A Deadly Mistake That Went Unnoticed | The Crash Of Pan Am Flight 799

Donations are never expected but appreciated: paypal.me/miniaircrash
Join My Discord: / discord
707 Image: Ken Fielding
JetPort Image: Jon Proctor
747 Image: Eduard Marmet - www.airliners.n...
707 Image: www.flickr.com...
Northwest Memorial: commons.wikime...
This is the story of pan am flight 799. Pan am, In a way it was the emirates of its day. It had a wide route network, amazing on board product and a kind of je ne sais quoi that very few airlines have. Over its long storied history it operated a lot of ground breaking planes, including the 707. On the 26th of december 1968 a cargo 707 was on its way from LA to Cam Rahn in Vietnam with two stopovers in Anchorage and da nang vietnam. The flight wasnt off to a good start, the leg from LA to anchorage was fine but they couldnt land at anchorage due to bad weather, so the captain opted to land at nearby Elmendorf airport. This made things a bit difficult for pan am, pilots who would fly the next leg were at the airport in anchorage and now theyd have to commute to elmendorf. In the grand scheme of things its not a big deal but its a nuisance nonetheless. When they finally got to Elmendorf both pilots got to talk a bit and they chatted about the plane. Apparently the thrust reverser on engine number 4 was being a bit troublesome.
On top of that timing at Alaska was another tricky thing, a lot of planes overflew alaska, so you had to take off at a specific time and take your place in the imaginary highway in the sky so that planes were spaced out by a very safe margin. But it would be hard for flight 799 to stick to those timings on the 26th of december as they were having some trouble on the ground. They had some fuel calculation issues and they needed more fuel to be added to the plane, then they couldnt get the engines to start as the ground equipment was having some issues. By 6:02 am the plane was alive and it was headed for the runway.
But the plane was held up again, the pilots wanted to climb to 31,000 feet and then climb to 35,000 feet after burning some fuel,but since they were delayed they missed their takeoff window, if they were to take off right now they'd have some traffic conflicts with those long range planes. There was another way they could take off right now and just cruise at a lower altitude but that would burn too much fuel and so the pilots opted to wait for 45 minutes and there the plane stood in the freezing cold for 45 minutes. Finally it was time for them to go they would be taking off from runway 23 as it was longer, as the crew did their checklist they called for a follow me vehicle, its basically a truck or car that you follow if youre not familiar with the airport.
They taxied, the captain was focused on taxing the plane safely on the icy taxiway, the first officer was on the radio with oceanic control making sure that there were safe to climb and the flight engineer was busy crunching the numbers to see how quickly theyd be able to get up to 35000 feet. Even as the plane lined up the first officer was on the radio with oceanic control making sure that their takeoff time was correct. Once everything was done the captain looked over to the first officer and said “okay you got it”. The four jet engines on the 707 roared to life pushing the plane down the runway. The plane lifted off into the sky, but instantly something was wrong. Their control columns began vibrating, this was a warning, They were very close to a stall. People watching from the airport saw the plane take off but they could tell that it was struggling to gain altitude. Soon the plane stopped climbing altogether, its right wing began to drop and within seconds the nose did as well. 2700 feet from the foot of runway 23, the right wingtip contacted the frozen ground and the plane crashed. None of the three people onboard survived.

[@rilmar2137]

Such a tragic irony in that "Okay, let's not forget them"

[@mynameisgladiator1933]

They were incredibly busy so it would be hard for them to remember. This is a system related problem. A better checklisting system is needed. Or was needed. Probably fixed I assume!

[@brabhamfreaman166]

@@mynameisgladiator1933 One would hope so, though in aviation priorities seem to get scrambled or misaligned with alarming frequency.

[@eucliduschaumeau8813]

Amazing how many crashes are from forgetting to set flaps and slats for takeoff. It seems so elemental and critical at the same time. The warning not working contributed to the crash only as a fail-safe, so if that was not working, they were doomed. This seemed at first like it would be ice on the wings.

[@luv2sail66]

I thought exactly the same thing.

[@R2Bl3nd]

I think the issue is that brains aren't perfect, and given enough time, someone will make every kind of possible mistake. It just so happens that forgetting to set the flaps alone is a big enough mistake to kill everyone on board. Usually a single mistake doesn't have such devastating consequences. While humans are definitely smarter than machines for now, we certainly aren't perfect, which is obvious given this and other incidents. I think that's why more and more automation goes into planes, because That's less and less possible mistakes people can make.

[@jessicasnaplesfl7474]

@@R2Bl3nd ICING, ICING, ICING, ICING . . . . . . That's where I was stuck . . . but we never got that far.

[@garman1966]

Well they did set the flaps, but then retracted them temporarily so ice wouldn't build up on them intending to reset them at takeoff. They forgot. They were distracted by the change in procedure.

[@colinpotter7764]

Spaniair 5022 being an example.

[@pickles3128]

I incorrectly guessed that it was ice buildup in the beginning.

[@awdrifter3394]

Same. I thought they forgot to de-ice when they're trying to make the takeoff time window.

[@willshedo]

Me too

[@hansvonmannschaft9062]

I was thinking about ice from the beginning, or mainly, since he said that the plane waited for 45 minutes out in the cold. The actual clusterflak that went on there didn't even pass near me. He had it well hidden, and even threw another false hint in the ice direction when saying that the wing analysis found some parts stuck.

[@arushdeep5521]

same

[@stevencooke6451]

A reasonable conclusion based on the flight leaving Alaska.

[@patriot03062]

I flew back from Vietnam on a Pan Am 747. My first flight on Pan Am. Great Airline just like TWA. Sad they are no more.

[@R2Bl3nd]

I think the checklist was the biggest issue. The automatic systems in a plane can fail, like in this flight or on Northwest 255. But a checklist will never fail, as long as the pilots follow it. In this case, they were doing everything by the book, unfortunately this meant that they had to keep a mental note regarding the flaps. However, because they were distracted, this mental note was forgotten. A checklist can offload plenty of mental effort, such as needing to remember something relatively simple, like extending the flaps. I think the more mental effort you can offload, the better. That's why checklists exist in the first place, because although someone could theoretically fly a plane without them, that would involve relying on unreliable human brains to always remember everything every time. I think if there's ever a point where a pilot has to make a mental note of something, that means that it would be a good candidate for a checklist item. But there also should be some kind of procedure for when you need to make a mental note for something that isn't on a checklist, since a checklist can't possibly cover everything. There ought to be, if there isn't already, some kind of failsafe way to record some kind of information you have to keep track of, such as the fact that you need to extend the flaps later, and have it be impossible to skip over that before it's too late.

[@Milesco]

Well, at least as far as flaps are concerned, the solution was to include the flaps again in the takeoff checklist, just in case the pilots missed it the first time around during the taxi checklist.

[@gabiold]

I disagree with that. Humans perform way worse than a properly designed automation. Humans excel in thinking and intelligence, but very poor in executing autonomous task sequences at the same precision and care every time and at every circumstances. Extending the checklist just increases the load. If something is mentioned only once, at an inappropriate time, it might get forgotten. If something is mentioned too many times, one might skip through it, "yeah, I did it already". But this could be proven. Give one group of people checklists and a sequence of some administrative tasks. Give the other group a software which requires them same beahviour as the checklist. The software allowed to aid the work, but strictly disallow doing something if required conditions are not met. Then run the experiment for a week. I guarantee you that it will start very good, but then you will start observing increasing number of mistakes in the first group (they are getting to confident themselves and start neglecting the checklist which takes away time from the actual task) These sorts of things are easy to automate or make warning for. I am not a pilot, but it seems by all of the videos that aviation moves sooooo slowly with the development on the "user experience" side of things, everything seems so ancient and needlessly complicated. My first issue is, why the plane have to guess the takeoff intent instead of exactly selecting that mode by the pilots? And why based on the thrust levers angle? Wouldn't be more objective to enable the warning above certain airspeed? Certainly above taxi speed, but way before v1. The current implementation is similar to as if you would keop your eye on the exact gas pedal angle in your car based on the speed limit tables, instead of checking the spedometer. Checklists are good, but it should be a fallback, in case the automation does not work.

[@None-zc5vg]

If correct flap-settings key factor to successful take-offs, why couldn't they be referred to SEVERAL times in the list of pre-take-off checks ?

[@Milesco]

@@None-zc5vg : These days, I believe they are.

[@billolsen4360]

I've seen a lot of air accident videos on this youtube channel & others and a number of no-flaps-extended conditions. If I were flying again, I tell myself, I'd definitely remember those damn things, but I know how hard it is to recall something mentally that's not on a checklist and would probably be just as human as anyone else if put in the same position. Glad they added some addl checks after those two tragedies.

[@commerce-usa]

Another terrific video. As with most crashes, multiple issues combined to result in this crash. Really interesting research. Hard to believe that there wasn't one final flaps check on the checklist to save them and at least one other flight I can recall.

[@MrFlysafely]

Having cut my jet teeth in the little Learjet model 23, I developed my own before takeoff check. It was flaps, trim and spoilers. Those are the things that will kill you.

[@obamabigears734]

Exactly, but there are times when even simple things like that gets overlooked

[@stuffthings1417]

Living near an airport is a small gamble for a catastrophe.

[@Relkond]

You’ve got takeoff configuration warnings, and crashes where the warnings are disabled or otherwise fail. You’ve got multiple checklists that include the takeoff flaps position, and less rigorous or rushed pilots skip the step or entire checklists time and again. You’ve also got the crash where the takeoff warning sounded in flight (hint, it wasn’t a takeoff warning, it just used the same alert sound for an equally serious problem)... dunno if we want a weight-on-wheels airspeed > x-mph based warning... it’s pretty hard to judge what a pilot is thinking, but if you have a plane moving at speed on the ground, he’s probably taking off, landing, or in a hurricane. Landing’s easy to check - ‘brakes on?’. Catch here is the weight-on-wheels sensors can also fail (causing their own crashes), as can airspeed indicators... This flying thing is pretty complicated.

[@obamabigears734]

No pilots taking off in a hurricane

[@michaelmartinez1345]

Warning systems save lives, and so do checklists... It is important to realise that a warning system might not work properly, so the checklist should always be used for pre-flight...

[@msmcboi3128]

tbh, the main purpose of the checklist is to remind the pilots abt what they hv to do, everyone knows that the most critical stage in a plane journey is Take Off n Landing, its obvious that the pilots would be stressed, the checklist shud hv been planned properly, so that even if the pilots forget, they would be reminded again.

[@obamabigears734]

That’s wrong, the purpose of a normal checklist is to confirm the required steps are accomplished, not to remind pilots what they have to do, but obviously you are not a pilot or you would have known that.

[@Eralov]

A automatic warning system with thermometer would be great

[@TheAlaskanfrog]

Just a heads up. I grew up in Anchorage. And some stories you'd cover come through here. Elmendorf is the military airfield, Ted Stevens is the civilian airfield!

[@obamabigears734]

And why is that important?

[@RealIsrael]

Awesome videos. Can you please make one for Dana Air that crashed please

[@Bobsunfire]

Always set the flaps for takeoff! Don't forget, even if it's sunny out.

[@MikeB_UK]

Sadly, pilots are always the weakest link. Being human, mistakes get made and airplanes don't tolerate much. A properly designed computer system can now monitor temperature and all the factors a pilot would, but not be overloaded when conditions or unfamiliar airports increase the workload and stress on the human pilot. Great video and very well narrated.

[@aquatikat]

Thanks for the birthday upload!

[@hecklepig]

Elmendorf is in Anchorage. Elmendorf is the USAF base of operations in Alaska separated from the the Anchorage international airport by about 2 to 3 km. He would have you think the distance is so far as to be wearying rather than an annoyance.

[@jorgemoro5476]

It was Elmendorf AFB, not airport. I was stationed year for four years

[@obamabigears734]

It’s still an airport…

[@timdawg53]

The combination of the miscalibrated warning system and missing flaps on the before takeoff checklist contributed to this crash. Either one of these probably would've prevented this crash.

[@skipgetelman3418]

Always check the killer items just before you advance takeoff thrust Flaps,trim,spoilers stowed brakes released

[@natehill8069]

They should have a checklist-checklist to make sure you checked all the checklists.

[@steveburchfield5576]

WHEN ITS ICY THINGS GET DICEY

[@NanNaN-jw6hl]

T6:44 -- Subtitle and accident summary says 7-zero-7, but audio says 7-four-7. It's a 707, though.

[@mijnbeeldscherm]

Pilots a human thus can forget, thats why checklist are very important !

[@medicinaemdia4895]

The lack of taking care of checklists by the airlines.

[@guitarholio]

Check list.

[@mustangnawt1]

Cold weather has also caused @ least one space shuttle to blow

[@BobbyGeneric145]

Sadly at one point in the late 50s-early 60s Pan Am was losing multiple 707s per year. Lots of reasons, one of which was the exotic destinatiins they operated to.

[@summushieremiasclarkson4700]

I would expect the plane to have problems maintaining lift, but after takeoff, with the speed increasing, why did it lose lift? And why did the wing tip over? I don't understand.

[@obamabigears734]

I assume you are not a pilot?

[@lucah1824]

Can you imagine if the flight number was Pan Am flight 800? How scuffed that would be?

[@andreaberryman5354]

That's way too bad. 😔

[@sharathpaps]

Hi, just a suggestion. Would it be possible for you to include an animation of the planned route for the accident plane in your videos? Like a tiny plane route traced on a map like you would see in movies. I feel like it would add more context to the situation.

[@MiniAirCrashInvestigation]

Sure

[@review6908]

Aircraft should warn if it is not in take off or landing configuration regardless of temperature.

[@kamilZ2]

The warning system should have multiple thermometers. For left-right symmetry and heat from jet engines the absolute minimum should be 4 fully operational thermometers, otherwise the engines should not start.

[@obamabigears734]

Remember, this is when Jets were fairly new and all those small bugs are all worked out in newer jets

[@patolt1628]

Answering to your question, I would say: 1. the pilots since there are not so many things to remember as "basic" before take-off: they rely too much on check-lists wythout thinking ... 2. the disarmed warning: that's not normal. By the way I never understood why airliners do not always take-off at full power, they would take off faster and safer. Instead they go through calculations to define the "best" power setting in relation to airfield altitude, air temperature, runway length ... to spare the engines! How many people died to spare the engines? 3. the check-list : check-lists are important for sure but there are only a few "very important" items to be properly set and pilots are not supposed to be only robots following check-lists, they are allowed to think a little bit (I was a pilot) Just my opinion

[@mikewisdom6520]

Allways use flaps and full throttle

[@CallistoTrains]

Things always go wrong with Pan Am

[@variantloki9478]

Looks like way too many things for pilots to do which makes them even forget the basics. There should be a Linear way of doing things. Considering they have to deal with the traffic, it's literally one man down when they have to do another thing. Many accidents happen because of Communication. Either by lack of it, or too much of it. There should be some grouping of Indicators done based on Essential, Optional and Situational/Special case. And it's too much of an ask for pilots to remember about the warning system that needs to be set for different weather. Complicating complex things. At least in the new designs, they should consider bringing in an AI as a third thing along with Autopilot. This should operate independently and show step by step instructions on what to do next if things are going wrong. In this case, if programmed well, an AI system can warn about the retracted Flaps well before.

[@gokhalemayur8524]

It's defective checklist only........after all pilot's r bound to follow checklist....right?

[@rafaelwilks]

Pan Am was basically the unsafe version of Emirates.

[@johnford5568]

So how did it even lift off at all?

[@Efecretion]

Why not just have a friggin button to press right before takeoff that will activate the alarm if wrongly configured?!?

[@SheepWaveMeByeBye]

"Yeah, we got this warning system, but it only works on a sunny day lol."

[@zoltanolah7360]

First I read "it only works on Sunday" :D

[@majorborngusfluunduch8694]

@@zoltanolah7360 On the contrary, it tends to call out on sundays, the lazy thing.

[@piotrnierobis7438]

It's only work 8:00-16:00 😂

[@PassiveSmoking]

So a system that warns the pilot has forgotten to configure the aircraft for takeoff doesn't work in cold weather unless the pilot remembers to configure the warning as well. That's not great human factors engineering (though given that these systems were designed in the 50s I guess that's to be expected)

[@danilon3121]

Mate, you make some real great aviation content. Love it & I'm always looking out for the notification.

[@MiniAirCrashInvestigation]

Thanks so much Danilo!

[@fluffy-fluffy5996]

Agree. Some other channels go into so many technical details it’s hard for me to understand what they are talking about and I get lost in these. But here it’s all concise, but still complete 💪

[@BobbyGeneric145]

@@MiniAirCrashInvestigation hey Mini, I shared the video with my acquaintances at the Pan Am World Airways Museum in nyc... They said they liked the content but found the title to be offensive clickbait. Theres always a possibility thst one of the cutators knew a member of this crew, so I told them I'd reach out and see if you would consider changing the title to something mire descriptive and respectfully accurate?

[@MiniAirCrashInvestigation]

Already changed

[@blairimani]

Your voiceover is more lively with excellent emphasis and I love to see the improvement!

[@coca-colayes1958]

Thanks mate I like a early release for me here in Sydney it’s only 9:30 pm I’m all set to watch

[@Willon]

Fellow Aussie

[@coca-colayes1958]

That was a fantastic video I was thinking you might have done this video before? But maybe I just read it or seen it on another channel anyway now I watched it I’m watching it again now that’s how much I like your work

[@MiniAirCrashInvestigation]

Thank you Andrew!

[@adamgropper2072]

Always wanted to visit Sydney.

[@omnipossum92]

@@adamgropper2072 Sydney is pretty neat. I spent a few days there in 2015 and I'm eager to go back one day, probably when everyone's vaccinated.

[@scott17601]

I love your videos and they are even better since you started including flight sim footage of the planes. Keep them coming! Liked and Subscribed!

[@andy99ish]

The special something of Pan Am was that it captured the optimistic spirit of the USA of these times. Its very name underlined that it was both an American and a global airline. And so it was: I can remember how as a teenager I was waiting with my parents in Pan Am's futuristic and elegant JFK terminal, the Worldport, looking at the remark next to flight PA 001. It said "Round the World". Which encapsulated the spirit of Pan Am and of the USA of those times at large. And the romance of travel. Emirates will never come close to that, for all its oriental opulence.

[@stevencooke6451]

I agree regarding Emirates. Pan Am set the standard and then upgrading it. It still remarkable that it has been gone for thirty years. Didn't think TWA would go as well, but the aviation industry has crushed many.

[@muslimcel4581]

That optimistic america has long been dead

[@Nobilangelo]

Cameras looking at the wings and tails and engines and displaying the images in the cockpits would prevent a lot of mistakes and crashes. Then, instead of having to rely on instruments to tell you what was happening back there, you would be able to see for yourself. Just as you could in a Tiger Moth.

[@JoshuaC923]

The latest planes do that have to help with taxiing on the ground, some airlines let passengers see the tail cam and belly cam too. Quite fun

[@Pedro-fh6if]

They couldn't be bothered to look at the flaps-handle. You think they would look at a display of the wings?

[@Ananth8193]

Awesome video as you said Pan am is Emirates of the beginning of the jet age...I am amazed by the animation you provide to your videos

[@MiniAirCrashInvestigation]

Thanks so much!

[@BobbyGeneric145]

I disagree with that comparison. Emirates was not groundbreaking. True, they had showers, 150 a380s, and beautiful Flight Attendants... But PanAm was a PIONEER. They developed a majority of the systems of operating a global airline that are still in use today. And the flight attendants on PanAm were world class women, not simply pretty to look at. So yes, in some regards it is a valid comparison... But PanAm was so much more important to the industry than Emirates will ever be. Still enjoy all of your vids... Please keep them coming!

[@rafaelwilks]

@@BobbyGeneric145 Pan Am was the pioneer - but not the best. Yes, Pan Am flight attendants were world-class - but so are Emirates flight attendants. Plus, in its 37-year history, EK has never had a single passenger fatality; the longest Pan Am ever went without a passenger fatality was 5 years. No matter how important Pan Am was - and they are very important - they definitely were not the best. Indeed, after a Pan Am crash, the captain wrote a book, The Myth of Aviation Safety, which was true for the entire airline industry during the "Golden Age" of air transport that never was. Seriously, Emirates (and, for that matter, Etihad, Singapore, and more airlines) offers first class products way above and beyond anything Pan Am ever had.

[@reedman0780]

Basically "If you've forgotten it, then its not important" *takes off anyways*

[@bocahdongo7769]

Rather "The all safety measure is gone." Flight Operation is designed as foolproof as possible. And this is what happen if you don't do that

[@andrewdillon7837]

You can tell old planes,,,little tiny motors on the wings,,,and lots of black smoke on take-off.. BTW , there are heaps of crashes on "Mayday, Air Crash Investigation ",where the flaps weren't extended ,,and checklist problems,,, NASA got involved, hence better checklists,,also,,warnings were introduced to stop flaps down take offs,,, BUT wait there's more,, one 3 engine plane crashed because of false horn announcements,, so the breaker waS ROUTINELY PULLED,,, CAN'T REMEMBER THE CRASH,, argghh, caps lock got me,,im heading down...owrihjgiuefhgbiweuthgp;weoitghn[weotv

[@mikestone9129]

Non pilots will say, pilot error. And they were 90% guilty of that. But any pilot, especially pilots of complex aircraft will tell you that b4 take off is always a very busy time and without proper training and without following strict procedures this can and does happen. More than non pilots would want to believe. Being in a hurry to make dead lines or beat weather etc is usually the factor in making deadly or even non deadly mistakes.

[@jonnybee48]

An old Navy saying - "check, double-check then check again".........

[@ursodermatt8809]

yes, that is what they were doing.

[@toddsmith8608]

Engineers: "Hey Boeing, the xyz system has issues that could cause a crash, that should be fixed." Boeing management: "That would cost $ to fix, leave it be." Sound familiar?

[@danilon3121]

Bro, don't be stressing. We'll just install cheap computer software to make sure the flaps are extended when required, and have it all hooked up to a single sensor that is prone to failure. Airlines wont even need to provide updated training to pilots, that's how amazing it'll be. Nothing can possibly go wrong.

[@richardjenkins4182]

Bean counters often win the day. That's what led to the poor design of the Piper Cheyenne III. Engineers warned management of design flaws, but bean counters won the day.

[@None-zc5vg]

@@richardjenkins4182 The same penny-pinching 'bean counting' helped to turn hundreds of DC-10 passengers into mincemeat* when McDonnell Douglas were allowed by the FAA to take their time retrofitting key safety mods into DC-10 hulls, in order that sales wouldn't be lost. * in1974

[@whiteonggoy7009]

Love how you explain so that even I with a limited knowledge can understand...many thanks

[@Rem255]

Thank you so much, you got me while I'm at work today and I'm so excited! Your content is awesome!

[@MiniAirCrashInvestigation]

Thanks!

[@adamw.8579]

Even on my FSX always checking before TO: flaps, trims, heading & altitude settings (according to ATC commands) and at last throttle up. I think so after many flights pilots became bored and less vigilant, too much routine also kills.

[@mynameisgladiator1933]

Pilots need to have a notepad in the cockpit where they can write ad-hoc notes to themselves of odd states - like when the pilot said "Let's not forget the flaps", he should have a place to write that and then reading that note pad will make up a sort of "Final Checklist" of things they have to do.

[@user-tq1tf6hh9w]

Northwest 255 was a repeat of the same failure of the crew to follow the checklist, plus, they disabled the configuration warning. The FAA should have issued an order to all towers in the U.S., that prior to granting takeoff clearance, the controller verify with the aircrew that the aircraft is configured for takeoff. This would cause flight crews to have to verify the flaps and slats are properly extended.

[@jamest2401]

What do you mean, Taking off without flap extension is “Unheard of”? Takeoff without proper wing configuration has been the cause of MANY crashes.

[@Anonymous-tu4pl]

There are many crashes attributed to not deploying flaps. There are like 5 Air crash investigation episodes in which the crew didn't deploy flaps So whenever a plane crashes on takeoff I first think it probably is not deploying of flaps

[@adamrak7560]

Engine failure at takeoff is also a big killer. It is usually possible to recover from a single engine failure at takeoff, but very difficult, so even experienced can fail. In case it is a cargo plane loaded to the absolute max, a single engine failure just after rotation is mostly likely deadly (unless they have empty field in front of them, and can crash land).

[@Anonymous-tu4pl]

@@adamrak7560 I am not saying it is always flaps I just think the probably cause may be not deploying flaps

[@ziggyzap1]

The high stress load combined with poor checklist and terrible weather would be my answer to this question

[@awdrifter3394]

It sounds like they are not at full throttle during takeoff, could they not have push the engine power higher to create more lift instead?

[@rayzorrayzor9000]

For Boeing not to define what they meant by ‘Cold Weather’ is a total failure by such a large company . I spent years in health and safety and when you write amendments to any rules or instructions the first thing you do once you’ve written it is to check your own wording to make sure that the new instructions are clear and concise, you then turn your finished amendment to someone else who checks to see if they understand what you’ve written . Only then is your amendment given to a test sample of people to see if they all agree on the new instructions . Once all this done it is finally approved by yet another separate person but this only happens if that person agreed with the writer, the first proof reader, the selection group and that he/she are also happy that the new instructions are clear and concise. So what the hell was Boeing doing ? They must, by way of legislation, have thier own system of checks to prevent that confusing type of amendment to be sent out . If I had even just for once ignored that system of checks my career would have been over , yet Boeing had more at steak , that being thier customers lives , I say again , I am appalled by the companies conduct . Edit : I just wanted to do this add-on cos I “slated” Boeing for thier confusing amendments, but I do remember now something that happened in my own career which highlights how easy mistakes are made . I was in charge of the safety on a very Dangerous and delicate job , what made it even more stressful was the fact that it was the first time in England that this particular procedure was undertaken . I thought I had done all my “homework” by chatting with safety officers from 2 other countries that had overseen the same procedure (Aswell as memorising around 2,000 pages of documentation ) Well the job got underway and at that point all I could do was to sit in my little portacabin and state at the blank walls . My job entailed me being the last line of defence should things go catastrophically wrong . I had a Big Red Button and all I had to do was to push it in an emergency . This action would set off an explosion that would sever all links between the worksite and the 2 tower blocks nearby , this would give any expanding explosive gasses an emergency place to vent out to the atmosphere (rather than heading to the 2 tower blocks and potentially bringing them down) Now remember I am head of safety, no matter what mistakes are made by other safety personnel in enforcing the safety protocols, the ‘Buck stops’, with me , I am ultimately responsible for any and all mishaps . So now imagine my horror as I suddenly realise that I am in a portacabin (it’s a wooden or aluminium box on wheels with a couple of windows in them ) , instead of what was supposed to be a portable “Bomb Proof” shelter . What made it worse was that I needed to be close to the “action” so I could visualise what was occurring instead of just having to rely on radio conversations . This meant that I was in the blast area (which is why I was supposed to be inside a reinforced steel and concrete structure). I realised that if I did need to set off my explosives then there was no question, I would be killing myself , a few milliseconds after my pushing that button then I would be vaporised, or if there was anything left of me then I’m sure I would be in vast amounts of little pieces . I quickly weighed up the options in the situation I was in only to realise that I had no options available , (once this particular undertaking had started it could not be stopped , the procedure was “All or Nothing”. I then decided not to let anyone know about my predicament cos I didn’t want to put any more pressure on to the guys that were carrying out the process. The only one option available to me was a “Non-Option”, cos this meant NOT pushing the Big Red Button if it was needed , Yes it would save my own life , but it would doom possibly hundreds of people to thier deaths . So seeing as there was no way I was going to trade my own life for around 200 other innocent people , All I could do was to sit , listen , and to watch , praying that I did not have to push that button . It took around 4 hrs for this delicate part of the operation to be completed (This was the only part of the job where a BIG RED BUTTON was needed). I had spent around 3 and a half hours with my hand poised ready to Push that Button , There was literally a puddle of Sweat underneath my chair, my clothes were as if I had jumped in to a pool fully clothed , I couldn’t talk cos my mouth was soo dry . Also I was ‘Frozen’ in my position and couldn’t move. Finally someone was sent to check on me, now I haven’t a clue of how I looked physically but this guy took one look at me and said , “OMG , WTF”, he then screamed for help. I was hospitalised for 4 days so that my body could recover from the stress and strain that I went through , those nearly four hours crippled my body. This was due to one mistake and that mistake could have ended up costing a lot of lives . So even though I chastised Boeing , I do realise that mistakes can (and will) happen . There was one good thing that I learnt from that experience, we all like to think that we are the type of person that would ‘Step up’ and ‘ do the right thing’ in a critical situation, but the truth is we don’t really know until such a situation is faced . Your probably reading this and saying to yourself, “Yeah but you didn’t have to push the Big Red Button”, And of course you are right , but as soon as the situation became obvious to me , I straight away accepted that I would not survive , I didn’t think too hard about it . Then there was the fact that I kept quiet about it cos I knew not only would more stress be put on the operatives but also my boss would’ve done whatever was needed to keep me safe . That would’ve meant other people putting themselves at risk by utilising the heavy plant and machinery and trying to put up some sort of blast protection for me . I didn’t want anyone else in harms way so I kept quiet. Put all these things together and it showed that my one and only responsibility at the time was to PUSH that Big Red Button should the need arise . So it’s good to know that I am the type of person that wouldn’t mess about , I would do what was right , even at my own demise . Anyway, Thankyou for sticking with this till the end, I really didn’t think that it would take so long to explain it all . Take Care . and , Be Safe , you never know what life is going to throw at you as you get around the next ‘corner’ . 😟

[@mickmeadows]

Always so sad any crash. Can’t imagine being onboard when it goes down. Nightmare. RIP.

[@hack1n8r]

My opinion is that the fault was shared by the flight deck members, the weather, and the industry itself. Yes, had they followed the checklist, the accident would most likely not have happened. However, the primary thing to remember is that the jet age was still in its infancy, and that the criticality of certain things were not known yet in the industry, like the importance of immediately revising checklists after it was demonstrated necessary. In the end, it was naivety and fixation that killed these people; its extremely sad that it took another like disaster to wake up the industry. Laissez faire is still common in this industry, but we react, respond & remediate *much* quicker today, and future tragedies are averted as a result (mostly).

[@jaredkennedy6576]

Well, at least Pan Am Railways doesn't need to worry about flap configuration.

[@ziiofswe]

I'll go with option 4... stress. The pressure to get up in the air in time. That's the kind of stuff that makes you forget things that you _know_ you should've done. That's the kind of stuff that can make someone miss (or skip) even multiple check lists.

[@grahamstevenson1740]

AAAAARRRGGGHHHH ! How many times do I have to write that LANDING *GEARS* is *WRONG* !!!!!!! The plural of landing gear is *LANDING GEAR*, the same. They aren't gears, you find gears (plural) in a gearbox, Gear in this case is simply another word for 'equipment' and equipment has no plural either. It's the same for aircraft. 1 aircraft, 3 aircraft just like 1 sheep, 16 sheep ! Learn the English language please.

[@powwowken2760]

Taking off without the flaps is very, very unusual Oh? Why is that? Cause if you don't use the flaps on takeoff you're basically guaranteed to die Oh.... Makes sense...

[@rob737700]

The crash was a result of all of the reasons that you mentioned, hence the term "error chain." Inserting another flap check would have broken this chain. Another nicely done video.

[@MaxLai_0104]

The warning system not working reminds me of One-Two-Go 269, where 40 knots of windshear and possible fatigue caused a them to forget TO/GA during go-around and they entered a stall, where controls were transferred without warning. There were 6 windshear sensors around the airport, but only 3 were working. The reason, was because they were solar powered, and the solar panels were blocked by clouds, where windshear would be most common.

[@recklessroges]

Warnings should be last hope. So Boeing failed to design an all weather plane and Boeing failed to write a complete checklist. The training was insufficient but the lack of response from Boeing after this crash... to let another one happen seems to be very Boeing. "The MAX in 737 MAX is *profit* not performance or safety or reliability."

[@larrybaker5316]

I was a 19 year old airman sound asleep near the end of the flight line. I heard these jet engines screaming louder than I have ever heard, and thought to myself, someone is crashing, the sky lite up orange from the fireball, horrible situation, I had horrible nightmares for months afterward. may they RIP.

[@peterirwin6409]

Regardless of poor checklists, making sure the flaps are set before rolling down the runway is the most basic, fundamental part of taking off.

[@Dovietail]

You can almost understand the industry and airlines not wanting to make safety changes that will cost millions of dollars. But how much does it cost to rework a checklist? Virtually nothing in the scheme of things.

[@quinton1661]

1. Elmendorf is an Airforce base 2. That looks nothing like Anchorage lol I live in Anchorage

[@danielringheim9002]

Takes 5 minutes to add a row to the take off checklist. Boeing: ”Nah. We dont’t need that”

[@richardjenkins4182]

As the video correctly points out, the pilots were very busy and had much to think about. Non-pilots want to put all the blame on the pilots, who had many complex variables taking up brain space. It seems like such a basic error today. But there are now improvements in checklists, as well as methods to use those checklists. I flew 727s in the 1990s. Our company checklists called for setting (or verifying) the flaps for takeoff 3 separate times, to ensure they weren't missed. If pilots are running a checklist and are interrupted for any reason, the crew member reading the checklist will either stop at the last verified step, or even start that particular checklist (Taxi, Descent, whatever) over from the beginning. We all benefit from improvements in technology and processes after these disasters. Sadly, as the video again points out, some improvements that could have been made after PanAm weren't done, until passengers were killed. Essentially the attitude in the industry is often "no humans were killed, only pilots, so let's not change anything yet."

[@xonx209]

It boggles the mind such sophisticated machine cannot automate part or all of the checklist.

[@Richard-bv3er]

@@xonx209 Not really. Electronics weren't nearly as advanced back then. No one had tablets or cell phones back then, either.

[@bobconnolly190]

why does it not mention ice,?

[@curbyourshi1056]

I like this a lot better than "Air Crash Investigation" from off of the tv. This is straight to the point. 👍

[@notme2day]

Right .. without all the personal baggage .. I like the straight to the point cause and effect but I miss some of the input by investigators putting the pieces together.

[@curbyourshi1056]

@@notme2day Aye. The real investigators are an added bonus.

[@billolsen4360]

And "Mayday" as well. So much melodrama about how scared the passengers were. I get it.

[@jamesmoore8558]

Seems to me placing the flaps as the last item on a checklist would help a great deal

[@adamgropper2072]

That’s why. Always good to lower the flaps after de-icing the wings and the whole plane.

[@BestIkeaTable]

Tables are better than chairs

[@ganzyjam2602]

Questions ? So are you able to safely deploy flaps and ailerons (if forgotten) at take-off while trying to gain altitude, any risk of damage? Does it all require configuration before take-off or can you deploy if needed ?

[@golson33]

Yes

[@obamabigears734]

@@golson33 you can, but on a large jet it would be too late anyway since the flaps move really slow, of course if you were an airline pilot you would know that.

[@oliwek70]

Thank you, always enjoying your content. I didn't see any link to JAL 8054 (10:17) on screen near the end of the video, maybe you could add this in the description ?

[@coca-colayes1958]

kzbin.info/www/bejne/eaCtc4ucgr2oipo

[@BytomGirl]

Of all the flights in my lifetime one on PAN AM from London to San Francisco was most memorable, it was huge, comfortable, lots of leg room, great food and great service. The best experience. Finnair was nr.2, would be possibly nr1 if it wasn't for a scare, fuel dumping and return to the airport after an hour of flying and being greeted by firetrucks but pilot landed perfectly. Another time our connecting plane from London to San Francisco (I don't remember which airline) didn't take off at all due to the storm in London at the time (it was in February), it was a great decision. They put us up in a 5 star Edwardian hotel in a luxurious room and with huge proper English breakfast. I didn't make it to work the next day but it was worth it. Conclusion, when the weather is bad and there are even small problems, stay put until you know it's safe...

[@ambassadorkees]

These no flap takeoffs have been too frequent. Configuration warning circuit breakers switched off due to another nuicance or anomaly, 3 times in the checklist, but always towards the end and each time other communication interrupted the checklist procedure etc..

[@hexadecimal7300]

I think the disarmed warning system doomed the plane. Pretty sure if it went off both pilots would have remembered the flaps immediately.

[@obamabigears734]

Obviously you have no clue what you are talking about

[@hexadecimal7300]

@@obamabigears734 Maybe, please explain why? My comment was based on the youtube. I have very limited flying experience other than simulations.

[@obamabigears734]

@@hexadecimal7300 Best way to explain is it no pilot depend on a warning system. Warning systems are just there for as a last line of defense. What doomed this flight was a chain of events, the major one being the taxiways were contaminated with snow/slush, hence the Captain elected to retract the flaps after they had been already been extended, this was never caught by the other crew members, most likely because they were busy with other tasks which were not normally done on a regular flight.

[@hexadecimal7300]

@@obamabigears734 Yes rarely do these disasters happen over one event, usually a connected series of them. I would hope that if the configuration alarm had sounded then possibly the crew would have done something about it.

[@obamabigears734]

@@hexadecimal7300 Yes, they would hopefully have aborted the takeoff since the warning comes on quite early. Someone pointed that just put a styrofoam cum over the flap handle as a reminder that flaps are not extended, if they had to been up for taxing in snow/slush, and that’s what many pilots do, but maybe that lesson was learned from this accident…

[@roachtoasties]

It's ultimately all the pilots' responsibility.

[@viewwwwer]

Sounds a lot like Spanair 5022.

[@sstarklite2181]

Would’ve it be great if everyone could get 7-8 hours of perfectly restful sleep every single night. And if there weren’t any time schedules to worry about.

[@ronjon7942]

Ugh, human factor accidents are so tragic. I'm no pilot, but I have that gift of being able to instantly put supposed checklist items completely out of my mind, so no lack of empathy there. It's terrible that these talented people lost their lives, the only silver lining there were no passengers.

[@yamato6114]

Yeah human factor accidents are unfortunately unavoidable. It’s easy to say “Oh I would never do that!” But think about it. How many times does the average person forget their phone, or their keys? How many times has someone forgotten to do something because they were tired or disoriented?

[@ianr]

Excellent video about an accident I had never heard of. Great graphics. 👏🙂

[@AK-ny5bz]

Just imagine if everytime one has to start driving a car there was a book to go through

[@watchforlife]

Funny thing is,if there's any mistake or trouble, you can easily pull over and investigate. Try that at 35,000 feet, onboard an aluminum tube with engines on each side. Lol,that would be one hell of an investigation.

[@77leelg]

There is a screw to adjust the horizontal stabilizer not the elevators. There is a specific setting for the stabilizer for takeoff depending on the weight and balance calculations.

[@yoursbrutal]

Boeing always needed casualties to implement safety systems in thier aircrafts..

[@obamabigears734]

As opposed to other manufacturers?

[@damongreville2197]

Great video. I find it difficult to understand how pilots can forget flaps for take-off. Mostly it is a critical thing for a successful takeoff. I would on occasion, when the runway was short and we were heavy, start the roll with no flaps, but with my hand on the flap switch. This allows you to pick up speed quicker without the drag of the flaps. Then at an appropriate speed pop the flaps.

[@obamabigears734]

He gave you a clue what underlying problem was, I you missed it then obviously you have never flown a large jet.

[@L4v3]

They had flaps out but their taxi checklist wanted them to retract them so ice wouldn't build up and so they did. If you always follow checklists and you are ready to take off with all checklists completed it's very easy to assume your plane's configured for takeoff.