It's the worst aviation disaster in Portuguese history.
这是葡萄牙历史上最严重的航空灾难。
144 people are killed.
144人遇难。
The scope of the devastation was remarkable.
灾难的范围令人震惊。
The wreckage provides little evidence.
残骸几乎没有提供任何证据。
They're way too damaged to test.
它们损坏得太严重，无法进行测试。
Air traffic control offers no insight.
空中交通管制没有提供任何线索。
Were they advised to use the ILS?
他们被建议使用仪表着陆系统（ILS）了吗？
Yes.
是的。
Only the final seconds of independent air flight 1851.
只有独立航空1851号航班最后几秒的飞行记录。
Pull up.
抬升。
They had seven seconds until impact.
他们距离撞击还有七秒钟。
Reveal the whole story.
揭示整个故事。
They don't say anything?
他们没有说任何话吗？
I've never encountered anything like this before.
我以前从未遇到过这样的情况。
And I never encountered anything like this afterwards.
而且之后我也再也没有遇到过这样的情况。
To say it was unique would be an understatement.
说这是独一无二的，都是轻描淡写了。
Independent Air Flight 1851 cruises above the Atlantic Ocean.
独立航空1851号在大西洋上空巡航。
There are 137 tourists on board the American charter flight.
这架美国包机上有137名游客。
Santa Maria Independent Air 1851 requesting MET report.
圣玛丽亚独立航空1851号请求气象报告。
Less than 30 minutes before landing, the crew prepares for descent.
距离降落不到30分钟，机组人员准备开始下降。
1851, wind 260, 14 knots.
1851号，风向260度，风速14节。
34-year-old flight engineer Jorge Gonzalez checks the weather ahead.
34岁的飞行工程师乔治·冈萨雷斯检查前方的天气。
He's a US Air Force veteran with a sterling reputation.
他是一名美国空军退役军人，拥有卓越的声誉。
41-year-old Captain Leon James Doherty is also from the military and has been flying jetliners for almost a decade.
41岁的机长莱昂·詹姆斯·多尔蒂也来自军方，已经驾驶喷气式客机近十年。
Let's request descent.
我们请求下降。
Santa Maria Control, Independent Air 1851 would like to descend.
圣玛丽亚控制台，独立航空1851号希望开始下降。
36-year-old First Officer Sammy Adcock just started with Independent Air two weeks ago.
36岁的副驾驶萨米·阿德科克两周前刚加入独立航空。
Independent Air 1851 clear to descend to flight level 40.
独立航空1851号获准下降至飞行高度40。
Cleared to flight level 40, Independent Air 1851.
获准下降至飞行高度40，独立航空1851号。
The crew was a balanced crew.
机组人员是一个平衡的团队。
They had flown together for about a week or 10 days, and they were doing fine.
他们一起飞行了大约一周或十天，表现都很好。
They're flying a four-engine Boeing 707.
他们驾驶的是一架四引擎波音707。
The long-range, narrow-bodied jetliner has dominated passenger travel for more than three decades.
这种远程窄体喷气客机已经主导了三十多年的客运旅行。
It wasn't a modern jet at the time, it was 21 years old, but it was well maintained within all the safety regulations.
当时它不是一架现代喷气机，已经有21年的历史，但它在所有安全规定范围内得到了良好的维护。
Today's flight from Bergamo, Italy, will refuel at Santa Maria, an island in the remote Azores, before continuing to its final destination, Punta Cana, in the Dominican Republic.
今天的航班从意大利贝加莫出发，将在大西洋中的偏远岛屿圣玛丽亚加油，然后继续前往最终目的地多米尼加共和国的蓬塔卡纳。
Santa Maria was a popular destination for refueling because of its location in the Atlantic.
由于其在大西洋中的位置，圣玛丽亚是一个受欢迎的加油目的地。
It's a small island with a large mountain in the center.
这是一个小岛，中心有一座大山。
That mountain is called Pico Alto.
那座山叫做皮科阿尔托。
At almost 2,000 feet, Pico Alto, or High Peak, is the highest point of a mountain range stretching across Santa Maria.
皮科阿尔托，或称高峰，几乎有2000英尺高，是横跨圣玛丽亚的山脉中最高的点。
Hey, close the door.
嘿，关上门。
It's a juggle out there.
外面真是乱哄哄的。
Are you finished with those?
你弄完那些了吗？
Yeah.
是的。
Thanks.
谢谢。
Thank you.
谢谢你。
What's your passing level?
你现在的飞行高度是多少？
Independent air 1851.
独立航空1851号。
Passing flight level 220.
正在通过飞行高度220。
60 miles from the airport, the first officer tunes in to the frequency for Santa Maria Airport.
距离机场60英里，副驾驶调到圣玛丽亚机场的频率。
today a trainee in the tower is guiding in the flight with the help of a supervisor independent 1851 Roger
当天在塔台的是一名受训者，在一名监督员的帮助下指导飞机独立航空1851号，收到。
In 1989, I would describe the Santa Maria air traffic control facility as being very unsophisticated, very small.
在1989年，我会说圣玛丽亚的空中交通管制设施非常原始，非常小。
The airport is also not equipped with radar.
机场也没有配备雷达。
There were only three scheduled airline flights per day.
每天只有三班计划航班。
It doesn't justify the cost of air traffic control radar, which is very challenging for air traffic control.
这并不足以证明安装空中交通管制雷达的成本，这对空中交通管制来说是非常具有挑战性的。
You're cleared 3,000 feet on QNH 1027.
你被清除至3000英尺，QNH 1027。
Runway will be one niner.
跑道将是19号。
Expect ILS approach.
预计进行ILS进近。
Runway one niner.
19号跑道。
Report reaching 3,000.
报告到达3000英尺。
The controller is relying solely on position reports from the pilot.
管制员完全依赖飞行员的位置报告。
So they have to be meticulous about protecting the airspace and documenting the altitude that the aircraft is at.
因此，他们必须非常细致地保护空域并记录飞机的高度。
Is that what they said?
他们是这么说的吗？
1027 on the millibars?
毫巴上是1027吗？
Yep.
是的。
Just over 13 minutes from the airport, the crew readies the plane for landing.
距离机场刚过13分钟，机组人员准备着陆。
Seat belts and shoulder harness.
安全带和肩带。
Secured.
已经固定。
We're having fun now.
现在我们玩得开心了。
Hey, hey.
嘿，嘿。
On that day, the weather in Santa Maria was fine.
那天，圣玛丽亚的天气很好。
There was just some cloud cover in the vicinity of Pico Alto.
只是皮科阿尔托附近有些云层。
That is very common.
这是非常常见的。
Switching off autopilot.
关闭自动驾驶。
The captain takes control of the aircraft.
机长接管飞机控制。
The captain would likely be hand-flying the airplane to get comfortable controlling it.
机长很可能会亲手操纵飞机，以便适应控制它。
It ain't looking too hot out there.
外面看起来不太好。
Yeah, we'll get down below.
是的，我们会下降到云层以下。
Depends on what level those are.
这要看那些云层的高度了。
There's cloud cover ahead.
前方有云层。
If conditions get worse, the crew will have to make the approach using only their instruments for reference.
如果条件变得更糟，机组人员将不得不仅使用他们的仪器作为参考来进行进近。
Okay, I'm gonna go ahead and put the ILS in on my side.
好的，我要在我的一侧输入ILS。
Okay.
好的。
ILS, or Instrument Landing System, is a navigation system that provides vertical and horizontal guidance to the runway.
ILS，即仪表着陆系统，是一种提供垂直和水平引导至跑道的导航系统。
That means that he can fly in clouds until he gets on to final approach.
这意味着他可以在云层中飞行，直到进入最后的进近阶段。
It's always better to have help.
有帮助总是更好。
35 miles from the airport, the coastline of Santa Maria comes into view.
距离机场35英里时，圣玛丽亚的海岸线映入眼帘。
When approaching from the east, you will see some big cliffs, some green, a lot of green.
从东面接近时，你会看到一些大崖壁，一些绿色，很多绿色。
Where's the airport?
机场在哪里？
It's on the other side of the island.
在岛的另一边。
As they approach the island, an alert in the cockpit tells the pilots that they are 500 feet above their selected altitude.
当他们接近岛屿时，驾驶舱内的警报告诉飞行员他们的飞行高度比选定的高度低500英尺。
400 to go.
还有400英尺。
Don't know if we're going to get visual or not here.
不知道我们能否在这里获得视觉。
Starting to pass through the layers.
开始穿过云层。
As they cross the coast of Santa Maria, weather conditions worsen.
当他们穿越圣玛丽亚海岸时，天气状况恶化。
The winds can be pretty severe around Pico Alto, and this can present a challenge for the pilots to maintain control of their aircraft.
皮科阿尔托周围的风可能非常强烈，这可能会给飞行员控制飞机带来挑战。
Can't keep this damn thing level.
无法保持这该死的东西水平。
Just two minutes from the airport, flight 1851 is seen flying very low overhead.
距离机场仅两分钟，1851航班被看到在头顶上飞得很低。
Pull up.
抬升。
All right, all right.
好的，好的。
Pull up.
抬升。
The equipment is telling the crew they are in a potentially dangerous situation.
设备正在告诉机组人员他们处于潜在危险的情况。
Just four and a half miles from the Santa Maria Airport in the Azores, Portuguese firefighters and civilians discover a horrific scene of devastation.
距离亚速尔群岛的圣玛丽亚机场仅四英里半的地方，葡萄牙消防员和平民发现了一幕可怕的破坏景象。
Independent Air Flight 1851 has crashed into the island's highest mountain.
独立航空1851航班已经撞上了岛上最高的山。
The jet hit Pico Alto very near the top of the mountain.
喷气机撞击了皮科阿尔托，几乎是在山顶附近。
The accident site was a bit of a chaotic scene.
事故现场有点混乱。
The wreckage was strewn all over the mountain.
残骸散布在整个山上。
There were some small fires.
有一些小火。
It was a very steep terrain.
地形非常陡峭。
It was very difficult for rescuers to work there.
救援人员在那里工作非常困难。
It soon becomes clear that all 144 passengers and crew have been killed.
很快就清楚了，所有144名乘客和机组人员都已遇难。
It was a big challenge for the locals mostly to deal with that.
对当地人来说，这是一个巨大的挑战。
Santa Maria has only 5,000 people living there.
圣玛丽亚只有5000人居住。
And in a flash, they became the scenario of the worst air disaster to occur in Portugal.
转瞬之间，他们成为了葡萄牙发生的最严重空难的现场。
Rescuers work through the night.
救援人员彻夜工作。
By daybreak, the Portuguese Civil Aviation Authority, known as the DGAC, arrives at the crash site.
破晓时分，葡萄牙民用航空局，即DGAC，抵达了坠机现场。
They are soon joined by American representatives from the NTSB, the National Transportation Safety Board.
他们很快得到了来自美国国家运输安全委员会（NTSB）的代表的支持。
The terrain that we traversed was very challenging.
我们穿越的地形非常具有挑战性。
There was a lot of personal effects.
有很多个人物品。
People were just vacationing.
人们只是在度假。
There were children whose dolls I could see in the trees.
我可以在树上看到孩子们的玩偶。
The scope of the devastation, it was remarkable.
破坏的范围，它是显著的。
Investigators need to get a better perspective if they are to understand why Flight 1851 crashed into a mountain so close to Santa Maria's airport.
调查人员需要更好的视角，才能理解为什么1851航班会在如此靠近圣玛丽亚机场的山上坠毁。
The overhead view revealed to us just how concentrated the wreckage was on the side of the mound where the airplane struck it.
从空中视角揭示了飞机撞击山体的一侧时残骸有多集中。
That was something I had not seen before.
这是我以前没见过的。
So this is the flight path.
所以这是飞行路径。
The plane impacts the east side of Pico Alto.
飞机撞击了皮科阿尔托的东侧。
Correct.
没错。
Investigators examine the wreckage pattern for clues as to how Flight 1851 was flying before impact.
调查人员检查残骸分布模式，寻找1851航班撞击前飞行状态的线索。
All concentrated right here.
都集中在这里。
Sending debris over the mountain ridge.
残骸飞过山脊。
Scars on the ridge give investigators their first clues.
山脊上的划痕给调查人员提供了第一个线索。
Looks like low angle, high velocity.
看起来是低角度，高速度。
It must have been flying level.
它一定是水平飞行的。
Seafit?
是CFIT吗？
Looks like it.
看起来是。
They quickly recognize this incident to be a controlled flight into terrain, or CFIT.
他们很快认出这起事件是受控飞行撞地面，或称为CFIT。
If one looks at CFIT accidents, there are really two types, one where an airplane descends prematurely, the other where it hits the side of a mountain.
如果看CFIT事故，真的有两种类型，一种是飞机过早下降，另一种是撞上山的一侧。
They must have known about the mountains.
他们一定知道有山。
What was the altitude where they hit?
他们撞击的高度是多少？
1,795 feet.
1795英尺。
And Pico Alto?
那皮科阿尔托呢？
What does the Jeppesen shark show?
Jeppesen图表上显示的是多少？
It's listed as 1,936 feet.
它标记为1936英尺。
Pico Alto is clearly identified on the Santa Maria approach chart.
皮科阿尔托在圣玛丽亚进近图上清晰标识。
So they struck the mountain 140 feet below what was listed on their chart.
所以他们在图表上标记的山高度以下140英尺撞上了山。
What were they doing so low?
他们为什么会飞得这么低？
The possibilities were, one, the crew was off course.
可能性之一是，机组人员偏离了航线。
there was an altitude error.
另一个是高度错误。
It was our job to find out which of those would explain the accident.
我们的工作是找出这些哪一个可以解释事故。
What's the minimum sector altitude?
最低扇区高度是多少？
3,000 feet.
3000英尺。
The minimum sector altitude is at least 1,000 feet above all terrain within 25 miles of the airport.
最低扇区高度至少比机场25英里范围内的所有地形高出1000英尺。
There's plenty of room.
有足够的空间。
According to the company's operations manual, there should be at least two Jeppesen charts on board the plane at all times.
根据公司的运营手册，飞机上随时应至少携带两份Jeppesen图表。
They had to have known.
他们一定知道。
Yeah.
是的。
This was the question.
这是问题所在。
I mean, why did these guys descend so low when they knew by the charts that the minimum altitude was 3,000 feet and there was a mountain there?
我的意思是，这些家伙为什么会下降得这么低，当他们通过图表知道最低高度是3000英尺并且那里有山的时候？
So this was the last flight of the day?
所以这是一天中的最后一班飞机？
Yes, it was.
是的，确实是。
What was the minimum sector altitude you gave them?
你给他们的最低扇区高度是多少？
The team turns to the air traffic controller for insight into why the aircraft was flying below 3,000 feet.
团队转向空中交通管制员，以了解飞机为何在3000英尺以下飞行的原因。
3,000 feet.
3000英尺。
You're sure?
你确定吗？
Yeah, I even made a note of it on my flight strip.
是的，我甚至在我的飞行条上做了记录。
He was perfectly calm.
他非常镇定。
He had the normal behavior.
他的行为很正常。
He thought he had done a good job.
他认为自己做得很好。
Were you the only controller on duty at the time?
那时你是唯一值班的管制员吗？
My supervisor was also there.
我的主管也在。
It was such a slow airport.
这是个非常慢的机场。
It was certainly not unusual for a supervisor to provide on-the-job training for an air traffic trainee.
主管为空中交通管制实习生提供实际操作培训并不罕见。
What was the weather like?
天气怎么样？
Fairly good at the airport.
机场的天气相当好。
No rain or strong winds.
没有雨或强风。
Visibility was unlimited.
能见度无限。
However...
然而...
The top of Piqualta was in cloud, and winds can be unpredictable up there.
Piqualta的山顶被云层笼罩，那里的风可能很难预测。
The weather was OK.
天气还可以。
The focus for the investigators was on how the cloud layer affected the pilot's ability to see and avoid the top of the mountain.
调查人员关注的是云层如何影响飞行员看到并避开山顶的能力。
Were they advised to use the ILS?
他们被建议使用仪表着陆系统（ILS）了吗？
Yes.
是的。
Expect ILS approach.
预计使用ILS进近。
Runway one niner report reaching 3000.
一九跑道，报告到达3000英尺。
The investigator learns that the pilots did encounter cloud cover near Pico Alto, but they shouldn't have had a problem using their instruments to get them to the runway.
调查员了解到飞行员在Pico Alto附近遇到了云层，但他们应该能够使用仪器安全到达跑道。
Did the crew report any mechanical issues?
机组有报告任何机械问题吗？
No, not to me anyway.
没有，至少没有对我说。
Thank you for your time.
谢谢你抽出时间。
I couldn't find anything that explains what happened from his part.
我没能从他那里找到任何解释发生了什么的线索。
So if the controller gave them the proper clearance, why are they so low?
那么如果管制员给了他们正确的许可，他们为什么会飞得这么低呢？
What if there was an issue with the plane that they didn't report?
如果飞机有他们没有报告的问题怎么办？
The team must now consider if a mechanical issue that wasn't reported to the controller prevented the crew from maintaining a safe altitude above the mountain.
团队现在必须考虑是否有一个未向管制员报告的机械问题，阻止了机组保持在山上方的安全高度。
Now, it's possible we couldn't rule this out until we looked more closely at the evidence that something very quickly happened, something catastrophic just before impact.
现在，我们不能排除这种可能性，除非我们更仔细地查看证据，即在撞击前的一瞬间发生了某些非常快速的、灾难性的事情。
Is this everything?
这是全部的东西吗？
So far.
到目前为止是。
Investigators are looking for clues in the wreckage of Flight 1851 to explain why it descended below minimum altitude and crashed into a mountain on Santa Maria Island.
调查人员正在检查1851航班的残骸，以找出它为何下降到最低高度以下并撞上圣玛丽亚岛的山。
Let's start here.
我们从这里开始。
Could a malfunctioning engine have forced the aircraft below the minimum safe altitude?
发动机故障是否导致飞机低于最低安全高度？
It says here the jet had less than 45,000 hours in the air
这里说这架喷气机在空中的飞行时间不到45000小时。
Seven service bulletins over the last six years.
过去六年有七个服务公告。
Any issues?
有问题吗？
No.
没有。
1983, agent two had suffered turbine failure.
1983年，发动机二曾遭受涡轮故障。
Looks like it was repaired.
看起来已经修好了。
It was full of wood and dirt.
里面满是木头和泥土。
A quick examination provides an answer.
快速检查提供了答案。
There's nothing wrong with these engines.
这些发动机没有问题。
Engines that are generating power at impact, if they hit a field of trees, will ingest part of the vegetation into the engines, and that will bring the engine fan blades to a stop.
如果发动机在撞击时正在产生动力，它们会吸入撞击树木区域的部分植被，这会使发动机风扇叶片停转。
And that's what happened here.
这就是这里发生的情况。
Engines that are not turning, that are not working, won't do that.
不转动、不工作的发动机不会这样。
What about the altimeter?
高度计怎么样？
If the altimeters were malfunctioning, the crew might have believed they were flying higher than they actually were.
如果高度计出现故障，机组可能会认为他们的飞行高度比实际高。
Hi.
嗨。
Thank you.
谢谢。
Look, way too damaged to test.
看，损坏得太严重无法测试。
What are the service records, sir?
维修记录怎么样，先生？
They were last calibrated four months ago.
它们最后一次校准是四个月前。
No problems.
没有问题。
It's another dead end.
又是一个死胡同。
Maybe the altitude alert survived.
也许高度警报器还能用。
Let's take a look.
我们来看看。
The altitude alert warns the crew with an audio alert when they're approaching a preset altitude.
高度警报器在飞机接近预设高度时通过音频警报提醒机组。
Hang on.
等一下。
Is this it?
这是它吗？
Yeah, that's it.
是的，就是这个。
Doesn't look too bad.
看起来没那么糟。
Yeah, check this out.
是的，看看这个。
The altimeter alert's set to 2,000.
高度警报器设定在2000英尺。
Investigators discover the altitude alert was set for 2,000 feet, not the required altitude of 3,000 feet.
调查人员发现高度警报器被设定在2000英尺，而不是要求的3000英尺高度。
I remember this shocked all of us.
我记得这让我们所有人都感到震惊。
We just couldn't believe it, how that could happen.
我们简直不敢相信，这怎么可能发生。
Why would the altimeter alert be set to 2,000 when the controller gave them a clearance of 3,000?
为什么高度警报器会设定在2000英尺，而管制员给了他们3000英尺的许可？
Maybe the controller remembered wrong.
也许管制员记错了。
Let's check the tapes.
我们来检查录音带。
ATC recordings gives you what's exchanged during the different phases of the flight.
空管录音可以提供飞行不同阶段交换的内容。
So you can confirm absolutely what was said, either contacting the plane or inside the ATC.
这样你就可以绝对确认是什么被说了，无论是联系飞机还是在空管内部。
Good afternoon, Santa Maria Tower.
下午好，圣玛丽亚塔台。
Will the air traffic control audio recording confirm what the trainee told investigators?
空中交通管制的音频录音会证实实习生告诉调查人员的内容吗？
Independent 1851, roger.
独立航空1851，收到。
You're clear to 3,000 feet on QNH 1027.
你被清除到3000英尺，QNH 1027。
Runway one niner.
跑道一九。
Expect ILS approach.
预计进行仪表着陆系统（ILS）进近。
Runway one niner.
跑道一九。
Report reaching 3,000.
抵达3000英尺时报告。
Stop there.
停在这里。
He said it.
他说了。
Twice.
两次。
The control tower recording confirms that the controller gave a 3,000-foot clearance.
控制塔录音证实管制员给出了3000英尺的许可。
Listening to the clearance did not explain the 1,000-foot error due to the altimeter over.
听许可并没有解释因高度表错误而导致的1000英尺误差。
We needed to listen to the CVR.
我们需要听驾驶舱语音记录器（CVR）。
Take it from the point where they first contact the controller.
从他们第一次联系管制员的地方开始。
Investigators now listen to the cockpit conversation to determine why the crew descended below the 3,000-foot minimum sector altitude given by the controller.
调查人员现在听驾驶舱对话，以确定机组为何下降到管制员给出的3000英尺最低安全高度以下。
Good afternoon, Santa Maria Tower.
下午好，圣玛丽亚塔台。
Independent Air 1851 passing flight level 200 to flight level 40.
独立航空1851通过飞行高度200到飞行高度40。
That's the first officer.
那是副驾驶。
Independent 1851, roger.
独立航空1851，收到。
You're clear to 3,000 feet, point QNH 1027.
你被清除到3000英尺，QNH 1027。
Clear to 2,000.
清除到2000英尺。
Did the first officer just say 2,000?
副驾驶刚刚说2000英尺了吗？
Go back, play it again.
倒回去，再放一遍。
Clear to 2,000.
清除到2000英尺。
Investigators wonder why the first officer misheard the altitude clearance as 2,000 feet instead of 3,000 feet.
调查人员想知道为什么副驾驶误听高度许可为2000英尺而不是3000英尺。
Maybe he heard two 3,000 and mistook it for 2,000.
也许他听到了两个3000，误以为是2000。
It's possible.
这是可能的。
It looked to us that perhaps the word three never was listened by the first officer.
我们认为副驾驶可能从未听到“三”这个词。
So the first officer only listened, you're clear, 2,000.
所以副驾驶只听到了你被清除，2000英尺。
Not 2,000, 3,000, but 2,000.
不是2000，3000，而是2000。
So he never heard the word three.
所以他从未听到“三”这个词。
The CVR recorded the first officer reading back an incorrect clearance.
CVR记录了副驾驶回读了一个错误的许可。
It was very puzzling to us when we heard the CVR why the crew did not act.
当我们听到CVR时，我们非常困惑，不明白为什么机组没有采取行动。
It was clear that that wasn't given much credence.
很明显，那并没有被重视。
The controller should have corrected him too, but doesn't.
管制员也应该纠正他，但没有。
Why?
为什么？
And that's an important part of this accident investigation.
这是这次事故调查的一个重要部分。
We couldn't figure out why the air traffic controller did not correct the first officer.
我们无法理解为什么空中交通管制员没有纠正副驾驶。
Hang on a second.
等一下。
The first officer's readback of 2,000 feet isn't in the controller's transcript.
副驾驶回读2000英尺的内容并不在管制员的记录中。
So he never heard it?
所以他没听到？
How is that possible?
这怎么可能？
We couldn't figure out how they could miss each other.
我们无法理解他们怎么会互相错过。
It was inexplicable.
这是无法解释的。
All right, so the first officer mishears the altitude.
好吧，所以副驾驶误听了高度。
He reads it back to the controller as 2,000 at 1,356.59.
他在1点56分59秒向管制员回读为2000英尺。
Investigators compare the conversations between the controller and the first officer of Flight 1851 to better understand why there was miscommunication between them.
调查人员比较了1851航班的副驾驶和管制员之间的对话，以更好地理解他们之间为何会有沟通误解。
What does the controller say next?
管制员接下来说了什么？
Well, he repeats the clearance by saying, expect ILS approach, runway one niner, report reaching 3,000.
嗯，他重复了许可，说预计ILS进近，跑道一九，抵达3000英尺时报告。
That's it?
就这样？
Hang on.
等一下。
They were talking at the same time.
他们同时在说话。
Yeah.
是的。
They canceled each other out.
他们相互抵消了。
It's a troubling realization, an overlap of communication between the tower and the pilot.
这是一个令人不安的认识，塔台和飞行员之间的通信重叠。
Passing flight level 200 for flight level 40.
通过飞行高度200到飞行高度40。
You're clear to 3,000 feet on QNH 1027, runway one niner.
你被清除到3000英尺，QNH 1027，跑道一九。
It was stunning.
这太令人震惊了。
We were stunned to finally understand how the two transmissions overlapped perfectly to cancel each other out.
我们惊讶地最终理解了两次传输是如何完美重叠以至于相互抵消的。
I was an investigator for over 30 years at the NTSB.
我在国家运输安全委员会（NTSB）做了30多年的调查员。
I've never encountered anything like this before, and I never encountered anything like this afterwards.
我以前从未遇到过这样的情况，之后也没有遇到过。
They're both talking at the same time.
他们同时在说话。
They're both pushing their PTTs.
他们都在按下他们的PTT（按键通话）按钮。
That's right.
没错。
Pilots and controllers use a push-to-talk or PTT button.
飞行员和管制员使用按键通话（PTT）按钮。
When it's pressed, the radio transmits but cannot receive.
当它被按下时，无线电会发送信号但无法接收。
To think that so many people died because of a simple error, that was just, that's sad.
想到因为一个简单的错误导致这么多人死亡，这实在是太悲哀了。
That's hard to deal with as an investigator.
作为一个调查员，这很难处理。
So the controller doesn't hear it.
所以管制员没有听到。
but he should still insist the first officer read it back or repeat it.
但他仍然应该坚持让副驾驶回读或重复。
There are some readbacks in air traffic control that you simply have to get back every single time, and altitude is one of them.
在空中交通管制中，有些回读你必须每次都要得到，高度就是其中之一。
The trainee controller did not request an altitude readback, and the supervisor didn't notice, and that was unfortunate.
实习管制员没有要求高度回读，监督员也没有注意到，这很不幸。
What about the supervisor?
那监督员呢？
Good question.
好问题。
According to the controller, she was there.
根据管制员的说法，她在那里。
Maybe she was busy with other things.
也许她忙于其他事情。
Possible.
可能。
Investigators wonder if the supervisor monitoring the trainee during the approach clearance was somehow distracted.
调查人员想知道在进行进近许可期间监督实习生的监督员是否有何分心。
Check this out.
看看这个。
According to the phone record, she took a call during her shift.
根据电话记录，她在班次中接了一个电话。
You don't want to take a phone call during something important like a descent clearance because they have to give them a course to follow and an altitude to maintain, really important stuff that you cannot possibly miss.
在像下降许可这样重要的事情中，你不想接电话，因为他们必须给出跟随的航线和保持的高度，这是非常重要的事情，你绝对不能错过。
Something doesn't line up.
有些事情对不上。
The plane's altimeter alert was incorrectly set to 2,000 feet.
飞机的高度警报器错误地设置为2000英尺。
Even at that altitude, they would have cleared the ridge by some 200 feet.
即使在那个高度，他们也会比山脊高出大约200英尺。
Yeah.
是的。
We still had to explain why the airplane struck the mountain 200 or so feet even further below the altitude that they were trying to maintain.
我们仍然需要解释为什么飞机在比他们试图保持的高度还要低200英尺左右的地方撞上了山。
Something had to explain that.
必须有东西能解释这个。
What else affects altitude?
还有什么因素会影响高度？
Q and H.
Q和H。
QNH is a pressure setting, pilot's input, so their altimeter measures the proper height above sea level.
QNH是一个压力设置，飞行员输入的，这样他们的高度表就能正确测量出海平面以上的高度。
It can change with weather conditions.
它会随着天气条件而变化。
If the altimeter is set to a higher QNH than its actual, the aircraft will actually be lower than what the altimeter is telling the pilots.
如果高度表设置的QNH比实际情况高，飞机实际上会比高度表告诉飞行员的低。
It says here they were given a QNH of 1019 at 1.44 p.m.
这里说他们在下午1点44分被给了一个QNH为1019的读数。
Then they were given a reading of 1027 at 1.56 PM.
然后在下午1点56分被给了一个1027的读数。
OK.
好的。
So it changed 8 millibars in 12 minutes.
所以它在12分钟内变化了8毫巴。
Could that be right?
这可能吗？
Check the weather reports.
查一下天气报告。
For an 8-millibar change to occur in 12 minutes would be something that may occur during a hurricane or something like that.
在12分钟内发生8毫巴的变化可能会在飓风或类似情况下发生。
I don't see anything that would make that possible.
我没有看到任何可能导致这种情况的东西。
So how much would they drop with an eight millibar increase?
那么他们因为8毫巴的增加会下降多少呢？
Investigators calculate the change in altitude between the two QNH values.
调查人员计算了两个QNH值之间的高度变化。
That QNH brought them at least 200 feet below 2,000, right into the mountain.
那个QNH至少让他们低于2000英尺200英尺，正好撞上了山。
The team concludes that an incorrect altimeter setting put the flight on a collision course with Pico Alto.
团队得出结论，错误的高度表设置使得航班与Pico Alto山发生了碰撞。
When you're close to the ground in restricted visibility conditions, an accurate altimeter setting is everything that will protect the airplane from a CFIT accident.
当你在能见度受限的条件下靠近地面时，准确的高度表设置是保护飞机免于CFIT事故的一切。
Thanks for talking with me again.
谢谢你再次和我交谈。
Yeah, of course.
嗯，当然。
Just one follow-up question here.
这里只有一个后续问题。
What was the pressure setting you gave them?
你给他们的压力设置是多少？
Investigators conduct a second interview with the controller to understand why he gave two very different QNH settings to the pilots.
调查人员对管制员进行了第二次采访，以了解他为什么给飞行员两个非常不同的QNH设置。
1019 was on the MET report.
1019是在MET报告上的。
12 minutes later, when you gave them a 3,000 foot clearance, you said, QNH 1027.
12分钟后，当你给他们3000英尺的许可时，你说，QNH 1027。
I asked the controller directly about the QNH he had given to the plane.
我直接问管制员他给飞机的QNH是多少。
And he couldn't explain why he had given that QNH at all.
他无法解释为什么他会给出那个QNH。
In my view, it's just he didn't notice he was giving the wrong information.
在我看来，他只是没有注意到他给出了错误的信息。
Sorry, I don't know where I got that second number.
对不起，我不知道我那第二个数字哪里来的。
For that Q&H to change so rapidly, it should have been noticed by both the air traffic trainee and their supervisor and the pilots as well.
对于Q&H如此迅速的变化，应该被空中交通实习生和他们的监督员以及飞行员注意到。
I'm surprised that the pilots didn't reach out and say, hey, can you repeat that Q&H again?
我很惊讶飞行员没有联系并说，嘿，你能再重复一遍Q&H吗？
After the first officer gets the minimum descent altitude wrong, he questions the Q&H.
副驾驶在最低下降高度出错后，他质疑Q&H。
Is that what they said?
他们说的是这个吗？
1027 on the millibars?
1027毫巴？
Yep.
是的。
He was right to question it.
他质疑是对的。
But the captain just dismisses it.
但是机长直接忽略了。
Thank you.
谢谢。
And the first officer just accepts it.
副驾驶也就接受了。
Because of the different experience levels, because of the prominence and assertiveness with which the captain said it, shut off any discussion when, in fact, there should have been.
由于经验水平的不同，由于机长说话时的显著性和断然性，关闭了任何讨论的可能，而实际上应该有讨论。
Makes me wonder what else these guys missed.
让我想知道这些家伙还错过了什么。
Yeah, let's play the tape.
好的，放录音带。
Investigators return to the cockpit voice recording to learn how the crew of Independent Air Flight 1851 allowed so many errors to accumulate on approach to Santa Maria.
调查人员回到驾驶舱语音记录，以了解Independent Air Flight 1851的机组人员是如何在接近圣玛丽亚时积累了这么多错误。
Altimeters set and cross-checked.
高度表设置并交叉检查。
Set and cross-checked.
设置并交叉检查。
Seat belts and shoulder harness.
安全带和肩带。
Secured.
已经固定。
We're having fun now.
现在我们玩得开心了。
Hey, hey.
嘿，嘿。
That's it?
就这样？
Stop the tape.
停止录音。
They discover the pilots missed important steps on the checklist.
他们发现飞行员漏掉了清单上的重要步骤。
They don't even mention the minimum descent altitude or pico alto here.
他们甚至没有提到最低下降高度或Pico Alto。
They hear a briefing that doesn't include reference to the navigation charts that were available to the pilots.
他们听到的简报没有提到飞行员可用的导航图表。
Had they done the approach briefing and reviewed the information and articulated the information as required, it's highly unlikely, in my opinion, that they would have struck the mountain.
如果他们进行了进近简报并复查了信息，并按要求表达了信息，我认为他们不太可能撞上山。
Another unfortunate error.
又一个不幸的错误。
There were a couple of things in the performance of the captain that were questionable.
在机长的表现中有几件事情是值得质疑的。
He didn't try to understand what was the real QNH that was given.
他没有试图了解给出的真正QNH是多少。
Then he didn't insist in a complete checklist.
然后他没有坚持完成完整的清单。
Let's hear what comes next.
让我们听听接下来的内容。
It ain't looking too hot out there.
外面看起来不太好。
Yeah, we'll get down below.
是的，我们会下降到下面。
Depends on what level those are.
这取决于那些云层的高度。
OK, I'm going to go ahead and put the ILS in on my side.
好的，我要在我的一侧输入ILS。
OK.
好的。
Uh, after 2,000, yeah, we'll get below these clouds.
嗯，在2000英尺以下，我们会穿过这些云层。
Stop.
停。
Right there, 2,000 again.
就在那里，又提到了2000英尺。
The captain says nothing and descends to 2,000.
机长什么都没说，就下降到了2000英尺。
Why?
为什么？
The captain is ultimately responsible as the pilot in command, but each crew member failed in that respect.
作为指挥飞行的机长最终负责，但每个机组成员在这方面都有失职。
Play the tape.
放录音带。
A thousand to go, one to go.
还有一千英尺，还有一千。
Wow, look.
哇，看。
There's the island.
那是岛屿。
Stop it.
停下来。
Who is that?
那是谁？
Investigators hear an unknown female speaking in the cockpit on approach into Santa Maria.
调查员听到一个不明女性在进近圣玛丽亚时在驾驶舱内说话。
She appears twice over 16 minutes, starting when they begin their descent.
她在16分钟内出现了两次，从他们开始下降时就开始了。
The flight attendant, maybe.
可能是空乘人员。
But what is she doing there?
但她在那里做什么？
I don't know.
我不知道。
That's not what I call a sterile cockpit.
那不是我所说的无干扰驾驶舱。
And the captain lets it happen.
而机长任由这种情况发生。
The captain violated the sterile cockpit rule, which bans non-essential conversation in the cockpit below 10,000 feet.
机长违反了无干扰驾驶舱规则，该规则禁止在1万英尺以下的驾驶舱内进行非必要的交谈。
Oh.
哦。
I believe that violating the sterile cockpit rule was consistent with the way they food the approach.
我相信违反无干扰驾驶舱规则与他们执行进近的方式是一致的。
They weren't sitting on the edge of their seats.
他们并没有坐在座位的边缘。
They were far too relaxed.
他们过于放松了。
There is no place like Santa Maria.
没有像圣玛丽亚这样的地方。
Is it nice?
那里好吗？
Yeah.
是的。
I have a beer.
我喝了啤酒。
Ignoring standard procedures, distractions.
忽视标准程序，分心。
The list keeps growing.
清单越来越长。
Starting to pass through the layers.
开始穿透层层迷雾。
Can't keep this damn thing level.
无法保持这该死的东西水平。
Help you?
需要帮忙吗？
No.
不用。
Pull up.
抬升。
They don't say anything?
他们什么都没说？
When the GPWS went off, there was no response from the crew.
当地面接近预警系统响起时，机组没有任何反应。
There was not even a, what's that?
甚至没有一个“那是什么声音？”
What's going on?
发生了什么？
There was nothing.
什么都没有。
They don't say anything, but do they do anything?
他们没有说什么，但他们有没有做什么？
Thank you.
谢谢。
So this is the plane's descent approaching Santa Maria.
所以这是飞机进近圣玛丽亚时的下降轨迹。
Investigators examine the flight data to determine how the pilots responded to the ground proximity warning.
调查员检查飞行数据，以确定飞行员对地面接近预警的反应。
So they're descending at about 2,500 feet per minute.
所以他们的下降速度大约是每分钟2500英尺。
They level off here.
他们在这里平稳飞行。
And the GPWS goes off here.
地面接近预警在这里响起。
And they crash about seven seconds later.
大约七秒钟后他们就坠毁了。
No reactions.
没有反应。
No change in altitude.
没有改变高度。
The data shows there were no inputs from the pilots to recover the aircraft.
数据显示飞行员没有进行任何操作来恢复飞机。
It's like they ignored the alarm.
就好像他们忽视了警报。
When the GPWS goes on, you apply maximum power, climb at the maximum rate, and get the heck out of there.
当地面接近预警系统启动时，你需要全力增加动力，以最大速率爬升，并迅速离开危险区域。
Seven seconds.
七秒钟。
They had seven seconds from the first warning until impact.
从第一个警告到撞击，他们有七秒钟的时间。
They could have climbed over the mountain in that time had they done what they should have done, and they didn't do that, and we couldn't figure that out.
如果他们按照应该做的去做，他们本可以在那段时间内爬过山头，但他们没有这么做，我们无法理解这一点。
Pull up.
抬升。
Why didn't the crew respond to the warning?
机组为什么没有对警告做出反应？
Surely the crew was trained to respond to the ground proximity warning.
当然，机组接受过对地面接近预警的响应训练。
Investigators closely examined the training manuals for independent air.
调查员仔细检查了独立航空的培训手册。
You are not going to believe this.
你不会相信这个。
The simulators were programmed with different approach speeds and flap settings than the accident aircraft.
模拟器的编程使用的进近速度和襟翼设置与事故飞机不同。
What does that mean?
这意味着什么？
It means that the GPWS would go off during normal approaches.
这意味着在正常进近时地面接近预警系统会响起。
Independent Air rented time on another company's 707 simulator.
独立航空在另一家公司的707模拟器上租用了时间。
It was configured differently from the accident aircraft.
它的配置与事故飞机不同。
Flaps 40.
襟翼40。
Pull up.
抬升。
Sir?
先生？
Pull up.
抬升。
By training the crew to ignore the GPWS in the simulators, they gave the crew the message to ignore the GPWS in the airplane.
通过在模拟器中训练机组忽视地面接近预警系统，他们向机组传达了在飞机上忽视地面接近预警系统的信息。
I can't believe how many things went wrong.
我无法相信出了这么多问题。
Investigators conclude that by avoiding any one of the minor errors, flight 1851 would have cleared Pico Alto, preventing the deaths of 144 people.
调查员得出结论，只要避免了任何一个小错误，1851航班就能越过皮科阿尔托山，避免了144人的死亡。
It all starts with the first officer mishearing the minimum sector altitude.
一切都始于副驾驶误解了最低安全高度。
Independent 1851, roger.
独立航空1851，收到。
You're clear to 3,000 feet.
你被清除到3000英尺。
Cleared to 2,000.
清除到2000英尺。
Make it three.
改为3000。
If the first officer had referred to his charts... Roger.
如果副驾驶参考了他的航图……收到。
Good catch.
好的发现。
The altitude alert would have been set at the proper elevation, and the aircraft would have cleared the mountain by more than 1,000 feet.
高度警告将被设定在正确的高度，飞机将比山高出1000多英尺。
Same result if the air traffic controller had asked for a re-back.
如果空中交通管制员要求复述也会得到同样的结果。
Independent Air 1851.
独立航空1851。
You're cleared to 3,000.
你被清除到3000英尺。
I say again, report reaching 3,000.
我再说一遍，报告到达3000英尺。
Over.
结束。
Or if the captain kept a sterile cockpit.
或者如果机长保持了无干扰驾驶舱。
After 2,000... Yeah, we'll get below these clouds.
2000之后……是的，我们会低于这些云层。
Wow, look.
哇，看。
There's the island.
那是岛屿。
It should be 3,000, not 2,000.
应该是3000，不是2000。
It's time to return to the cabin.
是时候回到客舱了。
You cannot be unattentive, especially in the last period of the flight.
你不能不专心，尤其是在飞行的最后阶段。
Even with all those mistakes, if the trainee controller had given them the proper altimeter setting?
即使有那么多错误，如果实习管制员给了他们正确的高度表设置呢？
You're cleared to 3,000 on QNH 1027.
你被清除到3000英尺，QNH 1027。
Correction, 1019.
更正，1019。
Flight 1851, would it clear Pico Alto by 200 feet?
1851航班，能否比皮科阿尔托高出200英尺？
Whoa.
哇。
We're close.
我们很接近了。
Finally, the GPWS.
最后，地面接近预警系统。
Pull up.
抬升。
If the crew had the proper GPWS training... Go around!
如果机组人员接受了正确的地面接近预警系统培训……绕飞！
...they would have had one last chance to avoid hitting the mountain.
...他们本来还有最后一次机会避免撞上山。
They might have made it.
他们可能会成功的。
I have never seen an accident with these many factors happen where any one of which, had they not been there, we wouldn't have had an accident.
我从未见过这么多因素导致的事故，任何一个因素如果不存在，我们就不会有事故。
In the wake of the crash, the NTSB recommends a careful review of airline training programs with a focus on international operations and safety, especially those related to the GPWS response.
在这次坠机事故之后，国家运输安全委员会建议仔细审查航空公司的培训计划，重点关注国际运营和安全，特别是与地面接近预警系统响应相关的内容。
The major lesson was that airlines need to train their crews better to improve aviation safety.
最重要的教训是航空公司需要更好地培训他们的机组人员，以提高航空安全。
Independent Air later settled with the victims' families for 34 million US dollars before a compensation case ever went to trial.
独立航空后来与受害者家属达成了3400万美元的和解，赔偿案件还未进入审判程序。
Independent Air went out of business in 1990.
独立航空在1990年停业。
In the aviation business, there is no room at all for complacency.
在航空业务中，根本容不得自满。
The longer we do a job, the more complacent we tend to get.
我们做工作时间越长，就越容易变得自满。
After a while, some of the things we do, even if they're unsafe, start to appear to be safe.
久而久之，我们做的一些事情，即使它们不安全，也开始显得安全。
And unfortunately, we can have an accident like the one that we witnessed here.
不幸的是，我们可能会遇到我们在这里目睹的那样的事故。