Details on Investigation into Turkish Airlines Plane Crash

1. (SBU) Summary: The Dutch Safety Board presented its preliminary
findings into the cause of the February 25 crash of Turkish Airlines
Flight 1951 at a March 4 press conference, pointing principally to a
malfunctioning radio altimeter. At the request of the Dutch, Boeing
issued a multi-operator message to all 737 model users warning of
the faulty altimeter. NTSB Team Chief Joseph Sedor debriefed
Mission personnel March 5 on its initial findings and assessed that
the altimeter's technical malfunction alone would not have caused
the plane to crash. Investigation continues into the role of pilot
error as a major factor in the crash. End Summary.



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PRESS CONFERENCE


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2. (U) On March 4, the Dutch Safety Board (DSB) presented its
preliminary findings on the causes of the plane crash in its first
press conference. The press conference was delivered in Dutch but
an English statement was concurrently issued and can be found in its
entirety at:

www.onderzoeksraad.nl/docs/
rapporten/Persverklaring_4_maart_GB.pdf.



3. (U) DSB key findings pointed to a technical problem with the left
radio altimeter, which measures the plane's altitude. The faulty
altimeter indicated an incorrect altitude of -8 feet, essentially
putting the plane already on the tarmac, while the plane was
approaching its descent at an actual altitude of 1950 feet. This
incorrect reading was passed onto the automatic pilot system, which
was engaged for the landing, causing the plane to slow down, lose
engine power, and ultimately stall. By the time the pilots realized
the problem and subsequently applied full throttle to the engines,
it was too late and the plane crashed. The black box recovered in
the crash indicated that a similar problem with the same altimeter
occurred in two previous flights captured on the 25 hours of black
box recording. The DSB claimed provisional data indicated that the
pilots did not initially regard the warning signal for the
malfunctioning altimeter to be a problem, implying the pilots did
not react to the issue in the most timely manner.



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MEDIA COVERAGE


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4. (U) Coverage of the crash has dominated Dutch media since it
occurred on February 25. Newspapers opened with front page headline
reports, including officially released information, eye witness
reports, and survivors' accounts. Survivors and aircraft experts
also appeared on many talk shows. While there was initially very
little information available about the nationalities of the
passengers, Dutch media picked up on a February 27 "Seattle Times"
report stating that two Boeing employees were among the victims.



5. (U) A sample of the March 5 headline stories include the
following:

--"De Telegraaf" (sensationalist, mass-circulation, conservative
paper):"Human Error"
--"Algemeen Dagblad" (popular, centrist publication): "Pilots
Responded Too Late"
--"De Volkskrant" (influential liberal paper): "Everything Was
Alright, Except for the Speed"
--"Trouw" (left-of-center paper): "Faulty Altimeter Caused Crash -
Pilots' Action at 150 Meters Was Too Late"
--"NRC Handelsblad" (influential liberal publication): "Crew Did Not
Act On Faulty Meter"



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BOEING STATEMENT


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6. (U) During the press conference, the DSB issued a warning to
Boeing on its findings about the faulty altimeter. In response, and
QBoeing on its findings about the faulty altimeter. In response, and
with the DSB's clearance, Boeing issued an immediate multi-operator
message to all 737 model users. Boeing recommends that all flight
crews operating any 737 model be informed of the preliminary results
of the DSB investigation and reminded to carefully monitor primary
flight instruments and the flight mode annunciation for autoflight
modes.



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NTSB DEBRIEF


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7. (SBU) NTSB Team Chief Joseph Sedor visited the Consulate General

THE HAGUE 00000163 002 OF 002


March 5 to debrief the Charge, Consul General and other Mission
personnel on his assessment of the causes of the crash and his
impressions of the investigation as a whole. Sedor generally agreed
with the DSB's findings (reflected in the DSB's English statement).
He added that the initial review indicates pilot error played a
larger role than the DSB has implied. According to Sedor, the
faulty altimeter alone should not have caused the plane to crash.
Sedor believes that the pilots should have been able to compensate
and recover from the technical malfunction. According to black box
data, 40 seconds had lapsed before the pilots even noticed the
warning light on the altimeter, and by the time the pilots took
action, it was too late. During this same 40 second interval, the
plane was experiencing a high rate of deceleration - well past the
speed the pilots had selected - that the pilots should have noticed
as well. Moreover, there were three pilots in the cockpit - one
more than is standard because this was a training flight for a new
pilot - providing an extra set of eyes which still missed the
warning light. Sedor thinks the three pilots were likely
distracted, possibly in conducting pre-landing checks that Sedor
maintains should have been completed before this stage in the
flight. Sedor also noted the evidence on the crash site suggested
the pilots took some corrective measures that limited the
fatalities.



8. (SBU) Sedor remarked that he and his team had received excellent
cooperation from the DSB. The NTSB also enjoyed good cooperation
from Turkish authorities on the ground in the Netherlands. Sedor
also compared the NTSB's and DSB's different approaches to victim's
assistance, offering to provide information on the U.S. Family
Assistance Act and the NTSB programs addressing the human tragedy of
such disasters. For example, the NTSB regularly briefs family
members of fatalities well before making any press comments. Sedor
and his team planned to leave the Netherlands by March 7, but some
members are likely to return to continue to assist with the
investigation, as requested by the DSB.

GALLAGHER