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00:00After declaring an emergency...
00:04Injured passengers due to severe turbulence.
00:07China Eastern Airlines Flight 583 seeks permission to land at a restricted U.S. military base in the Bering Sea.
00:14300 feet.
00:16The Pentagon has to take a look at what's happening.
00:18Is this a ruse to take a look at our radar site?
00:23Once the plane is examined, officials discount the possibility of espionage.
00:30Never seen anything like it before.
00:32This accident was definitely a catastrophic event.
00:36Two passengers died.
00:39The flight data recorder shows an erratic flight path.
00:43Wow.
00:44Being on this airplane was like being on a roller coaster.
00:50Only the cause is not what the pilots reported.
00:54The weather was clear. It's unlikely there was any turbulence.
00:58That changes everything.
01:00The crew of China Eastern Airlines Flight 583 is on an overnight flight from Beijing to Los Angeles.
01:29Approaching 39 degrees north, 172 degrees east.
01:35All good back there?
01:41In 1993, China Eastern Airlines was a fairly new company.
01:47It had only been around a couple of years.
01:49The entire China aviation market was rapidly changing.
01:59China Eastern Airlines began operation in 1988.
02:02It was an exciting time with people finding that they suddenly had the ability to start travelling overseas.
02:11Two hundred and thirty-five passengers have just finished their meal service.
02:20Some rest, while others watch a movie.
02:23The captain is a veteran pilot with more than 8,000 flying hours.
02:36The captain was flying the airplane from the right seat because he was training the person who was in the left seat to be a new captain.
02:49His first officer is a seasoned pilot, but new to this plane, an MD-11.
03:01McDonnell Douglas developed the MD-11 as a fuel-efficient option for long-haul flights.
03:07In the early 1990s, approximately 100 of them were in service worldwide.
03:16The MD-11 was an upgraded version of the DC-10.
03:20It was more efficient flying at cruise speeds.
03:23Although it had an automated system for flying the aircraft,
03:26it was also changed in such a way that it was very responsive to pilot input if they were flying it manually.
03:38This plane is one of five the airline bought to grow its international service.
03:44Field check numbers look good.
03:45Copy that.
03:51During the cruise portion of the flight, things are fairly routine.
03:55They've been flying at 33,000 feet.
03:58The autopilot's on.
04:03They've completed the first leg of the flight from Beijing to Shanghai
04:07and are now flying over the North Pacific bound for Los Angeles.
04:15Ladies and gentlemen,
04:17the cabin crew is now passing out customs declaration cards,
04:20which must be completed before entering the United States.
04:25For many passengers, this is their first overseas flight.
04:35The process is unfamiliar.
04:37Do you post a code of the hotel where it's named?
04:39Yeah.
04:44Something's going on with the speed indicator.
04:46The crew has pre-programmed a cruising speed into the computer,
04:51which is now telling them to fly at a different speed.
04:55The flight control computer is making numerous checks of various systems,
04:59including air temperature, air speed, fuel burn, etc.
05:01And they sometimes give suggestions to the pilots of how they can fly more efficiently.
05:06In this case, fly more slowly.
05:10Hmm.
05:11That didn't fix it.
05:13The captain tries to clear the computer's suggested speed.
05:19It's not a big concern.
05:20The airplane's flying fine.
05:21But it's just odd.
05:24And the captain tries to sort it out.
05:27I'm going to try this.
05:33What's that?
05:34While they're sorting out the speed issue,
05:37the plane seems to hit some turbulence.
05:40They start feeling this buffeting.
05:45And the airplane's shaking around.
05:47Definitely something that will get any pilot's attention.
05:51Suddenly,
05:52one of the worst things a pilot can hear,
05:56a stall warning alarm.
05:58I'm taking control.
06:00The nose of the plane is pitching up,
06:02which shouldn't happen while cruising at altitude with the autopilot on.
06:07He needs to get the nose down because the airplane truly stalls.
06:10It no longer has enough lift to stay flying.
06:13It's going to start dropping from the sky.
06:15The captain pushes the yoke with enough force to override the autopilot.
06:20Autopilot.
06:21Off.
06:23And to avoid a stall.
06:29But now the nose pitches too far down.
06:32Pull up.
06:34Light bullet.
06:36The effects of the dive are felt even more severely in the cabin.
06:40Trying to gain control of the airplane,
06:48trying to understand what's going on.
06:50The adrenal level goes dramatic real quick.
06:53The captain uses all of his strength to keep the plane from diving.
06:57But the aircraft pitches up steeper than expected,
07:03exerting massive G-forces on everyone and everything in the cabin.
07:07Turbulence!
07:08Seatbelt to everyone!
07:09What's going on?
07:14In essence, this airplane was pitching up, then pitching down.
07:19It's almost like being on a roller coaster.
07:22The captain attempts to level the plane, but it goes into an even more extreme dive.
07:30It happens so fast.
07:38The forces are so great.
07:41You wouldn't have time to even think of trying to get your seatbelt on.
07:46Eight degrees, no doubt.
07:48Five.
07:48Nine.
07:50Ten.
07:50Ten.
07:51Ten.
07:52Ten.
07:53The captain halts the terrifying dive,
07:55with severe consequences for unbuckled passengers.
08:00You're being slammed back into your seat,
08:03and then thrown back onto whatever might be below you at the time.
08:09As the plane is tossed up and down,
08:12the crew avoids a stall by keeping the nose from pitching up too much.
08:16But the nose-downs are a problem.
08:19The pitch-downs were more extreme than the pitch-ups.
08:22And the aircraft is losing altitude.
08:27On the next oscillation,
08:29the plane pitches down an astonishing 24 degrees.
08:42The captain battles to stop the plane from diving,
08:46while passengers struggle for their lives.
08:54A lot's going on.
08:56It's a dark night.
08:57He's using his instruments.
08:59Forces are nothing like he's ever seen before.
09:02And so it takes several of these cycles of this porpoicine
09:05until finally he is able to get the airplane back to level.
09:0830 seconds in,
09:15the oscillations lessen,
09:17and the plane begins to stabilize.
09:19Love that zero degrees.
09:23To the crew,
09:24it probably felt like it lasted,
09:26you know, an hour.
09:28In reality,
09:29it lasted a little less than a minute.
09:30What just happened?
09:39No idea.
09:40Even with the autopilot on,
09:43there's no time to relax.
09:45There's no guarantee that what happened won't happen again.
09:48They're flying over the vast Pacific Ocean,
09:53nowhere near an airport,
09:55and several passengers are seriously wounded.
09:59We have many injuries.
10:03We need to get this plane on the ground.
10:05China Eastern Airlines flight 583 is back at 33,000 feet.
10:15Now it needs a place to land.
10:18235 passengers on board.
10:20Unknown number injured.
10:22Call it in now.
10:24Flight 583,
10:25requesting the nearest airport.
10:27This is an emergency.
10:30Airspeed?
10:32298 knots.
10:33Angle of attack?
10:36Zero.
10:37For now,
10:38everything seems to be working.
10:41All they know at the moment is
10:43the airplane's flying,
10:44but it appears to be fine.
10:45But then again,
10:47until we land and get out,
10:48look at it,
10:49we don't know.
10:53With injured passengers on board,
10:55the captain can't take the risk
10:56of flying 3,700 miles
10:58to their destination,
10:59Los Angeles.
11:01We're 39 degrees north.
11:021,76 east.
11:05Copy.
11:06Please stand by.
11:07The crew considers where they might land.
11:10Are we closer to Russia or to the U.S.?
11:12This far out over the Pacific,
11:18mainland Russia is 2,200 miles to the northwest.
11:22Anchorage, Alaska is the same distance
11:24to the northeast.
11:26They're in one of the few places in the world
11:28where there's nothing really close by.
11:31Flight 583 is overseen by air traffic control
11:47in Honolulu,
11:482,000 miles away.
11:502,000 miles away.
11:51What is your emergency?
11:53Injured passengers due to severe turbulence.
11:57Stand by, please.
11:59It's an unusual situation.
12:01A civilian Chinese airplane
12:03in international airspace
12:05in urgent need of an airport.
12:07Looks like it's either Anchorage or Shemya
12:09waiting for clearance.
12:14Shemya, a tiny island
12:16on the western tip of Alaska's Aleutian Island chain,
12:19is about 1,000 miles away.
12:22Anchorage is twice as far.
12:23Because it's an air force base,
12:27Shemya has medical staff and equipment
12:29to treat injured passengers.
12:32Shemya is basically an island
12:33in the middle of nowhere.
12:36Operated by the U.S. Air Force
12:38is strictly for military operation.
12:41There are no commercial flights.
12:44The decision to allow
12:46the China Eastern Airlines flight to land
12:48is taken to the highest levels.
12:50The Pentagon have to take a look
12:54at what's happening here.
12:56Is this a real emergency
12:57or is this a ruse
13:00to take a look at our big radar site
13:02we have there?
13:03I imagine there was a lot of discussion going on
13:06from a security point of view.
13:09Clear to divert to Shemya.
13:11We're clear to divert to Shemya.
13:15The captain had a choice to make.
13:17Do I go to the closest available runway,
13:19which was Shemya,
13:20or do I go further on to Anchorage,
13:23which might be catastrophic
13:24had there been damage to the aircraft?
13:28Okay.
13:29We're going to Shemya.
13:31We have received permission
13:33to land at Shemya Air Force Base.
13:36Damage to our aircraft is unknown.
13:40Can we get a weather report?
13:41The crew prepares for a difficult night landing
13:46on an airstrip they've never seen before
13:48with unknown damage to their airplane.
13:52Shemya has extreme weather.
13:54Heavy cloud cover, fog, and high winds
13:57is the norm.
13:58After a nerve-wracking two hours in the air,
14:01the plane is now only 40 miles
14:03from the air base.
14:04Altimeters set.
14:06They really don't know
14:08what's going to happen
14:09when they slow up.
14:12Did the elevators get damaged?
14:14Will the landing gear come down?
14:16There's a lot of things
14:17they've got to be concerned about.
14:20As they get closer,
14:21the weather intensifies.
14:24Islas armed.
14:26Runway 28.
14:27The crew connects
14:28to an instrument landing system
14:30that uses radio signals
14:32to guide them in.
14:333,000 feet.
14:35The crew at this point
14:37is going to be under
14:37a good amount of stress
14:39and pressure
14:40to make sure that they do it right
14:41the first time.
14:43Wanting to get the people
14:44to help as quickly as possible.
14:50Autopilot off.
14:53Taking control.
14:55They're now only 6 miles
14:56from the runway.
14:57Gear down.
15:02Find the gears down.
15:19500 feet.
15:22400 feet.
15:25300 feet.
15:28The ILS gets the plane
15:30as far as 200 feet
15:31above the ground.
15:33Then the captain
15:34has to fly by sight.
15:44We have touchdown.
15:53Oh.
15:54Oh.
15:54Oh.
15:54Oh.
15:54Oh.
15:54Oh.
16:00The emergency is over.
16:06The plane is safely
16:08on the ground.
16:13Medical teams
16:15immediately assess passengers.
16:17The findings are grim.
16:20149 people are injured.
16:23Dozens of passengers
16:24and crew are taken to hospital.
16:26One passenger is dead.
16:29Another is fatally wounded.
16:32This accident
16:33was definitely
16:34a catastrophic event.
16:40Many, many passengers
16:41and flight attendants
16:43were seriously injured.
16:45passengers who are well enough
16:51to travel
16:52are flown to Anchorage
16:53International Airport
16:54and transferred to hospital
16:56for treatment there.
16:58At that time,
16:59I think I would die.
17:01Of course,
17:01surely I would die.
17:06A team of investigators
17:07from the National
17:08Transportation Safety Board
17:10or NTSB
17:11flies in from Washington.
17:13Greg Fythe
17:17leads the investigation.
17:24Never know anything
17:24that was wrong
17:25with it from here.
17:28They did land
17:29on U.S. territory
17:30and so
17:31we were going to conduct
17:32the investigation
17:33and because it was an MD-11
17:35it was a relatively
17:36new airplane.
17:37I'll go check inside.
17:39We needed to find out
17:40what really happened.
17:43as soon as investigators
17:49arrive at Shemya
17:50they inspect the aircraft
17:53for signs of damage.
17:57I'll go check out
17:58the cockpit.
18:05We didn't have
18:06a lot of information.
18:07We knew that there
18:07had been an emergency landing
18:09that the airplane
18:10had encountered
18:11severe turbulence.
18:12With that kind
18:13of information
18:14you can build
18:14a lot of different
18:15storylines.
18:19The cockpit
18:20looked normal
18:21but as soon as
18:25you looked down
18:25the aisle
18:26it looked like
18:27a bomb had gone off.
18:28never seen anything
18:35like it before.
18:39Row 15
18:40bend down
18:41on seats B
18:42and C
18:43seat 23B
18:46signs of impact
18:48damage.
18:49The cabin
18:50gives them a glimpse
18:51into the tragedy
18:52that unfolded
18:53during the flight.
18:54There was a lot
18:56of baggage
18:57that had come
18:57out of the overheads
18:59broken glasses
19:00broken dishes
19:01they are
19:02basically lethal
19:03weapons
19:03if they are
19:04flying through
19:05the air.
19:07Check out
19:08those marks
19:09likely scuff marks
19:11from shoes.
19:12That was really
19:18disturbing
19:18because passengers
19:20they had to have
19:21been floating
19:21not only in space
19:23but they had to
19:24have rotated
19:24so that their feet
19:26were above their head.
19:29Seems like there was
19:30a sudden pitch down.
19:42The damage is worse
19:43than the aft section.
19:46Someone got badly
19:47hurt here.
19:51People in the back
19:52are more likely
19:53to get injured.
19:54That tail of the
19:55airplane tends
19:56to get whipped
19:56about almost
19:58like a fish tail.
20:00Let's see if we
20:01can find some
20:01passengers that are
20:02well enough to
20:02talk to us.
20:07We really needed
20:08statements from
20:08passengers and
20:09flight attendants
20:10who had experienced
20:12the violence.
20:13They were going to
20:14give us a first-hand
20:15account of what
20:17really took place.
20:21Thanks for coming
20:22in today.
20:29Okay.
20:31When the incident
20:32happened,
20:33what's the first
20:34thing you remember?
20:37The plane started
20:38to shake.
20:39Then it went up
20:40and down like this.
20:42The shaking could be
20:44the result of
20:45turbulence.
20:46How quickly did
20:47this happen?
20:48So fast.
20:50I think I'm lucky
20:51to be alive.
21:04When the plane
21:05started shaking,
21:06did the crew
21:07give a turbulence
21:07warning?
21:07one of the common
21:15causes of turbulence
21:16tends to be bad
21:17weather, such as
21:18rain or hail
21:19storms.
21:21If the turbulence
21:22is unforeseen,
21:24passengers who don't
21:25have their seatbelts
21:26on are a much
21:27greater risk for
21:28injury.
21:29did you see out a window?
21:36Was there any bad
21:38weather?
21:40Not that I could see.
21:46Thank you.
21:47they described that the
21:49flight was actually
21:50relatively smooth.
21:51They didn't notice any
21:52kind of turbulence.
21:54There was nothing
21:55unusual about the
21:57flight leading up to
21:58the main event.
22:04Investigators turn to
22:05the weather reports
22:06from the day of the
22:06incident.
22:07This isn't what I
22:08expected.
22:10The weather was
22:11clear.
22:12It's unlikely there
22:13was any turbulence.
22:15That changes
22:16everything.
22:19What about the
22:20elevators?
22:25Definitely worth a
22:26look.
22:29A damaged elevator
22:30could have led to a
22:32loss of control.
22:33We had to determine
22:35whether or not there
22:36was a problem.
22:37elevators are hinged
22:40flaps on the trailing
22:42edge of the
22:42horizontal stabilizer.
22:44When the pilot pushes
22:46or pulls on the
22:47control column, the
22:48elevators respond by
22:50rising or lowering,
22:51creating pitch.
22:55Investigators look for
22:56any exterior signs of
22:58elevator damage.
23:00Everything looks good
23:00on the outside.
23:02I'll check for
23:03internal damage.
23:05We use what's called
23:06the tap test, and it's a
23:08very simple test, and in
23:10fact, it's done with a
23:11quarter.
23:13It should sound solid.
23:17If you hear a hollow type
23:20of sound, that's a very
23:21good indication that there
23:23is a delamination in one or
23:25multiple layers of that
23:26composite material.
23:28I'm hearing nothing out of
23:29of the ordinary.
23:33After we cleared the
23:34elevators, we still had to
23:35understand what may have
23:36caused this airframe
23:38buffet.
23:38No substructure failures or
23:41anomalies were found.
23:44Nothing wrong with the
23:45elevators.
23:47Then what else?
23:47What did the captain have to
23:54say?
23:56Check the status of his
23:57interview.
24:03We wanted to know what he
24:05was doing as far as his
24:07duties and responsibilities
24:08leading up to the upset.
24:13I'm taking control.
24:14Hey, you're not going to
24:25believe this.
24:26Page 22.
24:29NTSB investigators turned to
24:31the captain's account of
24:33China Eastern Airlines Flight
24:34583's high-altitude incident.
24:37He mentions turbulence before
24:38the onset of the incident.
24:40We knew there wasn't any.
24:41That's not all.
24:42Keep reading.
24:44He noticed the slats were
24:47extended?
24:48Yep.
24:53The MD-11 has eight slats on
24:56the leading edge of each wing.
24:58When extended, they change the
25:00curvature of the wing,
25:01creating more surface area.
25:04Used in tandem with the flaps,
25:05they provide extra lift during
25:08takeoff.
25:08That's weird.
25:10How would the slats be
25:10extended during cruise?
25:14Investigators now have a very
25:20promising lead.
25:23There's no reason to deploy
25:25slats at 33,000 feet.
25:27Soon as you would see that the
25:28slats are extended at that
25:30altitude, it cruised, that
25:32would be an alarm bell.
25:36If the slats were out, that
25:39would explain the pitch-up
25:40described by the passengers.
25:41They're controlled by this
25:44handle here.
25:46You should check the entire
25:48slats system.
25:51We had to determine whether one
25:54or more of the components in that
25:56slats system had either
25:57malfunctioned or failed.
25:58The first look is clean.
26:09No obvious signs of damage.
26:12We had to access all the
26:13mechanical linkages.
26:15There's hydraulic valves,
26:17electrical mechanical systems.
26:19So we had to make the
26:20determination whether or not they
26:21were functioning as designed.
26:23Okay, let's test them.
26:26Extend the slats.
26:30There's one handle in the
26:31cockpit that controls both the
26:33slats and the flaps.
26:39Typically the slats are deployed
26:41first, so when you pull it back
26:42to the first notch, the slats get
26:44deployed.
26:45You pull it back further, the
26:47flaps get deployed.
26:48It all seems to be working fine.
26:53I've not seen any mechanical
26:53issues at all.
26:56They examined the whole system
26:58and they extended normally,
27:00they retracted normally.
27:01There was no obvious damage to
27:03the aircraft.
27:07I still think the slots are part
27:08of the problem.
27:11Maybe it wasn't mechanical.
27:15Good thought.
27:16Maybe it wasn't.
27:18Everything showed that the
27:22airplane was perfectly fine to
27:24fly.
27:25And so the investigation would
27:26focus to what the pilots did
27:29or did not do that caused the
27:31upset.
27:33Did the pilots somehow deploy
27:35the slats at high altitude?
27:39Now we had to determine whether
27:40or not those slats had been
27:42deployed inadvertently.
27:45You got all the reports?
27:46Yep.
27:50Have any pilots accidentally
27:52deployed the slat handle in an MD-11?
27:55They review old incident reports.
28:01We do what's called a look back.
28:03So we're looking at whether or not
28:05this is an isolated event or a
28:07systemic problem.
28:11Hey, look at this.
28:13What have you got?
28:16Ten incidents in two years.
28:22Clipboard fell on the handle.
28:24First officer rested his arm on the handle.
28:27Slats extend in cruise flight.
28:29There had been other events with this
28:35particular system, either an
28:37uncommanded or inadvertent deployment
28:39of the slats.
28:4050% were due to some sort of pilot
28:43contact with the slat handle.
28:45If the pilot didn't know he knocked the handle,
28:49he probably didn't hit it that hard.
28:53So it could have moved
28:54to the slats-only position.
28:59Deploying the slats at high speed
29:00would trigger the buffeting,
29:02which was likely misconstrued as turbulence.
29:04What was happening in the cockpit
29:13right before the buffeting started?
29:16The captain said he was using
29:18the control keypad.
29:20Here.
29:22They are really close together.
29:27Investigators have a new theory.
29:29A simple movement could have triggered
29:31the entire chain of events.
29:34We've got to see how easy it is
29:36to knock this handle out of place.
29:44Investigators test whether the crew
29:45of China Eastern Airlines Flight 583
29:48could have inadvertently
29:50knocked the slat handle out of position
29:52during flight.
29:53Ready?
29:54Ready.
29:57They moved.
29:59Now the first officer was sitting
30:00in the left seat,
30:01so he could have knocked it.
30:02But the captain said he was
30:03playing with the keypad.
30:07They tried different techniques
30:09about, okay,
30:10if you hit the handle
30:12from the right side back,
30:13you hit the handle
30:14from the front side back,
30:15what would it take
30:16to jar the handle
30:18out of position?
30:19Yeah, let me try something.
30:25Bingo.
30:26That's what the captain was doing
30:27when the buffeting started.
30:27It didn't take much force either.
30:32It's a major breakthrough.
30:35Proof that the handle
30:36could have been accidentally moved
30:38while the captain reached
30:39for the keypad.
30:42It was real easy
30:43during normal movement
30:44using the keypad
30:46on the center pedestal
30:47to inadvertently strike the handle
30:50and cause an uncommanded
30:51slat deployment.
30:58Investigators have uncovered
30:59a dangerous design flaw
31:01in the MD-11.
31:02So the handle
31:03probably moved in flight.
31:05and then the captain
31:08retracted the slats.
31:11The captain said
31:13that he saw
31:13that the slat handle
31:14had been out of position
31:16at about the same time
31:17the stall warning system triggered.
31:19He immediately
31:20moved the slat handle
31:21back into the retract position.
31:25The slats were fully extended
31:27for just seconds.
31:30Now,
31:31that explains
31:31the initial pitch-up,
31:33but
31:33there must be more to it than that.
31:36I mean,
31:36the plane went up and down
31:37several times.
31:38The slats wouldn't have caused that.
31:48Investigators still don't understand
31:50why flight 583
31:51experienced so many
31:53extreme oscillations.
31:55The cockpit voice recorder
31:57would record for
31:5830 minutes
31:59and override itself.
32:01So we didn't have
32:02that information.
32:03However,
32:04with the flight data recorder,
32:05we could see
32:06control positions,
32:07we could gain
32:08other information.
32:11Okay,
32:12first up,
32:12let's look at pitch.
32:15So we have
32:15five big oscillations
32:16in roughly 20 seconds.
32:18Biggest pitch-up is here.
32:21Oscillation one,
32:229.5 degrees.
32:24Biggest pitch down
32:25happens here,
32:26minus 24 degrees,
32:28oscillation number four.
32:29for the first time.
32:30For the first time,
32:31they can see the severity
32:32of the oscillations
32:34passengers describe.
32:35And it starts to stabilize
32:37here.
32:41The team launches
32:42into a second-by-second
32:44analysis
32:44of the first pitch-up.
32:46The slats were extended here
32:51during the beginning
32:52of the first pitch-up.
32:55It's gradual at first.
32:58Is the autopilot on?
33:04So it's on
33:05for the first few seconds,
33:06and it would have been
33:07fighting to bring
33:08the nose down.
33:08When the slats deploy,
33:11the airplane will have
33:12a natural nose
33:13or pitch-up tendency.
33:15With the autopilot engaged,
33:16it will actually
33:18correct for that pitch-up
33:19and return the airplane
33:20to a level attitude.
33:24But
33:25the autopilot's
33:26losing the battle.
33:28The pitch
33:28keeps increasing,
33:30and that would trigger
33:30the stall warning.
33:36Yep.
33:37stall warning turns on here.
33:40A few seconds later,
33:41the autopilot disengages,
33:42and now
33:43the nose dives down sharply.
33:47I'm taking control.
33:50Autopilot
33:51off.
33:59So the captain's
34:00at the controls
34:00when the big drop happens.
34:03Show me the elevator data.
34:07Wow.
34:12So the captain
34:13made some elevator inputs
34:14starting right here.
34:16That is a huge
34:18nose-down command.
34:23It's an overcorrection,
34:25and I think I know why.
34:29I'm taking control.
34:30Up!
34:30Fight!
34:32Autopilot's are designed
34:34so they won't just
34:35let go easily.
34:37You don't want somebody
34:38just accidentally
34:39bumping against
34:40the controls
34:40to suddenly
34:41knock the autopilot off.
34:45He felt the resistance
34:47and pushed against
34:48that resistance
34:49of the autopilot,
34:51disengaging it.
34:53Unfortunately,
34:54that led to
34:56an excessive amount
34:57of nose-down elevator command.
34:59He started a chain reaction
35:04of pushing and pulling
35:06too hard on the yoke.
35:08At high altitude,
35:10the pitch forces
35:11are very light
35:12on the yoke.
35:14So when he pulls back
35:16to get the nose up,
35:18he's putting in
35:19too much up force.
35:21It goes up too high.
35:29He pitches down,
35:30it goes down too low.
35:39And he puts in
35:40several cycles
35:40on the control yoke,
35:42trying to get back
35:43to normal.
35:44It's called
35:49a pilot-induced
35:50oscillation,
35:51or PIO.
35:53The pilot
35:53overcorrects
35:54and the plane
35:55responds,
35:56creating increasingly
35:57uncontrollable movements.
36:03Once you get
36:04into the oscillation,
36:05it's hard to stop.
36:09Everything's
36:10happening fast.
36:14We were able
36:15to calculate
36:16that the occupants
36:17of the airplane
36:17experienced
36:181.24 negative G's
36:21and two positive G's.
36:24No wonder
36:25there were so many
36:26injuries,
36:26including two fatalities.
36:30He did get the plane
36:32back under control.
36:33It just took a while.
36:36Pilot-induced
36:37oscillations
36:38can cause
36:38extreme stresses
36:40on the aircraft.
36:42Usually the best
36:43course of action
36:43is to put in
36:44less control force.
36:46Once that happens,
36:47you can have
36:47a nice stable flight.
36:49So why would
36:50an experienced
36:51captain struggle
36:52so long
36:52to get a plane
36:53back under control?
37:03Long day ahead.
37:05Don't need this.
37:07I pulled
37:07the captain's files.
37:10Investigators
37:11turn their attention
37:12to the captain
37:12to the captain
37:12of Flight 583's
37:14training
37:14to determine
37:16why he repeatedly
37:17overcorrected
37:18with his control column.
37:20He had over 1,300 hours
37:21on the MD-11.
37:23That should be plenty.
37:26Flew other passenger jets too.
37:27The captain had flown
37:31to the airbus 300s.
37:34He had experience
37:36with big aircraft.
37:38He had experience
37:38with high-altitude flight.
37:41Everything would indicate
37:42that he was well-qualified
37:44to fly the airplane.
37:46No complaints.
37:48No prior accidents.
37:51He's clean as a whistle.
37:52The captain passed
37:55all of his MD-11
37:56training without incident.
37:58He even took
37:58a refresher course
37:59a few weeks
38:00before the accident flight.
38:02Hmm.
38:04Let me see
38:05the training manual.
38:11Investigators
38:12take a closer look
38:13at the training
38:14the captain received.
38:15A critical aspect
38:18of accident investigation
38:19when you're looking
38:20at an event like this
38:21is pilot training.
38:24The captain
38:25did go through
38:26a very comprehensive
38:27textbook
38:27or classroom training.
38:30Find anything?
38:33Actually
38:34it's what I didn't find
38:37that interests me.
38:39No simulator training.
38:41None.
38:42Nope.
38:43Not for an inadvertent
38:45SLAT deployment
38:46during cruise
38:46or an upset
38:48at high altitude.
38:51Hmm.
38:52Just giving them
38:53something to read
38:54is sort of like
38:55trying to learn
38:56to ride a bicycle
38:57if you've only
38:57read a manual.
38:59What's going on?
39:04With simulator training
39:05you get some
39:06hands-on training
39:07and you have a good idea
39:08of what to expect.
39:10He did not
39:13have that training
39:14so in fact
39:15he was really
39:16a test pilot
39:17trying to get
39:18this airplane
39:19back under control
39:20after this
39:21uncommanded
39:22SLAT deployment.
39:25Was there
39:26something about
39:27the design
39:28of the aircraft
39:28that made it
39:29difficult
39:30to regain control?
39:32This is the
39:33Airbus A300
39:34here
39:34and the DC-10.
39:36Here
39:37is our MD-11.
39:38When compared
39:40to other
39:40large passenger jets
39:42one design feature
39:43stands out.
39:45Look at the
39:45center of gravity.
39:46It's so far aft.
39:49Most planes
39:49have their
39:50center of gravity
39:51further forward
39:52in the midsection.
39:53That would make
39:54the MD-11
39:55less stable.
39:59The MD-11
40:00was designed
40:01to increase
40:02fuel efficiency
40:03and to do
40:04that
40:05you move
40:05the center
40:06of gravity
40:06back
40:07fairly far aft.
40:09The airplane
40:10becomes more
40:10pitch sensitive.
40:14I found
40:15the airplane
40:16to be
40:16very maneuverable
40:17but some people
40:19would get
40:19a little bit
40:20behind it
40:21and you could
40:22end up
40:22in cases
40:23where the airplane
40:24would overshoot
40:25what you were
40:26expecting.
40:30Investigators
40:30conclude that
40:31the captain
40:32could have
40:32stabilized
40:33the oscillations
40:34sooner
40:34with faster
40:35less forceful
40:36control inputs.
40:40But the design
40:41of the aircraft
40:42made that
40:44difficult to do.
40:50In their final report
40:52NTSB investigators
40:54found that
40:54an unintended
40:55movement of the
40:56slat handle
40:57likely caused
40:58the slats to extend
40:59and the airplane
41:00to pitch up.
41:01The probable
41:07causes determined
41:08by the NTSB
41:09did not place
41:10any kind of
41:11blame
41:12or even
41:13talk about
41:13the flight crew
41:14actually causing
41:15this event.
41:17This was a
41:18strict
41:19design issue
41:20that unfortunately
41:22the crew
41:23became a victim of.
41:24of the seatbelts.
41:26The report
41:29also notes
41:30that many
41:30of the severely
41:31injured passengers
41:32either had
41:33their seatbelts
41:34unfastened
41:35or were standing
41:36in the aisle.
41:40The flight attendants
41:42had made an
41:43announcement
41:43about seatbelts
41:44but as is often
41:46the case
41:46passengers may
41:47have ignored
41:48that announcement.
41:49And that
41:51left many
41:52passengers
41:53vulnerable.
41:56When you
41:57are in
41:58an airplane
41:58not just
41:59for takeoff
42:00not just
42:01for landing
42:01it is critical
42:03that you
42:04keep your
42:04seatbelt
42:05on.
42:06You never
42:07know what
42:08can happen
42:08in flight.
42:10of the
42:11seatbelts.