WEBVTT

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- [Petter] Aircraft accidents

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are always caused
by a combination

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of several factors and the thing

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that gets the sequence rolling

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is often something
simple and mundane.

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But this is the
first time I've ever come

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across a single letter kicking it off.

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- [GPWS] Sink rate. Pull up.

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- Stay tuned.

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When you hear the word Tenerife

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in aviation context,
people almost always think

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of the world's worst aviation disaster,

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the collision between two Boeing 747s

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at Tenerife's Los Rodeos
Airport back in 1977.

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But the island of Tenerife,

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the largest of Spain's Canary Islands,

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actually suffered a string of disasters

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between the 1950s and 1980s,

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who collectively claimed 950 lives

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and that infamous runway collision

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was just the worst one of those.

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So today I will tell you the story of

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the last major
incident to happen there,

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a story that took place on
a rainy spring day back in 1980.

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And this one, I think a lot
fewer of you have ever heard of.

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In the morning of the 25th of April 1980,

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the crew of Dan-Air Flight 1008

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were preparing to depart
from Manchester in England

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on a charter flight,
bringing tourists down

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towards Tenerife North Airport,

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then known as Los Rodeos.

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During the 1970s and '80s,

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Dan-Air was one
of Britain's largest operators

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of inclusive tour flights,
chartered by tour operators

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to transport fixed groups of people

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down to popular holiday destinations

00:01:35.460 --> 00:01:37.680
in Southern Europe and North Africa.

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Among the aircraft types operated

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by Dan-Air was the mighty Boeing 727,

00:01:43.340 --> 00:01:45.740
and Dan-Air were
actually the first British airline

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to import this model,
which had then had

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to undergo several unique modifications

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in order to
meet British safety standards.

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Now it would later turn out

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that the 727s were a
financial disaster for Dan-Air,

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but by 1980, that was
not yet very obvious.

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The aircraft that the
crew were going to operate

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on this day was 14 years old

00:02:06.660 --> 00:02:08.400
in generally good condition

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and could seat a
maximum of 144 passengers.

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So with a total
of 138 passengers booked,

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it was almost completely full.

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The crew consisted
of five flight attendants

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and three pilots, meaning that in total,

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there were going
to be 146 people on board

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once the flight got on the way.

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The pilot in command was a very

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experienced 50-year-old captain

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who had around
15,300 total flight hours,

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which included almost 2,000
on the Boeing 727.

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He had flown this route
down to Tenerife North

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a full 58 times before this flight,

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making him very familiar
with it in general.

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But as we will soon see,

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being familiar with the
destination doesn't mean

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that it can't throw a few surprises.

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His second-in-command
was a 34-year-old first officer

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who, on this day, had
about 3,500 hours in total,

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of which 618
were flown on the 727.

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And the third flight crew member

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was a 34-year-old flight engineer

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whose experience was similar
to that of the first officer.

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Now all of the pilots had been off

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for more than
24 hours before this duty

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and the scheduled departure time

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was at a very civilized hour,

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so there's no reason to believe

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that fatigue played any role

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in what was soon about to happen.

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Now instead the crew were
likely in a quite good mood

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as they completed their
normal pre-flight activities,

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checking weather,
NOTAMs and flight plans,

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which all looked okay.

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It looked like it was going
to be a very pleasant flight

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down towards the Canary Islands.

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So after having boarded everyone

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and completed the pre-flight set up,

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the crew started up their engines

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and taxied out for takeoff
from Manchester at time 9.22 am,

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with the captain as pilot flying

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and the first
officer as pilot monitoring.

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Now the climbout and cruise phases

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of this flight went off without a hitch,

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but the pilots then
likely started preparing

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and briefing for the approach

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a bit earlier
than usual on this day.

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And that was because
they had seen,

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during their pre-flight briefing

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that the approach
they had ahead of them

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was possibly going
to be a little bit unusual.

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You see, in the Canary Islands

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the prevailing winds normally blew

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from the Atlantic Ocean in the west,

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causing most flights to approach

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from the east using Runway 30

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in order to land with a headwind.

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But on this afternoon,
the wind was instead blowing

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from the other direction, from the east,

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forcing inbound aircraft to approach

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the reciprocal Runway 12 instead.

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Now we don't know how
many times the captain

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or the other crew members

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had actually used
Runway 12 in the past,

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but it was likely not something
that they did very often.

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And to make things even worse,
Tenerife North Airport was,

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and still is, notorious for its frequent,

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fast-building fog that can appear
from nowhere within minutes.

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The airport sits at
2,000 feet above sea level

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on a shoulder between two mountains,

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and the marine fog
that forms over the ocean

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frequently collides with
the western slopes of Tenerife

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and then gets funneled

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through the gap
directly over the airfield.

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But like I mentioned before,

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on this day the reported
weather at the airport

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was more or less okay, with
around six kilometers of visibility

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and scattered clouds at 400 feet,

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broken at 800 feet,
and further scattered clouds

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at 1,100 feet with some light drizzle,

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not great for sunbathing,

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but good enough for normal landings.

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But these cloud layers also meant

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that higher up on the mountainsides,

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the fog was extremely thick,

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so thick in fact that a
weather station located

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at a close to 8,000 feet elevation

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on the mountainside
reported nil visibility.

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This meant that the very
high terrain south of the airport

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would be completely obscured,

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including the nearly
12,200-foot Teide Volcano,

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which is the defining
geographical feature on Tenerife.

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Because of that,
the minimum safe altitude

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in the airspace south
of Tenerife North Airport

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was 14,500 feet,
which is worth remembering.

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Anyway, as the flight
near the Canary Islands,

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the first officer made contact

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with the Las Palmas
Area Control Center,

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who soon cleared them
to descend down to 11,000 feet.

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The first officer read this back

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and the crew initiated the descent,

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and after they reached that altitude,

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they contacted the Tenerife
North approach controller

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and reported that they were
now 14 nautical miles

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away from the Tango
Foxrot November VOR beacon,

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and that they were ready

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to receive their approach instructions.

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Before we continue here,

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it's probably worth explaining
a bit more about

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the different approach aids

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that the crew were now going to use

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as well as their procedures.

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A VOR beacon, where VOR stands for:

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Very High Frequency
Omnidirectional Range,

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is a type of radio navigation beacon

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that was very widely used
in the days before GPS

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and is actually still quite common,

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especially here in Europe.

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These VORs emit signals
hat are modulated differently

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depending on the
direction of the emission,

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which allow the VOR
receivers on board aircraft

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to determine the
precise magnetic bearing

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from the VOR to the aircraft.

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This enables the pilots
to navigate using imaginary lines

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or radios defined
by a particular bearing

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from the beacon.

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So, for example, the 270 degree radial

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from the VOR points
due west and so on.

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A lot of airports have VORs installed

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to help pilots locate the airport
before starting to maneuver

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for the approach, and
it can also be used

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to align the aircraft with
the runway as an approach aid

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if an instrument landing system,
ILS, is not available.

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But in this case, the
Tango Foxrot November VOR

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was not actually located at the airport.

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Instead it was sitting on a hilltop,

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a few miles northeast of the airport

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in order to maximize
its detectable range.

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Located at the northeast
end of Runway 12-30,

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there was a less-sophisticated
beacon called an NDB locator

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with the Morse
code identifier Foxrot Papa.

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A non-directional beacon, or NDB,

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is a radio aid that can be tracked

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using an automatic
direction finder, an ADF,

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and this is a very simple
instrument which just points

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in the direction that
a signal is coming from,

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but it doesn't
contain any radial information,

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which makes the NDB navigation less

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precise than navigating using a VOR.

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In this case, because the
Foxrot Papa beacon was used

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to mark the entry point
to the approach procedure

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for Runway 12, it was
also known as a locator

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rather than just an NDB.

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And in order to approach Runway 12,

00:08:32.420 --> 00:08:35.800
a flight inbound from the
northeast like this flight was

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would normally need to fly first

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via the Tango Foxrot November VOR

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and then turn southwest onto Radial 255

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directly towards
the Foxrot Papa NDB.

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After reaching the Foxrot Papa,

00:08:48.520 --> 00:08:51.360
the aircraft should then turn
right onto an outbound heading

00:08:51.360 --> 00:08:54.892
of 302 degrees, which
would take it out over the ocean,

00:08:55.092 --> 00:08:57.460
before making
a teardrop course reversal

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to the left back towards the airport.

00:08:59.860 --> 00:09:01.820
And from that point, the
aircraft would be in a position

00:09:01.820 --> 00:09:03.800
to pick up the instrument landing system,

00:09:03.980 --> 00:09:04.920
which would then guide

00:09:04.920 --> 00:09:07.180
the aircraft the rest of
the way down to the runway.

00:09:08.180 --> 00:09:10.658
Now this was quite
a bit more complicated

00:09:10.858 --> 00:09:13.120
than the more commonly
used Runway 30 approach,

00:09:13.280 --> 00:09:16.500
which just involved flying to
an NDB called Tango X-ray,

00:09:16.700 --> 00:09:18.460
from where the instrument landing system

00:09:18.660 --> 00:09:19.920
could then be 
picked up immediately.

00:09:20.680 --> 00:09:22.367
Now the reason that these procedures

00:09:22.567 --> 00:09:23.556
had to be flown this way

00:09:23.670 --> 00:09:26.980
was that there was no radar
available at Los Rodeos Airport,

00:09:27.140 --> 00:09:29.516
so all approaches
had to be intercepted

00:09:29.716 --> 00:09:31.100
using procedural arrivals.

00:09:31.960 --> 00:09:33.840
But then again,
flying procedural approaches

00:09:33.840 --> 00:09:35.980
would not have been
very uncommon back then,

00:09:36.080 --> 00:09:38.018
and there was nothing in this procedure

00:09:38.218 --> 00:09:40.724
that was particularly out of the ordinary,

00:09:40.924 --> 00:09:43.249
except maybe that high
terrain to the southwest,

00:09:43.449 --> 00:09:44.460
which I mentioned before.

00:09:45.980 --> 00:09:48.045
And when we're on the
subject of things

00:09:48.245 --> 00:09:49.556
that are out of the ordinary,

00:09:49.756 --> 00:09:51.362
have you noticed that some countries

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00:09:55.640 --> 00:09:59.240
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00:09:59.240 --> 00:10:00.720
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and now where were we?

00:11:11.840 --> 00:11:12.360
Yes.

00:11:13.320 --> 00:11:15.500
After establishing  
contact at time 13:16,

00:11:15.700 --> 00:11:18.368
the Tenerife North
Controller cleared the flight

00:11:18.568 --> 00:11:19.980
to descend down to 6,000 feet

00:11:19.980 --> 00:11:22.180
in preparation to cross
Tango Foxtrot November

00:11:22.180 --> 00:11:24.500
and then to enter
the approach procedure.

00:11:25.120 --> 00:11:27.836
The captain dialed in
the new cleared altitude,

00:11:28.036 --> 00:11:30.519
the flight engineer reduced
thrust in order to descend,

00:11:30.719 --> 00:11:32.100
and the first officer then reported

00:11:32.100 --> 00:11:34.100
when the aircraft was
seven nautical miles away

00:11:34.100 --> 00:11:35.980
from the Tango Fox November beacon

00:11:35.980 --> 00:11:38.140
in order to get further instructions.

00:11:38.940 --> 00:11:41.920
At that same time, he
also requested the local air pressure,

00:11:42.180 --> 00:11:44.320
QNH, in order to
get the correct reference

00:11:44.320 --> 00:11:45.860
to the altitude above the sea,

00:11:46.460 --> 00:11:48.540
and also the QFE,
which would give him

00:11:48.540 --> 00:11:50.500
the altitude reference
over the airfield.

00:11:51.119 --> 00:11:53.821
Once those values
had been received and set,

00:11:54.021 --> 00:11:55.540
they were then cross-checked

00:11:55.540 --> 00:11:57.960
in accordance with
their standard operating procedures,

00:11:58.540 --> 00:11:59.920
and the captain now also suggested

00:11:59.920 --> 00:12:01.440
that the first officer should tune

00:12:01.440 --> 00:12:04.040
the ILS frequency on
his navigational radio box,

00:12:04.540 --> 00:12:06.460
and he also confirmed
that the outbound heading

00:12:06.460 --> 00:12:09.320
after Foxtrot Papa
would be 302 degrees.

00:12:10.380 --> 00:12:12.780
So at this stage,
everything was completely normal

00:12:12.780 --> 00:12:14.840
and the crew seemed
to have a good grasp

00:12:14.840 --> 00:12:16.740
of the procedure they
had in front of them.

00:12:17.700 --> 00:12:19.900
But just a few miles ahead,

00:12:20.260 --> 00:12:22.200
an island-hopping
turboprop belonging

00:12:22.200 --> 00:12:25.400
to Spain's flag carrier,
Iberia, was also an approach

00:12:25.400 --> 00:12:27.920
to Runway 12, and the crew
on board that aircraft

00:12:27.920 --> 00:12:30.240
were communicating with
the controller in Spanish.

00:12:31.280 --> 00:12:34.720
Now the pilots of Flight 1008
didn't understand Spanish,

00:12:34.840 --> 00:12:36.040
and from their conversations,

00:12:36.320 --> 00:12:38.460
it doesn't seem like
they paid much attention

00:12:38.460 --> 00:12:40.080
to that aircraft at all.

00:12:40.540 --> 00:12:42.885
Instead, they continued to
monitor their position,

00:12:43.085 --> 00:12:44.720
relative to the Tango
Fox November VOR,

00:12:44.720 --> 00:12:47.980
and at time 13:18:15,

00:12:48.200 --> 00:12:50.940
the captain called out,
"Just about to go overhead."

00:12:51.600 --> 00:12:53.240
The first officer then reminded

00:12:53.240 --> 00:12:54.720
the captain that the procedure called

00:12:54.720 --> 00:12:57.960
for them to leave Tango
Fox November on Radial 255.

00:12:58.340 --> 00:12:59.760
But as it turns out,

00:12:59.940 --> 00:13:03.020
the aircraft actually passed a
little less than a mile east

00:13:03.020 --> 00:13:05.340
of the VOR, and after passing abeam it,

00:13:05.680 --> 00:13:08.000
they were also slow
to make the right turn,

00:13:08.080 --> 00:13:09.040
which meant that they never

00:13:09.040 --> 00:13:11.420
actually intercepted that 255 radial.

00:13:12.480 --> 00:13:15.860
Now, we can never know
for sure why this happened,

00:13:16.120 --> 00:13:18.640
but it was most likely done on purpose.

00:13:19.500 --> 00:13:20.160
You see, the distance

00:13:20.160 --> 00:13:23.760
between Tango Fox November
and Foxtrot Papa was very short,

00:13:24.020 --> 00:13:25.780
and Flight 1008 was traveling

00:13:25.780 --> 00:13:27.660
at an airspeed of around 250 knots

00:13:27.860 --> 00:13:29.540
when they passed abeam to the VOR.

00:13:30.580 --> 00:13:32.491
Today, we wouldn't fly that fast

00:13:32.691 --> 00:13:35.000
when starting a tight
procedure like this,

00:13:35.020 --> 00:13:37.421
since our aircrafts are now very slippery

00:13:37.621 --> 00:13:39.060
 and take time to decelerate.

00:13:39.420 --> 00:13:41.392
But older aircraft like the 727

00:13:41.592 --> 00:13:43.300
had much less effective wings,

00:13:43.300 --> 00:13:46.340
which meant that they could
easily keep the speeds up high

00:13:46.340 --> 00:13:49.368
for longer, since the speed
would just rapidly bleed off

00:13:49.568 --> 00:13:51.260
when the thrust levers were closed.

00:13:52.040 --> 00:13:53.580
This also meant that most jets

00:13:53.580 --> 00:13:56.140
approaching Tenerife back then,
including this one,

00:13:56.380 --> 00:13:59.200
would normally overshoot
this first turn slightly

00:13:59.200 --> 00:14:01.400
before correcting course
in order to be able

00:14:01.400 --> 00:14:03.820
to intercept the 302 outbound course

00:14:03.820 --> 00:14:07.400
from the NDB at a slightly
more comfortable angle.

00:14:08.060 --> 00:14:10.920
There was so little time
between Tango Fox November

00:14:10.920 --> 00:14:13.140
and Foxtrot Papa that
they probably wouldn't be able

00:14:13.140 --> 00:14:14.560
to intercept the radial anyway.

00:14:15.000 --> 00:14:18.096
And on top of that, if they
flew directly over Foxtrot Papa,

00:14:18.296 --> 00:14:20.620
they would potentially overshoot
the pattern significantly,

00:14:20.980 --> 00:14:22.080
which could take the aircraft

00:14:22.080 --> 00:14:24.228
into the area south of the airport

00:14:24.428 --> 00:14:27.260
where the minimum
safe altitude was 14,500 feet.

00:14:28.200 --> 00:14:31.280
Now, this is obviously not how
this was supposed to be done.

00:14:31.600 --> 00:14:34.400
A lower speed would have
solved all of those issues,

00:14:34.840 --> 00:14:38.480
but sometimes, procedural
shortcuts like this can start

00:14:38.480 --> 00:14:41.700
to creep in due to
pure convenience and time saving.

00:14:42.520 --> 00:14:45.300
And if I was to guess, this was likely

00:14:45.300 --> 00:14:48.180
the reason that the captain
of this flight flew a bit wide

00:14:48.180 --> 00:14:49.820
around the Tango Fox November.

00:14:50.740 --> 00:14:52.140
Now, due to some radio chatter

00:14:52.140 --> 00:14:53.310
with the Hapag-Lloyd flight

00:14:53.510 --> 00:14:55.167
that was taking off from Los Rodeos

00:14:55.367 --> 00:14:56.540
plus some other distractions,

00:14:56.980 --> 00:14:58.722
the flight crew didn't actually report

00:14:58.922 --> 00:14:59.960
crossing Tango Fox November

00:14:59.960 --> 00:15:03.180
until 33 seconds after they
had passed abeam hit.

00:15:03.800 --> 00:15:05.160
And like I mentioned,

00:15:05.580 --> 00:15:08.165
Tenerife North Airport
didn't have radar at the time,

00:15:08.365 --> 00:15:09.580
so position reports like this

00:15:09.580 --> 00:15:11.439
were the only way for the controller

00:15:11.639 --> 00:15:13.660
to determine where
the traffic was located.

00:15:14.700 --> 00:15:16.640
As a result, when the crew reported

00:15:16.640 --> 00:15:19.080
that they had just
passed Tango Fox November,

00:15:19.620 --> 00:15:22.829
the controller realized that
the 727 was traveling so fast

00:15:23.029 --> 00:15:24.820
that it would risk getting too close

00:15:24.820 --> 00:15:27.807
to the slower Iberia
turboprop in front of them

00:15:28.007 --> 00:15:29.460
if he didn't do something.

00:15:30.660 --> 00:15:33.860
So he hastily decided
to put Flight 1008

00:15:33.860 --> 00:15:35.040
into a holding pattern

00:15:35.040 --> 00:15:37.420
in order to ensure
sufficient traffic separation.

00:15:38.340 --> 00:15:41.580
At time 13:18:54,

00:15:41.820 --> 00:15:44.060
the approach controller
transmitted the following message,

00:15:45.020 --> 00:15:47.920
"Roger, the standard
holding overhead Foxtrot Papa

00:15:47.920 --> 00:15:49.560
is inbound heading 150,

00:15:50.200 --> 00:15:52.420
turn to the left,
call you back shortly."

00:15:53.400 --> 00:15:56.240
And this would end
up being the critical moment

00:15:56.240 --> 00:15:58.969
that put the accident
sequence into motion.

00:15:59.169 --> 00:16:01.380
So let's take a moment to analyze why.

00:16:02.460 --> 00:16:03.940
Despite the controller's statement

00:16:03.940 --> 00:16:05.520
that this was a standard holding,

00:16:05.820 --> 00:16:08.753
there was actually no officially
published holding pattern

00:16:08.953 --> 00:16:10.220
around the Foxtrot Papa beacon.

00:16:11.240 --> 00:16:12.620
There was a published holding

00:16:12.620 --> 00:16:14.085
around Tango Fox November,

00:16:14.285 --> 00:16:15.722
as well as around Tango X-ray,

00:16:15.922 --> 00:16:18.180
forming part of the go-around
procedure for Runway 12,

00:16:18.600 --> 00:16:22.840
but Flight 1008 was not in
a position to enter any of those.

00:16:23.620 --> 00:16:25.160
Instead, the controller essentially

00:16:25.160 --> 00:16:28.624
invented a holding pattern
based on Foxtrot Papa,

00:16:28.824 --> 00:16:30.320
and he did so so quickly

00:16:30.320 --> 00:16:32.475
that this was likely not the first time

00:16:32.675 --> 00:16:34.740
that he had used
this particular pattern.

00:16:35.560 --> 00:16:39.180
Now, it's not wrong or illegal
to make up holding patterns.

00:16:39.380 --> 00:16:42.000
In fact, that happens all the time,
and it's perfectly okay

00:16:42.000 --> 00:16:43.680
as long as it doesn't cause any issues

00:16:43.680 --> 00:16:45.540
with terrain or traffic separation.

00:16:46.160 --> 00:16:48.456
But the issue here
was that the controller said

00:16:48.656 --> 00:16:49.900
that this was a standard holding,

00:16:50.020 --> 00:16:52.240
which would imply that
the holding could be found

00:16:52.240 --> 00:16:53.740
in the published approach chart,

00:16:53.740 --> 00:16:56.460
and therefore needed to
be verified by the pilots.

00:16:57.080 --> 00:16:58.587
On top of that, the entry

00:16:58.787 --> 00:17:01.180
into this suddenly-proposed
holding pattern

00:17:01.180 --> 00:17:02.820
would not be very simple

00:17:02.820 --> 00:17:05.280
from the position that the
aircraft was now coming from.

00:17:06.140 --> 00:17:08.165
What the controller
wanted the aircraft to do

00:17:08.290 --> 00:17:11.560
was to join a left-hand holding
pattern over Foxtrot Papa

00:17:11.560 --> 00:17:14.096
with an inbound course of 150 degrees

00:17:14.296 --> 00:17:16.700
and an outbound
course of 330 degrees.

00:17:17.680 --> 00:17:19.460
If it was flown that way,

00:17:19.720 --> 00:17:22.140
it would keep the airplane
over relatively low terrain.

00:17:22.780 --> 00:17:24.424
But to do this, Flight 1008

00:17:24.624 --> 00:17:26.860
would have to first fly
over the beacon,

00:17:27.200 --> 00:17:29.525
then turn right onto heading of 330,

00:17:29.725 --> 00:17:32.720
fly outbound for one minute,
perform a course reversal,

00:17:33.160 --> 00:17:34.180
and then proceed inbound

00:17:34.180 --> 00:17:36.920
to Foxtrot Papa again
on the requested inbound course.

00:17:37.880 --> 00:17:39.458
Quite a complex maneuver to fly

00:17:39.658 --> 00:17:41.240
when you're
almost over the beacon.

00:17:42.240 --> 00:17:44.340
Now, the pilots might
have eventually figured this out

00:17:44.340 --> 00:17:47.700
if not for a tiny slip of
the tongue by the controller,

00:17:47.900 --> 00:17:50.380
which changed this
entire course of events.

00:17:51.740 --> 00:17:54.480
Remember that the
controller wanted Flight 1008

00:17:54.480 --> 00:17:56.060
to fly counter-clockwise

00:17:56.060 --> 00:17:58.560
around the holding pattern,
making left turns?

00:17:59.740 --> 00:18:02.436
Well, this meant that what
he wanted to say

00:18:02.636 --> 00:18:04.121
was turns to the left,

00:18:04.321 --> 00:18:06.644
but what he actually
ended up saying

00:18:06.844 --> 00:18:10.280
was, "Turn to the left," which
has a very different meaning.

00:18:11.400 --> 00:18:13.560
Turn to the left
is normally interpreted

00:18:13.560 --> 00:18:16.317
as a command to turn left, right away,

00:18:16.517 --> 00:18:18.551
which was not at
all what the controller

00:18:18.751 --> 00:18:19.751
wanted them to do here.

00:18:20.420 --> 00:18:21.540
What he attempted to say

00:18:21.670 --> 00:18:23.680
was only a description
of the holding pattern,

00:18:23.820 --> 00:18:25.520
which is technically just informational,

00:18:26.060 --> 00:18:28.435
not an order, and that also made sense,

00:18:28.635 --> 00:18:31.000
given that he didn't
have any radar available.

00:18:31.820 --> 00:18:33.900
Spanish investigators later used this

00:18:33.900 --> 00:18:36.400
to argue that the controller
didn't bear any responsibility

00:18:36.400 --> 00:18:38.580
for issuing a non-standard clearance,

00:18:38.680 --> 00:18:41.240
but given how his call actually sounded

00:18:41.240 --> 00:18:43.520
to the pilots,
that's not completely fair.

00:18:44.440 --> 00:18:46.640
Anyway, when the flight
crew received this message

00:18:46.640 --> 00:18:48.815
from the controller,
they simply replied,

00:18:49.015 --> 00:18:50.554
"Roger," with no further readback

00:18:50.754 --> 00:18:51.860
or request for confirmation.

00:18:52.980 --> 00:18:54.774
They might have thought at first

00:18:54.974 --> 00:18:56.680
that they understood what he said,

00:18:56.980 --> 00:18:59.255
but within 10 seconds,
the captain realized

00:18:59.455 --> 00:19:00.747
that he wasn't able to picture

00:19:00.947 --> 00:19:03.344
what the controller was asking from him,

00:19:03.544 --> 00:19:06.340
so he said, that's an odd
sort of one, the runway.

00:19:07.580 --> 00:19:08.920
He then interrupted himself

00:19:08.920 --> 00:19:11.100
with a confirmation that
they had 1,000 feet

00:19:11.100 --> 00:19:13.400
to go to their
cleared altitude of 6,000 feet,

00:19:13.840 --> 00:19:15.680
and after that, the first officer said,

00:19:16.180 --> 00:19:19.820
"No, I'm not, er...
Supposedit's all right?"

00:19:21.040 --> 00:19:24.060
The captain continued with,
"I'll just turn straight round

00:19:24.060 --> 00:19:26.560
to the left on the 150
when I go overhead then,"

00:19:26.900 --> 00:19:28.580
to which the first
officer seemed to agree.

00:19:29.780 --> 00:19:32.730
Now this shows that
the captain clearly believed

00:19:32.930 --> 00:19:35.980
that he had been told
to turn left on to heading 150

00:19:35.980 --> 00:19:37.840
after crossing Foxtrot Papa,

00:19:37.980 --> 00:19:40.820
which again was not at
all what the controller had intended.

00:19:41.720 --> 00:19:43.300
A command to turn to the left

00:19:43.500 --> 00:19:45.860
was completely incompatible
with an instruction

00:19:45.860 --> 00:19:49.040
to fly a holding
pattern inbound on 150 degrees

00:19:49.040 --> 00:19:51.940
to Foxtrot Papa since,
like what I said earlier,

00:19:52.500 --> 00:19:55.940
that would require a right turn
followed by a course reversal.

00:19:56.680 --> 00:19:57.880
So in the captain's mind,

00:19:58.120 --> 00:19:59.940
the instructions didn't make sense,

00:19:59.940 --> 00:20:02.720
but he had been able
to pick out two elements

00:20:02.720 --> 00:20:05.640
in the message which seemed clear to him,

00:20:05.840 --> 00:20:07.420
150 and turn to the left.

00:20:08.580 --> 00:20:10.280
So with Foxtrot Papa now coming up

00:20:10.280 --> 00:20:11.360
in less than one minute,

00:20:11.480 --> 00:20:13.480
he didn't have a lot
of time to figure it out.

00:20:14.140 --> 00:20:15.440
In a stressful situation,

00:20:15.720 --> 00:20:18.280
without fully comprehending
what the controller had said,

00:20:18.600 --> 00:20:20.540
he accepted that the best thing to do

00:20:20.740 --> 00:20:22.360
was just to execute
the part of the clearance

00:20:22.360 --> 00:20:23.080
that he understood,

00:20:23.640 --> 00:20:25.920
and then try to
figure out the rest later.

00:20:26.640 --> 00:20:28.223
In hindsight, it's easy to say

00:20:28.423 --> 00:20:29.700
that he shouldn't have acted

00:20:29.700 --> 00:20:32.840
on an incomplete understanding
of those instructions,

00:20:32.960 --> 00:20:35.700
but in that moment,
with the sudden time pressure

00:20:35.700 --> 00:20:38.100
and the added workload
of the sudden holding clearance,

00:20:38.520 --> 00:20:40.060
it would have been a lot harder

00:20:40.060 --> 00:20:41.700
to think with that kind of clarity.

00:20:42.540 --> 00:20:43.760
And it is also worth remembering

00:20:43.760 --> 00:20:46.320
that this all happened
in a 727 cockpit,

00:20:46.520 --> 00:20:49.680
with no fancy navigation
displays, only dials.

00:20:50.360 --> 00:20:52.380
Besides, this CVR transcript suggests

00:20:52.380 --> 00:20:54.552
that both the first officer
and the flight engineer

00:20:54.752 --> 00:20:56.620
were looking at the charts
when this all happened,

00:20:57.020 --> 00:20:59.553
likely searching for
that standard holding

00:20:59.753 --> 00:21:00.880
in order to be able to verify it.

00:21:01.440 --> 00:21:04.700
And the first officer had said,
"I suppose it's all right,"

00:21:05.040 --> 00:21:07.600
which might have reinforced
the captain's belief

00:21:07.600 --> 00:21:09.760
that he had understood
the clearance correctly.

00:21:10.840 --> 00:21:13.520
Anyway, seconds later,
having made his decision

00:21:13.520 --> 00:21:15.083
on how to fly, the captain focused

00:21:15.283 --> 00:21:17.001
his attention on the rapid approach

00:21:17.201 --> 00:21:18.201
of the Foxtrot Papa NDB.

00:21:18.980 --> 00:21:23.000
He said, "The only thing is,
we're just about to miss it.

00:21:23.720 --> 00:21:24.820
(chuckles) It's too close."

00:21:25.860 --> 00:21:28.100
At this point, the captain
and the first officer also agreed

00:21:28.100 --> 00:21:30.380
to tune both automatic
direction finders

00:21:30.380 --> 00:21:32.100
to the frequency of the Foxtrot Papa,

00:21:32.420 --> 00:21:34.086
so that they could track it more easily

00:21:34.286 --> 00:21:35.286
during the holding pattern.

00:21:35.900 --> 00:21:39.320
And finally, at time 13:19:46,

00:21:39.480 --> 00:21:41.356
they passed abeam Foxtrot Papa,

00:21:41.556 --> 00:21:44.400
slightly to the southeast,
and the captain called it out.

00:21:45.380 --> 00:21:47.320
This prompted the
first officer to report

00:21:47.320 --> 00:21:49.480
the waypoint passage to the controller,

00:21:49.720 --> 00:21:52.060
and he also confirmed that they
were now taking up the hold.

00:21:52.800 --> 00:21:55.600
But in reality, they actually
kept flying straight ahead

00:21:55.600 --> 00:21:57.240
for another about 20 seconds,

00:21:57.360 --> 00:21:58.980
covering around two nautical miles

00:21:58.980 --> 00:22:00.720
before beginning the left turn.

00:22:01.820 --> 00:22:04.487
Now, the reason for
this delay isn't really known,

00:22:04.687 --> 00:22:06.322
but it might have been
because the pilots

00:22:06.522 --> 00:22:07.840
were still trying to wrap their heads

00:22:07.840 --> 00:22:10.160
around the maneuver that they
now had ahead of them.

00:22:10.940 --> 00:22:13.435
In fact, a few seconds
before they began that left turn,

00:22:13.635 --> 00:22:16.960
the first officer said,
"Bloody strange hold, isn't it?"

00:22:17.260 --> 00:22:19.580
Which indicates that he
was still mentally focused

00:22:19.580 --> 00:22:21.200
on the confusing instructions.

00:22:22.140 --> 00:22:23.540
In response to that, the captain said,

00:22:23.940 --> 00:22:25.080
"Yeah, it doesn't...

00:22:25.360 --> 00:22:27.740
Isn't parallel with
the runway or anything."

00:22:28.760 --> 00:22:30.923
Now, I just want to
stop here and drive home

00:22:31.110 --> 00:22:32.020
what is probably one of

00:22:32.020 --> 00:22:34.320
the most important points
of this whole video.

00:22:35.360 --> 00:22:38.500
If something seems strange
with a clearance and you get

00:22:38.500 --> 00:22:40.180
that pit in the stomach feeling

00:22:40.180 --> 00:22:41.500
that something just isn't right,

00:22:42.260 --> 00:22:45.220
always speak up and
ask for further clarification.

00:22:46.160 --> 00:22:48.800
This goes for all walks
of life and all industries,

00:22:49.060 --> 00:22:51.280
but especially if
you're flying an aircraft.

00:22:52.340 --> 00:22:55.019
It's always better
to ask one time too many

00:22:55.219 --> 00:22:56.420
than one time too few,

00:22:56.680 --> 00:22:59.680
and I want every one of
you out there to remember that.

00:23:00.420 --> 00:23:03.180
This, by the way, is also exactly
the kind of discussions

00:23:03.180 --> 00:23:05.800
that I'm having regularly
on my Zoom hangouts

00:23:05.800 --> 00:23:06.740
with my Patreon crew,

00:23:07.080 --> 00:23:09.320
and I hope to see
you there as well next time.

00:23:09.800 --> 00:23:13.020
Just go to patreon.com/join/mentourpilot

00:23:13.020 --> 00:23:14.400
if you think that sounds interesting.

00:23:15.380 --> 00:23:18.625
Anyway, at this point, what
the flight crew didn't yet know

00:23:18.825 --> 00:23:20.660
was that by overshooting Foxtrot Papa

00:23:20.660 --> 00:23:23.577
and then turning left
onto a heading a 150 degrees,

00:23:23.777 --> 00:23:26.540
they were now on a track to
overfly the northern shoulder

00:23:26.540 --> 00:23:28.136
of La Esperanza, a sub-peak

00:23:28.336 --> 00:23:30.561
along the island's central volcanic ridge

00:23:30.761 --> 00:23:32.600
that stretched
north from El Teide.

00:23:33.280 --> 00:23:35.800
The terrain directly beneath
their projected flight path

00:23:35.800 --> 00:23:37.980
actually didn't exceed 5,000 feet,

00:23:38.520 --> 00:23:40.791
but it did lie within the sector,

00:23:40.991 --> 00:23:43.820
where the minimum safe
altitude was 14,500 feet.

00:23:44.700 --> 00:23:45.700
So strictly speaking,

00:23:46.040 --> 00:23:48.020
since they weren't
flying a published procedure,

00:23:48.240 --> 00:23:50.180
maneuvering at only 6,000 feet

00:23:50.180 --> 00:23:52.400
would have been
prohibited in this area.

00:23:53.000 --> 00:23:55.240
The final report would
later place some blame

00:23:55.240 --> 00:23:57.363
on the flight crew
for flying into this area

00:23:57.563 --> 00:23:59.560
without being aware
of the applicable MSA,

00:23:59.680 --> 00:24:02.201
but it seems likely
that at this point,

00:24:02.401 --> 00:24:04.060
they were still thinking that they

00:24:04.060 --> 00:24:05.660
were flying an official procedure,

00:24:05.780 --> 00:24:07.900
even though they couldn't
find it on their charts.

00:24:08.680 --> 00:24:11.160
At the same time
as Flight 1008 completed

00:24:11.160 --> 00:24:13.140
their left turn onto a heading of 150

00:24:13.140 --> 00:24:15.146
and started flying
towards the southeast,

00:24:15.346 --> 00:24:16.760
the approach controller called up

00:24:16.760 --> 00:24:18.671
the Iberia Airlines flight ahead of them

00:24:18.871 --> 00:24:22.000
and asked them to verify
when they had left 5,000 feet.

00:24:22.960 --> 00:24:25.400
Only seconds later, the
pilot of that aircraft replied

00:24:25.400 --> 00:24:27.200
that 5,000 feet was now free

00:24:27.200 --> 00:24:28.651
and that they were in the middle

00:24:28.851 --> 00:24:30.600
of a procedure turn
to intercept the ILS.

00:24:31.080 --> 00:24:33.125
As these calls in
Spanish were happening,

00:24:33.325 --> 00:24:34.920
the first officer on Flight Engineer

00:24:34.920 --> 00:24:38.600
on board Flight 1008 continued
to compare ATC's instructions

00:24:38.600 --> 00:24:41.199
with what was printed on their chart,

00:24:41.399 --> 00:24:44.220
saying things like,
"It's that way, isn't it?"

00:24:46.140 --> 00:24:47.700
"That's a tree, isn't it?"

00:24:47.920 --> 00:24:51.840
And, "Yes, well, the hold is
going to be here, isn't it?"

00:24:52.540 --> 00:24:55.150
It's likely that they
were now very skeptical

00:24:55.350 --> 00:24:56.980
about the maneuver
that they were flying,

00:24:57.360 --> 00:24:59.340
but we can never be 100% sure

00:24:59.340 --> 00:25:02.020
since that wasn't formally verbalized.

00:25:02.960 --> 00:25:05.194
Anyway, as these
discussions were taking place,

00:25:05.394 --> 00:25:06.664
the controller now called them up

00:25:06.864 --> 00:25:08.960
and cleared them to
descend down to 5,000 feet

00:25:08.960 --> 00:25:11.280
since the Iberia flight
had now left that altitude.

00:25:12.180 --> 00:25:14.880
And in response, the
flight engineer again reduced

00:25:14.880 --> 00:25:17.400
the thrust and the
captain initiated the descent.

00:25:18.460 --> 00:25:21.540
But as they were doing this,
the captain suddenly said,

00:25:22.040 --> 00:25:25.200
"Hey, did he say it was 1-5-0 inbound?"

00:25:25.860 --> 00:25:28.100
likely realizing that
his mental picture

00:25:28.100 --> 00:25:29.340
of where the controller was sending

00:25:29.340 --> 00:25:31.440
them didn't actually make any sense.

00:25:31.900 --> 00:25:34.140
The first officer
had probably suspected

00:25:34.140 --> 00:25:36.917
that from the very start
because he now replied,

00:25:37.117 --> 00:25:38.020
"Inbound, yeah."

00:25:38.660 --> 00:25:40.954
And in response to that,
the captain said,

00:25:41.154 --> 00:25:42.780
"That's... I don't like that."

00:25:43.580 --> 00:25:45.719
The first officer continued by saying,

00:25:45.919 --> 00:25:48.420
"They want to keep
going more around, don't they?"

00:25:49.360 --> 00:25:51.731
It's not completely clear
what he meant by that,

00:25:51.931 --> 00:25:54.200
but it is possible that
the first officer believed

00:25:54.200 --> 00:25:56.612
that they were supposed
to keep turning left,

00:25:56.812 --> 00:25:58.380
making a three quarters turn onto

00:25:58.380 --> 00:26:00.120
the outbound leg
of the holding pattern,

00:26:00.340 --> 00:26:02.100
after which they would come back

00:26:02.100 --> 00:26:04.940
to Foxtrot Papa on
the inbound heading of 150.

00:26:06.140 --> 00:26:08.120
If that was the case,
it would mean that

00:26:08.120 --> 00:26:10.200
even the first
officer had indeed interpreted

00:26:10.200 --> 00:26:13.140
the call from the controller
as an instruction to turn left.

00:26:13.600 --> 00:26:16.100
And that would also explain why he

00:26:16.100 --> 00:26:18.460
hadn't spoken up when the turn started.

00:26:19.460 --> 00:26:21.768
When I read this part of the report,

00:26:21.968 --> 00:26:24.617
I could really feel that
cold feeling in my stomach.

00:26:24.817 --> 00:26:26.420
You know, that feeling that you get

00:26:26.620 --> 00:26:29.616
when you realize
that something is really wrong,

00:26:29.816 --> 00:26:32.300
but you still can't
figure out what or how.

00:26:33.240 --> 00:26:34.968
But we don't know if the pilots

00:26:35.168 --> 00:26:36.920
had yet realized just how dangerous

00:26:36.920 --> 00:26:38.360
their current flight path was.

00:26:38.540 --> 00:26:39.960
But the captain's statement of,

00:26:39.960 --> 00:26:43.980
"I don't like that," definitely
showed some real concern.

00:26:45.060 --> 00:26:47.720
Again, make sure you
always know what clearance

00:26:47.720 --> 00:26:50.360
you have been given,
and if in doubt, ask.

00:26:51.400 --> 00:26:53.940
Anyway, before the pilots could
spend much more time trying

00:26:53.940 --> 00:26:55.694
to work out what was wrong,

00:26:55.894 --> 00:26:57.967
the ground proximity warning system

00:26:58.168 --> 00:27:01.100
suddenly activated at time 13:20:50.

00:27:02.380 --> 00:27:03.740
The Boeing 727 was equipped

00:27:03.740 --> 00:27:05.704
with a first generation GPWS,

00:27:05.904 --> 00:27:08.130
which was state of the art at the time,

00:27:08.330 --> 00:27:09.691
but also much less capable

00:27:09.891 --> 00:27:11.940
than the enhanced ground
proximity warning systems

00:27:11.940 --> 00:27:13.820
that we have on board today's aircraft.

00:27:15.260 --> 00:27:17.640
Modern EGPWSs compares the position

00:27:17.640 --> 00:27:19.808
and projected path of the airplane

00:27:20.008 --> 00:27:21.720
to a digital terrain database.

00:27:22.320 --> 00:27:24.640
But the original GPSs could only look

00:27:24.640 --> 00:27:26.928
at the terrain directly
beneath the aircraft

00:27:27.128 --> 00:27:28.280
using its radio altimeter.

00:27:29.240 --> 00:27:31.740
If the closure rate with
the terrain was too high,

00:27:31.740 --> 00:27:34.260
it would an issue sink rate
or pull up warnings.

00:27:34.800 --> 00:27:37.560
But if the terrain ahead
of the aircraft was rising steeply,

00:27:37.860 --> 00:27:39.300
the system wouldn't know that,

00:27:39.460 --> 00:27:41.840
so these warnings could
still come too late.

00:27:43.060 --> 00:27:44.100
In this case, the airplane

00:27:44.210 --> 00:27:45.840
was now passing over
the northern shoulder

00:27:45.840 --> 00:27:48.580
of the central volcanic
ridge while in descent,

00:27:49.060 --> 00:27:51.195
and that resulted in a
rate of terrain closure

00:27:51.395 --> 00:27:53.320
greater than 6,000 feet per minute,

00:27:53.520 --> 00:27:55.080
triggering the warning envelope.

00:27:55.820 --> 00:27:58.218
But the maximum height
of the ridge ahead of them

00:27:58.418 --> 00:28:00.830
was actually less than
their current altitude.

00:28:01.030 --> 00:28:02.438
So in their present trajectory,

00:28:02.610 --> 00:28:05.520
they were not in any
danger of striking the terrain.

00:28:06.680 --> 00:28:08.340
But, of course, the
pilots who had now lost

00:28:08.340 --> 00:28:10.200
their position situational awareness

00:28:10.200 --> 00:28:12.586
and were still flying
inside of the clouds

00:28:12.786 --> 00:28:14.120
had no way of knowing this.

00:28:14.960 --> 00:28:17.480
So in response to the GPWS warning,

00:28:17.760 --> 00:28:19.020
the captain immediately announced,

00:28:19.180 --> 00:28:22.600
"Okay, overshoot," which is an
old British term for go around.

00:28:23.140 --> 00:28:24.680
As the flight engineer advanced

00:28:24.680 --> 00:28:27.120
the thrust levers to
the takeoff go around thrust,

00:28:27.380 --> 00:28:29.831
the captain also halted their left turn

00:28:30.031 --> 00:28:32.901
and added, "He's taking us
around to the high ground,"

00:28:33.050 --> 00:28:35.460
and after stating that,
he continued rolling right

00:28:35.460 --> 00:28:38.340
onto a steeper and
steeper right-hand turn.

00:28:39.240 --> 00:28:40.780
But what he didn't do was

00:28:40.780 --> 00:28:43.420
to raise the nose in
order to initiate the climb.

00:28:44.340 --> 00:28:46.000
And why was that then?

00:28:46.600 --> 00:28:49.020
Well, during GPWS response training,

00:28:49.140 --> 00:28:50.620
we pilots today are required

00:28:50.620 --> 00:28:53.620
to practice a terrain escape
maneuver in the simulator,

00:28:53.620 --> 00:28:57.160
which includes disconnecting
the automatic setting,

00:28:57.440 --> 00:28:59.720
full thrust pitching up to 20 degrees,

00:28:59.840 --> 00:29:02.227
making sure the speed
brake lever is down,

00:29:02.427 --> 00:29:04.160
making proper
call outs and so on.

00:29:04.880 --> 00:29:07.560
This maneuver is drilled
into everyone flying today

00:29:07.560 --> 00:29:09.400
in order to make sure that the response

00:29:09.400 --> 00:29:11.140
to a hard GPWS warning

00:29:11.140 --> 00:29:15.280
is immediately executed from
memory and without questions.

00:29:16.100 --> 00:29:18.947
As it turns out, the captain
and the flight engineer

00:29:19.147 --> 00:29:21.184
had also undergone some type

00:29:21.384 --> 00:29:23.367
of GPWS training back in 1978,

00:29:23.567 --> 00:29:26.780
and Dan-Air did have a
procedure for GPWS response,

00:29:27.480 --> 00:29:30.800
but back in those days
GPWS was a very new technology

00:29:30.800 --> 00:29:32.140
and there is a possibility

00:29:32.140 --> 00:29:34.660
that training had
been only theoretical.

00:29:35.460 --> 00:29:38.380
So we don't know exactly what was going

00:29:38.380 --> 00:29:41.180
through the captain's head,
but based on his statement

00:29:41.180 --> 00:29:43.978
that, "He's taking us
around to the high ground,"

00:29:44.178 --> 00:29:47.097
he probably believed
that the controller's instruction

00:29:47.297 --> 00:29:48.340
to turn left was faulty

00:29:48.340 --> 00:29:50.300
and that the controller had told him

00:29:50.300 --> 00:29:52.420
to turn towards an unsafe direction.

00:29:53.220 --> 00:29:55.360
Believing that the
GPWS warning occurred

00:29:55.360 --> 00:29:58.198
because they were turning
left towards high terrain,

00:29:58.398 --> 00:29:59.780
the captain may have reasoned

00:29:59.780 --> 00:30:01.896
that the best way
to escape the situation

00:30:02.096 --> 00:30:03.600
was to turn to the right instead.

00:30:04.440 --> 00:30:06.116
So without having
practiced the maneuver

00:30:06.190 --> 00:30:08.577
in the simulator, the
captain's immediate reaction

00:30:08.710 --> 00:30:11.040
was to turn rather than to climb,

00:30:11.240 --> 00:30:13.440
which sadly would seal their fate.

00:30:14.300 --> 00:30:16.550
Because as the right turn now continued,

00:30:16.750 --> 00:30:17.900
the aircraft passed over

00:30:17.900 --> 00:30:19.815
the top of the ridge
and then over a valley,

00:30:20.015 --> 00:30:22.020
causing the radio altitude to increase,

00:30:22.560 --> 00:30:24.570
which silenced the GPWS warning,

00:30:24.770 --> 00:30:26.580
10 seconds after it had started.

00:30:27.620 --> 00:30:29.942
The captain commented,
"Watch my eepers,"

00:30:30.142 --> 00:30:32.547
referring to the engine
pressure ratio or EPR,

00:30:32.747 --> 00:30:34.838
essentially ensuring
that the flight engineer

00:30:35.038 --> 00:30:37.740
maintained TO/GA thrust and
didn't over-boost the engines.

00:30:38.940 --> 00:30:40.640
But it also now seems like

00:30:40.640 --> 00:30:42.400
the first officer wasn't convinced

00:30:42.400 --> 00:30:44.823
that they were now taking
the right course of action.

00:30:45.023 --> 00:30:45.939
So he called out,

00:30:46.139 --> 00:30:48.303
"I suggest a heading of 1-2-2 actually

00:30:48.503 --> 00:30:50.240
and take us through the overshoot."

00:30:51.320 --> 00:30:54.365
A heading of 1-2-2 degrees
was the heading prescribed

00:30:54.470 --> 00:30:57.120
by the official Runway 12
missed approach procedure,

00:30:57.300 --> 00:30:59.638
which would take them
east over the ocean,

00:30:59.838 --> 00:31:01.920
so this was a pretty sensible suggestion.

00:31:02.980 --> 00:31:05.440
But 1-2-2 degrees was also

00:31:05.440 --> 00:31:07.320
to the left of their current heading,

00:31:07.460 --> 00:31:09.320
which contradicted
the captain's assumption

00:31:09.320 --> 00:31:13.220
that their left turn was
what had caused the GPWS warning.

00:31:14.280 --> 00:31:17.960
As a result, he just continued
turning right past due south

00:31:17.960 --> 00:31:20.240
and then all the way
around to the southwest,

00:31:20.620 --> 00:31:25.520
directly towards the 5,700 foot
high summit of La Esperanza.

00:31:26.760 --> 00:31:29.372
Tragically, they might
still have cleared the summit

00:31:29.572 --> 00:31:31.180
if they had just maintained altitude

00:31:31.180 --> 00:31:33.800
or climbed following
the terrain escape maneuver.

00:31:34.640 --> 00:31:37.584
But due to the high bank angle
they were now using,

00:31:37.784 --> 00:31:40.243
the plane actually lost
lift during the maneuver,

00:31:40.443 --> 00:31:41.900
causing a slight descent instead.

00:31:43.080 --> 00:31:46.094
Still flying over the valley,
the flight engineer expressed

00:31:46.294 --> 00:31:49.260
his nervousness by commenting,
"Let's get out of here."

00:31:49.880 --> 00:31:51.220
But the captain simply repeated,

00:31:51.620 --> 00:31:53.440
"He's taking us around
to the high ground."

00:31:54.720 --> 00:31:57.637
Moments later, without any
new GPWS warnings,

00:31:57.837 --> 00:32:00.333
and believing that he
had corrected the situation,

00:32:00.533 --> 00:32:02.380
the captain
called up air traffic control

00:32:02.380 --> 00:32:06.100
and reported, "Dan-Air 1008,

00:32:06.320 --> 00:32:08.000
we've had a ground proximity warning."

00:32:08.880 --> 00:32:10.086
This was then followed

00:32:10.286 --> 00:32:13.575
by the flight engineer calling
out twice that their bank angle

00:32:13.750 --> 00:32:16.300
was now above the recommended
maximum of 30 degrees.

00:32:17.520 --> 00:32:19.576
And his words were
the last ones captured

00:32:19.776 --> 00:32:21.080
on the cockpit voice recorder.

00:32:21.900 --> 00:32:25.240
With the mountains shrouded in
clouds, the pilots never saw

00:32:25.240 --> 00:32:26.720
the danger coming towards them,

00:32:26.720 --> 00:32:28.300
and the GPWS never had time

00:32:28.300 --> 00:32:31.180
to react to the closure
rate of the steep mountain ahead.

00:32:32.300 --> 00:32:38.080
So at time 13:21:18 Dan-Air
Flight 1008 crashed

00:32:38.080 --> 00:32:40.626
into the forested
mountainside of La Esperanza

00:32:40.826 --> 00:32:42.839
at a speed of 260 knots,

00:32:43.039 --> 00:32:46.360
just 38 meters below
the top of the ridge.

00:32:47.720 --> 00:32:50.227
Most of the aircraft
disintegrated immediately,

00:32:50.427 --> 00:32:51.724
killing everyone on board,

00:32:51.924 --> 00:32:53.582
and a large portion
of the aft cabin

00:32:53.710 --> 00:32:56.312
was then thrown another
250 meters forward

00:32:56.512 --> 00:32:58.980
over the top of the ridge and
then down to the other side.

00:32:59.800 --> 00:33:02.736
Down at the airport,
the controller now tried repeatedly

00:33:02.936 --> 00:33:04.797
to contact the aircraft
in order to follow up

00:33:04.870 --> 00:33:06.300
on their reported GPWS warning,

00:33:06.720 --> 00:33:08.260
but when he didn't get any reply,

00:33:08.560 --> 00:33:10.620
he soon activated the accident alarm.

00:33:11.660 --> 00:33:13.139
The problem was though that

00:33:13.339 --> 00:33:15.440
with no radar available
at Tenerife North,

00:33:15.820 --> 00:33:18.800
rescuers had no idea
where the aircraft was located,

00:33:18.960 --> 00:33:21.100
especially since it had taken a turn

00:33:21.100 --> 00:33:23.580
that the controller had
not intended them to take.

00:33:24.340 --> 00:33:26.593
This meant that the
wreckage wasn't discovered

00:33:26.793 --> 00:33:28.336
until seven hours after the crash,

00:33:28.536 --> 00:33:30.060
when a couple of
motorists on the road

00:33:30.060 --> 00:33:33.034
to El Teide National Park
saw some debris on the road

00:33:33.234 --> 00:33:35.214
and correlated that to the radio report

00:33:35.414 --> 00:33:36.414
of a missing aircraft.

00:33:37.120 --> 00:33:41.325
This crash was, and actually
still is, the worst loss of life

00:33:41.525 --> 00:33:43.600
on board a British airliner ever,

00:33:43.820 --> 00:33:47.100
so the investigation received
considerable public attention

00:33:48.140 --> 00:33:49.660
especially when the Spanish

00:33:49.860 --> 00:33:51.800
and British investigators didn't agree

00:33:51.800 --> 00:33:54.340
on how to weigh
the causes of the accident.

00:33:54.980 --> 00:33:56.780
The Spanish investigators wrote

00:33:56.780 --> 00:33:59.140
that the pilots
were ultimately responsible

00:33:59.140 --> 00:34:02.220
for being aware of their position
in a non-radar environment,

00:34:02.400 --> 00:34:04.260
and that it was their obligation

00:34:04.260 --> 00:34:05.680
to climb to a safe altitude

00:34:05.680 --> 00:34:09.100
as soon as they became unsure
of where they actually were.

00:34:09.860 --> 00:34:12.920
They also cited the pilot's
failure to request clarification

00:34:12.920 --> 00:34:14.500
when they didn't understand

00:34:14.500 --> 00:34:16.060
the controller's initial transmission

00:34:16.060 --> 00:34:17.700
as a major cause of the accident,

00:34:18.140 --> 00:34:21.060
as well as their incorrect
response to the GPWS warning.

00:34:22.120 --> 00:34:25.191
They pointed out that if
the pilots had done nothing at all

00:34:25.391 --> 00:34:26.440
when the GPWS activated,

00:34:27.000 --> 00:34:29.276
they would have passed
safely over the ridge

00:34:29.476 --> 00:34:30.880
and continued out over the sea.

00:34:31.360 --> 00:34:32.790
So the Spanish investigators argued

00:34:32.990 --> 00:34:34.940
 that it was the captain's
decision to turn right

00:34:34.940 --> 00:34:37.558
that took them back
around to the high terrain

00:34:37.758 --> 00:34:39.380
and ultimately led to the crash.

00:34:40.340 --> 00:34:42.480
But the British
investigation team believed

00:34:42.480 --> 00:34:45.520
that the controller's use
of an unpublished holding pattern,

00:34:45.820 --> 00:34:48.063
one that didn't appear
on the pilot's chart,

00:34:48.263 --> 00:34:52.574
as well as its verbal slip-up
saying turn instead of turns,

00:34:52.774 --> 00:34:54.620
played a very important role

00:34:54.620 --> 00:34:56.880
in the pilots' loss
of situational awareness.

00:34:57.900 --> 00:35:00.050
They also noted that
if the holding pattern

00:35:00.250 --> 00:35:02.868
had been designed according
to international standards,

00:35:03.068 --> 00:35:05.880
the minimum altitude in the hold
would have been 6,000 feet,

00:35:06.100 --> 00:35:08.640
which would have
incidentally prevented the crash.

00:35:09.620 --> 00:35:12.498
But regardless of who made
the most serious errors here,

00:35:12.698 --> 00:35:14.040
the disaster was made possible

00:35:14.040 --> 00:35:16.740
by the poor infrastructure
at Tenerife North Airport,

00:35:16.860 --> 00:35:18.069
including the lack of radar

00:35:18.269 --> 00:35:20.040
and the poorly-designed
approach procedures.

00:35:20.840 --> 00:35:22.320
It's also important to remember

00:35:22.320 --> 00:35:24.804
that the technology available in 1980

00:35:25.004 --> 00:35:27.860
was far less capable than
what we now have available,

00:35:28.220 --> 00:35:30.700
and it's exactly because
of accidents like this

00:35:30.700 --> 00:35:33.540
that we today have
these vastly improved systems

00:35:33.540 --> 00:35:36.540
and that we pilots are
so well trained in using them.

00:35:36.540 --> 00:35:38.815
This accident led to recommendations

00:35:39.015 --> 00:35:42.800
to always question any clearances
that weren't 100% clear

00:35:42.800 --> 00:35:45.520
as well as some
other recommendations as well.

00:35:45.920 --> 00:35:48.080
But in the long run,
this accident also led

00:35:48.080 --> 00:35:50.740
to better training
around GPWS maneuvers

00:35:50.740 --> 00:35:53.780
and therefore, a
significant increase in safety.

00:35:54.600 --> 00:35:57.200
Our current fantastic
safety record proves

00:35:57.200 --> 00:35:59.840
that accidents like these
today are largely preventable,

00:36:00.000 --> 00:36:01.940
but they are only preventable

00:36:01.940 --> 00:36:03.380
because of stories like this

00:36:03.380 --> 00:36:05.420
and that's why I keep telling them.

00:36:06.560 --> 00:36:09.180
Now, please consider
subscribing to the channel

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if you found this video interesting

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and let me know what
you thought in the comments below.

00:36:13.900 --> 00:36:16.780
Watch these videos next and remember

00:36:16.780 --> 00:36:17.981
to check out my sponsor

00:36:18.181 --> 00:36:19.786
who made this video possible,

00:36:19.986 --> 00:36:22.000
together with my
fantastic Patreon crew.

00:36:22.680 --> 00:36:25.160
If you want to see my next
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just go to patreon.com/join/mentourpilot

00:36:28.860 --> 00:36:30.280
if you think that sounds interesting.

00:36:30.860 --> 00:36:33.520
Have an absolutely fantastic
day wherever you are

00:36:33.520 --> 00:36:34.780
and I'll see you next time.

00:36:34.980 --> 00:36:35.320
Bye bye.