Airfield in sight, runway in sight.
NARRATOR: Two pilots within a few feet of making a safe landing...
crash short of the runway in Colombia.
TRANSLATION: Our number one priority
was the passengers and getting everyone to safety.
The 737 broke apart upon hitting the ground.
Investigators search for a possible cause but find no useful evidence.
And we still can't explain why.
It's not until they scrutinise the entire chain of events
that they finally catch a break.
- That's it. - What?
Climb, Captain!
Mayday, mayday.
Pull up.
Just after midnight, Aires Flight 8250 is carrying a planeload
of tourists and locals from Bogota to the small Colombian island
of San Andres, an ocean playground in the Caribbean Sea.
So much for grabbing dinner on the ground.
Yeah, it's gonna be a late night.
Captain Wilson Gutierrez is a veteran pilot with almost
20 years of flying experience.
At least we're finally up in the air.
First Officer Camilo Pineros has flown for Aires for three years,
with a full year on the airline's new Boeing 737s.
It looks like there's some weather ahead of us.
Let's keep an eye on it.
There are signs of a thunderstorm in the distance.
For the next hour and 30 minutes, the 737 will fly north-west
to San Andres at a cruising altitude of 36,000 feet.
Passengers are restless after an unexpected four-hour delay
getting off the ground.
We should be landing just before 2am.
Flight attendant Adriana Cardenas Medina is working hard to
settle passengers - many heading to the small island for a holiday.
TRANSLATION: The flight was running late because it was
coming from Cali, and it was late due to poor weather.
They said it was running two hours behind,
but it actually ended up being twice that.
Just over 40 minutes into the flight,
the captain sees the storm clouds ahead are building.
Airlines operate 24 hours a day,
so pilots fly in all kinds of conditions,
both daylight, dark, good weather, bad weather.
As a professional pilot,
you deal with these environmental challenges constantly.
TRANSLATION: Prior to beginning our descent into San Andres,
we began to experience some light turbulence.
Ladies and gentlemen,
please return to your seats and fasten your seatbelts.
TRANSLATION: It was raining.
There was lightning - a lot of lightning,
and the turbulence started to intensify.
Now past the halfway point of the trip,
the captain is increasingly concerned with the possibility
of heavy storms gathering over their destination.
It doesn't look like we're gonna get any relief from this storm.
Yeah, lots of activity tonight.
Closer to San Andres, the already bumpy ride
is getting worse and worse for the passengers.
TRANSLATION: Normally you go through a patch and then it stops.
In this instance, there was lightning bolt after lightning bolt,
and the plane shook hard and the turbulence would not stop.
Check it out, Camilo. It's building all around the island.
Will this bad weather be on San Andres?
Less than 20 minutes away from the airport,
the weather on the ground appears to be changing rapidly.
Get a report from San Andres for me.
OK, I'll ask.
The San Andres air traffic controller
is also keeping a close eye on changes to the weather.
San Andres, good morning, Aires 8250.
Go ahead.
We want to know how the weather is at the airport, please.
OK, Aires 8250, wind calm, visibility more than 10km,
scattered clouds at 1,500 feet.
There's some bad weather near the airfield,
but right now there's no rain.
Despite the turbulent weather along the way,
conditions in San Andres seem to be much better.
Aires 8250, descend 3,000 feet. Clear for approach runway 0-6.
Roger, continue descending to 3,000.
In the cabin,
passengers are growing concerned by the intensity of the storm.
This shouldn't last long.
TRANSLATION: We told them that we were in an intense weather system
and that we would be out of it shortly,
but we never actually got out of it.
Aires 8250, there is a thunderstorm over the airport right now.
OK, roger, thank you.
Gear down.
Aires 8250, there is a little drizzle over the runway.
- A little what? - Drizzle.
Ah. OK. Give them the announcement.
Cabin crew to their stations for landing.
Please raise your table.
As the storm continues to build,
Aires 8250 is about to begin its final approach.
OK, flaps 5.
Wet runway. Three on the auto-brake?
Let's leave it on two.
The crew configures the plane for landing.
The weather in San Andres is changing fast.
Aires 8250, there's now heavy rain at the airfield,
and visibility reduced to 5km.
- Visibility down to 5km. - Oh, man.
When you see particularly weather that's deteriorating,
it causes you to be a little bit more cautious
because the trend is not going in a positive direction.
TRANSLATION: The rain became even more intense,
the turbulence more intense and the thunder was more frequent.
In deteriorating conditions, and just 7 miles from landing,
the captain confirms the procedure
in the event they have to abort the landing at the last minute.
In case we miss the approach we go right, correct?
Yes. Correct, sir.
As you get closer to your destination and you start getting
the latest weather, the thing that you're thinking about is,
OK, how are we gonna position the airplane to land in these conditions?
And if we don't land, what are we gonna do next?
Only minutes away from landing,
the pilots run through their final checks.
Landing checklist.
Speed brakes?
- Armed. - Landing gear?
- Down. - Flaps?
- 30. - Checklist complete.
TRANSLATION: We were about five minutes from landing.
I started to see lights in the ocean from the island.
But less than 2.5 minutes from touchdown,
visibility has reduced dramatically.
Aires 8250, do you have the runway in sight?
- Negative. - Not yet.
Seconds later...
Airfield in sight, runway in sight.
Aires 8250.
The clouds over San Andres lift.
In sight landing.
Check. We're all set for landing.
500.
500 feet from the ground, the crew spots the runway.
The captain lines up his plane.
Aires 8250, winds at 60 degrees at 15 knots.
Then the wind picks up.
15 knots, head on.
In case of windshear, we use maximum thrust for a go-around.
Don't touch flaps or gear.
Agreed. Yes, sir.
Caught in a sudden deluge, visibility decreases again.
50.
Look out, Captain.
The first officer now realises they are too low
to make a safe landing.
40.
- Can you make it? - 30.
20.
- Terrain. Terrain. Pull up. - Climb, Captain!
The captain pulls back on his control column.
But it's too late.
TRANSLATION: We felt a hard and sudden crash.
At 1:47am, Aires 8250 slams into the ground
with 131 passengers and crew onboard.
There's been an accident.
Aires 8250 has crashed just short of touchdown in San Andres
and broken into three pieces.
Inside the front section of the airplane,
flight attendant Adriana Cardenas Medina
has survived the horrific crash.
Are you OK?
Bruised and battered,
passengers near the front start lining up towards
the aircraft's main door and the emergency slide.
But now a new problem - the main exit door is jammed.
TRANSLATION: My co-worker and I tried to open the door,
but it would not open.
A passenger helped us to open it.
The flight attendants work as quickly as possible
to get all 125 passengers off the plane.
TRANSLATION: Our number one priority was the passengers
and getting everyone to safety, so we were all focused on that.
In the aftermath of the recovery,
one passenger is dead after being hit in the chest by a tray table.
A second passenger, who was severely injured on impact,
dies in hospital two weeks later.
TRANSLATION: When you think of boarding an aircraft,
you imagine leaving it in the same manner,
not forcibly or in pain, fear, frustration.
It's something you can never imagine happening.
The crash and destruction of Flight 8250
is quickly becoming a major international news story.
A plane crashed this morning in Colombia.
The 737 broke apart upon hitting the ground.
The Colombian Aeronautical Authority needs to find out what brought down
one of the most widely used passenger planes on Earth.
Investigator Julian Echeverri is one of the first investigators
on the scene.
Huh. Broken into three pieces.
He was definitely lined up for a landing.
From the orientation of the wreckage,
investigators can tell that Flight 8250 was lined up perfectly
with the runway at San Andres.
TRANSLATION: When we first looked at the debris,
we observed that the initial impact
was approximately 40m from the start of runway 0-6.
It was a low angle impact at a relatively high speed.
Very quickly, both the flight data and cockpit voice recorders
are recovered.
Excellent work.
Let's hope they provide some answers.
But until the recordings can be analysed,
investigators will need to rely on the wreckage at the crash site
to explain the cause of the accident.
The team studies the debris trail
that extends 160 feet from the runway's threshold.
Landing gear extended.
It snapped off.
Lined up and configured,
but somehow they hit the ground hard metres from the runway.
Investigators can't understand why the jet got so close to the runway
but ended up short.
While wreckage crews transport the debris
to a nearby facility for analysis,
investigators wonder what role the severe weather
played in the accident.
What if the storm brought them down?
The team studies meteorological reports
from the night of the crash.
TRANSLATION: The meteorological condition during the accident
was one of the things we considered in this investigation.
RADIO: Based on the first information that we received...
Turn that up, would you?
TRANSLATION ..a lightning bolt struck the airplane and caused
the tragedy that we're all aware of.
They're saying it's lightning? We'll see.
Echeverri and his team know that accidents caused by lightning
are virtually unheard of.
Lightning strikes, although they're very spectacular and can
visually impair you, just with that bright flash, they really don't pose
a great threat to the airplane during landing.
Investigators need to know if there was lightning
near the 737 as it approached San Andres.
TRANSLATION: There was video evidence
from a closed-circuit television camera
which recorded the final moments prior to the accident.
Sure looks like lightning. And the timing fits.
TRANSLATION: There was a big flash in the video, which led us to think
that the aircraft could have been struck by lightning.
The team studies the static wicks from the accident plane.
Static wicks are located on the trailing edges of
airplane wings and help discharge any build-up of static energy.
If the plane was struck by lightning,
they should be melted or burned.
But they are not.
Investigators can find no signs of a direct lightning hit
on the aircraft's surfaces.
TRANSLATION: During the inspection of the debris, which was carefully
performed, we found no traces of interaction with lightning.
They're clean.
But Echeverri still has a lot of unanswered questions
about the weather at the time of the accident.
Looks like it was a big storm.
TRANSLATION: The conditions in which the aircraft interacted
with the terrain before arriving at runway 0-6
raised the possibility of an encounter with windshear
in that last minute.
Windshear is a phenomenon in which the wind's direction or speed
changes extremely abruptly.
60 degree winds at 15 knots. The wind was picking up.
Could intense winds at the base of the runway
have played a role in the crash?
We need to look at windshear.
The team learns that just two minutes before the crash,
as the storm built, winds near the runway were gusting.
Digging further into the flight data...
So, lots of head wind...
but almost no downdraft.
Investigator Julian Echeverri discovers the powerful winds
were hitting the plane head-on, not from above.
Not enough to slam them to the ground.
TRANSLATION: During the landing there was an increase in wind speed,
but in this case it was a horizontal increase.
There was no trace in the flight data of a vertical change of wind
that would have caused the aircraft to lose altitude.
All investigators uncover is a moderate headwind
at the time of the crash, a discovery that leads nowhere.
So we'll rule out weather for now.
TRANSLATION: The fact that it was not windshear
made us focus on operational aspects that may have led to this accident.
What about the aircraft itself?
Investigators now wonder
if an engine malfunction led to the crash of Aries Flight 8250.
The blades are bent in the opposite direction of the rotation.
That tells investigator Julian Echeverri that the engines were
working when they hit the ground.
Let's move on.
Measurements of the flap settings show
they were in the correct position for landing.
OK, flaps 5.
Wet runway. Three on the auto-brake?
Let's leave it on two.
Flaps right where they should be.
In fact, investigators find nothing to indicate a mechanical cause
for the crash of Aires 8250.
TRANSLATION: We observed the flight control surfaces.
We observed the flap configuration, the cockpit switches.
Engines, rudder, control surfaces.
You name it, they all check out.
TRANSLATION: There weren't any system malfunctions or engine
or GPS problems that would have caused the aircraft
to land before the start of the runway.
Lieutenant Colonel Ever Sabogal
from the Colombian Air Force joins the investigative team.
TRANSLATION: The conditions that they had -
conditions of extremely bad weather, a particularly dark night.
They had a lot of lightning all around them
and they were feeling pressure to land.
Were they prepared to land in these stormy conditions?
Investigators now need to find out if the storm
took the pilots by surprise.
If it did, that might have led them to make errors in their approach.
The critical part is, what's the weather gonna be when we get there?
It's less critical of what it is right now. So as you get very close
to the airport, that's when you wanna make sure
that you have a good understanding of the weather that you're
about to deal with in the final approach segment of the flight.
Can I show you this?
The team already knows the weather was changing quickly
just before the crash.
But they need to determine if the air traffic controller
kept them up-to-date.
I updated them regularly once they were in my airspace.
San Andres, good morning, Aires 8250.
Go ahead.
We want to know how the weather is at the airport, please.
OK, Aires 8250, wind calm, visibility more than 10km,
scattered clouds at 1,500 feet.
There's some bad weather near the airfield,
but right now there's no rain.
Every time the weather changed even a bit, I told them.
Gear down.
Aires 8250, there is a little drizzle over the runway.
- A little what? - Drizzle.
Ah.
Minutes later, it turned into a full-blown storm.
Aires 8250, there's now heavy rain at the airfield
and visibility reduced to 5km.
Did they seem concerned about the weather?
No, they didn't sound overly concerned.
I was very careful to tell them everything.
The controllers are very good about reading up
changing weather conditions, particularly wind and visibility,
which is the two most critical factors
as they get very close to the airport,
but the decision to land or not to land rests with the captain,
and he or she is responsible to make the decision whether the conditions
are safe to land or not.
Aires 8250, do you have the runway in sight?
Negative.
Not yet.
Airfield in sight, runway in sight, Aires 8250.
And this is appropriate, because it's really only the pilots
that can see the exact conditions that the airplane is in
and the visibility they have to be able to see the runway
and land safely on it.
Look out, Captain!
Investigators now have the flight data
from Aires Flight 8250.
The digital flight data recorder records hundreds or thousands of
different parameters, and it tells you everything that the airplane's
doing - whether the landing gear's up or down, the altitude, airspeed,
and numerous other functions of the systems within the airplane.
The team is looking for clues that might indicate
how the pilots handled the plane in the thunderstorm.
Here. 45 minutes before reaching the airport,
they switched to vertical speed mode.
That's a questionable choice.
The investigators notice that the pilots selected an autopilot mode
called vertical speed.
Aires 8250, descend 3,000 feet, clear for approach runway 0-6.
In vertical speed mode,
the crew must manually select their rate of descent.
TRANSLATION: This mode requires a lot of work because you have to be
constantly calculating your altitude versus your distance.
The Boeing procedures are typically to utilise automation,
use the autopilot during approaches, particularly in bad weather.
For these pilots to have reverted to a manual system,
where they turn the autopilot off,
is against the Boeing recommendation.
Investigators check the plane's rate of descent.
Look at this.
They were descending to the runway at 1,100 feet per minute.
According to the manufacturer,
rate of descent shouldn't exceed...900 feet per minute.
It's an important clue.
If they are in excess of 1,000 feet per minute,
then it is unstable approach.
The team has now determined the plane was dropping too fast,
and they have a theory as to why.
They must have been trying to get a visual fix of the runway
as soon as possible.
By bringing the airplane down early,
the hope is that you'll see the runway earlier.
You'll be underneath the clouds
and your visibility will be improved the lower you get.
But that strategy didn't work for the crew of the Aires flight.
The question is, why not?
The investigators can now compare the approach
the crew should have flown to the one they actually did fly.
They should have stayed on the glide path.
But instead they come in too low the entire way.
And they didn't even try to get back on the glide path.
TRANSLATION: He played instead the entire time
with the vertical speed.
They didn't have an angle or a constant path,
and that made it so that they were always below it.
They were never on the right path for the type of approach
that they made.
Didn't they know they were coming in too low?
Wouldn't the PAPI lights have told them that?
PAPI lights, or precision approach path indicators,
are colour-coded lights along the side of the runway
that tell pilots if they are too high or too low on their approach.
The airport's PAPI lights were fully operational that night,
yet the plane still came in low.
TRANSLATION: Why would a person operating an aircraft make that
type of approach, even when the visual aids
are indicating the correct path to the runway?
The team hopes the cockpit voice recorder
can provide answers to all their unanswered questions.
They focus on the final approach.
- Landing checklist. - Speed brakes.
- Armed. - Landing gear.
- Down. - Flaps.
- 30. - Checklist complete.
We're too low.
Aires 8250, do you have the runway in sight?
- Negative. - Not yet.
Airway in sight, runway in sight, Aires 8250.
- In sight landing. - Check. We're all set for landing.
Stop. Did you catch that?
Go back 30 seconds.
- Checklist complete. - We're too low.
Aires 8250, do you have the runway in sight?
Stop.
The captain realises they're below the glide path.
But there's no discussion about it, no go-around.
They just keep going.
Why?
Continue.
TRANSLATION: On the final approach, the captain simply continues to fly,
focused on trying to reach the runway.
15 knots, head on.
In case of windshear, we use maximum thrust for a go-around.
Don't touch flaps or gear.
Agreed. Yes, sir.
Everything sounds OK.
50.
- Look out, Captain! - 40.
30. 20.
Climb, Captain!
The first officer knows something isn't right.
But the captain doesn't respond.
Why not?
Terrain. Terrain. Pull up.
The investigation finally has a solid lead to follow.
Investigators are baffled by
the captain's actions on board Flight 8250.
They question him about what happened on the approach
to San Andres.
I didn't think anything went wrong until the crash. It was stormy.
It must have been the lightning or the wind.
TRANSLATION: They never questioned the type of approach that they made.
They never doubted that their procedure was adequate,
and they said it was probably the wind that caused their accident.
But when the captain is asked about his use of the PAPI lights,
his answer provides the first big break in the investigation.
I'm not sure what the PAPI lights were showing.
I was focused on the green lights at the threshold, like I always do.
Airfield in sight, runway in sight, Aires 8250.
- In sight landing. - Check. We're all set for landing.
TRANSLATION: They were concentrated on the green lights
at the start of the runway,
and they ignored the information of the PAPI lights.
Instead of landing in the touchdown zone, which is here,
the Captain says that he always lands here, on the threshold.
TRANSLATION: We noticed in his statement
a recurring flight technique that involved pointing the nose
of the aircraft at the runway for approaches and landings.
The thinking of some pilots has been,
"I want on the runway as early as possible so that I can make sure
that we get stopped if there's a problem with the brakes,"
so they deliberately land short of the touchdown zone.
TRANSLATION: Possibly that's what the pilot was doing the whole time -
looking for the green lights and trying to make it.
Investigators ask the captain why he performed the landing this way.
That's my training. I was just doing what we've always done.
TRANSLATION: We saw that the crew decided to make an approach
using their own criteria,
not the criteria recommended by the manufacturer.
Investigators need to know what led the crew to do this.
They dig into their background.
Check this out. He's only been flying the 737 for eight months.
For 12 years before that, he flew turboprops.
The file reveals that Captain Gutierrez recently switched from
commanding Dash 8 turboprops to the much larger 737 jets.
The discovery provides a new clue.
That's it.
What?
He was flying like he was in a turboprop.
Not a 737.
The investigators found that the higher rate of descent
that they flew in the 737 was much more like the profile that
you would expect in the turboprop that they had flown previously.
TRANSLATION: In accumulating so much experience in the turboprops,
you develop habits,
and when one translates this to the cockpit of jets,
one starts to battle with all the tools that make your trip secure.
We gotta find out if these guys were properly trained to fly a 737.
Aires started as a small regional airline flying turboprops
around central Colombia.
Then in 2009, the year before the crash,
Aires underwent a huge expansion, adding nine 737s to its fleet.
Normally the industry practice is to hire experienced 737 pilots
to fly the new jets, but that's not what Aires did.
OK, thanks very much. They didn't hire any new pilots for the 737s.
They just transitioned the turboprop pilots into them.
That's a big leap.
TRANSLATION: In turboprops, everything is much easier.
It's a slower plane. It reacts faster. It raises up easily.
A turboprop is very forgiving. A jet doesn't forgive.
What did Aires do to safely transition their pilots
onto the new 737s?
The investigators take a closer look at the crew's training records.
The captain switched over to a 737 after only five weeks of training.
The first officer only trained for two weeks.
The team concludes the pilots didn't have enough training
to properly prepare them to fly the 737.
TRANSLATION: The most important thing about the transition
is to undo those concepts that one has of flying turboprops
and really just start over.
Jets are planes that require a lot of anticipation.
They require a lot of concentration.
They require you to understand what a computer is doing.
Investigators now conclude the captain likely reverted back
to his turboprop habits
while trying to land at the San Andres airport.
So, just as he would in a turboprop, he aims for the threshold.
But he crashes short of that.
And we still can't explain why.
Investigators now know that the captain of Aires 8250 was purposely
trying to land his airplane on the threshold of the runway...
- In sight landing. - Check. We're all set for landing.
..the same way he used to land in a turboprop.
500.
Aires 8250, winds at 60 degrees at 15 knots.
15 knots, head on.
But that still doesn't explain
why the crew crashed short of the runway.
The last piece of the puzzle is elusive.
The investigators listen to the cockpit recording once more,
hoping to hear something they missed.
50.
Look out, Captain!
40.
- 30. - Can you make it?
- 20. - Climb, Captain!
So from the point he gets a visual of the runway,
the captain does nothing to correct his altitude, right up to the crash.
Not even when the first officer gives him warnings.
So what's going on in his head?
When the investigators looked at the flight profile
and they realised that it ended up impacting the ground
short of the runway, without ever really arresting itself
and trying to hop up to the runway or make power adjustments
until the very last minute, the next question is,
what is this consistent with?
This is a classic undershoot accident in just about every sense.
It's a classic black hole illusion accident.
The black hole illusion occurs on dark nights when
there are no ground lights between an airplane and the runway threshold.
The contrast between the lights and the total darkness
creates an illusion that deceives pilots into thinking
the runway is closer than it really is,
causing them to put the plane down too early.
TRANSLATION: This creates the visual illusion like in a black hole,
where you completely lose your depth perception.
TRANSLATION: It was a night-time approach on an island
with no noticeable difference between land and water...
and only the runway lights as reference.
When doing this manually and visually,
the risk for entering a black hole illusion increases.
You have rain causing poor visibility.
Some lights on the right, very few. The runway lights, that's about it.
It's a black hole illusion.
In case of windshear, we use maximum thrust for a go-around.
- Don't touch flaps or gear. - Agreed. Yes, sir.
TRANSLATION: In this case,
the black hole effect was made worse by another effect
that was generated by the lights of the aircraft with the rain.
Why?
Because when the lights of the plane go on,
you start to see the rain falling.
The wipers start up and they also distract you,
and the brain has to play with all that
and be able to identify where the runway is.
You take all the problems the Aires 8250 had,
and it still doesn't necessarily give you a plane crash.
But throw a black hole in there and it makes sense.
The black hole illusion is the final piece of the puzzle.
TRANSLATION: That's why the crew was constantly below the flight path
without being aware of it, and they never made it to the runway.
The Colombian Aeronautical Authority issues a series of recommendations,
including a revision of Aires Airlines' procedures
for visual landings.
TRANSLATION: In this accident, there is no-one reason.
There are many reasons that brought them to this -
the type of approach, the kind of training.
- 40. - Can you make it?
TRANSLATION: I think one of the most important recommendations
from this investigation was strengthening crew training,
especially for those transitioning from turboprop to jet.
For flight attendant Adriana Cardenas Medina,
the memory of the doomed flight still haunts her.
TRANSLATION: My life became a struggle.
I was left with irreparable physical injuries and
with psychological trauma, which I will probably never fully overcome.
What I experienced was outside of the norm
and was totally devastating.
For investigators, the crash of Aires 8250 is a cautionary tale
about the dangers of an under-trained crew.
TRANSLATION: The most important recommendation we gave was
about ensuring and strengthening the crew training
and following manufacturer's instructions
so that they can prevent these types of accidents.
Captioned by Ai-Media ai-media.tv