He,they,them,her...whoEVER SAID ANYTHING AT ALL..1/2 ISNT PROBABLY HEARD " in the moment " there's no dress rehearsal 4 death. No rewind..no pass go, collect 200 dollars. ...in the moment each individuals mind is DIFFERENT.. hearing seeing smelling and whatnot. The coulda,shoulda,woulda... Amounts to ZIPPO. GOD BLESS EVERYONE SOUROUNDED BY TRAGEDY,LOSS,AND PAINFUL ,HURTFUL, NEVER EVEN DISCOVERD FEELINGS U never knew u had. I can go on but g.bless and to those...R.I.P. ....AMEN . AND happy holidays 2 all who took a few moments out of your busy life to comprehend what I'm trying to express. ..j.bibeau❤️
I think it's ridiculous that the pilots were criminally charged and sent to prison (The episode doesn't mention it, but both served roughly 3 years). They were heroes who saved a lot of lives. They may have made some mistakes, but those were not crimes.
I wouldn’t send them to jail…but they were guilty and had to be held responsible for their passengers…there are checklists for a reason. Procedures. I hate them too, but they’re there for a reason.
@@samueldocski4426 I can understand firing them and revoking their pilot's licenses for not following proper procedure in regard to the fuel slip. I just don't think they should have gone to prison for it. There was no criminal intent.
I don't know if it got cut off or if there's an alternate, longer, version of this episode. But there's a missing part of this episode where it adds onto the simulator investigation. It explains that yes, the plane could have made it to Palermo if the simulator pilots knew to feather and glide immediately after flaming out. But if the simulator pilots were instructed to go through the procedure to restart the engines multiple times, just like the crew did in real life, none of them would've made it to the airport afterwards.
20/20 hindsight is a wonderful property to have. You always have more info than the actual situation had at the time. The bottom line is that the wrong piece of equipment was installed which caused the entire disaster. The crucial piece of info that is missing in 20/20 hindsight investigations is the actual pressure that the pilots experienced at the time. Excellent video.
In hindsight yes, the fuel gauge did cause the crash. but also taking off without the fuel slip played a major part. I would never take off without a fuel slip and they shouldn't have either. On the other hand the pilots did everything they could given the situation at had. If only they had just told the ground and ATC that they can't leave without that slip it would have been a very different story.
Also, when the pilot asked about the fuel slip he was told they’d get him the slip when he got back. The controller didn’t say he didn’t have any record of refueling.
I understand, however we train pilots to deal with this and must hold them to superhuman standards because so many lives are at risk its the same with doctors and should be with police officers...."letter of the law" pilots follow procedures exactly as they are laid out and do not deviate, because they know these procedures have been painstakingly developed and they also know following them will absolve them of any sort of critisizm or culpability if something goes terribly wrong....no way of knowing what leaving without a fuel slip would mean, but seasoned pilots will tell you it doesnt matter, that every procedure is there for a reason and you follow it. Also, knowing the optimal glide speed and procedures to decrease drag during a glide are basics functions that would not only be in the procedure manual but are also vital pieces of data every pilot would have prior to flying that specific plane...I am not saying we should prosecute this particular pilot criminally, but knowing the mistakes he made in a dire situation and putting emphasis on these mistakes will ensure future pilots dont make them...also think it was important to point out what he did great, which was the nose angle on landing being spot on takes considerable talent and simulator practice
As soon as BOTH engines went out, it was pretty obvious it had to be a fuel problem, two engines don't just fail like that at the same time from some mechanical issue, first thing I thought was the idiots ran out of gas and I was right, it's not the first time, another of these videos a jet ran out of fuel because some idiot on the ground forgot to convert from one system to another- gallons to liters or pounds to KG I forget what it was, so the jet had HALF the fuel it was supposed to have.
Why don't they have sim pilots go in to the scenario completely blind, or at least have half of the sims done without any briefing? That way you can see how much of a difference the human factor made. You can't simulate an emergency if you know it's going to happen.
Exactly The simulator pilots already knew they were out of fuel so that's an unfair advantage on what should have been done. And now that I wanna bring the pilot up on charges like he intentionally killed people smh
Ah yes, ignore the flight crew. That should end well. Think about it. It's basically an rubber tube of air. It has no support structure. It will not prevent your neck from breaking. Do not inflate it in hopes it will protect you. Your seat belt is there to prevent you from slamming into the seat in front of you. Pretend it's a car accident, seatbelts save lives. The seatbelt keeps you into your seat for the collision. When things are moving slow enough or stop, you unclip your belt and swim out of the plane, only when you're free of the plane do you inflate the vest. That being said, it's no replacement for being able to swim. The ability to swim is helpful when clearing the plane.
Yes, the pilot left without the fuel slip - but pilots are also under immense pressure and timetables. If he had decided not to fly because of the missing slip, and then that slip would later appear, he would've more than likely faced a penalty for the airlines. At the end of the day, a bad design decision (letting the parts just be interchangeable) and a bad maintenance decision (installing an incorrect part) was the cause of the accident. The crew did the best they could and the pilot *did* manage to land the craft in a way that allowed for some passengers to survive. To place the pilot under criminal charges here seems like a move (by various bodies) to make sure the carrier is not 100% liable, which, evidentially, it is; by also charging the pilot, the carrier and manufacturer c were probably able to limit their liability and loses in the courts. The perfect simulation about having been able to make it by gliding was also very suspicious. IMO it was probably part of the effort to shift lame unto the crew and away from the carrier and manufacturer.
I agree, they should of flown another similar plane and shut the engines off and see if it could glide for 70 miles. But they did not do it because they knew it would drop in to the water again.
I agree 100% most airlines tend to value time over safety and honestly I'd rather be late to a destination than dead. Also its sad that they always put full blame the piolets when its also a management, maintenance, and manufacturing issue too.
I know, especially since the mechanic is the one that screwed up. The captain did everything in his power to save those people and his plane based off thinking he still had lots of fuel. He still landed amazingly and many people did survive. He shouldn’t have gone to jail. It wasn’t his fault.
people are missing the point. it is better to be alive and whole, than to be adjudged culpable, and in jail. I don't care about a time crunch--,and I've been under time crunches--, RUSHING usually DOESN'T end well. It would ALWAYS be imperative, had I been the Captain, that I feel comfortable KNOWING that EVERYTHING was done ACCORDING to the proper procedure, BEFORE I attempt to fly. people seem to forget: A plan is NOT akin to a leisurely car ride. One can put off car refueling--, a bit, --until the next gas station along the highway. There's NO refueling stations, for aircrafts, in the sky!!! That was a life-or-death situation for the passengers, and HIS FLIGHT CREW. The Captain and copilot were ultimately responsible for ALL the souls on board. They are culpable, and they were wrong. If the departure is late, it's late. The Captain sure wouldn't want to tell mechanic that the plane was refueled, so, WHY did he ALLOW an improper procedure re the fuel form, KNOWING THAT EVERYTHING can be, and is, recorded and/ or noted. It would be found out, anyway. The airlines live to deflect culpability. The planes, in general, are seemingly ALWAYS delayed, plenty , ANYWAY so no excuse...get the fuel form!!! As a Captain or a copilot, I would NEED to see the fuel slip-- double-check it!!-for my OWN peace of mind, and life; one IS flying a plane, after all!
As a yacht Capt for 30 yrs I always knew that the buck stopped with me, whether I was at the helm or not. And having incorrect data from your instruments can cause a chain of events with bad decisions, and one little fuel slip would have changed everything. I feel really bad for the Capt on this one.
The captain acted imperfectly to the situation, but I don't think he did wrong. they were basic human errors, and I doubt many would do much better in such a situation.
I agree. He reacted to the information he had on hand (which included faulty fuel gauges). I'm sure had he known he was out of fuel he might have chosen his next steps differently. It was an impossible situation caused by a series of errors. Human systems are often complex and small breakdowns can lead to disaster.
@@johnchedsey1306 You're right up to a point. It's his job not to make mistakes, but... Had he realized there really was no fuel, he wouldn't have wasted time trying to restart the engines. Still, those props would have been feathered if they followed procedure. But it's always easier to evaluate flights at 0 knots and 1 G sitting in the living room.
@@evanwindom3265 so true and these pilots start to develop complacency after flying time and time again. Throw in some technician installing a similar but wrong part for the aircraft and you have a recipe for disaster. Not to mention these airline companies are that want don't want planes grounded for fear of losing money. That puts more pressure on the pilot and the ground crew to take off without something like the refueling slip in this incident. Undoubtedly hard lessons were learned here let's just hope they're never forgotten.
From what I could tell, it wasn't that he acted imperfectly to the situation that ultimately got him charged, but rather not getting the fuel slip checked, and by extension breaking the law by flying his plane in the first place.
He probably saved his own future too though, planning marriage after only one year of a relationship, yikes, you know that's gonna end up in a world of troubles.
@@ChristopherGray00 been happily married for 21 years to a woman who I got engaged to 7 months after our first date, sorry you picked the wrong partner.
@@andrewfidel2220 good for you, that's not the case for most people, very naive move to marry someone you only knew for 7 months, go to the casino because you're a lucky man.
As always. When possible find a way to blame the pilots, seems like that's investigators favorite thing to do. Some of the things they say are good in theory but when your actually in a real life situation with tons of stress it doesn't happen that way.
You're right about actually being in the situation at the time and the stress and confusion involved, but he did blow through the refuel slip, against policy, which led to the crash. And then he again didn't follow procedure and check out the gliding procedure. But guess what? Bad things happen and people make big mistakes and that's how it goes with us people.
@@jimhere01 The only error I see is the fuel slip. Even so, he didn’t check it because he believed he had more than enough fuel to make it. As for the gliding procedure, he didn’t follow it because he believed he still had fuel and they attempted to restart the engines til the last minute. This is Sully all over again… just because it’s possible in the simulator, where the person flying it already has a head up and knows exactly what to do, makes it to land, doesn’t mean it will in real life. You have to take into account the human reaction and thought process. They were trying to do the same with Sully, until the decided to give a couple of seconds to count for the thought process and human reaction, which at that point, none of the simulation pilots made it to land.
Changed many many many FQIs on aircraft. The first thing is supposed to be a "Power on Defuel" which ensures ALL fuel is "sucked out of the aircraft," for "Low Side Cal." Then the FQI is calibrated to zero. Then refuel to full capacity and calibrated again, "Hi Side Cal." I'll bet they were "too busy."
Pilot and Co pilot both got 10 years of jail time which is absolutely ridiculous in my opinion. Apparently charges of manslaughter and "praying during emergency" which I think most of us would do during emergency. Basically the court was completely convinced that they should have made it to land but it seems like it would have been near impossible if in that situation.
Was that the only contributing issue, though? They also chose to go ahead with the flight without getting a refueling slip, and didn't confirm the fuel quantity. I can see how a court would include that choice (which was taken in a calm moment, rather than under crisis) when deciding their culpability.
@@jakual339 But did they really deserve prison time for that? I can understand revoking their pilot's licenses for not following proper procedures in regard to the fuel slip, but prison? That seems a bit much. There was no malicious intent or depraved indifference to human life on their part. It just seems like the pilots were made scapegoats because someone had to take the fall for an accident with so many deaths.
@@TheStapleGunKid It seems like certain countries have a pattern of locking up and unjustly punishing pilots for air disasters. Also ship crew and other transportation professionals for other accidents as well. I agree they are frequently made scapegoats and it seems quite prideful.
She's like the only flight attendant that was unhelpful.Most are heroes to the end. Strange how the tail section passengers survived and yet the cockpit in front where pilots survived too..Ditching is def the right name for it.
That guy actually unbuckled his own seatbelt as well as his girlfriend's!? How foolish. And didn't listen to NOT inflate his life jacket? He's very lucky that he was just knocked unconscious and spitting up blood. Meanwhile, who knows if his girlfriend died because of his actions.
So sad always sad when a child dies sigh 😔 poor babies my heart is with you all God will give all children a second chance at life again in the new world sleep well my sweethearts
Yep, there’s always the ones who think the know better than decades of research and testing. It’s very possible that she drowned because of his stupidity. I’m surprised he even appeared on this show.
Sometimes it seems as if maintenance doesn't get the gravity of the situation. There are lives depending on them getting it RIGHT! Quality control isn't always there, or tape gets left on etc...half the time I'm shaking my head at these guys. I know it's easier watching from home but sometimes it really is that simple.
Sadly a lot of the time maintenance workers are poorly paid & even poorly trained depending on their job title. When those who keep the planes flying SHOULD be fairly paid & highly trained! The further back you go in time the worse these issues become. Now things are better…in most countries & airlines at least. Another reason to think twice before taking small budget airline flights.
Wrong. Mistakes are human and inevitable. That the gauges for the two variants fit exactly the same is unforgivable on ATRs part. Automakers have figured out how to use poka yokes, airplane makers certainly should be doing so as standard. On something as safety critical as an airliner fuel gauge, the human factor should be designed out from the very beginning, as much as feasible, and this example is more than feasible.
As a former professional skydiver who has come through some close situations both while in and out of the aircraft, that one guy has some pretty horrible survival instincts
@@zorakj the life jacket..the seatbelt..the bracing position… hoenstly i dont know how he survived. Dont get me wrong im glad he did but its just sad that some passengers are that stubborn and arrogant
But he made the choice for his gf taking off hee seatbelt and deploying her jacket and she didn’t make it. He did what he thought was best in life and death but I can’t understand the reason behind that thinking.
@@ronniewall1481 🤔... pretty good idea after watching all these lol. However you likely can't use it without depressurizing the plane and killing everyone else.
It seems like the pilot is a catch-all scapegoat for any and all problems on the plane, after a crash or otherwise. After a crash the pilot is either an _instant hero_ or a _terrible monster._ there is no in between it seems.
@@janandnaomi2000 Ding! Ding! Ding! We have a winner. SOMETHING about the installation should be different enough to prevent the mistake. I realize the airlines try to reduce variation in order to control costs, but something as simple as different pin-outs on the connectors would be sufficient.
This accident was just a tragedy of small mistakes that compounded into 16 people dead. I don't think anyone should've been charged (the pilot should've received only minor sanctions for departing without a refueling slip, but something tells me that was just a thing pilots would do in that airport), because that discourages people from telling the truth. The pilot made mistakes, but he was never told by the checklist to "maximize glide while restarting both engines". He didn't know that the fuel gauge was not only the wrong one, but that the wrong one can have bad readings. And considering how he left Tunis without a refueling slip, that must've been an occasional thing done there, which is more an indictment on the airport culture. The fact that ATR had the exact same shapes for both fuel gauges with only a tiny number to differentiate, and that they could actually be connected to the wrong plane is shockingly bad design.
I wonder if that's a standard line of gauges from the original gauge manufacturer too, which they all build to fit in the same socket, so they don't have to have a large inventory of different sockets. If it was custom built, each gauge might be made to fit only in the correct socket, or at least have some kind of electronic matching part verification which would, say, flash a code on the display if it's installed in the wrong plane.
I disagree - airline rules are in place to save lives (and provide redundancy) and he should not have departed until he confirmed that the plane had been refueled. I don't care about his heroics at the end - had he insisted on seeing for himself the refueling slip, 16 people would have lived to see at least another day!
I'm curious did the glide tests done afterwards actually take into account both the pilots estimated fuel level and the actual fuel level? Thats a large weight difference
Interesting --- so you're saying they might have made a different decision if they knew they were actually 1800kg lighter? Great point. It would be interesting to see if the same flight in the sim would yield the same results with another 1800kg of aircraft weight, or if the manufacturer's glide data includes fuel loads. Good question, anyway. You should see if the NTSB is hiring. :)
Thanks! Yeah, my toughts are that 1800kg drastically changes your glide range. Potentially causing the pilots to discount the idea to glide to safety. I wonder if that planes has the ability to dump fuel.
@@varunvarshney When I said dump fuel, I also meant jettison. With it being a customer option on a handful of planes, I wasn't sure if it potentially had the ability or not.
I hate when they blame the pilots. They only tried to save lives not to destroy them. Its easy for those who've, maybe, never been in a life or death situation to judge those who were in that situation. Would it have been better for the pilots to attempt to glide all the way only to possibly crash on land and have more loss of life? The nerve of some people
I cant imagine drowning like that, man its scary to know what people have gone threw RIP to all those. You cant breath you know your about to die its hard to think and all you can think about at the last second is not having air and blacking out RIP angels
I thought it was interesting that when talking about test pilots attempting to glide the aircraft they never mentioned how many tried but it was in plurals, however it was only a single pilot who was actually able to do it. I was rooting for the pilot most of the way until I found that he took off without the refuel slip, and he was the last line of defense to prevent just what happened.
On one hand...yeah, not getting a refueling slip and maintaining that paper trail is kinda important. On the other hand...there's a _lot_ of paperwork involved with every aircraft. I don't know how common it is to just miss a slip here and or a page there, but I doubt it's completely unheard of and there's probably some kind of procedure for getting a plane's paperwork caught up to handle this sort of thing. And one then has to wonder how many such minor slips occur that don't involve a crash. Think about it, if the plane hadn't crashed because of a wrong part, then how much weight would that missing slip really be given?
True but the mechanic is at a bigger fault here... He should have noticed the before and after FQI installation fuel quantities... The after installation fuel quantity should match the before... There was such a big mismatch...it was a clear red flag !
@@nightrunnerxm393 Well... the wrong part is why it looked like fuel had been added. No slip would be expected if the right part had been in there, showing the same fuel level as what the plane had been left with before the repair. I think.
@@Abhi_upstate_ny You hit the nail on the head. The pilot is reasonable to believe that fuel might be added & a slip missing (though it shouldn't happen). The mechanic knew what they were doing & knew to check the displayed readings after to confirm that the repair is behaving as expected. There also has to be a way to independently verify the actual fuel present, aside from the gauge & it's standard practice to always calibrate/check new measuring devices to verify its accuracy. It's not exactly unusual for measuring devices to not give accurate reading after install. It's why we have standardized independent methods of verification. Like if they had just bothered to fill the tanks completely for the initial trip, they would have known immediately that the gauge was completely wrong. If anybody had double checked the measurement, if the pilot didn't overlook the missing slip, if the mechanic had done his job with any professionalism, etc. this wouldn't have happened. Any number of practices could have prevented this, heck just making the serial number match the model or not wholly mechanically interchangeable. The pilot was the last one of defense, but the mechanic & manufacturers were the ones who didn't do their job without defense. Like I said it's easy to miss a piece of paper, but a lot harder to ignore the core manual /rules of maintenance & design. Hopefully, pilots will be a bit more careful about ensuring they have actually dotted the I's & crossed the T's. They truly are the last line defence against such. Frankly, I want more legal protections for pilots that refuse to fly for any safety concerns. Right now, pilots are pressured to fly regardless of the circumstances & if they refuse, will likely fired. I want to see companies severely fined if they don't accept the pilots refusal. I also want rules about pilots not being financially invested in the company owning the plane. If a pilot sees their own financial future being dependent on the company's success; they are more likely to be willing to bend rules & take risks they shouldn't. Pilots should have 1 single priority & that's safely flying wherever you are going. Nothing should be higher on their minds than the safety of all aboard. Even if the company loses money, safety is what matters. If I had a meaningful way to determine which airline is actually serious about safety over money; I would only fly with them, even if it was a much higher cost. Unfortunately, it's not that easy to determine & actual cost is seemingly completed disconnected from commitment to safety. Unfortunately, it's the bad companies that are most successful because it's cheaper not to bother with the hard work & just keep good insurance. While good companies often destroy themselves trying to compete with the uneven playing field. It's frustrating, I wish there was independent bodies who verify that the company keeps the strict higher standards & thus justify its higher cost/why customers should choose them.
@@adambartlett114 all excellent points ! I would not blame the manufacturer here as it is in their interest to keep the mechanical design of parts same in the two models...that reduces their design efforts and thus reduces engineering cost... They should have made a different connector or something for the two different models.... Also I feel that no fuel should be added without crew's knowledge... captain has to be there to sign off during fueling ! As they said it was a chain of flaws which caused the disaster.... unfortunately it's always the passengers who have to pay with their lives Everytime !
Finally a new episode and actually a new kind of problem. The company that makes the fuel gage should not make the instruments not compatible through software.
He also broke protocol by taking off without confirming a refuel due to the missing refuel sheet. If he had followed protocol. He could have saved a lot of lives by not assuming and taking off with less fuel than needed for the entire trip. So, yes... he is also responsible for it. Not as much as the idiot who installed the wrong model fuel gauge but that's why they have so many fail safes and checklists for everyone to follow.
@@tylerxic3241 and that's why they were sentenced equally harshly as the pilots. it wasn't just the two pilots, everyone got about a decade with the least being 8 years.
As other commenters pointed out- the people in the sims already knew what was happened and they had 150% of the information needed to glide to land. I do fault the captain for ultimately not knowing/confirming fuel on board
It is partially the Captain's fault for taking off despite no refueling slip being present, but also I can say that schedule doesn't give them a whole lot of time to confirm that. Altogether it is the manufacturer that built the fuel gauge and engineer that installed it. The manufacturer for making both models look the same causing confusion and the engineer for not checking the models of the gauges
One sim pilot got to the airport, but did the others anyhow? A ditch closer to shore could have gotten help sooner. In spite of trying to ditch near the boats that were seen, no boats were in sight once the plane was down. So that didn't help.
I would insist that pilots get all the time they need for preflight because it's about SAFTY NOT GREED . Adding resources for stopping error, and being accident free is the goal. Not endangerment caused by mistake or greed to rush everything. If I was running an airport and I caught a plane company rushing the pilots over money I would make it a point to drag them in frount of the FAA and GROUND THEIR FLEET UNTILL THEY CHANGED THEIR ATTATUDE. Greed and safty don't mix . Period.
@@cynthiarothrock4255 You are so right! As a former airline pilot, I can attest to the fact that crews are definitely rushed to make that on time departure. A quick turn at an out-station is supposed to be done in less than 30 minutes...depending on aircraft type of course.
@@SeekingTheLoveThatGodMeans7648 That's a good question. Surely, when they're running simulations, they should be trying to establish whether a typical, well-trained pilot would be able to succeed, not whether the best pilot performing at the top of their abilities is able to succeed. Especially when the end result is criminal charges.
I have been fascinated with these episodes regarding aircraft disaster and have noted that the safest place is at the rear of the aircraft. I don’t know why I always gravitate to the rear when I fly but maybe my senses know best. This is the 3rd or 4th episode where survivors sat at the back😯😯😯
I've never been in a plane but just from watching these mayday's I've learned the best place to sit if I ever do board an aircraft. THE REAR... ALWAYS SIT AT THE REAR OF THE PLANE...
The only plane I was ever a passenger on, was a bush plane that took off from the lake and landed on it. It was pretty cool, but of course a much smaller plane and built with that purpose in mind. My heart goes out to the victims and all the loved ones they left to grieve them. 🕊
You could easily blame the captain or maintenance but an argument needs to be made here for the manufacturer. Who makes the model numbers so similar for parts that look exactly alike but could cause that large of a miscalculation? lol
Agreed, horrible engineering by the manufacturer. It was only a matter of time before someone somewhere in the world made this deadly mistake. This mistake was completely predictable, and thus the blame falls on the manufacturer.
The manufacturer should have been sued. Definitely at fault for making the gauges similar so that can easily be used and causing death 💀 in a matter of minutes.
Given the situation, I don't think the pilot should have been charged. He did the best he could with the data and knowledge he was given. To expect him to be able to know what was wrong with the plane mid flight while falling out of the air is ridiculous. He followed the checklist for the issue he faced, and when that failed, he made an amazing water landing.
He wasn't charged because of how he flew. He flew as was expected of him. What he did wrong was take off without the fueling slip. Even if your plane doesn't crash, you'd still face some repercussions for that.
The safety instructions are there for a reason. You don't know better than them. Drives me crazy that people don't follow instructions and then act shocked that it didn't work out.
I realize that hindsight is 20/20, but the first 2 steps for engine out procedure checklist are usually 1) select a suitable landing site and point the nose in that direction and 2) pitch for best glide speed. This was drilled into me as a Student Pilot. It should be the same on any plane from a Cessna 152 to a Boeing 747.
Please pay attention to the in-flight safety briefings and study the emergency exits of the aircraft. Furthermore, let this survivor be an example of why you should show respect for these safety procedures and don’t minimize or disregard them because you think they don’t make difference or you think you know better than a highly trained crew when you really don’t.
Bro, let this SURVIVOR show you to not do as he did. Do you hear yourself? Lol. How many people didn’t survive that DID follow the instructions?? I bet most!
@@anti-ethniccleansing465 I hear myself just fine. If someone jumps off an overpass into a freeway of traffic and survives I’m not going to make the dumb conclusion that’s it’s fine to follow their example because “hey, they did it and didn’t die”.
Unlike most mechanics an aircraft mechanic has to have all his worked checked by another mechanic that is more senior to him . If that was the case with auto mechanics and auto mechanics were charged if the auto broke down on the road following repairs there would be far fewer auto shops. So no I think the problem was that the two parts were identical except for the numbers on them .
@@bobbates6642 valid point, its small mistake, but it cost lives, air accidents are rare, and most of them have lead to some kinda safety upgrade, this is s tough one, the pilot should not have take off without verification of the added fuel, especially over water, I've flown in and of buffalo dozens of times, there probably 5 or 6 airpots between here and Boston or NYC to lsnd in that scenario.
Mechanics did cause this, but I think the captain could have made SURE the tanks actually were filled completely, not just trust the indicators. I say this because he reported a fuel indicator problem the previous day, AND the refueling slip could not be found on the accident day. So until you KNOW the problem was fixed properly, don't trust the indicators 100% right away. Just sayin.........
with Lives at stake I would have made sure about that slip Before I would have taken off. even at the expense of My Job.... Better My Job Than Blood on My Hands it's How I would have handled it Those Passenger would be My Motivation evertime I take off to any destination
How did the repair person not notice that the fuel level had changed dramatically? I would think on the replacement checklist for any item there would be some kind of record of the reading/measurements before and after.
ah yes, let me just take off both my seatbelt and my fiancés seatbelt and inflate both of our life jackets then blame the pilot for “murdering” my fiancé when I whom endangered me and my fiancé while killing her to just “soften” the impact. smart move, very smart move.
Maybe pilots didn’t feather props is because they dropped to 17,000 ft to try to restart engines , then they tried to restart again therefore letting props remain in position
I think landing the airplane in Palermo would have been a gamble to those on the ground. Pilots are responsible for those on the ground as well. "Might have been able" isn't good enough
Here's the thing though on the glide: Even though the crew might have made clear cut mistakes (i.e. feathering props) we CANNOT assume the tail wind would have been consistent or can we? Where is the proof of that?
@@matthewwilson5019 Right right dig it -- I'm just saying that even if they had done so we can't assume they would have made it unless we know more about the headwinds.
POV of Chief of Fuel Management: "Since the safety of passengers and the crews life are at stake and the consequences be catastrophic if these two part numbers be mistaken for one another, we are going to make the parts itself identical and only differentiate them by 1 digit in a simular number code". Low Key Employee: "But why make them so simular? That just begging for a disaster!" CFM: "Because CHAOS REIGNS!"
This episode is the perfect example of why so much time money and effort is put in to air crash investigations. There's no telling how many lives were saved by fully investigating this one crash And getting the word out about being extra careful about the fuel indicators.
Designing those two parts identical with very similar part numbers was an amateur mistake. I worked as a design/manufacturing engineer for 25 years. I designed parts that only the correct part in the correct configuration could be installed into the product.
The only issue I had was that the pilot didn’t seem to tell the investigators about the faulty fuel gauge replacement just one day before. Why? Perhaps because he knew the refueling slip wasn’t there and he decided to go anyway, rather than hold up the flight for a bit while someone manually checked the fuel levels in the tank. Certainly, it wasn’t because he forgot. That seemed to indicate to me knowledge of guilt.
There is a well known statement that was drummed into me as a young engineer that if a wrong part can be fitted it will be at some stage so ATR should be criticized for not designing the indicator so that the wrong indicator could not be installed.
captain's a hero for making the landing and saving as many lives as he did. sounds like the Italian investigators were just saving face for ATR - "identical" FQIs being able to fit in the wrong aircraft. *1* pilot made the landing in Palermo. in a simulator, with hindsight. maintenance should've still been crucified though. EDIT: oh, mechanic _was_ charged, they did recommend they make the FQIs physically incompatible.
The smart thing the manufacture of the plane and fuel gauge maker would have done is to key each differently. I am surprised it didn't have a small APU on board. If it didn't start then you know you have a fuel problem. You would think the gauge would have to be calibrated. Last what kind of mechanic installs a part without checking the part numbers to see if it can be substituted. Crazy stuff.
Well, it is a known characteristic of the craft. Was it somehow referred to in the checklist for both engines out? (It would seem logical that it would be.)
You're not actually "throwing away" speed if you do this properly, you're using it to maintain altitude for longer. Without engines, speed is controlled with pitch. Just reduce descent rate (or level out) until you've slowed down enough, then continue the descent at the optimum speed.
@@BJozaty Sounds reasonable, especially the part about going faster means descending faster, which means less time avail to be flying; I think I was trying to find a situation to match up to my crabbiness which made all thought processes grind to a halt. Its a good thing I wasn't flying something at the time... (Still I would want to conserve as much of the initial speed as possible and blend to a lower speed only as that speed was dragged off (which was probably fairly rapid). The 'host' made it sound like he 'needed' to slow down and by not doing so he made some terrible error.) I probably saw this show originally when it was first made and like many of the other 1980s-90s shows out there; quality suffered in retrospect. Now to the point where the plane actually breaks into two pieces, do you think that it was poor craftsmanship during manufctr that caused it to do so or was it some manner in which the Captain landed it on the water's surface or just unlucky physics?
@@CRSolarice Glad I could help explain, yeah the way they said it wasn't too clear. Since the rescuers mentioned it was rough seas I think it was just unlucky that it broke apart. At 47:55 they mention it touched down at the correct angle for ditching so it sounds like he gave it the best possible chance for staying in one piece.
As a flight attendant I use to feel take offense of the people who would never listen to crew instructions, or listen to the safety demo. Now I couldn’t care less. If you don’t care for your own life, I won’t. I won’t risk my life for yours.
5:00 Less than 2 minutes after engine 2 gives out then engine one does the same. Protocol was for them to loose 6,000 feet of altitude after engine 2 quit to make engine one more efficient but again it too quits within 2 minutes now that extra 6,000 feet or more is exactly what they need to increase glide time and at least give them a fighting chance to make it upon land.
Perhaps, but they did not realize the fuel gauge was the wrong one and was giving them a false reading. They focused on restarting the engines rather than feathering and gliding. They followed the manual to the letter.
I always get mad when passengers don't follow cabin crew instructions and they end up in a bad situation. But in this case, some were bad and good like the guy and that lady got their seatbelts off and inflated the life jacket.smh
We use a dipstick to verify the gauges for small aircraft. Many pilots I know do that before every flight. Airliner's don't do that. They had gauges saying they had fuel and were supposed to have received enough fuel.... Almost every airline pilot could be surprised by this indication of adequate fuel while the tanks were empty. Btw... Fuel is lighter than water. The fault goes to the mechanic who put in the wrong gauge.
It's criminal that airline manufacturing corporations and airline corporations always find excuses to blame the crew! It's sickening!, If there is nay truth to the investigation the story should focus on the mechanical errors and those who were responsible. It's not truthful to compare one theoretical simulator test and use it to crucify a heroic crew. Any pilots unions to defend this crew?? Always always always corporations try to blame crew- it's disgusting! Statement that the captain faces criminal charges is a result of sue you soon mentality! Pointing fingers (however misguided) can't bring back Pax lost. more emphasis on Passenger cooperation would also be helpful.
Its unfortunate that the pilots were not thinking about their plane as a glider once they lost both engines. Its one thing to try to restart the engines once or twice, but to just keep trying it over and over hoping that this next time they're going to relight, that was a critical miscalculation on their part, at least that is what it seems like to me. Wrong to send them to prison over it - it certainly wasn't criminal negligence on their part. If anyone should have been held accountable, it should be maintenance for installing the wrong part and thinking "well that should work".
Do commercial aircraft have a manual way to check fuel? As part of my preflight I had to dip the tanks and the internal bladders had a sight gauge I checked
Want to see more Mayday: Air Disaster Episodes in full? Watch them here: ruclips.net/p/PLiXVS8S6-YAUBts83-WRHLjn1DCSSNcjb
J
T
He,they,them,her...whoEVER SAID ANYTHING AT ALL..1/2 ISNT PROBABLY HEARD " in the moment " there's no dress rehearsal 4 death. No rewind..no pass go, collect 200 dollars.
...in the moment each individuals mind is DIFFERENT..
hearing seeing smelling and whatnot.
The coulda,shoulda,woulda...
Amounts to ZIPPO.
GOD BLESS EVERYONE SOUROUNDED BY TRAGEDY,LOSS,AND PAINFUL ,HURTFUL, NEVER EVEN DISCOVERD FEELINGS U never knew u had.
I can go on but g.bless and to those...R.I.P.
....AMEN .
AND happy holidays 2 all who took a few moments out of your busy life to comprehend what I'm trying to express.
..j.bibeau❤️
Holy mother of Christ ❤️
@@edwinagonzalaz7449 m
Always feels good when I see the actual passenger talking.
The only good spoiler ❤️
his girlfriend died😥
Yo same. I'm fascinated by crashes but I always love to hear survivor stories.
and when they don't talk about the pilots in past tense.
The best episodes are the ones where everyone dies
Don’t inflate life vests until outside of the aircraft.. 100 percent correct
Scared me when they did that! It’s a good way to get trapped in the sinking plane
ppl dont think , they panic
There’s great research on that topic - it’s never even close
I just keep my T-Rex suit inflated the whole flight.
plus he undid his seatbelt also a no no
I think it's ridiculous that the pilots were criminally charged and sent to prison (The episode doesn't mention it, but both served roughly 3 years). They were heroes who saved a lot of lives. They may have made some mistakes, but those were not crimes.
You're right, that is messed up
Absolutley, what an abhorrent miscarriage of justice.
Basically they were charged for being competent but not Sully-level competent.
I wouldn’t send them to jail…but they were guilty and had to be held responsible for their passengers…there are checklists for a reason. Procedures. I hate them too, but they’re there for a reason.
@@samueldocski4426 I can understand firing them and revoking their pilot's licenses for not following proper procedure in regard to the fuel slip. I just don't think they should have gone to prison for it. There was no criminal intent.
I don't know if it got cut off or if there's an alternate, longer, version of this episode. But there's a missing part of this episode where it adds onto the simulator investigation. It explains that yes, the plane could have made it to Palermo if the simulator pilots knew to feather and glide immediately after flaming out. But if the simulator pilots were instructed to go through the procedure to restart the engines multiple times, just like the crew did in real life, none of them would've made it to the airport afterwards.
20/20 hindsight is a wonderful property to have. You always have more info than the actual situation had at the time.
The bottom line is that the wrong piece of equipment was installed which caused the entire disaster.
The crucial piece of info that is missing in 20/20 hindsight investigations is the actual pressure that the pilots experienced at the time.
Excellent video.
In hindsight yes, the fuel gauge did cause the crash. but also taking off without the fuel slip played a major part. I would never take off without a fuel slip and they shouldn't have either. On the other hand the pilots did everything they could given the situation at had. If only they had just told the ground and ATC that they can't leave without that slip it would have been a very different story.
Also, when the pilot asked about the fuel slip he was told they’d get him the slip when he got back. The controller didn’t say he didn’t have any record of refueling.
@@lisabraun2659 Yes, that answer made the pilot think that the plane was refueled, not that it may have been refueled.
I understand, however we train pilots to deal with this and must hold them to superhuman standards because so many lives are at risk its the same with doctors and should be with police officers...."letter of the law" pilots follow procedures exactly as they are laid out and do not deviate, because they know these procedures have been painstakingly developed and they also know following them will absolve them of any sort of critisizm or culpability if something goes terribly wrong....no way of knowing what leaving without a fuel slip would mean, but seasoned pilots will tell you it doesnt matter, that every procedure is there for a reason and you follow it. Also, knowing the optimal glide speed and procedures to decrease drag during a glide are basics functions that would not only be in the procedure manual but are also vital pieces of data every pilot would have prior to flying that specific plane...I am not saying we should prosecute this particular pilot criminally, but knowing the mistakes he made in a dire situation and putting emphasis on these mistakes will ensure future pilots dont make them...also think it was important to point out what he did great, which was the nose angle on landing being spot on takes considerable talent and simulator practice
As soon as BOTH engines went out, it was pretty obvious it had to be a fuel problem, two engines don't just fail like that at the same time from some mechanical issue, first thing I thought was the idiots ran out of gas and I was right, it's not the first time, another of these videos a jet ran out of fuel because some idiot on the ground forgot to convert from one system to another- gallons to liters or pounds to KG I forget what it was, so the jet had HALF the fuel it was supposed to have.
Why don't they have sim pilots go in to the scenario completely blind, or at least have half of the sims done without any briefing? That way you can see how much of a difference the human factor made. You can't simulate an emergency if you know it's going to happen.
fantastic point, not a bad idea to make this the norm for accidents like this, or even for training pilots in these situation
That’s how sims are done
It's like you read my mind.
Exactly The simulator pilots already knew they were out of fuel so that's an unfair advantage on what should have been done. And now that I wanna bring the pilot up on charges like he intentionally killed people smh
I agree
"They said put your seatbelts on and don't inflate your life vest, so I toon my seat belt off and inflated my vest."
and the guy also did the same to his girl-friend and blame others for her death.
Excellent! Way to follow directions!
Good point.
And, wasn’t he a police officer?
??
Ah yes, ignore the flight crew. That should end well. Think about it. It's basically an rubber tube of air. It has no support structure. It will not prevent your neck from breaking. Do not inflate it in hopes it will protect you. Your seat belt is there to prevent you from slamming into the seat in front of you. Pretend it's a car accident, seatbelts save lives. The seatbelt keeps you into your seat for the collision. When things are moving slow enough or stop, you unclip your belt and swim out of the plane, only when you're free of the plane do you inflate the vest. That being said, it's no replacement for being able to swim. The ability to swim is helpful when clearing the plane.
In a sick way the wings floated due the lack of fuel. So lucky for the survivors.
Yes, the pilot left without the fuel slip - but pilots are also under immense pressure and timetables. If he had decided not to fly because of the missing slip, and then that slip would later appear, he would've more than likely faced a penalty for the airlines. At the end of the day, a bad design decision (letting the parts just be interchangeable) and a bad maintenance decision (installing an incorrect part) was the cause of the accident. The crew did the best they could and the pilot *did* manage to land the craft in a way that allowed for some passengers to survive.
To place the pilot under criminal charges here seems like a move (by various bodies) to make sure the carrier is not 100% liable, which, evidentially, it is; by also charging the pilot, the carrier and manufacturer c were probably able to limit their liability and loses in the courts.
The perfect simulation about having been able to make it by gliding was also very suspicious. IMO it was probably part of the effort to shift lame unto the crew and away from the carrier and manufacturer.
I agree, they should of flown another similar plane and shut the engines off and see if it could glide for 70 miles. But they did not do it because they knew it would drop in to the water again.
I agree 100% most airlines tend to value time over safety and honestly I'd rather be late to a destination than dead. Also its sad that they always put full blame the piolets when its also a management, maintenance, and manufacturing issue too.
It seems the captain was targeted or used as a Satanic sacrifice to gain publicity on senseless deaths.
I know, especially since the mechanic is the one that screwed up. The captain did everything in his power to save those people and his plane based off thinking he still had lots of fuel. He still landed amazingly and many people did survive. He shouldn’t have gone to jail. It wasn’t his fault.
people are missing the point. it is better to be alive and whole, than to be adjudged culpable, and in jail. I don't care about a time crunch--,and I've been under time crunches--, RUSHING usually DOESN'T end well. It would ALWAYS be imperative, had I been the Captain, that I feel comfortable KNOWING that EVERYTHING was done ACCORDING to the proper procedure, BEFORE I attempt to fly. people seem to forget: A plan is NOT akin to a leisurely car ride. One can put off car refueling--, a bit, --until the next gas station along the highway. There's NO refueling stations, for aircrafts, in the sky!!! That was a life-or-death situation for the passengers, and HIS FLIGHT CREW. The Captain and copilot were ultimately responsible for ALL the souls on board. They are culpable, and they were wrong. If the departure is late, it's late. The Captain sure wouldn't want to tell mechanic that the plane was refueled, so, WHY did he ALLOW an improper procedure re the fuel form, KNOWING THAT EVERYTHING can be, and is, recorded and/ or noted. It would be found out, anyway. The airlines live to deflect culpability. The planes, in general, are seemingly ALWAYS delayed, plenty , ANYWAY so no excuse...get the fuel form!!! As a Captain or a copilot, I would NEED to see the fuel slip-- double-check it!!-for my OWN peace of mind, and life; one IS flying a plane, after all!
As a yacht Capt for 30 yrs I always knew that the buck stopped with me, whether I was at the helm or not. And having incorrect data from your instruments can cause a chain of events with bad decisions, and one little fuel slip would have changed everything. I feel really bad for the Capt on this one.
Captain Lee?
@@UCCJGUY No, Im capt Greg, out of Ft Lauderdale, but thank you for the comment.
The captain acted imperfectly to the situation, but I don't think he did wrong. they were basic human errors, and I doubt many would do much better in such a situation.
I agree. He reacted to the information he had on hand (which included faulty fuel gauges). I'm sure had he known he was out of fuel he might have chosen his next steps differently. It was an impossible situation caused by a series of errors. Human systems are often complex and small breakdowns can lead to disaster.
@@johnchedsey1306 You're right up to a point. It's his job not to make mistakes, but... Had he realized there really was no fuel, he wouldn't have wasted time trying to restart the engines. Still, those props would have been feathered if they followed procedure. But it's always easier to evaluate flights at 0 knots and 1 G sitting in the living room.
@@evanwindom3265 so true and these pilots start to develop complacency after flying time and time again. Throw in some technician installing a similar but wrong part for the aircraft and you have a recipe for disaster. Not to mention these airline companies are that want don't want planes grounded for fear of losing money. That puts more pressure on the pilot and the ground crew to take off without something like the refueling slip in this incident. Undoubtedly hard lessons were learned here let's just hope they're never forgotten.
@@evanwindom3265 I get it but 10 years of jail time seems a bit extreme, but that's just me!
From what I could tell, it wasn't that he acted imperfectly to the situation that ultimately got him charged, but rather not getting the fuel slip checked, and by extension breaking the law by flying his plane in the first place.
Dude killed is fiance by unbuckling her seat belt and setting off the life jacket.
You know people heard him say that and were like "This works. Seatbelts obviously don't."
He probably saved his own future too though, planning marriage after only one year of a relationship, yikes, you know that's gonna end up in a world of troubles.
@@ChristopherGray00 been happily married for 21 years to a woman who I got engaged to 7 months after our first date, sorry you picked the wrong partner.
@@andrewfidel2220 good for you, that's not the case for most people, very naive move to marry someone you only knew for 7 months, go to the casino because you're a lucky man.
@@ChristopherGray00 Shouldn’t have been at the cost of her life.
As always. When possible find a way to blame the pilots, seems like that's investigators favorite thing to do. Some of the things they say are good in theory but when your actually in a real life situation with tons of stress it doesn't happen that way.
You're right about actually being in the situation at the time and the stress and confusion involved, but he did blow through the refuel slip, against policy, which led to the crash. And then he again didn't follow procedure and check out the gliding procedure. But guess what? Bad things happen and people make big mistakes and that's how it goes with us people.
Fuel slips !!!!!!!!
They have to so future pilots will learn
@@jimhere01 The only error I see is the fuel slip. Even so, he didn’t check it because he believed he had more than enough fuel to make it. As for the gliding procedure, he didn’t follow it because he believed he still had fuel and they attempted to restart the engines til the last minute. This is Sully all over again… just because it’s possible in the simulator, where the person flying it already has a head up and knows exactly what to do, makes it to land, doesn’t mean it will in real life. You have to take into account the human reaction and thought process. They were trying to do the same with Sully, until the decided to give a couple of seconds to count for the thought process and human reaction, which at that point, none of the simulation pilots made it to land.
He wasn't in a situation with a ton of stress when he peaced out before getting the fuel slip.
Thank you for posting the full episode instead of half. 😊 😊 😊
It's absurd to think the pilot was intentionality negligent... I mean his life was at stake as well.
Amazing Episode. RIP to all the victims. Land on Water is something Very Scary.
Changed many many many FQIs on aircraft. The first thing is supposed to be a "Power on Defuel" which ensures ALL fuel is "sucked out of the aircraft," for "Low Side Cal." Then the FQI is calibrated to zero. Then refuel to full capacity and calibrated again, "Hi Side Cal." I'll bet they were "too busy."
Literally drain/refill the fuel, or supply the indicator with signals that it would get if there were no/full fuel?
Pilot and Co pilot both got 10 years of jail time which is absolutely ridiculous in my opinion. Apparently charges of manslaughter and "praying during emergency" which I think most of us would do during emergency. Basically the court was completely convinced that they should have made it to land but it seems like it would have been near impossible if in that situation.
Was that the only contributing issue, though? They also chose to go ahead with the flight without getting a refueling slip, and didn't confirm the fuel quantity. I can see how a court would include that choice (which was taken in a calm moment, rather than under crisis) when deciding their culpability.
@@jakual339 But did they really deserve prison time for that? I can understand revoking their pilot's licenses for not following proper procedures in regard to the fuel slip, but prison? That seems a bit much. There was no malicious intent or depraved indifference to human life on their part. It just seems like the pilots were made scapegoats because someone had to take the fall for an accident with so many deaths.
@@TheStapleGunKid Personally? I would say no. But I admit that I know much less about it than the jury in the case would.
Fuel slip. 10 years for a fuel slip.
@@TheStapleGunKid It seems like certain countries have a pattern of locking up and unjustly punishing pilots for air disasters. Also ship crew and other transportation professionals for other accidents as well. I agree they are frequently made scapegoats and it seems quite prideful.
She's like the only flight attendant that was unhelpful.Most are heroes to the end. Strange how the tail section passengers survived and yet the cockpit in front where pilots survived too..Ditching is def the right name for it.
I cringed so hard when homie said he inflated his life jacket inside the plane to soften the impact 🤦♂️🤦♂️🤦♂️
yeah....not the brightest idea
And he took off his seatbelt...... yikes, its like a "how to" for getting killed.
As$$hat caused his own injuries and killed his fiance by his departure from instructions.
And then they showed him also inflating his fiancée’s, even after he was reminded not to!
I wonder if his taking off Paula's seatbelt and inflating her vest too might have contributed to her death :/
That guy actually unbuckled his own seatbelt as well as his girlfriend's!? How foolish. And didn't listen to NOT inflate his life jacket? He's very lucky that he was just knocked unconscious and spitting up blood. Meanwhile, who knows if his girlfriend died because of his actions.
yes, it is so easy to puncture the inflated life vest during impact or while exiting the crippled aircraft.
@@janandnaomi2000 Or get trapped underwater if the plane fills with water quickly and you are floating above the exits.
I hate to say it but I'm sure his actions absolutely played a part in her death.
So sad always sad when a child dies sigh 😔 poor babies my heart is with you all God will give all children a second chance at life again in the new world sleep well my sweethearts
Yep, there’s always the ones who think the know better than decades of research and testing. It’s very possible that she drowned because of his stupidity. I’m surprised he even appeared on this show.
Sometimes it seems as if maintenance doesn't get the gravity of the situation. There are lives depending on them getting it RIGHT! Quality control isn't always there, or tape gets left on etc...half the time I'm shaking my head at these guys. I know it's easier watching from home but sometimes it really is that simple.
Sadly a lot of the time maintenance workers are poorly paid & even poorly trained depending on their job title. When those who keep the planes flying SHOULD be fairly paid & highly trained! The further back you go in time the worse these issues become. Now things are better…in most countries & airlines at least. Another reason to think twice before taking small budget airline flights.
I don’t blame the pilots! It was the maintenance crew that was responsible
I feel the same way
The final report came to a different conclusion.
They didn't follow the checklist!
It takes two to pull the wagon
Wrong. Mistakes are human and inevitable. That the gauges for the two variants fit exactly the same is unforgivable on ATRs part. Automakers have figured out how to use poka yokes, airplane makers certainly should be doing so as standard. On something as safety critical as an airliner fuel gauge, the human factor should be designed out from the very beginning, as much as feasible, and this example is more than feasible.
As a former professional skydiver who has come through some close situations both while in and out of the aircraft, that one guy has some pretty horrible survival instincts
I know. Survive the crash first (keep your seatbelt on) THEN worry about escape.
@@zorakj the life jacket..the seatbelt..the bracing position… hoenstly i dont know how he survived. Dont get me wrong im glad he did but its just sad that some passengers are that stubborn and arrogant
But he made the choice for his gf taking off hee seatbelt and deploying her jacket and she didn’t make it. He did what he thought was best in life and death but I can’t understand the reason behind that thinking.
I WANTED TO MAKE A A CARRY ON OUT OF A PARACHUTE PACK.
@@ronniewall1481 🤔... pretty good idea after watching all these lol. However you likely can't use it without depressurizing the plane and killing everyone else.
It seems like the pilot is a catch-all scapegoat for any and all problems on the plane, after a crash or otherwise. After a crash the pilot is either an _instant hero_ or a _terrible monster._ there is no in between it seems.
Hope this has served as a lesson for aircraft manufacturers NOT to make different aircraft parts look too similar!
I know right? How hard could it be to just print some big letters that say the plane the part is for on it?
They can look similar, but they shouldn't fit.
@@janandnaomi2000 Ding! Ding! Ding! We have a winner. SOMETHING about the installation should be different enough to prevent the mistake. I realize the airlines try to reduce variation in order to control costs, but something as simple as different pin-outs on the connectors would be sufficient.
also dont make the part numbers so similar that its easy for someone to confuse them. you would think that's just common sense.
@@thequake180 SOUNDS LOGICAL. WE USE TO MARK STUFF AS WE STOCKED IT TO PREVENT ISSUES.
This accident was just a tragedy of small mistakes that compounded into 16 people dead. I don't think anyone should've been charged (the pilot should've received only minor sanctions for departing without a refueling slip, but something tells me that was just a thing pilots would do in that airport), because that discourages people from telling the truth. The pilot made mistakes, but he was never told by the checklist to "maximize glide while restarting both engines". He didn't know that the fuel gauge was not only the wrong one, but that the wrong one can have bad readings. And considering how he left Tunis without a refueling slip, that must've been an occasional thing done there, which is more an indictment on the airport culture.
The fact that ATR had the exact same shapes for both fuel gauges with only a tiny number to differentiate, and that they could actually be connected to the wrong plane is shockingly bad design.
I wonder if that's a standard line of gauges from the original gauge manufacturer too, which they all build to fit in the same socket, so they don't have to have a large inventory of different sockets. If it was custom built, each gauge might be made to fit only in the correct socket, or at least have some kind of electronic matching part verification which would, say, flash a code on the display if it's installed in the wrong plane.
I disagree - airline rules are in place to save lives (and provide redundancy) and he should not have departed until he confirmed that the plane had been refueled. I don't care about his heroics at the end - had he insisted on seeing for himself the refueling slip, 16 people would have lived to see at least another day!
It makes you wonder how many times pilots take off without that slip
And the Same color too!
So pleased when you post one that I have not yet seen like this one... Thank You!
I'm curious did the glide tests done afterwards actually take into account both the pilots estimated fuel level and the actual fuel level? Thats a large weight difference
That's a good point. Probably why they gave up on the idea so quickly.
Interesting --- so you're saying they might have made a different decision if they knew they were actually 1800kg lighter? Great point. It would be interesting to see if the same flight in the sim would yield the same results with another 1800kg of aircraft weight, or if the manufacturer's glide data includes fuel loads. Good question, anyway. You should see if the NTSB is hiring. :)
Thanks! Yeah, my toughts are that 1800kg drastically changes your glide range. Potentially causing the pilots to discount the idea to glide to safety. I wonder if that planes has the ability to dump fuel.
@@varunvarshney When I said dump fuel, I also meant jettison. With it being a customer option on a handful of planes, I wasn't sure if it potentially had the ability or not.
I hate when they blame the pilots. They only tried to save lives not to destroy them. Its easy for those who've, maybe, never been in a life or death situation to judge those who were in that situation. Would it have been better for the pilots to attempt to glide all the way only to possibly crash on land and have more loss of life? The nerve of some people
not only that i bet you if the pilots knew they were low or had no fuel they would have glided to land
I cant imagine drowning like that, man its scary to know what people have gone threw RIP to all those. You cant breath you know your about to die its hard to think and all you can think about at the last second is not having air and blacking out RIP angels
I thought it was interesting that when talking about test pilots attempting to glide the aircraft they never mentioned how many tried but it was in plurals, however it was only a single pilot who was actually able to do it.
I was rooting for the pilot most of the way until I found that he took off without the refuel slip, and he was the last line of defense to prevent just what happened.
On one hand...yeah, not getting a refueling slip and maintaining that paper trail is kinda important. On the other hand...there's a _lot_ of paperwork involved with every aircraft. I don't know how common it is to just miss a slip here and or a page there, but I doubt it's completely unheard of and there's probably some kind of procedure for getting a plane's paperwork caught up to handle this sort of thing.
And one then has to wonder how many such minor slips occur that don't involve a crash. Think about it, if the plane hadn't crashed because of a wrong part, then how much weight would that missing slip really be given?
True but the mechanic is at a bigger fault here...
He should have noticed the before and after FQI installation fuel quantities...
The after installation fuel quantity should match the before...
There was such a big mismatch...it was a clear red flag !
@@nightrunnerxm393 Well... the wrong part is why it looked like fuel had been added. No slip would be expected if the right part had been in there, showing the same fuel level as what the plane had been left with before the repair. I think.
@@Abhi_upstate_ny
You hit the nail on the head. The pilot is reasonable to believe that fuel might be added & a slip missing (though it shouldn't happen).
The mechanic knew what they were doing & knew to check the displayed readings after to confirm that the repair is behaving as expected.
There also has to be a way to independently verify the actual fuel present, aside from the gauge & it's standard practice to always calibrate/check new measuring devices to verify its accuracy.
It's not exactly unusual for measuring devices to not give accurate reading after install. It's why we have standardized independent methods of verification.
Like if they had just bothered to fill the tanks completely for the initial trip, they would have known immediately that the gauge was completely wrong.
If anybody had double checked the measurement, if the pilot didn't overlook the missing slip, if the mechanic had done his job with any professionalism, etc. this wouldn't have happened.
Any number of practices could have prevented this, heck just making the serial number match the model or not wholly mechanically interchangeable.
The pilot was the last one of defense, but the mechanic & manufacturers were the ones who didn't do their job without defense.
Like I said it's easy to miss a piece of paper, but a lot harder to ignore the core manual /rules of maintenance & design.
Hopefully, pilots will be a bit more careful about ensuring they have actually dotted the I's & crossed the T's. They truly are the last line defence against such.
Frankly, I want more legal protections for pilots that refuse to fly for any safety concerns. Right now, pilots are pressured to fly regardless of the circumstances & if they refuse, will likely fired.
I want to see companies severely fined if they don't accept the pilots refusal. I also want rules about pilots not being financially invested in the company owning the plane.
If a pilot sees their own financial future being dependent on the company's success; they are more likely to be willing to bend rules & take risks they shouldn't.
Pilots should have 1 single priority & that's safely flying wherever you are going. Nothing should be higher on their minds than the safety of all aboard. Even if the company loses money, safety is what matters.
If I had a meaningful way to determine which airline is actually serious about safety over money; I would only fly with them, even if it was a much higher cost.
Unfortunately, it's not that easy to determine & actual cost is seemingly completed disconnected from commitment to safety.
Unfortunately, it's the bad companies that are most successful because it's cheaper not to bother with the hard work & just keep good insurance.
While good companies often destroy themselves trying to compete with the uneven playing field.
It's frustrating, I wish there was independent bodies who verify that the company keeps the strict higher standards & thus justify its higher cost/why customers should choose them.
@@adambartlett114 all excellent points !
I would not blame the manufacturer here as it is in their interest to keep the mechanical design of parts same in the two models...that reduces their design efforts and thus reduces engineering cost...
They should have made a different connector or something for the two different models....
Also I feel that no fuel should be added without crew's knowledge... captain has to be there to sign off during fueling !
As they said it was a chain of flaws which caused the disaster.... unfortunately it's always the passengers who have to pay with their lives Everytime !
Finally a new episode and actually a new kind of problem. The company that makes the fuel gage should not make the instruments not compatible through software.
I kinda hate that they gave the pilot jail time over this. He did the best he could with the information he had
He also broke protocol by taking off without confirming a refuel due to the missing refuel sheet. If he had followed protocol. He could have saved a lot of lives by not assuming and taking off with less fuel than needed for the entire trip. So, yes... he is also responsible for it. Not as much as the idiot who installed the wrong model fuel gauge but that's why they have so many fail safes and checklists for everyone to follow.
@@OS10100 its also the person fault too that did the guage
@@tylerxic3241 and that's why they were sentenced equally harshly as the pilots. it wasn't just the two pilots, everyone got about a decade with the least being 8 years.
As other commenters pointed out- the people in the sims already knew what was happened and they had 150% of the information needed to glide to land. I do fault the captain for ultimately not knowing/confirming fuel on board
It is partially the Captain's fault for taking off despite no refueling slip being present, but also I can say that schedule doesn't give them a whole lot of time to confirm that. Altogether it is the manufacturer that built the fuel gauge and engineer that installed it. The manufacturer for making both models look the same causing confusion and the engineer for not checking the models of the gauges
One sim pilot got to the airport, but did the others anyhow? A ditch closer to shore could have gotten help sooner. In spite of trying to ditch near the boats that were seen, no boats were in sight once the plane was down. So that didn't help.
I would insist that pilots get all the time they need for preflight because it's about SAFTY NOT GREED . Adding resources for stopping error, and being accident free is the goal. Not endangerment caused by mistake or greed to rush everything.
If I was running an airport and I caught a plane company rushing the pilots over money I would make it a point to drag them in frount of the FAA and GROUND THEIR FLEET UNTILL THEY CHANGED THEIR ATTATUDE.
Greed and safty don't mix . Period.
@@cynthiarothrock4255 You are so right! As a former airline pilot, I can attest to the fact that crews are definitely rushed to make that on time departure. A quick turn at an out-station is supposed to be done in less than 30 minutes...depending on aircraft type of course.
@@SeekingTheLoveThatGodMeans7648 That's a good question. Surely, when they're running simulations, they should be trying to establish whether a typical, well-trained pilot would be able to succeed, not whether the best pilot performing at the top of their abilities is able to succeed. Especially when the end result is criminal charges.
Finally a new episode for me. Was getting tired viewing a show, from what ever channel, only for it to be a familiar seen episode.
Investigators: he was a great pilot
Also investigators: he sucked as a pilot
I have been fascinated with these episodes regarding aircraft disaster and have noted that the safest place is at the rear of the aircraft. I don’t know why I always gravitate to the rear when I fly but maybe my senses know best. This is the 3rd or 4th episode where survivors sat at the back😯😯😯
I've never been in a plane but just from watching these mayday's I've learned the best place to sit if I ever do board an aircraft. THE REAR... ALWAYS SIT AT THE REAR OF THE PLANE...
@@thomaskimparker809 or even where the wings mount to the plane
The safest part of a plane is any seat that's still on the tarmac .
Tenerife?
Yes, and aside from first and business class, you will usually be one of the first groups boarded.
The only plane I was ever a passenger on, was a bush plane that took off from the lake and landed on it.
It was pretty cool, but of course a much smaller plane and built with that purpose in mind.
My heart goes out to the victims and all the loved ones they left to grieve them. 🕊
You cant blame the Pilots, it was the person who replaced the wrong Guage...
You could easily blame the captain or maintenance but an argument needs to be made here for the manufacturer. Who makes the model numbers so similar for parts that look exactly alike but could cause that large of a miscalculation? lol
Agreed, horrible engineering by the manufacturer. It was only a matter of time before someone somewhere in the world made this deadly mistake. This mistake was completely predictable, and thus the blame falls on the manufacturer.
The manufacturer should have been sued. Definitely at fault for making the gauges similar so that can easily be used and causing death 💀 in a matter of minutes.
The imperfect claiming to be perfect judge the imperfect afterwards.
Given the situation, I don't think the pilot should have been charged. He did the best he could with the data and knowledge he was given. To expect him to be able to know what was wrong with the plane mid flight while falling out of the air is ridiculous. He followed the checklist for the issue he faced, and when that failed, he made an amazing water landing.
He wasn't charged because of how he flew. He flew as was expected of him. What he did wrong was take off without the fueling slip. Even if your plane doesn't crash, you'd still face some repercussions for that.
I'd like to know how the charges turned out
Piloting while Muslim...
@@alis05.....he was charged on his own country.....this wasent in the us.....
@@patrickgardner2204 who's talking about the U.S.? He was charged in Italy actually.
The safety instructions are there for a reason. You don't know better than them. Drives me crazy that people don't follow instructions and then act shocked that it didn't work out.
You know it's not gonna be good when the passengers mom has to be interviewed 😐☹
Excellent.🤔. documentary well done keep making quality documentary like this.👍.
Thanks for the upload; one of my favorite shows🌞
I still believe that what the pilot did was best
People: "Why did the plane run out of fuel ?"
Airline: "Well, you know, fuel is pretty expensive these days, so... we didn't put much in" 😂🤣
They rolled around to the pumps and said "put in $5".
@@riordandennis2389 hahahaha !
I realize that hindsight is 20/20, but the first 2 steps for engine out procedure checklist are usually 1) select a suitable landing site and point the nose in that direction and 2) pitch for best glide speed. This was drilled into me as a Student Pilot. It should be the same on any plane from a Cessna 152 to a Boeing 747.
A recurring theme in many of these accidents is that pilot experience doesn’t always correlate to good decision making.
Please pay attention to the in-flight safety briefings and study the emergency exits of the aircraft. Furthermore, let this survivor be an example of why you should show respect for these safety procedures and don’t minimize or disregard them because you think they don’t make difference or you think you know better than a highly trained crew when you really don’t.
Bro, let this SURVIVOR show you to not do as he did. Do you hear yourself? Lol. How many people didn’t survive that DID follow the instructions?? I bet most!
@@anti-ethniccleansing465 I hear myself just fine. If someone jumps off an overpass into a freeway of traffic and survives I’m not going to make the dumb conclusion that’s it’s fine to follow their example because “hey, they did it and didn’t die”.
@@OneOkami
Hahaha what a terrible false equivalency example. Too funny!
The Italian inspector is charming. I love how he speaks English, pronouncing all of his ed's as a separate syllable. It's absolutely Shakespearian!
I watch-Ed the video with interest. Yes; The inspector was quite a charming fellow.
Very tragic. I like the looks of the plane though. Thank you for sharing!
So many crashes caused by sloppy maintenance quality verification
Total agree, that a bad wether
Unlike most mechanics an aircraft mechanic has to have all his worked checked by another mechanic that is more senior to him . If that was the case with auto mechanics and auto mechanics were charged if the auto broke down on the road following repairs there would be far fewer auto shops. So no I think the problem was that the two parts were identical except for the numbers on them .
@@bobbates6642 valid point, its small mistake, but it cost lives, air accidents are rare, and most of them have lead to some kinda safety upgrade, this is s tough one, the pilot should not have take off without verification of the added fuel, especially over water, I've flown in and of buffalo dozens of times, there probably 5 or 6 airpots between here and Boston or NYC to lsnd in that scenario.
So sad that people that were the cause of the accident were not held accountable
Mechanics did cause this, but I think the captain could have made SURE the tanks actually were filled completely, not just trust the indicators. I say this because he reported a fuel indicator problem the previous day, AND the refueling slip could not be found on the accident day. So until you KNOW the problem was fixed properly, don't trust the indicators 100% right away. Just sayin.........
with Lives at stake I would have made sure about that slip Before I would have taken off. even at the expense of My Job.... Better My Job Than Blood on My Hands it's How I would have handled it Those Passenger would be My Motivation evertime I take off to any destination
How did the repair person not notice that the fuel level had changed dramatically? I would think on the replacement checklist for any item there would be some kind of record of the reading/measurements before and after.
ah yes, let me just take off both my seatbelt and my fiancés seatbelt and inflate both of our life jackets then blame the pilot for “murdering” my fiancé when I whom endangered me and my fiancé while killing her to just “soften” the impact. smart move, very smart move.
Maybe pilots didn’t feather props is because they dropped to 17,000 ft to try to restart engines , then they tried to restart again therefore letting props remain in position
I think landing the airplane in Palermo would have been a gamble to those on the ground. Pilots are responsible for those on the ground as well. "Might have been able" isn't good enough
It hurts so much to lose a loved one.
Here's the thing though on the glide:
Even though the crew might have made clear cut mistakes (i.e. feathering props) we CANNOT assume the tail wind would have been consistent or can we? Where is the proof of that?
well the crew didnt know they were out of fuel, otherwise yeah i belive they would have glided to land
@@matthewwilson5019 Right right dig it -- I'm just saying that even if they had done so we can't assume they would have made it unless we know more about the headwinds.
@@KingCast65 yup I agree with you, I just don't like how the test pilots knew about things ahead of time
He lost his fiancé, that just made me cry. Hearing the sadness from the survivors opened up the floodgates.😢😢😢
POV of Chief of Fuel Management: "Since the safety of passengers and the crews life are at stake and the consequences be catastrophic if these two part numbers be mistaken for one another, we are going to make the parts itself identical and only differentiate them by 1 digit in a simular number code".
Low Key Employee: "But why make them so simular? That just begging for a disaster!"
CFM: "Because CHAOS REIGNS!"
I'm so excited for this it looks interesting
Just make sure your not on a mayday flight ✈️
This episode is the perfect example of why so much time money and effort is put in to air crash investigations. There's no telling how many lives were saved by fully investigating this one crash And getting the word out about being extra careful about the fuel indicators.
Designing those two parts identical with very similar part numbers was an amateur mistake. I worked as a design/manufacturing engineer for 25 years. I designed parts that only the correct part in the correct configuration could be installed into the product.
"I inflated my life jacket to soften the impact and undid my seatbelt"
Universal groan
“We are in big trouble second engine has gone off” part was so funny. He sounded so calm
This was a sad one. But atleast some of them survived.
The only issue I had was that the pilot didn’t seem to tell the investigators about the faulty fuel gauge replacement just one day before. Why? Perhaps because he knew the refueling slip wasn’t there and he decided to go anyway, rather than hold up the flight for a bit while someone manually checked the fuel levels in the tank. Certainly, it wasn’t because he forgot.
That seemed to indicate to me knowledge of guilt.
Everyone not paying attention to the flight attendants.
The little girl being the only one to know how to inflate it
There is a well known statement that was drummed into me as a young engineer that if a wrong part can be fitted it will be at some stage so ATR should be criticized for not designing the indicator so that the wrong indicator could not be installed.
You can't help but think that he didn't think about that missing refuel slip when suddenly both engines stopped just like they ran out of fuel.
captain's a hero for making the landing and saving as many lives as he did. sounds like the Italian investigators were just saving face for ATR - "identical" FQIs being able to fit in the wrong aircraft. *1* pilot made the landing in Palermo. in a simulator, with hindsight. maintenance should've still been crucified though.
EDIT: oh, mechanic _was_ charged, they did recommend they make the FQIs physically incompatible.
What a praise that some lived it good that the pilot raised the noise when he did it saved lives.
the guy who took off his seatbelt was a police officer he should have known to buckle up
I have a hard time blaming the captain.
Damn seeing that shot of the doll floating under water is heartbreaking
Most of the time its a maintenance issue not following procedure.
Love the videos--i know they are triyig to be realistic, something about kids, there's no need to show.
The smart thing the manufacture of the plane and fuel gauge maker would have done is to key each differently. I am surprised it didn't have a small APU on board. If it didn't start then you know you have a fuel problem. You would think the gauge would have to be calibrated. Last what kind of mechanic installs a part without checking the part numbers to see if it can be substituted. Crazy stuff.
42:58 ...Ridiculous. Feather props, ok; but throw away speed (energy/momentum) just to reach 'optimum' gliding speed is totally ridiculous.
Well, it is a known characteristic of the craft. Was it somehow referred to in the checklist for both engines out? (It would seem logical that it would be.)
You're not actually "throwing away" speed if you do this properly, you're using it to maintain altitude for longer. Without engines, speed is controlled with pitch. Just reduce descent rate (or level out) until you've slowed down enough, then continue the descent at the optimum speed.
@@BJozaty Sounds reasonable, especially the part about going faster means descending faster, which means less time avail to be flying; I think I was trying to find a situation to match up to my crabbiness which made all thought processes grind to a halt. Its a good thing I wasn't flying something at the time... (Still I would want to conserve as much of the initial speed as possible and blend to a lower speed only as that speed was dragged off (which was probably fairly rapid). The 'host' made it sound like he 'needed' to slow down and by not doing so he made some terrible error.) I probably saw this show originally when it was first made and like many of the other 1980s-90s shows out there; quality suffered in retrospect. Now to the point where the plane actually breaks into two pieces, do you think that it was poor craftsmanship during manufctr that caused it to do so or was it some manner in which the Captain landed it on the water's surface or just unlucky physics?
@@CRSolarice Glad I could help explain, yeah the way they said it wasn't too clear. Since the rescuers mentioned it was rough seas I think it was just unlucky that it broke apart. At 47:55 they mention it touched down at the correct angle for ditching so it sounds like he gave it the best possible chance for staying in one piece.
One thing scary about plane crashes vs. Car crashes besides all the obvious, is all the time to think and ponder before hand in alot of incidents.
How tragic that the mechanic installed the wrong part.
I was on this flight thankful to be alive
As a flight attendant I use to feel take offense of the people who would never listen to crew instructions, or listen to the safety demo. Now I couldn’t care less. If you don’t care for your own life, I won’t. I won’t risk my life for yours.
These stories are intense.
5:00 Less than 2 minutes after engine 2 gives out then engine one does the same. Protocol was for them to loose 6,000 feet of altitude after engine 2 quit to make engine one more efficient but again it too quits within 2 minutes now that extra 6,000 feet or more is exactly what they need to increase glide time and at least give them a fighting chance to make it upon land.
Perhaps, but they did not realize the fuel gauge was the wrong one and was giving them a false reading. They focused on restarting the engines rather than feathering and gliding. They followed the manual to the letter.
I always get mad when passengers don't follow cabin crew instructions and they end up in a bad situation. But in this case, some were bad and good like the guy and that lady got their seatbelts off and inflated the life jacket.smh
We use a dipstick to verify the gauges for small aircraft.
Many pilots I know do that before every flight.
Airliner's don't do that.
They had gauges saying they had fuel and were supposed to have received enough fuel.... Almost every airline pilot could be surprised by this indication of adequate fuel while the tanks were empty.
Btw... Fuel is lighter than water.
The fault goes to the mechanic who put in the wrong gauge.
it impossible to do that on modern jetliners
Captain also didn't follow regulations. Most regulations are there due to accidents from the past.
I saw this one on TV.
There should be some sort of backup or manual fuel checks to verify the amount of fuel on board. I'm surprised there wasn't any here!
It's criminal that airline manufacturing corporations and airline corporations always find excuses to blame the crew! It's sickening!, If there is nay truth to the investigation the story should focus on the mechanical errors and those who were responsible. It's not truthful to compare one theoretical simulator test and use it to crucify a heroic crew. Any pilots unions to defend this crew?? Always always always corporations try to blame crew- it's disgusting! Statement that the captain faces criminal charges is a result of sue you soon mentality! Pointing fingers (however misguided) can't bring back Pax lost. more emphasis on Passenger cooperation would also be helpful.
@General Bismarck the captain isnt responsible for what he hasnt done
Its unfortunate that the pilots were not thinking about their plane as a glider once they lost both engines. Its one thing to try to restart the engines once or twice, but to just keep trying it over and over hoping that this next time they're going to relight, that was a critical miscalculation on their part, at least that is what it seems like to me.
Wrong to send them to prison over it - it certainly wasn't criminal negligence on their part. If anyone should have been held accountable, it should be maintenance for installing the wrong part and thinking "well that should work".
Do commercial aircraft have a manual way to check fuel? As part of my preflight I had to dip the tanks and the internal bladders had a sight gauge I checked
It’s so sad that we can see the child having fun and everyone having fun they won’t know what would happened next…….