have you ever had your plans changed last minute plans that might have been really detailed and you had a clear picture of what you were going to do just to have someone else tell you that you had to do something completely different stay tuned Finland is a country of immense Beauty thousands of lakes and among the happiest population in the world but it's also a country that like my home country Sweden have quite harsh Winters where the temperatures routinely drop down well below 0° C and the sun might be absent for month at a time because of that the fins just as we swedes are very keen on winter holidays which has caused a vibrant Charter industry to evolve and on the 2nd of November 1994 one of those charter flights had been organized to take a group of finished passengers back from Monas air in Tunisia to their home airport of cayan Finland this was planned as a Night Flight for the crew from the relatively new Airline air liberte tunisi and the leg up towards kayani was the first out of a total of three flights planned after cayan they were supposed to make a short flight to savola also in Finland before finally flying back to monaster again now when I say that the airline was young I really mean it it had been founded as a wholly owned subsidiary to the French Airline at there back in 1990 and had since grown enough to become its own entity at the time it operated three MD 83 aircraft with 11 captains and 11 first officers employed most of who had been previously flying for Tunis air these Pilots all answered to their Chief pilot but the company hadn't yet implemented their own safety department and because of that there wasn't really any organized safety promotion work being done and that included crew Resource Management courses but every did their absolute best though to operate the airline as efficiently and safely as they possibly could but their lives were made even more complicated by the fact that the manuals that the crews were using were written in both English from the manufacturer French from air liberte and Arabic which was the language that most of the employees used when it came to the training this was largely handled inhouse by four training captains who also did the simulator checks using least simulators abroad and that brings us to the pilots who have been roster to operate this night the captain was 41 years old and had a total flying experience of just over 99,100 hours he had operated on both the boing 727 and the 747 for various companies before and had been hired by a liberty at tunisi when they started operation in 1990 he had then been typ rated on the MD 83 by a training organization in the UK and had at the time of this flight amassed about 2,300 hours of experience on it but during his type rating training there had been several notes made by his instructors regarding him having issues with the handling of the aircraft in various faces of flight and these handling difficulties had taken up so much of his capacity that the rest of his cockpit management had suffered at times those Tendencies had been present throughout his training but during the following years there had been no further mentions about it in his internal recurrent training file his first officer was actually 2 years older than the captain 43 years old and had a total experience of just over 3,100 hours so which around 680 had been flown on the MD 83 he had previously been working as a flight instructor on light aircraft as well as an agricultural pilot before finally getting hired by air Liberty at tunisi in January of 1994 less than a year before this flight his initial training on the type had also been marred by relatively weak performance especially in the area of CRM and workload management and the combination of these two Personalities in the cockpit will become very important for this story now on the night in question the first officer arrived first to the air Liberty crew room around 2 hours before the scheduled departure which was around 2,300 local time it's very common in most airlines that the first officer is in charge of gathering all of the required briefing material and paperwork so when the captain checked in about 30 minutes later this had all already been done together they then went through the forecasted weather on rout chart flight plans and Nots and everything looked okay for the first long flight up towards Finland the flight plan suggested that they would need 17,1 155 kilos of fuel for the first leg but because they had a company rule of always planning with a cruise altitude 2,000 ft lower than Optimum and they also wanted to tanker as much as possible in order to avoid refueling in gyani the captain eventually decided on a final fuel of 20,8 166 kilos now that is a lot of fuel for an MD 83 but it was within performance limitations and the weather and Runway conditions at their destination were reported as good so when the pilots had ordered their fuel they walked over and started briefing their five cabin crew and when that was all done they walked together out of the aircraft which was being prepared for them out on the apron as they were walking the captain decided that the first officer was going to be Pilot Flying for the first flight and that he would then fly the subsequent two the first officer was happy with that he was still suffering from a bit of a cold and was therefore happy to just fly one out of the three legs so that meant that when they boarded the aircraft the first officer immediately started setting up the cockpit while the captain looked through the tech log and went outside for the exterior inspection the tech log didn't show anything particularly wrong with the aircraft there had been a note from a previous crew about some light wheel vibrations during Landing but apart from that the aircraft was good to go during the exterior inspection the captain probably noticed that the main gear tires were a bit worn that could possibly explain those light vibrations that the other crew had noticed but they were still well within limits now depending on how the wear manifests itself aircraft tires can actually be worn quite far down before they're legally required to be changed so it's unlikely that the captain saw this as any type of problem at this point when he got back into the cockpit the cabin crew had already started boarding the 164 passengers and the first officer was ready to start his briefing so far so good the boarding flowed smoothly partly with the help of a travel guide who had been following the charter group during their trip she spoke both Finnish French and English which meant that she could act as a translator when the crew who were speaking English to the passengers needed something explained in finish the quick boarding meant that the crew was ready for departure about 10 minutes ahead of schedule so as the cabin crew closed the doors and started their emergency brief the pilots requested push and start and a Time 00 56 flight 930 took off into the black Tunisian night and started climbing up towards the north The Climb segment was completely uneventful and about 1 and a half hours of the departure the pilots were offered some breakfast which the first officer declined and to be honest I don't really blame him I'm not sure how hungry I would be at 2:00 in the morning either but he did have some light refreshments and coffee later on now during the cruise phase the workload for the pilots is generally much lower but there is still a few things that we need to do the pet flying is obviously in charge of updating the out the pilet and making sure any direct routings received by our traffic control is being correctly executed and the pet monitoring is in charge of the paperwork noting down new frequencies direct routings as well as doing regular fuel checks and is also doing all of the radio communication but according to the records from this flight there were no paperwork being done at all and given that it was in the middle of the night there was likely very little activity on the radio either so my guess is that these two pilots were probably lulled into a generally low level of arousal arousal can be described as a person's level of alertness as in the Readiness to perform appropriate tasks and if the arousal drops to low like during extreme levels of boredom especially during the window of circadian low which these Pilots were now operating in well then it can be quite hard to quickly get back up again and perform well if something would suddenly happen and as it turns out something would happen which that's annoying right I hate when that happens especially when I'm researching for a new episode or want to watch a movie and that's why I am so happy to have nordvpn as a sponsor of this episode with Nord you can virtually move to almost anywhere in the world at a click of a button which will make sure that you always have access to your 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Descent and approach that they now had in front of them the captain left the frequency to get the latest weather and the first officer started setting up his nav according to the standard ILS approach that they were now planning to follow and here cayan airport was a bit different than most other places This Crew would be used to fly into gyani had what's known as an aphys or Airport flight information service and what that means is that the air traffic controller in the tower is not actually a controller at all instead that's a person trained in air traffic service but without any access to radar or ability to give clearances the apis office can only give information about weather and traffic which also means that the airport is open but uncontrolled all decisions have to be taken by the pilots themselves and on their own responsibility it's not clear whether the pilots in this story had understood this fact because while this is a very common practice in small airports in Scandinavia it's pretty rare in other places and actually I would love to hear if there is any examples of apis airport in the US or Canada if you know of any let me know in the comments below this by the way is a typical subject that I will be discussing with my patrons whenever we have our monthly Hangouts I cannot thank you guys enough for your support without you my team and I would never be able to produce these kind of videos anyway the apis officer had arrived early to the airport this morning specifically because this flight was coming in ahead of schedule and as the flight was now getting ready to descend she was now making sure that all of the approach lights were working that the runways were checked and that the weather was updated meanwhile the first officer briefed the captain about the upcoming approach and since the airspace was uncontrolled and without radar it meant that the aircraft would first need to join something known as a DME Arc from a VR naid called cenu This is a procedure where the aircraft follows part of a circle defined by a distance from the navate before it reaches a specific radial where it turns inbound towards the ILS and these DME arcs are pretty common and can be used for procedural step down descents to lead the aircraft in towards the airport but since that Arc is based on a different navate than the ILS it also means that the crew would have to at least initially fly with what's known as a split cockpit that meant that the first officer would have the ILS frequency tuned on his navigational radio and the captain would have the VR tuned on his side the ILS could then be tuned on the captain's side as well as soon as the aircraft turned in towards the runway but if that wasn't done the flight directors on the captain side would not be showing the s guidance and that's worth remembering around 0515 Tunisian time that's 0615 local the crew contacted the temporary area controller and asked for descent down from their flight level 330 which they had been maintaining up until then and the temporary controller responded and cleared them to initially descend down to flight level 110 which the captain also read back the first officer initiated the descend using initially the outter pilet and out the throttle in the vertical speed mode ofus 2,000 ft per minute and that was later change over to level change but everything was still completely standard at this point now it is worth pointing out here another little peculiarity with the air Liber procedures because they operated in something known as a silent cockpit what that meant was that only items that were deviating from the norm was required to be called out and whilst that might sound very sensible when you first hear about it it's actually very detrimental to the cockpit coroporation the reason for that is that this silence turns every call out into a much bigger deal which tends to hinder less experienced pilots from speaking up compared to if there would have been loads of other standard call outs this is why today we call out almost everything from what we select on the outop pilot panel to FMA changes and deviations because this assures a much more shared picture of what's going on it also highlights any potential incapacitations that an early stage and like I mentioned it makes the barrier for speaking up much lower anyway the aircraft continued to descend and at around flight level 1 15 Z they were told to switch over to the roban Yi controller he then told the crew that the local q& AG pressure was 1023 to continue to descend and that there was no reported traffic below flight level 95 now for those of you who are Eagle eyed you will have noticed that the controller didn't tell them how low they could descend and that's because they were now entering uncontrolled airspace in which The Descent was completely up to the pilots themselves this might sound crazy but in areas where there's only uncontrolled airspace there's normally so little traffic that traffic information is more than enough but this seemed to have stomped the captain a little bit he responded uh Roger we continue to descend towards cayan q& 1023 Liberty 930 and confirmed did you give me a level now what the controller should have said here was that they were descending into uncontrolled airspace and he therefore couldn't give a descent clearance but to make things easier for both himself and the crew he now just told him to descend to 5,000 ft instead now this won't have any impact on what's about to happen but it shows that the crew was maybe not as familiar with the local rules as they should be here when the aircraft passed flight level 100 the first officer reduced the speed back to 250 knots which is standard in most airspaces below that level the flight was then handed over to the cyani aphis officer who welcomed them onto the frequency and gave them a weather report for Runway 07 which was in use this included nice weather with a partially covering Cloud layer good visibility and light winds with a temperature of - 9° c what we Scandinavians refer to as a mild wi today but overall this was an almost perfect morning for flying the crew soon intercepted a distance 10 DME Arc from Kyo and when there were about 20 nautical miles left to run the first officer started reducing the speed to 210 knots and asked for the slats to be extended the aircraft then left 5,000 ft and descended down to 2,100 ft on the ark which was according to the stipulated procedure nothing looked out of the ordinary yet and the first officer was operating perfectly according to standard operating procedures the apis officer now came back and reported that Runway 07 was clear and dry with breaking action good and soon after that the first officer asked for flaps 15 and reduced speed further back to 170 knots in the back of the cabin the cabin had now been secured everyone was sitting down and most of the passengers were probably sleeping the lights were dimmed as per procedure when flying in the hours of darkness and that's to make sure that everyone's eyes are adapted to the light outside in case an evacuation would be needed and that was probably a good thing in this case because soon this flight would change character in a very dramatic way now before we get into the Final Approach here there is a small technical detail about the md-83 that is worth pointing out is it back in 1989 there had been a few accidents with this type because of severe vibrations of the main landing gear and where the vibrations had become so bad that they had actually damaged components of the gear itself some of them had damaged the gear uplock causing the affected gear to collapse and in other cases only smaller damages had occurred when looking into those incidents the investigators have found that they had all happened when the aircraft had landed at very high speeds with no spoiler activation on the wings and with immediate hard break applied the fact that the spoilers had not come up had together with high speed meant that the wings essentially kept flying a little bit and therefore didn't bring as much weight down onto the wheels as they were designed for what that in turn meant was that even though the gear had been equipped with shimmy dampers it had not been designed for the kind of extreme vibrations that these conditions could cause now McDonald doglas Had issued a service bulletin about this specifically to aircraft equip without the brakes which flight 9:30 was not but on top of that they had had also issued several aols or all operator letters to everyone operating these aircraft where they outlined the importance of verifying that after landing ground spoilers were used that all approaches were flown in a stabilized way with correct speeds and maximum flaps is possible that long Landings were avoided together with heavy braking and that the trust reverses was used whenever possible now if heavy vibrations would occur during the landing above 50 knots the braking should be momentarily reduced and then reapplied smoothly as soon as the vibration stopped now this sounds like quite obvious things to recommend but the aol's also outline why this was so important and what could happen if it was not done but it is unclear if the pilots of this flight was fully aware of these recommendations anyway the aircraft soon captured the localizer and as they started getting closer to the Glide slope they first officer called for the gear to be extended to together with flaps 28 and then he reduced the speed back to 150 knots the aircraft captured the Glide slope and started tracking it down towards the runway but the pilots never activated the ILS on the captain's side which meant that he now lacked any flight director guidance on his attitude director indicator they continued to configure the aircraft down to flaps 40 which would be the landing flaps and the speed was reduced back to 141 knots 5 knots above the reference speed and fully according to the company's procedures everything was stabilized at this point and the crew proceeded to complete the landing checklist as they passed the outer marker the captain sent a position update and the AAS officer responded that the runway was vacated confirmed the wind and that the approach and Runway lights were all active at 100% she didn't clear them to land because again she wasn't allowed to but the captain still read back clear to land and the AIS officer responded confirming again this was probably not the time to start educating the pilots about how apis actually worked but this all meant that the pilots were now very happy about the situation the first officer asked the captain to confirm that the landing checklist was complete which the captain also did so now everything looked ready for the landing at this point they were also fully visual with both the runway and approach lights but here something suddenly started to bother the captain remember how the AIS officer had told the crew that all of the lights were on at 100% well 100% is a lot especially in good visual conditions at night and the problem with that is that on top of being blinding it can also create an illusion of the Runway being much closer than it actually was in this case the runway also had a very slight up slope 0. 65% and the combination of these two factors could give the visual impression of the aircraft being high on approach now these type of Illusions can be easily counteracted by just looking down on the instruments will confirm that the aircraft is actually where it should be but remember the captain didn't have the ILS tuned on his side so he couldn't really make that quick verification the other thing that would have been worth doing here was to make a quick radio call saying dim lights which would have instantly caused the apis officer to reduce the intensity of the lights down to 50 or even 25% but that was not done either instead the captain now told the first officer to descend slightly below the Glide slope in response to this the first officer disconnected the autopilot but he kept the outo throttle engaged he then looked down onto his instruments where he saw that he was perfectly on the Glide slope and speed and likely just disregarded the Captain's Order to descend below which I fully understand you see an ILS approach is constructed to be followed and it's only really during the very last couple of 100 fet where the ILS signal can be partly disregarded in favor of outside references the idea is that this will lead the aircraft down to a height of 50 ft over the threshold which will then lead to an air distance of around 300 M over the runway before touchdown this distance is included in the landing distance calculations and it's important to have this buffer in order to give adequate margins for potential short Landings for example because of that even though it might feel tempting to go below the Glide especially on short runways this is not the way to do it and I'm guessing that the first officer was well aware of that this was especially through here since this Runway was 20500 M long which was more than enough for a normal Landing but the captain was not happy with this at all so he again told the first officer to increase The Descent rate and when that didn't happen he decided to take over the control walls and to just do it himself instead which happened at a height of about 150 ft so literally seconds before the aircraft would pass overhead the treshold now to be clear the captain had all the right in the world to do this it was ultimately up to him to keep the aircraft safe and I have taken over the controls at low altitude many times myself especially when training new cadetes but when you do it must be done for the right reasons in this case he was taking over an aircraft that was fully stabilized on speed and exactly where it should be and he did so at a very critical point during the approach this sudden takeover likely came as a big surprise for the first officer and when something surprising happens it can sometimes take a few seconds to rearrange yourself like I mentioned in the beginning of the video in this scenario as soon as the captain took controls this would have immediately turned the first officer into pilot monitoring which meant that it was now up to him to monitor all flight parameters and to call out anything that didn't look right and there would soon be a lot to call out the captain who was still suffering from the illusion of being slightly high realized that they were now so close to the runway that increasing The Descent rate was not really an option so instead he decided to aim slightly further down on the runway for the landing but the problem was that as soon as he had taken over the controls someone either the first officer as he removed his hands or the captain himself when he took over had inadvertently pressed the toga switches which meant that the now still engaged out the throttle went into toga mode and and started moving the trust levels forward this was not noticed by any of the pilots who were now both likely looking outside instead of monitoring the engine instruments and what that meant was that the trust now went from the approach setting of around 1.
35 VPR to 1. 98 basically full thrust over the following 6 seconds and since the captain was still aiming to land this meant that the speed now also increased to initially 149 knots while pushing the aircraft up above the intended path as the aircraft screamed in over the runway with full go around trust set the captain soon realized the problem and manually forced the trust levers back into idle but it still didn't disconnect the AO throttle the speed was now 155 knots 24 knots over the intended approach speed and the aircraft was descending through 30 ft whilst pausing the intended touchdown point 300 M into the runway and since the outer throttle was still active in go-around mode the trust levels almost immediately started going up again settling against the Captain's hand with an epr of around 1. 4 now the captain was probably fixating at this point on the fact that he was now eating more and more Runway below him and he therefore pitched forward to try and force the now completely unstabilized aircraft down onto the ground at only 5 ft this caused a nose down attitude of 1.
