Original subtitles

Morning rush hour, Charlotte, North Carolina.

Its busy airport is rocked by a massive explosion.

The flames were coming over the fence. Just total craziness.

Everyone was just running for their lives.

Firefighters rushed to one of the airport's main hangars.

They confront an inferno.

It was quite a while before we realized a plane had hit the hangar.

A packed commuter flight has plunged to the ground shortly after takeoff.

Everyone on board is killed.

We kept scratching our head, wondering, okay, this airplane

flew nine times previously and we had no problems.

Investigators uncover a string of errors.

Bill, I have an idea.

And learn that passengers on small planes

have actually been in danger for years.

Mayday! Mayday! Mayday!

It's morning on January the 8th, 2003, in Charlotte, North Carolina.

A city of half a million wakes.

At Charlotte Douglas International Airport,

commercial airline pilot Captain Katie Leslie is at work early.

Only 25 years old, this Texas native has been flying

for Air Midwest for almost three years.

One of the youngest flight captains at her airline.

Hey, Tom. Have a great flight.

She's a top-rated pilot, building her career

at one of the fastest growing airports in the United States.

This airport is an important domestic hub for US Airways,

with flights to most major cities in the eastern United States.

Air Midwest runs a commuter service as US Airways Express.

It operates a fleet of Beechcraft 1900D planes,

a 19 passenger short-haul commuter plane

and a trusted workhorse in the industry.

Today, Captain Leslie is in command of a 1900D

on a 30-minute hop to Greenville-Spartanburg Airport in Greer, North Carolina.

Her co-pilot is 27-year-old Jonathan Gibbs.

How did you sleep last night?

Had a dream I was in Miami.

Attention, ladies and gentlemen, this is the final boarding call

for Air Midwest Flight 5481 to Greenville-Spartanburg.

All passengers wishing to board should make their way...

Among the passengers flying to Greer this morning,

18-year-old Christiana Shepherd.

Christiana's parents, Doug and Tereasa,

are Baptist missionaries working in the Portuguese Azores.

Christiana left the seventh of January from the Azores,

spent the night in the airport in Boston.

And then flew the next morning on the early flight from Boston

to Charlotte to Greenville.

So, she was on her way back to college.

Christiana was very special and she was one that would come up

and give you a hug and say... You know, she'd come for no reason.

She would give you a hug and say, "Dad, I love you."

At 8:00 in the morning, Christiana boards her flight.

Meanwhile, as part of their standard

checklist before takeoff, the crew calculates

the weight of all the baggage, passengers and fuel on the plane.

That's to make sure the plane isn't overweight and the weight is spread evenly.

It's a calculation that's made on all commercial aircraft.

So, we got a full house back there?

You can count 19 people in the back.

- I don't know the bags yet. - Okay.

But baggage handlers raise concerns

that the luggage they're loading may be too heavy.

Damn. Captain, how many we got to take off?

We're figuring it out.

We don't think we're gonna have to take anything off.

Cool. Seventeen thousand eighteen.

Seventeen thousand one hundred and twenty is our weight, huh?

Yeah, as our max.

So, we're cool.

So, yeah.

Good morning. Welcome aboard US Airways Express Service to Greenville-Spartanburg.

It's a very short flight, maybe 30 minutes gate to gate.

So, sit back, relax,

and we'll have you there in a few minutes.

Before takeoff, the crew checks the flight controls,

including the rudder and elevator,

which help control the direction of the plane.

Flight controls free and correct.

Air Midwest 5481, Runway 18 right.

Taxi into position and hold.

Captain Leslie is moments from takeoff.

On the runway, ahead of them is a Bombardier CRJ ready for departure.

That CRJ sure is a good looking plane, isn't it?

Yeah. I wish I was flying it.

With powerful turbulence released from the CRJ,

Captain Leslie must keep a safe distance.

They're gonna blast us with his jet blast.

Air Midwest 5481. Turn right, heading 230. Cleared for takeoff.

Set takeoff power, please.

Power is set.

Eighty knots. Cross-check.

At 80 knots, pilots check that key instruments are working.

With no signs of trouble, Leslie and Gibbs proceed with their take off.

To air traffic control, Flight 5481's takeoff roll is perfectly normal.

Gear up.

What?

Oh!

But without warning, the plane's nose

pitches dramatically upward from seven to a staggering 54 degrees.

Help me.

- You got it? - I'm trying.

The crew struggles to get the nose back down again.

Airflow over the top of the wings creates lift, but if the nose keeps rising,

air won't flow smoothly over the plane's wings.

The plane will lose its lift, stall, and plunge from the sky.

Push the nose down.

Oh, my God. We have an emergency on Air Midwest 5481.

Alert 3. Standby Runway 18 right.

The controller handling Flight 5481 calls for emergency equipment.

Oh, my God.

The plane is now 350 meters from the ground.

It stalls, rolls to the left and begins falling from the sky.

Captain Leslie pulls on her control column with all her might.

If she can't get the plane to climb, she's going to hit the ground.

Air traffic controllers watch

as a 19-passenger plane plunges towards the earth.

Captain Katie Leslie struggles desperately to get her plane to climb,

but it won't respond.

The plane heads towards a packed US Airways hangar.

The flight was loaded with almost 1,000 kg

of highly flammable jet fuel just before takeoff.

The impact instantly ignites all that fuel.

Now the intense fire threatens to engulf the hangar.

There are several airplanes and hundreds of people working inside.

Fire station. Emergency.

- A plane just crashed. - There's a plane that's crashed.

Yes. At the US Airways entry.

Right at the corner of the building, there's a fire.

We got a Code 10, aircraft crash at the south end of runway 36 left.

I repeat, a confirmed aircraft crash, on fire.

Thirty-eight-year-old Fire Chief Keith Rogers

is driving to work when he gets a Code 10 call.

A Code 10 means that

there is a confirmed plane crash.

But usually this type of call is a once in a career type of incident.

Cindy Overcash is a firefighter with the Charlotte Fire Department.

You couldn't actually see the hangar from here,

but you just saw a huge black plume of smoke.

And we knew, you know, something really bad is here.

In the adjacent building,

Sales Director David Isola hears the explosion.

I was sitting at my desk and I heard this, uh... This loud boom.

And, uh, one of the guys came in from next door

and said that, uh, he just saw an airplane crash.

And, uh, so I hopped in my truck and drove down to the site.

From 60 meters away,

Isola records the opening moments of the tragedy.

There was a lot of smoke and, uh, it was just... Just like hell.

Looked just like hell.

The flames were coming over the fence.

Just total craziness.

Everyone was just running for their lives.

When Chief Keith Rogers arrives at the scene,

he finds himself swimming upstream against a mob in panic.

As I got onto the airport property and got onto the tarmac,

uh, the people were exiting the hangar.

Those people were running out in front of the fire trucks and the fire cars.

So, we had to drive with caution.

They were getting out of the building as fast as they could

because I think they definitely realized that this was not a drill,

this was a real emergency.

And we still weren't sure if we had a plane inside the hangar

that had caught on fire or if the hangar had caught on fire.

It was quite a while before we realized a plane had hit the hangar.

Chief Rogers immediately takes command of the scene.

He knows that there are aircraft parked inside the flaming hangar.

Their fuel tanks threaten to blow.

And our concern was, one, about the people

that were on board the aircraft. Two, for the people that were working in the hangar.

And three, we had to worry about the airplanes

that were in for repair, were those aircraft on fire.

So, we had a lot of major issues to deal with.

Within minutes, firefighters begin to get the inferno under control.

The hope now is that somewhere inside the wreck, survivors are clinging to life.

The main thing probably was on anybody's mind

once we realized what we had was survivors.

Chief Rogers sends a line of firefighters,

led by Cindy Overcash into the heart of the inferno.

Cindy Overcash and two of her team

make their way into the wreckage,

carefully putting out spot fires along the way.

As we walk up on the scene of the fire,

and we see the... What we think are crash-test dummies,

we thought a plane had blown up inside

and blew their training dummies out.

And then it dawned on me.

Uh-uh. That's not a training dummy.

It took them a few minutes in determining exactly what was happening.

And once they did that, it was obvious that there were no survivors.

It's a total loss.

All 19 passengers,

as well as Captain Leslie and First Officer Gibbs are dead.

At about 8:53 this morning, uh, we had an aircraft accident.

It had 19 passengers and two crew.

There are no survivors.

And we hope that we never have to respond

to a situation with such a large loss of life.

But that is our job.

This is some of the most difficult duty and tasks

that a firefighter will ever do in their career.

For medics and rescue workers, the ordeal is over.

But for friends and family of the victims, the anguish has just begun.

I was walking through the living room,

and I stopped and said... My heart's beating right now

just the way it was then.

I said, "Has Cristiana called yet?" She said no.

Okay. And I knew then what had happened.

I just... I knew.

So, I went and got the telephone and called the school.

He said, "Yes, Mrs. Shepherd, we have some sad news."

And he told me that the plane crashed on takeoff.

I asked if there were any survivors.

He said no.

So then I knew I had to go tell Doug, and he was in the garage.

Yeah, it's something you... You never forget about.

Uh, I was changing a fluorescent bulb,

and, uh, Tereasa came to the... to the doorway.

How do you say that? What word...

You use words every single day.

How can you use words...

...to ruin someone's life.

But I told him. I said, "Doug, Christiana's plane crashed."

At that moment, uh, my... my world fell apart.

Now, the Shepherds and the families of the other 20 victims

want to know what caused the deaths of their loved ones.

It's been almost five hours

since Flight 5481 crashed into a hangar

in Charlotte, North Carolina.

With no survivors to rescue,

neither bodies nor airplane parts are moved from where they fell

until the arrival of investigators

from the National Transportation Safety Board.

While medical examiners mark the location of human remains in red,

NTSB investigators mark scraps of metal in yellow,

looking for clues to help them figure out

what happened aboard Flight 5481.

Among those assigned to this case, lead investigator Lorinda Ward.

This is her first assignment as the lead investigator of a crash.

But today, she's not feeling her best.

That day, I was a little bit under the weather.

I was fighting off a cold.

You have the adrenaline that shoots through your body at the time.

And so, that actually makes up for when you're not feeling well.

And I knew that the other people on my team were experienced,

so I felt comfortable going to Charlotte.

At Charlotte Douglas Airport,

Ward takes the first steps towards solving this accident.

I checked in with the fire department

to make sure that the fires had been put out.

And then called a meeting with all the first responders

to see what they had noticed when they came to the crash site.

Ward acts fast.

Because there are bodies entangled with the wreckage,

she declares the crash site a potential biohazard.

Investigators who might come in contact with the wreckage

must wear protective suits while they examine the wreck

and identify the victims' remains.

When we arrived on scene,

the accident site did not look like an airplane was there.

Uh, due to the fire, the post-crash fire,

um, when you initially walked up to it,

it was hard to identify that you had an airplane that could hold 21 people.

While work continues at the crash site...

All right, let's go.

Lorinda Ward and her team look for clues nearby.

We had the folks go shoulder to shoulder

on the runway that the accident crew took off on

to pick up anything that they saw on the runway.

To see if it had any relevance to the accident investigation.

Runways must be clear of all debris.

The smallest object can become a deadly projectile

if it strikes a plane on takeoff.

Three years earlier, a Concorde jet

ran over a 40 centimeter strip of scrap metal on a Paris runway.

The plane's fuel tank was pierced and caught fire.

The aircraft rose to 200 meters before it crashed into a nearby hotel.

One hundred and nine people on board

and four people on the ground were killed.

At Charlotte Douglas International, investigators scour the area.

They find a fuel cap lying dangerously close to the runway.

What do we got?

It could be sucked in and it could damage an engine.

But the main part would be the damage that it could do to an engine.

The discovery raises an interesting possibility.

As Flight 5481 raced down the runway at takeoff,

the fuel cap bounced up off the tarmac,

struck the engine rotors...

Oh!

...and brought Captain Leslie's aircraft crashing to earth.

This was to be brought back to see if it had any relevance to the accident investigation.

Uh, whether it came off the airplane itself,

or if it could have done some type of damage to the airplane.

A closer examination leads Ward and her team to conclude

that the fuel cap could not have interfered with the propellers.

Investigators discover no other relevant debris on the runway.

The runway debris theory is ruled out.

Now, NTSB Air Traffic Control Investigator Bill English explores another scenario.

When we first heard about the accident, it looked like there might be

the possibility, uh, that we'd want to look at a wake-turbulence encounter.

The wings of a fast moving jet disturb the air around them,

creating a trail of violently swirling air.

NASA tests decades earlier had illustrated the power and danger

of wake turbulence to other planes.

We had to see... did another airplane depart before it.

That's where wake-turbulence hazard would come from.

And we wanted to look at what kind of airplane departed ahead of it.

Uh, larger, heavier airplanes

are the more risky wake turbulence, uh, creating airplanes,

Bill English examines radar records from the time of the accident.

He learns that a much heavier Bombardier regional jet,

a CRJ, took off moments before the Beech.

That CRJ sure is a good looking plane, isn't it?

Yeah. I wish I was flying it.

The wake turbulence is generated from the wing tips of any airplane

as soon as it starts to lift off the ground.

It makes what people sometimes call horizontal tornadoes.

Vortexes of air that can create hazardous turbulence.

Runway 18 right.

Taxi into position...

Air traffic controllers do have standard procedures

for spacing out airplanes

so that they have a chance to avoid the wake turbulence

or let the wake dissipate.

One year earlier, an American Airlines jet

taking off from New York encountered wake turbulence.

The plane crashed into a residential neighborhood.

Two hundred and sixty people on the plane

and five people on the ground were killed.

They're gonna blast us with his jet blast.

Air Midwest 5481 cleared for takeoff.

Oh!

Air Traffic Investigator Bill English

must now determine if wake turbulence from the CRJ

caused Flight 5481 to crash.

Bill English studies the flight path of Captain Leslie's plane

and finds it consistent with a plane flying into wake turbulence.

A pitch up is not unheard of in a wake-turbulence encounter

where the... the airplane will suddenly go nose up

and the crew has trouble to, uh...

Uh, to counter that and get the nose back where it belongs.

English needs to know how close the Air Midwest flight got to the larger jet.

The Charlotte Tower has a sophisticated computer system

that tracks the movement of planes while they're still on the ground.

The system gave Bill English his answer.

That system had a very rapid update

so we could see exactly where on the runway

and at what time the regional jet lifted off,

compared to when the accident airplane started its roll.

When Bill English plots the precise position

of the planes at liftoff, he makes a telling discovery.

Even though both planes used the same runway, their paths never crossed.

The RJ started lifting off much farther down the runway

than the accident airplane did.

And the climb-out angle of the regional jet

and the climb-out angle of the accident airplane

never intersected.

The angle of the accident airplane was very steep.

It really had no possibility of, uh, intersecting

the wake turbulence from the regional jet.

So, if our airplane lifted off

and climbed above the angle of the previous airplane

we knew then that it... it couldn't possibly be a factor.

The wake vortex theory is ruled out, and Bill English's work is done.

Now it's up to Ward and her crew to find clues

in the burnt out wreckage of the plane.

Within two days, her investigation will reveal

a string of errors and faulty assumptions

that has been putting tens of thousands of passengers at risk for years.

Within hours of the crash, investigators find

the cockpit voice recorder and flight data recorder from Air Midwest Flight 5481.

The recorders are designed to withstand temperatures of up to 1,100 degrees Celsius.

In this crash, parts of the voice recorder had actually melted.

The devices are photographed and sent for analysis.

Then, amongst the tons of debris on the ground,

investigators discover the shredded remains of the elevator control cables.

Vital to flight control,

these cables link the pilot's control columns to the flight elevator.

An aerodynamic panel that helps pilots climb and descend.

Turnbuckles keep the cables taut.

To climb, pilots pull on the column.

The cables pull the elevator up, forcing the nose to rise.

To descend, pilots push on the control column.

The cables tilt the elevator down and the nose falls.

But as investigators examine the burnt out cables and turnbuckles

on Captain Leslie's plane, already something looks wrong.

They looked unusual.

They weren't in, like, the normal position that you would find them.

In this case, we had one adjusted all the way out,

and then one adjusted all the way in.

Um, so those were set aside for us to look at later.

While the lab work continues,

NTSB Investigator Stephen Carbone travels to Huntington, Virginia.

He interviews mechanics who worked on the plane the day before the crash.

It's all there.

At the time, we had known that

it had just come out of an... of a detailed check,

which is a... a routine check.

And knowing that, we were looking into the possibility

that something had been done during the check that needed to be looked at

from an investigation point of view.

The cables needed servicing.

My guy wrote up a service order and I put him on it.

Don't forget the manual.

Got it.

Every 1,200 flight hours,

Air Midwest planes go in for routine maintenance work.

This includes adjusting the cables that control the plane's elevator.

In the process of doing this check,

he found that... The mechanic had found

that the cables were out of limits,

so he had written up that he was going to check the cable tensions

and then adjust them as per the manual.

Everything's all right?

The mechanics tell Carbone that the work was checked

and stamped for quality assurance.

They believe that the aircraft was properly rigged as per the manual.

At first glance, that belief appears to be right.

After maintenance, this Beech aircraft took off

and landed nine times without incident

before Captain Leslie took the helm.

Investigators turn to the flight data recorder

to learn what happened on those flights.

The flight data recorder stores data from numerous flights,

both before and after the plane's cables were adjusted.

No one on any of those flights

had encountered any problems with the plane's elevator.

So, at the time, we didn't know how that affected the airplane

because it had flown nine times successfully

before the accident flight.

Ward also discovers that the crew tested their elevator controls

before Flight 5481 took off.

Flight controls free and correct.

Air Midwest 5481.

Ward and her team dig deeper, looking to discover

if the unusual configuration of the elevator cables

could have played a role in this crash.

What they find strikes at the very heart of what went wrong.

Normally, both turnbuckles are almost exactly the same length.

But on Captain Leslie's plane,

one turnbuckle is noticeably longer than the other.

To establish the correct cable tension,

mechanics tighten the turnbuckles,

but too much tightening of a turnbuckle shortens the cables

and cuts the range of motion of the elevator control.

The elevator should be able to tilt to a nose down position of 14 degrees.

But their downward range has actually been cut in half to only seven degrees.

The result is deadly.

As the flight got underway, the nose pitched up as expected during takeoff.

What?

Push the nose down. Oh, my God!

But the reduced range in the elevator

made it impossible for the pilots to bring the nose down again.

Due to the adjustment that had been done

in the maintenance a few nights earlier,

there was nothing that the crew could have done at that time.

Unable to bring the nose down,

the pitch of the wings became too pronounced.

With no air flowing over the top of the wings, the plane lost its lift

and began falling from the sky.

The pilots' struggle with the elevator

helps explain why Flight 5481 crashed that day.

Somehow, the elevator cables were improperly adjusted.

The pilots simply could not control the pitch of their airplane.

Stephen Carbone wants to know how mechanics had made such a critical mistake.

Yeah, I see that here.

He goes back to the hangar

to question the mechanics on duty that night.

And this time they tell him a different story.

Most of the guys were just learning the ropes.

The mechanics working on the airline

were subcontractors to the contract company.

And the mechanics working on the aircraft that night

had limited experience on the Beech 1900D.

And the person performing the rig

was receiving training that night on that specific task.

Once you have the rig pin set, adjust the turnbuckle barrels for more tension in the cable.

Yeah, I see that here.

Adjusting the elevator cables is not a simple process.

It's a time consuming procedure that involves 25 different steps.

Got it.

Uh, well, what about the other steps?

Yeah. Uh, don't worry about those.

Just check the cable tension when you're done and we're good, that's it.

The quality assurance inspector

and the mechanic took it upon themselves

to decide which steps to perform because they felt that

the steps they were performing were the only ones necessary to get the task done.

The mechanic skipped nine steps that night,

one of those involved manipulating the elevator

through its full range of motion.

Had the mechanic tried to do that,

he would have noticed that the elevator's motion

was restricted by cables that had been improperly rigged.

If they had followed the steps as described in the manual,

they would have found the problems that had come up.

But there was an inspector supervising the work.

Carbone discovers that the inspector was actually the person

teaching the mechanics how to do the work.

The problem was that the quality assurance inspector

was actually acting as an instructor.

So, he was taking the mechanic

through the process of the job task

and teaching him how to do the rig.

Well, when you put yourself in that position,

you're actually doing the task because even as an...

as... as a teacher, you're performing the task.

And then he came in behind himself

and then signed off as an inspector what he had done.

When I found out that, uh, that this mechanic

had skipped procedures, uh, I was upset.

Uh... The procedures that... that affected our lives,

that affected the lives of 21 people,

21 families were... were destroyed.

You never get over something like this.

The Shepherds sue the airline.

They also demand something unheard of in US aviation, an apology.

They wanted more than just to achieve a just settlement in monetary terms.

They had a need to press the issues

that humanize and put a face

on the people who are the victims of these tragedies.

The Shepherds believe that their best chance of getting an apology

is by putting a face to Christiana's name.

So, we decided to take this picture and to send it to those people

that were involved in the... in the... in the accident and the investigation

so that... so that Christiana would... would not be just a number.

Or a seat number. Or a ticket number. Or a settlement amount.

So that they could actually see that she was a person.

The legal journey began when we determined

that we wanted the apology, that we wanted someone to say "We really blew this."

We assumed the airline would apologize.

We had no idea that airlines don't apologize.

They did something wrong.

Obviously, you should stand up and say,

"We are so sorry that we messed up in this, and we're fixing this."

In this case, the mechanics thought

they were doing something that was perfectly reasonable.

They thought this was, uh, you know, another day at the job.

And then they come to find out that now 21 people have been,

you know, killed due to their inadvertent act.

For Lorinda Ward and her team,

it looks like they've found the problem.

But something still doesn't add up.

Why didn't the problem with the plane's faulty rigging

surface on any of its previous flights?

We kept scratching our head, wondering,

okay, this airplane flew nine times previously, and we had no problems.

So, we're trying to decide, well, what was unusual about this flight.

Ward has to figure out what happened in the hours and minutes before the crash.

And did you notice anything unusual before takeoff?

Well, it was sitting low when it taxied out.

It looked heavy.

We had a couple of witnesses that were implying that

we had a very heavily loaded airplane.

The baggage people said that it was hard to shut the door

'cause they thought bags were gonna come out.

Each plane has a maximum weight it can handle

before the engines can't get it off the ground.

Before takeoff, it's the pilot's job to calculate the onboard weight.

We got a full house back there?

How many we got to take off?

We're figuring it out.

The crew of Flight 5481 did perform that calculation.

Cool. Seventeen thousand and eighteen.

We hear them on the CVR going through the numbers

to make sure that they'd have their center of gravity

within the range for them to take off.

Seventeen thousand one hundred twenty is our weight, huh?

Yeah, as our max.

On any plane, large or small,

the weight of cargo and passengers has to be distributed evenly.

The balancing point of an airplane is called its center of gravity.

For a plane to fly safely,

it can neither be too far forward nor too far back or aft.

So, we're cool.

So, yeah.

We don't think we're gonna have to take anything off.

Air Midwest pilots are instructed

how to make weight and center of gravity, or CG calculations.

They use average weights to make that calculation.

One hundred and seventy five pounds per passenger and 20 pounds per bag.

They knew that they had a very aft CG.

But due to using the average weights

and average calculations, the paperwork showed them

being within the range that they needed to take off.

But Ward needs to know if the plane really was

within the proper range of weight and balance to take off.

What we did was we looked at the weight

of the actual baggage itself that was on board,

and then the weight of the passengers and the crew.

Technicians weigh the remains of the burnt luggage from the wreckage site.

Doctor? Yes. Could you tell me, please,

what the last recorded weight of your patient was, please?

And obtain the real weight of passengers on board that day.

Two hundred and twelve. Thank you.

When all the numbers are in,

Ward discovers the real weight of Flight 5481 is 17,700 pounds.

Some 580 pounds over its maximum takeoff weight.

They would not have been able to take off if they had used actual weights.

They would have had to pull either passengers or bags off.

Because of the higher than expected weight

of the passengers and baggage on the flight

and the large number of bags stowed in the rear,

the airplane was tail heavy.

Its center of gravity ever so slightly too far to the rear,

which wasn't a problem until the landing gear was raised.

Gear up.

When the gears weight moved backwards from the nose,

it tipped the balance of weight...

What? ...too far back.

The pilots' efforts to regain control of the aircraft were futile,

crippled by the airplane's defective elevator controls.

When the nose gear moved aft, they lost the ability

to control the aircraft because all the weight went back

and they had no elevator movement enough to bring the nose back down.

And at the height that they were at, they had no recovery.

The passengers and crew of Flight 5481

were doomed the moment the plane left the ground.

They had no way of knowing that two unrelated problems

would combine to bring down their plane.

This was just a normal routine flight for them.

And they did all the pre-flight checks,

they did their weight and balance,

they did the correct calls, they were on the right runway.

They... It was just another day at the job

and they didn't know that they had

these two hidden latent failures that were waiting for them.

But faulty maintenance and above average weights

weren't the only issues uncovered by Lorinda Ward's investigation.

Hey, you got a sec? I have an idea.

Lorinda Ward suspects she's uncovered problems

that didn't just affect this one flight,

but that also affected every commuter plane in the air.

NTSB investigators say that every plane crash makes flying safer.

Flight 5481 was no exception.

Fourteen months after the accident, lead investigator Lorinda Ward

and her team file a comprehensive report

to ensure the mistakes that killed those aboard Flight 5481 are never repeated.

Among Ward's recommendations that the FAA review

its average passenger and baggage weights,

an average that had not been revised since 1936.

And since studies suggest that Americans and other adults

were getting heavier from year to year,

Ward suspected that the averages were off.

We made a recommendation to the FAA to have the operators go out

and survey their operations both summer and winter time

to see how accurate these average weights reflected the actual flying public

that was getting onto their airplanes.

After conducting a survey of passengers, the FAA comes to a shocking conclusion.

The average weight of adult American passengers was 195 pounds, not 175.

The FAA also discovered that the average weight of carry-on luggage

was being underestimated by 5 pounds per bag.

We had a average weight that were being used that needed to be updated.

Had these higher average weights been in effect

on January 8th 2003, Flight 5481 would not have been legal for takeoff.

Captain Leslie would have had to remove bags and passengers.

48107. Cool. 17018.

Air Midwest pilots now use an average weight of 200 pounds per passenger,

which means that their Beechcraft planes

can only carry 17 passengers, not 19.

But Ward's report goes on to say that even

with updated industry averages, there's still room for error.

Her report states that flying small aircraft

will be safest only when airlines

stop using average weight assumptions altogether

and calculate the real weight on board before takeoff.

New technologies are being developed to allow air carriers

to measure actual weight and control balance in real time as the plane is loaded.

Knowing the actual weight of passengers and baggage is vital.

More and more people are flying on small commuter jets.

As the cost of jet fuel soars, the smaller, fuel efficient planes

become more attractive to airlines.

In the United States alone, more than 10 million people a year

board planes with fewer than 30 seats.

Smaller aircraft are more sensitive to the weight,

weight and balance issue, than say a larger airplane.

In spite of Ward's recommendations and the available technology,

almost 70% of small planes on scheduled flights

still use average instead of actual weights.

For Doug and Tereasa Shepherd, there is still another danger

that threatens to strike again.

If the FAA took a very active role in their regulation,

then subcontracting could actually be a plus. The way it's handled today,

the mistakes will just continue.

Uh, what about the other steps?

Yeah. Uh, don't worry about those.

Just check the cable tension when you're done and we're good.

In her report, Ward states that all air carriers

need to provide direct oversight

to make sure that even subcontracted work is completed correctly.

This investigation was unique to me personally

because it was my first launch as an investigator in charge.

This was, in my mind, a significant investigation

in the fact that we had the 22 safety recommendations

that came out from a small accident investigation.

For the Shepherds,

the NTSB recommendations come too late.

But after a lengthy legal battle, Air Midwest does deliver

a rare and formal apology for the mistakes that cost

18-year-old Christiana Shepherd her life.

My name is Ron Goldman and, um, my role here today

is that I will be introducing the public apology and then I'll have a few words...

The public apology is in aviation cases unprecedented.

We are here today

to remember the victims

of Flight 5481, and to offer our apologies,

our condolences and sincere sympathy

to the surviving family members, of the passengers and crew who perished

in the January 8th 2003 crash of Air Midwest flight number 5481.

The acceptance of accountability suggests that the recommendations

made by the safety investigators

are not to be taken as a book to throw in a drawer and forget about

but are to be taken seriously because if you don't take them seriously,

there's going to be public accountability as well as private accountability.

What people should never forget

is that as we're going about and doing our job day to day,

we need to remember the importance of doing our job.

Doesn't matter where we're at on the ladder, or the corporate ladder,

whether we're at the bottom rung or the top rung, we have responsibilities.

It took a complicated string of errors and miscalculations

to bring down Flight 5481.

But some believe there was one person

who performed admirably that day.

Captain Katie Leslie. With an unbalanced plane

and faulty controls, Captain Leslie could not have saved the flight.

But her final actions may have saved some lives.

You know, she's an unsung hero to me

because I don't think many people know about what she did

and how she was fighting it and trying to pull the plane away from the hangar

and she actually did.

She kept it from really more of a head-on hit into the hangar.

Which probably saved countless other people

from perishing that day.

It was firefighter Cindy Overcash

who found the body of captain Katie Leslie among the wreckage.

To this day, Overcash still feels a special connection

to the young pilot.

I don't know. I just felt a kinship.

I don't know why. I don't know.

You know, it could be as simple as I found her,

and I was there when she left this world.

I don't know, but I thought about her a lot.

Lorinda Ward's investigation could have ended

when she uncovered the errors that caused the crash of Flight 5481.

By digging a bit deeper, she made flying safer for millions of people.