Original subtitles

We can't keep going down.

Above the Pacific Ocean,

the pilots of Transair Flight 8-10

can't get their cargo plane to climb.

- Just hitting the water is gonna tear the airplane apart.

- We're in the water. We're in the water!

Remarkably,

they survive the crash and are rescued by the Coast Guard.

- They're covered in gasoline and hydraulic fluid.

So it wasn't pretty.

Investigators are eager to interview the crew.

- Did both engines fail at the same time?

- Most likely. That's my conclusion.

The evidence does not support the pilot's assessment.

- It looks fine.

No internal damage.

- So it was critical for us to get more information

to better understand what had happened here.

Mayday! Mayday!

It's the middle of the night

at Daniel K. Inouye International Airport

in Honolulu, Hawaii.

- Okay.

Let's see.

Crews have just finished loading cargo

for Transair Flight 8-10.

- Okay, thank you. See ya.

The captain of tonight's flight is Henry Okai.

He has almost 16,000 flying hours.

- So this captain is highly experienced in the aircraft,

been doing it for a while.

- Engine start checklist.

- Engine start checklist.

Tail stand. - Removed.

- Cargo.

First Officer Gregory Ryan is a lawyer

who recently returned to flying part-time for Transair.

- It's not necessarily the best pilot career, straight up,

but you do get to be in Hawaii. You get to fly an airplane.

- Engine start checklist complete and...

...clear right.

- Clear right.

Transair flights use Rhoades Express as a call sign.

- Tower, Rhoades Express 8-10 Taxi Kilo.

- Rhoades Express 8-10, Honolulu tower,

runway 8 right, taxi via Charlie Romeo Tango Romeo Alpha.

Transair is owned and operated

by Rhoades Aviation,

which transports cargo between the Hawaiian Islands.

- They had the postal contract, which was quite lucrative.

Their focus was on keeping their costs down

to maintain their advantage over more and well-established competitors.

The plane is a Boeing 7-37-200

built in the 1960's and 70's for passenger travel.

Today,they're workhorses for transporting cargo.

- Twin engine, small aircraft,

it was designed for short haul operations.

It wasn't very sophisticated. No automation.

I loved flying that airplane.

The pilots prepare for takeoff.

- Runway 8 right confirmed.

Before takeoff checklist complete.

Rhoades 8-10, cleared for takeoff.

- Runway 8 right, cleared for takeoff, Rhoades 8-10.

Tonight's flight is a short hop to Kahului

on the neighboring island of Maui, only 100 miles away.

- Okay. You have control.

- Okay. I have control.

At 1:33 a.m.,

Captain Okai hands over the plane to first officer Ryan.

- Engines stable.

Eighty knots.

- Check.

- V-1...

Rotate.

- V2...

Positive rate.

Gear up.

Within seconds of lifting off ...

- Damn!

- Lost an engine.

You got it? - Yeah. I got it.

The pilots have lost thrust

in one of their engines only 390 feet off the ground.

- Losing an engine after takeoff is one of the most critical events

that can happen in a flight.

You're close to the ground, you're slow.

However, we also know from our training

that the aircraft will fly perfectly well on one engine.

The first officer levels the plane

and continues to climb away from the airport.

- Flaps.

- Turn 2-20 heading.

I'll give you the flaps.

- Okay.

- Rhoades 8-10, we have an emergency.

Standby.

We're on 2-20 heading.

You can inch up to 2,000.

The captain wants to put more distance

between the plane and the ocean,

so they have space to address the problem.

- Anytime you have an emergency situation,

maintain aircraft control. If you fail to do that,

nothing else you do matters.

- Okay, Rhoades 8-10, we've lost an engine.

We're on a 2-20 heading maintaining 2,000.

Declaring an emergency. How do you read?

- Rhoades Express 8-10,

you are cleared visual approach runway four right.

You can turn in towards the airport.

The controller clears Flight 8-10 to return to the airport.

- Okay, Rhoades 8-10, we're gonna run a checklist.

I'll let you know when we're ready to come to the airport.

Captain Okai wants to assess the situation further

before returning to the airport.

Flight 8-10 has been in the air less than three minutes

flying over the Pacific Ocean on a very dark night.

- Okay. I have control.

- Roger.

- Okay, let's see what's the problem.

What's going on with the gauges?

The pilots troubleshoot the situation.

- So it looks like the number one.

- Number one's gone? - Gone, yeah.

We still have the number two.

- So we have number two. Okay.

They confirm they've lost their number one -

or left - engine.

They now must rely on their right engine

to return to the airport.

- Let's do the engine failure shutdown checklist.

And I have the radios now. - Okay.

- There's a number of things this checklist is gonna do for you.

It's gonna confirm the failed engine

and you're gonna wanna secure that engine.

- Okay, engine failure or shutdown

when one of these occurs - an engine failure,

an engine flameout - another checklist directs an engine shutdown.

As the pilots zero-in on the problem engine,

the situation intensifies.

- Hey, we're red line here.

The right engine is now overheating

and they're losing altitude.

- We should pull back on the right one a little bit.

- Okay.

- We should head back to the airport.

- Yeah, we should. Yeah.

The pilots now face the possibility

of losing both engines.

- Problems on your second engine is going to significantly change your outlook

because you got the dark water below you

and you know you're running out of options.

- Okay, Rhoades 8-10,

we'd like to come to the airport now.

We might lose the other engine.

- Rhoades Express 8-10, roger.

Confirm you still have, uh, the airport in sight.

- Uh, negative.

The pilots have descended too low to see the airport.

Only the lights on the shoreline are visible.

- Hey man, we're going down.

We can't keep going down. - We're descending!

The captain has no other option

but to increase power to the overheating engine,

risking a double engine failure.

- How's the EGT?

- Ah, it's max. It's beyond max.

The temperature of the right engine is now dangerously high,

and the pilots suspect it could fail at any moment.

- Do we go flaps? Flaps one?

Fearing the worst,

the first officer suggests

configuring the plane for a water landing.

- No. Not... not, not yet.

- Okay, we're very slow, though.

The Captain's efforts to reduce the loss in altitude aren't working.

- Shoot. Okay, flaps one.

- Just hitting the water's gonna tear the airplane apart

so you want to be at the lowest possible airspeed.

The flaps will facilitate that.

- Oh.

Rhoades Express 8-10, low altitude alert.

As Transair Flight 8-10 descends below 400 feet,

the controller is automatically alerted to the aircraft's dangerously low altitude.

- Are you able to climb at all?

- Uh, negative. Can you let the Coast Guard know?

- We will.

Watch desk, please call the Coast Guard.

Flight 8-10, a 7-37, is probably going to be in the water.

- How's the EGT?

If the engine temperature has improved,

they might be able to climb.

- Hot. Way over.

Terrain. Terrain. Pull up.

The chances of reaching the airport six miles away

deteriorate as the plane descends even further.

The controller has an idea.

- Express 8-10, do you want Kalaeloa?

There's a closer airport.

It might be the pilots' last hope.

- We want the closest runway available, please.

- Anything we can land on.

If they can't make it to the closer airport,

there might be no other option

than to ditch the 7-37 into the Pacific Ocean

and hope for rescue.

Too low. Gear. Too low.

- Okay, give me a heading. Terrain. Terrain. Pull up.

The pilots of Transair Flight 8-10

have one last chance to reach land.

- Rhoades Express 8-10,

the airport is about a three one zero heading from you.

But it's too late.

Pull up. Pull up. Pull up. Pull up.

Terrain. Terrain. - We're in the water!

- Pull up. - We're in the water!

12 minutes after takeoff,

Transair Flight 8-10 hits the ocean

just two miles from the Kalaeloa airport.

- Watch desk, 8-10's in the water

two miles south-east of Kalaeloa.

Coast Guard Air Rescue is immediately dispatched.

- Hearing that there's a 7-37 that crashed, I didn't believe it.

But if there is and there's 200 people in the water,

what am I gonna do?

- They told me two souls onboard.

We're like alright, two's a lot more manageable than like 200.

45 minutes later,

there's still no sign of the plane, or the pilots.

Rescuers fear the worst, until...

- There were a bunch of boxes now floating by us.

I figured, alright, well, this might be the start of a debris field.

So we started our second pass,

and grabbing onto the vertical fin of the tail

was one of our pilots.

It's Captain Okai.

- And I was like, Alright, he is still okay.

Great. I still wanna find the second pilot.

They soon spot the first officer

on a cargo pallet, bleeding from the head.

- Right before we started to make the moves

to put me in the water to go up to him, the plane moved.

The tail section the captain had been clinging to

sinks beneath the waves.

- The captain is drowning right now.

They race back and deploy the rescue swimmer.

- And as soon as I grabbed his hand,

it's like his eyes rolled back and he went limp.

- And they're dripping wet, covered in gasoline

and hydraulic fluid, so it wasn't pretty.

The first officer is soon rescued

by a fire department vessel

as the captain is rushed to a local hospital.

Both pilots survive.

- Good planning, good crew, good decision-making

and then implementing those decisions

is how we came out on top.

While the pilots recover from their injuries,

investigators from the National Transportation Safety Board

or NTSB, arrive on the scene.

- Right now, we're in the fact-gathering phase.

Once we finish the fact-gathering,

we'll switch into the analytical side

and then that's when we'll go in to determine the probable cause

and contributing factors.

- What can you tell me about last night?

- It was a normal night. Slow.

There was another Transair flight inbound

around the same time.

- And when did Flight 8-10 alert you that there was a problem?

Investigators turn to the controller

to determine what might have caused Transair Flight 8-10 to ditch into the Pacific.

- It was about, uh, two minutes into the flight,

they reported they'd lost an engine.

- Okay, Rhoades 8-10, we've lost an engine.

We're on a 2-20 heading, maintaining 2,000,

declaring an emergency. How do you read?

- They wanted to work on the problem before turning back.

- Did they say which engine?

- No. But not long after they said that, uh...

they might lose the other engine as well.

- Really?

- Okay, Rhoades 8-10,

we'd like to come to the airport now.

We might lose the other engine.

Could Transair 8-10 have really lost both engines?

- The only information we had to go on initially was

the communications between the airplane and the controller.

But the airplane and its recorders

were at the bottom of the ocean.

- Thank you.

Another NTSB team is tasked with recovering the airplane

and its engines lying 350 feet deep on the ocean floor.

- At the depth that the airplane was at,

it's difficult to get divers down there.

So in order to actually hook all of our equipment

up to the aircraft and pull it up,

we needed to use ROV's.

It will take time for the investigation

to secure the necessary equipment

from a salvage company on the mainland.

- Good morning. - Good morning.

- I'm glad to see you here. - So am I, very glad.

Yeah.

Investigators meet with Captain Okai

to determine if Transair Flight 8-10 did lose both engines.

- The purpose of this investigation is to determine

probable cause and prevent recurrence.

Our role is not to assign fault.

- I understand.

- It's critical to speak to pilots as soon as we can

because we want to get those fresh memories.

- Walk me through what happened.

- Everything was normal up to about 400 feet.

- Gear up.

Damn!

- There was a whoosh sort of a sound, not a pow.

It was a whoosh.

Then it was in a roll.

And my first officer was able to counteract that.

Lost an engine.

You got it?

- Yeah. I got it.

- Eventually we leveled off at 2,000 feet

and I go, "Greg, what do we have?"

- So it looks like the number one.

- Number one's gone? - Gone, yeah.

We still have the number two.

- So we have number two. Okay.

I'm looking at Number 1 EPR, there's no power.

I'm looking at Number 2,

and the EPR, it-it's, it's coming down.

The captain explains he first lost power

in the left engine and was losing power in the right.

- How's the EGT?

- Ah, it's max. It's beyond max.

- Did both engines fail at the same time?

- Most likely. That is my conclusion.

- Thank you. - Thanks.

- We'll be in touch.

What could have caused both engines to fail

so soon after take-off?

- The purpose of this investigation...

- A dual-engine failure seemed improbable,

but both the crew

seemed to agree that that is what had occurred.

We couldn't confirm or deny it

unless we could actually look at the wreckage

and get the recorders.

But those vital clues remain out of reach,

deep on the bottom of the sea.

Could contaminated fuel

have brought down Transair Flight 8-10?

- You're looking for an item that's common to both engines,

would cause them both to shut down at the same time.

For that would be most likely the fuel.

- So one thing that we did do at the airport

was take samples from the fuel truck

that had been used to fuel the airplane before it departed.

The US Navy conducts the testing.

- If you have water in your fuel,

that was most likely to be the cause of fuel contamination.

When the fuel samples are analysed,

the results are conclusive.

- We actually found that the fuel that was in the aircraft

conformed to standards as we would expect.

- So according to the pilots,

they lose the left engine first and then the right.

- All the samples from the fuel truck tested clean.

What was the weather like on that night?

Any volcanic activity?

Hawaii is in an active volcano zone.

Could volcanic ash have caused the engines to fail?

- Volcanic ash is very bad for jet engines.

It's like throwing sand in the gears.

Jet engines will shut down.

In 1982, a British Airways 7-47

traveling from England to New Zealand

flew through an ash cloud over Indonesia.

All four engines failed.

The plane was high enough for pilots to be able to restart the engines,

find an airport and land safely.

- Nothing here.

Clear night.

- So that leaves maintenance.

- There were no reports of volcanic ash on that night.

The only information that we have to work on is what the crew was telling us

that they had a dual engine failure.

So we're gonna look at the maintenance on the engines.

In the meantime,

recovery crews pinpoint the exact location of the plane.

It has settled on the ocean floor in two large pieces.

- Often with water recoveries,

we have an airplane that's in multiple different pieces.

They're usually smaller pieces and they're less heavy.

So to bring them up intact

was a bigger engineering problem.

It means another delay for investigators.

- The plane is, what, like 40-something years old?

The team digs into the engine history of the accident aircraft

to determine why both engines might have failed.

- Uh, 46.

Flown over 69,000 cycles.

The engines have been around too;

the left engine 32,000 flying hours

and the right over 70,000.

- Engines that old are going to need upkeep.

- Jet engines are very solid machines.

With proper inspection and maintenance,

they can fly on forever.

- Anything in the FAA database?

Investigators look into service reports

filed by Transair with the Federal Aviation Administration,

or FAA, to see if the aircraft had any history

of engine troubles.

- I've got three reports on this aircraft.

The most recent

was two and a half years ago:

left engine failure at 2,000 feet.

- That's something.

Did an aging aircraft

put the lives of two pilots in jeopardy?

The team researches the repair work that's been performed

on the engines over the years.

- Both engines were serviced two years ago

and underwent a daily check the day before the accident flight.

- Did they report anything?

- No discrepancies.

- It's possible that maintenance could have missed something.

- Call your contacts at the FAA.

Maybe they can shed some light on Transair.

And I'll speak to maintenance personally.

- Because of the possibility that there had been

a dual engine failure,

we did a deep dive on the maintenance organization at the airline,

trying to find potential theories

for something that could have gone wrong.

- A bit of a mess over there at Transair maintenance.

- What did you find out?

- The chief maintenance inspector quit six weeks ahead of the accident

citing chronic maintenance issues and being understaffed.

I also found multiple reports from different pilots

about engines overheating.

Investigators uncover internal Transair reports

revealing issues with the engines.

- We noticed so many of these reported issues with temperature

that we were starting to think

that this might really involve a maintenance issue.

There was just so much smoke,

we thought there had to be some fire.

Anything specific to the accident aircraft?

- No. They involved other airplanes.

Not exactly a smoking gun.

Anything from the FAA?

- Most of the current inquiries into the company

are policy and procedure related.

Nothing to do with engine maintenance.

Investigators don't find any maintenance issues

that would have brought down Flight 8-10.

- We need those engines.

- So even though we were discovering these issues with pilot reports

and maintenance records, there wasn't anything clearly indicating a specific problem

that would have led to this reported dual engine failure.

With a salvage company in place

and the weather clearing,

the NTSB is finally able to attempt the recovery

of Flight 8-10 from 350 feet of water.

- This was one of the largest water recovery efforts we have done in a couple decades.

The wreckage is successfully raised

in two large pieces.

The black boxes are recovered from the rear fuselage

and sent to Washington for analysis.

The engines are retrieved separately

and brought to a warehouse for inspection.

- To be able to see that wreckage come up just creates immense satisfaction

because you're like, "Okay, now... now we can start this in earnest."

- Let's start with this one.

Investigators begin with an examination

of the right engine, the one the pilots say was overheating.

- It's in better shape than I expected.

- They were in pretty good shape.

There was damage due to the water impact.

- Let's take a look inside.

They perform a borescope inspection

of the right engine.

It enables them to examine the engine interior

without the need for disassembly.

- There. Take a look.

- Broken fan blades.

- See if there's any damage downstream.

- Multiple puncture marks on the turbine.

- With that type of damage

the engine could have easily overheated.

Investigators discover two fractured turbine blades

which caused shrapnel damage inside the right engine.

- The pilots were correct.

The right engine was giving them trouble.

- So from the examination on the right engine,

they were able to see that there were blades that had fractured

in the high pressure turbine. But it was only those two.

And they knew that it would still be able to produce power,

so it wasn't like a complete failure.

- It looks like rust and corrosion

inside of the blades caused them to rupture.

- The routine maintenance inspection procedures

contained in the maintenance manual

would not necessarily have revealed

the presence of cracks or one fractured blade.

- So this is the engine the pilots said failed first.

Investigators turn their attention

to the left engine.

- Let's see what we got.

- It looks fine.

No internal damage.

The pilots said the left engine failed,

followed by the right

but investigators can't find anything wrong with the left engine.

- When we found out that the left engine was undamaged

prior to impact,

it really changed the course of our investigation

in terms of focusing more on the crew actions.

- We pulatfrom the radar .

- I've got the CVR data.

And here's...

a copy of the transcript.

Investigators turn to the cockpit voice recorder,

or CVR, of Flight 9-10

to determine why the pilots thought the left engine failed

as the evidence suggests it did not.

- Let's hear it from takeoff.

80 knots.

- Check.

V1.

- Rotate.

- V2.

- Positive rate.

- Gear up.

Damn!

- Stop. Did you hear that?

Play it again.

- Gear up.

- It definitely sounds like an engine surge.

They discover that Flight 8-10

suffered engine trouble 17 seconds after takeoff.

- Most likely the blades

breaking apart in the right engine.

Keep playing.

Lost an engine.

You got it? - Yeah. I got it.

- Yup, looks like you lost number...

Number two. - Number two.

- Hold it right there.

- They both said number two, the right engine.

- They were correct.

The pilots' original assessment

matches what investigators have discovered:

the initial problem was with the right engine.

- So why did they think that the left engine had failed?

- We were able to hear the crew discuss they had correctly identified the right engine.

So at some point, you know, in their mindset,

it flipped to the wrong engine.

- Let's hear what happens next.

Flaps.

Turn 2-20 heading.

I'll give you the flaps.

- Rhoades 8-10. We have an emergency.

Standby.

We're on 2-20 heading.

You can inch up to 2,000.

- The captain calls in the emergency.

Tells the first officer to climb to a safe altitude.

It all sounds good.

- We're on 2-20 heading.

Say again. Heading two four zero.

- Two four zero heading Rhoades 8-10.

- No, Rhoades eight zero nine.

Rhoades eight zero nine left two four zero.

- It sounds like there's some overlap

with another Transair Flight.

- According to these transcripts,

the captain spends the next minute and forty seconds

communicating with the controller.

- That's a long time in a critical moment.

Investigators learn that instead of monitoring the engines...

- Rhoades Express 8-10, you are cleared visual approach

runway four right.

...the captain is distracted

by a conversation with the controller.

- Okay, Rhoades 8-10, we're gonna run a checklist.

I'll let you know when we're ready to come to the airport.

- When you have an emergency situation,

it is important to aviate, navigate and communicate.

And your third priority is communicating your emergency.

- What happens next?

- Okay. I have control. - Roger.

Okay, let's see what's the problem.

What's going on with the gauges?

- The captain starts flying the plane

and turns his attention to the engines.

- So it looks like the number one.

- Number one's gone? - Gone, yeah.

We still have the number two.

So we have number two. Okay.

- Stop.

The FO changes his diagnosis.

Investigators confirm

that the first officer correctly assesses

that the right engine lost power on takeoff.

- Yup. It looks like we lost number... - Number two.

But less than four minutes later,

he tells Captain Okai it's the left engine that's failed.

- So it looks like the number one.

- Number one's gone? - Gone, yeah.

- Why?

- It wasn't clear why they had changed their minds about it.

- The captain then instructs the FO

to do the engine shutdown checklist

but he only gets through the first step.

- Hey, we're red line here.

We should pull back on the right one a little bit.

- Okay.

The right engine overheats

because of the internal damage,

leading the pilots to believe they're losing both engines.

- Once the crew had convinced themselves that they had a dual engine failure,

they were focused almost exclusively on altitude and airspeed

and eventually, they ran out of options and had to ditch.

- It's clear that the right engine -

the one with the issue -

is overheating and not producing full thrust.

But what led them to think the left engine wasn't working?

- Let's see what the flight data recorder can tell us.

Okay. Let's see what the engines were doing.

Investigators examine the engine power data of Flight 8-10

to determine what actions the pilots took

that led them to believe their perfectly working engine,

the left one, had failed.

- After the right engine failed,

both engines are brought back to flight idle

once they level off at 2,000 feet.

That's proper procedure to get the speed down.

- But the first officer never told the captain

he brought the engines back to idle.

They discover a key step missing

in the pilots' actions.

- It was procedure for a crew member

to verbalize when they moved the engine controls.

In this case, the first officer actually did not do that.

And that could have affected the captain's situational awareness

of where those engine throttles were.

Why did the first officer fail

to inform the captain of his action?

- Send someone to interview the first officer again

about bringing the throttles back.

- So it was critical for us to get more information

to better understand what had happened there.

- Did anyone actually ever test the throttles?

After they leveled off,

the pilots could have increased power to the left engine

to confirm which engine had failed.

- No.

The left engine throttle stayed at idle

for the rest of the flight.

- If you're going into the water

and you have no other option left,

you're gonna firewall both throttles

just in case it might help.

- Why didn't the captain check the first officer's misdiagnosis?

- Let's ask him.

- When the first officer subsequently said it was the number one,

the captain just accepted it.

He didn't effectively cross-check

that erroneous assertion.

So we wanted to ask him

why... why did he accept that?

- Captain Okai.

Thanks for meeting with me again.

You're muted.

Investigators speak to Captain Okai one more time

to find out why he thought the left engine had failed.

- Sorry about that. Glad I can help.

- When Greg told you the left engine had failed,

do you recall initially thinking the right one had failed?

- No.

The thing with Greg is I've flown with him so many times.

He's never made a mistake.

If Greg says the left is gone, the left engine is gone.

Investigators learn the captain put his faith

in his first officer's diagnosis.

- While trust is very important,

when it comes to crew resource management,

you also want to verify.

The captain did not verify

the information that the first officer was giving him.

- Okay. Thank you.

- Sure thing.

- It's really critical when you do have an engine failure

to look at all the available information and cross-check

and agree that you have identified the correct engine.

In this case, that didn't occur.

- What were the power readings when the engines were at idle?

Even if the captain trusted the first officer,

wouldn't there be other indicators

showing which engine had failed?

- The left engine was 1.05

and the right 1.12.

The team discovers

the power was a bit lower on the left engine

even though both engines were set to idle.

- Okay, let's see what's the problem.

What's going on with the gauges?

- They did have slightly different power outputs.

And that is something you would see with two different engines.

- And that could have really affected the captain's decision-making.

If the captain had checked the gauges,

the readings would have supported his first officer's report

that the left engine had failed.

- So it looks like the number one.

- Number one's gone? - Gone, yeah.

- So we have number two. Okay.

But this doesn't explain why the first officer

never told the captain

that he brought both throttles back in the first place.

- If the first officer had said,

"Hey, I pulled the thrust back on both engines,"

then that might have caused the captain to engage

in a different thought process about what might be going on.

- First officer follow-up interview.

Why didn't the first officer of Transair Flight 8-10

tell the captain he brought the power levers back

after the right engine failed?

- He has no recollection of bringing either thrust lever

back to idle.

- We believe that the first officer forgot

because he was busy.

That leads to stress.

Stress leads to tunneling of attention.

That can lead to fixation on a small number of parameters.

- But even if the first officer didn't tell the captain about the thrust levers,

there must have been other signs which engine failed.

Check out the rudder data.

Immediately after the right engine failed on takeoff,

5.5 degrees of left rudder is applied.

- You got it? - Yeah. I got it.

After the right engine lost power on takeoff,

the plane pulled to the right.

When the first officer applied the left rudder,

the plane straightened out.

- The foot that isn't pressing on the rudder pedal

is the side with the bad engine.

So it's usually a pretty clear indication of which engine has failed.

- He held that left rudder for three minutes!

He had a clear indicator, but it never registered.

The fact that the first officer was applying left rudder

was an indication that the right engine had lost power.

- It's very possible that under those stressful conditions

in the middle of the night over the water,

you could make that mistake.

- They made the right assessment initially,

but in the end, the stress of the situation

degraded their ability to fly the plane.

Investigators now know the series of events

that led to the ditching of Transair Flight 8-10.

When the right engine loses power after takeoff...

- Damn!

...both pilots make the proper assessment.

- Yup, looks like we lost number...

- Number two... - Number two.

But while the captain communicates with air traffic control...

- Okay, Rhoades 8-10,

we're gonna run a checklist.

...the first officer reduces engine power.

- Okay, let's see what's the problem.

In a moment of stress, he forgets to tell the captain.

- What's going on with the gauges?

The slightly different readings on the gauges

lead the pilots to believe

the fully functioning left engine has failed.

- So it looks like the number one.

- Number one's gone?

The captain relies on the first officer's assessment

without doing his own analysis of the situation.

- Gone, yeah. We still have the number two.

- So we have number two. Okay.

Instead of confirming which engine had actually lost power

and forgetting their original assessment,

the pilots end up flying on a damaged engine.

- How's the EGT?

- Uh, it's max. It's beyond max.

Setting them up for an inevitable ditching.

- We're in the water. We're in the water!

- The pilots' misidentification of the damaged engine,

and their use of the only...

Before the NTSB's final report is published,

Rhoades Aviation is shut down by the Federal Aviation Administration

for numerous safety and maintenance violations.

- While it may be disappointing

that the crew never actually touched their left engine that was working properly,

it is a testament to the human limitations that actually arise

when you have stressful, high workload situations.

And that's what we need to account for.

With only 50 7-37-200's remaining in service,

it's deemed impractical to fit them with engine sensors

that would alert pilots to a failed engine.

But it's now standard in most passenger airliners.

- Engine monitoring technology has improved considerably

since this aircraft was manufactured.

Newer airplanes actually give very clear indications to the pilot

regarding which engine is bad

and reduces the risk of the crew misidentifying it.

Subtitling: difuze