- [Petter] Have you ever played the computer game Tetris? If you have, you will likely be familiar with the feeling of how fast things start to go wrong just before game over and how little it feels like you can do about it. Well, the pilots of this airplane is experiencing that exact same feeling, but for them, the stakes are much, much higher.
Stay tuned. - [Radio Altimeter] 100, 50, 40, 30, 20, 10. - On the 22nd of January, 2002, a Boeing 757 from Icelandair was cruising along at 37,000 feet over the North Atlantic.
This was the first leg of a three-leg day for the crew, who was enjoying some slow time before they needed to start preparing for their approach into Oslo Gardermoen. They had departed their home base in Keflavik, Iceland at 07:35 in the morning and was now heading first towards Oslo Gardermoen in Norway before they would continue to Stockholm Arlanda in Sweden and then finally back home again to Keflavik. The pre-flight planning had been pretty straightforward.
It was a standard January day in Scandinavia with some light snow forecasted, giving reasonable visibility and a cloud base around 500 feet. The temperature was hovering around minus 4 degrees centigrade. The only issue the pilots had seen was a possibility for some light freezing rain, which could potentially cause some icing on the ground, but apart from that, the weather didn't look like it would cause any major issues.
The aircraft was in good shape, except for a few inoperative systems that the engineering department had deferred to be fixed at a later stage. Those include the right GPS, the right ILS, and the center autopilot. But none of those systems were critical for the flights that they were planning to do, so the captain had accepted the aircraft.
The two pilots in charge of this flight were reasonably experienced. The captain was 43 years old with a total flying experience of just over 8,000 hours, and he had been working for Icelandair since 1975 when he started as a baggage handler and then worked his way up into the cockpit where he started as a first officer in 1986. The first officer was 26 years old and he had started his career in Icelandair as a flight dispatcher before he, a few years later, also joined the pilot ranks.
At the time of this flight, he had been flying for three years and amassed almost 2,500 hours of total time. As they were cruising along, they checked the progress page on the CDU and it indicated that they might arrive early to Oslo due to some really strong tailwinds. Now we pilots are generally great fans of tailwinds during the en route segment, but that feeling changes slightly when we start descending since the tailwinds can cause quite a bit of problems there as you will soon see.
The captain was pilot flying and initially he was planning to fly a practice Category II autoland approach into Runway 01 Right in Gardermoen. Now a Category II ILS approach is a low visibility procedure that we normally use only when it's very foggy and we therefore need to descend to a lower minima in order to be able to see the runway. There are several extra procedures required in order for such an approach to be flown.
Among other things, the area around the runway must be safeguarded. Extra separation is needed between the aircraft. And the aircraft itself also needs to have special equipment fitted and functioning.
Because this procedure is quite special, we pilots also need to go through special training for it and we're tested on our abilities twice a year. On top of that, we also need to fly at least one Category II or Category III approach for real during each six-month period before our checks. So that was likely why the captain wanted to fly a practice approach on this occasion.
Now one peculiar thing that wasn't mentioned in the final report but that I reacted to was the fact that the aircraft was dispatched with the right ILS inoperative as well as the center autopilot. Because normally, in order to be able to fly these type of approaches, the autopilots needs to be connected to separate sources of ILS signals and therefore, this aircraft shouldn't be able to fly even a practice Category II approach. Now in the end, this detail will not become that important, but either something is very different in the 757 from the 737 or the captain had completely missed this fact, which could point to some degraded technical situational awareness.
Anyway, around 200 nautical miles away from Oslo, the first officer left the radio frequency and started copying the weather information from Gardermoen Airport. The Automatic Terminal Information Service, ATIS, stated that Runway 01 Right was in use with a wind of 010 degrees, 3 knots, and a visibility of 3,000 meters in light freezing drizzle, few clouds at 200 feet, scattered clouds at 300 feet, and broken clouds at 500 feet. A temperature of minus 4 degrees centigrade and an air pressure of 985 hectopascal.
But the ATIS also included information about some temporary conditions, including a visibility of only 1,000 meters in freezing drizzle and mist. Vertical visibility of only 400 feet and, crucially, a tailwind of 20 knots reported down to 200 feet. The reason this is important is because it shows both a potentially worsening visibility situation and also, crucially, the combination of a very cold temperature on the ground with freezing drizzle and the mention of a strong tailwind on approach.
This is indicative of a potentially quite tricky atmospheric phenomenon known as a temperature inversion. So what's that, you're asking? Well, normally as we climb higher above the Earth's surface, the temperature will decrease with around 3 degrees centigrade per 1,000 feet of altitude.
This temperature drop then continues until we reach an area in the atmosphere known as the tropopause, under which most of the weather and clouds that we can see is located. The fact that the temperature decreases allows pockets of warmer air to float upwards, and those bubbles will continue to rise until they reach a temperature known as the dew point, where the water vapor inside of that pocket will start to condense into water droplets and form clouds. Those are the fluffy cumulus clouds that you often see during the afternoons during the summer.
Anyway, sometimes very special atmospheric circumstances can cause this rule of temperature reduction with altitude to locally reverse, meaning that the temperature, instead of getting colder with altitude, starts getting warmer for a short while, and that's known as a temperature inversion. This often happens during the presence of strong high pressure. And I'm sure that you've all seen this during the summer when the weather has been really good for a few days that the visibility often starts to decrease and it can become very hazy.
That's because the normal circulation of air, as I described earlier, has been halted by the inversion, which has created a kind of lid under which all pollution and moisture gets trapped. These inversions can also be caused by very heavy, cold air flowing down into valleys during the winter and creating these local lids, and that's often recognized, among other things, by the presence of freezing rain. The freezing rain is caused by the precipitation above the inversion being normal rain, which then suddenly falls into much colder air below it, where it becomes super cool, but it doesn't have time to freeze into snow or hail until it hits the surface.
That's why freezing rain can create so much problems with icing, but also, and crucially for this story, because this inversion has created this lid, the winds above and below it can be very different from each other. In this case, the wind above the inversion was westerly and quite strong, but below it, it was northeasterly. So why would that be an issue then?
Well, those of you who have been following this channel for a while know that aircraft always try to take off and land into the wind. That's because this will enable maximum speed of air flowing over the wings with the lowest actual speed over the ground. Basically, air speed for free.
That will enable us to take off using shorter distances. And it will also allow us to land with a lower ground speed, enabling a shorter landing roll. But what happens if there's a strong tailwind on the approach but still headwind on the ground?
Well, we're shortly about to find out after this. Don't you also find it tiring not to know what to trust when you switch on the news? I find it infuriating because if you follow both my channels, you know how important it is for me and my team to provide you guys with accurate and unbiased information.
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Or you can also subscribe with the link and get unlimited access at a 30% discount plus the knowledge that you're supporting a small team of media outsiders trying to make a real difference. Now back to the story. When the first officer came back on the radios after having copied the ATC, shared the weather information with the captain.
It was not great, but it was still within the Category 1 ILS requirements for the planned runway. And the detail about the reported tailwind was not really discussed or seen as a threat at this point. Instead, the captain handed over the controls and started setting up the flight deck for the Category II practice approach that he was still planning to do.
And he then proceeded to brief the first officer on the arrival route and the approach. In the back of the cabin, the 5 flight attendants were taking good care of the 75 passengers that they had on board. In total, there were only 82 people on this first flight, which is quite a light load, and that's something that will likely have an important impact on what's about to come.
Around 09:30 UTC, the Oslo Air Traffic Controller gave them their first descend clearance and then advised the pilots that they would be flying the SIG TWO ECHO arrival route into Gardermoen. The aircraft started descending with around 117 nautical miles to go according to the FMC. And that would be very close to the ideal distance they needed in order to descend.
A rule of thumb that we often use to calculate how many miles we need to descend for an aircraft of this size is that we need about three times the altitude in a thousand feet in track miles, plus 1 nautical mile for each 10 knots of airspeed that we need to lose above 200 knots. In this case, if the aircraft was cruising at 37,000 feet, that would mean 37 times 3 which is 111. And then their indicated air speed was likely around 260 knots, meaning another 6 miles added on top of that, which is 117.
The Aircraft Flight Management Computer will calculate the optimal descent path for us, which we normally tend to use, but its calculation assumes that we will be flying the entire programmed arrival route. But quite often we get shortcuts, making computer calculation less reliable. If that happens and we haven't prepared for it, we can end up high on our profile.
Something that we really want to try to avoid. And therefore, we tend to always sit and manually calculate how many track miles we need in a straight line distance to the airport in order to see if we can actually accept a shortcut that's given to us. On top of that, there is also another thing that we need to keep in mind when we are monitoring this.
The calculation that I just showed you assumes that we're descending in still air. If we're not, then we need to take the headwind or tailwind into account in this calculation as well. If we have tailwind like these pilots did, then we need to add around 1 nautical mile for each 10 knots of tailwind.
And that's something that can be very easily forgotten. During the descent, the pilots did discuss the unusually strong tailwind they had when they could clearly see it on their navigation display. But it was never really perceived as a real threat.
As they were getting closer to Oslo, the air traffic controller advised them that there had been a change of runway. Gardermoen was now using Runway 01 Left instead of Runway 01 Right due to snow clearing in progress on 01 Right. This new runway didn't have Category II approach capability.
So the captain now quickly handed over the controls again to the first officer and started resetting up for this new approach, which included changing to Category I minimums, as well as doing a full new briefing. This direct routing also meant a slight shortcut, meaning that they now had less track miles. And they suddenly found themselves getting a bit high on their descent profile.
Minutes later, the controller cleared Flight 315 to continue direct towards a waypoint called SONER. And he also told them that they could use free speed below flight level 100. Normally, we always have to reduce the speed to below 250 knots below flight level 100 because of potential general aviation traffic and birds and stuff below there.
But within controlled airspace, the controller can temporarily waive this rule. They typically do this, either to speed the traffic flow up or to help pilots to lose some altitude if they've ended up high, which was likely the case here. As the aircraft was clear to descend lower, they were now directed to fly direct towards a non-directional beacon called SOLBERG, meaning yet again, a further shortcut.
The captain had now realized the problem as his aircraft continuously kept getting higher and higher above the calculated descent profile. And he had started to use his speed brake to try to increase the drag. He also eventually reduced the speed a little bit.
And although that would have initially worked against him, since slowing down meant pitching up and reducing the descent rate, this would eventually enable him to start configuring the aircraft with flaps, which would further increase the drag and allow him to descend faster per nautical mile. You see, what you're seeing here is what we refer to as descent and energy management. And it's one of the most difficult parts of handling an airliner under normal conditions.
During line training, it tends to be among the last things that are signed off before a student is ready for their line check. And it takes years to properly master. In the end, though, if tailwind and shortcuts makes following the descent profile too hard, there is one sure remedy that always works, and that's asking for more track miles.
That can be done in the form of a longer radar vector from the air traffic controller or by entering a holding pattern for a short while. But in any case, more track miles will always slow things down and give some breathing room to the pilots. The problem though, is that pilots are proud people and we often try to fix the issue rather than adding a couple of minutes and extra fuel burn to the flight.
It is really easy, especially as pilot flying to become really goal-oriented and like, I must get this aircraft down in such a way that we miss the obvious solution, which is just to slow things down and get some more time. This is where a strong and assertive pilot monitoring can and must play a really important role. By not being in direct control of the aircraft, the pilot monitoring generally has a better overview.
And in these kind of situations, he or she must speak up and suggest the obvious solution which is asking for more track miles. Unfortunately, in this case, the first officer seemed to have not fully picked up on the deteriorating energy situation and therefore, he remained passive. The normal procedures were however followed and the cabin crew secured the cabin for landing and notified the pilots when they were ready.
When the aircraft was about 10 nautical miles away from the runway, they were cleared to descend to 3,000 feet, proceed direct on 8 miles final, and after that, they were cleared to intercept the ILS approach for Runway 01 Left. At this point, the aircraft had an indicated air speed of about 220 knots. It was still above the profile and with a tailwind of close to 45 knots, meaning that their ground speed was much higher than normal, at close to 270 knots.
Now a quite useful rule of thumb for most Boeing aircraft is what we call the 10-mile 3-2-1 rule. It states that at 10 nautical miles, we should be about 3,000 feet, 200 knots and with flaps 1 selected. In this case, the aircraft was both above this altitude and with a higher speed.
And on top of that, the tailwind was making it almost impossible to get back down onto the profile. In pilot terms, this is known as being hot and high. Even if they would have been able to correct the profile, dealing with such a strong tailwind on final would have been really challenging.
First, the tailwind in practice means that the aircraft will have to descend with a steeper than expected relative angle because it's moving faster. But on top of that, this tailwind would eventually disappear and below the inversion, it would turn into a headwind. What that would mean, since the aircraft gets its performance from the speed of the air that's flowing past it, is that it would suddenly go from a tailwind which caused a high ground speed into a sudden headwind.
And during that change, if the change comes suddenly, it would be indicated as a sudden increase in airspeed, which would increase the lift and could cause an overspeed of the flaps. Like I mentioned earlier, this kind of conditions can be really tricky and will require the pilots to be exceedingly careful and prepared for it. When they were cleared for the approach, the captain, who was still flying on autopilot, armed the autopilot approach mode.
In this mode, the autopilot will feel when the localizer and glide slope beams, transmitted from antennas on the ground, are close enough and it will then lock onto those and start following them down towards the runway. But because the aircraft was still flying with a much higher ground speed than the autopilot had calculated with, the aircraft just flew past the centerline when it captured the localizer and then proceeded out on the east side before turning back to the left to try and align with the beam again. At this point, the glide slope beam was so far below the aircraft that the autopilot was unable to capture it and instead, continued to descend using the previously selected descent mode.
At time, 09:46, the approach air traffic controller cleared the aircraft to descend further down to 2,500 feet. The captain reached over and set this new altitude on the Mode Control Panel, the MCP. And remember this altitude because it will become very important very soon.
After the new altitude had been set, he then called for the landing gear to be selected down and the landing checklist to be started. He also asked for the flaps to be extended to 20 degrees. The aircraft had now established itself on the localizer, but was still more than one dot high on the glide slope, which meant that the autopilot still had not been able to capture it.
The captain saw this and from the position they were now in, he doubted that the autopilot would be able to rectify the situation. So instead, he elected to disconnect both the autopilot and the autothrottle to start pitching down manually. Now this can sometimes help if a small correction is needed, but the overall energy situation of the aircraft is rarely rectified by disconnecting the automatics and instead, it often just increases the workload on the crew, which negatively impacts both communication and CRM.
The first officer was, up until this point, responding to commands from the captain and executing what he was told to do. But he appeared to be mentally falling behind the aircraft and did not try to prompt the captain about the increasingly unstabilized approach. And as if this wasn't enough, when the captain was now scanning his primary flight display, his ILS pointers suddenly and without any failure flag, just disappeared.
This caused the captain to decrease his descent rate slightly when he was trying to figure out what was happening, making the aircraft go even further above the glide slope. He called out the failure he was seeing to check if the first officer was also experiencing the same, but everything seems to be working on his side. This situation could really only be solved in two ways.
Either by immediately handing over the controls to the first officer, who would then have to try to manually deal with the high energy approach without being prepared for it. Or the captain could initiate a go-around, but none of these options were used at this point. The captain's ILS instrument kept appearing and disappearing as the aircraft descended down the approach which further distracted him from continuing to configure the aircraft and preparing it for landing.
They passed the 1,000 feet landing gate where they needed to be stabilized on the glide slope on speed and with all checklists completed without the landing flaps selected or the landing checklist complete. Also, they were still well above the glide slope, meaning that the aircraft was not stabilized. This is a mandatory go-around condition but the approach still continued for another few seconds.
Now remember how I said that the MCP altitude had been selected to 2,500 feet? Well, in normal conditions, the missed approach altitude, which is the altitude that the aircraft should climb to in case of a go-around, in this case 4,000 feet, should be set when the glide slope is captured. But since the glide slope was never captured, this altitude had also not been set, which would act as yet another brick added to the Tetris game in this case.
When the aircraft descended through 580 feet above ground, the captain finally decided that he had had enough and correctly decided to abandon the approach. He called out, "Go-around. " And this is where the incident really starts.
When the go-around maneuver started, the indicated airspeed was 182 knots. The aircraft was flown manually and the flaps were set at 20 degrees. When the captain pushed the TO/GA buttons, it activated the flight director's go-around mode, which moved the command bars up to guide the pilots towards an initial pitch of 15 degrees nose up.
It also reactivated the autothrottle which started moving the engine thrust levers forward towards maximum go-around EPR. Now since the engines on the 757 is mounted under the wings, a big thrust increase will cause a pitch up momentum. And that, together with the fact that the captain likely was starting to become overloaded might be an explanation to what happened next.
Because the pitch of the aircraft didn't stop at 15 degrees as the flight directors commanded. Instead, it continued up to 20 degrees, which caused a much higher than normal climb rate. The gear was selected up, which led to less drag.
And the speed initially increased to 198 knots before the high pitch caused it to start dropping again. The very high climb rate that the aircraft was now flying meant that the altitude capture function of the flight director almost immediately sensed that the aircraft was getting closer to the 2,500 feet that was still set on the MCP and therefore, it started moving the flight directors to level off at that altitude. This also sent signals to the autothrottle to start reducing thrust to maintain the speed selected on the Mode Control Panel of 150 knots.
But instead of following these commands, the captain continued to pitch up and manually forced the thrust levers to stay in go-around thrust. At this stage, the captain's situation awareness was likely quite reduced because of the destabilized approach behind him and the now rapidly changing go-around that was unfolding around him. He probably knew that the go-around altitude that he had briefed earlier was supposed to be 4,000 feet, and could therefore not understand why the aircraft suddenly wanted to start leveling off way lower than that.
The aircraft quickly climbed past 2,500 feet, with the flight directors now pointing down to indicate how to recapture that altitude. Meanwhile, the high pitch angle had now also caused the speed to reduce back to 137 knots, which was close to the minimum speed of 131 knots required for flaps 20, which they still had extended. Can you hear how the Tetris bricks are starting to fall faster and faster?
At time 09:49:34, the aircraft reached its maximum multitude of 2,895 feet as the captain suddenly started applying forward pressure on his yoke to pitch the aircraft down. It is unknown if he did this to try to stop the rapid speed decrease or if he, in his now quite confused state, just wanted to follow the flight directors who were directing him to pitch down. In any case, the pitch forward he now introduced was far beyond what any normal maneuver would require.
This sudden pitch forward created a negative G force of minus 0. 6G, causing water to be pushed out of the toilets like fountains, as well as throwing all loose items inside the aircraft up into the ceiling. In the cabin, purses and mobile phones were flying around so violently that some of the items from the pockets of passenger seats in rows forward of the wings were later found in the aft galley.
Luckily, all crew and passengers were seated down with their seatbelts fastened when this happened, except for one passenger whose seatbelt didn't lock for some reason, but he still managed to remain in his seat. Now the aircraft started descending rapidly. The first officer, who had been thoroughly behind the aircraft up until this point and hadn't provided much help, now called out, "Bug up!
" Which is the call that we use to move the speed bug up to the speed needed for safe flap retraction. The captain, still flying manually, now reached up and changed the selected speed on the MCP from 150 to 210 knots. And he then selected level change to try to get the flight directors to indicate something that made sense to him.
Since he was still flying manually at this point, him changing the values on the MCP was strictly against the standard operating procedures, as the pilot flying should only focus on flying when the autopilot is disconnected. And to show you why that is so important. As he was doing this, his forward pressure on the control column increased and pushed the nose down into a terrifying dive of 49 degrees nose down.
And this was happening at an altitude of only 2,500 feet or so. This dive obviously led to a very rapid acceleration. And now the first officer came back into the game and called out, "What are you doing?
Pull up, pull up! " At the same time, the autothrottle was finally left alone to do its job, which meant that it started pulling the thrust levels back to idle, which unfortunately, again, due to the engines under-mounted positions now led to a further pitch down momentum. The Ground Proximity Warning System had now joined the first officer and was calling out, "Terrain," and "too low, terrain.
" But none of the pilots registered those oral warnings. Again, showing that the hearing just doesn't seem to work well under extreme stress. The speed had now accelerated to 251 knots, which was way above the maximum speed for flaps 20, and the ground was now approaching fast.
Both pilots now realized what was happening and started pulling on their controls for dear life. We know that they both did this because the flight data recorder registered different values from the left and right elevator, showing that each pilot was now controlling one elevator, just as it was designed to do, but in case of a control blockage. This sudden pitch up caused a crushing positive G load of 3.
59Gs, around the same as you will experience on some roller coasters, but well outside of the maximum certified limits of a passenger aircraft, which is 2. 5Gs, with a safety factor of 1. 5G on top of that.
As this violent pull up was happening, people in the cabin were screaming for their lives, as all of the items that had been previously pinned up into the ceiling, including the toilet water, now came raining back down. The lowest point that the aircraft reached was 321 feet above the north threshold of Runway 01 Left. And the terrified passengers could, at that point, see the ground below them.
The pilots never saw the ground. This whole ordeal was done with no outside references for them. Like I mentioned earlier, it was lucky that this aircraft was relatively light, as a slightly higher weight would have likely meant that this recovery would have been impossible.
The aircraft now turned skywards again with an almost equally extreme pitch up attitude of 40 degrees. The autothrottle activated again and increased the thrust to 98% as the climb continued. After several more abrupt control inputs the aircraft finally regained some kind of stabilized climb and leveled off momentarily at 3,000 feet until it finally continued climbing to 4,000 feet.
The pitch attitudes during the maneuver had moved between 49 degrees pitch down to 40 degrees pitch up. And just to put that into context, an aircraft is deemed to be in an unusual attitude if it pitches below 10 degrees nose down or above 25 degrees nose up. Those attitudes require an immediate recovery procedure to be performed, something that we train in the simulators at regular intervals.
So what happened next then? Well, the aircraft had finally stabilized at 4,000 feet. The autopilot was engaged and the after takeoff checklist was completed.
The first officer then contacted air traffic control and reported the missed approach, but he didn't mention anything about the terrifying upset that they'd just experienced. The captain made a short PA to the passengers where he said that the previous approach had not been successful, which must be the understatement of the year. And he then told them that they would be doing another approach and that they should be on the ground within about 10 minutes.
As he was making that PA, the status in the cabin was absolute chaos, with items thrown around everywhere. And inside the cockpit, it looked the same, with approach plates, manuals and flight bags strewn all over. The second approach was much more stabilized, but just like on the first one, the captain's ILS instruments started misbehaving.
But this time, he handed over the controls to the first officer, who continued to a successful landing. During the taxi, the pilots tried to summarize what had caused the upset without coming to any real conclusions. When they parked at the gates, they cleaned up the cockpit and then proceeded to brief the shocked cabin crew about what had happened.
Unfortunately, at that point, the passengers had all disembarked, which meant that they never received any briefing or explanation about what had happened, something that eventually led to several of them contacting the aviation authorities to file reports about the flight. Others likely suffered long-term psychological trauma from the event. And this just goes to show how important proper information and communication is, especially after a traumatic event like this.
The captain checked with the cabin crew how they were feeling and if they felt fit to continue flying the next two flights, which they all said that they did. After this, technicians were called to check on the status of the captain's ILS system as well as the flaps that the first officer was worried about overspeeding. But nothing was mentioned about the possible overstress of the airframe itself as a result of the maneuver.
Instead, the aircraft was eventually released to service and the crew continued to fly over towards Stockholm. But the event must have been bothering the captain because once on the ground in Arlanda, he called up the chief pilot and asked him to meet up the aircraft in Keflavik so that he could report the event face to face. And it was after this debrief later in the evening that the first formal report about the aircraft upset was sent to the authorities, which eventually led to this report.
Obviously, the cockpit voice recorder had been long overwritten by then, but the flight data recorder was removed and preserved that same night. Once the full, terrifying story was made clear to the investigators, the aircraft was grounded and ordered by Boeing to go through a full structural inspection. Incredibly, not even a wrinkle on the skin was observed, which must stand as a testament to the fantastic durability of the 757.
Some engine support bolts were replaced just to be on the safe side, but the aircraft could then continue to operate without any further restrictions. The investigation led to several recommendations regarding flight crew training of go-around from unstabilized approaches and general CRM principles, with special emphasis on the role of the pilot monitoring. It also highlighted that Icelandair was not continuously monitoring its fleet for exceedances using operational flight data monitoring, even though the aircraft were equipped to do so.
If such a system would have been in place, it would have captured the extreme G loading that the aircraft had been subjected to much quicker than what happened in this case. Finally, some pointers were also sent to the Norwegian Air Traffic Control regarding the effect shortcuts could have on aircraft during the approach segment. But I want to take this opportunity to tell all of you young, budding pilots out there to always speak up if you start to feel uncomfortable.
And also, just ask for some more track miles when needed. It will only add a few minutes to the flight time, but it will save you many gray hairs throughout your career, I promise you. Now check out this video next or binge on this playlist.
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