Original subtitles

NARRATOR: Laredo International Airport, Texas.

Continental Express is such a watershed moment

for an accident investigation.

Outside looks good.

Okay. I've done the cockpit scans.

We're set for the before start checklist.

NARRATOR: Continental Express flight 25-74.

It happened extremely fast.

(THUDS)

I mean, the force was so violent.

The plane was unflyable.

CARY LABAY: Oh, my God. Look.

(BEEPING)

I was a little bit scared when I first saw the wreckage.

I told them that I thought it was...

...a bomb went off. Kaboom!

NARRATOR: The wreckage will tell a chilling story.

If they had strictly followed those procedures,

this accident should not have happened.

NARRATOR: Of good intentions gone terribly wrong.

PILOT: Mayday! Mayday!

(THEME MUSIC PLAYING)

(SUSPENSEFUL MUSIC PLAYING)

ATC (OVER RADIO): Jetlink 25-74.

They're going to bring everybody in on two-six or two-seven.

Okie-dokie.

COCKPIT COMPUTER: Autopilot off.

NARRATOR: Continental Express Flight 25-74

and its 11 passengers

nears the end of its one-hour flight from Laredo to Houston, Texas.

It's the second flight of the day for this crew.

They've already flown from Houston to Laredo.

Now they're on their way back.

15,000 feet below,

it's a warm late summer morning on the farms

and cattle ranches of Southern Texas.

Captured on the right.

NARRATOR: The pilots prepare the Embraer 120 Brasilia

for another routine landing.

Captain Brad Patridge is just 29 years old.

43-year-old first officer Clint Rodosovich

is now very close to becoming a captain himself.

They are 110 kilometers from Houston, home for both pilots.

Pushing this descent. Making like the space shuttle.

(THUDDING AND RATTLING)

(ALARMS BEEPING)

- (PEOPLE SCREAMING) - COCKPIT COMPUTER: High speed.

NARRATOR: In the blink of an eye,

the plane is plummeting towards the ground.

It drops 2,000 feet in just a few seconds.

COCKPIT COMPUTER: Stall.

NARRATOR: Far below, Cary Labay

and his brother Clifton are working on their farm.

My brother and I heard an explosion.

We both looked up in the air and, uh, it was, oh, my God. Look.

Seen the plane coming out of the air.

The plane was spiraling.

NARRATOR: Flight 25-74 plummets to the ground

at more than 500 kilometers an hour.

COCKPIT COMPUTER (SLOWED DOWN): Autopilot. Autopilot.

Unit one channel.

Unit one channel. Unit one channel.

(EXPLOSION BOOMS)

When it hit the ground, there was a massive explosion.

My brother said, let's go. And I said, "Man..."

I really don't think there's anything I want to see there.

LABAY: When I made the 911 call,

they were asking for directions and I told them, I said, uh,

all you have to do is follow the smoke.

REPORTER: What we see on the ground is not recognizable

in any shape, form, or fashion as having been an airplane.

NARRATOR: Firefighters find the smoldering wreckage of the aircraft

in the middle of a farmer's field near Eagle Lake, Texas,

just 110 kilometers west of Houston.

LABAY: As we went there, you,

if you wouldn't have knew it was an airplane,

you would have just thought it was a pile of trash.

It was burned so far.

REPORTER: Ten bodies were found inside the wreckage, four outside.

NARRATOR: All 14 people onboard

including Patridge and Rodosovich are dead.

Accident investigators must now figure out

why lives were lost on a popular commuter flight.

BRENNER: Whenever one passenger dies in a scheduled flight

we launch an entire team, that's understood.

We have about 12 specialties, uh, that form the go-team.

And we have to be prepared to launch on three to four hours' notice.

NARRATOR: Jim Ritter is an engineer who specializes in airplane mechanics.

RITTER: One of the key things that we do in every accident investigation

is we try to figure out

why did the airplane behave the way it did.

Was it normal performance or was there a malfunction

that can explain what caused the accident?

I was a little bit scared when I first saw the wreckage.

The airplane was destroyed, and there wasn't a lot to go on.

NARRATOR: Deepak Joshi is an expert on the structure of the aircraft itself.

I went straight to the main wreckage

where I found most of the airplane.

My first order of business was

to locate the four corners of the airplane.

NARRATOR: The small plane was a Brazilian made twin turboprop,

the Embraer 120.

Its size and speed have made it popular with regional airlines in the US.

The Continental Express fleet includes 34 of the aircraft.

(SUSPENSEFUL MUSIC PLAYING)

The first day, uh, when we got down there

I led the group in terms of interviewing six witnesses.

And one of them reported that the airplane appeared

to be in a routine descent to the airport,

and as he watched it, he saw that, uh, there was an explosion.

There was an explosion.

I told him that I thought it was a...

...bomb went off

And, uh, it was spiraling as it went down.

When it hit the ground, there was a secondary explosion.

And kaboom!

The primary explosion's what caused us to go, oh, my God.

I could see a hole in it.

It looked like it had a hole in it about the size of a Volkswagen.

BRENNER: The eyewitnesses were unanimous

that the airplane was on fire before it reached the ground.

Seen this plane. Saw the fire just at the outside wings and going straight down.

The wing was blown completely off.

And it was just dangling there.

NARRATOR: The eyewitness testimony is compelling.

An onboard explosion caused by a bomb seems like a very real possibility.

Agents from the Federal Bureau of Investigation are quickly on the scene

looking for evidence of foul play.

The FAA said that they believe

that there had been a mid-air explosion, and it went off the,

it went off the screen very rapidly.

RITTER: The FBI had gotten a report

that, uh, someone had placed a bomb on the aircraft

and they were being very careful

and making sure that there was no evidence

of any kind of bomb or criminal activity.

REPORTER: The NTSB has heard reports of a federally protected witness

testifying in a Laredo drug trial

who was reportedly booked on the Continental flight.

The suspect missed the flight after the trial ran late.

What I'm telling you is our investigators have nothing on that.

I don't know how much more clear I can be on that.

NARRATOR: The wreckage itself gives the investigators

an immediate clue about the crash.

JOSHI: I saw the cockpit was there. The fuselage was there.

The left wing had folded under the right wing.

And a portion of the vertical stabilizer was there.

But the horizontal stabilizer was missing.

NARRATOR: The Embraer 120 is what's called a T-tail airplane.

The horizontal stabilizer sits on top of the vertical stabilizer.

And then I wondered where could it be?

NARRATOR: 200 meters away, well back from the main wreckage,

Joshi finds the missing tail section.

Can someone help me get a bearing on this?

That made me believe that there is definitely

an in-flight breakup of an airplane.

Alright.

RITTER: A lot of the various pieces were scattered around,

so one of the key questions that we kept asking ourselves

was what happened first?

What initiated this event?

(CAMERA SHUTTER CLICKS)

I'm guessing that tail came off at about 9,000 feet.

There's something there that, something speaking to us in that evidence.

NARRATOR: Deciphering the message won't be easy.

But as the story of Flight 25-74 unfolds,

investigators will uncover a shocking accident scenario

unlike anything seen before.

(AIRPLANE DRONING)

REPORTER: All 14 people aboard were killed,

among them the pilot Captain Brad Patridge of Kingwood.

NARRATOR: NTSB investigators recover the black boxes

from the rear fuselage of Continental Express Flight 25-74.

RITTER: The recorders are pivotal in our work.

It's really what gives us a window into what happened.

If we didn't have the flight data recorder

or we don't have the cockpit voice recorder,

we don't have a lot of information to go on.

NARRATOR: The black boxes will be rushed to Washington for analysis.

Investigators focus next on the plane's severed tail.

JOSHI: There is a missing piece, uh, of the puzzle,

and it does not reach the main wreckage.

That's where the focus tends to go.

NARRATOR: From its position 200 meters back

from the rest of the wreckage,

investigators can tell it was one of the first parts

to come off the plane.

(DRAMATIC MUSIC PLAYING)

They wonder if corrosion or metal fatigue

may have weakened the tail to the point of failure.

When a piece of metal bends back and forth over time,

it eventually snaps.

Called fatigue, that failure is identified by a smooth clean break.

JOSHI: We started to look at the fracture surfaces

of the vertical stabilizer.

NARRATOR: But the edges of the tail section aren't smooth.

They're jagged.

In this particular accident, we did not see any brown color, rust.

No corrosion. No fatigue.

NARRATOR: The fracture surfaces clearly indicate

that the tail was ripped off suddenly.

In Washington...

...NTSB technicians open the black boxes.

BRENNER: The cockpit voice recorder is our single most important piece of evidence.

It records everything that's said,

all sounds in the cockpit for the last half hour before impact.

You can hear cockpit sounds that can be very helpful.

So you can hear what the engines are doing.

You can hear a whole bunch of things. We do analysis on that.

NARRATOR: But no voice recorder comes with a guarantee.

It's a complicated piece of electronics hooked up to several microphones.

After slamming into the ground at more than 500 kilometers an hour,

there's a chance the recording may be damaged or lost.

In Texas, the FBI field unit

finishes testing remnants of the plane for any residue from explosives.

I think it was a bomb went off.

NARRATOR: The results are conclusive.

There was no bomb onboard Flight 25-74.

(AIRPLANE DRONING)

It became pretty obvious that we had a structural reason for the accident

and not really a bomb or any kind of criminal event.

(EXPLOSION BOOMS)

NARRATOR: The fire and a mid-air explosion reported by witnesses

were likely caused when the wing broke off igniting the fuel inside.

Investigators discover that the tail section

did not fall off in one piece.

JOSHI: I noticed that the leading edge

on the left side horizontal stabilizer was missing.

This is very unusual.

Maybe a small section of the leading edge would be missing

but not the whole complete 10 foot section.

NARRATOR: The leading edge on the right side

is still attached to the stabilizer,

but the one on the left is missing entirely.

So when did this piece break off?

RITTER: A key question there is,

what was the first part that came off of the airplane?

Because a lot of times, the initiating event

is going to be found in those early parts

that break from the airplane in an in-flight breakup.

NARRATOR: It's now vitally important

for investigators to find the missing leading edge.

It's a piece of molded composite material three meters long.

Its rounded shape allows air to pass smoothly over the stabilizer.

But the missing piece can't be found anywhere near the crash site.

We really needed it, and there was a growing frustration

because we thought this part was critical.

NARRATOR: Without it, they don't have all the pieces of the aircraft.

More importantly, they're missing the piece that most likely came off first.

(INDISTINCT)

JOSHI: That piece of evidence

was very, very important for this investigation.

And, uh, we made our best effort to find this leading edge.

The FAA asked us to assist in, uh, the search.

We walked our property.

I knew every bit of that property.

NARRATOR: As searchers comb the area...

...Jim Ritter receives a copy of the CVR data

from the lab in Washington.

The good news is that the recording is intact.

The pilots' final moments have been clearly captured.

RODOSOVICH (ON TAPE): Radio check.

NARRATOR: Ritter wants to see if they discussed a developing crisis

or perhaps were forced to make a sudden maneuver

to avoid an oncoming obstacle.

If the airplanes are flying within 6,000 to 8,000 feet,

you know, you might have some involvement of birds.

NARRATOR: But the twin turboprop was flying much higher,

well above any threat of a bird strike.

RODOSOVICH: Radio check.

- I can hear you loud and clear. - As you also.

OFFICER PATRIDGE (ON TAPE): Okay...

NARRATOR: But the CVR is mostly filled with the sound of controllers

giving the pilots routine instructions.

ATC (ON TAPE): Jetlink 25-74, say your heading.

Zero-five-zero.

ATC (OVER RADIO): Jetlink 25-74, Roger.

Fly heading zero-three-zero.

NARRATOR: And normal conversation between the pilots.

(RODOSOVICH SIGHS)

RODOSOVICH (ON TAPE): Got a few days off coming up.

I'm gonna head down to the coast, a little R and R, a little golf.

NARRATOR: There are no hints of trouble on this flight

until the First Officer pushes his plane into a rapid descent towards Houston.

RODOSOVICH: (ON TAPE) Pushing this descent.

Making like the space shuttle.

(RATTLING)

Well, the CVR showed us that,

that the flight crew was totally professional.

I mean, they were not doing anything that they shouldn't have been doing.

NARRATOR: Investigators listen for any other clues...

...the sounds of objects being upset in the cockpit.

- (THUDDING) - (RATTLING)

- NARRATOR: The engines suddenly screaming. - (ENGINES WHINING)

- The blare of flight warning alarms. - (ALARM BEEPING)

COCKPIT COMPUTER: Stall. Stall. Stall.

NARRATOR: But there's no more conversation at all.

The recording tells investigators that Patridge and Rodosovich

had absolutely no advance warning of their plane's sudden plunge.

The event happened extremely fast.

I don't think there was anything that the crew could have done.

(EXPLOSION BOOMS)

(KEYPAD BEEPING)

NARRATOR: An analysis of the flight data recorder

comes to the same conclusion.

RITTER: We didn't see anything unusual about the accident flight

until the very instant that we had the pitch down.

NARRATOR: Until the plane went into a dive at near top speed and broke up,

there was nothing abnormal about this flight.

The cause of the crash remains a mystery.

Finding the one missing piece of the tail is now more important than ever.

BRENNER: We were doing marches through the area,

and after several days went by, it was difficult.

We had flights by the local volunteer groups,

were flying over the site.

NARRATOR: They're searching a 12-square kilometer area

for a three-meter-long composite piece.

Finding it is a long shot.

BRENNER: There was this growing theme

that we have to find that part.

And there was a frustration that it was way more difficult than we thought.

RITTER: We had engineers from the aircraft manufacturer

helping to tell us how heavy the parts were.

Do... Well, do you have the weight of the piece?

RITTER: The dimensions of the parts

so that we could figure out what drag levels we might see.

NARRATOR: Ritter logs the coordinates of the crash site.

He studies the weather patterns from the day of the accident.

So I took that information,

put it together, and calculated

where the leading edge radius should be.

NARRATOR: Finally he comes up with a possible location

for the missing piece.

RITTER: I think it's somewhere in here.

Over the next couple of days, we went to that area and we...

We laid out a grid to search for it.

We searched for it on, uh, in the four-wheelers,

and in the helicopter.

NARRATOR: On the third day of the search, some good news.

BRENNER: We were flying over the Texas countryside,

big cattle country.

Suddenly the, uh, the pilot

sitting next to me said, "I think I see it."

(HELICOPTER WHIRRING)

NARRATOR: The piece is in the area predicted,

but it's so well camouflaged that it was nearly impossible to spot.

BRENNER: People had walked by it hundreds of times,

but it just happened to blend in with the cattle fence.

Uh, hey, Jim, we found it,

and it's just where you said it was.

Of course it is, you just weren't looking hard enough.

We had spent several days all day long,

long days and nights calculating where to look,

and so I was elated when we finally found the part.

NARRATOR: Now that the leading edge has been found,

investigators believe they finally have all the pieces of the plane.

RITTER: We were really excited because it's important.

You want to do your best to understand what happened in an accident.

And if you didn't have the key part...

...there would always be questions.

(CAMERA SHUTTER CLICKING)

NARRATOR: Right away, they notice something unusual.

The evidence indicated that the leading edge

upper surface holes were absolutely clean.

No elongation. No damage.

NARRATOR: But the holes that hold the piece

to the bottom of the stabilizer look quite different.

Uh, the lower surface holes onto the leading edge were elongated.

They were cracked as if you have pulled it through the fasteners.

NARRATOR: The missing piece was found over a kilometer

southwest of the tail section.

There is no question it was the first piece to fall off the plane.

(DRAMATIC MUSIC PLAYING)

Look here, look here, absolutely perfect on top...

...but destroyed at the bottom.

NARRATOR: The fact that the screw holes

on the leading edge aren't damaged

presents a frightening prospect.

It looked like there was no screws attached

onto the top surface

of the horizontal stabilizer leading edge.

NARRATOR: The discovery presents the team with two important questions.

Why were the screws missing and...

Could losing this actually cause the plane to crash?

NARRATOR: The leading edge improves the aerodynamics of the plane.

But it's not a moving part that controls direction.

It's hard to see how losing it would cause the plane

to plummet from the sky.

At that time, I was kind of, uh, surprised

that losing a composite leading edge would actually cause such a severe impact.

NARRATOR: Now that all the pieces of the plane have been found,

the investigation moves to NTSB headquarters

in Washington, D.C.

Well, we were just trying to put all the pieces of the puzzle together...

...and try to make sure that we understood

what the motion of the airplane was after the leading edge radius broke off.

NARRATOR: The horizontal stabilizer is like an upside down wing.

It pushes the tail down while the wings lift it up.

Reducing the force on the stabilizer lifts the tail

and makes the flight unstable.

RITTER: There were still questions about

maybe it would still be controllable,

and so we did an engineering simulation

to try to see if maybe there was a way

that the airplane could still fly after it lost the leading edge.

But we found that it really was not a controllable situation.

After the leading edge radius broke off of the airplane,

it was a negative five-G pitch over.

Once the angle of attack exceeded the negative limits,

it actually broke the wing apart.

So it was not a survivable event.

NARRATOR: The simulations are conclusive.

Losing just one leading edge along the horizontal stabilizer

will send the plane into a catastrophic nosedive.

Precisely what witnesses say happened...

...to Flight 25-74.

(EXPLOSION BOOMS)

If there is any component of the wing

that you don't want to lose, it's the leading edge.

NARRATOR: The team now knows what triggered the crash,

the loss of the stabilizer's leading edge.

But what they still don't know

is why the part seems not to have been properly attached.

Examining the maintenance records for the aircraft,

Brenner makes a disturbing find.

A maintenance crew worked on the horizontal stabilizer

the night before the accident.

The evidence was mounting that we really needed to look in-depth

at the maintenance procedures done the night before

and the maintenance area.

(SIREN WAILING)

NARRATOR: Continental Express is one of the most popular carriers

in the United States.

The lives of thousands of passengers depend on the entire fleet of aircraft

being properly maintained.

Investigators urgently need to find out what went wrong

in the hours leading up to the crash.

NARRATOR: NTSB investigator Malcolm Brenner

travels to Houston Intercontinental Airport

to talk with the maintenance crew that worked on the plane

the night before it crashed.

BRENNER: In general, we wanted to visit the facility

to see what the facility looked like,

and then to go through specifically what had been done the evening before.

VON THADEN: Now, many times, a lot of work happens

on these overnight shifts,

and they have to get an airplane back out to fly the next day.

NARRATOR: Terry von Thaden teaches aviation safety.

She uses Flight 25-74 as a case study.

So there's a push to turn this aircraft around quickly.

Sometimes you can get the work done, sometimes you can't.

NARRATOR: In preparation for winter,

Continental Express had been inspecting and repairing the deice boots

on its fleet of Embraer 120s.

The deice boot is a rubber bladder

that can be inflated by the pilots to break up ice on the wings and tail.

We wanted to interview every mechanic, uh, supervisor,

and inspection person who took part in that activity.

NARRATOR: Brenner is particularly interested in three employees.

Shift Supervisor Adam Dillon...

...Troy Anderson, an inspector responsible for checking the work of the mechanics...

...and the evening shift supervisor who started the job, John LePage.

Thanks for taking the time.

So, uh, what was the plan for the night?

Uh, we had about 10 hours to change both boots.

NARRATOR: Replacing the boot involves removing the leading edge,

stripping the old boot off it, and putting on a new one.

The entire piece gets screwed back onto the horizontal stabilizer.

This is a big job to do all in one night.

This was scheduled to have these replaced

during the, uh, midnight shift.

Somehow, the evening shift had some extra time

and decided they can help out get this airplane, uh, out

so we'll get it started.

Grab what you need. I'll get the boots.

NARRATOR: Watching over the work being done by the mechanics

is Inspector Troy Anderson.

I had some time to lend a hand.

We went up the stabilizer to start the job.

(LIFT WHIRRING)

The mechanic started working on the bottom.

The inspector volunteered

to climb up on top of the thing and get the top ones.

NARRATOR: The evening shift, the second shift of the day,

was going to remove the screws holding the leading edge in place.

The rest of the work would be done by the midnight shift.

NARRATOR: At 10 pm, Adam Dillon takes over

as supervisor for the midnight shift.

Hey-hey, finishing a C-check, engine maintenance, and a boot swap.

- Both sides? - LEPAGE: Yup.

Shift change is such a crucial time

because we're taking work that's halfway done.

And we have to be very, very specific

about what's been done and what the other people are taking over.

When I came on to my shift,

I asked how far they got on the deice boots.

NARRATOR: The mechanics find that many of the screws are stripped.

Getting them out takes longer than expected.

DILLON: I found out they were still trying

to remove the leading edge on the right side.

It was looking like they weren't going to get both sides done.

NARRATOR: Then, a crucial decision is made.

Have you started on the left side yet?

No.

(BEEPING)

NARRATOR: The crew that started work on the deice boots went home at 10:30.

There was no way we were going to get both sides done,

so I decided to just do the right side that night.

NARRATOR: Investigators learn that the supervisor of the midnight shift

decided there wasn't enough time to do both sides.

Guys, forget the left side for tonight

and let's get this plane out of here.

So the guys, they spent most of their shift

replacing the right side boot.

NARRATOR: A few hours later,

mechanics finish changing the deice boot

and reinstall the right side leading edge.

So the mechanics didn't do any work at all on the left side?

No. We didn't touch it.

NARRATOR: After having changed just the right deice boot,

airplane 701 is rolled out to the gate for the first flight of the day.

Three hours later, the left leading edge rips off the tail

causing the aircraft to plummet almost 12,000 feet to the ground.

(EXPLOSION BOOMS)

Back in Washington, NTSB investigators try to piece together

the information they've gathered so far.

BRENNER: Dillon...

...and LePage.

The individual mechanics, the supervisors,

in general I thought we had good cooperation.

They did describe what they were doing?

I think they, they were credible.

I believe they were trying to help.

Where was Anderson?

LEPAGE: We had about 10 hours...

DILLON: No way we were going to get both sides...

ANDERSON: I had some time to lend a hand.

BRENNER: The second shift.

NARRATOR: Investigators are almost certain that the screws were removed

from the top of the left side leading edge and never replaced.

But maintenance workers insist they only worked on the right side.

Investigators are puzzled.

So the second shift started the job.

These guys, they started on the right side.

Their inspector, he helped them.

BRENNER: It's always dangerous when you change

from one shift to another shift.

And that's why there are very strict procedures about that.

They were bypassing them.

The inspector jumped in to get this airplane moving.

That was all disturbing.

Did he ever say what he did up there?

Yeah, that's great. Let me see that.

"Helped the mechanics remove the deice boots."

What does that mean?

(AIRPLANE DRONING)

NARRATOR: Malcolm Brenner returns to Houston

to try to determine precisely what work

Inspector Anderson performed on the doomed plane.

"Helped mechanics remove deice boots."

It's a very simple statement.

It's not specific as to what was taken off the aircraft,

what was done, where the maintenance stood

at that time of the shift turnover.

"Helped the mechanics remove the deice boots."

What did you do?

Well, it wasn't that busy, so I offered to help the guys.

BRENNER: The inspector went up on, on the man lift

and started helping the mechanics.

That's not his job.

He said he wasn't too busy, and they needed help.

They were going to turn this around.

It wasn't his role.

It wasn't a good idea.

(SUSPENSEFUL MUSIC PLAYING)

So which side did you work on, Troy? Just the right?

Both.

Look. When I left, the plan was to do both sides.

BRENNER: For me, the most disturbing was the inspector.

He was up there, and he was the one who actually took the screws off.

(DRILL WHIRRING)

Part of the philosophy of maintenance is that,

you have one group that does the work, and then you have another group...

...the best of the best, the cream of the cream,

who are then inspecting the work.

And their function is to sign off

and make sure that this work is being done properly.

(DRILL WHIRRING)

He had a bag of 40 screws.

And he left the bag of 40 screws that he took out

on the man lift for the oncoming shift.

- Have you started the left side yet? - No.

I spoke with the second shift supervisor. We decided to skip the left side.

So he asked the supervisor, "Have you done any work on the left side?"

The supervisor looked up and said, "No. No, not that I know of."

Guys, forget the left side for tonight and let's get this plane out of here.

NARRATOR: No one on the midnight shift

knew that Anderson had started pulling screws from the left side.

BRENNER: The work records weren't done.

And the procedures, even though they're in place

and should have worked, they weren't followed.

BRENNER: Did you give your mechanics the paperwork to fill out on the job?

No.

Sometimes the paperwork takes longer than the job itself.

BRENNER: On a shift turnover,

that's one of the critical things that you have.

You have a written record that anyone can go back to. It wasn't done.

NARRATOR: None of the mechanics from the evening shift

filled in the cards which detail the work they've done

for the next shift.

VON THADEN: Paperwork is never fun.

And then when you're describing something you've already done,

people don't necessarily want to do that. I've already done it. I did it.

I don't necessarily want to go back and write it down that I did it.

And we asked the supervisor why wasn't it done

and he said, well, it's a simple procedure

and sometimes it's not worth doing.

If you take out a bunch of screws, you wouldn't issue the work card.

It's more trouble than, than to do it.

That was disturbing.

NARRATOR: And Inspector Troy Anderson was vague about the work he did.

His write-up didn't really describe the fact

that he took the screws out on the left.

He did not see his role as a mechanic on that aircraft.

So I think perhaps,

he didn't take writing on those cards as seriously as he should have

because that was the mechanic's job to do that.

NARRATOR: A failure in routine maintenance caused the crash of Flight 25-74.

But there is still one lingering question.

Captured on the right.

NARRATOR: The plane flew more than 800 kilometers

before the leading edge tore off.

It is pretty amazing that the, that the horizontal tail

stayed intact for that first flight.

NARRATOR: The deadly failure came near the end

of the crew's second flight that day.

RODOSOVICH: Pushing this descent.

Making like the space shuttle.

NARRATOR: Why didn't it happen sooner?

(THUDDING)

(RATTLING)

Investigators pore over the recorded data from both flights.

They compare flight parameters like speed, heading, altitude

in search of anything that might provide an answer.

It was a question of, you know, how,

how much the forces, uh, would have changed.

NARRATOR: They zero in on the plane's airspeed during descent.

Just before its fatal dive, Flight 25-74 hit a speed of 260 knots.

Though safe under normal conditions, that's close to top speed

and 44 knots faster than the previous descent.

They conduct a study

to confirm suspicions that those 44 extra knots

were enough to trigger disaster.

The leading edge stays on at 216 knots,

the plane's maximum speed during the first flight.

RITTER: The aerodynamic forces never quite rose

to the level that they did on the accident flight.

NARRATOR: But an increase of 44 knots

drastically increases the amount of drag on the leading edge.

Once the plane got up near its maximum speed...

...it had this failure waiting to happen.

NARRATOR: The tragic significance of First Officer Rodosovich's last words

is now clear to investigators.

Pushing this descent.

Making like the space shuttle.

NARRATOR: His high speed descent sealed the fate of Flight 25-74.

The airplane broke apart at the highest speed

that it reached since the maintenance was done the night before.

The aerodynamic forces were very high and so eventually they were enough

to bend the leading edge radius downward because it wasn't attached anymore

on the top of the horizontal tail.

And they bent it downward to the point where finally the oncoming air

was powerful enough to break it off.

NARRATOR: At 260 knots, the leading edge rips off.

When that part failed, the plane was unflyable.

COCKPIT COMPUTER: High speed. High...

I mean, the force was so violent.

COCKPIT COMPUTER: Engine. Engine.

On the cockpit voice recording,

the pilots don't say anything after it happens.

They were probably incapacitated.

It's that violent.

NARRATOR: The massive negative G-force

would have instantly sent blood rushing to the brains of the passengers and crew

rendering them unconscious.

COCKPIT COMPUTER: One channel. Unit one channel.

One channel. Unit one channel.

Unit one channel.

Unit one channel.

(EXPLOSION BOOMS)

NARRATOR: The NTSB blames the accident on the failure to reinsert all the screws

holding the left leading edge to the tail.

My heart reached out to the people that had worked on the airplane

because I knew that this was a human error.

And whoever had been involved in that maintenance,

I'm sure was going to feel very badly about the situation.

(DRILL WHIRRING)

NARRATOR: The safety board also takes the unprecedented step

of faulting Continental Express

for not making sure all maintenance procedures were followed.

In particular, the failure to ensure the mechanics

and inspectors completed the proper paperwork.

LEPAGE: Sometimes the paperwork takes longer than the job itself.

BRENNER: This was a preventable accident.

If they had strictly followed those procedures,

this accident should not have happened.

VON THADEN: The Continental Express accident

is such a watershed moment for accidents

and accident investigation in particular

because it's one of the first times

that the culture of the organization was mentioned

in an accident investigation.

NARRATOR: Never before has the NTSB cited

an airline's senior management

for allowing a climate where rules get bent.

Leadership needs to understand their accountability in these accidents

and have more commitment towards the people on the line

so that they can do their jobs properly and effectively.

NARRATOR: As a result of the crash...

...airlines now put much greater emphasis

on making sure all safety procedures are followed.

They use computerized systems to more precisely track mechanics' work.

But better technology is only part of the solution.

One of the things we try and get people on the front line to do is talk.

We try and encourage them to speak up, that there are no stupid questions.

Every question is important.

This is a case where...

...small deviations...

...by many people...

...where cutting corners in small ways

that appears small to each person,

can accumulate to cause this horrible accident.

A horrible and preventable accident.

(CLOSING THEME MUSIC PLAYING)