A Horrible Chain of Mistakes! TransAsia Airways flight 235

Imagine you are sitting in a taxi, the driver has just played soft music in the front and you are looking out the window at the gray clouds outside thinking about other things, suddenly the left wing of an airplane cuts across your taxi. Before hitting the sidewalks next to you, the plane falls into the river below from what just happened. Pay attention. Many thanks to Curiousstream for sponsoring this video. In this video I will tell you the story of Trans Asia Airways

flight

235. The

flight

itself. It's very short, only about three and a half minutes long, but in those three and a half minutes, years of personal capacity issues, organizational problems, and technical failures came together in the most tragic way possible.

This video will include the story of the very sensitive loss of life. Viewers please note that the circumstances leading up to this accident actually began several years earlier, in 2009, the captain of the plane whom we will call Captain A had just finished his duty in the Taiwanese Air Force and began looking for employment. In the civilian sector, he applied to become an Airbus 330 first officer at a local Taiwanese airline where he was accepted to start the cut and began going through his typing cut, but very quickly the instructors of this airline began to notice that this pilot had some problems.

Training reports indicate that he was falling behind the aircraft, that he had trouble learning procedures, that his general situational awareness, such as knowing what is going on around him, was not at the level it was supposed to be, and also He had trouble prioritizing tasks and managing well. Due to his stress, he received additional training during the typing course, but eventually the airline decided that he was not going to be successful in this, so they discontinued his training course. This happened in March 2010 and a few months later in August 2010 he applied for another airline this time trans-asia

airways

and he was successful in his interview and started his training on the atr 72 500 model this time he was successful in his training and started to work as a first officer successfully flew as a first officer for approximately four years and in April 2014 it was time to take his command refresh train to become a captain during his command refresh training, further issues were identified, first , the airline itself did not follow the correct command refresh procedure as they had written that it was supposed to be done in their operations manual, but also once the candidate entered the simulator obvious deficiencies were noted, he ultimately failed his command update simulator verification and the reasons given for not passing the verification were incomplete knowledge of procedures and execution incomplete knowledge of qra checklists not applying full confidence during a single engine tour incomplete knowledge of handling a command procedure engine fire and cabin management and flight planning need improvement, so these are some pretty serious deficiencies right here and your case was brought up in front of a review board, the airline review board decided that it should have a second chance, so he was put through additional training and after this additional training he managed to pass his final command check and was released for online training during the online training, another instructor pilot also raised more points about his ability, but eventually, through some additional flight sectors, he managed to obtain his command and began working as a captain in the ATR 72 500 fleet.

At this time the transaction waves had also included a new type of ATR in his fleet, the atr 72600, which is a slightly more advanced model. This means that the captain now needs to do something called differential training, which is where you do a shore school course and eventually simulated training for display. how all the new systems work on this new aircraft on the last day of this conversion training the instructor was training with the captain and wrote in his training file that he might need additional training and also added rather ominously now the czech efatto endian failed in the takeoff procedures but finally his commercial training was passed and he began to fly on the line in the atr 72 600 which is the plane that will be involved in this accident now let's talk a little about these airplanes so that both the atr 72 500 and 600 are considered quite modern turboprop aircraft, they are equipped with two Prattan Whitney turboprop engines and these engines are equipped with a system called atpcs automatic take-off control system.

Now what the atpcs does when it is armed is monitor the power output. of these two motors and if it detects that one of the motors is failing during the take-off phase and it detects it by a reduction in torque output, then it will automatically deactivate that faulty motor using the off-boom drive and the outboard boom afu basically. It means that as the engine fails, the propellers will go from the position they were in trying to build confidence to a position where they are simply flapping in the airstream to give as little resistance as possible. The other thing the atpcs system will do is that it will trim the remaining engine that is still running, this means it will increase the power output by nine to ten percent, so if it was given around ninety percent power for the normal takeoff, will now give around one hundred percent and both actions.

Upgrading the running engine and outboard alignment of the failed engine will increase the takeoff performance of the aircraft during the takeoff phase. Both the 500 and 600 had the atpcs system installed, but there were some differences in the way it was handled. because it was supposed to be armed before takeoff and if it couldn't be armed it was an early sign that there might be a problem with the atpscs system. In the years prior to this accident there had been a series of uncommanded fade events in which the ATPSCS system had been considered part of the problem, so if the pilots attempted to arm it and it did not arm on the Model 500 , the pilots were allowed to take off anyway, as long as they had verified before their departure that they had sufficient performance. margin, but at 600 it was deemed unwise to do so, so they had to reject takeoff.

The problem was that Trans Asia Airways had not adequately communicated this difference to its pilots and since most of its pilots were used to flying in the 500s where they were fine to take off, most of them did not know that they had to refuse takeoff in In case this happened in the 600th and this will become very important very soon, on February 4, 2015, Captain A was scheduled to fly four sectors he was supposed to start in Seongshan where he was based, then fly to his relatives and then return to seongshan and then do the same rotation once again.

He was afraid to fly together with another captain, captain b, and this happens sometimes, it doesn't. a big problem is when there are not enough first officers available for some reason two captains are perfectly fine to fly together also in the cockpit was a first officer who was doing his transition training from the atr 70 to the 500 to the 600 and part of that training included I needed to make a certain number of observation flights. The first two flights of the day left without any problem and on the third flight there were 53 passengers on board, two cabin crew and three pilots, making a total of 58 people on board. at 10:45 a.m. local time, Transacia flight 235 requested a turnback and clearance from its position at Seongshan airport.

They were cleared for a lot exit to Quebec which would take them to turn right and they ascended to an altitude of 5000 feet on this exit there. It was also something called endian standard instrument sortie and that is a specific sortie route that you have to fly in case you have an engine failure because the standard instrument sortie that you were cleared for might have higher obstacles which is not feasible. with single engine performance, but there is no indication on the cockpit voice recorder that they ever discussed this or any other part of an emergency before takeoff.

The weather at the airport was quite pleasant, there was cloud cover at 2800 feet, good visibility and wind. It was straight down runway 1-0, so that was going to be the starting runway. Captain b was going to be the pilot monitoring this flight. He was sitting in the right seat and Captain A was the designated piloting command for all four flights. and he was sitting on the left, they were going to post him flying for the flight and they completed their pre-flight procedures as per standard operating procedures, they started both engines and started taxiing for departure now during the taxi, the cockpit voice came out The recorder generated many arguments between captain b and the first officer who was sitting in the jump seat.

It seems that captain b was actually instructing the first officers on the differences in the atr 72600 model, but the problem here is that during filming. it's considered a sterile light phase, it's a part of the flight where we're only supposed to talk about really operational stuff and him instructing the first officer here might mess up the crm a bit between the two flying pilots, as in the captain In this case he was left out of the communication, he was just concentrating on the filming while these other two pilots were talking to each other now, before we get into the accident sequence, I just want to share a brief message from one of my sponsors who told him makes possible. for my team and I to create these types of videos, now I know that you guys are watching my videos because you love learning new things and finding out the nitty gritty details behind each story and if that's true you should seriously check out the sponsor. of this episode, which is a curiosity stream, a curiosity stream is a high-quality subscription streaming service with thousands of great non-fiction stories and documentaries from some of the world's best filmmakers.

I'm watching a series right now called What Went Wrong With the Shuttle Challenger? disaster, which is terrible but also very, very interesting, if you think Peter, that sounds very interesting, then consider supporting me by supporting my sponsor, go to the description, click on the link which is Curiousstream.com, slash mentor pilot and the mentor pilot coupon code which will give you a huge 25 discount on the annual subscription fee which is expect only 14.99 per year which is amazing value for money. Now let's go back to the video at time 10, 51 and 39 seconds, the plane begins its takeoff run just four seconds later.

The pilot monitoring exclaims that there are no armed atpcs, the pilot flying actually exclaims and the monitoring response, but yes, the takeoff is inhibited and then the pilot flying repeats it. Remember we talked earlier that if the atpcs system didn't arm, it could be an indication of other problems. What really happened here is that on the inside of the outer boom unit on the number two engine on the right side, a connector started to have some problems, the solder on one of the connector pieces started to develop microcracks and due to those microcracks. breaks, the connector is not sending consistent signals to the atpcs and that is why it is not arming, but this is where captain a makes the first of many mysterious decisions during this flight because even though both pilots have said to inhibit the takeoff, indicating that they are Aware that in the 600 they should not continue taking off with this problem, now they turn around and say, okay, the takeoff continues and the takeoff has continued.

The pilot's tracking seems to agree with that and it's impossible to know exactly why they thought this. way, but there is a possibility that because both pilots had flown most of their experience on the atr 72500, where they were allowed to continue taking off if their performance was sufficient, it is possible that that is what was overridden in this situation a few seconds later. The monitoring pilot looks and notices that the atpcs system is already armed and says this. He also says 70 knots, which is the difference between the low speed regime and the high speed regime at atr and the aircraft accelerates normally, it reaches v1. rotate tours normally raise their rig after the rig retracts there is a brief conversation between the pilots about whether or not the atpcs didn't arm because the truss lever angle wasn't in the correct position but then they continue to go up about 40 Seconds into the flight, the tower controller calls the aircraft and tells them to change frequency to Taipei departure control.

Instead, the pilot's monitoring reads this, and as he reads it, a brief noise is heard in the cockpit indicating one of the air bleed valves. is now closing and this is the first indication that something is about to go wrong, this is immediately followed by the main warning sound being activated on thecockpit and while this is happening the aircraft is turning right climbing to 1200 feet, what is really happening is that faulty connector inside the external boom units on engine number two is now starting to send signals to the atpcs system of that the engine needs to take out the boom, the system then reacts to this like on this engine. fails and begins to automatically engage the propeller, the system also closes the air bleed valve on enemy number one and increases the settings, remember, increase the power of that engine to maximize the available performance while this happens, the warning screen of the engine inside the cockpit correctly shows that engine 2 shuts down on takeoff and also shows the checklist items that the pilot must complete, but now a couple of things happen very quickly, first of all, the Captain says I have control and disengages the autopilot.

On the ATR 72600 it is a very capable autopilot, it can handle an engine failure on takeoff because you can adjust the rudder from the outside and it has a powerful shock absorber that can counteract the thrusts. asymmetrics that come from engine failure, but because the captain now has it disconnected it means that he now needs to manually fly the plane and that increases the workload for both him and the entire crew. The second thing that happens is the captain yells that I'm going to take the throttle off engine number one. This doesn't make sense because everything in the cockpit indicates that it is the number two end that is defective, even the ewd says so, so the pilot's monitor responds with a hold cross check, but is then immediately interrupted by the captain A, who calls him to activate heading mode because he remembers that Now they are following a sid that they cannot follow, they have to turn left to follow the engine out of the sid, so captain b is momentarily distracted by this , enters heading mode and gives a heading of 092 degrees to captain a and then to captain. b continues to try to solve the fault in question, but has not realized that captain a has already reduced the power lever on engine number one.

The aircraft is now initiating a 131-degree left turn at approximately 0.92 degrees heading. It has an altitude of 1485 feet and the speed is approximately 106 knots, we are just over a minute into this emergency, the pilot monitoring Captain B is now going over the engine failure checklist, he reads out loud the engine shutdown check and then trim control and then out of the boom control and to this bunch of flights it responds well a few seconds later the pilot monitoring looks up and calls out the control speed because the airspeed now is down to 101 knots, which is only a few knots above stall. speed, inexplicably the pilot flying responds to this with recoil number one and pushes back the active engine even further, unfortunately the pilot monitoring did not realize that Apollo Flying was doing this because he is still reading the list of verification and reaches a point where it says Ok, fire number two is now confirmed and the flight responds with OK, but it still does not add power to the engine power lever number one at time 10, 53 and 9 seconds, The aircraft reaches its highest recorded altitude of 1,630 feet at this point. you don't have enough confidence to continue climbing, so the pitch mode switches from iis, which is a mode that provides continuous climb to maintain altitude just a few seconds after the first stall warning sounds in the cockpit, reminds the pilot and flight captain. terrain ahead and the monitoring pilot responds with OK check lower probably referring to the tone to lower the tone to get out of the stall.

Now the first officer in the observer seat also jumps into the conversation and says, low and that is immediately followed by another stall warning and stick jerk. The pilot monitor looks and says, "Okay, push, push back, which sounds a little strange, probably referring to push, push forward to lower the nose, but remember this is an English translation." and the translation may not be perfect, but it also adds wait for a second throttle, probably referring to the fact that the throttle is not going up as part of the stall recovery procedure, now the pilot flying responds by increasing the power lever on the engine. number two and reducing it further on engine number one, once again making the situation even worse, the plane is now on a 20 degree left bank, has turned on the planned heading of zero nine out of five degrees and is now heading to zero five zero degrees altitude. is descending, they are at 1526 feet and the speed is back to 101 knots and now Captain A's bunch of pilots are about to make their biggest mistake yet because five seconds later Captain A shouts out the number one pen indicating that You are about to actually shut down engine number one, remember this is not your area of ​​responsibility, this is something the pilot monitor should do with the use of the checklist and by checking with your colleague, the pilot monitor responds with a numerical pen showing some possible confusion. here, but what you need to understand is that at this exact moment the aircraft is experiencing several stall warnings, stick jerk events and even stick pushes at time 10, 53 and 35 seconds, the aircraft has stopped its turn at the left and has now begun a turn to the right.

Instead, rotate your hand to try to return to its 095-degree path. This is where the pilot monitor finally issues a distress call to air traffic control and they are still on the tower frequency, they haven't changed yet, but at the same time the monitoring pilot calls this call may , another call is heard on the tower which prevents the air traffic controller from hearing correctly what transaction flight 235 is saying, they simply assume that they have returned to the frequency, so instead of acknowledging the power they call, the traffic control air now calls them again to change the frequency to the departure frequency, instead in the cockpit, the confusion is now getting worse and worse, the first officer sitting in the folding seat shouts how come it becomes like this and the Pilot monitoring captain b says we've lost both, we've lost both sides and finally recognizes the seriousness of the problem when the pilot flying hears this, says, restart the engine and then repeats the exact same phrase seven times during the There are only a few seconds left of this flight because the plane has already descended a thousand feet and is reaching about 500 feet when the vane monitoring arrives and raises the number one engine condition level again and this initiates the engine restart procedure, but It's just a path.

Too late at time 10, 54 and 27 seconds, the pilot, Flight Captain A, says his last words into the cockpit voice recorder and they are: Whoa, he pulls the throttle on the wrong side, which indicates that he now understood what caused the problem while saying this. The airplane enters a left turn roll and when it does so it also enters an aerodynamic stall from which it will not be able to recover. The roll increases from 10 degrees to 80 degrees as the airplane approaches a highway overpass. of the key area. river, hits a taxi traveling on the road and that exact moment is captured by a dash cam from a car behind the taxi, the left wing then hits the road and the guardrail on the side of the road before the plane continues descending towards the kilon river and continues to rise its bank, meaning it hits the river in an inverted position when the plane hit the river, broke into several pieces and 39 of the 58 people on board were instantly lost, including the three pilots and one of the flight attendants after the crash, some of the survivors managed to get out through a hole in the body and climb onto the wing to wait for the rescue workers who were on the scene very, very quickly, another few survivors were trapped in an airbag in the rear of the plane and the rescue teams managed to open the emergency exits from the outside and the people were able to escape and now the investigation really began and fortunately both the flight data recorder and the voice recorder of The cabin was not damaged in the accident and can be quickly examined. and from a very thorough investigation of both engines, they were able to identify the faulty connector inside the outer boom unit and therefore understand why the flag loss event had started, but then the investigators dug a little deeper and They began to wonder why not The crew rejected it and very quickly realized that this was probably due to organizational problems within Trans-Asia Airways because upon interviewing several of the pilots they discovered that there was not much agreement as to whether or not it was a mandatory rejection if the atpcs system was not armed on takeoff, causing the investigation team to delve even deeper into the organizational issues within the airline and they realized that the command update procedure the airline had built and approved by the authorities had not been properly followed.

In the case of Captain A, it was also very clear that Captain A had shown significant deficiencies during several training events before this happened, not only at this airline but also at previous airlines, but this had not been adequately captured and was not Obviously it was a threat to flight safety because dealing with engine failure on takeoff is something airline pilots are trained to do every six months throughout our entire career. Several recommendations emerged from this accident, some of them were aimed at The engine manufacturers made sure that this faulty connector was fixed and so that it could not happen again, but most of the emphasis was placed on the airline itself and this me It leads to a really important point that I want you to take with you. you and that is the use of the term pilot error.

Yes, in this case, I know a lot of people will say in the comments section that this guy should never have been allowed near a plane, etc., but that's not really the point. The point here is that there was no good enough selection. processes and there was no good enough training process at this airline to help this guy and prevent him from progressing to command and this was exactly what the investigation ultimately showed after this accident, this airline was effectively grounded until they could prove to the authorities that all of its pilots had sufficient knowledge and competence necessary to fly its aircraft safely.

This was the second accident in a few years with fatal results for this airline and eventually bankrupted the airline, so it's not there. But every time you hear the word pilot error you should ask yourself why it was pilot error, because unless the pilots made

mistakes

voluntarily, broke the rules and knew they were doing something wrong, there is something else at play, there is anything else. What we can learn from it to make sure the airline industry is as safe as possible now if you want to watch a video where the pilot willingly broke the rules and almost ended up crashing into the sea twice in one. day, then watch the video here and if you want to support the work my team and I do for the channel, consider becoming part of my patreon team or buy yourself a couple of merch t-shirts.

Have an absolutely fantastic day. bye