.

33:11That's why he disconnected the autopilot to begin the descent.

33:17The plane is very close to stalling.

33:19But the crew is just a few seconds away from overcoming the problem.

33:24If he would have attained 31,000 feet,

33:27during that descent, the speed would have gone up

33:31and he would have recovered the lift.

33:34And after levelling off, there would have been no problem at all.

33:39They almost made it.

33:41But the captain was oblivious to his biggest threat.

33:46The plane is still travelling slowly,

33:48with its nose raised at a dangerously high angle.

33:53That's when the crew experienced some bad luck.

33:56The weather they were flying through was turbulent,

33:59winds were intense, and the plane was vulnerable.

34:02Our study showed that it would only take a 20 mile an hour updraft

34:05to push the aircraft into a stall.

34:09Investigators conclude that the plane was hit with a ferocious updraft

34:14that lifted the plane's nose just enough to put it into a stall.

34:20A crisis the crew then mishandled.

34:24There was very little communication between them.

34:27The captain thought he was having a flame-out in both engines.

34:32Tell him we've had a flame-out in both engines.

34:37We have a flame-out in both our engines.

34:39The captain was not telling the first officer what to do.

34:43The captain was only fixating,

34:46or if you will, have tunnel vision on the engines.

34:51Which is a very big problem in this situation.

34:55As the investigation into the crash of Flight 708 nears completion,

35:00only one mystery remains unsolved.

35:03It's a stall!

35:05Munoz seems to know what was happening.

35:07Why did the crew fail to recover from a stall

35:10that they'd been trained to overcome?

35:12To get out of a stall, a pilot should increase thrust and pitch over.

35:17That is, push forward on the control column.

35:19But as the recovered flight data showed,

35:22that is not what Captain Ospina did.

35:24There is no indication that the pilot pushed forward on the control column

35:28to reduce the angle of attack and to increase speed.

35:34He's pulling back on the control column.

35:37At that point, it was impossible to recover from the stall.

35:40The captain should have pushed forward.

35:43The question remains, why didn't he?

35:47Investigators get their first clue

35:49when they re-examine the engine data at the precise moment of the stall.

35:54That's what distracted the captain.

35:57At the time that the airplane stalled,

35:59we also saw that both engines rolled back at the same time.

36:03This most likely confused the pilots.

36:07When airflow to the engines is disrupting,

36:10it causes the engines to stall.

36:13When airflow to the engines is disrupting,

36:16it causes a rollback, reducing thrust.

36:21Because of the updrafts in the area,

36:24it most likely increased the angle of attack of the engine inlet,

36:27which then caused the engines to roll back.

36:30With his engine power temporarily reduced,

36:33the captain wrongly concluded that his engines had quit.

36:36It's a stall!

36:37The first officer yelled, it's a stall, Cappy, it's a stall.

36:44There was no response from the captain.

36:47This showed that the captain was fixating most likely on the engines.

36:52Unaware he had stalled,

36:54the captain made things worse by pulling back on his control column.

36:58That kept the nose of the plane angled dangerously high.

37:02Tell them we've had a flame-out on both engines.

37:05We've had a flame-out on both engines.

37:08The crew couldn't understand the situation presented to them.

37:12West 7-0-8, go down to level 2-4-0.

37:15Do you have a problem on board?

37:17We've had a flame-out on both engines.

37:19They had a heavy buffet from the stall.

37:22They were looking at the engines, which were rolled back,

37:25and they were also communicating with the air traffic controller.

37:28During that time, there was not much troubleshooting going on in the cockpit.

37:33This was a very, very difficult time for the pilots.

37:38It is very important that the crews communicate in an effective way.

37:44And in this case, you don't hear the two pilots communicating between themselves.

37:55It was an almost silent cockpit until the time just before the accident,

38:00when they realized they were in deep trouble.

38:09But by that time, it was already too late.

38:12They were past the point of no return.

38:17During that descent, according to the flight data recorded,

38:21they reached a rate of descent, on average, of more than 12,000 feet per minute.

38:28That rate of descent, not only the G-force would prevent them from any coordinated action,

38:35but the vibration in the aircraft would be a lot.

38:41That's why when you hear the voice recorder, you hear the voice trembling.

38:51That's because of high vibration in the aircraft.

38:57For everyone on board, the final plunge was a nightmare,

39:02lasting almost three minutes.

39:16When Colonel Lawless-Ramos and her team interview friends and family

39:20of the pilots of West Caribbean Flight 708...

39:23How was he when he was at home?

39:25...they uncover other long-standing issues that may help explain the crew's behavior.

39:30The West Caribbean airline was going through a very critical financial status.

39:42Because of West Caribbean's economic struggles,

39:45the crew members hadn't been paid for six months.

39:51And this could have influenced the captain's concentration.

40:00Investigators discover that Captain Ospina was forced to take a second job,

40:05moonlighting in a bar, in order to make ends meet for his family.

40:12The level of stress that the captain was under because of his financial situation was huge.

40:20We saw the fuel situation yet?

40:22I think we're getting close, Captain.

40:24Before the accident, the crew was delayed in Colombia for hours

40:27because the airline couldn't pay for their fuel.

40:30That was their third of four flights that day.

40:36The crew was under a lot of stress because they were already late

40:39and they didn't know if their flight would be cancelled.

40:46It's a storm, Captain! It's a storm!

40:50Investigators also believe that the 21-year-old first officer

40:54should have voiced his opinions more clearly.

40:58There was a considerable age difference between the captain and the co-pilot,

41:02and this might have intimidated the co-pilot when he needed to speak up.

41:09Can I turn it on, Captain?

41:10Do we have ice?

41:13No matter how young the co-pilots and the first officers are,

41:18how old and experienced the captain is,

41:23they have the right to preserve their life.

41:27If they see something that's going wrong...

41:30It's a storm, Captain! It's a storm!

41:33...and they alert the captain and he does not react,

41:37they should react by themselves.

41:45The investigation's official report concludes that there was

41:48an insufficient level of situational awareness in both pilots.

41:54Although the pilots' actions are in question in this flight,

41:57we also have to look at the operator.

42:00Did the operator provide proper training?

42:02We found that the training was insufficient,

42:05that they did not receive proper CRM training

42:07and they did not receive proper stall training.

42:18This accident happened as a result of numerous factors

42:21that aren't only attributable to the crew.

42:25There were deplorable conditions in the operation of the airline

42:29and over time, these faults can lead to accidents.

42:40Negative, negative!

42:41We're at 14,000 feet!

42:45The report makes a long list of recommendations

42:48to ensure that the tragedy of Flight 708 never happens again.

43:00We made recommendations to the Colombian aviation authorities

43:03to improve pilot training.

43:05Specifically, better training in crew communication

43:08and having a better awareness about the use of the plane's autopilot.

43:19After this accident occurred, the airline was grounded

43:22and it never operated again.

43:24It went bankrupt and simply disappeared.

43:29But West Caribbean Airways did leave a valuable legacy.

43:34Better safety measures for every other MDAT taking to the skies today.

43:48For more UN videos visit www.un.org

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