Unforgivable!! The Tragic tale of Air Algérie Flight 6289

Mentour Pilot
25 Nov 202325:23

Summary

TLDROn March 6, 2003, Air Algerie Flight 6289 crashed after an engine failure during takeoff from Tamanrasset Airport. The crew's inadequate preparation and non-adherence to standard procedures, such as not retracting the landing gear and the captain's sudden takeover, contributed to the tragedy. The flight, operated with a 20-year-old Boeing 737-200, had a takeoff weight close to its maximum, exacerbating the situation. Despite the captain's inexperience on the aircraft type, he failed to identify the problem and follow proper emergency protocols, leading to the aircraft's rapid descent and crash, resulting in 102 fatalities and a sole survivor.

Takeaways

  • 😨 The flight was delayed due to a hydraulic pump issue, highlighting the importance of pre-flight checks and maintenance.
  • ✈️ The aircraft was a 20-year-old Boeing 737-200, indicating that age can be a factor in aircraft performance and safety.
  • 🔥 The left engine's high-pressure turbine blades fractured due to thermal fatigue, underscoring the need for regular engine inspections.
  • 📉 The aircraft was close to its maximum takeoff weight, which could have affected its performance during the emergency.
  • 🛫 The first officer was left to complete pre-flight preparations alone, emphasizing the necessity of teamwork and communication in flight operations.
  • 👨‍✈️ The captain's lack of recent experience on the 737 and his distraction during the flight contributed to the inadequate handling of the emergency.
  • 🛑 The crew failed to follow standard operating procedures, such as retracting the landing gear and using correct engine thrust settings after an engine failure.
  • 🚨 The captain took control from the first officer without fully understanding the situation, demonstrating the potential dangers of non-standard cockpit responses during emergencies.
  • 🔇 The lack of effective communication and crew resource management (CRM) in the cockpit was a significant factor in the accident.
  • 🔥 The aircraft's impact and subsequent fire resulted in a high number of fatalities, illustrating the critical nature of quick and correct emergency response.

Q & A

  • What was the date of the Air Algerie flight incident described in the script?

    -The incident occurred on the 6th of March, 2003.

  • What was the issue that caused the initial delay of the flight?

    -The flight was delayed almost three hours due to a problem with the system B hydraulic pump.

  • How old was the Boeing 737-200 aircraft involved in the incident?

    -The aircraft was almost 20 years old at the time of the incident.

  • What was the significance of the left engine's status in the story?

    -The left engine had clocked over 30,000 hours, and its high number of hours, along with cracks in the high-pressure turbine blades, played a crucial role in the engine failure during the flight.

  • Why did the captain not attend the initial briefing with the rest of the crew?

    -The captain did not attend the initial briefing because he arrived later when the issue with the hydraulic pump had been resolved.

  • What was the impact of the high temperature and high altitude on the aircraft's performance?

    -The high temperature and high altitude affected the aircraft's performance by increasing the density altitude, which reduced the air density and thus the lift and thrust, requiring a higher speed and longer takeoff distance.

  • Why was the first officer preparing to operate as pilot flying for the first flight?

    -The first officer was preparing to operate as pilot flying for the first flight because the captain arrived later and she had completed all the pre-flight preparations by herself.

  • What was the takeoff weight of the aircraft, and how did it compare to the maximum takeoff weight?

    -The takeoff weight of the aircraft was 48,708 kilos, which was only about 800 kilos away from the aircraft's maximum takeoff weight.

  • What was the role of the purser in the cockpit, and why was his presence unusual?

    -The purser, who is the most senior cabin crew member, was present in the cockpit during takeoff, which is unusual as his role requires him to be in the cabin to guard the main emergency exits and help organize any issues that might arise.

  • What was the sequence of events that led to the aircraft's stall and crash?

    -The aircraft's stall and subsequent crash were caused by a combination of factors: an engine failure, the captain taking over controls without properly identifying the problem, failure to retract the landing gear, and the aircraft's rapid descent due to the captain maintaining a high pitch attitude without enough speed.

  • What were the recommendations made by the investigation after the accident?

    -The investigation recommended increased Crew Resource Management (CRM) training for all pilots at Air Algerie, more focus on conformity of engine failure training, and the implementation of a better flight safety program to monitor and analyze flight data.

Outlines

00:00

🛫 Flight 6289: The Tragic Beginning

The script opens with a suspenseful narrative about the critical moments in a pilot's career, leading to a tragic incident on Air Algerie Flight 6289. The flight, operated by a Boeing 737-200, was scheduled for a domestic route with a crew of six, including two pilots. The aircraft, despite being nearly 20 years old, was in good technical condition. However, a delay due to a hydraulic pump issue and the absence of the captain from the pre-flight briefing set the stage for potential problems. The first officer, who had less experience on the 737 than the captain but was more senior, was left to handle pre-flight preparations alone, including calculating for the impact of high density altitude due to the airport's high elevation and increasing temperatures.

05:02

📞 Pre-Flight Preparations and Personal Distractions

The narrative continues with the first officer's diligent preparations, which included fueling the aircraft and calculating takeoff weights. Meanwhile, the captain's delayed arrival and subsequent engagement in unrelated conversations with the male purser, instead of assisting with preparations, raised concerns about the cockpit's focus on safety. The purser's decision to stay in the cockpit during takeoff, a deviation from standard procedures, is highlighted as a significant oversight. The script also touches on the purser's personal call home, which was misinterpreted by the media, and the boarding of passengers, one of whom would later be the sole survivor due to not fastening his seatbelt.

10:04

🛫 Departure and the Engine Failure

The script describes the commencement of the flight with the crew failing to adhere to standard operating procedures, including an incomplete pre-takeoff briefing. As the aircraft began its takeoff roll, an engine failure occurred in the left engine due to undetected cracks in the high-pressure turbine blades. The first officer's reaction to the yaw caused by the engine failure was to apply rudder correction, but the captain's delayed response and lack of situational awareness led to a series of critical errors.

15:07

🚨 Crisis Management and the Tragic Outcome

The engine failure led to a rapid series of events where the captain's decision to take control without understanding the situation, coupled with the crew's failure to retract the landing gear and manage the aircraft's configuration, resulted in a stall. The aircraft crashed shortly after takeoff, with the right wing and rear of the aircraft hitting the ground first, leading to a massive explosion and fire that claimed the lives of all but one on board. The sole survivor was the conscript who had not fastened his seatbelt and was ejected from the aircraft during the impact.

20:09

🔍 Investigation and Recommendations

The investigation into the accident revealed that the loss of engine thrust during a critical phase, failure to retract the landing gear, and the captain's unprepared takeover were the primary causes. Contributing factors included substandard flight preparation and poor crew resource management. The report recommended enhanced CRM training, standardized engine failure training, and the implementation of a robust flight safety program to monitor and analyze flight data to prevent similar incidents.

25:11

🌟 Conclusion and Call to Action

The script concludes with a personal reflection on the importance of following standard operating procedures, emphasizing their potential to save lives. It also encourages viewers to subscribe to the channel for updates, support the sponsor, or join the Patreon crew, highlighting the community aspect of the channel.

Mindmap

Keywords

💡GPWS

GPWS stands for Ground Proximity Warning System, an aircraft system designed to alert pilots when there is a risk of collision with the ground or an obstacle. In the context of the video, the GPWS is mentioned as 'Don't sink,' indicating a warning that the aircraft is in a descent rate that could lead to a crash. This system is crucial for flight safety, particularly during critical phases of flight such as takeoff and landing.

💡Density Altitude

Density altitude is the effective altitude adjusted for temperature and humidity, which affects aircraft performance. It is a critical factor in determining takeoff and landing distances, as well as climb and descent rates. In the video, the first officer considers density altitude due to the high temperature and altitude of Tamanrasset Airport, which can impact the aircraft's ability to generate lift and thrust, thus affecting its takeoff performance.

💡Hydraulic Pump

A hydraulic pump is a mechanical device used to transfer energy into hydraulic fluid to provide mechanical force or to control movement. In the video, a problem with the system B hydraulic pump caused a delay for the Air Algerie flight, highlighting the importance of hydraulic systems in aircraft for functions such as flight control and braking.

💡JT8D-17A

The JT8D-17A is a type of turbofan engine used in commercial aircraft, including the Boeing 737-200 mentioned in the video. These engines are significant for their role in providing thrust for the aircraft. The script mentions that both engines were in check, indicating that they were functioning correctly, but the left engine's high hours of operation foreshadowed potential issues.

💡First Officer

The first officer is the pilot who is second in command on a flight and is responsible for assisting the captain. In the video, the first officer is depicted as having to handle pre-flight preparations alone due to the captain's delayed arrival, which is unusual and potentially unsafe. This role is crucial for the operation of the flight, especially in emergency situations.

💡Engine Failure

An engine failure refers to a complete or partial loss of thrust from one or more engines during flight. In the video, the left engine experiences a catastrophic failure due to fractured turbine blades, leading to a loss of thrust. This is a critical event that requires immediate and correct response from the flight crew to ensure the safety of the aircraft.

💡CRM

CRM stands for Crew Resource Management, which is a set of training procedures focused on optimization of crew interactions and utilization of available resources in the cockpit. The video suggests that poor CRM was a contributing factor to the accident, as the captain and first officer failed to effectively communicate and manage the emergency situation following the engine failure.

💡EPR

EPR stands for Engine Pressure Ratio, which is an indicator of engine thrust output. In the video, the first officer briefs that an EPR of 2.18 is required for takeoff, indicating full thrust. This is an important parameter for pilots to consider, especially under high-density altitude conditions where additional thrust may be necessary.

💡V1, Rotate, V2

V1, Rotate, and V2 are critical speeds in aircraft takeoff. V1 is the speed at which the aircraft must decide to take off or stop, Rotate is the speed at which the pilot initiates the takeoff, and V2 is the minimum speed to safely continue the takeoff in the event of an engine failure. These speeds are crucial for ensuring safe takeoff performance, as highlighted when the first officer calls out these speeds in the script.

💡Stick Shaker

The stick shaker is a warning system in aircraft that vibrates the control stick to alert pilots of an impending stall. In the video, the stick shaker activation indicates that the aircraft's speed has decreased to a dangerous level, which is a critical warning that requires immediate corrective action to prevent a stall and potential crash.

Highlights

The flight was delayed due to a hydraulic pump issue, highlighting the importance of pre-flight checks.

The aircraft was nearly 20 years old, emphasizing the need for rigorous maintenance on older planes.

The left engine's high hours and potential maintenance history played a crucial role in the incident.

The captain's late arrival and the first officer's solo pre-flight preparation underscored the impact of team coordination on flight safety.

The significance of density altitude and its effects on aircraft performance were discussed, indicating the need for accurate performance calculations.

The first officer's handling of pre-flight checks without the captain present raised concerns about procedural adherence.

The captain's inexperience on the 737 type compared to the first officer was noted, suggesting the importance of cockpit crew experience balance.

The purser's decision to stay in the cockpit during takeoff was criticized, highlighting the necessity of crew following their designated roles.

The departure briefing was interrupted, pointing to a lack of focus on critical pre-flight procedures.

The aircraft's takeoff weight was close to maximum, nearly 800 kilos away, which could have implications on performance.

The captain's decision to allow the purser to stay in the cockpit for takeoff was questioned, reflecting on the cockpit's sterile environment during critical phases.

The left engine's failure during takeoff due to turbine blade fractures was a pivotal moment in the flight's tragic outcome.

The crew's lack of preparedness for engine failure procedures was evident, showing the necessity of regular and effective training.

The captain's takeover of controls without understanding the situation was a critical error, demonstrating the importance of clear communication and role understanding in the cockpit.

The aircraft's configuration and handling post-engine failure indicated a stall, highlighting the crew's failure to manage the crisis effectively.

The sole survivor, ejected due to not wearing a seatbelt, illustrated the life-saving importance of following all safety protocols.

The investigation's recommendations for improved CRM training and flight safety programs underscored the need for ongoing aviation safety enhancements.

Transcripts

play00:01

(suspenseful music)

play00:09

- [Petter] As a pilot, you train your entire career

play00:11

for that one moment, that one time

play00:14

when fate, circumstance and bad luck comes together

play00:17

to force you to save the day.

play00:19

- [GPWS] Don't sink.

play00:20

- But what happens if you, in that moment,

play00:22

haven't prepared at all

play00:24

and instead is completely caught off guard?

play00:27

Stay tuned.

play00:31

On the 6th of March, 2003, an Air Algerie crew

play00:34

consisting of two pilots and four cabin crew

play00:37

were preparing for a two-leg domestic flight

play00:39

starting in Tamenghasset, Algeria

play00:41

and then continuing via a short stop

play00:43

in Ghardaia to their final destination, Algiers.

play00:47

The flight had been delayed almost three hours

play00:49

due to a problem with a system B hydraulic pump

play00:51

but the Boeing 737-200 that they were gonna fly

play00:54

was in an otherwise seemingly good technical shape.

play00:58

It was a reasonably old bird

play01:00

which had been delivered new to Air Algerie

play01:02

back in December of 1983,

play01:04

meaning that it was almost 20 years old

play01:06

but it was maintained according to the maintenance handbook

play01:09

and had no open defects on the day of the flight.

play01:13

It was equipped with two

play01:14

JT8D-17A ducted low bypass turbofan engines

play01:18

which were both also in check

play01:21

but had a lot of time on them

play01:23

with the left engine having clocked over 30,000 hours

play01:26

and the right close to 23,000.

play01:29

And the status of that left engine

play01:31

will come to play a really important role in this story.

play01:35

Anyway, because of that delay,

play01:36

the captain had not turned up

play01:38

to the briefing along with the rest of the crew.

play01:40

Instead, he would arrive a little bit later when the issue

play01:42

with the hydraulic pump had been solved.

play01:45

This meant that the first officer,

play01:46

who had turned up on time, was left to complete all

play01:49

of the pre-flight preparations by herself.

play01:52

This included checking the weather for the two flights

play01:54

which was fine but the temperature

play01:56

was steadily getting higher

play01:58

and since Tamanrasset Airport was situated quite high up

play02:02

at an altitude of around 4,500 feet,

play02:04

the density altitude was now becoming a factor.

play02:08

Density altitude is the altitude

play02:10

the aircraft performance is calculated on,

play02:12

corrected for temperature

play02:14

and it can have a major impact on,

play02:15

for example, the climb or takeoff performance

play02:18

as well as the landing distance required.

play02:20

Because since air with higher temperature

play02:22

has less density, it means that,

play02:24

effectively, there's less air molecules

play02:27

moving around the wings as well as through the engines,

play02:30

causing less lift at a given speed

play02:33

as well as less thrust.

play02:35

This means that the aircraft in hot weather will need

play02:38

to accelerate to a higher speed

play02:39

using less available thrust before it can take off,

play02:43

which will mean a longer takeoff distance

play02:45

or less ability to carry weight.

play02:48

With a delay, the aircraft would now depart

play02:50

around 14:00 which was the hottest time of the day

play02:53

with temperatures around 25°C.

play02:57

Now that might not sound like much

play03:00

but at this higher airport altitude,

play03:02

it can actually make a big difference,

play03:04

especially with a heavy aircraft.

play03:07

But these calculations would have to be checked

play03:09

before departure anyway and if the aircraft

play03:12

was too heavy, well then, there was always the possibility

play03:14

of just offloading some bags or cargo

play03:17

so the first officer wasn't too worried about that.

play03:20

She instead continued to look through

play03:21

the briefing material and there was nothing in the NOTAMs

play03:23

or flight plans that stood out to her.

play03:26

The first officer was 44 years old

play03:27

at the time of this flight and had amassed

play03:29

a total flying time of 5,219 hours

play03:33

of which 1,292 had been flown on the 737-200.

play03:38

The captain that she was now waiting for

play03:41

was 48 years old and had 10,760 hours

play03:44

but he had only been a captain

play03:46

on the 737 for around 1,100 hours.

play03:49

So he actually had less experience

play03:51

on the type than the first officer did.

play03:54

And curiously, he was also operating

play03:56

as a first officer on the Boeing 767

play03:59

within the same company

play04:00

and had been flying around 31 hours on that type

play04:03

during the 30 days before this flight.

play04:07

The first officer and the cabin crew

play04:08

eventually started walking out to the aircraft

play04:10

and also started preparing it for departure.

play04:14

Naturally, since she was the only pilot there,

play04:16

the first officer prepared herself

play04:18

to operate as pilot flying for the first flight

play04:20

and completed all of the initial setup

play04:22

and walk around by herself.

play04:24

She also asked the fueler to uplift 4.6 tons of fuel,

play04:27

bringing the departure fuel up to close to 10 tons.

play04:31

And this fuel, together with the 97 passengers

play04:34

would bring the aircraft up to a takeoff weight

play04:36

of 48,708 kilos which was only

play04:40

about 800 kilos away from

play04:41

the aircraft's maximum take-off weight.

play04:43

That's worth keeping in mind.

play04:46

Eventually the captain turned up

play04:48

and agreed to allow the first officer to fly the first leg.

play04:52

And while she continued to prepare everything,

play04:54

instead of helping out, he instead started talking

play04:57

to the male purser about some other unrelated stuff.

play05:02

The purser had, by the way,

play05:03

called home a bit earlier and told his 17-year-old son

play05:06

that he would be home late due to some technical issues

play05:09

they were having with the aircraft.

play05:10

And this call would later be very misinterpreted

play05:13

by the local press.

play05:15

Anyway, eventually the maintenance team

play05:17

had completed the work on the hydraulic pump

play05:19

and the cabin crew started boarding the 97 passengers

play05:22

who were scheduled for the flight.

play05:25

In reality, there had actually been 100 passengers booked

play05:28

but three of them had encountered

play05:30

some type of document issues

play05:31

during the checkin process

play05:33

and had therefore been denied to travel.

play05:35

Among the passengers who were allowed to board

play05:37

were a 28-year-old conscript who had been assigned a seat

play05:41

in the very last row in front of the aft galley.

play05:44

He was not paying much attention

play05:46

to the safety briefing that the cabin crew were giving

play05:49

and instead decided to just relax

play05:51

without fastening his seat belt,

play05:53

something that will have

play05:54

profound consequences for him later on.

play05:57

In the cockpit, the first officer

play05:59

had now completed the setup

play06:00

and the performance calculations as well.

play06:02

When the load sheet arrived, she had spotted several mistakes

play06:06

including a one-ton discrepancy

play06:08

between the calculated and actual fuel as well

play06:10

as some passenger number mistakes

play06:12

but that had now been corrected.

play06:14

Since everything was now done,

play06:15

she started the departure brief

play06:17

by calling out the takeoff speeds

play06:19

which included a V1 decision speed of 144 knots,

play06:22

a rotation speed of 146 knots

play06:25

and the single-engine climb speed, V2 of 150 knots.

play06:31

Now these were quite high speeds

play06:32

for a 737-200 but like I mentioned before,

play06:35

that was due to both the high-density altitude

play06:38

and weight of the aircraft.

play06:40

Because of this, she also briefed

play06:42

the captain that they would need to use

play06:43

an engine-pressure ratio,

play06:45

EPR of 2.18, which basically meant full thrust.

play06:50

After she had called that out,

play06:52

she tried to continue the brief but was interrupted by the captain

play06:55

who wasn't interested in hearing the rest at all.

play06:58

And instead he just continued

play07:00

his conversation that he was having with the purser

play07:02

who was still present in the cockpit for some reason.

play07:06

This meant that the rest of the briefing

play07:08

was never done and instead, the before-start checks

play07:11

was eventually completed

play07:13

and the first officer called up the tower

play07:14

to advice that they were now ready for push and start.

play07:18

And at some point around here,

play07:19

the captain had also decided

play07:21

that he wanted his friend, the purser,

play07:23

to stay in the cockpit for the takeoff

play07:25

so that they could continue their conversation.

play07:28

This meant that the purser would now be occupying

play07:30

the middle jump seat in the cockpit

play07:32

instead of his cabin jump seat

play07:34

as the aircraft started taxiing out.

play07:37

Now those of you who are frequent viewers of my videos,

play07:40

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play07:42

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play07:44

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play07:47

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play07:50

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play07:52

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play07:54

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play08:00

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play08:03

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play08:06

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play08:08

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play08:10

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play08:12

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play08:15

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play08:17

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play08:29

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play08:37

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play08:45

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play08:48

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play08:54

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play09:00

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play09:02

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play09:09

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play09:12

At time 14:08:36, the crew

play09:15

had completed their push back and startup procedures

play09:18

and received an instruction from the tower to start taxiing out

play09:20

towards the holding point for Runway 02.

play09:24

The surface wind was reported as 330°

play09:26

at 12 knots, meaning a slight cross wind from the left

play09:29

but otherwise the weather was absolutely perfect.

play09:33

As the aircraft started taxiing out,

play09:35

the first officer continued to try and follow

play09:37

the standard operating procedures

play09:39

but the captain and the purser

play09:40

were seemingly not interested in that at all

play09:43

and this just makes my blood boil.

play09:48

Because first of all, in a Boeing 737,

play09:50

there are four cabin crew members for a reason.

play09:54

The idea is that they should guard

play09:56

all of the main emergency exits

play09:58

in case of an evacuation and also

play10:00

to help organizing and deal

play10:01

with any issues that might arise in the cabin.

play10:04

The one in charge of that work is the purser

play10:06

who is the most senior cabin crew

play10:08

and he's also the number three

play10:09

in the chain of command after the captain and the first officer.

play10:13

So for the purser to choose

play10:14

to stay in the cockpit during one of the most critical phases

play10:18

of any flight is just completely unacceptable.

play10:22

And secondly, from the start of the pre-flight briefing

play10:25

and until we pilots complete

play10:26

the last shutdown checklist of the day,

play10:28

our focus must be solely on the safety of the flight.

play10:33

Now can we chat a little bit

play10:35

about unrelated stuff during the flight?

play10:37

Well, of course we can, especially up in the cruise

play10:40

but during the briefing and during

play10:42

the sterile phases of flight, absolutely not.

play10:45

And there are very good reasons for this.

play10:48

If we look at what happened so far,

play10:49

in this example, the fact that the departure briefing

play10:52

was interrupted by the captain indicates that he didn't see

play10:55

that briefing as having any great significance

play10:58

but the problem is no matter how used

play11:00

you might be with flying a specific departure,

play11:02

dealing with an airport, the briefing forms

play11:04

a hugely important role in providing focus

play11:07

and facilitating crew resource management.

play11:10

During the first light of the day,

play11:12

we tend to always conduct an emergency brief

play11:14

and touch drill all of the items

play11:16

that needs to be done in case something goes wrong.

play11:19

This will wake up the muscle memory

play11:21

and bring any rusty procedures back into focus

play11:24

and it will clarify the roles of each crew member

play11:28

in case something unexpected happens.

play11:31

This emergency briefing is then repeated again

play11:34

in a shortened form during the taxi out

play11:36

to make sure that this is the last briefing

play11:38

that we hear before departure.

play11:41

And on top of all of that,

play11:42

there is also often special engine failure procedures

play11:45

that differ between each airport

play11:47

and must be followed in case an engine failure occurs.

play11:50

These can be either company-specific

play11:52

or airport-defined and in case

play11:54

of Tamanrasset Airport, the procedure from Runway 02

play11:57

was to climb straight ahead

play11:59

to the TMS VOR

play12:01

and then turn left to a heading of 239°

play12:04

and climb to above the minimum sector altitude

play12:06

of 5,036 feet.

play12:09

None of that had been briefed

play12:10

prior to the engine start

play12:12

and as the aircraft was now taxiing out

play12:14

towards the holding point,

play12:15

the captain and the purser again ignored it

play12:17

and instead just continued their private chat.

play12:21

Obviously, we don't know

play12:22

what the first officer was thinking at this point

play12:24

as the aircraft was taxiing out

play12:26

but I doubt that she was very impressed with it.

play12:29

And even if she was mentally briefing herself

play12:33

about how to fly the departure

play12:34

and what to do in case of an emergency,

play12:36

this would be of little help

play12:37

if the captain who was the pilot in command

play12:39

was not prepared and we will see

play12:41

what I mean by that very soon.

play12:44

Eventually, the aircraft reached the holding point

play12:46

and at time 14:12:30, the first officer called up

play12:50

the tower and advised them

play12:51

that they were now ready for departure.

play12:54

The tower controller responded

play12:55

that they were cleared to line up and take off Runway 02

play12:58

with a surface wind of 330° at 12 knots

play13:01

and as soon as this was heard,

play13:03

the crew verified that flaps one

play13:05

was set for takeoff and the first officer

play13:06

read back the clearance as they

play13:08

started lining up on the runway.

play13:10

Now what no one knew at this stage

play13:12

was that inside of the left engine,

play13:14

a big problem had already started developing.

play13:18

Several small cracks had started

play13:20

to form on the blades of the high pressure turbine

play13:23

situated just behind the combustion chambers.

play13:27

These cracks had been forming due to thermal fatigue

play13:30

and had been covered with a layer of old coke

play13:32

which is a type of black solid residue

play13:35

formed when oil oxidizes and breaks down

play13:37

from extreme temperatures.

play13:40

And this had allowed the cracks to go unnoticed

play13:43

and it is possible that they had started

play13:45

to form after the last engine overhaul.

play13:48

No one will ever really know.

play13:52

In any case, the pilots knew nothing about that

play13:54

and the captain now finished lining up

play13:56

the aircraft with the center line

play13:58

and moved the engine thrust levers

play13:59

up to around 1.2 EPR to stabilize them.

play14:03

The first officer called out stabilized

play14:05

which prompted the captain

play14:06

to then set take off thrust and the two engines

play14:09

now roared into full thrust as the first officer called out,

play14:12

"I have controls."

play14:14

The aircraft started accelerating down the runway

play14:16

and initially, everything looked completely normal.

play14:20

The captain called out, "You have uh, 90, uh 100."

play14:23

And then a few seconds later, "V1, rotate."

play14:27

The first officer responded by rotating the aircraft

play14:29

nice and slowly with around 3° per second

play14:32

up to an initial attitude of around 18°.

play14:35

The aircraft had accelerated

play14:36

to a speed of 160 knots at this point

play14:39

and about five seconds into the flight,

play14:41

the first officer asked for gear up.

play14:44

But almost exactly at the same time as she did that,

play14:46

several of the blades inside of the left, number one engine,

play14:50

high-pressure turbine, suddenly fractured.

play14:54

When they did so, it led to an immediate loss of thrust

play14:56

from engine number one

play14:58

as the turbine slowed down dramatically.

play15:01

This also meant that the second stage turbine blades

play15:03

behind the first, sustained severe damage from the debris

play15:07

and since there was now no first stage

play15:09

to push the air out, the second stage

play15:11

received all of the hot air coming directly out

play15:14

of the combustion chamber with now nowhere to go.

play15:18

Without the normal cooling from the airstream,

play15:20

those blades now started melting down from

play15:22

the incredible heat and this whole process

play15:25

all happened within a few seconds.

play15:29

Now this was not great

play15:30

but it was far from catastrophic either.

play15:34

The failure was contained inside of the left engine

play15:36

and there was no fire and the right engine

play15:38

was still providing full take-off thrust.

play15:42

This is a scenario that all pilots

play15:43

train to handle every six months and although extremely rare,

play15:47

it is well within the performance of the aircraft

play15:50

as long as it's handled promptly

play15:52

and in the correct way

play15:54

but here the results of the crew's poor preparation

play15:57

would start to really show its true effects.

play16:01

As the engine failure happened, the aircraft veered about 12°

play16:04

to the left due to the effect

play16:06

of asymmetric thrust from the still working right engine

play16:09

and the now dead left engine.

play16:11

The first officer reacted to this

play16:12

by pushing right rudder and correct the aircraft

play16:14

back to the right again and remember,

play16:16

she had already called for the gear

play16:18

to be retracted just a second

play16:19

before the engine failure occurred

play16:21

but the captain had either missed this completely

play16:25

or become so surprised by the sudden loud bang

play16:28

and the yaw that he completely forgot about it.

play16:31

The first officer let out a few exclamations

play16:33

as she was now struggling with the crippled aircraft

play16:35

and she also called, "What's going on?"

play16:39

Now in a functioning cockpit,

play16:41

this failure is supposed to be followed

play16:42

by some very defined actions.

play16:45

The pilot flying needs to concentrate

play16:47

on flying the aircraft and getting it climbing safely

play16:50

away from the ground.

play16:52

The pilot monitoring, on the other hand,

play16:53

should be making sure that the aircraft is climbing safely

play16:56

and then support the pilot flying

play16:58

by retracting the gear once a positive rate of climb

play17:00

has been confirmed and then cancel

play17:02

any warnings who might be distracting.

play17:06

The first 400 feet after takeoff

play17:07

should be dedicated to only fly the aircraft

play17:11

and making sure that the configuration is correct

play17:13

and that the aircraft is climbing safely.

play17:16

Once above 400 feet, the pilot flying should call

play17:18

for heading select and state

play17:19

the malfunction while still concentrating

play17:21

on handling the aircraft.

play17:24

The pilot monitoring should then start trying

play17:26

to diagnose the failure and do any memory items

play17:29

that might need to be done

play17:30

in a quick but controlled way

play17:32

whilst also verifying these actions

play17:34

with his colleague.

play17:36

This case is actually a great example of why

play17:38

we have memory items as a severe damage like this

play17:41

where the engine is essentially melting down,

play17:43

can be stopped from getting worse

play17:45

by moving the engine start lever to cut out

play17:47

to stop the flow of fuel but did this happen, you think?

play17:52

No, unfortunately it did not.

play17:54

Instead, the captain, only five seconds

play17:56

after the failure occurred took controls from the first officer

play18:00

and continued to pitch up towards 18°.

play18:03

So here some of you might think

play18:05

that this would be a logic thing to do by the captain,

play18:08

after all he is the pilot in command

play18:10

so it is his prerogative to take controls

play18:12

especially if the first officer is struggling

play18:15

but it is important to remember a few things first.

play18:19

Number one, the captain had no idea, at this point,

play18:22

what was actually causing the handling problems

play18:24

for the first officer.

play18:26

Now he'd heard a bang and felt a yaw but he had not

play18:29

had enough time to actually assess the situation.

play18:33

Number two, the first officer who was asking what was going on

play18:36

was actually handling the situation

play18:37

according to her training and in a quite good way.

play18:41

It is profoundly hard to take controls

play18:44

during an emergency which is including handling difficulties

play18:47

when you haven't been handling

play18:48

the aircraft from the very beginning.

play18:50

An engine failure or flight control problems

play18:52

can manifest themselves in very different ways,

play18:55

depending on what's causing them.

play18:56

So trying to shift controls at a very low altitude

play18:59

can be hard even if you know what's going on and this captain

play19:02

did not know that.

play19:05

The aircraft was still climbing at this point

play19:07

and the first officer had called for gear up

play19:09

so the best thing to do here would have been for the captain

play19:11

to follow the procedures who had been created

play19:13

for exactly this scenario but, unfortunately, as we know

play19:17

these procedures had not been briefed earlier

play19:20

so the captain now found himself in control of a situation

play19:23

he had not mentally prepared for,

play19:24

flying an aircraft with an unknown fault

play19:27

at an altitude of only 300 feet.

play19:30

He just continued pitching for the normal takeoff attitude,

play19:33

which with a failed engine and a fully-loaded aircraft

play19:36

with the gear still hanging out,

play19:37

meant that the speed now started decreasing rapidly.

play19:42

During the next few seconds,

play19:43

the captain shouted to the first officer several times

play19:46

to let go of the controls which she read back

play19:48

that she had already done.

play19:50

She also offered to retract the landing gear but got no reply

play19:53

from the captain who was likely

play19:55

now so deep down into the stress cone

play19:57

that he didn't didn't even hear her.

play19:59

This meant that the gear was never retracted

play20:02

and with the configuration they were now in,

play20:03

they would have needed to pitch down substantially

play20:06

to keep the speed and to still climb.

play20:09

The normal pitch attitude after an engine failure

play20:11

once the gear is up would be around 12°

play20:14

but the aircraft was still maintaining

play20:16

around 18° at this point.

play20:19

Now even with the gear out,

play20:21

the performance of the aircraft

play20:22

would have allowed for a climb of around 150 feet per minute

play20:26

if the speed was capped at V2.

play20:28

This would have increased to around 450 feet per minute

play20:31

if the gear was actually retracted

play20:33

but, unfortunately, there was now also another issue

play20:37

because at some point, during the initial seconds

play20:39

after the failure, the thrust on the remaining engine

play20:42

on the right side had also been reduced.

play20:46

We don't know if this happened

play20:47

when the captain took over the controls

play20:49

or if it was a knee-jerk reaction

play20:51

to the yaw by the first officer

play20:53

but the combined effect of the fully-loaded aircraft

play20:56

with one failed engine and the other working

play20:58

below full thrust and the gear still hanging out

play21:02

was that this aircraft was now quickly approaching a stall.

play21:06

The captain continued to call

play21:08

for the first officer to remove her hands

play21:10

which she responded that she had already done.

play21:12

Now it is possible that he felt some resistance in the controls

play21:16

and assumed that this was caused

play21:18

by inputs from the first officer

play21:19

or she might have just instinctively

play21:21

kept her hands on the yoke.

play21:23

We don't really know but we do know

play21:26

that the first officer now took up her hand mic

play21:28

and called air traffic control saying,

play21:31

"We have a small problem."

play21:33

And only one second after that call,

play21:35

the first stick shaker activation

play21:37

could be heard on the cockpit voice recorder,

play21:39

lasting for about one second.

play21:42

Now the first officer should not have concentrated

play21:44

on communicating with air traffic control at this point.

play21:47

Instead she should have been monitoring

play21:49

and calling out the speeds and altitude tendencies

play21:52

that she could see from her instruments.

play21:54

But the fact that she had been turned

play21:56

from pilot flying to pilot monitoring

play21:58

without any type of formal handover

play22:00

had likely disoriented her and, at least, she was trying

play22:03

to do something by calling air traffic control

play22:06

and suggesting the gear to be retracted.

play22:09

The aircraft reached its highest altitude

play22:11

of 390 feet about 12 seconds after the engine failure occurred

play22:16

and at that point, the speed had degraded so much

play22:18

that the stick shaker now started working continuously

play22:22

and it continued doing so for the rest of the flight.

play22:26

The captain did not verbaIize this warning in any way.

play22:29

He just continued to pitch with the same attitude

play22:32

as the aircraft now started

play22:33

descending rapidly towards the ground.

play22:36

In the tower, the controller had seen the initial yaw

play22:39

of the aircraft and had recognized

play22:40

that they were in some deep trouble.

play22:43

He immediately pushed the accident alarm

play22:45

which alerted the airport firefighters

play22:46

who now started rushing out towards the runway end.

play22:50

In the cockpit, the stick shaker was now also accompanied

play22:53

by a GPWS, "Don't sink," warning

play22:56

and the right wing now started to slowly drop,

play22:58

likely due to the impending stall.

play23:01

At time 14:15:18, Air Algerie Flight 6289

play23:06

touched down just beyond the end of Runway 02

play23:09

with the back of the aircraft

play23:11

and right wing hitting the ground first.

play23:13

The huge amount of fuel inside of the wing

play23:15

was almost immediately ignited

play23:17

turning the aircraft into a fireball

play23:19

as it broke into several pieces

play23:21

sliding through an airport perimeter fence

play23:23

and over a road before it finally came to a halt.

play23:27

The majority of the aircraft was almost immediately

play23:30

consumed by the fire and there was not much

play23:32

the firefighters could do when they reached the wreckage

play23:35

only about three minutes after the alarm had been sounded.

play23:40

Out of 97 passengers and six crew members,

play23:43

102 of them perished immediately

play23:45

which meant that there was only one survivor.

play23:48

This was the 28-year-old conscript

play23:51

that I mentioned earlier.

play23:52

Because he hadn't fastened his seat belt,

play23:55

he was ejected from the aircraft

play23:57

as it started break breaking apart

play23:58

and that likely saved his life.

play24:00

He was still seriously injured and lay in a coma for several days

play24:04

before eventually waking up and that means that he

play24:06

and the three passengers who missed their flight,

play24:09

should consider themselves very, very lucky.

play24:13

The investigation concluded that the accident was caused

play24:15

by a loss of engine thrust during a critical phase of flight

play24:19

followed by a failure to retract the landing gear

play24:21

and the captain taking controls

play24:22

without being properly prepared or having identified the problem.

play24:27

The below-standard flight preparation,

play24:28

the fact that the failure happened

play24:30

just as they were about to retract the gear

play24:32

and the non-existing CRM

play24:34

after the failure also contributed to the accident.

play24:38

There were four different recommendations

play24:39

as a result including increased CRM training

play24:41

for all pilots at Air Algerie, more focus on conformity

play24:45

of engine failure training as well as the implementation

play24:47

of a better flight safety program

play24:50

who could monitor and analyze flight data

play24:52

to identify dangerous trends.

play24:54

And from a very personal note,

play24:56

this is exactly why following

play24:58

and respecting standard operating procedures

play25:01

is so important.

play25:03

You never know when they might save your life

play25:06

just like you will never know

play25:07

when I release my next video

play25:08

unless you have subscribed to the channel.

play25:11

You can support me by supporting my sponsor,

play25:13

getting an awesome t-shirt

play25:15

or joining my fantastic Patreon crew.

play25:18

Have an absolutely fantastic day

play25:20

and I'll see you next time, bye-bye.

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Etiquetas Relacionadas
Air AlgerieFlight 6289Aviation SafetyPilot TrainingEngine FailureCockpit CrisisAir DisasterFlight ProceduresCrew CoordinationAccident Analysis
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