SIX FEET from Disaster, the PILOTS didn’t NOTICE!!
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- Опубліковано 24 кві 2024
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On the 23rd May 2022, an #Airbus #A320 was performing a standard RNP #approach into Runway 27R at Charles De Gaulle #Paris. Unknown to the pilots at the time, the aircraft was on a #descent path straight into the ground below. How was this possible and why did the pilots not notice? Let’s explore
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Below you will find the links to videos and sources used in this episode. Enjoy checking them out!
Sources
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Final Report:
bea.aero/fileadmin/user_uploa...
Sim Aircraft USed:
A32NX by FlyByWire
flybywiresim.com/
737-800 by Zibo:
forums.x-plane.org/index.php?...
Nav Aids: skyradar.com
www.skyradar.com/hubfs/Images...
en.wikipedia.org/wiki/Require...
simpleflying.com/paris-airbus...
mentourpilot.com/incident-a32...
samchui.com/2022/07/12/6-feet...
infotourism.news/yikes-the-ai...
www.dailymail.co.uk/news/arti...
CHAPTERS
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00:00 - Start
00:20 - Flight overview
02:42 - ATIS information
06:43 - RNP approaches
08:53 - Go-around procedures
12:32 - The confusion begins
14:37 - Not an isolated case
15:46 - Weather problems
18:01 - Configured for landing
20:22 - 6 feet above
23:36 - Lined up again
27:29 - Visual with runway
29:31 - QNH blunder error
It's astonishing to think that in 2022 an entire jetplane was nearly lost because an air traffic controller said "1011" instead of "1001."
there should be redundancies, it seemed like a single point break/failure
And also controller ignored msaw warning!
Why is there no system cross checking gps, radar and barometeic altitudes? Its so stupid that a wrong readback nearly killed people
There were redundancies. But both the tower and the pilots missed it. MSAW and radio altimeter respectively
So, basically... you didn't watch the video?
Else you didn't understand it, and it's much worse.
I am not a pilot, but an engineer and I love that his channel doesn't glorify disasters but educates, especially on technical and interpersonal issues. It's so interesting and so affirming for our next flight.
Ditto. Incidents happen in the non-air world; the consequences are, generally, less but the review policy is similar
. I m not an engineer either, but a passenger & i am reassured by the fact that most airlined take passenger safety so seriously. In life, we'd shrug off such incidents as our lucky day, but Airlines don't have such luxury. Feel sorry for the ATC. Hope he wasn't fired??🤗
@@jonathanwetherell3609 Yeah far too many descriptions of incidents just say "Human error happened" and don't go into the specifics. Understanding how/why is often crucial to avoiding such things.
Forgive me, but where does any channel glorify disasters? I’m not sure that I understand what you mean by that.
@@gwenjackson8583 I think he means how some channels focus on how much death and destruction happens and ignore well.. everything else.
This is terrifying. I know there were pilot mistakes too, but how is it that the Charles de Gaulle control made SO MANY critical errors. Repeatedly giving wrong pressure (and not noticing discrepancies in readback), not turning the lights on, repeatedly not bothering to pass on a critical collision warning or doing so incorrectly. I know that this channel is normally about understanding not blame, but the person responsible for training and establishing standards in this team should be fired.
My thoughts exactly!
While I certainly appreciate the instinct to place blame, generally these types of failures are systemic, not individual. Just Culture suggests that we understand and focus on the "why" rather than the "who" to promote cultures of safe practice.
Why did the controller have so many unforced errors? Was fatigue a factor, or interpersonal conflict? Was there additional cognitive load on the controller? Was there a lack of review for the controller, or lack of critical feedback?
These are all questions that can lead to increased safety, where firing the controller would likely have a negative impact to safety as someone in a similar position would likely be inclined to supress or hide it out of fear.
@@the-real-chaosaffe That's exactly why I didn't suggest firing the controller but rather the person responsible for this team. It sounds like they (the team) are either understaffed or undertrained.
And the fact that French ATC (OK, others too, but they are the worst) insist on speaking French to French pilots. There is a reason we use English as a common language and it's NOT because we (native English speakers) think it is 'better', so just get over yourselves and conform to the ICAO standards! In this incident, hearing other pilots being given a different QNH could have removed just one more hole from the Swiss cheese.
She got fired soon after this incident !
This channel should be taken as an example of ideal research and journalism. Only facts, no opinions, not trying to frame or point finger of faults. Just a nice, clean, visual story-telling of an actual incident. Brilliant.
“Since the aircraft are not made of sugar, we can just fly straight through them.” What a memorable line!
"You are not made of sugar" is a common Dutch saying used when someone is complaining about or does not want to cycle in the rain :)
@@velox__ This was also used on a regular basis by the headmaster of my Irish school five decades ago when any student dared to complain that our beautiful Irish weather made outdoor activities unattractive. He was a hard but also affectionate teacher, always correct and a man of exemplary character - time and the success and really positive memories of his many, many students have demonstrated this conclusively! The curious thing for me is that we students thought that "You are not made of sugar" was a provincial Irish aphorism but I am delighted to hear that we share this with our beloved Dutch neighbors! We are thinking alike!
Same in French!
Despite being a sweet plane!
@@paullaurencesweeney5255 Lovely story! I was also unaware we shared it, apparently with the French too!
At this point, it is a family tradition to watch your videos ASAP every other week
Awesome! I really love hearing that. Thank you for being awesome supporters! 💕💕
Right!? I started watching, and now my entire family watches with me.
U
i can fly a plane just by watching these videos! hahaha
@@MentourPilot Only responds to compliments. Previously was a post from a retired ATC, but no comment there. Mentour actually never reads youtube comments. He has a host of volunteers who do this for him which is a little pathetic.
As usual, a superb analysis of the incident. It is very tempting for ATC to talk to their local airlines in the language of that country. This results in all foreign aircraft being out of the loop, thereby possibly missing another chance to pickup a mistake.
My thought exactly! I’m not a pilot, just a couch pilot, but isn’t this the reason why English is the official ATC language internationally??
@@DaMrSterlingyes. But France has an exception to this rule. ATCs in France are allowed to speak in French to French aircrafts. I'm guessing that it is because of old french small aircrafts pilots who don't want to bother learning English, but it's coming out of my ass
I am not sure about this. Maybe by speaking English to French pilots the ATC would have given the wrong QNH to them too. I think the ATC could just repeat the QNH using groups of two figures, like saying "one zero one one" and then repeating the value by saying "ten eleven" to confirm the former.
Some of these kind of issues could be improved by automation. For example, the QNH settings could be transmitted as data to the plane and processed automatically. A voice alert for the QNH mismatch could have prevented the near accident. Also, the MSAW warning could have been transmitted to the plane automatically, to avoid human error in relaying the message.
you forgot intentional misinformation from a hacker/ terrorist.
My thoughts exactly! I also wondered, why does this system even need the QNH in the first place? It would seem to me that GPS plus terrain mapping (the latter of which already exists due to GPWS) should be able to accomplish the same with greater precision and fewer opportunities for errors. (If altitude measurement redundancy is a concern, I would think the radio altimeter could be used.) This would give you an internal instrument landing system that doesn't rely on ambient air pressure at all.
@@mnxsPWS warnings are based off of the radio altimeter, not GPS altitude mapping, which does exist but is not nearly precise enough as the radio altimeter. In this case you need QNH because you are determining the aircraft altitude based off of barometric pressure. Outside of that the aircraft is blind and doesn't know it's altitude above 2500 feet where the radio altimeter kicks in. GPS cannot determine the altitude of an aircraft (or anything, for that matter), it can only detect coordinates. Say you're flying at an unknown altitude. The GPS tells you that the terrain exactly below your coordinates is 1500 feet ASL. But it doesn't tell you how high _you_ are above that terrain. Unless the QNH is set correctly, you wouldn't be able to tell at how high above the ground you are.
@@raidzor5452 GPS definitely can tell you altitude. Low cost retail GPS receivers have an horizontal precision of +/- 15m, and vertical precision 1.5 times greater than that so +/-23m. However, barometric altimeters are much more precise than GPS (less than 1m of error).
@@vegiimite You are, in fact, correct, didn't know that!
This is one of the most messy situations I've heard on flight scenarios without there being an actual collision. Scary stuff. I hope the finished investigation does everything possible to encourage proper checks and verifications.
It's incomprehensible they don't do basic things right in the first place. Makes a mockery of training and this supposed safety culture the airline industry waffles on about
@@redboyjan The issue is no matter how good your training is our brains will never be perfect. It's absolutely normal to fluff numbers, and it's absolutely normal for confirmation bias to escalate into a dominos effect.
That's why at the end the comment about removing confirmation bias is extremely essential. All the read-backs on the radio are completely 100% pointless if confirmation bias is in effect.
The pilots really should have caught it when they had to change from the pre-entered or pre-planned number and questioned it there and then. Also the tower fluffing the numbers once is 1 thing but not realizing and continuing to do so multiple times is a pretty damn big deal and that operator really needs a different profession.
That's all common sense stuff, you don't need to be a pilot to understand these extremely simple points.
Also the airline industry is not a safety culture in any way lol. That's a fluff sales pitch. It's an industry that created safety measures out of the blood of the dead but changes nothing until they absolutely have to.
They are statistically 1 of the safest ways to travel, but that doesn't make them a safety culture, it means they do the bare minimum better than other industries. Nobody and no industry is above criticism, especially when they waffle on propping themselves up to make a profit.
@@redboyjan it's a low cost carrier. I'm shocked we haven't seen more crashes from them. They are all a recipe for disaster. Sun country, frontier, spirit, Norwegian, Iceland Air and Ryanair. I'm sure there are others but all of those low cost carriers cut safety corners
It's also strange that there is no alert if the radio altimeter height deviated a lot from the calculated height.
A simple "Height disagreement" alert, would have been enough to alert the crew to the fact that their radio altimeter had a much lower altitude than the calculated one.
@@ihateusernamesgrrr can't argue with most of that of course. It'll change if a billionaire is killed on the ground by a plane crashing due to ignorance or stupidity. In the meantime I'll take the ferry to Europe and drive in beautiful scenery instead. Its funny these videos should show its a good culture, when it just makes you think they don't deserve my money, like so much nowadays
As a retired air traffic controller, I love these videos. Hearback readback errors are always items we train for but as human beings we have difficulty overcoming, especially when values such as altitude assignments, altimeter settings and call signs are similar sounding. Following procedures is important. In the En Route system in the U.S. Datablock would flash MSAW when an aircraft was too low and the query was always to ask the pilot to verify both altitude and altimeter setting. Amazed nobody picked this up on the first attempted approach. Thank you for these videos
Top comment
One example i heard was that it's like sketching with ink. you try to get everything just right first try, but odds are you won't get it right every time.
ATC in France isn’t very good, they often sound confused..
@@ACPilot that. Flying into France always makes me a little bit nervous. I'd never fly Air France.
Isn't aircraft ADS-B data based on the same readings as the pilot in charge sees in front of them?
So ATC would see the same screen altitude unless they had some other accurate altitude sensing equipment? Tricky error to pick up without lots of on-ground gear, which many smaller airports just don't have.
Ok I know flying is difficult but this case is infuriating (thanks Mentour for the great report, as always). Every second video of yours includes the ILS being taken down in the airport, then things go wrong. Why don't we have mandatory backup ILS always in place or disable landings on airports with sudden ILS turnoffs. Secondly, It's unimaginable that the cockpit audio (and why is it even only audio in the first place, we should have live video, audio and button pressing history logs) has to be manually turned on. Just backup everything for 6 months in a drive and recycle-record it! Thirdly, why do we keep broadcasting crucial objective information (NUMBERS) over a bad audio signal that can be misinterpreted, can not be heard, can be difficult to understand due to language barrier issues, and not broadcasting it in a VISUAL text message. Automatically. Like "Press here to send over approach information". I can't believe 170 passengers flew to their deaths because of someone mistakenly saying 1011 instead of 1001. And lastly, how is it possible that you are flying downwards, like you know, the ground is coming up at some point, you have two numbers on your display (the radio and the altitude), you see them being of by 500 feet and you just don't question that? Like, it's either wrong OR THE GROUND IS COMING TOWARDS YOU FASTER.
I won't even mention the lights being off. Like, JUST KEEP THEM ON ALL THE TIME. Is the airport caring about the electricity bill?!
I don't know, maybe this case got to me. But I can't believe this whole multi billion industry with multi million vehicles still depend on crunched up audio and multiple people hearing numbers and gibberish for 8-10 hours straight and expect them to not miss a single digit and not "tune out" once in a while, while the other person is doing the same and repeats the wrong thing.
Same though. This triggers me so hard.
Yeah it's beyond crazy it's not fucking 1970. But it makes sense. Who makes money off of everyone being able to see those things? Airlines make billions every month. We can pretty much see everything on the Internet live nowadays, hell we were able to send people to another planet almost 60 years ago at this point but somehow there is no video evidence from aircraft cockpits, doesn't matter! The fucking audio is sometimes fucked up and unintelligible, or just not there. Tells you quite a lot about our society doesn't it.
Planes, in general, could use a serious UI overhaul.
I think the point is that things are grandfathered in. These systems evolved from previous systems, and they work well enough most of the time that no one sees the need to replace them. Couple that with the fact the people who know best how they work are so laser-specialised in their job they often can't even see alternatives.
Simple QoL fixes get shoved by the wayside as the inertia of milions of man hours rolls on.
Electricity bill!!!😮😮🤣😭🤣
The QNH issue is reminiscent of the very, VERY close call of a plane on approach into Hartford, Connecticut in stormy weather. (I was living about 10 miles from the airport at the time, and yes, it was quite stormy.) The plane landed safely, but they found tree branches in the engines. If the plane had been merely a few feet lower, it would have flown straight into a vertical rock cliff.
What year was that?
American Airlines Flight 1572 in case anyone was wondering.
Thanks Petter for this masterclass. I'm an flight instructor here in Brazil, and also teaching meteorology classes. I've always made very clear to the students the importance of the correct QNH settings during approaches, and I've been searching for good examples to use in my classes. This video (and report) fit like a glove! It's exactly what I was looking for.
Not only perfectly showed the importance of correct QNH settings, gave a good insight on how barometric pressure systems work, but it is also a great demonstration of Dr. James Reason Swiss Cheese theory.
Thanks again Petter, on behalf of all us teachers who cares about good teaching for the new pilots, and increasing aviation safety levels in general! Keep up the excellent work!
Support Bolsonaro!
Sir i have a question, as a safety measure why don't they put a camera inside the cockpit where someone on land can monitor what's happening inside most esp during problems because based on the videos have just watched on this channel, most accidents occur cause of tiny things like not changing some instruments which can easily be noticed by someone else and hence alert the pilots
Am just so confused why this can't be done
And also what's the role of instructors? Are you supposed to also monitor the captain when he's flying?
In USA ×everyone not Clear with " knots" we use miles/ gallons can u say both?
@@edwinawilliams6976 Knots are a maritime unit for nautical miles per hour. A nautical mile is equal to the distance of one minute of latitude, or 1/60 of a degree of latitude. This unit makes maritime navigation easier, since maritime charts use longitude and latitude to specify location. A nautical mile is equal to 1.1508 miles of the sort you're used to.
@@grizzlygrizzle bolsonaro is a criminal thug
So lemme get this straight: The controller calls out the wrong QNH multiple times to multiple planes, misses several "incorrect" readbacks (the whole purpose of which is to CONFIRM communications), forgets to turn on approach lights, waits an inordinate amount of time to alert on MSAW, and had to be relieved of duty for performance issues. Is this dude in jail or what? I thought France took draconian action against things like this... And not to excuse their malfeasance at all but I wonder what drove the controller to such error? Intoxication, stress, unqualified, uncaring, what?
Oh and in 2022 we STILL have CVRs with less recording time than an MP3 player from the early 2000s...
Indeed - the number of failures from the ATC is disturbing.
Just to clarify, there are a few different controllers in play here:
* The radar approach controller, who fouled up the initial QNH.
* The first North tower, who didn't turn on the lights and messed up the the MSAW phraseology
* The second North tower, who had initially caught the lights when they were working the South side, but also messed up the MSAW phraseology.
I actually find it surprising how such simple errors in verbal communication aren't much more common. There's probably a lot of small incidents that never make it into an investigation or such. Errors are human and we're probably better off not knowing every little mistake pilots make.
I am not a pilot however I have learned so much about aviation and the workings of modern aircraft from watching your channel
They way you present each accident report is always respectful of the pilots ,crew and passengers. You have a real gift of telling the events that led up to the accident including how the pilots are feeling , their mood that day and their level of expertise and even bringing up any isssues they had in training and hours logged on the aircraft.
The phrase ‘“what would cause” is the start of your deep investigation of the accident report, I am hooked on the way you present the report findings even going into to how different devices work and interact with each other You keep my attention waiting for next bit of data or clue to solving the puzzle of the causes of the crash. The amount of responsibility on a cockpit crew and attendants is enormous, i have gained new respect for you guys.
Thank you for sharing your knowledge with this curious mind.
I work in software engineering, but i learned a lot from your videos: situational awareness, team and personal resource management, following proper procedures and clear communications help not only flying planes, but writing better software! Was there an accident/incident caused by software error? Thank you for your videos, all of us can learn from aviation industry
There have been some incidents of software error, yes. I’m going to cover one soon.
Thanks for your support!
737MAX MCAS...
737 max Buggy software with messed up sensors pushed the nose down at critical phases of flight
@@EugeneF35 Is it a software error when it was designed deliberately that way?
@@FriedrichHerschel Or as Microsoft would say, it's a "feature." lol
They were flying basically blind, completely unaware of their situation - and when they decided to go around, it was literally in the last second for them to avoid a crash. That was really good timing!
Really fortunate timing.
They knew nothing about their situation....not good timing at all.......pure ignorance. ....
Just luck.....another 1mb in error and they would have crashed.
They were not flying blind .
They were lazily flying with
absolutely no monitoring of their radio altimeter ...........just following their OWN computer generated false flight directors to their near death.
No scan !!!!???
No cross check with the radio altimeter. ...a completely independent system and not dependent on the altimeter setting.
The most important instrument in low visibility approaches and landings......totally ignored.
Such good timing I can barely stand to think about it ...
They followed procedure. Luckily the terrain wasn't higher at that particular spot and there was nothing in the way. even a simple thing such as a road being there could have resulted in a tragedy
Fire everyone involved
How does the 172 passengers who were on the flight feel while watching this video
A reflexive clenching of the anus would probably have been the initial reaction.
Not quite as bad as the passengers who watched their own plane come in for an emergency landing, live on tv (and inflight entertainment system). An incident also covered by MentourPilot
@@Strathclydegamer Haven't seen that one yet, do you know what the title of the video is?
@@Blex_040 „These Passengers watched their own emergency, LIVE“
@@Strathclydegamer Which video of MentourPilot is it?
We live in an era where data storage is ridiculously cheap. Why is it that every voice recorder isn't set to save everything no matter what and send the recordings to some data center automatically for preservation in case of being needed for future investigations? If something minor happens during a previous flight goes unreported, you could just listen to the archive of those flights to investigate the current major issue that prompted an investigation to ensure it wasn't some long term issue that compounded suddenly!
The flight recorders have to be enormesly resistant and tested against lots of threds and forces. Also they would need to be changed on existing airplanes that fly for years....
The downstream approach also causes problem with sensitive information being broadcast to everyone to listen, and jams up communication channels als this data will take up a lot of bandwidth, that would bee needed to transported uninterrupted from airplane to recording center
@@TecSanento i can buy streaming quality wifi on a transatlantic flight for $30. surely an airline can afford to upload audio and flight-metric data via SFTP or other secure method.
@@cgalon6781 and you would rely on that for your life?
How many gigabytes of data are included in this? And also what is the ping time you get on these connections, because this is what you would lose in the crash
@@TecSanento Even if it's only 80% reliable that is still 80% more than we have if the recorder isn't functional...
@@cgalon6781 they were functional, but just like a dashcam, if you dont save the data, it will be overrwritten.
if storage is that cheap, why isnt tv and radio recorded 24/7?
Or demand this kind of surveilance mandatory in all cars?
i guess in the end, its not worth it enough
Even in clouds, it's remarkable to be six feet from the ground and not see it
Maybe because they were nose up for the go around at that point?
@@ntdscherer *Or, **_they did see it and that is why they _**_-forgot-_**_ to save the pilots coms._*
@@changeminds2736 ha I guess that's a possibility! Hope that wasn't it.
@@changeminds2736 Then they wouldn't have done the same approach again.
I remember walking to school in heavy fog in California - I couldn't see the path across the schoolyard six feet in front of me. Really spooky!
As always, bringing us all the necessary detail and info without unnecessarily stretching the video. Petter never disappoints.
I love how you only use commentary necessary to explain what is going on. No nonsense or fluff. Thank you for a superb and professional breakdown and analysis!💪👌
As a nervous flyer, i want to let you know how much these videos have HELPED with my fear of flying. Watching your videos, I am amazed at how many security layers exist and have to be breached until an accident happens
I always loved flying, but three years lack of any vacation and this awesome weekly documentary made me nervous about flying 😳
I have to unwind my mind somehow and teach myself, that there is no fatal plane crash every other week 🫣
Me too mate first ever time flying couple of years ago I watched these vids to mess with my mates but made me terrified when that door shut but after the take off I was like oh
I used to love flying when young but slowly after 9/11 I became somewhat nervous. These UA-cam airplane videos have cured me.
For me did the opposite. I work in industrial setting and people make mistakes all the time. Poka-yoke procedures are something common here. Calibrating the altitudemeter by hand at every airport is just crazy prone to human errors. This can be used as example of a bad procedure.
I'm also reassured by those videos but on the other hand... sometimes when I'm on a plane I catch myself thinking: is this it? is it one of those 1 in a million flights that will end up on Peter's youtube channel? :D
I feel a little sorry for the pilots on this one. Plenty of compounding errors from ATC that put the aircraft into an incredibly dangerous situation.
Great job by the captain rigorously following minima procedures. Just a couple of seconds of 'maybe we'll see the runway in just a second here' (which we've seen in other incidents) would have had a very different outcome.
That’s not how I see it. Nothing to do with the minima procedure, they were well below that but got very lucky! Very strange the radio altitude didn’t save the mistakes made by atc.
Pilots didn’t question a changed QNH from the ATIS, didn’t see they weren’t at the correct altitude on approach, missed erroneous calls to traffic, “didn’t hear” the radio altimeter and erased the CVR. Not sure I feel sorry for them until a final report comes out.
@@_-BikerBoi69_- - That was but one of many communication errors and omissions. Very, very frightening. I hope a bunch of ATCs (and a couple of pilots) get retraining if not fired.
@@rutgerw. - It should have. But they never looked at it. Once the incorrect QNH was set, they never questioned it, despite numerous opportunities and indications they received.
@@rdspam They didn't erase the CVR, they just didn't pull the circuit breaker that stops (and preserves) the loop recording. They didn't know they had experienced an emergency situation, so it would be odd for them to pull the circuit breaker.
What i get from your video is that in order for something bad to happen in a flight multiple systems and or people have to fail.
I’m a layperson but for some reason fascinated with Mayday series, Kelsey, and this guy. It always seems that there’s more than one reason, usually several, and usually small things. Then it just combines into the perfect combination of awful. That’s what I get from all of these channels. It’s almost never just ONE mistake.
It’s sometimes horrifying to find out how greedy airlines can be but at the same time, there are so many redundancies built in that it’s unlikely that one small mistake alone will take a plane down. And in general it’s a safe industry…I’m impressed by how thorough they can be.
The swiss cheese model!
Your accent and your style of presentation is so addictive to listen to. I am hooked!
For a non aviator , it’s amazing to me how well you describe different aircraft operations and scenarios and how they come into play latter on when things go wrong … thank you for taking us on an amazing journey each video.
Thank you for watching and supporting!
@@MentourPilot The planes aren’t made of sugar, MP?
@@The_ZeroLine Even though planes are usually referred to as female, they aren't made of sugar and spice and all things nice. Honest !
It's so wild how such a seeming innocuous error like that could have been so disastrous. Literally if ATC gives you the wrong pressure while you're doing that kind of landing you could be screwed if nobody picks that up. Wow.....
This is in fact why Airbus is absolutely correct in its attitude of automating everything it possibly can - take as much as possible out of the hands of the aircrew. Humans, even thoroughly reprogrammed ones, just have too many bugs in their software. They make far more errors than the automation.
I was under the impression that all ATC is accomplished in English.
@@tango_uniform In many countries it is not, but usually everybody only complains about France. There are scary things happening in Italy or Latin America, too. Just to name a few.
@@tango_uniform iirc, as per ICAO standards, it _should_ be. But there are some notable diasporas around the world who seem to think that talking English to their own countrymen is a crime to all honor and decency.
The sad thing is that the radio altimeter was telling them the right thing all the time, but since a radio altimeter gives height above ground rather than height above sea level, it would have been hard to notice the discrepancy, without something like the Boeing display he describes.
This may be an odd comment, but there are other ways to represent numbers that don't allow for repeating numbers in a sequence like this to get misinterpreted. And what I mean is those two QNH numbers ( 1001 & 1011 ) could also be interpreted in computer hexidecimal format as ( 3E9 & 3F3 ) respectively. Obviously we couldn't just switch overnight, but using Hexidecimal format along with the current method on readback would prevent this.. There's a big difference between "3 Edward 9" & "3 Frank 3." But not such a distinct difference between 1001 & 1011. But the display would have to be updated to show both.
Yes, but a similar mess up would be possible with e.g. 3-Echo-Foxtrot and 3-Foxtrot-Echo
The relaxed way controllers dispatch crucial information is incredible.
What kind of scrutiny exists?
This report lets some hope that there are some mechanisms addressed to avoid tragedies due to unacceptable negligence.
@Chidis Skaniukas my thought as well. At first my thought was, why didn´t the pilots or later the controller react to the not matching QNH or wrong readback, but on the other hand, I can only guess what the amount of concentration and workload was both in the cockpit or the tower.
Knowing the way the controllers are trained and scrutinized in France, it is, indeed, inexplicable. I can guarantee you that the specific controller did not keep his/her job. The French don't usually fool around with that.
@@patrickbotti2357 faut l'excuser. Il était occupé à préparer mentalement la prochaine grève
😃@@hundredfireify
Déjà que je n'aime pas beaucoup CDG, cette histoire ne me rassure pas! '
This actually sounds like something that should be automated. It's crazy how much the airline industry still relies on verbal human-to-human communication.
Enroute over most busy parts of Europe CPDLC datalink communication is used, and instructions are sent as messages.
ill never fly on a tesla airplane
I thought this as well. Surely a digital system should back up these comms. Also a warning system that alerts a discrepancy between radio and barometric altimeter. The warnings are not distinctive enough or are too frequent. The cognitive overload is massive.
@@fredjones554 That's pretty normal as altimieter is giving sea level, and the ground could be at 500ft MSL
As a pilot with a background in network/IT administration, I don't think it should be automated. The devil is in the details and corner cases.
Ok. I'm not a pilot. But your delivery of these stories are second to none. Very endearing and obviously genuine. Thanks so much for your obvious hard work.
Just like the sequence of events that lead to an accident the timing and sequence of events that occur in this situation help the pilots & pax survive. Thank goodness the balance was tipped in the right direction. They say God protects babies & fools and they are not babies. Not fools but ignorant to what was going on.
@dish dog Petter is Swedish - he has a light Swedish accent and speaks some words like "norderly" in a way as native speakers of Northern Germanic Languages like Swedish, Danish and Norwegian are doing. No fake accent. In opposite, it´s astonishing how close he comes to an English Native Speaker.
@@sharoncassell9358 Indeed, exactly.
@dish dog It would be cool if you'd heard enough international accents to be able to tell real from fake.
@dish dog Is not fake. Nordic way of speaking English as a second language - that is altered by a solid British accent. (He was in the UK for several years).
As a software engineer that has learned to be very very wary of complexity I’m honestly amazed planes don’t fall out of the sky left and right
Soo many incredibly complex and complicated procedures and systems stacked on top of each other combined with decades of legacy technology…
A 300 ft difference from RA to ALT can be difficult to spot on non SL airports, plus can be due to terrain
While I'm simply a fan of aviation, I watch all your videos. To state that you're a valued asset to your industry understates your thoughtful, thorough analysis, integrating your technical smarts and humanitarian compassion to discuss insights that may never be revealed by a lesser communicator. Hats off to you, and thank you.
Eric, I couldn't of said that better... I sir, totally agree! My hat is also off and thanks given to the Mentour Pilot.
I took off my hat as well
Absolutely correct. We have doorbells that do more.
Engineer here. I like to think that the lessions learned from these incidents are very valuable for my work. Clear communication, following correct procedures, not assuming things that should be double checked, avoiding bias, not blaming people for errors, taking input from less experienced colleques or laymen seriously: these are the things I hope I can keep in mind and foster in my workplace.
Also, maybe change the software to give the pilot an alert if the calculated height based on air pressure, deviates "a lot" from the radio altimeter height.
I swear I saw a similar comment here
@@JohnDoe-bd5sz this is one of those things I personally don't get.... these systems are sooo.. separate that... they often can't cross-check like that. sems logical to me, but... they don't.
At any rate i've had a lot of experience in communications where having a single wrong digit means... no communications happens. ooh boy....
In God we trust, EVERYTHING else we check.
Likewise. Just good life advice
As a student pilot, this definitely reinforces the saying regarding pressure: "From high to low, look out below"!
I really appreciate your root cause analysis approach in analyzing these incidents Petter. Any up and coming pilot would be very fortunate to have you as an instructor.
WOW! The number of blunders was unreal. And they landed without ever realizing how close to a fiery death they all were.
Indeed.
They would have landed on a plain field. The 320 could easily handle that.
@@gigagurke7364 They would not have landed, they would have crashed! A CFIT in Air-Industry-Language = A Controlled Flight Into Terrain. Please remember: the pilots had no clue that they were near the ground. And if a plane should land - you have to land it!
@@gigagurke7364 They would not have been fine, there is a difference between hitting ground while descending and actually landing.
@@speckkatze Indeed. And a difference with a lot of possible fatalaties and seriously injured people when hitting the ground unexpected while descending.
I’ve now seen it more than once that talking in local languages on frequency either causes problems or prohibits the possible prevention of problems.
I think there should be zero tolerance for speaking any other language than English on frequency, especially at such a large airport.
It's not a question of 'tolerance', it's a question of rules, and they were following the rules, and were allowed to speak their native language. You shouldn't jump to the conclusion - based on nothing - that it's a problem. Keep in mind that the people speaking French were not the pilots of this flight, it was between another flight and the ATC, so there is no need for another pilot to need to know about a conversation that does not include him and is not about him and which he is not a part of.
And the pilots had many chances to catch the problem in English, and they didn't. They missed it the first like six times, hearing it in seventh time would clearly have not made a difference at all.
Also there are advantages to speaking your native language, I would be willing to bet that it has saved people, because you will always speak better, more clearly, and more quickly in your native tongue, so it should be allowed.
@@Julia-nl3gq Definitely a wrong take. Another pilot absolutely needs to know what is going on in the same airspace as he is. He is a part of that conversation, it includes him and it is about him because he is only minutes away from other aircraft, sometimes only a few metres away on the ground. There have been many situations in the past during which a crash was prevented by a pilot listening in and having good situational awareness. There have also been multiple incidents when speaking a different language might've caused a dangerous situation/crash. It is industry norm to only speak english on frequency. Multiple countries and individual airports have established this rule as it improves safety by keeping everyone invloved informed.
Also, where did you see that the pilots had a chance to catch the problem in English? As far as I've watched the video, there was only a single instance of the correct number being said in english before the incident - and that was a readback by an EasyJet pilot. The ATC hadn't said the correct number in english once before the go-around. Only in French. The ATC had repeated the incorrect number multiple times in english to the aircraft in question, and once in english to an EasyJet plane - which read back a different number (the correct one).
It was only after the pilots initiated a go-around that the ATC said the correct number in english - howewer, the ATC didn't catch an incorrect readback by the pilots of the aircraft in question. If the AirFrance pilots received the correct or incorrect number in english, there would've been a much higher chance someone on frequency could've finally caught that error. France is an exception in this and I think it is very dangerous to keep so many pilots on international flights and airports uninformed of what is going on around them.
I am a huge fan of your videos. I was in the AF as a meteorologist and worked both with aircraft and middle launches. I study for my small plane license but never finished. I really appreciate your Swiss cheese model and are never quick to point the finger at the pilot. On that note, in this specific video I was a little confused by your terminology with the weather in France. You said that the weather was pretty good with light rain showers and some “cumulonimbus” clouds and that they should only be concerned if there are “Thunderstorms” around. My concern was that the Cumulonimbus clouds are Thunderstorm clouds. If the cloud is producing rain by definition it is to be a thunderstorm weather you can see or hear lightning or not. Cumulus clouds can also produce rain, but are not yet a CB or thunderstorm cloud.
Thanks again for all the info I have received from you.
Yes, I agree but I’m also actively aware of the fact that “Cb’s” are often reported instead of TCU or even CU when those are actually more appropriate... especially in the winter-time in Northern Europe.
23:13 Petter made this whole video just so he could casually mention that he's 1.85m tall and you've kind of got to respect that flex
💪🏻💪🏻
I know I have said it before, but I am always blown away by the attention to detail you put into these videos. I’m not a pilot, but I have always had a deep appreciation for aviation. Thank you for teaching us so much, and for being so careful to respect your viewers, your peers, and all the people who experienced these events in real life. Kudos!
Likewise. I only discovered that I find aviation fascinating a few months ago and I’ve been learning about it since. Mentour Pilot was my first source of information. He taught me much of my basic knowledge that serves as the foundation of the now much more advanced and complicated knowledge that I now have. But I have a great deal to learn still. I’m in no rush since I’m not a pilot nor an engineer and I’ll never need to use it. But I still like learning
@@mikoto7693 no NPno
Yea, I would say exactly this. Thank you.
@@bartb9730 p9900
And the graphics are impressive. Must take a lot of work. I love these videos
Literally holding my breath during this entire episode!! I love your channel. I find it SO interesting. I'm constantly replaying certain parts to further understand.. I'm not a pilot. But I am a bit of a math nerd, so I really appreciate how accurately descriptive you are with these incidents. Again, GREAT video.
Thank you! 💕
That's a world record!
The entire episode through which you were literally holding your breath was 32 minutes long. Condolences to your family.
@@StevenBanks123 They might have been watching on 2x playback speed. Though still an impressive feat, that’s lower than the world record.
Yes, when I said "literally", it wasn't an exaggerated statement. I truly meant it. I'm now a ghost. 👻
... thoroughly captivating! One of your best. I'm glad there weren't injuries. It's good that procedures have been revised. It's hard to believe this could have happened. Airframe, Fuel, Engines, Control Surfaces, Air Speed, Rates of This and That, Altimeter, Radio(s), and more ... each one of these plays a role ... and one could say they are 'interdependent'. All of these (status') should be continuously echoed back and forth especially at hand-off like for something as comprehensive as landing procedures.
Could you please make a video about an aircrash that happened in Brazil. An aircraft was due to fly from A to B in nothern Brazil, B was north of A. The captain set the direction to 270 degrees in stead of 027 degrees and the first officer set the same direction without checking anything further, just copying the number from the captain. At the time of the departure it was evening and they started flying towards the setting sun. The aircraft crashed when it ran out of fuel. As they did not arrive to their destination on time, rescuers started searching for the aircraft in the area between the two cities. When they were finally found, to everybody's surprise they were about thousand miles south-west from their destination. I would be so interested to hear your wiew of the incident.
Regarding people turning numbers around when entering data:
Twenty YEARS after graduating from college, I applied for a job. The hiring firm wanted an official copy of my college degree from the university. I gave them permission, but the university would not give them a copy of my degree, saying I still owed them $0.63.
Long story short, on my long-ago final payment, some clerk had entered that I had paid $nnn.07 instead of the proper $nnn.70 I had actually paid - leaving a $0.63 discrepancy. Once I told this to the lady I talked to there, she was very understanding and corrected the error, so I could then obtain the official copy of my degree.
People mess up numbers when entering data all the time, and the results can be catastrophic! 😱
@T.J. Kong Absolutely! It blows my mind that in this age of computerization and digital communication, why important key numbers like this are still communicated by voice, and then have to be manually set by pilots. That’s a fragile and error-prone process.
All communications like these important numbers should just be sent as digital messages to the aircraft, and the aircraft should change the settings accordingly. A message could also automatically appear on a display to let the pilots know that the settings were automatically set to the values, to call their attention to that. Unacknowledged messages could be retransmitted automatically, and controllers and pilots could be alerted if the aircraft hasn’t positively acknowledged a message after say, three attempts in 5 or 10 seconds.
This is not rocket science. We have had the technology to do this for a long, long time. Frankly it seems to me that it’s an industry bias towards voice communication between pilots and controllers that it HASN’T already been implemented. Computers can do these kinds of things MUCH more reliably than people can. Voice communication is very weak link in the aviation industry.
@@kencarp57 They do it because having people to catch computer or inputting errors is vital and that people working have routine experiences with communication and inputting. Computers aren't perfect and even if they were people will have to involved to potentially corrupt the data in some point anyway. Top that with situations changing all the time and you need a regular human touch surface. To keep those in air and ground who will have to try to save the day if something goes really wrong informed and experienced. Plus there are redundancies for both computers and people doing something wrong anyway.
@@kencarp57 Computers mess up too, it seems important to me that the pilots enter the actual numbers so they know what's happening. However I see no reason why things shouldn't _also_ be communicated digitally so the computer can check the pilots and warn them if there's a miss-match.
@T.J. Kong Machine-to-machine can be hacked and manipulated in (subtle) ways that can maximize damage before the source of error can be identified and isolated. The point of maximum intentional damage appears to be much lower when humans are involved. Of course there is a cost, agreed.
@T.J. Kong Cryptography helps with protecting against attacks that take place in the network / in transit, not at the end points. I don't know what the FAA understands or fails to understand.
By my reckoning, your aviation-oriented content is simply UA-cam's best 👌 Sincere thanks for continuing to share!
Blancolirio's is excellent too ! Mentour Pilot has had him on the channel in the past.
I agree. The best.
Agreed
This could have gone so horrifically wrong, it's honestly amazing it didn't.
Yep, there is a lot we can learn from this.
The incompetence of the ATC at Paris is astounding! I cannot believe these people still have a job. They are only good at striking and throwing the entire European airspace into disarray but when it comes to doing their job… pure incompetence! As for the pilots… I mean, it feels like they are on drugs. They came to just a blink of an eye from killing themselves & everyone onboard and they were still completely oblivious… so much for situational awareness & all those multi-million dollar safety equipment… all rendered useless by a miscommunication of a single digit between 2 oblivious humans. It’s absolutely terrifying!
How can someone “forget” to turn on runway lights at one of Europe’s most important hubs and still have job is beyond me! Is this normal? How can they not have procedures in place at CDG? How can they have them and not follow them? Did anything even change after this incident? How is this not criminal negligence exactly? Only in France! Crazy!
I’m a pilot. We NEVER stop training and learning. Your channel is extremely good and well prepared. I am hooked. Very cool. I was involved in TWA-514 at Dulles. Love it if you could do that one. Thanks fo every show. Keep posting please, we need this type of analysis it really helps pilots crew ATC and flying public. Or anyone who loves flying and aviation system!!
That TWA514 in 1974 was a gross altitude error caused by a failure of training of pilots in the U.S.A.. There is seldom any need to descend below a 3 degree descent profile at any time from top of descent until touchdown. The only exception is an ATC requirement due to controlling authority of different ATC units and the ownership of airspace. In the case of TWA514 crew failed to stop their descent at 3400’ the minimum altitude at that point and descended to 1800’ but I recall the impact elevation was 1675’. The FAA and NTSB made a big thing about being required to be established on a segment of the approach. If TWA 514 had adhered to a 3 degree profile they would have been about 7500’ as they flew over their point of impact. Mount Weather is approximately 25 nautical miles from touchdown. The NTSB speculated why they had been below their intended 1800’ never mentioning the real probable cause was altimeter error caused by high winds. I learned of this potential error from LIDO charts(Lufthansa I believe) which my company had switched. Simple math provides the two pieces of information required to fly the desired 3 degree profile. Am I High/On/Low on the 3 degree profile? 3 x Distance in NMs provides Altitude. 3x30NM=9000, 3x60NM=18000. 5xGround Speed= Vertical Speed Required to maintain.
The litany of errors noted on this fine report are almost too many to fathom. Yet like most accidents, there is not ONE single error. QNS notwithstanding, I am amazed that GPWS did not alert the pilots when 500 ft AGL telling them that their altimeter was wrong based upon faulty QNH setting. Thanks, Mentour!
Yeah, good point! With an accurate ground-elevation map of the world, and GPS to figure out which part you're over, that could let the radar altimeter cross-check the pressure altimeter.
And the GPS receiver could directly calculate an altitude as well as lat/lon and check that, too, without needing to know exactly what the radar altimeter was pinging off. GPS is more accurate horizontally than vertically, but should be accurate enough, like within several meters, to catch errors like hundreds of feet.
I’ll be a passenger on a flight next week, it’s my first flight in three years. I’m not a nervous flier but your videos help me understand what’s going on in the overall situation. Great video.
Thank you David. Enjoy your flight! 💕
Get drunk, you cant be scared if youre unconscious (probably not the safest thing to do but im not getting on a plane sober)
@@eriktruchinskas3747 in most cases, being drunk in aircraft or even in a bus, is illegal. They can make You go out and give You a another ticket to pay.
@@norbert.kiszka it may be illegal but how many people do you think get arrested for being intoxicated if they are not causing a disturbance? Ive flown plenty of times intoxicated and nothing ever happens because I sit quietly in my seat until I pass out
@@eriktruchinskas3747 And if the airline you are traveling with are in the least bit savvy, you will not be allowed to board the aircraft drunk. AND THAT'S AIR LAW!
I can't believe that the QNH value was missed so many times, given how it is a matter of life and death to get that one right.
Thanks Mentour! Very interesting how a seemingly small communication error can become a serious problem if not corrected.
I can't stop watching this channel. I've been on a full binge since I discovered it. And I have zero aviation experience - I just find it fascinating!
That day when Orville wright had the brilliant insight “hey, Wilbur what do you think of not making this plane out of sugar?” Was a great advance in airplane technology! As always a great video with really good explanation of what happened here. I’m a bit perplexed why the radar altimeter isn’t the sensor fusion priority since that’s really the only important value which is how high am I above terrain, as opposed to absolute altitude about MSL
It’s something we try and check but unless you’re over featureless flat ground (like inside the airport perimeter) there is a variability to what the RAD ALT may read further away from the airport at a particular range. Imagine flying over a city with tall buildings, or hills on the approach: a small lateral deviation could lead to a difference of hundreds of feet which would mask any but the grossest of mis-set altimeters. Comparing with a GNSS system, especially a SBAS one is probably a better idea and doesn’t require you to detailed RAD ALT surveys of possible approaches.
Santos Dumont was the true real, proven and documented pioneer. Cheers.
I can just imagine the looks on the pilots' faces when they were shown what had actually happened. And I wonder what has happened on flights I was a passenger on, without me actually ever hearing about.
So so much painstaking effort is taken to tell correct story....God bless him
I’m a doctor and my job requires paying attention to detail but pilots really have lots of details to pay attention to. One oversight can easily lead to a disaster. Yes , We all get used to complex procedures over time but damn
What is it you look for primarily? The lungs or the heart?
@@electricheartpony I’m rather into women 😀
Ignoring simple things they must do is incomprehensible. They can't understand complex things proply at all clearly
@@redboyjan some definitely have been careless and negligent . But sometimes the oversights are understandable especially under intense pressure. Sadly we can’t excuse them if it leads to loss of lives
@@solomonarhin I meant as a job. When you look at people medically
The point near the end of the video about challenging a perceived faulty piece of information without restating that faulty information is very important. Forcing the other party to check the actual value versus telling them a value that they might gloss-over helps reduce the potential for spurious agreement. This applies not just to this particular exercise, but to just about everything where the proper communication of fact is essential.
I've also found that it's essential when giving instructions to tell people what they need to do, rather than what they need to refrain from doing. Many people will fixate on what they were told not to do, and ignore the 'not' part, leading to some people to actually carry out that which they were forbidden by-direction.
I'm an actuary and so work with extremely large amounts of numbers on a daily basis, including their receipt and communication. Periodically despite any level of focus and attention to detail and working with some of the sharpest most numerate and mathematical people around, there'll always be number slips/number fatigue/saying a slightly different number to what is held in the mind etc. There definitely needs to be a confirmation procedure that's more rigorous/check/double/triple check if a human communication of a value and some passing rain clouds can put an entire aircraft/crew/passengers/people on the ground at this level of risk. I'm quite astonished this risk and necessary procedure hadn't already been identified. Great video thank you
i love hove you cover all these cases! easily understandable for people who have no experience in aviation and the engineering in connection with it. i’m HOOKED on your videos!! 🥰
I am a pilot and assure that you are one of the best channel in youtube, not only for the good reports and coments but also for all video aids, maps, pictures and all material that you bring up to explain eadh detail of the accident/incident. Congratulations and thanks for your service.
This is, from a passenger’s point of view, bliss. What you don’t know about cannot alarm you. In this instance, the flight crew were also blissful!
Yeah… but we prefer to know what’s going on..
To quote a comedian:
"They say ignorance is bliss. Well, not if you're aware of it."
@@MentourPilot - So do the passengers.
Someone looking out the window could probably see the ground
@@jamescollier3 - If one is to trust Petter's description no one was able to see the ground as they were in the midst of a severe rain shower and ground level clouds at 0.8 miles short of the runway. Even so, had a passenger seen the ground at such a low altitude (roughly 80 - 90 feet AGL) they could not have intervened in any way. It is extremely fortunate the captain reacted to the absence of visual contact with the runway in time to save the aircraft. Even at that altitude neither he nor the pilot monitoring had any idea how close to the ground they were.
This channel is absolute gold.I’m an aviation enthusiast and I find this content unparalleled. I’ve watched tons of documentaries over the years but the amount of lessons and information from this channel is incredible.
I im a trainee air traffic controller
I love this channel
Helps me to learn things in a more sophisticated way
The incorrect QNH was given by the original tower controller in English to two flights, but correctly in French to another, which should make one concerned about some linguistic confusion here. Language aside, I can say from personal experience in the cockpit that these numerical inversions are quite easy to make especially in single pilot ops where cross-checking is not possible.
I thought all ATC comms were made in English.
@@JamesDavy2009 The ICAO standards allow the native language at the station to be used through informal mutual agreement with the flight crew. This is very common with French ATC communicating with French crews. Listen on LiveATC sometime; it's eye-opening.
If language was the difference, the controller couldn't successfully count to '1' in the non-native language. Yes, from that point of view it's worrying.
@@tsuchan a lot of languages don't list the digits in the order English does. French i believe is one of them. In German for example 34 is vier und dreißig, so four and thirty. I was raised bilingually German/English and really struggle with this in day to day life
In my workplace we require original speaker to respond to read back with the original message. I'm surprised that's not done in aviation. Is it because the tower is too busy?
Example of what I'm talking about, something like..
Tower: Rednose 1311, set QNH to 1001.
Pilot: Roger, Rednose 1311 setting QNH to 1001.
Tower: correct, QNH to 1001.
I can’t state enough how much better the quality of your videos are when you use Microsoft Flight simulator instead of Xplane. It just makes a world of difference to the immersion.
I feel like you could at least have some kind of checksum on critical values transmitted over voice. So instead of having 1011 you can have 1001A where A is an additional checksum character that depends on the previous ones. The plane instrumentation will do the check on input. Easy to implement, retro-compatible and gives you good chance to catch the error on input.
Do you happen to know the range of expected values? I only ask because if there's a lot of variance, you'd probably need two, or three letters. There's a 1/26 chance of any two given values sharing a single letter a-z checksum, that's not fantastic coverage.
@@paxwort barcodes can checksum 11 digits with only 1. bank account numbers can checksum 19 digits with 2. ISBNs work 9 digits with 1. my country's national ID checksums 8 decimal digits with a single (base 11) digit.
checksumming 4 decimal digits with one base-26 digit is extremely easy. you don't need to fully represent the value within the checksum digit, only to check for common errors.
Very interesting idea. Could be an interesting technology to implement to potential single point of failure settings for such critical systems
For those that might wonder why 1013hPa, that's equivalent to 1 atm (atmosphere), which is the air pressure we typically have on sea-level.
They were blessed that there were no obstacles above 6ft.
I can't think of many approaches where they would have got away with this!
Exactly. A farm field placed in just the right place perhaps.
Right? Even a farm field can have a 10 foot tall tractor in it that would have been disastrous if hit.
Learning how much has to go wrong for something to turn into a disaster gives me much more confidence about flying. Also, I love learning about intricate details such as hPa settings while cruising and while approaching. The more you understand how something works, the less mystical and scary it is.
Also, the graphics are amazing!
That has to be the most emberassing moment in the ATC controller and both pilot's life.
I love watching these. not because I love seeing loss of life (though i'm partial to that in horror movies) but because it's interesting to see A: how people can come together at a time of crisis and demonstrate incredible teamwork and desire to defy all odds and survive and B: How the aviation industry as a whole learns from each and every tragedy rather than things just being swept under the the rug in the interest of company reputation. It's these things imo that make it safe and also that companies that have been proven to act shady in their own interests are in many cases no longer flying.
How did they become aware of this incident? It seems that neither crew nor tower realised the error even after they had landed.
I’m going to guess that the two MSAW warnings initiated the investigation
@@MentourPilot Thanks! I thought you were going to tell us in the video how this was discovered and started scrolling down the comments to find out. Thanks for all the great videos!
At our company we are required to get a QNH check when getting in contact with the tower controller. So we normally have 3 different sources to confirm QNH (ATIS -> Approach Controller-> Tower Controller).
Can you rely on both approach and tower controllers to give you the information ?
Unlike Mayday/Air Cradh Investigation I really like how there is no alarmist tone in the language, just an engaging and technical breakdown that is entertaining and informative
Wow, this is incredible. Thanks for such a content. I'm working on my PPL and trying to immerse myself in the aviation world.
Peter, I have a question...If the pilots remained unaware that they had just been thru "an incident", who was it that finally realized an incident had just taken place and needed to be investigated? (By the way, thank you so much for these videos.)
My guess is that they investigated on why an aircraft triggered the airport tower MSAW warning twice, when it worked fine for other aircrafts.
Probably the person who investigated why MSAW was activated twice
I was wondering the same. I've skimmed the report and it doesn't seem to say how this was picked up, so I think it must be either the double MSAW, or perhaps the fact that the on-duty North Tower controller was taken off duty (because of failing to switch on the approach lights and getting an MSAW) was sufficient to trigger an investigation. The report does state that the Tower controllers saw the aircraft coming out of the clouds at low altitude after they had started their go-around, so perhaps that also factored into it.
It's very fortunate that the land on the approach to 27R is mostly open country. Had they been approaching from the west over Goussainville to 09L it might have been a different story...
I believe all stick shaker and serious alarm events are logged and flagged by the airlines. Likely go arounds are flagged as well, in addition to the tower's warnings based on their airports altitude warning system.
@@chuckschillingvideos what makes your say this? Can you tell us where you've seen that what you've written is standard practice or part of aviation rules? An airplane full of people almost crashed so please don't just say stuff that isn't correct.
You have a gift for explaining nuanced, technical issues in an understandable and simple way. I bet you are an outstanding training pilot! Interesting video as always.
Those pilots should've done the lottery that day, Petter, being 6ft off the ground and not hit anything was a miracle.
Of the 25-25 vids I've watched on this channel - which I love, thanks Petter - this is by FAR the most disconcerting.
Fascinating and well done! Just landed on 27R at CDG yesterday. I had the ILS, but in the past I have flown the RNP. I will definitely share it with the other pilots.
If an ATC questions a pilot: "Are you ok?" - probably the answer is: "NO".
One way of avoiding confusion with numbers is to call them out in two different ways e.g "QNH one zero one one, QNH ten eleven". This is commonplace in airline ground operations, especially in safety critical areas such as specifying fuel loads. I am surprised that it does not appear to be standard procedure in the cockpit.
Agree. Also, adding a checksum character, making 1011A invalid, and 1001A valid would greatly reduce the likelihood of this.
very good point
Dang... I used to work for Norwegian, backoffice, but loved my job with them. I'm so sorry for them, they had enough issues in recent years for this to happen too
Amazing pilots. Completely screwed and reacted without hesitation. 👏🏻 towers alerting each other and reacting. The detail of your videos, the settings through even when not the focus is amazing
With the landing gear extended is it not likely that the wheels would have almost been touching the terrain (inches)? Thanks.
10 months and no answer!
Hey Mentour, as a PPL pilot I pretty much like this type of videos: no loss of life neither injuries, even the aircraft remained airworthy after the incident - still there are a lot to learn. Also none of the involved personnel was undisciplined or sinfully negligent, just a worse-than-average day for the both the guys in the cockpit and one in the tower. Even it happened me once on a first cross country after a long winter break that I switched two digits in the QNH on read back - certainly it was immediately picked up by the FIC and corrected it, just I was angry on myself making an error on the frequency where quite a few fellows are also listening. On the other hand, the resilience of the current system in commercial aviation amazes me: in this situation many slices of the cheese was aligned - but not all of them. The captain strictly held the rule of the Decision Height and didn't try to push the envelope with even a tiny bit - that earned them that very important 1-2 seconds of margin to avoid the ground contact.
The tower controller was guilty of at least two breaches of standard operating procedure, and in slightly different circumstances he could have killed nearly 180 people. I suggest that "undisciplined" does apply, and that what happened was far worse than "a bad day at the office".
making french reports sound like you wanna pop some popcorn and play it on audible
Very detailed and informative explanation. Cockpit graphics are also top-notch. Subscribed!!!!
Here in New Zealand the country is divided up into 11 QNH Zones (for cross country flights mainly VFR, airports of course still have ATIS etc). So basicly when yoou see as you fly along that you are approaching the boundary you find out what the QNH is and chnage as you cross. So I knew this but flew a Cherokee 140 from Christchurch through the Sothern Alps to Hokitika Airport on the West Coast. (Christchurch is on the East coast). I was scratching my head trying to figure out why I had made a balls up on finals as I seemed to be too high. Fortunaely this was a Dual flight so when I commented this my Instructor said " Gee I wonder what the QNH is?". And straight away I went "Oh s#$%t". Yeah we landed and taxied to take off again (this was just an exercise not a stop off) and did my pre-takeoff check I adjusted the QNH and watched the altitude change by 200 feet down! Yeah definilty a learning experience!
I’m glad they’re ok. That’s a really easy mistake to make that many of us have done at one point or another. The lack of redundancy on a baro-vnav type approach is not something that I’ve seen strongly emphasized before. I’ll definitely exercise a higher level of caution in the future to make sure it doesn’t happen to me.
May be an easy mistake but it’s an unacceptable mistake
I'm just in awe of his aeronautical knowledge! And he explains in a language that's understandable! ❤️
It may be just me , astonishment at the very poor handling of the towers comms with plane?? Dismissals in the win
So very very fortunate that nothing terminal took place!!
Finally, who was best served by not having a copy of the cockpit tape recording?
Great stuff especially the Simon and Garfunkel lines!!!
Bob
England
@@Nazar33 sorry , I just don’t know the difference.
Bob
The pilots were completely unaware how close they were from a catastrophe * - and as a matter of routine did not actively store the audio. Their blissful ignorance at that point is obvious because they also made the second approach in good faith - it was really lucky that visibility had much improved by then. Remember: the first controller (that was replaced later) gave the wrong pressure value 3 times in English: Twice to this aircraft and once to another - only the other aircraft had also already set a value before, which happened to be valid, those pilots did ALSO not pick up on the error and read back _their_ differing (but correct) value and luckily did not change anything. Neither those pilotes nor the controller noticed the discrepancy.
During that time one airplane got the correct pressure value from the (later replaced) controller - in French. Which makes me think the controller gave that value from memory and had the English version of it with the wrong sound bite in his head. (I notice with myself that I must memorize words in a foreign language (also) by sound. I notice that when I make a mistake. Not sure if that applies to other humans as well. In French the higher double digit numbers are weirdly expressed so to a native French speaker has to transform. Of course it would be best to READ the numbers always from a visual (like a card), so it is not possible to slip up, never mind the language. Giving 4 single numbers should not be too complicated.
* calculating with their descend rate they had half a second to spare - meaning had the pilots finished their go around preparations (full thrust) 1 second later or if the decision to have a go around had been delayed a tiny bit - they would have unexpectedly landed /crashed on the ground.The pilots got the wrong value twice from ATC so they had no good reason to doubt it. But if the height of the incoming path is low all together and a crew sees nothing - then the barometer value is a top critical value.
Maybe the ATC was unaware of it that the pilots saw nothing ?
But obviously the first ATC was expected to know that visibility was not good - after all the first controller was getting noticed for not activating the light - that led to his replacement.
Normally low visibility would be no problem - the ILS of Chalres de Gaulle works no matter what. But obviously the controllers were not aware of how critical their correct barometer reading was when the ILS was under maintainance (I think the interim report mentions that staff was not fully aware of it) - so that is a matter of training and being prepared when some of the tech that normally helps (like ILS) is not available.
Im not a pilot, but your videos have educated me at how stressful things can be for a pilot. If you think it's all glory and roses, you are seriously mistaken! Heck, the passengers lives are in your hands, and that is stressful as is! Love your informative videos! Please keep them coming!
I can't imagine anyone actually thinking it's all glory and roses unless you think movies like "Top Gun" are realistic ...
Nothing better than Mentour Pilot on a Saturday morning. Greetings from Oxford, Connecticut!
That’s the spirit!! Greetings from Santiago, Spain.
@@MentourPilot I love your channel but my profession as a financial advisor has nothing to do with air travel. I like how you break down what went wrong and how the incident could have been avoided. When I watch your videos, I always wish you were in the cockpit to help the pilots. Thank you for such a great channel!
Such fine speech! Man, I miss people speaking well! Excellent detail (I feel like I've taken an aviation class after watching 10 of these) but not overly detailed (great discrimination between central and peripheral). Slow enough it doesn't feel rushed at x1.25. Great job relating the facts to the themes: we really benefit from your expertise, which gives us a frame of reference; and you provide subtle distinctions e.g. when sharing what is expectable vs challenging vs near-impossible. Also respectful, not sensationalized, but still engaging; just quality work. I feel much better informed in case the pilot keels over, thanks! 😆
Wow! I wonder how many times in our life we have come fractions of a second from disaster and not known it.