Original subtitles

- Scoops.

Pilots from Airborne Express...

- On.

-...are testing a plane

that's been recently modified.

- Kick the tires, light the fires, and make sure

she's exactly as advertised.

- The next thing is our stall series.

- These pilots were trying

to test the stall warning system.

- Feeling some buffet here.

- That's a stall right there.

- But something goes terribly wrong.

- It's number two engine.

Pull up.

- Really? Really?!

- Terrain.

Flight 8-2-7 crashes into a mountain in Virginia.

Everyone onboard is killed.

- It was just complete devastation.

- While the flight data confirms the plane entered a stall...

- And then here, the airspeed falls off a cliff.

- ...it doesn't explain why the pilots weren't able

to recover from the very condition they were testing.

- It's a sobering thought and a significant one.

- Mayday, Mayday.

- Pull up.

It's three days before Christmas

at Piedmont Triad International Airport

in Greensboro, North Carolina.

The crew of Airborne Express Flight 8-2-7

and three technicians in the cabin

have been waiting more than four hours

for maintenance to be completed.

- Think we're getting out of here tonight?

- At this rate, I think we're all gonna be spending

Christmas together in this cockpit.

What do you think, Terry?

- I think you can explain that one to my wife and kids.

Flight 8-2-7, aircraft is cleared

and released. Have a good flight and a Merry Christmas.

- Roger, 8-2-7. Happy holidays, Dispatch.

Finally.

Just after 5 p.m.,

Flight 8-2-7 is given clearance to fly.

The flight engineer is 52-year-old military veteran

Terry Waelti.

- Taxi and pre-takeoff checklist. Brakes.

- Flying tonight is 37-year-old Captain Keith Leming.

- Checked. - Checked.

- Cabin and freon compressors are off. Anti-skid?

- Armed. - While not flying,

48-year-old Captain Garth Avery,

is the designated pilot-in-command.

- They were very experienced as pilots.

The flight engineer was incredibly experienced,

and they all knew the DC-8 and had many, many hours

in this airplane.

- Taxi and pre-takeoff checklist complete.

Tower, ABX 8-2-7 heavy is ready to go.

- The flight crew is operating

a modified McDonnell Douglas DC-8.

- The DC-8 is an incredibly reliable machine,

and it always has been.

- The DC-8 is a long-range,

narrow-body jetliner introduced in 1959.

- As long as you use it exactly the way it was designed,

they're just as tough as nails.

- V-1. Rotate.

- At 5:40 p.m., Flight 8-2-7 takes off.

- Positive rate, gear up.

- Positive rate...

One thousand feet.

- Roger.

- Although it's a lesser-known airline,

Airborne Express, or ABX,

is one of the largest cargo carriers

in the United States,

after both Federal Express and UPS.

In a bid to expand its fleet,

ABX purchased the aircraft

that would become Flight 8-2-7

and modified it before putting it into service.

- ABX 8-2-7

is 2,500 for 5,000.

- MCT set. Ignition off.

- But before this plane can be added to the fleet,

it has to be taken for a test flight.

This is known as a Functional Evaluation Flight,

or F-E-F.

- A Functional Evaluation Flight

is basically to see that everything

is as it's supposed to be,

kick the tires, light the fires, go out and fly,

and make sure she's exactly as advertised.

- After departing Greensboro,

Flight 8-2-7 is scheduled to spend about two hours

flying the F-E-F before returning to the airport.

ABX 8-2-7, for our maintenance

check, can we get a block of 1-0 to 1-2 thousand?

- The flight crew needs a dedicated block of airspace

to perform the tests.

Could you take a block of, uh,

thirteen to fifteen?

- We can do that.

- ABX 8-2-7, roger,

climb and maintain block altitude

of 1-3 thousand through 1-5 thousand.

- Having reached a quiet block of airspace,

the crew works its way through the F-E-F checklist.

- Scoops?

- On.

- The DC-8's scoops are part

of its pressurization system.

- Didn't get the left one. Try again.

- It's really common on test flights,

to have issues crop up.

This airplane had undergone so many changes

that it needed a thorough test flight.

- Alright. Scoops... off.

- The left one ain't working.

- With multiple redundancies built into

the pressurization system,

the pilots are safe to continue their flight.

- ABX 8-2-7, turn right, heading of 3-6-0

vectors for traffic.

- Air Traffic Control monitors the airspace,

redirecting Flight 8-2-7 when necessary.

ABX 8-2-7,

right 3-6-0.

And then we're gonna do our manual drop.

You ready for hydraulics to come off, Keith?

- Uh, yeah, go right ahead.

- Okay, go ahead, Terry.

- The manual drop tests the plane's landing gear

without the use of hydraulics.

- Okay, gear free fall one point five, V-S zero.

- Okay, you ready? - Ready. Gear down.

- Gear... down. Three green.

- Got it.

- We're getting a little bit of ice here.

- The biggest hazard from icing

is that it changes the shape of the wing.

And the airplane doesn't fly nearly as well as it did.

- The crew comes up with a plan

to avoid performance issues from ice build-up.

- Garth, if we go up 15,

I think we could get out of this stuff.

- Uh, yeah, you can go up there.

We've got that block.

- As the flight climbs out of the weather,

the crew continues the tests.

- The next thing is our stall series.

- For the stall series, the pilots will intentionally

slow the airplane until it's just about to stall,

to determine when the stick shaker activates.

Most commercial planes use a stick shaker system.

It's a vibrating warning on the control column

that alerts the pilots to take action

before the plane actually stalls.

- We should stall at 122.

I'm gonna set that in my interior bug.

- The pilots set their target speed

for when the plane is expected to stall.

- Mine's set.

- Shaker 128.

If you just call out your numbers, I'll record 'em.

- They have to write down the airspeed at which

the stick shaker triggers,

and then they have to write down the airspeed

at which the stall begins.

- Captain Leming slows the plane

at a rate of one knot per second

to reach the stall speed.

- Feeling some buffet here.

- The pilots detect a change in the aircraft.

- Yeah, that's pretty early.

- As an airplane approaches stall,

it starts talking to the pilots.

The airplane starts vibrating or buffeting.

- They quickly take action to avoid a stall.

- Set max power.

- One thirty-three.

- Then, one of the plane's left engines begins to surge.

- That's number two engine.

- That's not normal, and you know it's not normal.

And so, something like that's gonna get your attention.

- Pull it back.

- You got it.

- The plane now banks to the left...

and begins to drop.

The pilots attempt to level the wings

and slow the plane's descent.

- Alright. - Okay?

- Got it.

- Realising that the plane is descending

below his jurisdiction, the controller

assigns the pilots to a new radio frequency.

- 8-2-7, change to Indianapolis 1-2-8 point four.

- But the controller's calls to change frequencies

go unanswered.

The flight crew is busy trying to recover the plane.

ABX 8-2-7,

Indianapolis 128 point four.

- Uh, ABX 8-2-7,

we're gonna stay on this frequency a minute,

descending through 8,000, call you right back.

- ABX 8-2-7, you're in an emergency descent?

- Yes, sir.

Airborne Express Flight 8-2-7

is out of control and plummeting to the ground.

- Rudder. - I got it.

Seeing that Flight 8-2-7 is in trouble,

the controller checks air traffic in the area

to find a safe altitude for the plane.

- Okay, um, can you hold 7,000?

- But there's no answer.

Flight 8-2-7 is less than 5,000 feet from the ground

and descending fast.

- Now bring it back. Left rudder.

Okay good. Easy.

- They could tell they were in an emergency.

They could tell they'd lost control.

They were probably frightened to death.

- The pilots continue their efforts

to recover the aircraft, but are now too low.

Pull up.

Terrain. Terrain. Pull up.

- Really? Really?!

- Airspeed low. Pull up.

Just half an hour into a standard test flight...

...the DC-8 crashes

into the East River Mountain in Narrows, Virginia.

- ABX 8-2-7, do you copy?

ABX 8-2-7, do you copy?

- No one has survived.

- The mountains lit up, and there was a explosion,

black smoke,

and red and blue flames coming up off that.

- News of the crash

quickly spreads throughout the community.

Grief counselors arrived today

at Airborne's headquarters

to help family and friends cope with their loss.

- Obviously, it's just a terrible time

for everyone here, particularly at...

at this time of year.

- Bob MacIntosh from the NTSB,

the National Transportation Safety Board,

leads the investigation.

- We know this was a...

a maintenance examination flight.

Obviously, it was not successful,

and that's about all I can tell you right now.

The wreckage site certainly presented some challenges.

We were going to have to deal with some mountainous terrain.

We had to get to work.

- Benjamin Berman is one of the first team members

to arrive at the crash site.

- I got to the top of the mountain

and I looked out at the scene,

and it was just complete devastation.

I really thought, you know, what is it that could have

brought that plane down?

That's our job as NTSB investigators.

- Investigators begin their painstaking efforts

to transport pieces of the demolished plane

to a hangar for examination.

- We found the four corners.

Looks like the plane was intact when it hit the mountain.

- So, if you can see all four corners,

which are the nose, the right-wing tip,

the tail, and the left wing tip,

in close proximity, it probably means

the airplane was intact until it hit the ground.

- This particular wreckage scene told us

that we most probably had a loss of control,

and that we were gonna have to find the, uh...

reason for that loss of control.

- We recovered the CVR and FDR.

Let's get them off to Washington.

- That cockpit voice recorder was going to tell us

not only what they said, but how they said it.

- While investigators wait for the CVR download...

- I got the checklists for the FEF.

- ...they review the checklist the flight crew was using

during the Functional Evaluation Flight

to get a better understanding

of what they were doing prior to the crash.

- It looks like standard FEF stuff.

They're testing the flaps, rudder,

landing gear, stall system.

- There's nothing unusual on the list of tests

the pilots were performing.

- Well, maybe there was a problem with the plane

before the FEF.

I'll get Berman to talk to the maintenance team

that modified the plane.

- It was an old airplane,

but it had just come out of a major retrofit.

- Can you take me through exactly

what you guys did to the airplane?

- Well, it was a fairly major overhaul.

- Investigators learn that extensive maintenance

and modifications were carried out on the aircraft

over the course of six months.

- Yeah, it looks like you guys pretty well

took the whole thing apart and put it back together, huh?

- As we looked at the maintenance records,

we could find that, uh, there was a great deal of work

that had been done on the aircraft.

Perhaps something had fallen through the cracks.

- Could technicians have overlooked something

during the modification of the airplane,

causing the pilots of Flight 8-2-7

to lose control?

Pull up.

Terrain. Terrain. Pull up. - Really? Really?!

- I've got the dispatch logs for the plane right here.

Investigators review Airborne Express Flight 8-2-7's

dispatch logs to see if any malfunctions

were reported after the plane was released from maintenance.

- It looks like they finished the modifications

and delivered the plane on December 15th,

one week before the crash.

Wait a second...

This wasn't the pilots' first attempt at this flight.

- The fact that they tried to do the flight earlier,

that was really relevant.

- Look here. The pilots conducted

a partial FEF the day before the crash.

They scrapped it midway through, low hydraulic pressure.

- That can mean getting the landing gear down

and in place or not, uh...

or being able to power the flight controls or not.

If the hydraulic pressure is not right,

that's very serious.

- Okay.

And what did you think caused the low hydraulic pressure?

- Did a hydraulic issue cause a loss of control?

- Got it. The maintenance crews say

that they suspected that trapped air in the lines

led to low hydraulic quantity indication.

- Did they fix it? - Yeah.

They replaced the nose gear actuator

the day of the accident. - But was that the end of it?

Or did our pilots end up having issues

with the hydraulics again?

- We needed to figure out what had been going on.

Could something have gone wrong in that maintenance?

- Investigators are able to recover the plane's

rudder components from the crash site.

They examine them for any signs of damage

to the hydraulic system.

- No pre-impact hydraulic leaks.

The hydraulic system was working fine.

- The hydraulic system wasn't a probable cause

for the mishap and loss of control.

- If it wasn't the hydraulic system, what was it?

We should call the witness list. Maybe somebody saw something.

You were outside your home at the time?

And what did you hear?

- The team begins to interview witnesses

to see if anyone heard or saw something

that could point to the cause of the crash.

- The local newspaper people were there

asking people what they had heard and seen that night.

- All you could see was just parts.

It just, the plane had cleared out a big path.

- That area was full of information.

- Witnesses describe seeing the plane descend

out of the clouds at a steep angle

and hit the mountain at high speed.

- Thank you so much for your time.

I think we've got something.

- Three witnesses confirm

they could hear the plane making a banging sound

followed by a slapping sound.

- Kind of an odd noise.

It sounded kind of low,

and then he started coming up real loud.

- The witnesses told us that there was slapping

and banging that they heard.

- If airflow entering the engine is disrupted,

it can cause the engines to backfire.

If airflow over a wing is disrupted,

it can make a slapping sound.

Both can be signs of a stall.

- If the witness reports were true,

it suggested that possibly there was an engine issue

that may have been part of the sequence of events.

However, it would require further examination

of the flight data recorder.

- NTSB Investigators turn to the plane's

Flight Data Recorder to confirm

whether Flight 8-2-7

was in a stall before it crashed.

- Isolate the airspeed.

There's a gradual reduction in airspeed here.

- One knot per second. It looks like they were setting up

for the stall series.

- And then here, airspeed falls off a cliff.

- That's a stall.

- Let's see the engine parameters.

- They search for further confirmation

that Flight 8-2-7 stalled.

- It looks like a compressor surge

from the number two engine.

- That tracks with what the witnesses said

they were hearing.

- Lack of airspeed and a compressor surge

are clear signs that the plane stalled.

- Give me the roll angle.

- They were banking left, right, left, right, left.

- They were in a roll reversal.

- A roll reversal is a phenomenon that occurs

when a plane banks steeply to the left and right,

in the opposite direction of a pilot's inputs.

It's usually the result of a stall.

- You're flying slow enough. You're just barely possessed

of enough lift to stay in the air.

And now the airplane does exactly the opposite

of what you were asking it to do.

- Yeah, that's four roll reversals before the crash.

- How did the crew of Flight 8-2-7

allow their plane to get so out of control?

With the arrival of Flight 8-2-7's

Cockpit Voice Recorder, or CVR,

investigators zero in on the test

the pilots were conducting immediately

before the plane stalled.

- Okay, are you ready?

- Ready.

The next thing is our stall series.

We should stall at 122.

I'm gonna set that in my interior bug.

- Mine's set.

- Shaker 128.

If you just call out your numbers, I'll record 'em.

Investigators listen to the pilots

working their way through the stall series.

Feeling some buffet here.

- Yeah, that's pretty early.

- So the plane entered a stall sooner than they expected.

- Yeah.

- When I was looking through the transcript before,

there was something that Captain Leming said earlier

in the flight, uh...

Captain Leming, "We're getting a little bit of ice here."

- Garth, if we go up 15,

I think we can get out of this stuff.

- Uh, yeah, you can go up there. We've got that block.

- So ice builds up,

disrupts airflow over the wing...

- Decreases lift, increases drag...

- And the plane would have stalled at a higher airspeed

than they calculated.

- Did ice accumulation on Flight 8-2-7

cause a premature stall?

It's happened before.

December the 12th, 1985.

Evidence suggested that shortly after taking off

from Gander International Airport in wintry conditions,

a build-up of ice on Arrow Air Flight 12-85

caused the plane to stall at a higher airspeed,

leading to a crash that killed all 256 people on board.

Investigators study meteorological reports

to determine if Flight 8-2-7

was flying through icing conditions.

- There's a scattered area of light rain here

along 8-2-7's flight path.

Cloud tops out at around 14,000 feet.

What was their altitude block again?

- Uh, 13 to 15,000.

- The type of weather they were in the night of the accident

was really conducive to icing.

They were in prime territory to pick up ice

whenever they were in the clouds.

- What speed did the pilots say they expected the stall?

- Stall 1-22, shaker 1-28.

- Well, according to the FDR,

the plane stalled at 126 knots.

- That's only four knots earlier.

- So even if there was ice, it was likely to have had

little impact. I mean, certainly not enough

to make the plane unrecoverable.

- Whether there was a great deal of contribution from ice,

we could never determine,

but, uh, the consensus

was that it was not a major element

in the cause of the accident.

- You said stall 1-22 knots, shaker 1-28?

Mm-hmm. - Well, when we were listening

to the CVR, I don't remember hearing

the stick shaker.

- The purpose of the stick shaker

is to get your undivided attention,

not only by noise, but by shaking you.

Because there's only one thing that that's telling you,

and that is, "If you slow any more,

I'm gonna stall."

- Let's have a listen.

- Did the pilots receive proper warning

that their plane was entering a stall?

I'm feeling some buffet.

- Yeah, that's pretty early.

- That's a stall right there, that ain't no shaker.

- So, they're slowing the plane down,

waiting for the shaker to activate...

- Then all of a sudden, they're in a stall.

No warning. - So the shaker failed?

- With no stall warning there, the pilots had, in a sense,

a right to believe they weren't stalling.

Well, what's going on here? Well, it's not a stall,

because the stick shaker's not vibrating.

- Well, the question is, when did it fail?

During the flight or before?

To determine if the stick shaker malfunctioned,

investigators search the wreckage

for stall components that might have survived the fiery crash.

- Nothing, huh?

Yeah, that's what we thought.

The stall system was completely destroyed.

- We never were able to exactly identify

what that failure point was in the system.

Our team wanted to find out how much maintenance

and inspection had taken place on the system.

- With no clues in the wreckage,

NTSB Investigators speak to the maintenance technician

about Flight 8-2-7's stall warning system.

- Hey, thanks for your time.

Did you test the stick shaker?

- Yeah, we did, on...

On December 5th.

- Two weeks before the accident. How extensive a test?

- Quite extensive. Have a look.

- The shaker, the heating components.

- The stick shaker system

passed all those pre-flight maintenance checks.

- What about the transducer?

- Let me check.

- The transducer is a small flap

nestled in the recessed part of the wing.

It moves backwards when airflow is detected.

When there is insufficient air over the wings,

it moves forward and triggers the stick shaker to activate.

- No.

No, it doesn't look like we tested the transducer.

- That part is not covered by the pre-flight test.

It suggests that the failure of the stick shaker to work

was a bad transducer.

But to me, why it failed

wasn't as important as...

what the effect of it failing was on the crew.

- Feeling some buffet here.

- Yeah, that's pretty early.

- That's a stall right there, that ain't no shaker.

- Even without the stick shaker activating,

the flight crew knew they were in a stall.

That's number two engine.

Bring it back. Okay, good.

- But if they knew...

- Left rudder.

- ...why couldn't they recover?

- Easy. - Terrain. Terrain.

- Bring it back. - Pull up.

Rudder.

- Really? - Terrain. Terrain.

Investigators return to Flight 8-2-7's CVR

to get a better sense of the actions the pilots took

when their aircraft went into a stall.

That's a stall right there.

That ain't no shaker.

- Set max power.

- One thirty-three.

- So, as soon as they recognize they're in a stall,

they push power to the engines.

- That's the right move.

That's number two engine.

- There's the engine surge.

- Pull it back.

- So what did they do next?

- Alright.

- Okay.

Start bringing the nose back up.

- They pulled the nose up?

- That would make the stall worse.

- Pulling back on the control column

in response to a stall is inconsistent

with a normal stall recovery

and would not reduce angle of attack and break the stall.

- Well, that's what would have triggered the roll reversal.

- How'd they deal with that?

- Rudder.

- Got it. - Rudder.

- Got it. - Left rudder.

- The left rudder's buried.

- Investigators discover that in addition

to moving the control wheel right and left,

the pilots also used the rudder to stop the plane from rolling.

- You have to be ahead of it.

And that's a very difficult thing to do.

- So they spend almost a minute

trying to fight the roll reversal

with the rudder. And no mention of a stall.

- Investigators suspect that the pilots

were so preoccupied dealing with the roll reversal

that they failed to realize that the plane was in a stall.

- It still doesn't explain why Captain Leming

would have pulled back on the yoke

to try to recover from the stall.

- To recover from the stall, you can't pull back.

You need to point the nose of the airplane down

even more in order to gain speed,

or you will not recover.

You will fly into the mountaintop in Virginia.

Terrain. Terrain.

Pull up.

Terrain. Terrain.

- And we wanted to know why,

why did he do that?

Especially at those most critical moments.

- Morning, Bob.

- I'm looking to see if there's anything

in ABX's operations manual on the DC-8.

Here's a copy.

- Investigators search through ABX's procedures

to understand why Captain Leming

pulled back on the control column

to recover from Flight 8-2-7's stall.

- Wait.

Bob, did you see this?

It says that priority in a stall recovery

is to maintain altitude by increasing the pitch.

- Pulling back on the control column

increases the pitch of an aircraft.

- Well, it might be okay for an approach to a stall,

but not for an actual stall.

- So, the things that you do to recover

from an approach to stall

are totally different from what you do

to recover from an actual stall.

If you're right over the trees, you gotta try

the approach to stall recovery

because you're gonna hit the trees.

If you're at 36,000 feet and you stall,

if you don't put the nose down five or ten degrees,

you're not gonna recover.

- That can't be the current procedure, can it?

- I've got a joint memo with the FAA.

- Investigators discover an update

to Airborne Express' flight test procedures.

- And what's it say?

- The updated procedure called for a reduction of pitch

to recover from a stall.

- The revised procedure called for pilots

to lower the nose when entering a stall,

the opposite of what Captain Leming did.

- The change was made after a loss-of-control incident

in May 1991.

- May '91... May.

What flight was that?

- It was a DC-8 doing a post-modification FEF.

- The same plane and flight as 8-2-7.

- On May 16th, 1991,

another Airborne Express DC-8 lost control during an F-E-F.

- The pilots managed to recover from the stall.

And the policy has been to reduce pitch

during a stall ever since.

- So, why didn't the crew of Flight 8-2-7

use the updated procedure?

Okay.

- We learned that the director of Flight Technical Programs

was responsible for the procedures,

the checklists, and the selection

and training of pilots.

As a result, we wanted to talk to him to learn more.

- The NTSB meets with the airline's

Director of Flight Technical Programs

to determine why the crew of Flight 8-2-7

didn't follow the updated procedure.

- I just have a few questions to ask,

and then I'll let you get back to work.

- Of course.

- How do ABX pilots train to recover from a stall?

- I tell them whatever you do, don't lose altitude.

So if you're in a stall, you set max power

and you increase the pitch of the aircraft.

- Well, that's different from the updated policy,

which calls for a nose down pitch recovery.

- Correct.

- He just didn't agree that that was necessary.

- If you increase the pitch,

you'll make the stall even worse.

- The engines are properly spooled

as you're approaching a stall.

You can power your way out of it.

- The director believed that if the engines

were running properly,

pilots could increase thrust

and fly out of a stall.

- He had his own opinions about what should be done,

and they were not in agreement

with the proper procedure.

- See, what I don't get is...

old procedure, new procedure,

there is no procedure that says to pull back

for the duration of the stall.

- I keep going back to the way they were dealing

with this roll reversal.

- Rudder. Rudder.

- Got it.

- And left rudder.

- The crew were unable to recover the airplane

in the approximately 90 seconds that it took

from when this lack of the stick shaker

was identified, to when it impacted terrain,

and our question was, why?

- Investigators assess ABX's DC-8 flight simulator

to see exactly how flight crew experienced a stall

during their training.

- Now, I'm going to slow this thing down into a stall.

There's the shaker...

There's the stall.

And I'm going to pull back on the yoke

like our pilots did.

- So, I continued to raise the nose

up higher and higher,

and I was just astounded at what the simulator did,

or mainly, what it didn't do.

- Well, we're in a stall

and there's no roll, no pitch down,

nothing like you would see in a real life stall.

- The simulator just kind of reached the end of its program.

It just sat there.

- If this is how they were trained,

they would have no idea how a stall truly feels.

- Their training was not only zero training,

it was negative training.

It gave them a false impression

of what they would experience.

They would have been startled...

- Left rudder. - at what the wings did

- with the roll... - Okay. Easy.

Don't... Don't...

- ...and they would not have recognized it

necessarily as a symptom of a stall,

because in their simulator, it didn't have that symptom.

- Maybe they didn't realize they were still in the stall,

but surely, there were other indicators

that they were falling out of the sky.

Why didn't the pilots of Flight 8-2-7

realize they were diving towards a mountain?

- Okay, put yourself in the pilot's shoes.

You realize you're in a stall.

- Feeling some buffet here.

- Yeah, that's pretty early.

- That's a stall right there. That ain't no shaker.

- You push power to the engines. Pull back on the yoke.

- Start bringing the nose back up.

- Your number two engine surges.

- That's number two engine. - Pull it back.

- Now you're dealing with a roll.

The plane's banking left and right.

You're applying rudder.

- Rudder. - Got it.

- Rudder. Rudder. - Got it.

- You got ATC in your ear

telling you to switch frequencies.

- 8-2-7, change to Indianapolis 128 point four.

- You look outside. What do you see?

- Nothing.

- Right, because it's pitch black out,

and you're in the clouds.

There's no visible horizon.

You're just flying on instruments.

- They had no visual cues. - Exactly.

- You're now removing the visual aspect

of a horizon out there that can help anchor you.

You're just stacking the deck against yourself.

- Now, the question is,

what were they doing flying a stall series test at night

in the first place?

- Investigators review the flight's dispatch logs

to retrace the pilots' steps on the day of the accident.

- The FEF was scheduled for 1:20 p.m.,

but the maintenance delays pushed it past sundown.

Had they just pushed it to the next day,

none of this would have happened.

- So why didn't they?

Why go through with the FEF at night?

- Alright.

- One of the key decisions was to conduct the check flight

later at night than they'd planned

in the darkness hours. And so, you know,

did anyone pressure them into doing that?

- What was the ABX policy on when to fly an FEF?

- Investigators return to ABX's Director

of Flight Technical Programs

to find out why the pilots proceeded with an FEF at night.

- No policy, necessarily.

Just a preference to fly them during the day.

- Do ABX pilots understand the risks

of flying an FEF at night? - Sure,

and I'd rather they conduct them during the day,

but there's no prohibition against doing them at night.

- And what are the recommended weather conditions

for flying an FEF?

- Preference is to fly in clear skies

and not on instrument,

but we have no specific restrictions on that.

- We discovered that there was no written policy

prohibiting this flight from being conducted at night.

- The NTSB's investigation

has uncovered numerous factors

that led to the crash of Flight 8-2-7.

- Stick shaker malfunction,

incorrect stall procedure,

negative simulator training,

FEF at night.

Had just one of these factors not been present,

the crew would likely have survived.

- I think this accident was caused by a failure

to recognize that a functional evaluation flight

requires rigorous preparation

and criteria and controls to be placed on it

to protect the pilots who are flying it.

- Start bringing the nose back up.

- This was not God reaching down

and slapping an airplane out of the sky.

There were reasons for this happening,

and this could have been avoided.

- In the wake of the crash of Flight 8-2-7,

the NTSB makes a series of recommendations

to make Functional Evaluation Flights safer,

and to better prepare pilots for stall conditions.

- This accident brought a lot of significant

changes to the industry.

- We issued recommendations to try to improve

airline oversight and FAA oversight

of functional evaluation programs.

And those efforts were successful.

- Flight simulators used for airline training

were made much more realistic.

Every airline pilot

receives training in recovering the airplane

from a high-altitude stall

where they have to use this Airborne Express

revised stall recovery procedure to get the job done.

- The report also recommends a revision

to the DC-8 maintenance manual

calling for regular calibration

and testing of the complete stall warning system.

- There might have been other airplanes out there,

you know, flying around in service

where the stall warning system really wasn't working.

It's a sobering thought, and a significant one.

- The strength of aviation safety

is a direct result of learning the most we can learn

from every single accident.

This wasn't an accident in vain.

Yes, it could have been prevented,

but now, we know how.

Subtitling: difuze