All language subtitles for Air.Disasters.S18E04.Dead.Tired.1080p.SMIT.WEB-DL.AAC2.0.H.264-maldini_track3_[eng]

NARRATOR: February 12, 2009.

Just outside Buffalo, New York.

Gear down.

Looks alive.

Gear's down.

[whimpers]

Jesus Christ!

[passengers screaming]

The airplane entered
an aerodynamic stall.

[screaming]

It did not recover.

[sirens blaring]

CLINT CROOKSHANKS: It was one of
the grisliest, nastiest scenes

that I think I've seen.

NARRATOR: The crash of
Continental Connection flight

3407 would be one of the NTSB's
most important in decades,

and would see a grieving
father fight for changes

to the laws governing
small airlines.

JOHN KAUSNER: I'm
focused and determined

to change what exists, and not
have another dad sitting here.

FLIGHT ATTENDANT:
Ladies and gentlemen,

we are starting our approach.

PILOT: We lost both engines.

FLIGHT ATTENDANT: Put
your mask over your nose.

Emergency descent.

Brace for impact!

NARRATOR: Continental
Connection flight

3407, operated by Colgan Air,
is en route from Newark, New

Jersey, to Buffalo, New York.

It's been a busy flight
for Captain Marvin Renslow.

He's providing guidance
to a new first officer,

Rebecca Shaw, a former flight
instructor from Seattle.

[sneezes]

Bless you.

NARRATOR: Shaw's only
been with the airline

for just over a year.

Yeah.

NARRATOR: She must decide if she
now wants to become a captain.

I don't know what I want
to do with the upgrade.

It depends where I'm based.

Well, think of it this way.

If you stayed on the
queue, obviously,

you're not making
the captain rate.

Right.

But you may have a
better quality of life,

with regards to buying a
house, having a schedule--

NARRATOR: Shaw trained
to be a first officer

on the plane they're flying
now, a Canadian-made Bombardier

Q400.

It's a twin engine, popular
with regional airlines.

The 45 passengers
have had a long night.

Their plane was held up
for two hours at Newark--

a delay considerably
longer than their journey.

Flight 3407 is
heading northwest,

over upstate New York.

The trip is only 53 minutes.

Visibility is poor, and
there's a forecast of snow

and moderate winds in Buffalo.

Just some water, please.

NARRATOR: Ellyce Kausner is
a student at Florida Coastal

School of Law in Jacksonville.

She's on her way to visit
her family in Buffalo.

JOHN KAUSNER: She had five
nieces and nephews at the time,

and they had a love
luncheon at the kids' school

with a couple of the nephews.

And they both wanted
Elly be their guest.

Any excuse to come
home, she came home.

She talked to all
of us from Newark.

Hey.

JOHN KAUSNER: And she
called us from the lounge.

Yeah, it's been
over two hours.

JOHN KAUSNER: She was
PO'd because of the delay.

Folks from the flight deck,
your first officer speaking.

It looks like, at this
time, we're about 10,

maybe 15 minutes
outside of Buffalo.

Weather in Buffalo
is pretty foggy.

It's snowing a little bit there.

I'd like to make sure everyone
remains in their seats,

so the flight attendants can
prepare the cabin for arrival.

Thank you.

FLIGHT DECK: Colgan 3407,
descend and maintain, 2,300.

REBECCA SHAW: OK, down to 2,300.

Colgan 3407.

Let's do a descent
checklist, please.

We can do the approach
checklist along with it.

Sure.

Bug set.

Set.

GPWS, landing flaps
selected, 15 degrees.

NARRATOR: The pilots
go through a list

of settings for the plane to
continue its landing approach.

Yup.

NARRATOR: Passengers can
already glimpse the lights

of Buffalo's suburbs.

Clarence Center is on the
approach path for aircraft

landing at Buffalo's airport.

Gear down.

Looks alive.

Gear's down.

All right.

Flaps 15.

NARRATOR: Extending
the flaps provides

more lift, allowing
the plane to slow

to its final approach speed.

Uh-- [whimpers]

Jesus Christ!

NARRATOR: Suddenly, the
control column starts to shake.

The Q400 is slipping
out of control.

[passengers screaming]

Captain Renslow struggles
to keep his plane flying.

Mother-- ah!

NARRATOR: But it seems to
have a mind of its own.

[shaw yelling]

[passengers screaming]

Mother bear.

Should the gear be up?

Gear up!

Agh, damn!

Ah, we're down!

[screaming]

Oh, my god!

NARRATOR: The plane crashes into
a house at 6038 Long Street.

At air traffic
control in Buffalo,

flight 3407
disappears from radar.

DAVID CASE: I'll never forget
the dispatcher's words.

Plane crash, house on fire.

I immediately got my
shoes on and my coat on.

Got in my truck and started
heading down the driveway.

NARRATOR: Firefighters
don't have far to go.

6038 Long Street, home
of the Wielinski family,

is less than a block from
the Clarence Center Station.

As I turned
towards the village,

the whole village was aglow.

You could see the smoke.

You could see the flame.

NARRATOR: Karen Wielinski
and her daughter

make it out of
their house alive.

But her husband,
Douglas, is killed.

My initial reaction
was, there's no--

there was no way that
somebody made it out.

But the EMS, the
division reported

that they had two
people, and they were

taking them to the hospital.

And I said, well, which
firefighters are they?

And they said, they're
not firefighters, Chief.

They are survivors
from the house.

I actually physically had
to go to the ambulance

and look inside for
myself to to believe.

NARRATOR: Firefighters have
never seen a blaze like this.

DAVID CASE: But if you've
ever gone to a bonfire

and stood 5 feet from it, and
you couldn't take it anymore,

that's what it felt
like from 100 feet away.

MICHAEL ROGOWSKI:
The height of it was

was just unbelievable,
obviously, because of the fuel

that was probably added to it.

And the debris area
was was very large.

It was a very, very
horrific sight.

We live in the
town where the plane

went down right down the road.

My son was driving
home from a soccer game

and went right by the plane
crash, and called me up

and said, there's a
plane down in Clarence.

It never really entered our
brain that it was Elly's plane.

NARRATOR: Flight
3407 has crashed 5

miles short of Buffalo Airport.

All 49 passengers
and crew are dead,

including Captain Marvin Renslow
And First officer Rebecca Shaw.

But many more people could
easily have been killed.

You picture a house.

And to see a plane on
top of this house--

no more house left,
no more plane.

Only the tail section.

You're asking yourself, how in
god's creation did this happen,

and not wipe the
whole block out?

JOHN KAUSNER: The next
call was again from my son,

and said, in fact,
it was Elly's plane.

And he said, Dad,
there's no survivors.

At which point, my wife shrieked
and just hit the ground.

Chris said he'd never heard his
mother make a sound like that,

and I hope he never does again.

So that's when I knew
that she was gone.

And that was probably within
45 minutes of the accident.

NARRATOR: The scene
in the morning

is one of utter devastation.

Clint Crookshanks
from the NTSB.

Can I start poking around?

NARRATOR: Clint Crookshanks is
one of the first Investigators

on the case.

CLINT CROOKSHANKS: When
we arrived on scene,

there was a fire still burning.

It turns out it was
from a gas line that

had been broken in the house.

The firemen would
put the fire out,

and it would reignite
every couple of minutes.

It was one of the
grisliest, nastiest scenes

that I think I've seen.

NARRATOR: Flight 3407 may
have been a small plane,

but it's the worst crash in the
US in more than seven years.

It will become one of the NTSB's
most important investigations.

preventing investigators
from examining the wreckage.

Right in there.

That's where I think the--

the box--

The airplane had
crashed into a house,

and then it had
burned all night long.

So all the debris was
basically in the house.

LORENDA WARD: Our concern is
that we're losing evidence.

It's perishable.

And if we can't get in
there and get the fire out,

then we're not able
to maybe get a hold

of evidence that might help
us during the investigation.

NARRATOR: Clint
Crookshanks urgently

needs to recover
the black box flight

recorders, which could
contain valuable clues

about the accident.

We knew that the recorders
were in the tail part

of the airplane.

NARRATOR: Ordinarily,
investigators

don't go near a crash
site that's still burning.

But if the black boxes
can't be rescued,

they may never find out what
brought down flight 3407.

We started looking around and
poking around into the wreckage

and actually found
out where they were.

OK, whoa, whoa.

It's probably in here, OK?

The access panel is
on the other side,

so we're going to have to
cut a hole right there.

OK?

The fire department
produced a chop saw.

We were able to cut a hole
in the side of the fuselage,

and go in and grab the
recorders and pull them out.

All right.

That should do it.

NARRATOR: To the
immense relief of all,

the recorders are undamaged.

Once we took the recorders
out of the airplane,

we put them on the jet, and they
were flown back to Washington,

DC, to our headquarters.

NARRATOR: Now, investigators
are faced with a new hurdle.

What little is left
of the aircraft

is hopelessly jumbled together
with human remains and debris

from the house.

CLINT CROOKSHANKS: It all burned
and settled into the basement.

So we had probably
10 feet of debris

that we had to dig
through in order

to recover all of the airplane.

NARRATOR: Authorities
wonder how they

can salvage any useful
evidence from this chaos.

They get invaluable assistance
from an unusual source.

A group of students learning
to process crime scenes

is enlisted to
separate human remains

from the rest of the debris.

CLINT CROOKSHANKS: They
were graduate students

from a local college, forensic
anthropology students.

And this was good
experience for them

to come dig through
wreckage like this

and look for human remains.

So landing gear
over there, please.

NARRATOR: It's dirty
painstaking work.

But it frees up
investigators to concentrate

on the aircraft ruins.

We were on our
hands and knees,

with brooms, with
little shovels,

scooping out debris,
identifying it

as to house debris
or airplane debris,

and then putting it
in different piles.

The first question for me,
as a structures engineer,

is to figure out if
the whole airplane made

it to the scene of the crash.

NARRATOR: The wreckage is
carefully studied to determine

if the plane's four corners--

nose, tail, and both
wingtips-- are present.

If we find all four corners of
the airplane, then we know that

there was no in-flight breakup.

There was nothing that
departed the airplane

during the flight that may
have caused the accident.

NARRATOR: One wing has
been consumed by fire.

The other is
shattered into pieces.

Hey!

Have a look at this!

NARRATOR: But Investigators
are gradually finding what

they've been searching for.

Oh, yeah, it's the last piece.

It's the left one.

CLINT CROOKSHANKS: It
wasn't until several days

into the investigation, as
we were scraping away some

of the debris, that we
actually found evidence

of the left wing and the nose.

NARRATOR: Investigators
now have all the pieces

they need to conclude
that the entire plane is

at the crash site.

Whatever caused the
disaster was not the result

of a breakup in flight.

The tragedy of flight 3407
is under intense scrutiny at

the NTSB offices in Washington.

Officials there try to determine
if some kind of malfunction

caused the crash.

On this particular
accident, we

knew it was a landing accident.

So we want to check the
aircraft's performance,

and then also, we checked for
flight control continuity.

NARRATOR: Much of
this responsibility

falls to Scott Warren.

SCOTT WARREN: My role
in the investigation

was to be the systems group
chairman for the Safety Board,

so I was in charge of looking
at all of the aircraft systems.

NARRATOR: Warren analyzes
the aircraft's cockpit voice

recorder, or CVR, to determine
if there were any indications

of a problem in the cockpit.

REBECCA SHAW (ON RECORDING):
Flight attendants can

prepare the cabin for arrival.

Thank you.

Is that ice on the windshield?

NARRATOR: He discovers that
six minutes before the crash,

the crew of Flight 3407 had
noticed a buildup of ice

on the aircraft.

MARVIN RENSLOW (ON
RECORDING): Got it on my side.

You don't have yours?

Oh, yeah.

Oh, it's lots of ice.

NARRATOR: Ice can be a deadly
threat to any airplane.

SCOTT WARREN: If an
aircraft has ice on it,

it will have more drag on it,
so it'll require more power

to maintain a given airspeed.

MARVIN RENSLOW: Oh, yeah.

That's the most I've seen on the
leading edges in a long time.

NARRATOR: Until a year ago,
Rebecca Shaw had no experience

with ice on an aircraft.

I'd never seen
icing conditions.

Never de-iced.

Never experienced any of that.

ROGER COX: When ice
accretes on a wing,

it adds weight to the airplane,
but most importantly, it

changes the shape of the wing.

And of course, it's the shape--
the curved shape of the wing--

that actually creates the lip.

So by changing the
lift characteristics

of the airplane, it makes
it less able to fly.

You know, I'd
have freaked out.

Like, I'd have seen this much
ice and thought, oh my gosh,

we were going to crash.

[sighs]

ROGER COX: Observing that
there was ice on the airplane

was an important thing to do.

But then, it would
be important to turn

around and verify that your
anti-ice and de-ice equipment

was on.

And there was no indication
on the voice recorder

that they actually rechecked.

NARRATOR: The CVR
reveals that only minutes

after the crew detected
ice, a device called

the stick shaker went off.

[rebecca shaw yelling]

It was a warning that the plane
was about to stall, literally,

to fall out of the sky.

Shortly afterwards, the
aircraft did precisely that.

[screaming]

We know there were
icing conditions.

The only question
was, were they bad

enough to induce this
airplane to have a failure?

NARRATOR: Ice is now
the chief suspect

in the crash of Flight 3407.

If it's ice, let's prove it.

CLINT CROOKSHANKS:
We were all convinced

that we had an icing accident.

We said, yeah, it's going
to be an icing accident.

We just got to make sure we
look for these few key aspects

of icing, verify
that, and we're good.

NARRATOR: But some of the
victim's family members

are less convinced.

Our initial thought was that
it was an ice-related incident,

that it was the icy night
that brought the plane down.

And as we began to talk to
people who knew airline travel,

who were pilots themselves,
they would look kind of askance

and say, I don't think so.

That doesn't make sense.

NARRATOR: Some investigators
share that suspicion.

Scott Warren knows a
plane like the Q400

has a sophisticated
de-icing system.

It's designed to keep
ice from building

up on the wings and other
critical parts of the aircraft.

To prevent ice
accumulating, the plane

has rubber bladders along
the front of the wings,

called de-icing boots.

A series of valves uses
air from the engines

to inflate the boots and
crack the ice off the wing.

Those boots are designed
to inflate periodically.

And that inflation breaks off
the ice that's accumulated

on those leading edges.

NARRATOR: Warren now wonders
if the crew of flight 3407

actually turned on their
de-icing equipment.

He studies data from the plane's
other black box, its flight

data recorder, or FDR.

It tracks the workings of
crucial aircraft systems,

including the
de-icing mechanism.

SCOTT WARREN: We know
from the FDR data

that the deicing system had
been selected on by the crew.

And it was on during the
majority of the flight,

and certainly, at the
end of the flight,

it was recorded in
the on position.

NARRATOR: But now, Warren needs
to figure out if the device was

actually working.

SCOTT WARREN: Just because the
data records that the system is

on, that's a start, but you
can't necessarily believe

that one piece of information.

NARRATOR: The only
way to know is

to find what remains of the
plane's de-icing system,

and determine if it was active
when the aircraft went down.

Clint Crookshanks' team
hunts for a crucial component

of the system--

the valves.

Excuse me.

OK.

Everyone, I just--

CLINT CROOKSHANKS:
For the de-ice valves,

we said, here's
what it looks like.

Look for something like this.

If we can find those valves,
then we can test them and see

if they're operating correctly.

SCOTT WARREN: The valves
were very important to us,

because they are the key
component that moves air

from the engines where
the bleed air originates

for the de-icing system.

OK, good.

Five more to go.

NARRATOR: Five of the
plane's six de-icing valves

are eventually recovered.

SCOTT WARREN: Some
were badly burned.

Some were in fairly good shape.

And we took those valves, and
we conducted as much testing

on those valves as we thought
was appropriate for the level

of damage.

We looked at the level of
electrical conductivity,

and we looked at the
pressure testing.

We looked at a wide
variety of things,

depending on the condition
of the valve itself.

And as far as we could
tell, all those valves

were working properly.

Is that ice on the windshield?

I've got it on my side.

NARRATOR: Now,
investigators have

to consider the possibility.

Oh, yeah.

Oh, it's lots of ice.

NARRATOR: But there is
so much ice on the wings,

that the de-icing system
couldn't get rid of it

fast enough.

Oh, yeah.

That's the most I've seen on the
leading edges in a long time.

NARRATOR: It has
happened before.

In Roselawn, Indiana, a
French-built commuter plane

crashed in 1994 after suffering
a catastrophic buildup of ice

on the wind.

By analyzing how much power
was needed for the plane

to maintain its
airspeed, investigators

reach a surprising conclusion.

Basically, the aircraft
was flying as if it had

a relatively small
amount of ice on it,

but a very manageable
amount of ice.

Looks normal.

SCOTT WARREN: It
was not overloaded.

It was not excessive.

NARRATOR: If ice didn't
bring down the plane,

something else must
have caused it to stall.

Warren studies the
Q400 operating manual

to learn the plane's
stall speed, the velocity

at which it can
no longer generate

enough lift to stay in the air.

He discovers that
in the conditions

flight 3407 was flying through,
it's roughly 111 knots.

He now compares the
plane's stall speed

with its actual airspeed
just before the stall

warning went off.

131 knots, well above
the danger zone.

Flaps 15.

When the stick
shaker went off--

Uh, oh!

Jesus Christ!

--they were not necessarily
at the edge of a stall.

They were still 20 knots
or so away from the stall.

NARRATOR: This new
revelation deepens

the mystery of flight 3407.

If it wasn't stalling, why
did it fall out of the sky?

to the critical
seconds before flight

3407 went out of control.

They look for clues that could
explain why the stall warning

went off when the
aircraft was flying

well within its safety margins.

They discover that this plane
has a unique feature, known

as a reference speed switch.

It governs the sensitivity
of the plane's stall warning.

ROGER COX: Very few
airplanes, in my experience,

have such a switch.

This airplane is
the only one I know

of that has an actual switch
on the overhead panel.

It was designed by
the manufacturer

to be an extra safety feature.

Some kind of
variable ref speed?

NARRATOR: Pilots are supposed
to turn on the reference speed

switch when they're
going to be flying

through icing conditions.

And we'll probably
be picking up some ice.

NARRATOR: When in the
increased position,

it reminds pilots to fly faster
to counteract any drag effect

ice will have on the aircraft.

ROGER COX: When you
are in icing conditions

and ice does accrue
on the wing, it can

cause the stall speed to go up.

And so this ref speed
switch correspondingly

causes the warning to come on
sooner or at a higher speed.

What that switch does is it
basically changes the trigger

settings for the stick shaker.

So we had to ask
the manufacturer,

how does this switch work?

ROGER COX: And
what we found was,

it was part of the
systems description

that the crews got when
they went through training.

But they didn't get
a lot of training

on how to handle that switch.

It seemed like it was too
simple to worry about.

NARRATOR: Investigators need to
know if the crew of flight 3407

had turned on the
reference speed switch,

triggering the stick shaker
at a faster-than-normal speed.

The flight data recorder doesn't
show whether the switch was on.

Investigators must find another
way of determining its position

at the time of the accident.

[phone ringing]

Clint here.

NARRATOR: Clint Crookshanks
is given a new priority.

All right.

I'll see if we have it.

NARRATOR: Recover the
ice protection panel

from the Q400 cockpit,
where the reference

speed switch is housed.

Since the panel was in
the cockpit, finding it

is a challenge.

CLINT CROOKSHANKS: Most of
the front end of the airplane

was consumed by fire, and
so we didn't find anything

except for little balls of
molten aluminum, little wire

bundles, and a lot of ash.

NARRATOR: But after
an extensive search,

Crookshanks discovers
that the ice

protection panel is
one of the few pieces

of the cockpit that survived.

Bingo.

NARRATOR: However,
the knobs and switches

are barely recognizable.

Crookshanks examines the charred
panel to check the position

of the reference speed switch.

It was set to activate
stall warnings

at higher-than-normal speeds.

CLINT CROOKSHANKS:
We did find the ref

speed switch in the
wreckage, and it

was in the increased position.

NARRATOR: This discovery
only raises more questions.

[yawns]

MARVIN RENSLOW (ON
RECORDING): And we'll probably

be picking up some ice.

NARRATOR: The cockpit
voice recorder

indicates that as Renslow
was beginning his descent

into Buffalo, he
commanded his plane to fly

at the normal approach speed.

MARVIN RENSLOW (ON
RECORDING): Gear down.

NARRATOR: But what's strange
is that with his reference

speed switch on,
he actually should

have been flying faster--

[sneezes]

--as this is what the switch
would remind him to do.

So why wasn't he?

The plane's computer warned
the crew to fly faster,

according to the settings
they had configured,

by displaying a set of red
bars in the airspeed indicator.

But you may have a
better quality of life

with regards to--

NARRATOR: These bars are meant
to warn the pilots that a stick

shaker activation is imminent.

If you're looking at
the airspeed indicator,

you should be aware that
you're getting slow,

and the stall
warning may come on.

Jesus Christ!

NARRATOR: It seems Renslow and
Shaw were caught off-guard.

Still, they could have easily
corrected the situation.

Once the stick
shaker had activated,

they could have
turned the switch off,

or they could have
put the nose down

and increased their airspeed.

NARRATOR: It's clear
to investigators

that flight 3407 wasn't
in danger of stalling

when the stick shaker went off.

So now, they need
to know exactly

what happened after the
stall warning was activated.

An animated simulation
of the crash

is constructed,
based on information

from the flight recorders.

Watch what happens just after
the stick shaker goes off.

NARRATOR: It
illustrates that just

after the stick
shaker was triggered,

the plane suddenly pulled up.

This action dramatically
slowed the aircraft,

and at this point, it did stall.

Essentially, the airplane
entered an aerodynamic stall

from which it did not recover.

It pitched over
and hit the ground.

NARRATOR: Investigators
are dumbfounded.

Flight 3407 wasn't stalling
when the stick shaker went off.

But a few seconds later, it was.

The crew's every action
during that brief time

now demands careful scrutiny.

What did they do?

NARRATOR: It's a puzzle.

How could a trained
flight crew take a plane

that wasn't stalling, and in
the space of a view moments,

make it fall from the sky?

ROGER COX: Any time you
have an apparent stall

for no apparent reason,
that's a mystery.

We would expect that no flight
crew would stall an airliner.

So the question is, why?

NARRATOR: The focus
of the investigation

now switches from the
plane to the crew.

Specifically, on
the moves they made

during the critical
seconds after the stall

warning sounded.

ROGER COX: We wanted to see if
the way they flew the airplane

was the way they were
trained, according

to the standard operating
procedures that are portrayed

in their flight manuals.

NARRATOR: The flight data
recorder retains information

from more than 1,000 different
aspects of the Q400's flight

operations.

From the airspeed and altitude
to the position of the rudder

pedals and throttles,
it also records

the movements of the most
critical flight control--

the control column.

Pilots use the control
column to change the position

of the elevators and
ailerons, which manage

the direction of the plane.

The flight data recorder
stores information, not just

about the control
columns position,

but how much force is
applied to it as well.

The FDR records what the
control positions were.

It has sensors built
into the control column.

It has sensors built
into the control wheel.

NARRATOR: What
Scott Warren finds

when analyzing the control
columns position is stunning.

In response to the stick
shaker, Captain Renslow

should have pushed the
column forward to bring

the nose down and gain speed.

But for some reason, he
did the exact opposite.

SCOTT WARREN: We found that
the crew, instead of pushing

forward, which is the
normal response to a stick

shaker triggering,
the crew was actually

pulling back on the controls.

NARRATOR: This had the effect
of pulling the nose up, causing

the airspeed to drop
and tipping the aircraft

into an actual stall.

Captain Renslow had apparently
mishandled one of the most

elemental piloting maneuvers--

how to recover from a stall.

Above everything, it
requires gaining air

speed to get out of the red.

ROGER COX: The recovery
procedure is fairly

simple and straightforward.

It requires pushing
forward on the controls

and adding full power.

At any point in time, had
the captain pushed forward

on those flight controls,
he had a reasonably good

chance of recovering quickly.

JOHN KAUSNER: From
everything we've gained,

that stall was recoverable
on a repeated number

of levels and a repeated basis.

There was no reason for
their plane to go down.

NARRATOR: Investigators also
learned that First Officer

Shaw, in trying to help
Renslow deal with the crisis,

inadvertently made things worse.

I put the flaps up!

NARRATOR: She
retracted the flaps,

reducing the amount
of lift as the plane

struggled to stay in the air.

ROGER COX: Had the First
Officer simply called out,

you're stalled, advanced the
power, pushed the nose over,

the airplane would have
been able to recover.

SCOTT WARREN: From a
human point of view,

it's sad to recognize that
those sorts of things happened

and the tragedy
that came from that.

to properly respond
to the stall warning

was the primary cause of
the crash of Flight 3407.

As the issue is now pilot error
rather than mechanical failure,

human performance
investigator, Evan Byrne,

is brought on board.

His first question-- why
hadn't either Renslow or Shaw

noticed that their airspeed was
too low for the icy conditions?

Byrne listens to the
cockpit voice recording

to try to understand what might
have led to that oversight.

REBECCA SHAW (ON
RECORDING): Exactly.

MARVIN RENSLOW (ON
RECORDING): Where

you could be home with
your husband to take

care of and all that stuff.

NARRATOR: He learns
that the crew had been

talking throughout the flight.

The conversation continued
during a landing approach.

It's a violation of a rule known
as the sterile cockpit, which

bans nonessential conversation
during critical phases

of a flight.

--be upgraded in six months.

Blah, blah, blah.

[laughter on recording]

EVAN BYRNE: Quite
simply, it prohibits

conversations that
aren't related

to the operation of the flight.

MARVIN RENSLOW (ON
RECORDING): Let's

do a descent checklist, please.

We can do the approach
checklist along with it.

REBECCA SHAW (ON
RECORDING): Yeah, sure.

Bug set.

NARRATOR: Byrne also discovers
that because of the cockpit

banter, the crew performed
critical checklists

and briefings late.

Off.

Hydraulic pressure and--

NARRATOR: Distracted, the crew
probably didn't see the red bar

indicating they were
flying too slowly

for the conditions the plane
had been configured for.

--on.

Approach checklist complete.

Rock and roll.

When crews deviate from
standard operating procedures

and perform checklists late
or don't make the required

call-outs, they
become more vulnerable

to subtle mistakes that
they may make inadvertently.

That could lead to
startle and surprise

or unanticipated events that
they have to respond to.

NARRATOR: The evidence
is unequivocal.

The crew of flight 3407
was badly distracted

throughout the approach.

He came in when
we interviewed.

And he said, yeah, you're going
to be upgraded in six months.

NARRATOR: They had
forgotten a key setting

they had made that required
them to fly faster than normal.

They had missed indications
that they were flying

too slow for icing conditions.

Then, Captain Renslow
had reacted incorrectly

to a stall warning--

Jesus Christ!

NARRATOR: --sealing
the fate of the plane.

Evan Byrne wonders,
what could have

caused a trained
airline flight crew

to have made such missteps?

He finds a clue on the
cockpit voice recording.

[yawns]

MARVIN RENSLOW (ON
RECORDING): Excuse me.

[groans]

NARRATOR: The crew was
showing signs of fatigue.

Could Renslow and Shaw have
been too tired to function

effectively on the flight deck?

It's a tough question.

Answering it will
require tracking

their movements during the 72
hours leading up to the crash.

Byrne interviews the
families of the pilots.

Can I speak to
Mrs. Renslow, please?

NARRATOR: He studies the
pilots mobile phone bills

and records of text messages.

He searches the
airline's computer system

to determine if and
when the crew used

it to check their schedules.

He needs to track
their every move.

And what time did
Rebecca leave the house?

EVAN BYRNE: We're talking to
colleagues or other pilots,

check airmen, instructors.

And we ask all those
people about the pilots,

about their recent activities.

NARRATOR: He learns that neither
pilot actually lived anywhere

near Newark, but could
not afford to stay

in hotels on their salaries.

Captain Renslow was earning
$60,000 a year at Colgan Air.

First Officer Shaw was being
paid less than $16,000 a year,

substantially less than
an average bus driver.

As a result, both pilots
had made long cross-country

commutes to Newark--

Captain Renslow, from
his home in Florida,

and Rebecca Shaw, from
Seattle, Washington.

In fact, Shaw had
commuted all night

from Seattle on a cargo flight
that connected through Memphis.

Captain Renslow had spent the
night in the airline's crew

lounge at Newark Airport after
having already worked two days.

He was seen sleeping on
a couch in the lounge.

It was against
company rules, but

pilots who couldn't afford
housing near the airport

did it anyway.

Records show that at 3:10
AM, the morning of the crash,

Renslow was awake.

He checked his work schedule in
the airline's computer network.

Next stop, Buffalo.

NARRATOR: At 7:29
AM, Rebecca Shaw

sent a text message
to her husband,

telling him she'd
arrived safely in Newark.

Hi, honey.

It's me.

NARRATOR: Phone records indicate
that later in the morning,

Captain Renslow was on
the phone several times.

Rebecca Shaw was
noticed having a nap,

catching up on the rest she'd
lost flying the night before.

It's not a lot of sleep.

EVAN BYRNE: We ultimately
concluded that it was likely

that both crew members
were experiencing

some effects of fatigue at
the time of the accident.

JOHN KAUSNER: Her job is
to watch the airspeed.

Her job was to watch
the instrument panel.

And my view is, she was
fatigued to the point

where it's, like, right here.

And you're so dull.

I think that's where she was,
and he just was not capable.

He was just-- he shouldn't
have been flying an airplane.

of flight 3407
leads John Kausner

to rally support and
become a fierce advocate

for changes in the industry.

He raises awareness among
both lawmakers and the public

about the need to improve
regulations governing

pilots at regional airlines.

JOHN KAUSNER: This
is just saying

we support 3407 families, their
fight for aviation safety.

And these representatives
and congressmen

and senators have
done that for us,

and we're very appreciative.

NARRATOR: He takes his fight
all the way to Washington, DC.

JOHN KAUSNER: We
needed to do something.

And so we began to advocate
in Washington weekly.

Every other week,
I mean, we've made

innumerable trips down there.

And immediately, the
families just gelled.

We all attended the
hearings and began to say,

this is what we can do.

NARRATOR: The crash
of Flight 3407

exposed wide-ranging
shortcomings in the regulations

that govern regional airlines.

These smaller airlines now make
up 1/2 of all daily passenger

flights in the US.

Their pilots are generally
younger, less experienced,

earn less, and work long hours.

Their levels of safety are
way different from the majors.

They have a much lower threshold
in training, in ability--

so in pay, obviously,
so they can't attract

a higher-qualified pilot.

There are pretty
low wages, pretty

difficult working conditions.

And we don't seem to attract
the same level of applicant

that we used to.

Some regional airlines
get into a bind,

and they have to hire the first
people that meet the minimums.

NARRATOR: In the US, of the
seven fatal accidents involving

passenger jets over
the past 10 years,

five have involved
regional airlines.

Those include the crash of
Delta Connection flight 5191

in August 2006, which killed
49 people when the crew

took off from the wrong runway.

John Kausner's campaign to
change laws governing pilots

has paid off.

JOHN KAUSNER: We
relied on your support.

We needed your support.

You nurture us.

We want to thank all
of you from all of us.

NARRATOR: A year and a
half after the crash,

under pressure from Kosner and
other victim's family members.

The US Senate passed a bill,
which toughens training

requirements and
forces the FAA to draw

up new rules on pilot fatigue.

Studies into the problem
of overtired pilots

are already underway.

At the University
of Iowa, researchers

are developing a system that
could help pilots resist

fatigue, stay engaged with
the critical task of flying,

and prevent future tragedies
like that of flight 3407.

Thomas Schnell is a
human factors engineer.

THOMAS SCHNELL: We use a
number of neurocognitive and

physiological sensors that
we apply on subjects, pilots,

that we invite for our studies.

--114 is going to
be free floating.

OK.

Welcome.

Just go ahead.

NARRATOR: He's studying how
pilots stay alert on the flight

deck as a test subject conducts
a cross-country journey

in a simulator.

Using sensors, he can
determine how alert

and engaged a pilot really is.

The research could lead
to the development of

fatigue detectors on airplanes.

THOMAS SCHNELL: We are trying to
predict pilot state, so that we

can adjust something
on the flight deck

to prevent the problem
from getting worse

or starting in the first place.

We monitor brain activity,
eye movement activity, heart,

the EKG, and respiration,
and other parameters,

in an effort to figure out
what the pilots or the crew's

state is.

Are they fatigued?

Overworked?

Are they disengaged
or distracted?

This section is where
they were really drowsy,

and you can see that gaze
has become kind of bored.

NARRATOR: Schnell
instructs the flight

simulator to trigger a major
systems failure in the cockpit.

It's no good.

Everything's good.

Hydraulic systems have failed.

Flaps not applicable.

THOMAS SCHNELL: Crank
up that heat map,

so we can see what this
brain activity was.

Brace for impact.

[alarm blaring]

THOMAS SCHNELL: When a crew is
fatigued, what you might see

is their reaction to
events may slow down.

So you'll see mistakes being
made on the flight deck.

NARRATOR: It's precisely these
kinds of mistakes on the part

of Renslow and Shaw that
ultimately crashed flight 3407

and killed 50 people.

It's a tragedy that
should not have happened.

That was foreseeable,
was preventable,

and it's repeatable, if we
don't do something about it.

I'm focused and determined to
change what exists, and not

have another dad sitting here.