Anytime I operated in an area that included rapidly rising terrain I was always super cautious when a controller issued me instructions that were outside of the normal procedures and routing. More than once in my 29.5 years of airline flying I have had a controller go - oops - and issue me amended instructions when I questioned them!! It appears that the supervising authority did not provide the controller with the necessary resources to safely do his job, that 'make do' pushing of employees in safety related jobs has caused untold death and destruction over the years!!
This is something I've read about before, I think it might have also be covered here - it's about situation awareness. If you know that turn will take you towards the mountains and you are given that turn then you question it.
@@gdwnet Indeed, one of the abilities of a good pilot is to be able to have a 3D picture of the airspace in his head and his place in it as well as any other aircraft on the frequency.
@@kikobarros76 The video does not really go into the preflight actions in depth. T/O Briefings are usually done after you get your clearance while at the gate or on the ramp before engine start. Then you make any amendments to it if you receive any chances to it while taxing or waiting for T/O. I do not know about Lufthansa's procedures, BUT the whole briefing concept has been an evolving one since the early days of Airline Transportation. Even in recent years the FAA and others have updated those recommended procedures.... so Lufthansa may not have even required such a briefing at the time.
It's easy to forget how much less tech they had 42 years ago. Today, GPS and mapping would have told the crew where they were and alerted them to the mountain. Given the circumstances pertaining then, the ATC restricted them unnecessarily and for too long. But in such a country, he likely wasn't able to complain about workload without risking his job. If his assistant was doing another person's job, where was that person?
Quite. Also yes, flying could be said to be a lot more dangerous and risky 40 years ago. Sorry, but I don’t get the comment about “it’s a 707 …..” etc. Am I missing something obvious?
@@moiraatkinson Not at all. Just that this is quite an old airplane, and as both of you had said - technology was different back then. I was scratching my head trying to figure out how they were so off, and I’m assuming this is why.
" Never trust atc...always double check what they're saying "...this has saved me from flying straight into prohibited areas..cbs...into another plane twice n preventing an RA..runway incursion..the list goes on...atc can make mistakes on a bad day but eventually it's the pilots decision that saves his life / license.
A good friend of my father was over Stockton, Ca at 4000 in IMC. He was ordered to turn east to avoid a traffic conflict but a few minutes later the controller still hadn't called him to turn back to the north. Several miles east of Stockton are mountains that are 7000 feet high so he called ATC to ask about turning back north. Turns out the controller had just forgotten he was there. If dad's friend hadn't asked he would have crashed into the mountains. The controller's chair doesn't move in the slightest if you crash into terrain.
I’ve flown in the area you’re referring to. Your dads friend must’ve been in a pretty fast plane. But yes, the Sierra foothills to the East can become an issue at 4000 in IMC. I’m only a VFR pilot so easy to question how these pilots could’ve let it happen but IFR flying is way more demanding on the pilots so it’s easy to become overwhelmed for a minute or two, which, sadly as was in this accident, just enough to get them killed.
@@minakiel2930 well, similar. Don’t think it was a controller directing them. I think that was a CFIT - Controlled Flight into Terrain. Just loss of situational awareness when in IMC.
Well, it’s difficult to find the ONE person who’s “fault” this accident is altogether, but air traffic controller decently had too much to do, but still should not miss that a plane is going straight for the mountains. I was a German pilot on Boeing 737 and what I miss most is the situational awareness of the cockpit crew… you ALWAYS have to have a “rough” idea where you are, and with their chats they knew about the mountains and the altitude restrictions. It’s as always an accident where there are many little failures, but if only one of these would have been resolved, they would have arrived in Dakar no problem…
I guess it's a difficult balance between complying with ATC instructions, remembering all the terrain of everywhere you fly in and out of, and keeping track of where you are and how fast you're going in the dark. It's not like you can wait to see if you bump into something.
I look at this as a foreseeable error. So, the direct fault was the controller's, yes, but it was an overall weakness in the regional setup that ultimately caused the crash, and that weakness should have been spotted long before.
The complexity of the system was known, and why an assistant was required. I think it's more inadequate staffing at the time. (I don't know if that was an ongoing problem, somebody didn't show up to work that night, one of the controllers went to the restroom...)
It’s one of those instances where we let things get out of hand because we can’t imagine the negative consequences, like disabling the fire alarm system for a few days. Had the controller really understood that his systemically induced lack of focus would result in an accident, I am sure he would have suspended takeoff operations until he got the help he needed. Sure, he thought about it in the abstract, but only when it was suddenly made manifest did he realize the magnitude of the problem. Right afterwards, after the, oh sh!t moment. His fault? Yes, definitely, for being aware that what was going on was unsafe, and not taking the required steps to prevent the outcome from happening. Understandable? Also, yes. We’ve all been in similar situations, most likely where fate intervened on our behalf and didn’t call us on the risks we were taking.
@@douggodsoe The fact that he didn't react to the risk is indicative of a system/environment/company culture long standing practice that this is the normal mode of operation and these risks are part of everyday duties.
@@vedranb87 Right. It’s called negligence. The system is people, not some ephemeral thing that is indirectly responsible for our actions. It’s people doing their work in a way that is foreseeably careless. Ultimately, they don’t put the system in prison for killing people. If, while you are doing your job, you think, “somebody’s goin’ die,” and you knowingly keep doing what you are doing, it’s negligence. Or, at least depraved indifference.
@@douggodsoe Oh, I absolutely agree it's people, don't get me wrong, it's just that I blame more the higher management for not making absolutely sure there is enough people on the shift. On any and every shift. Or do you think they should be left off the hook while the one person who inevitably failed under these conditions?
Very good content! By 1979, Galeão Airport (GIG) was the main International terminal in Brazil and I bet controllers were overworked. In my humble opinion, this was a totally avoidable tragedy and responbility is primarilly on ATC System's court. Very sadly, it happened exactly on my 11th birthday. Best wishes from Brazil.
I feel it was a perfect storm of errors. Main one being the controller being overwhelmed with tasks beyond his load and the pilot misunderstanding the controller's instructions. But then again, the pilots usually have a chart marking all high terrain in the region around the airport or was it not mandatory during the time of accident or not required for take off. If I recall correctly, the charts are used during the briefing for the flights.
@@ursodermatt8809 yep, they trusted the controlers, BUT if they had a takeoff brieffing concerning high and abundant hills around all of Rio de Janeiro, they would have provoked the flight control and cerntainly get a climb to higer level... I invate you tho get pictures or videos taking of and departure from Rio, is wonderfull, also complex and dangerous!!! Best regards!!!
That's where a navigator was relevant in the earlier flight decks. The B707 at that time was either a 3 or 4 person crew , someone should have had a situational awareness of their environment... just saying
Having done most of my flying in the 1970's (all personal, no professional) in older airplanes with basic six pack instruments but in a very mountainous area (Reno, Nevada and over the Sierra Nevadas to the San Francisco area) I never did a preflight or started an engine without reviewing planned route AND TERRAIN. I've done too much search and rescue for airplanes that ran into cumulus granitus. This incident is a classic swiss cheese. Captain, FO, Flight Engineer, ATC, the ATC system all are slices in the cheese. The holes lined up.
This is sad. Most accidents didn't have to happen, if only one piece of the puzzle was discovered many accidents would not have occurred. This is one of those. I think people get complacent, they think technology will keep them safe, ATC is watching over them... I'll bet all of us have narrowly avoided disasters that we don't even know about. When we do avoid one, we think it was a very rare situation, I believe it's more common than we realize. We are in vehicles that have the potential to do a lot of damage. Accidents are, for the most part, a string of little mistakes piling up. They can be stopped or allowed to progress in one, seemingly insignificant action. Most of the time things go as planned, never knowing how close we were to a potential disaster. You do such a great job making your videos! Can't wait to see more! Take care!!
Love your videos, sir. As an “okay” Portuguese speaker, I have to mention that the departure airport Galeão is gah-lay-ow and the Caixas VOR is kai-shuhs 😊
Actually it’s not “Caixas” but “Caxias” (you changed the i for the x giving it a total different meaning) and it should be pronounced ka-shee-us. The airport is Galeão instead of Galeo as shown in the video.
Nice job Rod Serling. This had to have been one of my favourite airframes of all time. What a beautiful machine. I was lucky enough to have flown a lot of them but this was one special as it was the first one and so sleek.
9:22 "this could have been easily avoided if people had just talked to each other" This is so true for many conflicts and issues. Like in relationships. It's been said that all problems are communication problems. I'm sure there are exceptions but it's basically true for virtually every hole in the Swiss cheese of every air crash. It seems that the airlines with the best safety records encourage a lot of open communication. The more you talk to other people about what you're doing and what's going on, the better. When it's a safety critical industry, it's deadly to not talk about things.
Good comment. IMHO we had here an accident that occurred due to one missed communication. Any time vital information is communicated by only one communication then an accident must occur eventually. The pilot here had a working idea that something was unusual about the takeoff, even with the overloaded ATC the 707 captain would have been justified in having the copilot contact ATC for clarification. As busy as the ATC was he should have been able to see immediately that the 707 was well beyond the position it was expected to be in. I wonder if the 707 was lightly loaded and accelerated faster than normal to the open ended instruction to 'increase speed'? While we must grieve for the losses on the plane still it always saddens me when a controllers career is ended by a mistake that takes several specialists in a quiet room with a big chalk board listening to the recordings repeatedly to figure out what the ATC's mistake was.
An accident is never a single error, it's always a chain of errors. E.g., if my approach is not stable it's often a combination of wrong height, wrong speed and wrong glide path and to make it a problem I need to decide not to go around but try to save the landing against better judgement. If it's any one of those, I can compensate and make it stable very easily or just go around and try again. The system is wrong for putting such a workload on the controller, but the controller is also wrong for not signalling his excessive workload. When in doubt, shout. And the assistant for simply not doing his job. And the pilot for flying faster than 250 kts IAS below 10.000 ft. And the pilot for not asking again when he got no answer. When in doubt, shout. Anyone of those things could have avoided the accident if it was done differently.
Reminds me of TWA 514, a Bo-727 that crashed into the mountains NW of Dulles years ago. plates/charts nowadays have easy-to-read graphical minimum safe altitude views in place of text. Procs now also include more intuitive step-down/step-up fixes. In the TWA-Dulles flight the PIC almost had it figured out - they were too low and far out from the field when more chatter broke out in the cockpit over procedures. They hit a mountainous leeward downdraft and turbulence which didn’t help but when they finally pulled up they almost made it over the ridge. things do happen but it’s amazing how safe things are today thanks to those who’ve gone before us
To ask your question in another way..." Who performed their jobs at a standard lower than their training required"......The answer is....everyone. The controller was not in control. The Assistant was not doing their job. Pilots were not situationally aware or getting confirmations for their questions. Flying blind and behind the plane.
Not a pilot so it's taken me a while to see the simple approach to flying that would always prevent something like this from happening. A few observations. 1) There doesn't seem to be any redundancy in the atc duties which seems like a bad idea. In effect you have to plan on controllers to perform perfectly. 2) I've recently been made aware that this would fall under the concept of a "flight plan" which the flight crew is supposed to do before liftoff, which would be part of knowing where you and the mountains are at all times . This would avoid the passive approach to relying on atc to keep you out of trouble. 3) Following the low altitude speed limits would have given them more time to correct any errors before crashing. 4) When something doesn't seem right, there's a good reason not to dismiss it.
Aside from the very interesting, detailed description of the event(as always), those graphics are amazingly detailed. Having cut my aircraft maintenance teeth on 707’s, the images just bring back all the memories. I’d just love to hear the Pratt & Whitney JT3’s screaming as well!
The previous comment that they always have to apportion blame is a good one. Sometimes it’s better to work out how an accident could be avoided in future if similar circumstances arose. I feel the only thing the Controller could have done would have been to stop his traffic until he was able to deal with it. He has to land the planes in the air, but he can stop any departures until he’s not so overworked. Nobody wants a late departure, but it’s better than crashing into a mountain. Also, is it just me, or do the GPWS call outs never seem to allow enough time for pilots to take evasive action ?
Usually the GPWS gives enough time for evasive action. But the GPWS doesn't tell you how the terrain looks like in detail. It doesn't tell you that you might hit trees with a wing: too late. On the other hand engines react quite slow after pushing the throttles forward and this might have happened with this flight. Since Brazilian ATC was run by the military at that time, it was famous for not being very effective and sometimes even not very safe. Many pilots complained about that. Unfortunately the Lufthansa pilots were probably not aware about their real location due to their high speed. They knew for sure about the mountainous terrain around Rio's airports. R.I.P.
GPWS goes off, command maximum thrust and climb as aggressively as possible with potentially a clearing turn away from terrain. But in a civilian aircraft, passengers will be upset, or the freight may shift position, so most pilots will instinctively fly with more moderate control inputs so as to avoid over stressing the aircraft, passengers, or risk the cargo shifting. GPWS is really a last resort when everything else has gone wrong.
Yes, those are very interesting remarks. I guess pilots who are conditioned to follow civilian airline rules would not be instinctively taking the action needed. Maybe there should be more training and clearer memory items to follow? At any rate, TCAS seems to give a lot more time for a resolution. I’d also set a minimum number of experienced ATC staff to be on duty during hours of darkness. If an airport is that dangerous, even go as far as only allowing one of the two airports to schedule flights arriving and departing during night time darkness.
You are certainly correct in stating that the GPWS is triggered far too late for anything other than completely flat terrain. Once the ground proximity warning goes off the pilot, not expecting it, is momentarily stunned & it takes several seconds to assess the situation. Then going to full throttle there is a significant lag between the pilot input and the response of the plane to accelerate and lift; and the heavier the plane, the longer that lag will be. (Former pilot)
“Aviate, Navigate, Communicate”. There is no excuse for a pilot not knowing where the plane is, where it will be in 30 seconds and what the terrain is like. Especially when flying so low. Hills don't appear suddenly out of nowhere. Also, the control tower was inadequately staffed, but there is no way a politician will ever accept responsibility for failing to properly manage a service under his/her watch. Controllers are not the ones who are responsible for hiring the necessary personnel, but in this case i am sure they paid the price for the incompetency of the managers/politicians who failed to do their jobs.
I think I agree with Jake. It's a harsh judgement on the pilot, but even though the controller (and the system he was working in) let the pilot down, ultimately, the pilot should have maintained better situational awareness given the hazardous nature of the terrain. Great video, btw - always fascinating and thought provoking.
Agreed, ultimately it is the aircraft crews responsibility to maintain separation from terrain, the other factors were contributing causes, very sad avoidable event. Always, Always ...Aviate, Navigate, Communicate...
Youre not wrong, but remember: this was back before GPS...and it was at night. Definitely makes navigation in close quarters terrain in such a large aircraft difficult, especially with other traffic very close by. Unfortunately the crew had too much faith in the ATC, leading them to take too long in questioning their heading/vector instructions
@@razorfett147 GPS definitely makes life easier, but the root cause of this accident is a lack of situational awareness by the Captain. Got my private pilot license in 1977. Later spent 6 years as a navigator and tactician on US Navy P3 Orions. A general briefing prior to takeoff would have easily made the pilot in command aware of the fact that there was rising terrain not far from the airport to the West and North. Plain old dead reckoning (position, course, speed) in conjunction with situational awareness would have made the captain aware of danger within just a few minutes of takeoff. He waited for the controllers to tell him what to do. Flew all around the world using dead reckoning and a sextant. Also, a 707 of that era (equipped for trans oceanic flight) almost certainly would have had an INS (Inertial Navigation System). The would have known within a mile or two where they were with an INS. Close enough to know they were in trouble. The Litton 72 INS I used was generally within 1-3 miles of actual position (latitude and longitude of our parking space) on the P3 after 10+ hours in the air. GPS is definitely a tool to make life easier. But the pilot didn’t know where he was 2-3 minutes after takeoff. That’s the #1 issue.
This is definitely a system failure. Doing air traffic control work on prescribed working conditions is already hard work that requires multitasking like you have 4 hands and 3 brains. This airport even needs more due to its location. Just looking at 5 blips on a screen at the same time is already tough. Expecting someone to watch, calculate, and coordinate at the same time is just too much. I feel sorry for the traffic controller for this flight.
Possibly this crash was a beneficial one for future flights, as it highlights not only the need for better communication, but also the massive over demand put on controllers, And thankfully l the lessons didn't involve the death of hundreds, although my apologies to the families affected by this crash, if my comments appear somewhat harsh Thanks for your brilliantly executed channel
I agree - I love this guy's sweet and charming delivery of a very complex subject indeed in which he is clearly an expert. A very winning combination. As regards to fault, way before we were requested for that feedback I was saying to myself that it's the airport owners/management's fault. I was tempted to say it was 90 or 95 or even 99% management, with the rest, the controller. But no, hindsight is far, far too easy. It was 100% management's fault. In fact, assuming that the controller's work conditions had previously been similar - under staffed and overstretched - it is a miracle, given the complexities introduced by the other airports nearby, that a (far worse) accident had not previously occurred.
You answered your own question at about 5:30. The crew DID NOT FOLLOW the departure procedure that they had been cleared to perform. They assumed that they should continue to follow the "040" heading given to them by the controller. Big error. We can assume that the Lufthansa crew were at least generally aware of the terrain in that area of the country. At Caxius, they should have continued to follow the departure procedure or at very least gotten an immediate answer from the controller. It's hard to believe that three guys in the cockpit of an airliner would accelerate to over 300 knots while at only 2,000 feet agl. Each of them must have thought, "This is pretty crazy." Which kind of explains the *immediate* reaction to the GWPS. Somewhere in their brains they (or at least the captain) knew that they were not in a good place. Lots of crews have been lost because of a delayed (or disbelieving) reaction to the GWPS. Yes, the system let these guys down. But they too bear at least some of the responsibility for the crash. I mean, what was the FE doing while they were screaming along at 300+ knots at 2,000 feet? One of them should have said, "Hey, are there any tall antennas...or, you know...MOUNTAINS around here?"
At the time, ATC in Brazil was under the control of the Brazilian military. The incompetence was alarming! Not the first nor the last deaths caused by poor training in their ranks of corruption.
Aaaa... 707, my favorite aircraft. Once, just once in my life, I was lucky to fly on one before they were taken out of passenger service. PanAm flight WAW-FRA, August 28, 1979. Normally, PanAm flew 727s on tfat route, but that day they switched. Flew several times on 727, but on 707 just that one time.
Poor controller had to live with that all his life, no matter how much he should not have been put under that load. Late 1970s , no GPS on the flight deck for the pilots and no inertial navigation, just dead reckoning. That controller was pretty much in an impossible situation an accident waiting to happen.
It was both a systemic error and an error by the controller. The controller was vectoring the flight so it was his responsibility to do it correctly. The pilot should always be aware of where the aircraft is and what is around it so ultimately he is responsible for his own demise.
Pilot error. Pilot is supposed to know where he is. He knows his position when he takes off, he knows his course and speed, so he can figure out where he is. The charts tell him if there's something solid in the way. He doesn't need any controller to tell him any of that. Other aircraft nearby, well, that's a dynamic situation and the pilot is not likely to have complete information, so timely external assistance is appropriate. But terrain isn't dynamic; the hills are in the same places they've always been, and they're shown accurately on the charts. Now if the pilot messes up, there are backup systems. That's where the controller comes into the picture. But failure of the backup system doesn't absolve the pilot of responsibility. Of course since I've only flown dinky little airplanes out of dinky little airports, I have no idea what I'm talking about.
That system is stupid. Yes, the controller made a mistake, but with that workload, it's only a matter of time before one controller makes a mistake. If you look at this from a swiss cheese standpoint, only a few conditions needed to be met: - lots of traffic, so busy controller - will happen 100% - a single misunderstanding re speed - an unnecessary (but usual) climb restriction - the pilots not catching the error None of these things seems out of the ordinary, and none of them is a big deal where alarm bells would go off. This needs to be simplified, or simple safeguards need to be implemented - which I assume happened in the last 40 years.
Yeah the captain is at fault for speeding so much in low altitude and not knowing there the mountains were. Somehow they missed the direction they should've been heading for based on the map shown here. If a pilot asks a question that is not answered and is an important one about heading/vector then he is the one who should repeat it.
Reminds me of the mid-air collision on 29 September 2006 between Gol Transportes Aéreos Flight 1907 and an Embraer Legacy 600 over Brazil. The cause: under-staffed ATC in Brazil did not inform the Embraer to adjust altitude when needed. The upturned wingtip of the Embraer sliced off the 737's wing as they crossed paths head-on. Brazil had a poorly managed ATC system for decades, resulting in avoidable fatalities.
Thank you so much for this. I think this is not only the employment system fault but also the pilots mistake to surpass airspeed limits at given altitude: the lower the speed the later they would reach terrains and the more time to react to warning.
Blaming just one person runs the risk of the fallacy thinking that if that one person is gone then such accidents would never happen again. If this crash didn't happen on that day another one would likely have happened within just a few years due to similar circumstances. In fact there continue to be accidents due to distracted/confused/overworked controllers worldwide. Perhaps the most famous set-up-for-failure was the 2002 Uberlingen collision.
My humble opinion is that the pilots should have had an awareness (by looking at maps/charts) of the surrounding terrain. Also it seems inexcusable for them to have given the jet “the beans” not aware that faster meets further quicker! So an over tasked controller and pilots just letting someone else watch out for them. Complacency/arrogance.
I feel so bad for the controller, imagine being swamped with 5 planes and turning to check in on a plane you had no worries about only for it to crash seconds later. Even if the company allowed me to keep my job, I’d quit. That’s some serious mental toll.
I remember clearly .. as told by a classmate in university who was a controller in the tower tnis day, the departure controller ^ froze ˆ and was arrested and handcuffed in front of his colleagues. By the time there were only military controllers from air force (FAB). He was blamed for the accident and took time in jail.. Great vid.. greetings from Rio... Brazil..
The mistake was made by the controller, but that doesn't mean that he is to blame for it. I have worked a busy aerodrome in the past, keeping track of everything is taxing and should not be one mans burden. Having said that, if you issue a radar vector as a controller, the buck stops with you...
I have flown there, my opinion I don't trust brazialian english and during breifing I use to metion msa is XXX to the north-south, actually i wrote down on the ofp as a double reminder, atc has part of it but the crew is also a goalkeeper in the game!!!
I Am Brazilian, I am also a Pilot. This accident happened because of flight control structure as a whole. By that time it was ran by our air force personel, all military, some were very clever, others not. regarding Instrument depart SID 16, the 707 crew did not follow because they were instructed to a specific course ( 040 if Im not Mistaken) radial after crossing Caxias VOR. The plane was fast and the turn radius was large, that put the acft further away from Galeão and dangerously close tho the high mountains... Some argue the 707 was way to fast, indeed speed limitation in that area is 250ias Kt below 12.000ft agl. Yes, the conroller " forgot" them. Unbeliveably, the 707 flew in to a valley, with forrest covered hills well above them!!! If only they had climbed some 2.000ft,.... Also I have to mention that when the Rio departure " remembered" them , departure instructed the 07 to turn SOUTH and then climb. The began turning when they hit the mountain. The wreckage is istll there, a place called Morro do macaco ( monkeys hill)
This is my first video on this channel I’ve watched”fresh”, and I’m halfway thru the whole list 😬 …tells you how many airplane videos I’ve watched in the last 5 days.
100% the system and lack of staff to blame here. However, I think I've said this before but it's a valid point, the terrain warning goes off, the pilots react immediately but it's alway too late. Why are the terrain alerts not made to go off earlier to save the aircraft?
In scuba diving we often talk about a thing called the incident pit, this where multiple seemingly unconnected missteps leads to one big disaster. I think this is a good example of that as it wasn't just one factor that caused this tragedy.
As a pilot i believe that it was BOTH the controllers fault AND the pilot's fault!!! Almost 50/50 equal responsibility!!! The controller made a lot of mistakes by LETTING himself get overwhelmed by the other planes e.t.c.....i thought very seriously about becoming a controller after i got a tour of Denver center in Longmont Co (my cousin Howard was a senior controller there and since i had a lot of experience talking to them as a pilot, I thought it was really cool to see how/what they did up close and in person.....I got to sit with Denver approach, departure, and enroute center controllers at like 7pm on a Thursday which Howard said was probably the best time for me to get to see what they did and how they did it, but not get in their way since that day/time was their "least stressful" and i could ask questions without distracting them too much and actually get answers in a reasonable time since they wouldn't be controlling the maximum number of planes!!! He was right!!! Everybody was very friendly, and seemed to really like showing a guy that had never seen a sector screen just what they did when us pilots called them and why they did what they did!!! Since it wasn't too busy at all that evening, some of the controllers actually seemed a little bored!!!! Like until they got a certain number of planes to push around, they didn't quite know what to do with all the extra time in between close calls and near misses!!! (I'm kidding..... they hadn't had a "reportable incident" their version of the plant safety sign saying xxx days since a time off injury in years i believe...) I even got to hand off frontier from center to Grand Junction Approach (my home airport!!!)!!! I got a lot of good insight into exactly what the approach, departure, and enroute center guys see and do when we call them up!!!! And i truly feel for them when it gets crowded and they are alone or have no assistance like the poor controllers had in this case.... so yeah it's partly their fault..... BUT the NUMBER ONE THING I was taught in flight school is NO MATTER WHAT IS GOING ON FIRST AND FOREMOST.... FLY THE DAMN PLANE!!!! And they seemed to forget that rule and they let their speed get really high and they didn't communicate with the controller nearly as much as they should have since they didn't get answers to at least a couple of their contacts and since they didn't follow up on those missed calls they probably missed out on the chance to verify the altitude and speed and direction assignments and to possibly ask to continue their enroute climb so they could avoid any mountainous interference!!! If only...... the two biggest words in the English language!!!!! If only they had communicated better..... if only the pilots had noticed the minimum safe enroute altitude for whatever sector they were in and decided to climb up above that altitude just to be safe...... and called the controller to tell them what they needed to do to be above the mountains and they most likely would have been cleared up to their cruising altitude..... or somewhere close to that..... and no crash would have happened!!!!! All it would have taken is a bit more communication with air traffic control and they wouldn't have crashed..... and flying the plane includes communicating with atc.... Too many distractions on both the pilots and controllers sides...... distractions cause crashes!!!
I am sorry that the pilots died. If they had stayed to the lower speed mandated by the regs they would not have been so far along when it was obvious they were too low. It would appear to me that was the one mistake that killed them. In the situation it did behoove them to fly according to ATC edicts. Had they been flying for themselves they would have made themselves aware of terrain. The lesson is always fly for yourself regardless of what Control tells you to do. Other traffic is moving and of course you do want to know what it is likely they are doing, but the mountains don't move and you can have no doubt what altitude you must be at.
I see this as being CFIT... controlled flight into terrain. the pilots did not have spatial awareness of where they were, and where they needed to be, the controller put them on a dangerous heading without notifying them they were heading towards high terrain. the layout of the airports and the lack of ATC personnel were a major factor in this, but the pilot did fail his ultimate responsibility... he should have been pro-active, not so unaware of where he was as to rely on ATC to avoid the mountains.
@@briant7265 I think it's in many ways the other way round, in the old days, pilots would maintain there own navigation much more... ATC could not give pilots as accurate information, since there equipment was far less accurate
@@mal2ksc good meme... if to be totally pedantic not the real etymology: it was opposed to live reckoning (making constant course correction based on visually monitoring your change in position, rather than a predetermined course, this has to be done when currents are unknown or unstable), but like your version....
Honestly this whole accident could've been avoided. 1.Controller prioritizes his airplane traffic; lets departures go safely, advises incoming airplanes to reduce speed or go in to hold pattern briefly. He further should've reached out to the 527 and advised them at xxxxx point on the map "increase your altitude" as that would've got them clear of the mountains. (Putting a speed limit too, so rate of distance covered can be tracked) 2.Have more staff and equipment on hand to deal with the workload so 1-2 people are dealing with like say 5-7 planes all at once. Imagine if they had 1-2 extra ATC staff on hand who could assist with monitoring and clearances ect.
Please record these louder, I can't hear a damn thing at 100% volume on my laptop or phone, I have to come home and watch at 100% with my volume boost to hear clearly. Other comments have said the same, I have said the same on other videos, we worked out you're recording at -12 to -16dB, PLEASE just go to 0db so there is enough volume to hear you!
With a span of over 32 years in aviation, both as an airline and military captain, I would like to share this: "Every fault is on the pilots flying the aircraft, even it is not them to blame! The price is paid by them for all the faults created by anyone. So it is always imperative that You do not loose situational awareness at any cost, at any time!" This only will keep You safe.
The pilot has the final say over any one, I was a pilot for many years the p.i c should know all of the information mountains,speed, I know if I listened every a.t c that did not sound right I could be flying a cloud now.
This reminds me of when I was living near Seattle WA: "U.S. Air Force C-141A Starlifter crashes into Mount Constance, on the Olympic Peninsula, killing 16 servicemen, on March 20, 1975." I knew a pilot of C-141's that made the circuit between Japan and McChord Air Force Base south of Tacoma (almost twin cities with Seattle). He made that circuit once per week, he said. The route should have been well-known and well documented. It made zero sense to me to fly into a mountain when the problem was so well-known. If the tallest mountain on your route is 5000 feet in elevation, then know where you are on the face of the Earth and do not descend lower than 6000 feet until nearing the destination airfield. Aren't there radars that can see all approaching aircraft?
“95% OF THE PROBLEMS AND THE ABILITY TO FIX THEM BELONG TO THE SYSTEM, NOT THE PEOPLE.” - Dr. W. Edwards Deming, The Einstein of Quality who taught Toyota and who’s proven principles guide the manufacture and delivery of quality products, services and training worldwide. Deming proved that fixing the system holds the solution, NOT blaming the people; blame people and you have a 5% or less chance of being right. We must move from blaming to training and working together to fix the SYSTEM. GREAT PRESENTATION AND CHANNEL - KEEP UP YOUR SUPER WORK!
why do all of your videos have different audio volume? I mean a huge difference. Maybe Im just spoiled, coming from Mentour Pilot type videos.. where things are..different.
Overworked ATC, misunderstanding ATC instructions, and deviating from the standard procedures all contributed to this incident. But I'm thinking that the majority of the blame should go with the system that overworked their controllers.
Accidents are typically referred to as a chain of events ... remove a link and the accident does not occur. The controller was a link and perhaps the final link so he was an easy target!
Did the atc have radar? We must not forget that back then the planes had no moving map gps position indicator like today's aircraft. So position had to be determined by help of radio navigation. VOR radial and DME would be the most accurate. And the maps need to be up to date and complete.
I lived nearby Caxias, one says it Ca as in CArgo, Xi as in SHE, As as in aliAS. CA(rgo)SHE(ali)AS, got it? Edit: when you make a video about Brazil's crashes, feel free to message me to check wording or if you need any help.
Interesting video of a tragic situation... It seems that a combination of things happened that contributed to this crash... 1) The WORKLOAD on the one controller who was handling departures at that time, was excessive.... 2) The pilots and FE should have recognised the terrain that was ahead of them by knowing where they actually were.... 3)The pilots did not follow the 250 knot speed rule below FL 10 at that time in that area.... 4) The agency that trained and hired the controllers, should have had at least 2-experienced people dedicated to handle departures at ALL TIMES... This is probably the main issue, that caused this accident... The overloaded sole departure controller who was handling this very complex departure process.....
Non-pilot here. I have watched several vids on these channels where the pilot has told he controller (basically) "I am turning whether you like out or not". The controller certainly has a heck of a lot of responsibility to keep things safe but..... In the end, it is the pilot that is flying he airplane and that person is, ultimately, responsible for keeping it safe. You can argue things later, if you are alive. There is no arguing if you are dead. Seems to me, the crew did not like what was going on. Time to turn or climb or turn and climb. Just letting things happen turns out very badly all too often.
Agreed Bryan. We all make mistakes, misjudgements, etc. I am not usually a "systems fault" guy, but asking people to take on too many complex tasks is basically asking for trouble. And it will find you. I feel very badly for the flight crew.
It's the Swiss cheese again. I think that ultimately the controller is at fault, as he could, perhaps should have raised the issue of being overworked. Surely there would be a usual staffing level and on noticing this wasnt met them there would be justification for not operating the tower, or severely restricting operations. I do a safety critical job, and even if I could theoretically do something, there are Manning and equipment levels that must be available. If these things are not available I don't work until these criteria can be met. If the controller felt he couldn't take the decision to close the operation down, or perhaps just deal with inbound traffic then that is systemic too. But I think too many people try and shift the blame. Everyone couldn't done something different. The crew on the aircraft were not totally sure of their position, so they could've avoided this. Lots of things went wrong. Unfortunately none caught it in time.
I think at the time, ATC was done by the Air Force (it was when I lived in Rio) so the controller would not have had an opportunity to complain that he was overworked.
@@Gingerharry2011 , not sure but I doubt it unless he wanted to be transferred to some place in the middle of nowhere. This is Brasil, remember. Nowadays, civilian ATC is no longer run by the military in Brasil.
At many workplaces, SOPs are partially ignored and nothing happens at first. People start feeling that nothing is wrong and everything is going fine. Doing the same over extended period of time this becomes a habit. Now this is ticking time bomb... everything looks normal until there is a disaster.
Anytime I operated in an area that included rapidly rising terrain I was always super cautious when a controller issued me instructions that were outside of the normal procedures and routing. More than once in my 29.5 years of airline flying I have had a controller go - oops - and issue me amended instructions when I questioned them!! It appears that the supervising authority did not provide the controller with the necessary resources to safely do his job, that 'make do' pushing of employees in safety related jobs has caused untold death and destruction over the years!!
great answer!!!
This is something I've read about before, I think it might have also be covered here - it's about situation awareness. If you know that turn will take you towards the mountains and you are given that turn then you question it.
@@gdwnet Yes you are right! and my question remais: no take off brieffing??? no questioning the controller?
best regards
@@gdwnet Indeed, one of the abilities of a good pilot is to be able to have a 3D picture of the airspace in his head and his place in it as well as any other aircraft on the frequency.
@@kikobarros76 The video does not really go into the preflight actions in depth. T/O Briefings are usually done after you get your clearance while at the gate or on the ramp before engine start. Then you make any amendments to it if you receive any chances to it while taxing or waiting for T/O. I do not know about Lufthansa's procedures, BUT the whole briefing concept has been an evolving one since the early days of Airline Transportation. Even in recent years the FAA and others have updated those recommended procedures.... so Lufthansa may not have even required such a briefing at the time.
It's easy to forget how much less tech they had 42 years ago. Today, GPS and mapping would have told the crew where they were and alerted them to the mountain. Given the circumstances pertaining then, the ATC restricted them unnecessarily and for too long. But in such a country, he likely wasn't able to complain about workload without risking his job. If his assistant was doing another person's job, where was that person?
I was wondering “How do they not know where they are?” And that’s when i realized - it’s a flying 707…
Quite. Also yes, flying could be said to be a lot more dangerous and risky 40 years ago.
Sorry, but I don’t get the comment about “it’s a 707 …..” etc. Am I missing something obvious?
@@moiraatkinson That's when TCPUDPATM realized the time period.
@@moiraatkinson Not at all. Just that this is quite an old airplane, and as both of you had said - technology was different back then.
I was scratching my head trying to figure out how they were so off, and I’m assuming this is why.
@@markgouthro7375 Ah …. I’m with you now. 😊
" Never trust atc...always double check what they're saying "...this has saved me from flying straight into prohibited areas..cbs...into another plane twice n preventing an RA..runway incursion..the list goes on...atc can make mistakes on a bad day but eventually it's the pilots decision that saves his life / license.
A good friend of my father was over Stockton, Ca at 4000 in IMC. He was ordered to turn east to avoid a traffic conflict but a few minutes later the controller still hadn't called him to turn back to the north.
Several miles east of Stockton are mountains that are 7000 feet high so he called ATC to ask about turning back north.
Turns out the controller had just forgotten he was there. If dad's friend hadn't asked he would have crashed into the mountains.
The controller's chair doesn't move in the slightest if you crash into terrain.
I’ve flown in the area you’re referring to. Your dads friend must’ve been in a pretty fast plane. But yes, the Sierra foothills to the East can become an issue at 4000 in IMC. I’m only a VFR pilot so easy to question how these pilots could’ve let it happen but IFR flying is way more demanding on the pilots so it’s easy to become overwhelmed for a minute or two, which, sadly as was in this accident, just enough to get them killed.
@@shreedhar333 is that similar to where Kobe Bryant and ?6 others were killed?
@@minakiel2930 well, similar. Don’t think it was a controller directing them. I think that was a CFIT - Controlled Flight into Terrain. Just loss of situational awareness when in IMC.
@@shreedhar333 Yeah something like that. The pictures were horrible
Can you please elaborate on your last sentence about the controller's chair?
Well, it’s difficult to find the ONE person who’s “fault” this accident is altogether, but air traffic controller decently had too much to do, but still should not miss that a plane is going straight for the mountains.
I was a German pilot on Boeing 737 and what I miss most is the situational awareness of the cockpit crew… you ALWAYS have to have a “rough” idea where you are, and with their chats they knew about the mountains and the altitude restrictions.
It’s as always an accident where there are many little failures, but if only one of these would have been resolved, they would have arrived in Dakar no problem…
Well, they had the “rough” idea that they were over Brazil. I guess.
@@MothaLuva They know Brazil has mountain ranges in its Eastern provinces?
@@brabhamfreaman166 Obviously not. This knowledge is already too detailed.
Whose, not who's.
I guess it's a difficult balance between complying with ATC instructions, remembering all the terrain of everywhere you fly in and out of, and keeping track of where you are and how fast you're going in the dark. It's not like you can wait to see if you bump into something.
I look at this as a foreseeable error. So, the direct fault was the controller's, yes, but it was an overall weakness in the regional setup that ultimately caused the crash, and that weakness should have been spotted long before.
The complexity of the system was known, and why an assistant was required. I think it's more inadequate staffing at the time. (I don't know if that was an ongoing problem, somebody didn't show up to work that night, one of the controllers went to the restroom...)
It’s one of those instances where we let things get out of hand because we can’t imagine the negative consequences, like disabling the fire alarm system for a few days. Had the controller really understood that his systemically induced lack of focus would result in an accident, I am sure he would have suspended takeoff operations until he got the help he needed. Sure, he thought about it in the abstract, but only when it was suddenly made manifest did he realize the magnitude of the problem. Right afterwards, after the, oh sh!t moment.
His fault? Yes, definitely, for being aware that what was going on was unsafe, and not taking the required steps to prevent the outcome from happening.
Understandable? Also, yes. We’ve all been in similar situations, most likely where fate intervened on our behalf and didn’t call us on the risks we were taking.
@@douggodsoe The fact that he didn't react to the risk is indicative of a system/environment/company culture long standing practice that this is the normal mode of operation and these risks are part of everyday duties.
@@vedranb87 Right. It’s called negligence. The system is people, not some ephemeral thing that is indirectly responsible for our actions. It’s people doing their work in a way that is foreseeably careless. Ultimately, they don’t put the system in prison for killing people. If, while you are doing your job, you think, “somebody’s goin’ die,” and you knowingly keep doing what you are doing, it’s negligence. Or, at least depraved indifference.
@@douggodsoe Oh, I absolutely agree it's people, don't get me wrong, it's just that I blame more the higher management for not making absolutely sure there is enough people on the shift. On any and every shift. Or do you think they should be left off the hook while the one person who inevitably failed under these conditions?
I always like how you show the planes landing, makes me think of another world where these flights arrived safely
Very good content! By 1979, Galeão Airport (GIG) was the main International terminal in Brazil and I bet controllers were overworked. In my humble opinion, this was a totally avoidable tragedy and responbility is primarilly on ATC System's court. Very sadly, it happened exactly on my 11th birthday.
Best wishes from Brazil.
Oi evandro!!! eu tinha 13!!! me lembro muito bem!!! gde abas
@Andrew_koala What a troll! :D
Another great video from my favourite aviation UA-camr!!
Thank you!!
I feel it was a perfect storm of errors. Main one being the controller being overwhelmed with tasks beyond his load and the pilot misunderstanding the controller's instructions. But then again, the pilots usually have a chart marking all high terrain in the region around the airport or was it not mandatory during the time of accident or not required for take off. If I recall correctly, the charts are used during the briefing for the flights.
more like understaffed as the bean counters were more concerned with prohit than saftey!,i think thats the root cause!.
the pilot did NOT misunderstand any instructions. they followed them. they trusted the controller.
@@ursodermatt8809 yep, they trusted the controlers, BUT if they had a takeoff brieffing concerning high and abundant hills around all of Rio de Janeiro, they would have provoked the flight control and cerntainly get a climb to higer level... I invate you tho get pictures or videos taking of and departure from Rio, is wonderfull, also complex and dangerous!!! Best regards!!!
@@kikobarros76
thank you
That's where a navigator was relevant in the earlier flight decks. The B707 at that time was either a 3 or 4 person crew , someone should have had a situational awareness of their environment... just saying
You know it's a happy day when you get a notification from this channel 😀
Thank you so much!
Agreed, i love the story telling, short and concise while being engaging.
Airplane crashes make you happy? That's dark...
@@flyingark173 Aviation is all about learning from mistakes, mishaps, crashes etc mate😬😕
@@flyingark173 Agreed, wrong choice of words
No matter what a controller tells you, final authority is with the flight crew to avoid terrain.
Love ALL your videos so far , been going back in your catalog, so many great ones !
I am now a subscriber!!! Came upon your channel and quickly knew this is where I need to be.. much love from North Carolina ⚘🌷
The best aviation yter uploads a new vid again
love ur vids man i am an aviation geek and i know some of the air crash investigation videos ypu made
Another great video!
Another great video. My day immediately got better
Having done most of my flying in the 1970's (all personal, no professional) in older airplanes with basic six pack instruments but in a very mountainous area (Reno, Nevada and over the Sierra Nevadas to the San Francisco area) I never did a preflight or started an engine without reviewing planned route AND TERRAIN. I've done too much search and rescue for airplanes that ran into cumulus granitus. This incident is a classic swiss cheese. Captain, FO, Flight Engineer, ATC, the ATC system all are slices in the cheese. The holes lined up.
"cumulus granitus" is clever! :-D
@@alessandroarcuri209 Agreed. Aviators do have some pitchblack humour. To the OP, I salute to you as a diligent, careful, responsible pilot.
Awesome video man ..... Really excited to see your videos ✌️✌️✌️
Thank you so much!
This is sad. Most accidents didn't have to happen, if only one piece of the puzzle was discovered many accidents would not have occurred. This is one of those. I think people get complacent, they think technology will keep them safe, ATC is watching over them... I'll bet all of us have narrowly avoided disasters that we don't even know about. When we do avoid one, we think it was a very rare situation, I believe it's more common than we realize. We are in vehicles that have the potential to do a lot of damage. Accidents are, for the most part, a string of little mistakes piling up. They can be stopped or allowed to progress in one, seemingly insignificant action. Most of the time things go as planned, never knowing how close we were to a potential disaster.
You do such a great job making your videos! Can't wait to see more! Take care!!
Love your videos, sir. As an “okay” Portuguese speaker, I have to mention that the departure airport Galeão is gah-lay-ow and the Caixas VOR is kai-shuhs 😊
I'd pronounce it kah-shee-us.
Sorry but is Galeao
Não percebi
Actually it’s not “Caixas” but “Caxias” (you changed the i for the x giving it a total different meaning) and it should be pronounced ka-shee-us.
The airport is Galeão instead of Galeo as shown in the video.
Thanks again MACI man.
Well done.
Things learned, I hope.
Nice job Rod Serling. This had to have been one of my favourite airframes of all time. What a beautiful machine. I was lucky enough to have flown a lot of them but this was one special as it was the first one and so sleek.
9:22 "this could have been easily avoided if people had just talked to each other" This is so true for many conflicts and issues. Like in relationships. It's been said that all problems are communication problems. I'm sure there are exceptions but it's basically true for virtually every hole in the Swiss cheese of every air crash. It seems that the airlines with the best safety records encourage a lot of open communication. The more you talk to other people about what you're doing and what's going on, the better. When it's a safety critical industry, it's deadly to not talk about things.
Good comment. IMHO we had here an accident that occurred due to one missed communication. Any time vital information is communicated by only one communication then an accident must occur eventually. The pilot here had a working idea that something was unusual about the takeoff, even with the overloaded ATC the 707 captain would have been justified in having the copilot contact ATC for clarification. As busy as the ATC was he should have been able to see immediately that the 707 was well beyond the position it was expected to be in. I wonder if the 707 was lightly loaded and accelerated faster than normal to the open ended instruction to 'increase speed'? While we must grieve for the losses on the plane still it always saddens me when a controllers career is ended by a mistake that takes several specialists in a quiet room with a big chalk board listening to the recordings repeatedly to figure out what the ATC's mistake was.
your videos have encoraged me to make videos of my own passion topic, cricket the sport, still learning the whole process
An accident is never a single error, it's always a chain of errors. E.g., if my approach is not stable it's often a combination of wrong height, wrong speed and wrong glide path and to make it a problem I need to decide not to go around but try to save the landing against better judgement. If it's any one of those, I can compensate and make it stable very easily or just go around and try again. The system is wrong for putting such a workload on the controller, but the controller is also wrong for not signalling his excessive workload. When in doubt, shout. And the assistant for simply not doing his job. And the pilot for flying faster than 250 kts IAS below 10.000 ft. And the pilot for not asking again when he got no answer. When in doubt, shout. Anyone of those things could have avoided the accident if it was done differently.
Reminds me of TWA 514, a Bo-727 that crashed into the mountains NW of Dulles years ago. plates/charts nowadays have easy-to-read graphical minimum safe altitude views in place of text. Procs now also include more intuitive step-down/step-up fixes. In the TWA-Dulles flight the PIC almost had it figured out - they were too low and far out from the field when more chatter broke out in the cockpit over procedures. They hit a mountainous leeward downdraft and turbulence which didn’t help but when they finally pulled up they almost made it over the ridge. things do happen but it’s amazing how safe things are today thanks to those who’ve gone before us
To ask your question in another way..." Who performed their jobs at a standard lower than their training required"......The answer is....everyone. The controller was not in control. The Assistant was not doing their job. Pilots were not situationally aware or getting confirmations for their questions. Flying blind and behind the plane.
Well said.
Not a pilot so it's taken me a while to see the simple approach to flying that would always prevent something like this from happening. A few observations. 1) There doesn't seem to be any redundancy in the atc duties which seems like a bad idea. In effect you have to plan on controllers to perform perfectly. 2) I've recently been made aware that this would fall under the concept of a "flight plan" which the flight crew is supposed to do before liftoff, which would be part of knowing where you and the mountains are at all times . This would avoid the passive approach to relying on atc to keep you out of trouble. 3) Following the low altitude speed limits would have given them more time to correct any errors before crashing. 4) When something doesn't seem right, there's a good reason not to dismiss it.
Addicted to your detailed videos about aviation accidents. Keep up the great work
thank you!
Aside from the very interesting, detailed description of the event(as always), those graphics are amazingly detailed. Having cut my aircraft maintenance teeth on 707’s, the images just bring back all the memories. I’d just love to hear the Pratt & Whitney JT3’s screaming as well!
Such a beautiful aeroplane. I sometimes wish that widebodies were never invented!
Good informative vlog.
The previous comment that they always have to apportion blame is a good one. Sometimes it’s better to work out how an accident could be avoided in future if similar circumstances arose. I feel the only thing the Controller could have done would have been to stop his traffic until he was able to deal with it. He has to land the planes in the air, but he can stop any departures until he’s not so overworked. Nobody wants a late departure, but it’s better than crashing into a mountain. Also, is it just me, or do the GPWS call outs never seem to allow enough time for pilots to take evasive action ?
Yes good remark. We saw that on other crash, when the terrain alert poped up too late. Why?
Usually the GPWS gives enough time for evasive action. But the GPWS doesn't tell you how the terrain looks like in detail. It doesn't tell you that you might hit trees with a wing: too late.
On the other hand engines react quite slow after pushing the throttles forward and this might have happened with this flight.
Since Brazilian ATC was run by the military at that time, it was famous for not being very effective and sometimes even not very safe. Many pilots complained about that.
Unfortunately the Lufthansa pilots were probably not aware about their real location due to their high speed. They knew for sure about the mountainous terrain around Rio's airports.
R.I.P.
GPWS goes off, command maximum thrust and climb as aggressively as possible with potentially a clearing turn away from terrain. But in a civilian aircraft, passengers will be upset, or the freight may shift position, so most pilots will instinctively fly with more moderate control inputs so as to avoid over stressing the aircraft, passengers, or risk the cargo shifting. GPWS is really a last resort when everything else has gone wrong.
Yes, those are very interesting remarks. I guess pilots who are conditioned to follow civilian airline rules would not be instinctively taking the action needed. Maybe there should be more training and clearer memory items to follow? At any rate, TCAS seems to give a lot more time for a resolution. I’d also set a minimum number of experienced ATC staff to be on duty during hours of darkness. If an airport is that dangerous, even go as far as only allowing one of the two airports to schedule flights arriving and departing during night time darkness.
You are certainly correct in stating that the GPWS is triggered far too late for anything other than completely flat terrain. Once the ground proximity warning goes off the pilot, not expecting it, is momentarily stunned & it takes several seconds to assess the situation. Then going to full throttle there is a significant lag between the pilot input and the response of the plane to accelerate and lift; and the heavier the plane, the longer that lag will be. (Former pilot)
“Aviate, Navigate, Communicate”. There is no excuse for a pilot not knowing where the plane is, where it will be in 30 seconds and what the terrain is like. Especially when flying so low. Hills don't appear suddenly out of nowhere. Also, the control tower was inadequately staffed, but there is no way a politician will ever accept responsibility for failing to properly manage a service under his/her watch. Controllers are not the ones who are responsible for hiring the necessary personnel, but in this case i am sure they paid the price for the incompetency of the managers/politicians who failed to do their jobs.
Good analysis.
I think I agree with Jake. It's a harsh judgement on the pilot, but even though the controller (and the system he was working in) let the pilot down, ultimately, the pilot should have maintained better situational awareness given the hazardous nature of the terrain. Great video, btw - always fascinating and thought provoking.
Agreed, ultimately it is the aircraft crews responsibility to maintain separation from terrain, the other factors were contributing causes, very sad avoidable event. Always, Always ...Aviate, Navigate, Communicate...
Youre not wrong, but remember: this was back before GPS...and it was at night. Definitely makes navigation in close quarters terrain in such a large aircraft difficult, especially with other traffic very close by.
Unfortunately the crew had too much faith in the ATC, leading them to take too long in questioning their heading/vector instructions
@@razorfett147 GPS definitely makes life easier, but the root cause of this accident is a lack of situational awareness by the Captain. Got my private pilot license in 1977. Later spent 6 years as a navigator and tactician on US Navy P3 Orions. A general briefing prior to takeoff would have easily made the pilot in command aware of the fact that there was rising terrain not far from the airport to the West and North. Plain old dead reckoning (position, course, speed) in conjunction with situational awareness would have made the captain aware of danger within just a few minutes of takeoff. He waited for the controllers to tell him what to do. Flew all around the world using dead reckoning and a sextant. Also, a 707 of that era (equipped for trans oceanic flight) almost certainly would have had an INS (Inertial Navigation System). The would have known within a mile or two where they were with an INS. Close enough to know they were in trouble. The Litton 72 INS I used was generally within 1-3 miles of actual position (latitude and longitude of our parking space) on the P3 after 10+ hours in the air. GPS is definitely a tool to make life easier. But the pilot didn’t know where he was 2-3 minutes after takeoff. That’s the #1 issue.
This is definitely a system failure. Doing air traffic control work on prescribed working conditions is already hard work that requires multitasking like you have 4 hands and 3 brains. This airport even needs more due to its location. Just looking at 5 blips on a screen at the same time is already tough. Expecting someone to watch, calculate, and coordinate at the same time is just too much. I feel sorry for the traffic controller for this flight.
Do you work in ATC?
Possibly this crash was a beneficial one for future flights, as it highlights not only the need for better communication, but also the massive over demand put on controllers, And thankfully l the lessons didn't involve the death of hundreds, although my apologies to the families affected by this crash, if my comments appear somewhat harsh Thanks for your brilliantly executed channel
I agree - I love this guy's sweet and charming delivery of a very complex subject indeed in which he is clearly an expert. A very winning combination. As regards to fault, way before we were requested for that feedback I was saying to myself that it's the airport owners/management's fault. I was tempted to say it was 90 or 95 or even 99% management, with the rest, the controller. But no, hindsight is far, far too easy. It was 100% management's fault. In fact, assuming that the controller's work conditions had previously been similar - under staffed and overstretched - it is a miracle, given the complexities introduced by the other airports nearby, that a (far worse) accident had not previously occurred.
You answered your own question at about 5:30. The crew DID NOT FOLLOW the departure procedure that they had been cleared to perform. They assumed that they should continue to follow the "040" heading given to them by the controller. Big error. We can assume that the Lufthansa crew were at least generally aware of the terrain in that area of the country. At Caxius, they should have continued to follow the departure procedure or at very least gotten an immediate answer from the controller. It's hard to believe that three guys in the cockpit of an airliner would accelerate to over 300 knots while at only 2,000 feet agl. Each of them must have thought, "This is pretty crazy." Which kind of explains the *immediate* reaction to the GWPS. Somewhere in their brains they (or at least the captain) knew that they were not in a good place. Lots of crews have been lost because of a delayed (or disbelieving) reaction to the GWPS.
Yes, the system let these guys down. But they too bear at least some of the responsibility for the crash. I mean, what was the FE doing while they were screaming along at 300+ knots at 2,000 feet? One of them should have said, "Hey, are there any tall antennas...or, you know...MOUNTAINS around here?"
P.S. Great video!
At the time, ATC in Brazil was under the control of the Brazilian military. The incompetence was alarming! Not the first nor the last deaths caused by poor training in their ranks of corruption.
Aaaa... 707, my favorite aircraft. Once, just once in my life, I was lucky to fly on one before they were taken out of passenger service. PanAm flight WAW-FRA, August 28, 1979. Normally, PanAm flew 727s on tfat route, but that day they switched. Flew several times on 727, but on 707 just that one time.
Poor controller had to live with that all his life, no matter how much he should not have been put under that load. Late 1970s , no GPS on the flight deck for the pilots and no inertial navigation, just dead reckoning.
That controller was pretty much in an impossible situation an accident waiting to happen.
That reckoning was definitely dead.
man i love your videos. they are very interesting and informative. right now i am in high school and its my dream to become a pilot
It was both a systemic error and an error by the controller. The controller was vectoring the flight so it was his responsibility to do it correctly. The pilot should always be aware of where the aircraft is and what is around it so ultimately he is responsible for his own demise.
This was 1979, so I would guess the pilot had to rely on ATC for an accurate location fix.
"The sea was angry that day my friends, like an old man trying to send back soup in a deli."
I love this channel because it's the same narrorator as fascinating horror
It sounds like it was just a matter of time before the accident factors lined up.
Pilot error. Pilot is supposed to know where he is. He knows his position when he takes off, he knows his course and speed, so he can figure out where he is. The charts tell him if there's something solid in the way. He doesn't need any controller to tell him any of that. Other aircraft nearby, well, that's a dynamic situation and the pilot is not likely to have complete information, so timely external assistance is appropriate. But terrain isn't dynamic; the hills are in the same places they've always been, and they're shown accurately on the charts.
Now if the pilot messes up, there are backup systems. That's where the controller comes into the picture. But failure of the backup system doesn't absolve the pilot of responsibility.
Of course since I've only flown dinky little airplanes out of dinky little airports, I have no idea what I'm talking about.
That system is stupid. Yes, the controller made a mistake, but with that workload, it's only a matter of time before one controller makes a mistake.
If you look at this from a swiss cheese standpoint, only a few conditions needed to be met:
- lots of traffic, so busy controller - will happen 100%
- a single misunderstanding re speed
- an unnecessary (but usual) climb restriction
- the pilots not catching the error
None of these things seems out of the ordinary, and none of them is a big deal where alarm bells would go off.
This needs to be simplified, or simple safeguards need to be implemented - which I assume happened in the last 40 years.
I find it odd that a pilot would take off without knowing how high the local mountains were and which direction or height would allow me to miss them.
Yeah the captain is at fault for speeding so much in low altitude and not knowing there the mountains were. Somehow they missed the direction they should've been heading for based on the map shown here. If a pilot asks a question that is not answered and is an important one about heading/vector then he is the one who should repeat it.
Reminds me of the mid-air collision on 29 September 2006 between Gol Transportes Aéreos Flight 1907 and an Embraer Legacy 600 over Brazil. The cause: under-staffed ATC in Brazil did not inform the Embraer to adjust altitude when needed. The upturned wingtip of the Embraer sliced off the 737's wing as they crossed paths head-on. Brazil had a poorly managed ATC system for decades, resulting in avoidable fatalities.
I was getting my kids ready for school when I got this notification. Needless to say they missed the bus.
Sorry! lol
@@MiniAirCrashInvestigation It was well worth it. Your videos are the absolute best of the best! Thank you for all you do!
What happened with the controller? Did he/she get fired? They were clearly overloaded and didn’t deserve this tragedy
Unfortunately we don’t know :/. The report didn’t mention that
Short of nautical mile is NM, not a "Nm". Nm is for niutonometr.
Just 20m higher, no crash, damn. Poor controller must of been devastated.
Thank you so much for this.
I think this is not only the employment system fault but also the pilots mistake to surpass airspeed limits at given altitude: the lower the speed the later they would reach terrains and the more time to react to warning.
Commercial airline crashes are now relatively rare so it seems most lessons have been learned. Still, it's a sad story.
Blaming just one person runs the risk of the fallacy thinking that if that one person is gone then such accidents would never happen again.
If this crash didn't happen on that day another one would likely have happened within just a few years due to similar circumstances. In fact there continue to be accidents due to distracted/confused/overworked controllers worldwide. Perhaps the most famous set-up-for-failure was the 2002 Uberlingen collision.
My humble opinion is that the pilots should have had an awareness (by looking at maps/charts) of the surrounding terrain. Also it seems inexcusable for them to have given the jet “the beans” not aware that faster meets further quicker! So an over tasked controller and pilots just letting someone else watch out for them. Complacency/arrogance.
I feel so bad for the controller, imagine being swamped with 5 planes and turning to check in on a plane you had no worries about only for it to crash seconds later. Even if the company allowed me to keep my job, I’d quit. That’s some serious mental toll.
Hi have you done a video on Urg. flight 571?
I remember clearly .. as told by a classmate in university who was a controller in the tower tnis day, the departure controller ^ froze ˆ and was arrested and handcuffed in front of his colleagues. By the time there were only military controllers from air force (FAB). He was blamed for the accident and took time in jail.. Great vid.. greetings from Rio... Brazil..
Man poor guy. He was given too much to do tbh
The mistake was made by the controller, but that doesn't mean that he is to blame for it. I have worked a busy aerodrome in the past, keeping track of everything is taxing and should not be one mans burden. Having said that, if you issue a radar vector as a controller, the buck stops with you...
I have flown there, my opinion I don't trust brazialian english and during breifing I use to metion msa is XXX to the north-south, actually i wrote down on the ofp as a double reminder, atc has part of it but the crew is also a goalkeeper in the game!!!
I Am Brazilian, I am also a Pilot. This accident happened because of flight control structure as a whole. By that time it was ran by our air force personel, all military, some were very clever, others not. regarding Instrument depart SID 16, the 707 crew did not follow because they were instructed to a specific course ( 040 if Im not Mistaken) radial after crossing Caxias VOR. The plane was fast and the turn radius was large, that put the acft further away from Galeão and dangerously close tho the high mountains... Some argue the 707 was way to fast, indeed speed limitation in that area is 250ias Kt below 12.000ft agl. Yes, the conroller " forgot" them. Unbeliveably, the 707 flew in to a valley, with forrest covered hills well above them!!! If only they had climbed some 2.000ft,.... Also I have to mention that when the Rio departure " remembered" them , departure instructed the 07 to turn SOUTH and then climb. The began turning when they hit the mountain. The wreckage is istll there, a place called Morro do macaco ( monkeys hill)
This is my first video on this channel I’ve watched”fresh”, and I’m halfway thru the whole list 😬 …tells you how many airplane videos I’ve watched in the last 5 days.
100% the system and lack of staff to blame here.
However, I think I've said this before but it's a valid point, the terrain warning goes off, the pilots react immediately but it's alway too late. Why are the terrain alerts not made to go off earlier to save the aircraft?
I wonder what rio and what Lufthansa did to prevent recurrence of this accident
The System! The System! The System! Not that poor bedraggled Human!:-)
A little correction here: it's Galeão not "Galeo"
I am from Brazil and I have to say we don’t have mountains…it was a Hill
0:17 how did you display your notification bell on your screen?
In scuba diving we often talk about a thing called the incident pit, this where multiple seemingly unconnected missteps leads to one big disaster.
I think this is a good example of that as it wasn't just one factor that caused this tragedy.
As a pilot i believe that it was BOTH the controllers fault AND the pilot's fault!!! Almost 50/50 equal responsibility!!! The controller made a lot of mistakes by LETTING himself get overwhelmed by the other planes e.t.c.....i thought very seriously about becoming a controller after i got a tour of Denver center in Longmont Co (my cousin Howard was a senior controller there and since i had a lot of experience talking to them as a pilot, I thought it was really cool to see how/what they did up close and in person.....I got to sit with Denver approach, departure, and enroute center controllers at like 7pm on a Thursday which Howard said was probably the best time for me to get to see what they did and how they did it, but not get in their way since that day/time was their "least stressful" and i could ask questions without distracting them too much and actually get answers in a reasonable time since they wouldn't be controlling the maximum number of planes!!!
He was right!!! Everybody was very friendly, and seemed to really like showing a guy that had never seen a sector screen just what they did when us pilots called them and why they did what they did!!! Since it wasn't too busy at all that evening, some of the controllers actually seemed a little bored!!!! Like until they got a certain number of planes to push around, they didn't quite know what to do with all the extra time in between close calls and near misses!!!
(I'm kidding..... they hadn't had a "reportable incident" their version of the plant safety sign saying xxx days since a time off injury in years i believe...) I even got to hand off frontier from center to Grand Junction Approach (my home airport!!!)!!! I got a lot of good insight into exactly what the approach, departure, and enroute center guys see and do when we call them up!!!! And i truly feel for them when it gets crowded and they are alone or have no assistance like the poor controllers had in this case.... so yeah it's partly their fault..... BUT the NUMBER ONE THING I was taught in flight school is NO MATTER WHAT IS GOING ON FIRST AND FOREMOST.... FLY THE DAMN PLANE!!!! And they seemed to forget that rule and they let their speed get really high and they didn't communicate with the controller nearly as much as they should have since they didn't get answers to at least a couple of their contacts and since they didn't follow up on those missed calls they probably missed out on the chance to verify the altitude and speed and direction assignments and to possibly ask to continue their enroute climb so they could avoid any mountainous interference!!!
If only...... the two biggest words in the English language!!!!! If only they had communicated better..... if only the pilots had noticed the minimum safe enroute altitude for whatever sector they were in and decided to climb up above that altitude just to be safe...... and called the controller to tell them what they needed to do to be above the mountains and they most likely would have been cleared up to their cruising altitude..... or somewhere close to that..... and no crash would have happened!!!!! All it would have taken is a bit more communication with air traffic control and they wouldn't have crashed..... and flying the plane includes communicating with atc....
Too many distractions on both the pilots and controllers sides...... distractions cause crashes!!!
I am sorry that the pilots died. If they had stayed to the lower speed mandated by the regs they would not have been so far along when it was obvious they were too low. It would appear to me that was the one mistake that killed them. In the situation it did behoove them to fly according to ATC edicts. Had they been flying for themselves they would have made themselves aware of terrain. The lesson is always fly for yourself regardless of what Control tells you to do. Other traffic is moving and of course you do want to know what it is likely they are doing, but the mountains don't move and you can have no doubt what altitude you must be at.
Lt. Kaffee: "Grave danger?"
Col. Jessup: "Is there another kind?"
I see this as being CFIT... controlled flight into terrain.
the pilots did not have spatial awareness of where they were, and where they needed to be, the controller put them on a dangerous heading without notifying them they were heading towards high terrain. the layout of the airports and the lack of ATC personnel were a major factor in this, but the pilot did fail his ultimate responsibility... he should have been pro-active, not so unaware of where he was as to rely on ATC to avoid the mountains.
This was 1979. I doubt the pilots could get an accurate fix on their own.
@@briant7265 I think it's in many ways the other way round, in the old days, pilots would maintain there own navigation much more... ATC could not give pilots as accurate information, since there equipment was far less accurate
@@stanislavkostarnov2157 But it was called dead reckoning for a reason. Screw it up and you're dead.
@@mal2ksc good meme... if to be totally pedantic not the real etymology: it was opposed to live reckoning (making constant course correction based on visually monitoring your change in position, rather than a predetermined course, this has to be done when currents are unknown or unstable), but like your version....
Honestly this whole accident could've been avoided.
1.Controller prioritizes his airplane traffic; lets departures go safely, advises incoming airplanes to reduce speed or go in to hold pattern briefly.
He further should've reached out to the 527 and advised them at xxxxx point on the map "increase your altitude" as that would've got them clear of the mountains.
(Putting a speed limit too, so rate of distance covered can be tracked)
2.Have more staff and equipment on hand to deal with the workload so 1-2 people are dealing with like say 5-7 planes all at once.
Imagine if they had 1-2 extra ATC staff on hand who could assist with monitoring and clearances ect.
The major problem was the proximity of The Other airport and the situation created. Another. Accident Will occur unless. It is Fixed!
Please record these louder, I can't hear a damn thing at 100% volume on my laptop or phone, I have to come home and watch at 100% with my volume boost to hear clearly.
Other comments have said the same, I have said the same on other videos, we worked out you're recording at -12 to -16dB, PLEASE just go to 0db so there is enough volume to hear you!
With a span of over 32 years in aviation, both as an airline and military captain, I would like to share this: "Every fault is on the pilots flying the aircraft, even it is not them to blame! The price is paid by them for all the faults created by anyone. So it is always imperative that You do not loose situational awareness at any cost, at any time!" This only will keep You safe.
Very sad. Are there any simulators for ATCs for exact this sort of situation ?
The controllers had the flight under MVA (since they hit the ground). There were no alarms on the radar that they were under the MVA?
Love your channel and the content you provide, I think the system failed the controller with too many airplanes to be dealt with at the same time.
The pilot has the final say over any one, I was a pilot for many years the p.i c should know all of the information mountains,speed, I know if I listened every a.t c that did not sound right I could be flying a cloud now.
This reminds me of when I was living near Seattle WA: "U.S. Air Force C-141A Starlifter crashes into Mount Constance, on the Olympic Peninsula, killing 16 servicemen, on March 20, 1975."
I knew a pilot of C-141's that made the circuit between Japan and McChord Air Force Base south of Tacoma (almost twin cities with Seattle). He made that circuit once per week, he said. The route should have been well-known and well documented.
It made zero sense to me to fly into a mountain when the problem was so well-known. If the tallest mountain on your route is 5000 feet in elevation, then know where you are on the face of the Earth and do not descend lower than 6000 feet until nearing the destination airfield.
Aren't there radars that can see all approaching aircraft?
“95% OF THE PROBLEMS AND THE ABILITY TO FIX THEM BELONG TO THE SYSTEM, NOT THE PEOPLE.” - Dr. W. Edwards Deming, The Einstein of Quality who taught Toyota and who’s proven principles guide the manufacture and delivery of quality products, services and training worldwide. Deming proved that fixing the system holds the solution, NOT blaming the people; blame people and you have a 5% or less chance of being right. We must move from blaming to training and working together to fix the SYSTEM. GREAT PRESENTATION AND CHANNEL - KEEP UP YOUR SUPER WORK!
What 707 addon did you use?
The 707 freeware from rikooo
@@MiniAirCrashInvestigation is this fsx? Or fs2004
@@Asterarchive89 I think its P3D
@@MiniAirCrashInvestigation what sim was this on? And if it was on fsx can you show us how to convert planes from p3d to fsx?
why do all of your videos have different audio volume? I mean a huge difference. Maybe Im just spoiled, coming from Mentour Pilot type videos.. where things are..different.
Overworked ATC, misunderstanding ATC instructions, and deviating from the standard procedures all contributed to this incident. But I'm thinking that the majority of the blame should go with the system that overworked their controllers.
FEEL NEAR WHERE I LIVED IN FRAGOSO,MAGÉ ,RIO DE JANEIRO !!THE PILOTS NAMES WAS EDWARD EWENS !!!
Like Uberlinger mid-air collision. One ATC operator handle so many plane without assistence.
Where was the ground proximity warning system?
Accidents are typically referred to as a chain of events ... remove a link and the accident does not occur. The controller was a link and perhaps the final link so he was an easy target!
Did the atc have radar? We must not forget that back then the planes had no moving map gps position indicator like today's aircraft. So position had to be determined by help of radio navigation. VOR radial and DME would be the most accurate. And the maps need to be up to date and complete.
I lived nearby Caxias, one says it Ca as in CArgo, Xi as in SHE, As as in aliAS. CA(rgo)SHE(ali)AS, got it?
Edit: when you make a video about Brazil's crashes, feel free to message me to check wording or if you need any help.
Interesting video of a tragic situation... It seems that a combination of things happened that contributed to this crash... 1) The WORKLOAD on the one controller who was handling departures at that time, was excessive.... 2) The pilots and FE should have recognised the terrain that was ahead of them by knowing where they actually were.... 3)The pilots did not follow the 250 knot speed rule below FL 10 at that time in that area.... 4) The agency that trained and hired the controllers, should have had at least 2-experienced people dedicated to handle departures at ALL TIMES... This is probably the main issue, that caused this accident... The overloaded sole departure controller who was handling this very complex departure process.....
Non-pilot here. I have watched several vids on these channels where the pilot has told he controller (basically) "I am turning whether you like out or not". The controller certainly has a heck of a lot of responsibility to keep things safe but..... In the end, it is the pilot that is flying he airplane and that person is, ultimately, responsible for keeping it safe. You can argue things later, if you are alive. There is no arguing if you are dead. Seems to me, the crew did not like what was going on. Time to turn or climb or turn and climb. Just letting things happen turns out very badly all too often.
They always have to blame someone, the controller was the fall guy! The system was clearly below par.
Agreed Bryan. We all make mistakes, misjudgements, etc. I am not usually a "systems fault" guy, but asking people to take on too many complex tasks is basically asking for trouble. And it will find you. I feel very badly for the flight crew.
It's the Swiss cheese again. I think that ultimately the controller is at fault, as he could, perhaps should have raised the issue of being overworked. Surely there would be a usual staffing level and on noticing this wasnt met them there would be justification for not operating the tower, or severely restricting operations.
I do a safety critical job, and even if I could theoretically do something, there are Manning and equipment levels that must be available. If these things are not available I don't work until these criteria can be met.
If the controller felt he couldn't take the decision to close the operation down, or perhaps just deal with inbound traffic then that is systemic too. But I think too many people try and shift the blame.
Everyone couldn't done something different. The crew on the aircraft were not totally sure of their position, so they could've avoided this.
Lots of things went wrong. Unfortunately none caught it in time.
I think at the time, ATC was done by the Air Force (it was when I lived in Rio) so the controller would not have had an opportunity to complain that he was overworked.
@@mikemoreno4469 surely tho he would've been able to raise concerns that it was not safe. He's a trained professional and all
@@Gingerharry2011 , not sure but I doubt it unless he wanted to be transferred to some place in the middle of nowhere. This is Brasil, remember. Nowadays, civilian ATC is no longer run by the military in Brasil.
At many workplaces, SOPs are partially ignored and nothing happens at first. People start feeling that nothing is wrong and everything is going fine. Doing the same over extended period of time this becomes a habit. Now this is ticking time bomb... everything looks normal until there is a disaster.