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Morning rush hour,
Charlotte, North Carolina.
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00:00:05,241 --> 00:00:08,000
Its busy airport is rocked
by a massive explosion.
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00:00:10,103 --> 00:00:12,965
The flames were coming
over the fence.
Just total craziness.
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00:00:13,068 --> 00:00:16,068
Everyone was just
running for their lives.
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Firefighters rushed
to one of the airport's
main hangars.
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They confront an inferno.
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It was quite a while
before we realized
a plane had hit the hangar.
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00:00:29,000 --> 00:00:32,655
A packed commuter
flight has plunged to the ground
shortly after takeoff.
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00:00:33,620 --> 00:00:34,965
Everyone on board is killed.
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We kept scratching our head,
wondering, okay, this airplane
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flew nine times previously
and we had no problems.
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Investigators uncover
a string of errors.
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Bill, I have an idea.
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And learn that
passengers on small planes
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have actually been in danger
for years.
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Mayday! Mayday! Mayday!
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It's morning
on January the 8th, 2003,
in Charlotte, North Carolina.
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A city of half a million wakes.
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At Charlotte Douglas
International Airport,
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commercial airline pilot
Captain Katie Leslie
is at work early.
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Only 25 years old,
this Texas native
has been flying
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for Air Midwest
for almost three years.
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One of the youngest
flight captains at her airline.
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Hey, Tom. Have a great flight.
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She's a top-rated pilot,
building her career
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at one of the fastest
growing airports
in the United States.
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This airport is an important
domestic hub for US Airways,
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with flights to most
major cities
in the eastern United States.
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Air Midwest runs
a commuter service
as US Airways Express.
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It operates a fleet
of Beechcraft 1900D planes,
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a 19 passenger short-haul
commuter plane
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and a trusted workhorse
in the industry.
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Today, Captain Leslie
is in command of a 1900D
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on a 30-minute hop to
Greenville-Spartanburg Airport
in Greer, North Carolina.
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Her co-pilot is 27-year-old
Jonathan Gibbs.
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How did you sleep last night?
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Had a dream I was in Miami.
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Attention, ladies and gentlemen,
this is the final boarding call
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for Air Midwest Flight 5481
to Greenville-Spartanburg.
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All passengers wishing to board
should make their way...
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Among the passengers
flying to Greer this morning,
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18-year-old Christiana Shepherd.
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Christiana's parents,
Doug and Tereasa,
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are Baptist missionaries working
in the Portuguese Azores.
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Christiana left
the seventh of January
from the Azores,
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spent the night in the airport
in Boston.
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And then flew the next morning
on the early flight from Boston
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to Charlotte to Greenville.
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So, she was on her way
back to college.
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Christiana was very special
and she was one
that would come up
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and give you a hug and say...
You know, she'd come
for no reason.
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She would give you a hug
and say, "Dad, I love you."
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At 8:00 in the morning,
Christiana boards her flight.
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Meanwhile,
as part of their standard
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checklist before takeoff,
the crew calculates
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the weight of all the baggage,
passengers and fuel
on the plane.
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That's to make sure
the plane isn't overweight
and the weight is spread evenly.
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It's a calculation that's made
on all commercial aircraft.
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So, we got a full house
back there?
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You can count 19 people
in the back.
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- I don't know the bags yet.
- Okay.
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But baggage handlers
raise concerns
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that the luggage they're loading
may be too heavy.
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Damn. Captain,
how many we got to take off?
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We're figuring it out.
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We don't think we're gonna
have to take anything off.
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Cool. Seventeen thousand
eighteen.
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Seventeen thousand
one hundred and twenty
is our weight, huh?
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Yeah, as our max.
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So, we're cool.
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So, yeah.
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Good morning. Welcome aboard
US Airways Express Service
to Greenville-Spartanburg.
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It's a very short flight,
maybe 30 minutes gate to gate.
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So, sit back, relax,
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and we'll have you there
in a few minutes.
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Before takeoff,
the crew checks
the flight controls,
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including the rudder
and elevator,
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00:06:01,034 --> 00:06:03,034
which help control
the direction of the plane.
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Flight controls
free and correct.
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Air Midwest 5481,
Runway 18 right.
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Taxi into position and hold.
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Captain Leslie
is moments from takeoff.
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On the runway, ahead of them
is a Bombardier CRJ
ready for departure.
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That CRJ sure is
a good looking plane, isn't it?
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Yeah. I wish I was flying it.
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With powerful turbulence
released from the CRJ,
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Captain Leslie
must keep a safe distance.
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They're gonna blast us
with his jet blast.
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Air Midwest 5481.
Turn right, heading 230.
Cleared for takeoff.
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00:06:59,793 --> 00:07:01,172
Set takeoff power, please.
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00:07:06,068 --> 00:07:06,931
Power is set.
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00:07:10,413 --> 00:07:12,241
Eighty knots. Cross-check.
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00:07:14,689 --> 00:07:19,068
At 80 knots,
pilots check that key
instruments are working.
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00:07:19,172 --> 00:07:22,827
With no signs of trouble,
Leslie and Gibbs
proceed with their take off.
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To air traffic control,
Flight 5481's takeoff roll
is perfectly normal.
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Gear up.
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What?
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Oh!
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But without warning,
the plane's nose
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pitches dramatically upward
from seven
to a staggering 54 degrees.
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Help me.
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- You got it?
- I'm trying.
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The crew struggles
to get the nose back down again.
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Airflow over the top
of the wings creates lift,
but if the nose keeps rising,
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00:08:00,586 --> 00:08:03,413
air won't flow smoothly
over the plane's wings.
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The plane will lose its lift,
stall, and plunge from the sky.
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Push the nose down.
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Oh, my God. We have an emergency
on Air Midwest 5481.
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00:08:14,827 --> 00:08:17,172
Alert 3.
Standby Runway 18 right.
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The controller
handling Flight 5481
calls for emergency equipment.
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00:08:21,931 --> 00:08:23,137
Oh, my God.
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The plane is now
350 meters from the ground.
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It stalls, rolls to the left
and begins falling from the sky.
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Captain Leslie
pulls on her control column
with all her might.
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00:08:37,000 --> 00:08:40,655
If she can't get
the plane to climb,
she's going to hit the ground.
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Air traffic controllers watch
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as a 19-passenger plane
plunges towards the earth.
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Captain Katie Leslie
struggles desperately
to get her plane to climb,
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00:09:01,793 --> 00:09:03,758
but it won't respond.
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The plane heads towards
a packed US Airways hangar.
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00:09:13,103 --> 00:09:16,000
The flight was loaded
with almost 1,000 kg
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00:09:16,103 --> 00:09:18,758
of highly flammable jet fuel
just before takeoff.
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The impact instantly
ignites all that fuel.
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Now the intense fire
threatens to engulf the hangar.
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There are several airplanes
and hundreds of people
working inside.
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Fire station.
Emergency.
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- A plane just crashed.
- There's a plane
that's crashed.
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Yes. At the US Airways
entry.
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Right at the corner
of the building,
there's a fire.
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00:09:42,586 --> 00:09:47,862
We got a Code 10,
aircraft crash at the south end
of runway 36 left.
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00:09:47,965 --> 00:09:51,068
I repeat, a confirmed
aircraft crash, on fire.
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00:09:51,172 --> 00:09:53,758
Thirty-eight-year-old
Fire Chief Keith Rogers
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00:09:53,862 --> 00:09:56,689
is driving to work
when he gets a Code 10 call.
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00:09:56,793 --> 00:09:58,724
A Code 10 means that
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00:09:58,827 --> 00:10:01,482
there is a confirmed
plane crash.
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00:10:01,586 --> 00:10:06,034
But usually this type of call
is a once in a career
type of incident.
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00:10:09,758 --> 00:10:13,413
Cindy Overcash
is a firefighter with
the Charlotte Fire Department.
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00:10:14,862 --> 00:10:16,379
You couldn't actually
see the hangar from here,
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but you just saw a huge
black plume of smoke.
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And we knew, you know,
something really bad is here.
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In the adjacent building,
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00:10:29,482 --> 00:10:33,310
Sales Director David Isola
hears the explosion.
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00:10:33,413 --> 00:10:37,517
I was sitting at my desk
and I heard this, uh...
This loud boom.
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00:10:37,620 --> 00:10:40,551
And, uh, one of the guys
came in from next door
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and said that, uh,
he just saw an airplane crash.
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And, uh, so I hopped in my truck
and drove down to the site.
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From 60 meters away,
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Isola records
the opening moments
of the tragedy.
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00:11:01,103 --> 00:11:05,379
There was a lot of smoke
and, uh, it was just...
Just like hell.
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00:11:05,482 --> 00:11:06,344
Looked just like hell.
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00:11:07,758 --> 00:11:09,551
The flames were coming
over the fence.
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00:11:09,655 --> 00:11:10,793
Just total craziness.
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00:11:10,896 --> 00:11:12,344
Everyone was just
running for their lives.
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00:11:21,241 --> 00:11:23,793
When Chief Keith Rogers
arrives at the scene,
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00:11:23,896 --> 00:11:28,103
he finds himself
swimming upstream
against a mob in panic.
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00:11:28,206 --> 00:11:31,310
As I got onto
the airport property
and got onto the tarmac,
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00:11:31,413 --> 00:11:34,068
uh, the people
were exiting the hangar.
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00:11:34,172 --> 00:11:37,241
Those people were running out
in front of the fire trucks
and the fire cars.
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00:11:37,344 --> 00:11:41,310
So, we had to drive
with caution.
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They were getting
out of the building
as fast as they could
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00:11:44,275 --> 00:11:47,448
because I think
they definitely realized
that this was not a drill,
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00:11:47,551 --> 00:11:48,655
this was a real emergency.
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00:11:52,620 --> 00:11:56,413
And we still weren't sure
if we had a plane
inside the hangar
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00:11:56,517 --> 00:12:00,482
that had caught on fire
or if the hangar
had caught on fire.
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00:12:03,137 --> 00:12:07,517
It was quite a while
before we realized
a plane had hit the hangar.
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00:12:07,620 --> 00:12:11,137
Chief Rogers
immediately takes command
of the scene.
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00:12:11,241 --> 00:12:15,137
He knows that
there are aircraft parked
inside the flaming hangar.
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Their fuel tanks
threaten to blow.
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And our concern
was, one, about the people
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00:12:20,379 --> 00:12:25,103
that were on board the aircraft.
Two, for the people that were
working in the hangar.
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00:12:25,206 --> 00:12:28,862
And three, we had to worry
about the airplanes
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00:12:28,965 --> 00:12:31,793
that were in for repair,
were those aircraft on fire.
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So, we had a lot of
major issues to deal with.
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00:12:36,275 --> 00:12:40,758
Within minutes,
firefighters begin to get
the inferno under control.
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00:12:40,862 --> 00:12:45,344
The hope now is that
somewhere inside the wreck,
survivors are clinging to life.
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The main thing probably
was on anybody's mind
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00:12:55,482 --> 00:12:57,620
once we realized what we had
was survivors.
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00:13:03,275 --> 00:13:05,724
Chief Rogers sends
a line of firefighters,
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00:13:05,827 --> 00:13:09,000
led by Cindy Overcash
into the heart of the inferno.
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00:13:40,310 --> 00:13:42,482
Cindy Overcash
and two of her team
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00:13:42,586 --> 00:13:44,551
make their way
into the wreckage,
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00:13:44,655 --> 00:13:47,068
carefully putting out
spot fires along the way.
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00:13:50,137 --> 00:13:51,517
As we walk up on
the scene of the fire,
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00:13:51,620 --> 00:13:54,379
and we see the...
What we think
are crash-test dummies,
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00:13:54,482 --> 00:13:57,620
we thought a plane
had blown up inside
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00:13:57,724 --> 00:13:59,965
and blew their
training dummies out.
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00:14:07,482 --> 00:14:08,551
And then it dawned on me.
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00:14:10,931 --> 00:14:12,862
Uh-uh. That's not
a training dummy.
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00:14:20,103 --> 00:14:22,517
It took them
a few minutes in determining
exactly what was happening.
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00:14:22,620 --> 00:14:26,000
And once they did that,
it was obvious that
there were no survivors.
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00:14:29,689 --> 00:14:31,448
It's a total loss.
192
00:14:31,551 --> 00:14:33,172
All 19 passengers,
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00:14:33,275 --> 00:14:37,655
as well as Captain Leslie
and First Officer Gibbs
are dead.
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00:14:37,758 --> 00:14:43,034
At about 8:53 this morning,
uh, we had an aircraft accident.
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00:14:43,137 --> 00:14:45,655
It had 19 passengers
and two crew.
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00:14:46,551 --> 00:14:47,689
There are no survivors.
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00:14:50,827 --> 00:14:52,241
And we hope
that we never have to respond
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00:14:52,344 --> 00:14:54,137
to a situation
with such a large loss of life.
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00:14:54,241 --> 00:14:55,103
But that is our job.
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00:14:56,275 --> 00:14:59,793
This is some of the most
difficult duty and tasks
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00:14:59,896 --> 00:15:01,655
that a firefighter
will ever do in their career.
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00:15:04,724 --> 00:15:08,758
For medics
and rescue workers,
the ordeal is over.
203
00:15:08,862 --> 00:15:12,724
But for friends
and family of the victims,
the anguish has just begun.
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00:15:14,724 --> 00:15:17,310
I was walking
through the living room,
205
00:15:17,413 --> 00:15:20,724
and I stopped and said...
My heart's beating right now
206
00:15:20,827 --> 00:15:22,965
just the way it was then.
207
00:15:23,068 --> 00:15:26,241
I said, "Has Cristiana
called yet?" She said no.
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00:15:27,724 --> 00:15:29,068
Okay. And I knew then
what had happened.
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00:15:30,241 --> 00:15:32,103
I just... I knew.
210
00:15:32,206 --> 00:15:34,724
So, I went and got the telephone
and called the school.
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00:15:34,827 --> 00:15:37,620
He said, "Yes, Mrs. Shepherd,
we have some sad news."
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00:15:37,724 --> 00:15:39,689
And he told me that
the plane crashed on takeoff.
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00:15:40,931 --> 00:15:42,413
I asked if there were
any survivors.
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00:15:42,517 --> 00:15:43,344
He said no.
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00:15:44,827 --> 00:15:48,172
So then I knew
I had to go tell Doug,
and he was in the garage.
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00:15:48,275 --> 00:15:50,482
Yeah, it's something you...
You never forget about.
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00:15:51,655 --> 00:15:53,793
Uh, I was changing
a fluorescent bulb,
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00:15:53,896 --> 00:15:57,034
and, uh, Tereasa came
to the... to the doorway.
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00:15:58,586 --> 00:16:00,862
How do you say that?
What word...
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00:16:00,965 --> 00:16:03,517
You use words every single day.
221
00:16:03,620 --> 00:16:05,103
How can you use words...
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00:16:09,172 --> 00:16:10,620
...to ruin
someone's life.
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00:16:19,344 --> 00:16:22,689
But I told him. I said, "Doug,
Christiana's plane crashed."
224
00:16:28,655 --> 00:16:33,310
At that moment, uh, my...
my world fell apart.
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00:16:37,310 --> 00:16:40,827
Now, the Shepherds
and the families
of the other 20 victims
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00:16:40,931 --> 00:16:43,448
want to know what caused
the deaths of their loved ones.
227
00:16:50,172 --> 00:16:51,689
It's been
almost five hours
228
00:16:51,793 --> 00:16:54,482
since Flight 5481
crashed into a hangar
229
00:16:54,586 --> 00:16:56,172
in Charlotte, North Carolina.
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00:16:57,413 --> 00:16:59,413
With no survivors to rescue,
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00:16:59,517 --> 00:17:03,310
neither bodies
nor airplane parts
are moved from where they fell
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00:17:03,413 --> 00:17:05,103
until the arrival
of investigators
233
00:17:05,206 --> 00:17:07,310
from the National Transportation
Safety Board.
234
00:17:13,655 --> 00:17:17,655
While medical examiners
mark the location
of human remains in red,
235
00:17:17,758 --> 00:17:21,689
NTSB investigators mark
scraps of metal in yellow,
236
00:17:21,793 --> 00:17:23,655
looking for clues
to help them figure out
237
00:17:23,758 --> 00:17:26,103
what happened aboard
Flight 5481.
238
00:17:29,379 --> 00:17:34,689
Among those
assigned to this case,
lead investigator Lorinda Ward.
239
00:17:34,793 --> 00:17:38,034
This is her first assignment
as the lead investigator
of a crash.
240
00:17:42,137 --> 00:17:44,965
But today,
she's not feeling her best.
241
00:17:45,068 --> 00:17:47,896
That day, I was a little bit
under the weather.
242
00:17:48,000 --> 00:17:49,965
I was fighting off a cold.
243
00:17:50,068 --> 00:17:53,551
You have the adrenaline
that shoots through your body
at the time.
244
00:17:53,655 --> 00:17:57,034
And so, that actually
makes up for when
you're not feeling well.
245
00:17:57,137 --> 00:18:00,724
And I knew that
the other people on my team
were experienced,
246
00:18:00,827 --> 00:18:03,620
so I felt comfortable
going to Charlotte.
247
00:18:03,724 --> 00:18:05,206
At Charlotte Douglas Airport,
248
00:18:05,310 --> 00:18:09,413
Ward takes the first steps
towards solving this accident.
249
00:18:09,517 --> 00:18:11,517
I checked in
with the fire department
250
00:18:11,620 --> 00:18:15,034
to make sure that the fires
had been put out.
251
00:18:15,137 --> 00:18:18,310
And then called a meeting
with all the first responders
252
00:18:18,413 --> 00:18:22,000
to see what they had noticed
when they came
to the crash site.
253
00:18:25,000 --> 00:18:26,310
Ward acts fast.
254
00:18:29,172 --> 00:18:31,655
Because there are bodies
entangled with the wreckage,
255
00:18:31,758 --> 00:18:35,655
she declares the crash site
a potential biohazard.
256
00:18:35,758 --> 00:18:38,448
Investigators who might come
in contact with the wreckage
257
00:18:38,551 --> 00:18:41,482
must wear protective suits
while they examine the wreck
258
00:18:41,586 --> 00:18:43,551
and identify
the victims' remains.
259
00:18:44,620 --> 00:18:46,275
When we arrived on scene,
260
00:18:46,379 --> 00:18:50,137
the accident site did not look
like an airplane was there.
261
00:18:50,241 --> 00:18:53,241
Uh, due to the fire,
the post-crash fire,
262
00:18:53,344 --> 00:18:55,586
um, when you initially
walked up to it,
263
00:18:55,689 --> 00:18:59,931
it was hard to identify
that you had an airplane
that could hold 21 people.
264
00:19:04,241 --> 00:19:06,275
While work continues
at the crash site...
265
00:19:07,379 --> 00:19:09,103
All right, let's go.
266
00:19:09,206 --> 00:19:11,896
Lorinda Ward and her team
look for clues nearby.
267
00:19:16,758 --> 00:19:19,586
We had the folks
go shoulder to shoulder
268
00:19:19,689 --> 00:19:22,655
on the runway that
the accident crew took off on
269
00:19:22,758 --> 00:19:26,379
to pick up anything that
they saw on the runway.
270
00:19:26,482 --> 00:19:29,137
To see if it had any relevance
to the accident investigation.
271
00:19:31,310 --> 00:19:34,206
Runways must be clear
of all debris.
272
00:19:34,310 --> 00:19:37,241
The smallest object
can become a deadly projectile
273
00:19:37,344 --> 00:19:39,034
if it strikes a plane
on takeoff.
274
00:19:43,103 --> 00:19:45,310
Three years earlier,
a Concorde jet
275
00:19:45,413 --> 00:19:49,103
ran over a 40 centimeter
strip of scrap metal
on a Paris runway.
276
00:19:50,793 --> 00:19:54,551
The plane's fuel tank
was pierced and caught fire.
277
00:19:54,655 --> 00:19:58,896
The aircraft rose to 200 meters
before it crashed
into a nearby hotel.
278
00:20:02,620 --> 00:20:04,413
One hundred
and nine people on board
279
00:20:04,517 --> 00:20:06,379
and four people on the ground
were killed.
280
00:20:08,965 --> 00:20:12,517
At Charlotte
Douglas International,
investigators scour the area.
281
00:20:14,000 --> 00:20:17,586
They find a fuel cap
lying dangerously close
to the runway.
282
00:20:17,689 --> 00:20:18,586
What do we got?
283
00:20:21,034 --> 00:20:24,448
It could be sucked in
and it could damage an engine.
284
00:20:24,551 --> 00:20:26,931
But the main part
would be the damage
that it could do to an engine.
285
00:20:28,413 --> 00:20:31,655
The discovery raises
an interesting possibility.
286
00:20:31,758 --> 00:20:35,517
As Flight 5481 raced down
the runway at takeoff,
287
00:20:35,620 --> 00:20:37,931
the fuel cap
bounced up off the tarmac,
288
00:20:38,034 --> 00:20:39,551
struck the engine rotors...
289
00:20:40,241 --> 00:20:41,896
Oh!
290
00:20:42,000 --> 00:20:44,344
...and brought
Captain Leslie's aircraft
crashing to earth.
291
00:20:54,482 --> 00:20:59,482
This was to be brought back
to see if it had any relevance
to the accident investigation.
292
00:20:59,586 --> 00:21:01,931
Uh, whether it came off
the airplane itself,
293
00:21:02,034 --> 00:21:04,620
or if it could have done
some type of damage
to the airplane.
294
00:21:06,620 --> 00:21:09,724
A closer examination
leads Ward and her team
to conclude
295
00:21:09,827 --> 00:21:12,586
that the fuel cap could not have
interfered with the propellers.
296
00:21:14,793 --> 00:21:17,965
Investigators discover no other
relevant debris on the runway.
297
00:21:19,206 --> 00:21:21,413
The runway debris theory
is ruled out.
298
00:21:25,000 --> 00:21:32,034
Now, NTSB Air Traffic Control
Investigator Bill English
explores another scenario.
299
00:21:32,137 --> 00:21:34,551
When we first heard
about the accident,
it looked like there might be
300
00:21:34,655 --> 00:21:37,586
the possibility, uh,
that we'd want to look
at a wake-turbulence encounter.
301
00:21:41,758 --> 00:21:45,482
The wings
of a fast moving jet
disturb the air around them,
302
00:21:45,586 --> 00:21:49,482
creating a trail
of violently swirling air.
303
00:21:49,586 --> 00:21:53,379
NASA tests decades earlier
had illustrated
the power and danger
304
00:21:53,482 --> 00:21:55,758
of wake turbulence
to other planes.
305
00:21:55,862 --> 00:21:58,724
We had to see...
did another airplane
depart before it.
306
00:21:58,827 --> 00:22:01,275
That's where wake-turbulence
hazard would come from.
307
00:22:01,379 --> 00:22:04,068
And we wanted to look at
what kind of airplane
departed ahead of it.
308
00:22:04,172 --> 00:22:06,034
Uh, larger, heavier airplanes
309
00:22:06,137 --> 00:22:12,310
are the more risky
wake turbulence, uh,
creating airplanes,
310
00:22:12,413 --> 00:22:16,000
Bill English
examines radar records
from the time of the accident.
311
00:22:16,103 --> 00:22:19,137
He learns that a much heavier
Bombardier regional jet,
312
00:22:19,241 --> 00:22:22,551
a CRJ, took off
moments before the Beech.
313
00:22:22,655 --> 00:22:25,103
That CRJ sure is
a good looking plane, isn't it?
314
00:22:25,206 --> 00:22:27,448
Yeah. I wish I was flying it.
315
00:22:27,551 --> 00:22:30,482
The wake turbulence
is generated from the wing tips
of any airplane
316
00:22:30,586 --> 00:22:32,896
as soon as it starts
to lift off the ground.
317
00:22:33,000 --> 00:22:36,103
It makes what people sometimes
call horizontal tornadoes.
318
00:22:36,206 --> 00:22:40,655
Vortexes of air that can create
hazardous turbulence.
319
00:22:40,758 --> 00:22:42,655
Runway 18 right.
320
00:22:42,758 --> 00:22:44,034
Taxi into position...
321
00:22:44,137 --> 00:22:46,413
Air traffic controllers
do have standard procedures
322
00:22:46,517 --> 00:22:47,689
for spacing out airplanes
323
00:22:47,793 --> 00:22:50,344
so that they have a chance
to avoid the wake turbulence
324
00:22:50,448 --> 00:22:51,793
or let the wake dissipate.
325
00:22:57,931 --> 00:23:00,344
One year earlier,
an American Airlines jet
326
00:23:00,448 --> 00:23:03,896
taking off from New York
encountered wake turbulence.
327
00:23:04,000 --> 00:23:06,758
The plane crashed into
a residential neighborhood.
328
00:23:06,862 --> 00:23:08,896
Two hundred and sixty people
on the plane
329
00:23:09,000 --> 00:23:10,827
and five people on the ground
were killed.
330
00:23:14,620 --> 00:23:16,655
They're gonna blast us
with his jet blast.
331
00:23:19,758 --> 00:23:23,000
Air Midwest 5481
cleared for takeoff.
332
00:23:35,241 --> 00:23:36,448
Oh!
333
00:23:39,931 --> 00:23:41,724
Air Traffic
Investigator Bill English
334
00:23:41,827 --> 00:23:44,448
must now determine
if wake turbulence from the CRJ
335
00:23:44,551 --> 00:23:47,379
caused Flight 5481 to crash.
336
00:23:49,172 --> 00:23:52,551
Bill English studies
the flight path
of Captain Leslie's plane
337
00:23:52,655 --> 00:23:56,034
and finds it consistent
with a plane
flying into wake turbulence.
338
00:23:56,137 --> 00:23:59,206
A pitch up is not unheard of
in a wake-turbulence encounter
339
00:23:59,310 --> 00:24:02,310
where the... the airplane
will suddenly go nose up
340
00:24:02,413 --> 00:24:04,827
and the crew has trouble
to, uh...
341
00:24:04,931 --> 00:24:08,896
Uh, to counter that
and get the nose back
where it belongs.
342
00:24:09,000 --> 00:24:14,310
English needs to know
how close the Air Midwest
flight got to the larger jet.
343
00:24:14,413 --> 00:24:17,172
The Charlotte Tower
has a sophisticated
computer system
344
00:24:17,275 --> 00:24:20,172
that tracks the movement
of planes while they're still
on the ground.
345
00:24:21,413 --> 00:24:23,689
The system gave
Bill English his answer.
346
00:24:23,793 --> 00:24:26,206
That system had
a very rapid update
347
00:24:26,310 --> 00:24:29,965
so we could see exactly
where on the runway
348
00:24:30,068 --> 00:24:32,620
and at what time
the regional jet lifted off,
349
00:24:32,724 --> 00:24:36,758
compared to when
the accident airplane
started its roll.
350
00:24:36,862 --> 00:24:39,034
When Bill English
plots the precise position
351
00:24:39,137 --> 00:24:42,275
of the planes at liftoff,
he makes a telling discovery.
352
00:24:42,379 --> 00:24:46,241
Even though both planes
used the same runway,
their paths never crossed.
353
00:24:47,655 --> 00:24:50,448
The RJ started lifting off
much farther down the runway
354
00:24:50,551 --> 00:24:52,275
than the accident airplane did.
355
00:24:52,379 --> 00:24:55,689
And the climb-out angle
of the regional jet
356
00:24:57,034 --> 00:24:59,275
and the climb-out angle
of the accident airplane
357
00:25:00,448 --> 00:25:02,344
never intersected.
358
00:25:02,448 --> 00:25:04,655
The angle of the accident
airplane was very steep.
359
00:25:04,758 --> 00:25:07,379
It really had no possibility
of, uh, intersecting
360
00:25:07,482 --> 00:25:09,689
the wake turbulence
from the regional jet.
361
00:25:09,793 --> 00:25:12,965
So, if our airplane lifted off
362
00:25:13,068 --> 00:25:15,655
and climbed above the angle
of the previous airplane
363
00:25:15,758 --> 00:25:18,241
we knew then that it...
it couldn't possibly
be a factor.
364
00:25:20,620 --> 00:25:24,896
The wake vortex theory
is ruled out,
and Bill English's work is done.
365
00:25:27,241 --> 00:25:30,068
Now it's up to Ward
and her crew to find clues
366
00:25:30,172 --> 00:25:31,793
in the burnt out
wreckage of the plane.
367
00:25:33,241 --> 00:25:35,827
Within two days,
her investigation will reveal
368
00:25:35,931 --> 00:25:39,068
a string of errors
and faulty assumptions
369
00:25:39,172 --> 00:25:42,724
that has been putting
tens of thousands
of passengers at risk for years.
370
00:25:55,034 --> 00:25:57,620
Within hours of the crash,
investigators find
371
00:25:57,724 --> 00:26:03,344
the cockpit voice recorder
and flight data recorder
from Air Midwest Flight 5481.
372
00:26:07,586 --> 00:26:12,241
The recorders are designed
to withstand temperatures
of up to 1,100 degrees Celsius.
373
00:26:13,896 --> 00:26:17,000
In this crash,
parts of the voice recorder
had actually melted.
374
00:26:18,206 --> 00:26:20,758
The devices are photographed
and sent for analysis.
375
00:26:24,482 --> 00:26:27,241
Then, amongst the tons of debris
on the ground,
376
00:26:27,344 --> 00:26:31,551
investigators discover
the shredded remains
of the elevator control cables.
377
00:26:34,137 --> 00:26:35,655
Vital to flight control,
378
00:26:35,758 --> 00:26:39,586
these cables link
the pilot's control columns
to the flight elevator.
379
00:26:39,689 --> 00:26:43,551
An aerodynamic panel
that helps pilots
climb and descend.
380
00:26:45,241 --> 00:26:47,275
Turnbuckles keep the cables taut.
381
00:26:48,448 --> 00:26:51,206
To climb,
pilots pull on the column.
382
00:26:51,310 --> 00:26:54,758
The cables pull the elevator up,
forcing the nose to rise.
383
00:26:57,000 --> 00:27:00,034
To descend, pilots push
on the control column.
384
00:27:00,137 --> 00:27:03,448
The cables tilt
the elevator down
and the nose falls.
385
00:27:07,206 --> 00:27:10,448
But as investigators examine
the burnt out cables
and turnbuckles
386
00:27:10,551 --> 00:27:14,551
on Captain Leslie's plane,
already something looks wrong.
387
00:27:14,655 --> 00:27:16,413
They looked unusual.
388
00:27:16,517 --> 00:27:19,931
They weren't in, like,
the normal position
that you would find them.
389
00:27:20,034 --> 00:27:22,827
In this case, we had one
adjusted all the way out,
390
00:27:22,931 --> 00:27:25,068
and then one
adjusted all the way in.
391
00:27:25,172 --> 00:27:27,724
Um, so those were set aside
for us to look at later.
392
00:27:30,034 --> 00:27:31,827
While the lab work continues,
393
00:27:31,931 --> 00:27:37,068
NTSB Investigator
Stephen Carbone
travels to Huntington, Virginia.
394
00:27:37,172 --> 00:27:40,724
He interviews mechanics
who worked on the plane
the day before the crash.
395
00:27:40,827 --> 00:27:42,068
It's all there.
396
00:27:42,172 --> 00:27:43,448
At the time, we had known that
397
00:27:43,551 --> 00:27:45,931
it had just come out of an...
of a detailed check,
398
00:27:46,034 --> 00:27:49,206
which is a... a routine check.
399
00:27:49,310 --> 00:27:52,068
And knowing that, we were
looking into the possibility
400
00:27:52,172 --> 00:27:57,137
that something had been done
during the check
that needed to be looked at
401
00:27:57,241 --> 00:27:58,931
from an investigation
point of view.
402
00:28:00,000 --> 00:28:01,965
The cables needed servicing.
403
00:28:02,068 --> 00:28:04,448
My guy wrote up a service order
and I put him on it.
404
00:28:05,310 --> 00:28:06,172
Don't forget the manual.
405
00:28:06,827 --> 00:28:08,379
Got it.
406
00:28:08,482 --> 00:28:10,206
Every 1,200 flight hours,
407
00:28:10,310 --> 00:28:14,482
Air Midwest planes go in
for routine maintenance work.
408
00:28:14,586 --> 00:28:18,000
This includes adjusting
the cables that control
the plane's elevator.
409
00:28:19,310 --> 00:28:21,517
In the process
of doing this check,
410
00:28:21,620 --> 00:28:23,931
he found that...
The mechanic had found
411
00:28:24,034 --> 00:28:26,896
that the cables
were out of limits,
412
00:28:27,000 --> 00:28:31,482
so he had written up that
he was going to check
the cable tensions
413
00:28:31,586 --> 00:28:33,379
and then adjust them
as per the manual.
414
00:28:34,448 --> 00:28:35,827
Everything's all right?
415
00:28:35,931 --> 00:28:37,413
The mechanics
tell Carbone that
the work was checked
416
00:28:37,517 --> 00:28:40,068
and stamped
for quality assurance.
417
00:28:40,172 --> 00:28:43,344
They believe that the aircraft
was properly rigged
as per the manual.
418
00:28:48,862 --> 00:28:51,310
At first glance,
that belief appears to be right.
419
00:28:52,724 --> 00:28:55,137
After maintenance,
this Beech aircraft took off
420
00:28:55,241 --> 00:28:57,379
and landed nine times
without incident
421
00:28:57,482 --> 00:28:59,241
before Captain Leslie
took the helm.
422
00:29:01,103 --> 00:29:03,655
Investigators turn
to the flight data recorder
423
00:29:03,758 --> 00:29:05,517
to learn what happened
on those flights.
424
00:29:13,344 --> 00:29:16,448
The flight
data recorder stores data
from numerous flights,
425
00:29:16,551 --> 00:29:19,379
both before and after
the plane's cables
were adjusted.
426
00:29:20,689 --> 00:29:22,310
No one on any of those flights
427
00:29:22,413 --> 00:29:24,931
had encountered any problems
with the plane's elevator.
428
00:29:27,517 --> 00:29:30,827
So, at the time, we didn't know
how that affected the airplane
429
00:29:30,931 --> 00:29:33,827
because it had flown
nine times successfully
430
00:29:33,931 --> 00:29:35,275
before the accident flight.
431
00:29:37,655 --> 00:29:41,068
Ward also discovers
that the crew tested
their elevator controls
432
00:29:41,172 --> 00:29:43,482
before Flight 5481 took off.
433
00:29:45,551 --> 00:29:48,000
Flight controls
free and correct.
434
00:29:48,103 --> 00:29:49,758
Air Midwest 5481.
435
00:29:52,793 --> 00:29:55,620
Ward and her team dig deeper,
looking to discover
436
00:29:55,724 --> 00:29:58,551
if the unusual configuration
of the elevator cables
437
00:29:58,655 --> 00:30:00,344
could have played a role
in this crash.
438
00:30:08,137 --> 00:30:11,206
What they find
strikes at the very heart
of what went wrong.
439
00:30:13,241 --> 00:30:16,448
Normally, both turnbuckles
are almost exactly
the same length.
440
00:30:17,482 --> 00:30:19,275
But on Captain Leslie's plane,
441
00:30:19,379 --> 00:30:21,965
one turnbuckle is noticeably
longer than the other.
442
00:30:25,448 --> 00:30:27,655
To establish
the correct cable tension,
443
00:30:27,758 --> 00:30:30,275
mechanics tighten
the turnbuckles,
444
00:30:30,379 --> 00:30:33,620
but too much tightening
of a turnbuckle
shortens the cables
445
00:30:33,724 --> 00:30:36,310
and cuts the range of motion
of the elevator control.
446
00:30:38,931 --> 00:30:44,103
The elevator should be able
to tilt to a nose down
position of 14 degrees.
447
00:30:44,206 --> 00:30:48,482
But their downward range
has actually been cut in half
to only seven degrees.
448
00:30:50,413 --> 00:30:51,655
The result is deadly.
449
00:30:56,655 --> 00:31:00,758
As the flight got underway,
the nose pitched up
as expected during takeoff.
450
00:31:03,931 --> 00:31:04,827
What?
451
00:31:05,689 --> 00:31:09,000
Push the nose down. Oh, my God!
452
00:31:09,103 --> 00:31:10,862
But the reduced range
in the elevator
453
00:31:10,965 --> 00:31:13,827
made it impossible
for the pilots
to bring the nose down again.
454
00:31:15,034 --> 00:31:17,517
Due to the adjustment
that had been done
455
00:31:17,620 --> 00:31:19,862
in the maintenance
a few nights earlier,
456
00:31:19,965 --> 00:31:22,448
there was nothing that the crew
could have done at that time.
457
00:31:23,655 --> 00:31:25,275
Unable to bring the nose down,
458
00:31:25,379 --> 00:31:28,310
the pitch of the wings
became too pronounced.
459
00:31:28,413 --> 00:31:32,241
With no air flowing
over the top of the wings,
the plane lost its lift
460
00:31:32,344 --> 00:31:33,793
and began falling from the sky.
461
00:31:36,379 --> 00:31:38,103
The pilots' struggle
with the elevator
462
00:31:38,206 --> 00:31:42,827
helps explain why
Flight 5481 crashed that day.
463
00:31:42,931 --> 00:31:46,793
Somehow, the elevator cables
were improperly adjusted.
464
00:31:46,896 --> 00:31:50,724
The pilots simply
could not control
the pitch of their airplane.
465
00:31:50,827 --> 00:31:55,206
Stephen Carbone wants to know
how mechanics had made
such a critical mistake.
466
00:31:55,310 --> 00:31:57,172
Yeah, I see that here.
467
00:32:00,137 --> 00:32:01,344
He goes back to the hangar
468
00:32:01,448 --> 00:32:04,206
to question the mechanics
on duty that night.
469
00:32:04,310 --> 00:32:07,000
And this time they tell him
a different story.
470
00:32:07,103 --> 00:32:09,551
Most of the guys
were just learning the ropes.
471
00:32:09,655 --> 00:32:11,275
The mechanics working
on the airline
472
00:32:11,379 --> 00:32:14,724
were subcontractors
to the contract company.
473
00:32:14,827 --> 00:32:17,103
And the mechanics
working on the aircraft
that night
474
00:32:17,206 --> 00:32:21,103
had limited experience
on the Beech 1900D.
475
00:32:21,206 --> 00:32:22,620
And the person
performing the rig
476
00:32:22,724 --> 00:32:28,206
was receiving
training that night
on that specific task.
477
00:32:28,310 --> 00:32:33,413
Once you have the rig pin set,
adjust the turnbuckle barrels
for more tension in the cable.
478
00:32:33,517 --> 00:32:36,068
Yeah, I see that here.
479
00:32:36,172 --> 00:32:39,586
Adjusting the elevator cables
is not a simple process.
480
00:32:39,689 --> 00:32:43,827
It's a time consuming procedure
that involves
25 different steps.
481
00:32:43,931 --> 00:32:44,827
Got it.
482
00:32:46,482 --> 00:32:49,068
Uh, well, what about
the other steps?
483
00:32:49,172 --> 00:32:52,275
Yeah. Uh,
don't worry about those.
484
00:32:52,379 --> 00:32:55,413
Just check the cable tension
when you're done
and we're good, that's it.
485
00:32:57,000 --> 00:32:59,103
The quality
assurance inspector
486
00:32:59,206 --> 00:33:01,068
and the mechanic
took it upon themselves
487
00:33:01,172 --> 00:33:04,482
to decide which steps to perform
because they felt that
488
00:33:04,586 --> 00:33:09,827
the steps they were performing
were the only ones necessary
to get the task done.
489
00:33:09,931 --> 00:33:13,344
The mechanic
skipped nine steps that night,
490
00:33:13,448 --> 00:33:15,965
one of those involved
manipulating the elevator
491
00:33:16,068 --> 00:33:17,620
through its full range
of motion.
492
00:33:19,000 --> 00:33:20,517
Had the mechanic
tried to do that,
493
00:33:20,620 --> 00:33:22,793
he would have noticed
that the elevator's motion
494
00:33:22,896 --> 00:33:25,655
was restricted by cables
that had been improperly rigged.
495
00:33:29,482 --> 00:33:32,655
If they had followed the steps
as described in the manual,
496
00:33:32,758 --> 00:33:36,448
they would have found
the problems that had come up.
497
00:33:36,551 --> 00:33:40,000
But there was an inspector
supervising the work.
498
00:33:40,103 --> 00:33:43,068
Carbone discovers
that the inspector
was actually the person
499
00:33:43,172 --> 00:33:45,482
teaching the mechanics
how to do the work.
500
00:33:45,586 --> 00:33:47,896
The problem was that
the quality assurance inspector
501
00:33:48,000 --> 00:33:50,379
was actually acting
as an instructor.
502
00:33:51,241 --> 00:33:53,551
So, he was taking the mechanic
503
00:33:53,655 --> 00:33:56,034
through the process
of the job task
504
00:33:56,137 --> 00:33:58,103
and teaching him
how to do the rig.
505
00:33:59,379 --> 00:34:01,620
Well, when you put yourself
in that position,
506
00:34:01,724 --> 00:34:05,241
you're actually doing the task
because even as an...
507
00:34:05,344 --> 00:34:09,206
as... as a teacher,
you're performing the task.
508
00:34:09,310 --> 00:34:11,551
And then he came in
behind himself
509
00:34:11,655 --> 00:34:14,275
and then signed off
as an inspector
what he had done.
510
00:34:16,965 --> 00:34:19,413
When I found out that, uh,
that this mechanic
511
00:34:19,517 --> 00:34:25,034
had skipped procedures,
uh, I was upset.
512
00:34:25,137 --> 00:34:31,310
Uh... The procedures that...
that affected our lives,
513
00:34:31,413 --> 00:34:33,931
that affected the lives
of 21 people,
514
00:34:34,034 --> 00:34:38,000
21 families were...
were destroyed.
515
00:34:39,310 --> 00:34:41,275
You never get over
something like this.
516
00:34:45,000 --> 00:34:47,413
The Shepherds sue the airline.
517
00:34:47,517 --> 00:34:52,896
They also demand something
unheard of in US aviation,
an apology.
518
00:34:53,000 --> 00:34:59,655
They wanted more than just
to achieve a just settlement
in monetary terms.
519
00:34:59,758 --> 00:35:03,482
They had a need
to press the issues
520
00:35:03,586 --> 00:35:06,137
that humanize and put a face
521
00:35:06,241 --> 00:35:08,724
on the people
who are the victims
of these tragedies.
522
00:35:10,620 --> 00:35:13,689
The Shepherds
believe that their best chance
of getting an apology
523
00:35:13,793 --> 00:35:16,068
is by putting a face
to Christiana's name.
524
00:35:20,586 --> 00:35:24,310
So, we decided
to take this picture
and to send it to those people
525
00:35:24,413 --> 00:35:28,931
that were involved in the...
in the... in the accident
and the investigation
526
00:35:29,034 --> 00:35:33,103
so that...
so that Christiana would...
would not be just a number.
527
00:35:33,206 --> 00:35:37,413
Or a seat number.
Or a ticket number.
Or a settlement amount.
528
00:35:37,517 --> 00:35:40,551
So that they could actually see
that she was a person.
529
00:35:42,172 --> 00:35:45,793
The legal journey
began when we determined
530
00:35:45,896 --> 00:35:50,241
that we wanted the apology,
that we wanted someone to say
"We really blew this."
531
00:35:50,344 --> 00:35:53,000
We assumed
the airline would apologize.
532
00:35:53,103 --> 00:35:55,586
We had no idea
that airlines don't apologize.
533
00:35:56,310 --> 00:35:57,344
They did something wrong.
534
00:35:57,448 --> 00:35:59,241
Obviously, you should
stand up and say,
535
00:35:59,344 --> 00:36:02,551
"We are so sorry
that we messed up in this,
and we're fixing this."
536
00:36:04,965 --> 00:36:06,275
In this case,
the mechanics thought
537
00:36:06,379 --> 00:36:09,965
they were doing something
that was perfectly reasonable.
538
00:36:10,068 --> 00:36:13,896
They thought this was,
uh, you know,
another day at the job.
539
00:36:20,034 --> 00:36:24,862
And then they come to find out
that now 21 people have been,
540
00:36:24,965 --> 00:36:28,379
you know, killed
due to their inadvertent act.
541
00:36:31,206 --> 00:36:33,034
For Lorinda Ward
and her team,
542
00:36:33,137 --> 00:36:35,413
it looks like
they've found the problem.
543
00:36:35,517 --> 00:36:37,206
But something
still doesn't add up.
544
00:36:38,517 --> 00:36:41,172
Why didn't the problem
with the plane's faulty rigging
545
00:36:41,275 --> 00:36:43,344
surface on any
of its previous flights?
546
00:36:44,758 --> 00:36:46,724
We kept scratching our head,
wondering,
547
00:36:46,827 --> 00:36:53,724
okay, this airplane flew
nine times previously,
and we had no problems.
548
00:36:53,827 --> 00:36:58,344
So, we're trying to decide,
well, what was unusual
about this flight.
549
00:36:58,448 --> 00:37:03,482
Ward has to figure out
what happened in the hours
and minutes before the crash.
550
00:37:03,586 --> 00:37:06,551
And did you
notice anything unusual
before takeoff?
551
00:37:06,655 --> 00:37:09,448
Well, it was sitting low
when it taxied out.
552
00:37:10,931 --> 00:37:11,827
It looked heavy.
553
00:37:13,172 --> 00:37:15,724
We had a couple of witnesses
that were implying that
554
00:37:15,827 --> 00:37:18,586
we had a very
heavily loaded airplane.
555
00:37:18,689 --> 00:37:21,793
The baggage people
said that it was hard
to shut the door
556
00:37:21,896 --> 00:37:24,551
'cause they thought
bags were gonna come out.
557
00:37:24,655 --> 00:37:27,137
Each plane
has a maximum weight
it can handle
558
00:37:27,241 --> 00:37:30,241
before the engines
can't get it off the ground.
559
00:37:30,344 --> 00:37:34,793
Before takeoff,
it's the pilot's job
to calculate the onboard weight.
560
00:37:34,896 --> 00:37:36,000
We got a full house back there?
561
00:37:37,620 --> 00:37:38,931
How many we got to take off?
562
00:37:39,034 --> 00:37:39,931
We're figuring it out.
563
00:37:41,551 --> 00:37:45,793
The crew of Flight 5481
did perform that calculation.
564
00:37:45,896 --> 00:37:47,482
Cool. Seventeen thousand
and eighteen.
565
00:37:47,586 --> 00:37:51,275
We hear them on the CVR
going through the numbers
566
00:37:51,379 --> 00:37:54,034
to make sure that they'd have
their center of gravity
567
00:37:54,137 --> 00:37:57,241
within the range
for them to take off.
568
00:37:57,344 --> 00:37:58,965
Seventeen thousand
one hundred twenty
is our weight, huh?
569
00:37:59,068 --> 00:37:59,965
Yeah, as our max.
570
00:38:01,448 --> 00:38:03,344
On any plane,
large or small,
571
00:38:03,448 --> 00:38:06,724
the weight of cargo
and passengers
has to be distributed evenly.
572
00:38:09,172 --> 00:38:12,482
The balancing point
of an airplane
is called its center of gravity.
573
00:38:13,655 --> 00:38:15,586
For a plane to fly safely,
574
00:38:15,689 --> 00:38:19,379
it can neither be
too far forward
nor too far back or aft.
575
00:38:22,758 --> 00:38:24,241
So, we're cool.
576
00:38:25,034 --> 00:38:27,172
So, yeah.
577
00:38:27,275 --> 00:38:29,896
We don't think
we're gonna have
to take anything off.
578
00:38:30,000 --> 00:38:31,827
Air Midwest pilots
are instructed
579
00:38:31,931 --> 00:38:36,482
how to make weight
and center of gravity,
or CG calculations.
580
00:38:36,586 --> 00:38:39,379
They use average weights
to make that calculation.
581
00:38:39,482 --> 00:38:43,551
One hundred and seventy five
pounds per passenger
and 20 pounds per bag.
582
00:38:43,655 --> 00:38:47,827
They knew that
they had a very aft CG.
583
00:38:47,931 --> 00:38:50,206
But due to using
the average weights
584
00:38:50,310 --> 00:38:53,275
and average calculations,
the paperwork showed them
585
00:38:53,379 --> 00:38:58,482
being within the range
that they needed to take off.
586
00:38:58,586 --> 00:39:01,275
But Ward needs to know
if the plane really was
587
00:39:01,379 --> 00:39:04,931
within the proper
range of weight
and balance to take off.
588
00:39:05,034 --> 00:39:06,551
What we did was
we looked at the weight
589
00:39:06,655 --> 00:39:09,551
of the actual baggage itself
that was on board,
590
00:39:09,655 --> 00:39:11,448
and then the weight
of the passengers and the crew.
591
00:39:13,655 --> 00:39:17,172
Technicians weigh
the remains of the burnt luggage
from the wreckage site.
592
00:39:21,586 --> 00:39:23,034
Doctor? Yes.
Could you tell me, please,
593
00:39:23,137 --> 00:39:25,689
what the last recorded weight
of your patient was, please?
594
00:39:25,793 --> 00:39:29,241
And obtain
the real weight of passengers
on board that day.
595
00:39:29,344 --> 00:39:31,724
Two hundred and twelve.
Thank you.
596
00:39:35,655 --> 00:39:37,103
When all the numbers are in,
597
00:39:37,206 --> 00:39:43,827
Ward discovers the real weight
of Flight 5481 is 17,700 pounds.
598
00:39:43,931 --> 00:39:47,551
Some 580 pounds over
its maximum takeoff weight.
599
00:39:51,758 --> 00:39:55,724
They would not have been able
to take off if they had
used actual weights.
600
00:39:55,827 --> 00:39:58,241
They would have had to pull
either passengers or bags off.
601
00:39:59,724 --> 00:40:01,724
Because of the higher
than expected weight
602
00:40:01,827 --> 00:40:04,034
of the passengers
and baggage on the flight
603
00:40:04,137 --> 00:40:06,827
and the large number of bags
stowed in the rear,
604
00:40:06,931 --> 00:40:09,620
the airplane was tail heavy.
605
00:40:09,724 --> 00:40:13,551
Its center of gravity
ever so slightly
too far to the rear,
606
00:40:13,655 --> 00:40:16,896
which wasn't a problem
until the landing gear
was raised.
607
00:40:17,344 --> 00:40:19,793
Gear up.
608
00:40:19,896 --> 00:40:22,448
When the gears weight
moved backwards from the nose,
609
00:40:22,551 --> 00:40:24,034
it tipped
the balance of weight...
610
00:40:24,137 --> 00:40:25,724
What?
...too far back.
611
00:40:29,172 --> 00:40:32,896
The pilots' efforts
to regain control
of the aircraft were futile,
612
00:40:33,000 --> 00:40:35,931
crippled by the airplane's
defective elevator controls.
613
00:40:37,758 --> 00:40:41,379
When the nose gear
moved aft, they lost the ability
614
00:40:41,482 --> 00:40:46,724
to control the aircraft because
all the weight went back
615
00:40:46,827 --> 00:40:52,310
and they had
no elevator movement enough
to bring the nose back down.
616
00:40:52,413 --> 00:40:54,689
And at the height
that they were at,
they had no recovery.
617
00:40:56,344 --> 00:40:59,137
The passengers
and crew of Flight 5481
618
00:40:59,241 --> 00:41:02,310
were doomed the moment
the plane left the ground.
619
00:41:02,413 --> 00:41:05,137
They had no way of knowing
that two unrelated problems
620
00:41:05,241 --> 00:41:08,310
would combine
to bring down their plane.
621
00:41:08,413 --> 00:41:11,241
This was just a normal
routine flight for them.
622
00:41:11,344 --> 00:41:13,241
And they did
all the pre-flight checks,
623
00:41:13,344 --> 00:41:14,758
they did their weight
and balance,
624
00:41:14,862 --> 00:41:17,034
they did the correct calls,
they were on the right runway.
625
00:41:18,379 --> 00:41:19,965
They... It was just
another day at the job
626
00:41:20,068 --> 00:41:22,137
and they didn't know
that they had
627
00:41:22,241 --> 00:41:27,310
these two
hidden latent failures
that were waiting for them.
628
00:41:27,413 --> 00:41:29,758
But faulty maintenance
and above average weights
629
00:41:29,862 --> 00:41:33,103
weren't the only issues
uncovered by
Lorinda Ward's investigation.
630
00:41:34,137 --> 00:41:36,931
Hey, you got a sec?
I have an idea.
631
00:41:37,034 --> 00:41:39,655
Lorinda Ward suspects
she's uncovered problems
632
00:41:39,758 --> 00:41:42,344
that didn't just affect
this one flight,
633
00:41:42,448 --> 00:41:45,517
but that also affected
every commuter plane in the air.
634
00:41:54,551 --> 00:41:58,655
NTSB investigators
say that every plane crash
makes flying safer.
635
00:42:00,758 --> 00:42:03,103
Flight 5481 was no exception.
636
00:42:05,896 --> 00:42:09,448
Fourteen months
after the accident,
lead investigator Lorinda Ward
637
00:42:09,551 --> 00:42:12,275
and her team
file a comprehensive report
638
00:42:12,379 --> 00:42:17,034
to ensure the mistakes
that killed those aboard
Flight 5481 are never repeated.
639
00:42:19,482 --> 00:42:22,862
Among Ward's recommendations
that the FAA review
640
00:42:22,965 --> 00:42:25,724
its average passenger
and baggage weights,
641
00:42:25,827 --> 00:42:29,344
an average that had not
been revised since 1936.
642
00:42:30,862 --> 00:42:33,758
And since studies suggest
that Americans and other adults
643
00:42:33,862 --> 00:42:36,137
were getting heavier
from year to year,
644
00:42:36,241 --> 00:42:38,655
Ward suspected that
the averages were off.
645
00:42:40,793 --> 00:42:44,344
We made a recommendation
to the FAA
to have the operators go out
646
00:42:44,448 --> 00:42:49,103
and survey their operations
both summer and winter time
647
00:42:49,206 --> 00:42:53,931
to see how accurate
these average weights reflected
the actual flying public
648
00:42:54,034 --> 00:42:55,586
that was getting
onto their airplanes.
649
00:42:58,758 --> 00:43:05,241
After conducting
a survey of passengers, the FAA
comes to a shocking conclusion.
650
00:43:05,344 --> 00:43:12,000
The average weight of adult
American passengers
was 195 pounds, not 175.
651
00:43:14,896 --> 00:43:18,448
The FAA also discovered
that the average weight
of carry-on luggage
652
00:43:18,551 --> 00:43:21,379
was being underestimated
by 5 pounds per bag.
653
00:43:24,689 --> 00:43:29,862
We had a average weight
that were being used
that needed to be updated.
654
00:43:31,931 --> 00:43:34,586
Had these higher average weights
been in effect
655
00:43:34,689 --> 00:43:41,379
on January 8th 2003, Flight 5481
would not have been legal
for takeoff.
656
00:43:41,482 --> 00:43:44,827
Captain Leslie
would have had to remove bags
and passengers.
657
00:43:44,931 --> 00:43:48,862
48107. Cool. 17018.
658
00:43:54,413 --> 00:43:59,551
Air Midwest pilots
now use an average weight
of 200 pounds per passenger,
659
00:43:59,655 --> 00:44:01,655
which means
that their Beechcraft planes
660
00:44:01,758 --> 00:44:04,931
can only carry 17 passengers,
not 19.
661
00:44:09,206 --> 00:44:11,482
But Ward's report
goes on to say that even
662
00:44:11,586 --> 00:44:16,103
with updated industry averages,
there's still room for error.
663
00:44:16,206 --> 00:44:18,586
Her report states
that flying small aircraft
664
00:44:18,689 --> 00:44:20,620
will be safest
only when airlines
665
00:44:20,724 --> 00:44:23,482
stop using average weight
assumptions altogether
666
00:44:23,586 --> 00:44:26,275
and calculate the real weight
on board before takeoff.
667
00:44:29,034 --> 00:44:31,931
New technologies
are being developed
to allow air carriers
668
00:44:32,034 --> 00:44:36,413
to measure actual weight
and control balance in real time
as the plane is loaded.
669
00:44:38,655 --> 00:44:42,896
Knowing the actual weight
of passengers
and baggage is vital.
670
00:44:43,000 --> 00:44:46,655
More and more people are flying
on small commuter jets.
671
00:44:46,758 --> 00:44:50,862
As the cost of jet fuel soars,
the smaller,
fuel efficient planes
672
00:44:50,965 --> 00:44:52,758
become more attractive
to airlines.
673
00:44:54,827 --> 00:44:58,379
In the United States alone,
more than 10 million
people a year
674
00:44:58,482 --> 00:45:00,965
board planes
with fewer than 30 seats.
675
00:45:01,068 --> 00:45:04,137
Smaller aircraft
are more sensitive
to the weight,
676
00:45:04,241 --> 00:45:08,517
weight and balance issue,
than say a larger airplane.
677
00:45:08,620 --> 00:45:12,379
In spite
of Ward's recommendations
and the available technology,
678
00:45:12,482 --> 00:45:15,965
almost 70% of small planes
on scheduled flights
679
00:45:16,068 --> 00:45:18,689
still use average
instead of actual weights.
680
00:45:26,172 --> 00:45:29,310
For Doug
and Tereasa Shepherd,
there is still another danger
681
00:45:29,413 --> 00:45:30,896
that threatens to strike again.
682
00:45:32,551 --> 00:45:36,551
If the FAA took a very active
role in their regulation,
683
00:45:36,655 --> 00:45:41,172
then subcontracting
could actually be a plus.
The way it's handled today,
684
00:45:42,551 --> 00:45:44,758
the mistakes
will just continue.
685
00:45:44,862 --> 00:45:47,551
Uh, what about the other steps?
686
00:45:47,655 --> 00:45:50,689
Yeah. Uh,
don't worry about those.
687
00:45:50,793 --> 00:45:54,655
Just check the cable tension
when you're done
and we're good.
688
00:45:54,758 --> 00:45:57,310
In her report,
Ward states that
all air carriers
689
00:45:57,413 --> 00:45:59,482
need to provide direct oversight
690
00:45:59,586 --> 00:46:03,000
to make sure
that even subcontracted work
is completed correctly.
691
00:46:04,689 --> 00:46:06,827
This investigation
was unique to me personally
692
00:46:06,931 --> 00:46:10,655
because it was my first launch
as an investigator in charge.
693
00:46:10,758 --> 00:46:14,620
This was, in my mind,
a significant investigation
694
00:46:14,724 --> 00:46:18,551
in the fact that we had
the 22 safety recommendations
695
00:46:18,655 --> 00:46:22,344
that came out from a small
accident investigation.
696
00:46:25,310 --> 00:46:26,586
For the Shepherds,
697
00:46:26,689 --> 00:46:29,344
the NTSB recommendations
come too late.
698
00:46:31,172 --> 00:46:34,862
But after a lengthy
legal battle,
Air Midwest does deliver
699
00:46:34,965 --> 00:46:38,034
a rare and formal apology
for the mistakes that cost
700
00:46:38,137 --> 00:46:40,241
18-year-old
Christiana Shepherd her life.
701
00:46:44,931 --> 00:46:49,103
My name is Ron Goldman
and, um, my role here today
702
00:46:49,206 --> 00:46:55,620
is that I will be introducing
the public apology and then
I'll have a few words...
703
00:46:55,724 --> 00:47:00,620
The public apology
is in aviation cases
unprecedented.
704
00:47:01,655 --> 00:47:03,000
We are here today
705
00:47:03,896 --> 00:47:05,793
to remember the victims
706
00:47:05,896 --> 00:47:09,965
of Flight 5481,
and to offer our apologies,
707
00:47:11,068 --> 00:47:15,137
our condolences
and sincere sympathy
708
00:47:15,241 --> 00:47:21,103
to the surviving family members,
of the passengers
and crew who perished
709
00:47:21,206 --> 00:47:26,172
in the January 8th 2003 crash
of Air Midwest
flight number 5481.
710
00:47:28,551 --> 00:47:34,241
The acceptance
of accountability suggests
that the recommendations
711
00:47:34,344 --> 00:47:36,275
made by the safety investigators
712
00:47:36,379 --> 00:47:40,551
are not to be taken as a book
to throw in a drawer
and forget about
713
00:47:40,655 --> 00:47:45,103
but are to be taken seriously
because if you don't take them
seriously,
714
00:47:45,206 --> 00:47:49,103
there's going to be
public accountability as well as
private accountability.
715
00:47:49,206 --> 00:47:50,413
What people should never forget
716
00:47:50,517 --> 00:47:55,034
is that as we're going about
and doing our job day to day,
717
00:47:55,137 --> 00:47:59,931
we need to remember
the importance of doing our job.
718
00:48:00,034 --> 00:48:02,862
Doesn't matter
where we're at on the ladder,
or the corporate ladder,
719
00:48:02,965 --> 00:48:08,137
whether we're at the bottom rung
or the top rung,
we have responsibilities.
720
00:48:08,241 --> 00:48:11,655
It took a complicated string
of errors and miscalculations
721
00:48:11,758 --> 00:48:13,689
to bring down Flight 5481.
722
00:48:14,965 --> 00:48:16,827
But some believe
there was one person
723
00:48:16,931 --> 00:48:19,724
who performed admirably
that day.
724
00:48:19,827 --> 00:48:23,862
Captain Katie Leslie.
With an unbalanced plane
725
00:48:23,965 --> 00:48:28,620
and faulty controls,
Captain Leslie
could not have saved the flight.
726
00:48:28,724 --> 00:48:32,103
But her final actions
may have saved some lives.
727
00:48:32,206 --> 00:48:33,689
You know,
she's an unsung hero to me
728
00:48:33,793 --> 00:48:37,620
because I don't think
many people
know about what she did
729
00:48:37,724 --> 00:48:41,206
and how she was fighting it
and trying to pull the plane
away from the hangar
730
00:48:41,310 --> 00:48:42,724
and she actually did.
731
00:48:42,827 --> 00:48:46,551
She kept it
from really more of a head-on
hit into the hangar.
732
00:48:51,724 --> 00:48:54,827
Which probably saved
countless other people
733
00:48:54,931 --> 00:48:56,448
from perishing that day.
734
00:48:58,103 --> 00:49:00,379
It was firefighter
Cindy Overcash
735
00:49:00,482 --> 00:49:04,413
who found the body
of captain Katie Leslie
among the wreckage.
736
00:49:04,517 --> 00:49:07,689
To this day,
Overcash still feels
a special connection
737
00:49:07,793 --> 00:49:08,689
to the young pilot.
738
00:49:10,586 --> 00:49:12,103
I don't know.
I just felt a kinship.
739
00:49:12,931 --> 00:49:14,724
I don't know why. I don't know.
740
00:49:14,827 --> 00:49:16,724
You know, it could be as simple
as I found her,
741
00:49:17,827 --> 00:49:21,517
and I was there
when she left this world.
742
00:49:21,620 --> 00:49:23,655
I don't know,
but I thought about her a lot.
743
00:49:29,379 --> 00:49:31,689
Lorinda Ward's investigation
could have ended
744
00:49:31,793 --> 00:49:36,655
when she uncovered the errors
that caused the crash
of Flight 5481.
745
00:49:36,758 --> 00:49:41,206
By digging a bit deeper,
she made flying safer
for millions of people.