V1 rotate.
Just seconds after takeoff from Addis
Ababa. GE up. The pilots of Ethiopian
Airlines Flight 302 are faced with an
emergency masssterauution Anti ice.
You're literally fighting to maintain
control of the jet. Stabm cut out. Yes,
yes do it. But the procedure they've been
taught for the Boeing 737 Max 8 doesn't
work. They know what to do and they tryied
to do it. Investigators are astonished.
If the pilots knew the proper procedure
why didn't it work? Boeing didn't say
anything about the trim wheel being
difficult to move.
Could the pilots have been misled about
how to save their plane? They've still
left the Boeing Max unairworthy and it
caused the life of my daughter and 157
people.
Boarding has commenced for 149 passengers
on a short flight from Addis Ababa,
Ethiopia to Nairobi, Kenya. Perfect.
Thank you.
This was really a UN shuttle flight.
There was a UN environmental conference
happening in Nairobi so the there were
about a couple dozen people on the plane
who were headed to that conference.
Ground equipment is removed and engineer
is clear. The captain on Today's flight is
29 year old yard Getichu. The captain
was considered one of the best pilots in
the airline. He had 8,000 hours which was
unheard of for someone that young.
Before start Checklists complete. Request
pushb back clearance. Ground Ethiopian 302
requesting pushback clearance. 25 year old
Ahmed N. Mohammed is the first officer.
Ethiopian 302 you are clear to push.
Ethiopian Airlines was considered the
model airline in Africa. It had the best
run training school and it had a well
oiled system for bringing new pilots into
the airline. They're on a Boeing 737
Max 8 a brand new passenger jet that's
already at the center of a major
investigation in Indonesia.
Five months earlier a Max 8 crashed into
the Java Sea killing all 189 people on
board.
That accident is still under
investigation.
Just before 8:30am Flight 302
taxis towards the Runway at Addis
Ababa'bole International Airport.
Ethiopian 302 cross Runway is 07 left at
Alpha and hold short of 07 right. Cross 07
left at Alpha and hold short. Ethiopian
302 free. Take off checklist
please. Landing lights on.
Among the passengers on Today's flight is
24 year old Canadian Danielle Moore.
She's traveling to the UN summit.
She really astonished us when she
toldaught us that she would be going to
the United Nations Environmental assembly
in Nairobi and she was selected out of a
number of people. We thought this was so
tremendous.
Flight 302 reaches Runway 7 right, the
longest Runway at the airport. Ethiopian
302 ready for departure. 302 Claire for
takeoff. Runay 7 right. Have a good
flight.
Ready. Ready.
Take offff. Thrust set.
Speed increasing.
Flight 302 departs on time.
The 725 mile flight to Nairobi should
take just over two hours.
The Max 8 was designed for routes like
this. It's a short hop, quick turnaround.
Plane also had much more
fuel efficiency compared to the previous
version of the max, about 20%.
V1 rotate positive
rate. Gear up.
Gear up. Less than 10 seconds after
takeoff, the pilots get a stick shaker
warning indicating that they're in danger
of losing lift and could stall. If you
experience a stall right after departure,
it can be extremely serious.
Captain Getachu reduces his plane's pitch
angle in an effort to prevent a stall. If
you are taking off and you get a stick
shaker, crews are going to be hesitant,
you know, to push their nose over because
they're close to the ground.
Massstiveauution anti ice.
Okay,
when master cautions come on. The first
thing is to diagnose what's occurred and
consider what implications it has on the
flight. What's going.
Captain Getachu doesn't understand what's
behind the multiple warnings. There's a
lot going on here and it's a very
distracting, loud environment with a stick
shaker going. Where do you start to
deal with this complex emergency that you
have? Flight 302 is
only a few hundred feet off the ground as
the pilots struggle to understand the
problem.
As far as passengers are concerned, this
is a routine takeoff.
Okay, Contact radar. Captain Gettu decides
to continue climbing. If you have a
problem, the thing you want to do is get
it away from the ground where you can sort
through your problems. Radar Ethiopian
302. Good morning. Crossing 8,400
and climbing to 320. First Officer
Mohammed reports his altitude 8,400ft
above sea level, which is only 750ft above
the ground. Continue climb to flight level
340. Climb to 340.
Ethiopian 302. Flaps up.
Flaps up. Retracting the flaps should
help the aircraft climb,
but it has the opposite effect.
1500ft from the ground, the jetliner with
157 people on board begins to fall.
We'having flight control problems. Don't
sink. Don't think. You've gone from
a series of cautions,
a series of system malfunctions now into a
flight Control problem where you're
literally fighting to maintain control of
the jet.
Passengers now sense that there is
something wrong.
One woman whose brother was on the
airplane and he called her soon after
takeoff he knew something was wrong.
The plane was not climbing the way
aircraft normally do. The 737's nose
continues to pitch down. Trim TR
Captain Getichu uses the trim switch to
level his plane. The trim switch
controls the position of the horizontal
stabilizer keeping the plane balanced
during flight it can be used to adjust the
pitch of the airplane.
Captain Getachu manages to raise the nose
slightly, but not for long.
The plane dips again, bringing it closer
to the ground. Too low terrain and the
pilots are struggling Too low terrain.
Now you start dealing with how do we rec
gain control and to keep the nose
up while we sort through this. And that's
where the time can become critical.
Less than three minutes after takeoff and
only 1 18, 800ft above the ground, the
pilots of Ethiopian Airlines Flight 302
are desperately trying to get their plane
to climb. Pull up.
Okay. If as we maintain 6,500 we have
a flight control problem. They're trying
to reach the minimum safe altitude
surrounding the airport.
Ethiopia 302, we'like to maintain 6500.
We have a flight control problem. Say
again. We have a flight control problem
and we'd like to maintain 6500.
Approved and report intion well, are you
Ethiopia 302. First and
foremost they said okay, we have a flight
control problem and that says get other
airplanes away from me. And that was a
very appropriate thing to do. Set 6500.
6500 set the
speed. As they fight to climb to 6500ft,
the plane's speed becomes dangerously
high.
They try to raise the plane's nose further
to decrease speed. P up with me.
Even with both pilots pulling back on
their control columns, the plane refuses
to climb. The forces necessary to hold
that yoke are increasing and they're
increasing quite rapidly.
Less than five minutes into the flight,
Captain Getichu decides to turn around.
Request a return Vector Radar. Ethiopian
302 requesting Vector back to airport.
There was a lot going on in that cockpit.
There were indicators going off showing a
disagreement in altitude, disagreement in
airspeed. The stick shaker was going off
so the best thing for them to do was to
turn around. Confirmed. Do you want to
hold or make an approach? W to commence
approach turn
rights two six zero two
hundred sixty zero.
The pilots have managed to get their plane
to 6,000ft above the ground. Pitch up
with me, I. The pitch, not the pitch.
But now it starts to plummet. Think great.
Good job. Terrain, terrain,
terrain.
Flight 302 slams into the ground just 30
miles from the airport.
It's the second Max 8 to have crashed in
less than five months. In today's world,
even a single accident is an extreme
rarity. To have two within five months,
it is inconsistent with the level of
safety of modern airliners.
Everyone wants an answer to the same
question. Is there something wrong with
Boeing's latest jet? And we begin tonight
with the Myster swirling around a deadly
plane crash overseas. The new Boeing 737
crashing just minutes after takeoff in
Ethiopia. 157 people were on board
the flight and there were no survivors.
News of the Ethiopian Airlines crash
quickly makes headlines around the world.
The phone rang and my wife answered it.
And I recall hearing her scream and
saying, danielle is dead.
My hearing her shriek and
saying those words was the death
of me too. I died.
This is the last thing that any father
wants to experience.
A team from Ethiopia's Accident
Investigation Bureau is tasked with
finding out why Flight 302 crashed just
five minutes after takeoff. To make a
critter like this, the speed must have
been tremendous.
Much of the wreckage is buried in a crater
more than 30ft deep. You can tell that it
was in a high energy state, that just due
to it creating a crater that it had to
have some kind of angle to it.
The plane's two black boxes are quickly
found.
The Ethiopian government decides to send
them to France's investigative agency to
have the data downloaded.
In Indonesia, the investigation into the
previous Max 8 accident is still underway
as investigators get the news about the
Ethiopian Airlines accident.
First time I heard about Ethiopian Flight
302 crash, I was shocked knowing that
another 737 Max has gone down. The
Indonesian accident involves Lion Air
Flight 610, a Max 8 that took off from
Jakarta with 189 people on board five
months earlier. I was afraid that the
accident was caused by similar issue with
the Lion 610 that we were investigating.
The Indonesian pilots also began
experiencing warnings shortly after
takeoff and also reported having flight
control problems. Following a
series of altitude fluctuations, the
pilots attempted to return to the airport.
The 737 plunged into the Java Sea 11
minutes after takeoff. The investigation
into that accident has zeroed in on an
electronic system known as mcas, the
Maneuvering Characteristics Augmentation
system. It's a piece of software in the
flight control computer that directs the
stabilizer to push the nose down.
Investigators in Indonesia have learned
that MAS was added to the max 8 to
compensate for a design problem. In order
to achieve the fuel efficiency Boeing
wanted to, it needed to put bigger engines
on the airplane. And in certain flight
conditions, the nose had a tendency to
pitch up and that's why MCAS was
introduced. If the system
sensed the plane's nose was pitched too
high, it would automatically adjust the
plane's stabilizer to lower the nose.
Indonesian investigators have determined
that a faulty sensor on the Lion Air
flight led MCAS to conclude the plane was
climbing more steeply than it was,
causing it to activate repeatedly until
the plane hit the water. We found that
there was some issue with the TC design of
the system. There are 387
Max 8s flying worldwide with another 5,000
on order. It's rapidly becoming one of
Boeing's most successful airliners. The
Max 8 was the fastest selling aircraft in
Boeing's history. Airlines were really
drawn to the fuel efficiency. The pressure
is on investigators to determine if a flaw
with MCAS also caused the Ethiopian
accident. There was worldwide attention to
this investigation. The whole team was
under a lot of pressure to get answers and
to find out what happened.
Ethiopian investigators start with the
last people who spoke to the crew of
Flight 302 air traffic controllers.
Thanks for your time. Can you take me
through the flight? Normal tax can take
offff Nothing unusual until 2 1/2 minutes
later when they reported a flight control
problem.
Ethiopia 302 would like to maintain 6500.
When we have a flight control problem.
They asked to maintain the current headed
requested permission to at 6,500ft.
And you approved the request? I did, yes,
sir. All investigators know
is that the pilots had a flight control
problem that developed early and prevented
the crew from continuing the flight.
They're aware that they were dealing with
a flight control issue. It would have been
helpful if they could have identified
which control surface they'having the
problem with.
The team turns to Flight 302's radar track
to understand the sequence of events.
Slow, shallow, climb out.
Now look here. Instead of climbing, they
lose altitude, regain it, then lose more.
Instead of continuing to climb or to
maintain an altitude, there was actually
dips in the altitude.
The radar data paints a picture of a crew
struggling to keep its plane in a climb.
Don't sink, don't sink.
They're trying to get to 6,500ft
but never get higher than 6,200.
They're starting to make a turn back to
the airport. Now they're in a dive,
descending at 33,000ft per minute.
The speeds were at the maximum for this
aircraft. The intensity inside the plane
must have been terrifying.
Let me see the Lion Air track, please.
A slow climb, a series of altitude
fluctuations. I turn back to
the airport and rapid descent.
They're pretty close.
The fact that this plane crashed almost
immediately after takeoff in very similar
circumstances raised a lot of questions in
everyone's minds. Investigators turned to
a key piece of the wreckage for
confirmation that MCAS played a role in
the accident. Pretty good shape. You got
lucky. A jack screw, the device that
controls the position of the plane's
horizontal stabilizer, is recovered.
A ball nut moves along the jack screw to
help adjust the plane's pitch.
5 inches full
nose downt trim. The evidence shows that
the plane went into its final dive because
the stabilizer had moved to an extreme
nose down position.
Full nose down trim is not something that
you ever see in the normal flight of a
737. In the 15 years that
I flew it, I don't know that we ever got
even close to full nose down.
The Lion Air flight is identical. A pitch
trim of 1.5 degrees resulting in our rapid
descent. The pilots wouldn't
do that. The jack screw all but confirms
that Ethiopian Airlines Flight 302 and
Lion Air Flight 610 had the same cause.
A malfunction of the plane's electronic
MCAS system that was literally the smoking
gun that def definitively told them what
had happened to the airplane. There's now
enough evidence to convince aviation
authorities around the world that the Max
8 presents a risk to passengers. We're
going to be issuing an emergency order of
prohibition to ground all flights of the
737 Max 8.
The question now facing Ethiopian
investigators is how could this have
happened again?
These documents came out four months ago.
Following the accident in Indonesia. Both
Boeing and the FAA issued bulletins
advising pilots of the steps to take if
MCAS began forcing the nose down.
The documents advise pilots to follow the
existing procedure for a malfunctioning
trim system and disengage the autopilot,
set the stabilizer trim switches to cutout
and to use their manual trim wheel to
counteract the automatic downward
stabilizer movement. BOEING and the FAA
felt that the AirWortthhi directive was
all pilots needed to be able to recover
from what they thought would be an
extremely rare event.
Did the pilots know about this procedure?
You'd hope so. The airline
has an obligation to train the pilots to
ensure that there is a sufficient
understanding of what the information is
trying to tell them so that they act
appropriately. We incorporated the borring
bulletin into our flight manual.
Were you pilots advised of the revision?
All our pilots were fully breathed. Of
course,
the pilots of Flight 302 knew the
procedure for disabling MCAS. The question
is, did they follow it?
Here it is. Let's load it up. The cockpit
voice recording from Ethiopian Airlines
Flight 302 has been successfully
downloaded by technicians in France.
Okay, let's hear it.
The one. Rotate positive rate.
Gear up. Takeoff rol as normal.
Investigators listen for clues that can
explain how MCAS brought down the plane.
Climb to 340. Ethiopian 300 twoaps
up. Flaps up.
The MCAS system is designed to activate
only when it senses that three conditions
are met. Nose up, flaps fully retracted,
and autopilot off.
That's the autopilot disconnecting. O.
Okay. So now they've met the three
conditions for MCAS activation.
Investigators continue listening for
evidence that MCAS activated pitching the
plane downwards. We're having flight
control problems. We right on here.
He's losing altitude.
MCAS is pushing the nose down.
Up.
Investigators hear the pilots struggling
to trim their plane nose up. So you begin
to get this tug of war between the pilot
trimming nose up and MCAS trimming nose
down. But mcksas is relentless. It doesn't
stop. Tr Tr up.
The team then hears an exchange that
transforms the investigation.
Stab. Trim. Cut up. Stabrum. Cutout. Yes.
Yes. Do it. Stabt from cut out.
Can you pause for a second? They did it.
They set the trim switches to cut out
exactly as Boeing advised them to do. I
think that's the surprise. The crew
attempted to do that procedure and it
wasn't successful. The autopilot
disengaged. We heard the alarm.
They set their stabilizer trim switches to
cut out. Now they need
to manually trim to get their nose back
up. Let's hear Gettch up.
Pitch up. Gettch up. Do with me.
Is the TRM engaged?
No. Shall I try manually? Try it.
The 737 has a manual backup about how to
move trim using cables. And the wheel
has actually got a handle in it where you
can manually trim it.
It's not working on the
pitch. Not the pitch. But the pilots are
not able to adjust the pitch manually.
They don't physically have enough strength
to move the horizontal stabilizer via the
manual trim wheel. They're trying to
do this, but it doesn't sound like it's
working.
And then they come up with a solution that
seals their fate. Put them up.
No. Oh, no. No. Unable to
pitch the plane up manually, the pilots
make one final desperate move. They
reengage the automatic trim to help move
the stabilizer.
Unfortunately, that wakes the beast. And
then it's going to sit there and it's
going to trim it down one more time again.
So it works against them.
Cautioninch there
was no way to control the airplane. The
pitch was going to continue to go nose
down. Rian Terrain terrain.
Terrain by they
knew what to do. He tried to do it.
For whatever reason, it didn't work.
The Ethiopians have made a stunning
discovery, one they quickly share with the
world. The crew performed all the
procedures repeatedly
provided by the manufacturer, but was not
able to control their craft.
STABT TRM Cut up ST STATTRUM Cutout yes.
Yes, do it. Investigators are left with a
burning question. STABTRAM Cutout. If the
pilots did what Boeing advised, why
weren't they able to pull out of the dive
that MCAS put them into? P Investigators
turned to the flight data recorder from
Ethiopian Airlines Flight 302 to better
understand why MCAS was activated,
causing the plane to crash right here.
Ten seconds after takeoff, readings for
angle of attack, airspeed and altitude
begin to diverge. MCAS is only
supposed to activate when the max 8
reaches an extreme angle of attack or high
pitch angle. A sensor on
each side of the airplane calculates the
angle of attack by measuring the plane's
angle into the oncoming air.
Sure looks like a sensor issue. The
captain's side can't be right.
Absolutely. The data shows a steep spike
in the captain's angle of attack reading.
That explains the stick shaker. Yep,
false alarm. The plane
was never in danger of stalling. The
warning was triggered by faulty pitch data
from a malfunction in an angle of attack
sensor. The captain's side shows a pitch
up of as much as 74 degrees. The first
officer s side is correct. A any 15 degree
pitch. Investigators discover the
malfunction was only on the captain's
side. So up until this point, the flight
is actually fine on the Ethiopian
airplane. Something happened to that
sensor just shortly after takeoff.
So one faulty sensor brings down the
plane. A single failure should not be
catastrophic. There should be backup.
There should be redundancy. So if there is
something that occurs within the system,
that the crew should be able to counter
it. The FDR
data can show us when the MCAS activated.
The team studies how MCAS behaved for
Flight 302. Here,
here and here. The plane
pitches down even though the pilots are
pulling up on their control columns. The
faulty sensor led to four separate
activations. Of the MCAS system driving
the planes's nose down as the pilots were
trying to pitch up. The fourth MAS
activation pitched the nose down when the
plane was only 6,000ft above the ground.
It put the plane into a steep and rapid
descent from which the pilots
could not recover.
So why couldn't the pilots disable the
MCAs even though they followed the
recommended procedure? Investigators
examine Flight 302's speed leading up to
the crew's attempt to override the MCAs.
They lift off at 140 knots. Absolutely
perfect. But as they climb, their speed
increases. It reaches 340
knots by the time they try to use manual
trim. The overspeed warning sounds here
and stays on for the rest of the flight.
Normally you would be in the 220,
250 knot range. This was 100 knots
plus faster than that. No wonder they
couldn't move their trim wheel.
The speed increased the air load on the
stabilizer, making it impossible for the
pilots to move it manually with their trim
wheel.
It's not working.
Once you get to high speed, you're no
longer strong enough as a human to move
it.
Why such high speed? Have a look at their
auto throttle setting. They lift off with
the auto throttle in takeoff mode. Right
about here. The auto throttle should be
pulling back from takeoff thrust to climb
thrust. But that never happens. It stays
at max takeoff thrust.
Same sensor I guess. Uh huh. The auto
throttle is also connected to the left
side angle of attack sensor. Once the
sensor failed, that disabled the auto
throttle system, so the power stayed where
it was.
We're having blight control problems. As
they dealt with the escalating crisis,
the pilots didn't notice that their thrust
levers remained at maximum takeoff power.
737s are very powerful jets and they
will continue to accelerate very rapidly
if you don't reduce the power.
Boeing didn't say anything about the trim
wheel being difficult to move or about
air sped. The Ethiopian
investigators now turn their attention to
the advice Boeing gave pilots after the
Lion Air accident. The Lionair flight
had necessitated this airorthiness
directive. So the question becomes, was
that enough? No mention of M Testss.
No mention of how much force may be needed
to trim manually. No mention of Aireed.
That's a lot to leave out. The
investigation has uncovered shortcomings
in the guidance Boeing provided following
the Lionair accident in
Indonesia. Investigators have discovered
that a maintenance error led to the
failure of the crucial angle of attack,
or AOA sensor in the Lionair accident.
What caused its failure on the Ethiopian
Flight investigators
examine maintenance records for any
evidence of trouble. So the Ethiopian
investigation did look into the
maintenance to the sensor. There was none
its original install to the airplane.
They do uncover several other maintenance
issues on the four month old plane.
It's a lot of electrical faults for a
brand new airplane. The Ethiopian team
suspects the AOA sensor on Flight 302
failed due to an underlying electrical for
the sense of failure is also being
scrutinized by the ntsb. We also looked at
how the AOA could fail and what that
failure would look like. That analysis is
coming to a very different conclusion
about the origins of the failure.
44 seconds after they start to roll, this
happens. Captain's angle of attack,
airspeed and altitude values deviate. The
NTSB travels to Collins'aerospace the
manufacturer of the angle of attack sensor
and asks their engineers to look at the
fault Data for Flight 302. Six seconds
later, the heater on the sensor goes
offline.
Massive caution. Anti ice okay.
These simultaneous failures all point to
one thing. Sensor broke off. It's the only
explanation to determine
what could have caused the sensor to break
off. Have a look at this.
They compare the FDR data to data from
a bird strike. They're almost identical.
The US investigation side
felt that the data supported more of a
in inflight impact with the angle of
attack cesor the
hazard posed by eagles and other large
birds is well known at Addis Ababa's
airport. The airport in Addis Ababa had
had problems with bird strikes. The
airport had several mitigation strategies
in place because of that.
D1 Rotate.
Collins Aerospace concludes that as Flight
302 lifted off the ground, a bird struck
the sensor, tearing the vein from the hub.
GE're up.
We were having flight control problems.
Whether the sensor failed due to
electrical failure or a bird strike,
investigators now know why Ethiopian
Airlines Flight 302 crashed shortly after
takeoff. Here's a chain of events.
The failed sensor triggers a series of
warnings and alarms.
Gear up.
The erroneous angle of attack data causes
MCAS to activate. Pitching the nose down.
Don't think, don't think,
don't think.
They do what Boeing recommends and move
the trim switches to cut out. Stab himim
Cut out. Statab him cutout. Yes. Yes. Do
it. Stattrum cut out.
But they're unable to manually trim the
wheel is almost impossible to move. They
never recover.
On m the pitch. On m the pitch. It was
very obvious to them that they no longer
had control of the airplane and that they
couldn't stop. This recovery was
impossible. Good job.
For the NTSB, the Max 8 accidents provided
a valuable lesson about assumptions made
by aircraft manufacturers regarding how
pilots respond to emergencies. I think
these two accidents are going to be the
watershed events on how we look at the
human factors for design and
certification.
As a result of the two accidents, Boeing
overhauls the Max 8'MCAS system. The MCAS
system now relies on information from two
sensors. It will only activate once and it
will not override pilots? S ability to
control the airplane with the control
column. Boeing also offers pilots enhanced
training on the MCAS system.
Many feel the changes Boeing made to the
max 8 came too late.
Ethiopian 302 should have been prevented.
Boeing should have got to the root causes
of the problems on the Lion Air flight.
Boeing didn't. For the devastated family
of Danielle Moore, Boeing's greater
failure was not advising pilots about the
danger of mcas. The Bolton from Boeing was
not good enough to prevent an accident.
The plane was still unsafe and
it caused a life of my daughter and 157
people.
In November 2020, after a 20 month
grounding, the Max 8 is cleared to fly.