Air Crash Investigation

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Transcript

00:00 (plane engine roaring)

00:02 - The pilots of Air Transport International Flight 782

00:05 prepare to depart from Kansas City

00:08 with just three of their four working engines.

00:10 - A three engine ferry.

00:12 It's a difficult maneuver.

00:14 - 100 knots.

00:15 - Okay.

00:16 - Their takeoff goes tragically wrong.

00:19 - We're off the runway.

00:20 - Go max power.

00:21 - You got it.

00:23 (plane crashing)

00:26 - This accident of course was very tragic

00:28 and they did not make it.

00:30 - Exonation of the wreck reveals very little.

00:32 - Stem to stern, wingtip to wingtip was airworthy.

00:35 - But when investigators visit the simulator

00:37 used to train the pilots.

00:39 - This is not how their aircraft would have behaved.

00:41 - They begin to understand the origins of this accident.

00:45 - The simulators are extremely accurate.

00:48 We were shocked that this one was not.

00:51 (plane engine roaring)

00:54 (glass shattering)

00:57 (plane engine roaring)

01:00 (soft music)

01:11 - Okay, first things first.

01:19 Let's review our three engine ferry procedure.

01:21 - Sure thing.

01:22 - Yep.

01:25 - Air Transport International flight 782 has been canceled.

01:30 One of its four engines won't start.

01:32 - Maintain directional control using rudder

01:36 and nose wheel steering.

01:38 - The replacement crew is taking the cargo plane

01:41 for repairs to a maintenance facility in Massachusetts.

01:44 - The only crews that are permitted to do

01:46 a three engine ferry are the very experienced crews

01:49 because it is very dangerous.

01:51 It does not happen very often.

01:55 - Captain Walter Meager has worked his way up

01:57 from flying the DC-6 and DC-7

02:00 and is now captain on the airline's DC-8 aircraft.

02:03 - The captain had about 4,000 hours in the DC-8.

02:08 He'd been flying the DC-8 for years.

02:11 - Max wind for takeoff, crosswinds 10 knots,

02:15 tailwinds five knots.

02:16 - Okay, let's check the weather on that.

02:18 - First officer Mark Alma is new to the company

02:23 and the plane, but he's been flying for 14 years.

02:26 - He only had about 200 hours in the DC-8.

02:29 However, he was commended for being enthusiastic,

02:33 for trying to learn and being an important part of the crew.

02:37 - There's a third crew member on board,

02:39 flight engineer Kerry Hardy.

02:41 - Flight engineer had more than 4,000 hours of flight time

02:46 and in large airplanes.

02:48 He was a very experienced pilot.

02:52 - It's a two hour flight from Kansas City

02:54 to Chicopee, Massachusetts,

02:56 where the engine is to be repaired.

02:58 - Here you go.

03:00 - Thank you.

03:02 - The crew has concerns about their schedule.

03:05 - There is a curfew on the airport in Massachusetts.

03:12 The airline had told the crew that they needed to land

03:14 by 11 p.m. because that is when that airport would close.

03:21 - What we're gonna need to do

03:22 is get as much direct as we can.

03:23 That'll allow us to fly a little bit better

03:25 than the 280 knots indicated.

03:26 - Well, as pilots, we're always trying to hurry.

03:31 The crew had decided that they wanted to fly

03:33 a more direct route at a faster speed.

03:36 - So we'll be using one nine right?

03:39 - First officer Alma wants the longest runway

03:42 for their takeoff.

03:43 - I'm gonna request right

03:45 because we'll get an extra 1300 feet.

03:46 - Okay.

03:50 - In order to take off, the DC-8 needs power

03:53 from at least three of its four engines.

03:56 - You always want the longest runway that you can get

04:00 with a takeoff like this,

04:02 so that you have more room to get the airplane

04:04 up to the proper speeds.

04:06 - Kansas City, this is Air Transport 782, ready to taxi.

04:11 We're gonna be a three engine departure.

04:13 - Flight 782 checks with air traffic control

04:19 about their runway assignment.

04:21 - Air Transport 782, south on Bravo, taxi runway one left.

04:25 - Okay, south on Bravo, taxi one left, Air Transport 782.

04:31 What's the winds?

04:33 - Winds, two four zero at four.

04:36 - Roger.

04:36 - That's a tailwind, right?

04:38 - Yeah.

04:39 - You don't want a tailwind with a three engine takeoff

04:42 because it's going to take more runway.

04:44 - Two four zero and we're running into what?

04:48 - Four.

04:49 - Four knots.

04:50 - The tailwind was acceptable.

04:54 The maximum tailwind allowed was five knots

04:57 and they had four knots.

04:59 - Flight 782 taxis to the longer runway.

05:02 - Takeoff data.

05:05 - Okay, this is a max power takeoff.

05:09 - The pilots review the required speeds

05:11 for the three engine takeoff.

05:13 - Okay, I got VMCG of 107, 123 for VR,

05:17 140 for V2 and 210 for the cleanup.

05:20 - Set.

05:21 - This takeoff requires raising both inboard engines,

05:26 engine two and engine three, to max power.

05:29 Only when the plane reaches a certain speed

05:32 can the third working engine, engine four,

05:34 be increased to max power.

05:36 - Controlling the airplane on the runway

05:38 while you are adding the power

05:40 from the third engine is vital.

05:42 It must be done slowly and you must be able

05:44 to keep control of the airplane at all times.

05:47 - And of course, we'll all be watching real close

05:50 for loss of directional control.

05:52 - Two engines on the right side

05:56 are gonna cause the aircraft to veer to the left.

06:00 It's only gonna have one engine operating on the left side.

06:03 So directional control is the critical issue

06:06 on that three engine takeoff like this.

06:10 - Number one engine is inoperative.

06:12 So what we're gonna do is set max power

06:14 on number two and number three.

06:16 - Right. - Right.

06:17 - As the crew nears the end of the taxi,

06:19 they finalize the takeoff plan.

06:21 - Okay, then I'll ease in number four.

06:25 - And I'll call increments at 0.1.

06:26 - Yeah.

06:27 - Flight 782 is now ready for takeoff.

06:39 - Okay, coming up on two and three.

06:41 - The crew lets the inboard engines spool up

06:47 before the plane starts moving.

06:49 - Set max power.

06:52 - Max power two and three.

06:53 - At 8.20 PM, Air Transport International Flight 782

06:59 begins its takeoff.

07:08 - 1.3, 1.4.

07:11 - The flight engineer closely monitors engine power.

07:14 - Airspeed's alive, 1.6.

07:16 - 80 knots.

07:17 90 knots.

07:21 - But 20 seconds into the takeoff roll,

07:23 the plane veers left of the center line.

07:25 - 1.8, 100 knots.

07:29 - The captain uses his rudder to redirect the plane

07:33 to the center of the runway, but it doesn't work.

07:38 - Stopboard.

07:39 - Spoilers.

07:43 - Air Transport 782, aborting takeoff.

07:47 - Flight 782 aborts its three-engine takeoff.

07:53 - Air Transport 782, roger.

07:57 When able, turn right off the runway.

07:59 Do you need any assistance?

08:01 Negative assistance?

08:02 - No, negative.

08:03 - Negative assistance, Air Transport 782.

08:07 - The crew considers what went wrong.

08:09 - We were at 1.6 and then power went all the way up to 1.9.0

08:15 as you ran it up.

08:16 So it went up real fast.

08:18 - And number four jerked up

08:20 while I was trying to ease it in.

08:22 - You brought it up too fast or it jerked up or what?

08:25 - The power on, it just came on too fast.

08:28 That's what happened.

08:29 - Hardy proposes a solution.

08:37 - If you want to try it again,

08:37 I could try adding the power if you like.

08:39 - Okay, let's do it that way.

08:42 - It was decided that the flight engineer

08:46 would help the captain and he would add the power

08:49 on the third engine for the second takeoff.

08:52 - Tell him we want to taxi back and have another try at it.

08:55 - Kansas City Ground, Air Transport 782.

08:58 We'd like to taxi back to depart one left again.

09:02 - Air Transport 782, roger.

09:04 Taxi one left.

09:06 - Okay.

09:07 - While returning to the runway,

09:12 the crew revisits the takeoff procedure.

09:15 - Okay, when do I have to have max power

09:17 in on the outboard engine?

09:18 - 107.

09:21 - Flight 782 is again ready for takeoff.

09:34 - Kansas City Control, Air Transport 782,

09:37 ready to go at the end of one left,

09:38 three engine takeoff.

09:40 - Air Transport 782, heavy, control one left.

09:44 Turn right, zero, three, zero.

09:47 Clear for takeoff.

09:48 - I've lined up just to the right of the center line here.

09:54 - That's a good idea.

09:55 - The captain did line up on the right side of the runway

09:59 because they veered off to the left on the first takeoff

10:03 and he wanted to give himself more runway width available

10:07 in order to do the second takeoff.

10:09 - Okay, make sure the two and three are set.

10:12 - Max power?

10:13 - Yeah.

10:14 - At 826 in the evening,

10:16 Flight 782 begins its second takeoff attempt.

10:20 - One one, one two.

10:23 One three, one four.

10:30 One five, one six.

10:35 Airspeed's alive.

10:45 - 10 seconds into the takeoff roll,

10:47 the plane again starts veering to the left.

10:50 - One seven.

10:52 - The captain tries to direct it back to the center line

10:56 with the rudder.

10:57 (plane engine roaring)

11:01 - God bless it.

11:03 - Keep it going.

11:08 - Keep it going? - Yeah.

11:09 - 80 knots, 90 knots.

11:13 - The captain attempts to get airborne.

11:16 - We're off the runway.

11:24 - But he doesn't have the speed.

11:26 - Go max power.

11:27 - He tries to salvage the takeoff.

11:33 Flight 782 is barely in the air.

11:35 - Get the nose down.

11:39 - Go max power.

11:40 - You got it.

11:40 - Max power.

11:43 (plane engine roaring)

11:46 - Alert three, runway zero one, north end.

12:01 DC eight on takeoff.

12:02 - Air Transport International,

12:06 Flight 782 has crashed beside the runway

12:10 at Kansas City Airport.

12:12 Fire and rescue units are nearby

12:15 on a night training exercise.

12:17 They rush to the crash site.

12:18 - We heard a real loud boom

12:21 like something hit the dock real hard.

12:22 - Take long for fire rescue crews to arrive

12:24 on the scene I'm assuming?

12:25 - No, no, just in a matter of 60 seconds.

12:27 - All three crew members are dead.

12:31 The National Transportation Safety Board or NTSB

12:37 is notified and Bob Benzon is named lead investigator.

12:41 - The aircraft had broken apart

12:43 although it was in three large pieces.

12:45 A fuselage behind the wings

12:48 seemed to be reasonably intact.

12:50 The wing assembly itself seemed to be in one piece.

12:52 - The question Benzon must answer,

12:56 why was the crew unable to execute this takeoff?

13:00 Not once, but twice.

13:02 - We were aware that it was an attempted

13:05 three engine takeoff.

13:07 And because that is an unusual maneuver,

13:09 we wondered if that could have been part

13:11 of the reason the aircraft crashed.

13:13 - Thanks for taking the time to meet.

13:16 - While the plane wreckage is collected,

13:19 investigators speak to the controller

13:21 to learn more about the crash.

13:23 - When did you realize there was an issue with flight 782?

13:26 - I guess the first thing that caught my attention

13:30 was that they aborted their first takeoff.

13:32 - Why?

13:34 - I was told the plane veered left on the runway.

13:36 - And then?

13:39 - They lined up for their next takeoff

13:41 and the same thing happened, only worse.

13:43 The plane veered left,

13:46 and this time they rotated awkwardly, nose high.

13:49 There was a fire coming out of one of the engines

13:53 and then there was a loud bang.

13:54 Then the plane stalled, rolled left and crashed.

14:02 (plane engine roaring)

14:06 - The fire, what side?

14:14 - Left.

14:15 - That had to be engine number two.

14:18 - Plane engines are numbered from left to right.

14:27 For flight 782, the number one engine was inoperative.

14:31 If engine two failed,

14:33 the crew would be left with only the right engines.

14:36 - We knew because this was a three engine takeoff attempt.

14:40 And if we'd lost any more power

14:42 on the left side of the aircraft,

14:43 it may have caused an immediate crash.

14:46 - What have you got?

14:51 - Investigators examine engine number two

14:53 after its recovery from the crash site.

14:56 - No penetration on the nose cowl.

15:01 Fuel is present throughout.

15:03 Compressor bleed valve is closed.

15:06 - They discover that it was operative

15:08 and it didn't fail on takeoff.

15:10 - That fire in the engine was probably a compressor surge.

15:15 - A compressor surge is a phenomenon that occurs

15:20 when the tilt of the engine is high enough

15:24 that it disturbs the airflow going into the intake

15:27 and causes a big bang,

15:29 flames coming out both ends perhaps.

15:32 But technically the engine isn't damaged at all.

15:37 - No unusual wear.

15:41 - If all three remaining engines were working,

15:46 could one of the brakes have locked,

15:48 causing the plane to veer left?

15:50 - Treads look almost new.

15:52 No flat spots.

15:53 - The tires show no sign of abnormal braking.

15:57 - Okay.

15:58 Let's have a look at the brakes.

16:00 - We thought that because they had aborted

16:02 the earlier takeoff,

16:04 maybe they used the brakes very heavily

16:08 and caused them to fail frankly or weaken

16:12 and then fail completely during the second takeoff.

16:15 - Brake stack assembly looks fine.

16:23 - No discoloration or pitting on the pads.

16:26 - Discs are clean.

16:28 No signs of overheating.

16:30 - We looked at brakes very carefully.

16:35 We found nothing really physically wrong.

16:37 There was no overheating or melting together.

16:40 So in essence, the brake system did not become an issue.

16:44 - The NTSB is still unable to determine

16:48 whether the brakes are working properly.

16:50 The NTSB is still unable to determine

16:54 why the crew lost control.

16:56 - Let's check out the rudder.

16:58 - The rudder plays a massive role

17:02 in a three-engine takeoff.

17:03 It is the key to keeping the airplane going straight

17:06 and being safe.

17:07 - Three-engine takeoffs require the two inboard engines

17:12 to reach VMCG, or minimum control speed on the ground.

17:16 Only then can the rudder counteract

17:19 the directional force of the third working engine

17:21 as it's powered up.

17:22 - The faster you are going,

17:27 the more rudder control you have,

17:29 and you need that rudder control

17:31 to be able to keep the airplane on the runway.

17:33 - How's the rudder control cable look?

17:41 - Did the rudder malfunction,

17:43 causing the crew to lose control of the plane?

17:46 - The cable's severed in several different places, see?

17:49 - There's no corrosion or fraying.

17:51 Probably severed in the crash.

17:53 - Agreed.

17:54 Let's test the rudder.

17:57 - We looked very carefully at the cabling

18:00 that we used in the rudder system,

18:02 and the only thing we did note were simple breaks

18:05 in the cables because of overload, instant overload,

18:09 which occurred during the crash.

18:11 - Control cable ready?

18:13 - Good to go.

18:16 - If the rudder cables didn't fail,

18:18 then could the rudder itself have malfunctioned?

18:21 - Okay, deflect left.

18:22 - Investigators test its movement.

18:27 - Turning to the left.

18:28 - But the rudder moves freely.

18:33 - We're good.

18:34 - On occasion in previous accidents,

18:38 rudders have locked up or become blocked

18:41 by some broken part,

18:43 and we found that this did not occur during this event.

18:47 - The mystery of Flight 782's crash deepens.

18:53 - In the end, we looked at the entire wreckage

18:58 very, very carefully, from stem to stern, wingtip to wingtip,

19:02 and determined that it was airworthy.

19:04 We had to look into other areas to determine what happened.

19:13 - Okay, we found skid marks on the runway

19:15 for the first takeoff, starting here, all the way to here.

19:20 Then they aborted.

19:23 - Investigators now turn to evidence left behind

19:26 by Flight 782 to determine why it veered off the runway.

19:30 - In the second takeoff, the skid starts even earlier, here.

19:34 And the marks last till here.

19:42 Skid marks were there, indicating that,

19:44 although the aircraft was rolling forward,

19:47 it was skidding to the left side of the runway.

19:49 - The skid marks are a telltale sign.

19:53 - It looks like they had too much power

19:54 to the right side of the plane,

19:57 and it happened early on.

19:58 Look, on both takeoffs,

20:01 they skidded to the left after only 500 feet.

20:04 - Correct.

20:06 So maybe there was an issue with the power

20:10 in that third working engine.

20:13 - Let's find out.

20:14 - We discovered that the engine operation

20:16 would probably be some kind of an issue.

20:19 And the only way we could determine that

20:21 was to go to the flight data recorder.

20:23 - Did engine number four somehow cause the plane

20:27 to veer too far to the left?

20:29 - There's the airspeed data there.

20:33 - Investigators examine the flight data recorder

20:37 to learn how the crew managed their engines.

20:40 - Looks like we have a glitch here.

20:42 - To learn more about how the crew

20:45 manipulated the throttles,

20:47 we needed two parameters from the FDR,

20:49 airspeed and the engine pressure ratio, or the EPR.

20:53 We had airspeed, but unfortunately,

20:55 this FDR did not record correctly the EPR.

20:59 - We need a workaround to get that engine data.

21:03 - What about a sound spectrum analysis?

21:06 - Sure, let's give it a shot.

21:10 (engine whirring)

21:13 - Okay, coming up on two and three.

21:15 - There's a microphone in the cockpit

21:22 that records every sound.

21:25 And they can record and hear the engines

21:28 as they are increased or decreased.

21:31 And they're very accurate.

21:32 (engine whirring)

21:35 - The team conducts a digital analysis of the engine sounds.

21:46 - Done, great work.

21:50 Let's compare the third working engine, engine four,

21:55 with the plane's overall airspeed data.

21:59 In the end, we use both the FDR and the CVR

22:02 to determine the airspeed throughout the entire flight

22:05 and the power setting for all three of the operating engines.

22:10 - It looks like the third working engine, engine number four,

22:20 almost reaches max power in 10 seconds

22:22 when the airspeed is only about 65 knots.

22:28 - That seems awfully slow.

22:29 - Was the power to engine four

22:34 increased too soon in the takeoff roll?

22:36 - Let's check the three engine takeoff chart.

22:40 - Investigators examined the chart used by the crew

22:44 to determine the speed they needed to reach

22:46 before applying max power to engine number four.

22:49 - What was their weight?

22:53 - Their weight was 220,000 pounds.

22:56 Temperature is zero degrees.

22:57 (dramatic music)

23:00 - They shouldn't have put the third working engine

23:02 to max power until they reached 116 knots.

23:05 That's the target speed.

23:07 - At 65 knots, it was way too much power too soon.

23:11 - One three, one four, one five, one six.

23:18 - Airspeed's alive.

23:22 - One seven.

23:23 - Investigators conclude engine four

23:25 was powered up too fast, pushing the plane to the left.

23:29 - They never reached the speed they needed

23:36 for the rudder to counteract the power of both engines

23:38 on the right side of the plane.

23:40 - That's why they veered off the runway.

23:44 - Why did the pilots increase power

23:48 to the right outboard engine so quickly?

23:53 - We knew that the issue here was reaching VMCG

23:57 at exactly the right time

23:59 with the correct airspeed and everything,

24:01 but the crew didn't do that

24:02 and that became the big question.

24:04 Why?

24:04 Why didn't they do that?

24:05 - Whenever you're ready.

24:13 - Benzin's team listens to the cockpit voice recorder

24:16 or CVR to better understand how the pilots of flight 782

24:20 performed the three engine procedure.

24:23 - Okay, this is a max power takeoff speeds.

24:27 VR of 123, 140 and 210.

24:31 VMCG of 107.

24:33 - Okay, I got VMCG of 107, VR of 123, 140 for V2,

24:40 and 210 on the cleanup.

24:41 - Both pilots think the VMCG is 107 knots.

24:50 Should be 116.

24:52 - Yep, VMCG is 116 knots.

24:56 - So how did the flight engineer get that wrong?

24:58 - Wait a minute.

25:02 Check this out.

25:03 107 is the speed for a temperature of 30 degrees.

25:08 Celsius.

25:11 - Investigators discover the flight engineer

25:17 used the speed for a temperature of 30 degrees Celsius,

25:22 but on the night of the crash, it was 30 degrees Fahrenheit,

25:25 approximately zero degrees Celsius.

25:28 - That C for Celsius is so small.

25:33 He must've used 30 Celsius,

25:35 thinking the chart is in Fahrenheit.

25:45 - They selected the wrong line to get their V speeds.

25:49 - Here you go.

25:50 - Thanks.

25:52 - They were nine knots off on what VMCG should have been.

25:59 - It's happened before.

26:04 Four years earlier, a flight engineer

26:07 on another Air Transport DC-8

26:09 miscalculated the plane's weight,

26:11 providing the captain with the wrong takeoff speeds.

26:15 - I was one of the first investigators

26:17 from the NTSB to arrive on scene.

26:19 When I went into the cockpit,

26:22 it didn't take any smarts at all

26:23 to see the takeoff data was 100,000 pounds too low.

26:28 - And as a result, the company very seriously

26:32 began to emphasize the need to check those calculations

26:35 and make sure they're accurate.

26:37 And so it's disturbing that in this accident,

26:39 that did not happen.

26:40 - Is that the only thing the pilots missed?

26:43 (dramatic music)

26:46 - A question I consider, Captain.

26:54 Once we get near VMCG, if we've used all the rudder control,

26:59 you might want to consider abort.

27:01 'Cause when we get higher,

27:01 we're gonna be in worse trouble, correct?

27:04 - That's correct, absolutely.

27:05 - The CVR of flight 782 reveals

27:12 that the captain and first officer were uncertain

27:15 about the impact of VMCG speed on rudder control.

27:20 - The first officer made the comment

27:22 that you have, the rudder control is less effective

27:26 once you go beyond VMCG.

27:28 When actually the opposite is true.

27:31 - No, actually.

27:35 - The flight engineer realizes their mistake.

27:39 - Above the VMCG, your rudder has more authority.

27:41 It's helping you more.

27:42 - I understand.

27:45 - But the captain fails to acknowledge the correction.

27:48 - The flight engineer had the right answer

27:50 that the faster the airplane goes,

27:52 the more effective the rudder becomes.

27:55 And you need that effectiveness

27:57 to keep the airplane on the runway.

27:59 - Why didn't the crew stop and discuss it

28:03 until they reached a consensus?

28:05 - That's the advantage of having three people in the cockpit.

28:10 - The right answer generally exists somewhere in the cockpit.

28:13 In this instance, the flight engineer had the right answer.

28:16 - Maybe the lack of understanding about the procedure

28:19 caused them to abort their first takeoff.

28:21 - It's possible.

28:22 - Here it is.

28:28 - Check that out.

28:30 - Power went all the way up to 190 as you ran it up.

28:36 So it went up real fast.

28:39 And number four jerked up while I was trying to ease it in.

28:43 - You brought it up too fast?

28:44 - Investigators learned that the captain struggled

28:48 with engine four's thrust during the first takeoff roll.

28:52 - Power on, it just came on too fast.

28:54 That's what happened.

28:55 - If you wanna try it again,

28:59 I can try adding the power if you like.

29:01 - The flight engineer proposes

29:03 an unorthodox change to the procedure.

29:06 - Okay, let's do it that way.

29:08 (dramatic music)

29:10 - The flight engineer took over control of engine four.

29:13 - That's crazy.

29:14 - They couldn't have understood the difficulty

29:18 of the procedure if they split the responsibility.

29:21 - The core problem is the captain could not tell

29:24 how much rudder he was going to need

29:26 because he wasn't the one adding the thrust to the airplane.

29:29 It's like trying to have two people drive a stick shift car,

29:33 one doing the steering, one doing the shifting.

29:36 It just doesn't work.

29:37 You need to have one person in control at one time.

29:41 - The flight engineer and the captain thought

29:44 they could coordinate the takeoff together.

29:46 Let's figure out how they did.

29:51 - We worked with the Douglas Aircraft Company

29:55 and they produced a graph of what an ideal

29:59 three-engine takeoff should look like

30:01 with airspeed and engine speed.

30:04 We compared that with what actually happened.

30:07 - So this is what the crew was supposed to fly.

30:10 - Seems like the power and speed rise steadily

30:13 in unison until they reach VMCG.

30:15 - Very, very smooth and synchronized.

30:18 But in the accident flight, the flight engineer

30:22 brings up power to the engine number four really quickly.

30:25 - The plane begins to veer left off the runway.

30:32 Then he brings down the power abruptly here,

30:37 probably in reaction to the plane being out of control.

30:40 - Most probable thing we think happened

30:43 was that the flight engineer saw the aircraft

30:46 going off to the left of the runway and kind of panicked

30:49 and tried to pull the engines back a little bit.

30:52 - God bless you.

30:53 Keep it going.

31:00 - Keep it going? - Yeah.

31:01 - Instead of aborting, the captain attempts to get airborne

31:04 because they're about to veer off the runway.

31:06 - He was countermanded by the captain,

31:09 who said, "No, no, keep going."

31:10 So the engines went back up.

31:12 - We're off the runway.

31:13 Go max power.

31:14 - Then the captain insists that he goes to max power

31:21 a few seconds later.

31:23 - They don't have enough speed for takeoff.

31:25 - The captain never decided to abort,

31:27 and it appeared to be that he thought

31:29 he could get the airplane in the air.

31:32 We will never know.

31:33 - The captain and the flight engineer

31:39 can never coordinate their actions.

31:41 - One, two.

31:47 One, three.

31:49 - Why did the crew fail to execute a takeoff procedure

31:52 that they were specifically sent to Kansas City to perform?

31:58 - You got it!

31:59 - Find anything?

32:07 - Investigators review the work history

32:10 of Flight 782's crew to determine their experience

32:14 with three-engine takeoffs.

32:16 - Our flight engineer and our first officer were new hires.

32:21 They were still on probation.

32:22 It's almost certain that neither

32:23 had performed a three-engine takeoff.

32:26 - And the captain?

32:27 (papers rustling)

32:30 - He'd done it three times, but only his first officer.

32:36 He'd never actually flown as a captain.

32:39 - They were all green.

32:41 - The closest the captain came to flying

32:45 this type of takeoff was in a simulator.

32:48 He only trained on it twice.

32:54 Investigators traveled to Colorado

32:56 to assess the simulator the airline used

32:59 to train its pilots to perform three-engine takeoffs.

33:02 - Okay.

33:05 This is a three-engine takeoff,

33:08 and we're watching for directional control.

33:11 - Did the pilots have sufficient training

33:13 to perform this difficult procedure?

33:16 - I'll call it engine power and take it to max.

33:18 - Part of the examination was to see

33:20 if the simulator accurately portrayed

33:23 what a three-engine takeoff should entail.

33:25 - Okay.

33:27 Let me give this a try.

33:28 Engines two and three are spooled up.

33:32 Engine four is set.

33:33 Here we go.

33:35 Slowly bringing up four.

33:40 One, five.

33:46 One, six.

33:48 One, seven.

33:52 I am barely using my rudder.

33:54 There is no force pushing me off the runway.

33:57 - One, eight.

34:00 - We have VMCG.

34:01 Max power to engine four.

34:04 And rotate.

34:07 - In the simulator, the three-engine takeoff

34:09 is no different from a regular takeoff.

34:12 - Okay, cut.

34:13 - The simulator was not calibrated properly

34:19 and did not require the normal amount of rudder

34:23 that would be required with a three-engine takeoff.

34:26 - This is not how their aircraft would have behaved.

34:29 - Not a chance.

34:30 - Simulators are, for the most part, extremely accurate.

34:36 And in this particular case, we were frankly shocked

34:39 that this one was not.

34:41 It also happened to be the one that the crew trained on.

34:44 And this would really give them, I think,

34:47 a false sense of security when it came to the difficulty

34:51 of making a three-engine takeoff.

34:54 - I'm calling from the NTSB.

34:55 - How did Air Transport International, or ATI,

34:59 compare to other cargo operators on three-engine takeoffs?

35:03 - I'd like to talk to your chief pilot.

35:06 - We checked with the other cargo operators

35:09 who were operating the DC-8.

35:11 There were nine of them.

35:13 - So only your most qualified pilots do it, huh?

35:16 - The vast majority of them

35:18 use their most experienced crews

35:20 and limited the operation to daytime and good weather.

35:24 Now, this led us to believe that the industry as a whole

35:29 understood the danger and the difficulty

35:32 of a three-engine takeoff better than ATI did.

35:35 - Why did the airline choose such an inexperienced crew

35:39 for such a difficult flight?

35:40 - I think it's time we asked them that.

35:44 (gentle music)

35:46 - Our team went to Little Rock,

35:48 which is the headquarters of the ATI operation,

35:51 and we met with all of the key people there.

35:53 - Thanks for meeting with me.

35:56 So I've been told that you didn't use

35:59 your most experienced crew.

36:01 Why not?

36:02 - I needed my experienced crew for a revenue flight.

36:05 The Flight 782 crew is only legal for a non-revenue flight.

36:09 - How so?

36:12 - They'd only had enough rest for a non-revenue flight.

36:15 - You don't say.

36:16 - They discover that the crew was selected

36:20 because of a critical regulation

36:22 governing non-revenue flights and rest times.

36:25 - Normal flights where the company makes revenue

36:28 are covered by flight and duty time regulations.

36:31 For safety reasons, they have to provide a crew

36:34 that has been properly rested,

36:36 but there is a loophole that if the flight is not revenue,

36:41 then there are no flight and duty time regulations.

36:45 In theory, a crew could fly

36:47 in non-revenue flights indefinitely.

36:49 - Abort.

36:51 - Investigators now wonder how rested the crew was

36:57 when Flight 782 prepared for takeoff.

37:00 - So, think it's through this.

37:05 - Investigators closely examine the crew

37:10 of Flight 782's recent flight assignments.

37:13 - Okay, the morning before the accident,

37:16 our crew lands in Germany after a seven hour flight.

37:18 From Delaware.

37:22 - And how many time zones did they cross?

37:27 - Six.

37:29 Later that same day, they return,

37:34 landing first in Gander, Newfoundland,

37:38 and another flight to Delaware.

37:39 - So they crossed another six time zones heading back.

37:44 - We were aware that their circadian rhythm

37:49 had to be pretty much out of sync.

37:51 It's simply not a good thing.

37:55 - Fatigue is not easy to recognize,

37:59 but it degrades all aspects of thinking,

38:04 decision-making, and performance.

38:08 - They got into their hotel in Delaware

38:09 at 2.40 a.m. on the day of the crash.

38:11 - How much uninterrupted rest did the captain get?

38:15 - Less than five hours.

38:19 - So they didn't have enough rest

38:20 to fly anything except this flight,

38:23 and they were sent despite lacking the training

38:26 and experience they needed.

38:27 - The NTSB concludes its investigation

38:37 outlining the fateful steps

38:39 that caused the crash of Flight 782.

38:42 It begins with the poorly rested crew.

38:44 - One of the consistent findings of fatigue research

38:50 is that people tend to underestimate how tired they are.

38:54 Much of the time, you can conduct a safe flight doing that,

38:58 but if something unexpected happens,

39:01 you're at a real disadvantage.

39:03 In this case, the takeoff procedure

39:06 was much more complicated

39:07 than the crew had been trained to expect.

39:10 - Here you go.

39:11 - Thanks.

39:13 - The flight engineer makes an error in a calculation

39:17 that the other pilots don't catch.

39:19 - Once we get near VMCG,

39:21 if we've used all the rudder control,

39:22 you might wanna consider abort.

39:24 - 'Cause when we get higher,

39:25 we're gonna be in worse trouble, correct?

39:27 - That's correct, absolutely.

39:29 - The pilots are confused about the takeoff procedure.

39:33 - I know, actually.

39:36 Above VMCG, your rudder has more authority.

39:38 It's helping you more.

39:40 - This was a very delicate procedure

39:43 and they seemed to think otherwise.

39:46 - If you wanna try it again,

39:48 I could try adding the power if you like.

39:50 - Okay, let's do it that way.

39:51 - A decision to improvise a difficult takeoff

39:55 leads to the plane veering out of control.

39:59 - It was a very bad decision to improvise on this procedure

40:03 because only the person operating the rudder

40:06 can tell how effective that is when advancing the throttle.

40:10 - Okay.

40:12 - The captain decides not to abort a second time.

40:15 The plane lacks enough speed to safely get airborne.

40:22 - We're off the runway.

40:25 Go max power.

40:33 - It's hard to say what was going through his mind,

40:35 but I think he believed

40:36 he could get the aircraft airborne.

40:38 - In their report, the NTSB

40:42 makes several key recommendations.

40:45 One is to revise the training procedures

40:47 for three-engine takeoffs.

40:48 - The crew not only was not trained well,

40:53 it was inexperienced in the particular maneuver

40:55 they were talking about, and they retired.

41:00 - Closing the loopholes that allow flight crews

41:03 to perform non-revenue flights without adequate rest

41:06 is another recommendation.

41:07 - The reason this is relevant is because the company

41:11 elected to have this tired crew fly the three-engine ferry

41:16 rather than the rested crew

41:17 that was already present in Kansas City.

41:20 It was legal, but it was not a good idea.

41:24 - The NTSB also recommends that three-engine ferry flights

41:29 be assigned to specially designated experienced crews.

41:33 Training instructors advised pilots

41:35 of the simulator's shortcomings for three-engine takeoffs.

41:39 - Company exceeded the board's requests.

41:42 They really took it very seriously

41:43 and did change their whole procedure to prevent this.

41:47 - The airline industry as a whole does not follow suit.

41:50 Non-revenue flights remain exempt

41:52 from flight and duty time regulations.

41:55 - There should be no difference with safety,

41:58 whether there are people on the airplane,

42:00 freight on the airplane, or the airplane is empty.

42:03 One rest rule requirement should apply

42:05 to everybody, every time, everywhere.

42:08 (upbeat music)

42:10 (upbeat music)

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