@@jasonnemeroff3353what’s not true? The pilots and engineer shut down the number 2 engine after they got a #2 engine thrust reverser fail to lock, after takeoff. They returned to Dover to land, the pilots and engineer left the #3 engine throttle at idle and continued to use the #2 engine throttle. They literally forgot what engine they shut down and on top of that they used too high of a flap setting. they did not fallow proper emergency procedures. They followed a normal landing procedure when clearly nothing about this landing was normal.
They didn’t have enough thrust because they had full flaps causing huge drag. Had they identified things sooner they could have called go-around, selected full thrust, continued descending safely on the glide slope or PAPI, whilst cleaning up in stages meeting the minimum speed per flap stage criteria, and then climbed out. I flew the Falcon 50EX tri-jet. This is effectively what we did for a two-engine inop missed approach. You have a higher minimum to accommodate the need to descend and accelerate but it is perfectly safe. These gust had no awareness that they had full flaps because there was zero crosscheck as far as the audio suggests. They assumed they had 40, even though they realised even that was too much. It also seems like there was zero briefing or plan. Everything rushed. Unless there was something else going on, a single engine failure on any (multi-engine) aircraft is a complete non-issue, or at least should be! I did a G4 type rating with a military guy. After things like an engine fire he’d just take manual control and want to get in the ground ASAP. No CRM. No teamwork. No emergency checklist. No briefing. I don’t know what happened here but assuming plenty of fuel and no other issues why not enter a hold with the AP on. Ensure the pilot flying is 100% monitoring the aircraft, and other pilots assess the situation, run the emergency checklist, discuss the situation, formulate a plan, brief the plan, and fly the plan. The shocking thing here is that this is reasonably recent all things considered and the CRM is ZERO!
@@germanpoweractivatedYes. Indeed. This certainly did not help, but this is just another factor of poor CRM, rushing, confusion, and many other complications. But even with three engines, dealing with that much drag is going to be a handful (albeit doable). But the point I’m making is that they could have gone around if they had good CRM and if they acted sooner, probably even with only two engines. The getting low on approach, the incorrect flap setting, the use of only two out of three available engines, and the general chaos, can all be attributed to shockingly bad CRM. Mistakes happen. That’s life. That’s aviation. But SOPs and CRM go a long, long way to catch them before they become another layer of ‘Swiss Cheese’ peeled away.
When the animation starts they’re already almost 500’ below their glide slope! Yet you never heard a single one of the pilots mention that. The pilot flew past the runway and had to turn back to align with it. Losing airspeed the entire time. Yet no one said a word. When the one pilot FINALLY spoke up that he was concerned, the cockpit went silent. Not one crew member thought to say “add power!!” Not one pilot bothered to look at the throttles to see that two were retracted instead of just the one on the shut down engine. Just an amazing amount of unforced errors that caused a very unnecessary accident. Thankfully everyone onboard survived.
Only one throttle was closed but it was the throttle for a good engine. The failed engine was shut down but with its throttle wide open, but not producing any power
@@2Phast4RocketTo be fair, this was a severe problem in the commercial airliner industry for a very long time. In fact Tennerief, the worst accident in aviation history, was largely due to this exact same issue. The industry has undergone many changes to crew resource management traing to ensure first officers can speak up when captains make mistakes.
In addition to the crew there was also evaluation pilot sitting right between the crew. He also missed that the good engine had been idled. This crew sounds like complete bozos. I blame the squadron and wing leadership for having such a clueless crew on flight ready status.
Transcript! Start of video: 0:01 NTSB animation starts: 0:07 ATC/Approach Superior: 4059 Heavy. Delta tower wind 170 at 32 cleared to land. 0:08 Pilot: Clear to land, uh.. reach four zero five nine. 0:14 Pilot: Engineer, you've referenced the landing with one more engine and operative right. we've covered all the items that we need to cover. Our brake temp's gonna be fairly hot, im sure. 0:17 Pilot: Just let me know if you got to clear the runway and overlapping taxi. 0:27 Pilot: I'll calculate. 0:31 ((CAM - Sound of a noise from the flight crew)) 0:33 Pilot: Okay, just put it perfectly on the ground. 0:33 Pilot: Before landing. 0:35 Pilot: You don't need a smooth touchdown. 0:37 Pilot: Roger. 0:38 Pilot: Before landing check-list. 0:40 Pilot: Landing gear. 0:41 Pilot: On the line co-pop. 0:43 Pilot: No problem. 0:44 Pilot: Flaps and Slats. 0:45 GPWS: "1000 to go". 0:47 Pilot: Throttle 70%. 0:48 Pilot: AGV WS. 0:50 [Throttle Swap happens] 0:51 Pilot: Flaps for Landing. 0:52 Pilot: Flaps..Landing. 0:55 Pilot: Very fresh. 0:56 Pilot: Flaps checked. 0:59 Pilot: (Unintelligible) 1:01 Pilot: (Unintelligible) 1:02 Pilot: I'll fed ya this.. Before landing check-list cleared. 1:03 Pilot: Thanks, Approach speed is 146 (Knots). 1:05
He was the aircraft commander who broke off the ILS approach and went visual because he wanted to land, instead of taking the time the brief his crew. He was fried in the investigation. Turned out his call sign was 'Golden Boy',
@@2Phast4RocketShocking. They shouldn’t even have been in the approach. There was apparently no assessment or briefing. Why not just hold somewhere (assuming enough fuel and no other issues), run the checklists, make the performance calculations, brief the plan and fly the brief? Absolutely shocking CRM, or lack of. Utterly different to how things are trained in the civilian world.
“Pilot: I’ll calculate”! What?!!! Too late. Why didn’t they do this sooner? What was the rush to land? Just hold and brief everything. The CRM (or lack of) is shocking.
Not sure what the rush was. I was on duty at Dover at the MOCC when this occurred. They had just departed and turned to come back due to getting a thrust reverse not locked indication which was likely just an indication error.
@@jamesdenatale2918Exactly. They would have had hours and hours of fuel. If the aircraft was otherwise controllable then just hold and carry out checklists and formulate a plan. Having said that, I, a civilian commercial pilot, had a sim partner who was (not western) military, on our G-IV type rating. He was amazing. Well ahead of me on theory, checklists, and cockpit familiarity. It was as if he just had to read or do something once and it would stick. Obviously capable. However, one day we are on approach to land and the instructor gave is a fairly minor failure, and then a second slightly more serious one a few minutes later. He literally grabbed the controls, disconnected the autopilot, said “I’m landing!”, and that was that. I could do nothing to stop him and mine and the instructor’s faces were just incredulous. I tried to rationalise with him; “we have hours of fuel”, “let’s put the AP on again and hold, se we can run the emergency checklist, secure the failure, brief the crew, come up with a plan, and most importantly, recalculate our landing and missed approach performance”. Nope, nothing worked. He was utterly in the mi dart of failure -> land. Coming from the civilian world where CRM is king, this was a real shock. He just reverted to his single-pilot mission-oriented mindset and that was that. It was fascinating. A very rewarding experience for me. The debriefing was really illuminating, and the value of CRM was highlighted to me very well that day and the following days. He learned from it, and improved, albeit seemingly reluctantly, but it’s clear that if under pressure in reality he may act like this again. (NB: I point out him being from a non-western airforce simply because I believe that since the tragedy like this, there has been a much better respect for the value of CRM in the western militaries. It’s reasonable to think that this may not yet have trickled into other world militaries.)
Seems the copilot was in an unnecessary hurry to get on the ground. They were getting vectors for an approach but ATC was asking for a delay so fire trucks could get on scene. Copilot aborted the instrument approach and and proceeded direct to final, which instantly put the entire rest of the crew 10 steps behind the plane, scrambling to catch up. No one spoke up, no one caught the mistaken "landing flaps" callouts and incorrect flap landing speed callout. The copilot finally recognized the error toward the end when he asked to raise the flaps to 40, but immediately corrected because he knew he was outside the speed envelope and would have caused a stall at a higher altitude.
Does anyone know why you wouldnt move the throttles as a full set if said problem engine is shut down? Also jist before the stall it seemed as if someone reconized the error with number 3 throttle but then pulled it back again.
At the time... Whenever pilots trained for engine malfunction in the simulator, they always used #3 engine. This created a muscle memory for a real emergency. Even though they had done the correct thing in shutting down #2 engine originally, muscle memory kicked in when they moved throttles up and left #3 in the idle position while moving #2 forward. Many lessons were learned from this catastrophic mishap.
Also, some aircraft, when an engine is shutdown following the checklist, it is ‘secured’ (fuel, oil, etc shutoff) in the shutoff detent which is usually mechanically locked. However, you still want to be moving everything else that moves. And if they hadn’t ‘secured’ the engine then they should just move everything!
Glad no one was killed but it does raise my concern about flying Space A in the future. Only time on a C-5 was back in 1994 Japan to Hickam and then back to Guam. Hope to fly a bit in the future.
@@ww1fan-b5hthe answer is no survivor because you can see at the end the cocpit is broke and rolled over that maybe make the pilot and all people has Dizzy and hurt, and theres Will be exploxion to the aircraft
@@TotallyNotPolishMan821they’re designed to break off specifically at that part of the jet for the very reason of saving the crew up in the cockpit. It breaking off was exactly what saved their lives. There was no explosion though as far as I know, and all survived even with injuries
“Guys I’m Concerned” 🧐
2:09
Why he didn't firewall all 4 throttles is beyond me. Nothing to lose if the ground is coming to meet you.
as you can see 1 engine is out
@@marcinmackowicz1332yes and one good engine was at idle
@@ectobluntus that is not true
@@jasonnemeroff3353what’s not true? The pilots and engineer shut down the number 2 engine after they got a #2 engine thrust reverser fail to lock, after takeoff. They returned to Dover to land, the pilots and engineer left the #3 engine throttle at idle and continued to use the #2 engine throttle. They literally forgot what engine they shut down and on top of that they used too high of a flap setting. they did not fallow proper emergency procedures. They followed a normal landing procedure when clearly nothing about this landing was normal.
"Go Around" isn't that difficult to say. When indecisive and or confused: Go Around.
They couldn’t, they had an emergency and needed to land.
going around without enough engine thrust to maintain level is hard to do
They didn’t have enough thrust because they had full flaps causing huge drag.
Had they identified things sooner they could have called go-around, selected full thrust, continued descending safely on the glide slope or PAPI, whilst cleaning up in stages meeting the minimum speed per flap stage criteria, and then climbed out.
I flew the Falcon 50EX tri-jet. This is effectively what we did for a two-engine inop missed approach. You have a higher minimum to accommodate the need to descend and accelerate but it is perfectly safe.
These gust had no awareness that they had full flaps because there was zero crosscheck as far as the audio suggests.
They assumed they had 40, even though they realised even that was too much.
It also seems like there was zero briefing or plan. Everything rushed.
Unless there was something else going on, a single engine failure on any (multi-engine) aircraft is a complete non-issue, or at least should be!
I did a G4 type rating with a military guy. After things like an engine fire he’d just take manual control and want to get in the ground ASAP. No CRM. No teamwork. No emergency checklist. No briefing.
I don’t know what happened here but assuming plenty of fuel and no other issues why not enter a hold with the AP on.
Ensure the pilot flying is 100% monitoring the aircraft, and other pilots assess the situation, run the emergency checklist, discuss the situation, formulate a plan, brief the plan, and fly the plan.
The shocking thing here is that this is reasonably recent all things considered and the CRM is ZERO!
@@CrapUsername62944 well. They had an engine failure but they put the wrong engine ( a working one )into idle.. so effectively they only had 2 engines
@@germanpoweractivatedYes. Indeed. This certainly did not help, but this is just another factor of poor CRM, rushing, confusion, and many other complications.
But even with three engines, dealing with that much drag is going to be a handful (albeit doable). But the point I’m making is that they could have gone around if they had good CRM and if they acted sooner, probably even with only two engines.
The getting low on approach, the incorrect flap setting, the use of only two out of three available engines, and the general chaos, can all be attributed to shockingly bad CRM.
Mistakes happen. That’s life. That’s aviation. But SOPs and CRM go a long, long way to catch them before they become another layer of ‘Swiss Cheese’ peeled away.
They all survived.
With serious injuries unfortunately
@charleskennedy1712 did they suffer from being killed instantly in a firey wreck?
When the animation starts they’re already almost 500’ below their glide slope! Yet you never heard a single one of the pilots mention that. The pilot flew past the runway and had to turn back to align with it. Losing airspeed the entire time. Yet no one said a word. When the one pilot FINALLY spoke up that he was concerned, the cockpit went silent. Not one crew member thought to say “add power!!” Not one pilot bothered to look at the throttles to see that two were retracted instead of just the one on the shut down engine. Just an amazing amount of unforced errors that caused a very unnecessary accident. Thankfully everyone onboard survived.
Only one throttle was closed but it was the throttle for a good engine. The failed engine was shut down but with its throttle wide open, but not producing any power
Typical AF not wanting to question the senior officer.
@@2Phast4RocketTo be fair, this was a severe problem in the commercial airliner industry for a very long time. In fact Tennerief, the worst accident in aviation history, was largely due to this exact same issue. The industry has undergone many changes to crew resource management traing to ensure first officers can speak up when captains make mistakes.
situational bewilderment
Poor guys, like three student pilots.
In addition to the crew there was also evaluation pilot sitting right between the crew. He also missed that the good engine had been idled. This crew sounds like complete bozos. I blame the squadron and wing leadership for having such a clueless crew on flight ready status.
Low and Slow - and then "Bring the Flaps Up" (!) - that was a disaster waiting to happen.
an effort to reduce the drag
1:25 you shouldn't talk about things unrelated to the flight in an emergency!!!!!
Extremely incompetent pilots who seem to not understand how the plane works
Transcript!
Start of video: 0:01
NTSB animation starts: 0:07
ATC/Approach Superior: 4059 Heavy. Delta tower wind 170 at 32 cleared to land. 0:08
Pilot: Clear to land, uh.. reach four zero five nine. 0:14
Pilot: Engineer, you've referenced the landing with one more engine and operative right. we've covered all the items that we need to cover. Our brake temp's gonna be fairly hot, im sure. 0:17
Pilot: Just let me know if you got to clear the runway and overlapping taxi. 0:27
Pilot: I'll calculate. 0:31
((CAM - Sound of a noise from the flight crew)) 0:33
Pilot: Okay, just put it perfectly on the ground. 0:33
Pilot: Before landing. 0:35
Pilot: You don't need a smooth touchdown. 0:37
Pilot: Roger. 0:38
Pilot: Before landing check-list. 0:40
Pilot: Landing gear. 0:41
Pilot: On the line co-pop. 0:43
Pilot: No problem. 0:44
Pilot: Flaps and Slats. 0:45
GPWS: "1000 to go". 0:47
Pilot: Throttle 70%. 0:48
Pilot: AGV WS. 0:50
[Throttle Swap happens] 0:51
Pilot: Flaps for Landing. 0:52
Pilot: Flaps..Landing. 0:55
Pilot: Very fresh. 0:56
Pilot: Flaps checked. 0:59
Pilot: (Unintelligible) 1:01
Pilot: (Unintelligible) 1:02
Pilot: I'll fed ya this.. Before landing check-list cleared. 1:03
Pilot: Thanks, Approach speed is 146 (Knots). 1:05
bank angle, bank angle, bank angle, bank angle (overspeed alarm) bank angle
1:34 flaps
Who said hes concerned at 2:09? Seemed to be the only one aware of the issues.
Pilot. But, at that point there wasn't much they could do.
@@crazylong127 Besides bring up that #3 engine 🤣
It's funny you say that, the guy who says that was primarily the one who put them in that place
He was the aircraft commander who broke off the ILS approach and went visual because he wanted to land, instead of taking the time the brief his crew. He was fried in the investigation. Turned out his call sign was 'Golden Boy',
@@2Phast4RocketShocking. They shouldn’t even have been in the approach. There was apparently no assessment or briefing. Why not just hold somewhere (assuming enough fuel and no other issues), run the checklists, make the performance calculations, brief the plan and fly the brief? Absolutely shocking CRM, or lack of.
Utterly different to how things are trained in the civilian world.
“Pilot: I’ll calculate”! What?!!! Too late. Why didn’t they do this sooner? What was the rush to land? Just hold and brief everything. The CRM (or lack of) is shocking.
Not sure what the rush was. I was on duty at Dover at the MOCC when this occurred. They had just departed and turned to come back due to getting a thrust reverse not locked indication which was likely just an indication error.
@@jamesdenatale2918Exactly. They would have had hours and hours of fuel. If the aircraft was otherwise controllable then just hold and carry out checklists and formulate a plan.
Having said that, I, a civilian commercial pilot, had a sim partner who was (not western) military, on our G-IV type rating.
He was amazing. Well ahead of me on theory, checklists, and cockpit familiarity. It was as if he just had to read or do something once and it would stick. Obviously capable.
However, one day we are on approach to land and the instructor gave is a fairly minor failure, and then a second slightly more serious one a few minutes later.
He literally grabbed the controls, disconnected the autopilot, said “I’m landing!”, and that was that. I could do nothing to stop him and mine and the instructor’s faces were just incredulous.
I tried to rationalise with him; “we have hours of fuel”, “let’s put the AP on again and hold, se we can run the emergency checklist, secure the failure, brief the crew, come up with a plan, and most importantly, recalculate our landing and missed approach performance”. Nope, nothing worked. He was utterly in the mi dart of failure -> land.
Coming from the civilian world where CRM is king, this was a real shock. He just reverted to his single-pilot mission-oriented mindset and that was that.
It was fascinating. A very rewarding experience for me. The debriefing was really illuminating, and the value of CRM was highlighted to me very well that day and the following days.
He learned from it, and improved, albeit seemingly reluctantly, but it’s clear that if under pressure in reality he may act like this again.
(NB: I point out him being from a non-western airforce simply because I believe that since the tragedy like this, there has been a much better respect for the value of CRM in the western militaries. It’s reasonable to think that this may not yet have trickled into other world militaries.)
They could have continued to their destination on 3 engines!
Seems the copilot was in an unnecessary hurry to get on the ground. They were getting vectors for an approach but ATC was asking for a delay so fire trucks could get on scene. Copilot aborted the instrument approach and and proceeded direct to final, which instantly put the entire rest of the crew 10 steps behind the plane, scrambling to catch up. No one spoke up, no one caught the mistaken "landing flaps" callouts and incorrect flap landing speed callout. The copilot finally recognized the error toward the end when he asked to raise the flaps to 40, but immediately corrected because he knew he was outside the speed envelope and would have caused a stall at a higher altitude.
First flight
"Guys im concerned" 🤓☝️
Wow. Some people just shouldn’t fly.
guys i think hes concerned
Does anyone know why you wouldnt move the throttles as a full set if said problem engine is shut down? Also jist before the stall it seemed as if someone reconized the error with number 3 throttle but then pulled it back again.
At the time... Whenever pilots trained for engine malfunction in the simulator, they always used #3 engine. This created a muscle memory for a real emergency. Even though they had done the correct thing in shutting down #2 engine originally, muscle memory kicked in when they moved throttles up and left #3 in the idle position while moving #2 forward. Many lessons were learned from this catastrophic mishap.
Also, some aircraft, when an engine is shutdown following the checklist, it is ‘secured’ (fuel, oil, etc shutoff) in the shutoff detent which is usually mechanically locked.
However, you still want to be moving everything else that moves. And if they hadn’t ‘secured’ the engine then they should just move everything!
Glad no one was killed but it does raise my concern about flying Space A in the future. Only time on a C-5 was back in 1994 Japan to Hickam and then back to Guam. Hope to fly a bit in the future.
They had PAX onboard. I guess a credit to the C5s design, the passengers supposedly didn't even know they crashed lol
No survivors?😊
why happy emoji also i think they survived im not sure
@@ww1fan-b5hthe answer is no survivor because you can see at the end the cocpit is broke and rolled over that maybe make the pilot and all people has Dizzy and hurt, and theres Will be exploxion to the aircraft
@@TotallyNotPolishMan821false... All survived although the head pilot was fired.
@@williamginn6234Oh the Head Pilot got fired? Crazy but Everyone Survived.
@@TotallyNotPolishMan821they’re designed to break off specifically at that part of the jet for the very reason of saving the crew up in the cockpit. It breaking off was exactly what saved their lives. There was no explosion though as far as I know, and all survived even with injuries