Chuyến bay 105 của Midwest Express Airlines là chuyến bay chở khách nội địa theo lịch trình đã đâm vào một cánh đồng trống ở Oak Creek, Wisconsin ngay sau khi cất cánh từ Sân bay quốc tế General Mitchell vào ngày 6 tháng 9 năm 1985. Chiếc máy bay, một chiếc McDonnell Douglas DC-9 , chở 31 hành khách và phi hành đoàn. Không ai trong số họ sống sót sau vụ tai nạn.
Nhiều nhân chứng đã báo cáo rằng máy bay đã bốc cháy ngay sau khi cất cánh khỏi sân bay. Vụ cháy xảy ra do hỏng động cơ bên phải, một trong những miếng đệm ống lót có thể tháo rời bị bong ra. Miếng đệm ống lót có thể tháo rời bị mỏi kim loại khiến động cơ phát nổ.
Nhiều nhân chứng đã báo cáo rằng máy bay đã bốc cháy ngay sau khi cất cánh khỏi sân bay. Vụ cháy xảy ra do hỏng động cơ bên phải, một trong những miếng đệm ống lót có thể tháo rời bị bong ra. Miếng đệm ống lót có thể tháo rời bị mỏi kim loại khiến động cơ phát nổ.
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01:00There are 27 passengers boarding Midwest Express Airlines Flight 105, a cross-country commuter flight from Milwaukee to Atlanta.
01:27Many are employees of the manufacturer Kimberley Clark.
01:33Midwest Express Airlines used the slogan best care in the air and they really meant it because they had as close to an all business aircraft as you could have.
01:45Treats for when we're airborne.
01:46And they also baked fresh cookies on board and made the place smell amazing when you walked on.
01:59Mid X 105 requesting IFR clearance to Atlanta.
02:03Both pilots on this flight are captains with the airline.
02:08They've already flown two flights together today.
02:15Mid X 105, clear to Atlanta.
02:17Climb and maintain 5000.
02:20Climb and maintain 5000.
02:22Mid X 105.
02:23For this leg of the flight, Danny Martin will be the acting captain and Bill Weiss the first officer.
02:30You had two captains and they literally could switch seats because of that.
02:36And they did do that over the course of two days.
02:39Flipping out who was the pilot flying and who was the pilot not flying.
02:42Our alternate will be DCA if we can't make Atlanta.
02:48There are thunderstorms in Atlanta, so the crew has taken on additional fuel in case they have to divert to another airport.
02:57Takeoff weight is 771, 22 pounds.
03:00Set stab trim to 2.2.
03:06Just past three in the afternoon, the pilots start the engines.
03:12The DC-9 used for today's flight is powered by two Pratt & Whitney engines, mounted on the fuselage at the rear of the plane.
03:28Because the engines were in the back, they were close together, which made for a little bit easier flying in emergency situations.
03:37Second of all, for the passengers, it's quieter.
03:41Thank you.
03:42Oh, can I put that up here for you?
03:47Thank you.
03:49The plane is loaded and ready to depart on schedule.
03:57Airspeed bug, 1.33 set and 1.9 on the EPR.
04:02Okay.
04:02Ladies and gentlemen, we are number one for departure, so we should be airborne within one minute.
04:16Flight attendants, please be seated.
04:17This was a very normal morning for a very normal flight.
04:43It was a gorgeous blue sky, September day.
04:48There was a little bit of gusty winds, but it was nothing for Milwaukee.
04:55Power normal.
04:56The pilots need to reach a speed of 127 knots for takeoff.
05:05V1.
05:08Rotate.
05:08At 3.21 in the afternoon, flight 105 begins its journey.
05:21The flight plan calls for the plane to climb to an altitude of 33,000 feet for the two-hour trip to Atlanta.
05:28You're up.
05:38Just 450 feet above the ground.
05:40The pilots lose power in one of the engines.
05:52It's a critical situation because if you don't do something about it immediately, you won't have time to do anything about it.
06:00Altitude is your friend.
06:01The plane begins rolling to the right and dropping.
06:31Oh, crap.
06:38The DC-9 is stalling.
06:42Get your heads down.
06:51Heads down!
06:52Heads down!
06:53Heads down!
06:53Less than a minute after takeoff, flight 105 is diving towards the ground at more than 170 miles an hour.
07:03The plane hits the ground, less than 1,700 feet from the runway.
07:20A DC-9 has crashed southwest of runway 19R.
07:26All 31 people on board have been killed.
07:38The crash of Midwest Express Flight 105 is the third major accident in the United States this year, and the eighth accident worldwide.
07:53With more than 1,200 people killed, this is becoming one of the deadliest years in the history of civil aviation.
08:00Passengers are unnerved.
08:02Everyone says, my God, another one.
08:04What do you say to the public about the crashes that we've been having?
08:09Well, insofar as the National Transportation Safety Board is concerned, we are sparing no effort to determine the cause of each one of them, and we will make the necessary recommendations to keep any repeat of any one of them from happening.
08:19Can you show me where it started at a bank?
08:26Investigators from the NTSB begin by interviewing witnesses of Midwest Express Flight 105's fatal dive.
08:34They either came forward or we tracked them down.
08:37We ended up making out a questionnaire with 40 or 50 questions on it to kind of cover all the bases.
08:43Okay, got it.
08:48While the witness accounts differ in detail, they all describe more or less the same thing.
08:57I saw a couple puffs of black smoke come out, and I just figured that they had gunned the engines a little bit.
09:04Instant later, the left wing rose up, and it tipped over and went nose first into the trees here.
09:11Most of the witnesses agree that takeoff appeared normal until the airplane was about 300 feet off the ground.
09:21Almost all report smoke and fire coming from the right engine.
09:26Several remember hearing loud bangs. Most said that the plane then rolled abruptly into a steep right bank, went into a nose-low spin, and crashed.
09:41The value of having so many witness statements to look at, they gave us a picture of what happened right at the end.
09:47The loss of control, fire, and of course the impact itself.
09:53Investigators must now determine what could have caused such a catastrophic loss of control so soon after takeoff.
10:02I'm guessing this was made by the right wing.
10:07Yep, agreed.
10:09Let's see what we can figure out.
10:15After securing the crash site of Midwest Express Flight 105, investigators begin mapping the wreckage field.
10:24I think the whole length of the impact site was about 295 feet, not much more than two times the length of the airplane.
10:32So the airplane hit pretty steeply and didn't go very far.
10:36Right wing tip here, and the horizontal stabilizer here.
10:45This is how the plane hit the ground.
10:48A 90 degree right roll, and a right yaw.
10:56Can you grab the picture?
10:57Got it.
10:59The wreckage path confirms eyewitness reports.
11:03Right.
11:04Okay.
11:05It very definitely indicates right up front that you've got a lost control.
11:08It doesn't suggest why you had the lost control.
11:11It kind of opens the door to a lot of different investigative avenues.
11:14Yeah, it's fire damage for sure, but it looks like all the pieces are here.
11:23Investigators study the plane's control surfaces, starting with the ailerons.
11:28The ailerons on each wing direct the plane's roll.
11:34If an aileron malfunctions and gets stuck in one position, it could cause a devastating lack of control.
11:41Control tabs are in place. They seem to be intact.
11:47We didn't find a problem with other components that are part of that system.
11:53With the ailerons ruled out, investigators turned their attention to the rudder system.
12:00The dampers are still working. Hinges are intact.
12:06The fractures look like overload, not stress.
12:10I don't think the rudder is our culprit.
12:17We didn't find anything wrong with any of the control systems based on that preliminary look-see.
12:25Could the engines provide insight into the crash of Midwest Express Flight 105?
12:31If the engines were, well, obviously banged up, they were fire damaged, and they were along the wreckage path, which is always good,
12:40that means they didn't fall off somewhere earlier.
12:46There's a spacer missing here.
12:53Most of the blades from this stage are gone.
12:56The team finds damage inside the right engine that could not have been caused on impact.
13:03The missing engine pieces include a spacer and the compressor blades from the 9th and 10th compressor stages.
13:13They're found more than half a mile from the main wreckage site.
13:18Finding any part of the airplane short of where the airplane had crashed was a suggestion of a malfunction or failure that had occurred in flight and required further investigation.
13:31The engine and the pieces are moved to a nearby warehouse where they can be more closely examined.
13:37In the end, we ended up finding about 90% by weight of the spacer, so that was a big boon to the investigation.
13:45Investigators study the recovered spacer to determine why it failed on Midwest Express Flight 105.
13:52All on the pedestal here, it's definitely not overstressed.
14:01They discover a telltale crack on the spacer that appears to have spread over time, what's called progressive cracking.
14:10There may be stress marks, there may be cracks, there may be things that suggest a direction of failure and a timeframe where the fracture would have occurred.
14:22It doesn't occur all at one time.
14:24Can we determine how long that crack has been spreading for?
14:28I'll see what I can do.
14:29We became interested not just in detailing that but trying to find whether this was a fracture that could have been detected previously.
14:41A closer look at the crack on the steel spacer reveals it's filled with nickel.
14:47A lightweight nickel coating is applied to certain vital engine pieces like the compressor spacers and blades to prevent corrosion.
14:58The compressor was brought in to be refurbished in 1981.
15:02Coating stripped, spacer examined and here we go.
15:08Re-plated.
15:10That was four years ago.
15:13The maintenance records tell investigators that work had been done on the spacer that failed on Midwest Express Flight 105.
15:21Nickel-cadmium plating is the last step of the refurbishment process that would have been done by the maintenance facility that was involved with essentially the overhaul of that part.
15:34Four years before the accident, the spacer was removed from the engine, stripped of its coating and examined for cracks.
15:43The inspector reported no cracks and sent the part to be re-plated with nickel.
15:48Since nickel was found inside the crack, it must have been present when the nickel was applied.
15:55The DC-9 flew about 2,500 flights over the next four years with the damaged spacer until it finally ruptured on Flight 105.
16:12It should have been caught during an overhaul, but it wasn't.
16:15And so the crack kept growing and growing until it finally hit its failure point.
16:20Investigators wonder what caused the crack to form on the spacer in the first place.
16:26These spacers have been used inside the JT-8D for more than 20 years.
16:31This can't be the first one to break.
16:33There are identical spacers in more than 14,000 JT-8D engines used on airplanes around the world.
16:44Is there any history of similar failures?
16:47It turns out that Pratt and Plady were well aware of spacer failures that occurred before.
16:53So we started to wonder, what have they done about it?
17:02Seems to happen a lot.
17:04While researching spacer issues in other aircraft, investigators uncover 45 similar failures prior to Midwest Express Flight 105's accident.
17:16Well, when we heard that this part had failed 45 times before, we kind of looked askance a bit at the manufacturer.
17:24And that's a big deal.
17:25But of all the failures uncovered by the NTSB...
17:31Not a single loss of aircraft or even a single injury.
17:35Well, that says something.
17:37In every previous incident, the plane landed safely.
17:42So why did the rupture of a spacer on Flight 105 cause the plane to become uncontrollable and crash?
17:49Well, we knew that none of the previous failures had led to an accident.
17:55So one of the questions was, what made this one different?
17:58Let's see what got hit.
18:01Investigators consider the possibility that pieces of the ruptured spacer on Flight 105 punctured the plane's fuselage and damaged vital control systems, such as cables or hydraulic lines.
18:16When a part like a spacer or a fan disc breaks under a lot of stress, it's almost like a small explosion going off.
18:28You have fragments of metal flying at very, very high speeds.
18:33Okay, let's see 894.
18:38They study the location and pattern of all the puncture marks found on the skin of the plane to see if any were near vital control links.
18:48No control cables, no hydraulics.
18:541012.
19:00No control cables, no hydraulics.
19:02What about the pieces of the plane that we haven't been able to find?
19:09There are many critical pieces of the plane that have not been recovered or are too badly damaged to study.
19:17Is it possible to figure out if they could have been hit by the engine pieces?
19:22We have what we need to run a trajectory analysis.
19:25We were looking at could these parts that have left the engine strike a control surface or the hydraulic system or anything else where they could have done secondary damage that would have compounded the situation the pilots were facing.
19:45Knowing the plane's velocity, angle of ascent and the wind speed at the time the engine failed, the team calculates the path of debris ejected from the engine.
19:58The smallest piece we found was about half an ounce.
20:01The largest piece was just over a pound.
20:04So everything moves away from the plane, nothing hits it.
20:07The trajectory analysis tells investigators that none of the ejected engine pieces would have struck the airplane with enough force to cause substantial damage to the control systems.
20:20The analysis indicated that it was so unlikely that we considered it an impossibility that those parts leaving the engine in the direction they went and the size that they had could have caused secondary damage that would cause lost control.
20:38If spacer fragments didn't hit vital components and cause the loss of control, perhaps the initial explosive force opened the cowling or engine cover, affecting the plane's aerodynamics.
20:53If the cowling had been blown open, it would cause a lot of drag, it might cause the airplane to roll, it might cause the airplane to become uncontrollable.
21:03There's a hole in the cowling, it looks to be about two square inches.
21:08The team finds evidence that the cowling was pierced by fragments ejected from the engine.
21:14But all four latches, one, two, three, four, they're all latched.
21:21Can't have opened in flight.
21:23They found them all either latched or fully intact with no damage at all.
21:30So that scenario kind of went out the window.
21:35So the ruptured red engine didn't bring down this plane?
21:38It did not.
21:43Reasonably early in the investigation, the team figured out that a spacer had failed and the engine had failed.
21:49And now we had the rest of the accident to figure out.
21:53Why would that cause a crash?
21:55Investigators examine Midwest Express Flight 105's flight data recorder in hopes of understanding how the loss of the right engine caused the death of 31 people.
22:11Doesn't give us much, but it's all we've got to work with.
22:14It was only recording four flight parameters.
22:17It had airspeed, altitude, heading, and vertical acceleration.
22:23Right here, a sudden deceleration at 450 feet. This must be where the right engine failed.
22:29Well, that's consistent with what the witnesses told us.
22:32The engine failure we know occurred above the airport, so the airplane had only been airborne for a few seconds.
22:45But the heading doesn't change when the engine fails. They must be applying left rudder to compensate.
22:52Dead right engine, left rudder. That's the right move.
22:54When the right engine fails, the remaining engine should force the plane to the right.
23:03To counteract that, a pilot would apply left rudder to keep the plane flying straight.
23:15The data shows that's precisely what Captain Martin did in response to Flight 105's engine failure.
23:23After a few seconds, they start this yaw to the right.
23:28So, right rudder?
23:32Four seconds after the failure of the right engine, the FDR data indicates that the pilot moved the rudder from left to right.
23:41That forced the plane into a sudden yaw to the right.
23:47He's in a side slip.
23:48And he's deviating further and further to the right.
23:54Then he starts to lose altitude.
23:57Huh. 148 knots.
24:01He's in a high-speed stall.
24:04How'd they let that happen?
24:05You went into a right skid and then followed by an abrupt right turn and dive.
24:14That would be consistent with a stall, but the air speeds indicated were high enough that you wouldn't normally have a stall at those speeds.
24:24Clearly lost control of the plane.
24:27Five seconds later, they hit the ground.
24:31The flight data tells investigators that it took only 10 seconds for the pilots to lose control of the plane after the failure of the right engine.
24:40I have never seen an accident sequence that brief, um, before or since.
24:50So, he responds correctly at first with left rudder and nose down pitch.
24:58Then he inexplicably switches to right rudder?
25:00And that's what leads to the yaw, the right roll, and the eventual stall.
25:05Right rudder, it makes no sense.
25:08It was clear from all the data that the pilot didn't understand what happened.
25:13He responded inappropriately, and within seconds the airplane was lost, and everybody on board was killed in the accident.
25:20Was there something about the DC-9's handling characteristics that led the pilot to input the right rudder?
25:30So, it was relatively easy to control then?
25:35Just with the control wheel?
25:39Investigators interview DC-9 pilots to determine how the plane handles with only one engine.
25:45The DC-9 pilots that we talked to, it was overwhelmingly described as a very easy, docile aircraft to handle in those situations.
25:53Oh, this has been extremely helpful.
25:55Thanks.
25:56Okay, bye.
25:58They all say the same thing.
26:01It's no big deal with one engine.
26:05Because the DC-9's engines are mounted on the fuselage instead of the wings,
26:10when one engine fails, it does not force the plane into a severe turn.
26:15DC-9 is almost a centerline thrust aircraft, so if you lose one engine on either side,
26:22there's not that much excess yawing or controllability problems at all.
26:31How easy is it to handle a DC-9 in the situation the pilots of Flight 105 found themselves in?
26:37It was valuable to do a simulation or test flight to get a better idea of exactly how the airplane performed under the circumstances of the accident, but at a higher altitude.
26:52Okay, when we get to 10,000 feet, I'm going to cut power to the right, leaving the left at takeoff power.
27:01Keep the flaps at 20, target speed is 170 knots.
27:05They tried to match the parameters of the airplane in terms of the flaps, gear, and airspeed, and then proceeded to cut the engine power.
27:16Cutting power.
27:17Okay.
27:18Cutting power.
27:19Okay.
27:20Thank you.
27:21Let's go around for another.
27:22Flight demonstrations showed that the pilot didn't have to input rotor at all.
27:25If he had only used the ailerons, he could have safely fallen out of it.
27:30Okay.
27:31This time, no reaction.
27:32Let's see what the plane does.
27:33With no input from the pilot after the loss of the right engine, the plane rolls right and the nose drops.
27:45Okay.
27:46You can recover?
27:47Even with no immediate action, the pilot is easily able to recover the plane.
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42:09Cảm ơn các bạn đã theo dõi và hẹn gặp lại.
42:39ATSB's final report makes several key recommendations to prevent this type of accident from happening again.
42:45They recommend a directive requiring airlines to replace the existing spacers with a new type of spacer which is less likely to fail.
42:55They also recommend that airlines are advised to teach their pilots to communicate during on-board emergencies.
43:01It should never be overstated the importance of crew coordination.
43:05Every crew member has something valuable to add.
43:09Anything that is in abnormality needs to be discussed at the proper time.
43:16They also suggest that airlines review their simulator training to ensure pilots are taught to use their instruments to assess the nature of engine failures.
43:27I think this accident still has an impact today because it's such a clear illustration of what happens when you don't do what you should do in an emergency.
43:43Anytime there's an emergency, you should have the exact same procedures and you should run right to them.
43:50Midwest Express Airlines continued to operate until 2009.
43:57It merged with Frontier Airlines in 2010.
44:00ATSB's final reporthält