Original subtitles

(narrator): Pilots of Colgan Air Flight 9446 fight for their lives

as their plane dives towards the ground.

- You pull for all you're worth. Just keep pulling for all you're worth.

- Picture trying to do your day job

while... deadlifting 250 pounds.

(both groaning) - Oh, no! (TAWS): Pull up!

(narrator): Both pilots are killed.

The wreckage reveals very little.

- That is a rat's nest.

(narrator): The cockpit voice recording... (Captain): Got a runaway trim.

(narrator): ...provides a key insight.

- Listen to how exhausted they are, trying to keep the nose up.

(narrator): But analysis of flight data turns the case on its head.

- This doesn't look right. - Well, that was the huge aha moment for me.

- How's that possible?

- Everybody missed what was just...

such a simple mistake.

- Mayday, Mayday!

- It's going up!

(indistinct radio chatter)

(narrator): A Colgan Air crew prepares for the last flight of the day

in a recently serviced aircraft.

- Weather looks good. Should be an easy ride.

(narrator): Captain Scott Knabe has been with Colgan Air for more than two years.

Six months ago, he was promoted to captain.

- Scott Knabe was among the most careful and meticulous pilots.

He was a very successful and very good accountant.

But he had the aviation bug.

- How's the paperwork? - Uh, weight and balance is checked and filed.

(narrator): First Officer Steven Dean has been with the airline

for less than a year.

- Did you put in for that upgrade? - Actually, no, I didn't.

I put in my notice. I can't afford to do this anymore.

- Understood.

- Being a young pilot moving his way up the ladder in the regionals,

the first officer quickly discovered that his pay

could not support his wife and daughter.

So a week before this flight... he gave notice.

- Don't mind these reposition flights.

- Yeah, no passengers, no problems.

(narrator): Colgan Air has a small fleet of Beech 1900s.

The aircraft operate as part of US Air's regional arm.

The Beechcraft is a smaller plane, popular for commuter flights.

(Schiavo): They fly short distances.

They fly into places that the big-name carriers...

wouldn't be able to fill up or make a lot of money.

- Maintenance log: checked. And aircraft is released.

(narrator): After four days of routine maintenance in Hyannis,

the plane is being returned to service.

Colgan 9446 will fly empty to Upstate New York.

- Sometimes we have to resort to these non-revenue flights

to reposition the plane from one location to another.

Occasionally that could also happen when you have to bring a plane

to a specified maintenance facility.

(narrator): Today's flight from Hyannis, Massachusetts,

west to Albany, New York, should take 50 minutes.

- Circuit breakers checked? - Checked.

(narrator): The pilots perform their final checks.

- Alright, I'm not getting any radios here. Anything in your headset?

- Check, check, check. (blowing air)

- What a cluster.

- When an airplane is returned back to service,

pilots will expect that all sub-systems are working.

So you will show up to the airplane

and expect that everything has been serviced accordingly

and it's safe to return back to flying.

(narrator): After a short delay because of a minor radio problem,

Flight 9446 taxis for takeoff.

- Takeoff trims are set. Cabin PA not required.

- Tower, Colgan 9446. We're good to go: 24.

- Uh, Colgan 9446,

Runway 24...

cleared for takeoff.

- Cleared for takeoff: 24.

Colgan 9446.

- Set the power.

- Power set.

- The Beech 1900, being such a stable aircraft,

as soon as it accelerates on the takeoff roll,

it will reach flyable speeds in a distance as short as 4,000 feet.

- Eighty knots.

- And it will basically fly itself off the runway with very minimal pilot input.

- V1, rotate.

(narrator): At 3:38 p.m.,

Flight 9446 lifts off the runway...

...but it's barely gaining altitude.

- We have a hot elevator trim.

(narrator): The captain suspects there's an issue with the trim system,

which is preventing the plane from climbing normally.

Trim tabs on the elevator adjust the plane's pitch during takeoff.

They're powered by a switch on the control column.

But the captain's trim switch isn't working.

- If you have a trim issue on takeoff,

it is very difficult to overcome.

You have seconds, not minutes, because you don't have any altitude.

(narrator): Just 50 feet off the ground, the plane's nose is dropping.

- Roll back, roll back, roll it back. - I got it.

(narrator): Knabe instructs the first officer to adjust the trim manually.

- The manual trim is a wheel located on the left side of the throttle quadrant

that allows you to trim it into a nose-up attitude.

(narrator): But that doesn't help.

- Pull back.

- An airplane that is nose-heavy will continuously require back pressure on the control yoke.

(groaning) - It's heavy, buddy.

(narrator): Using brute force,

the pilots manage to raise the plane's nose and climb away from the runway,

despite the plane's determination to pitch down.

- Do the electric-trim disconnect? (grunting)

(narrator): The captain wants to cut the power to the trim altogether.

- Ah... (groaning)

(narrator): But before the co-pilot can even find the right circuit-breaker...

- Ah! Back, Steve! No, stay on the controls with me.

(narrator): ...the nose drops again.

- Put up our gear.

- Selecting the gear-up in an airplane

will reduce the amount of drag being exposed to the airstream,

improving your climb performance.

This would have made the pilots gain altitude at a faster rate.

(narrator): Forty-five seconds into the flight,

the pilots still can't get the plane to climb normally.

- 9446 is requesting emergency back, sir.

We got a runaway trim.

(narrator): The captain wants to return to Hyannis Airport.

- Colgan 9446, Roger.

Right or left downwind. Your choice.

Report midfield.

- Okay, Roger. Will do.

(narrator): Using all of their physical strength,

the pilots manage to level off at 1,200 feet

and start the turn back to Hyannis.

- Alright.

- We have a Beech 1900 aircraft that just took off reporting control problems.

We need Fire and Rescue to Runway 33.

(narrator): With brief respite from the struggle...

- Can I pull the breaker? - Yeah.

Pull the breaker, Steve. Pull the breaker. I have the yoke.

(narrator): ...the pilots return to troubleshooting the trim issue.

- Where is it? - Find it! (narrator): In the confusion,

the first officer can't locate the breaker for the automatic trim.

- Look left of the silver thing, Steve. Left of the silver thing. - Left of the silver thing?

- Left of the silver thing. Ugh! The stick!

Steve, stay with me! (groaning)

(narrator): The second attempt to disconnect the trim system also fails.

Less than two minutes after taking off,

Colgan 9446 is losing altitude.

(groaning)

- You pull for all you're worth. Just keep pulling for all you're worth.

- Really what he was saying is, "Pull for your life,"

because that was the only hope they had at that time.

(groaning)

(narrator): Five miles from the airport,

the pilots struggle to return to Hyannis.

- 9446 is requesting 33, sir.

- 9446, Roger.

Runway 33. Cleared to land.

- We're gonna need both of us on this, Steve.

(TAWS): Terrain. Terrain. Pull up!

(narrator): The pilots use all their strength to keep their plane airborne...

(TAWS): Terrain. Pull up! - Steve, keep-- - I'm pulling!

(narrator): ...but it's still not enough. - Hold on, Steve!

(groaning) (TAWS): Pull up!

- Oh, no! (screaming)

- We have a Beech 1900 aircraft down east of Point Gammon.

Two pilots, no passengers.

(narrator): Two minutes after takeoff,

Colgan 9446 crashes

3.5 miles from the airport in Hyannis, Massachusetts.

- The Coast Guard was there almost immediately,

but they were not able to save the pilot and the co-pilot.

Hitting the water at a very high rate of speed...

...is like hitting cement.

(narrator): The pilots' bodies are recovered from the wreckage within four hours.

A team from the National Transportation Safety Board, the NTSB,

arrives in Cape Cod to begin the investigation.

- Keep me posted on the recovery process.

(narrator): This is the second Beech 1900 to crash in six months.

- There was the Air Midwest accident down in Charlotte.

The big question was, you know: Is there anything related?

Was there a fleet-wide problem?

(narrator): NTSB investigators consider why Colgan Air Flight 9446 crashed

so soon after takeoff, killing both pilots.

It's similar to an Air Midwest crash in Charlotte, North Carolina,

which took the lives of 21 people.

- Witnesses reported that the aircraft...

climbed for a few seconds...

...and then the nose pitched up high in the air, it edged over,

and then literally tumbled...

towards the ground into a building.

(narrator): With hundreds of American-built Beech 1900s in service...

...investigators need to find out if there's a design fault

with the aircraft that could put even more lives at risk.

- Steve. Hey, great. You can set up over there. - Thanks, boss.

(narrator): The NTSB calls in Steve Carbone,

an investigator who has been working for months

on the Beech 1900 accident in Charlotte.

- What do we know so far about the cause

of that other Beech 1900 crash, the one in Charlotte?

- We think the plane was loaded wrong,

and the pilots lost control of it.

- A witness reported the Colgan Air 1900 seemed to struggle to hold altitude

before descending into the water south of the airport.

- Pilots understand that altitude is their best friend,

and taking off from the airport and then...

pretty much flying right into the ocean...

...is a sure sign that something was wrong.

It could be control problems after takeoff in both accidents.

The similarities between Colgan and Air Midwest

wasn't just the fact that both were Beech 1900.

In both instances, the attitude of the aircraft was uncontrollable.

Charlotte.

They lost control of the pitch.

- Was it outside its centre of gravity?

(narrator): The balancing point of an airplane is called its centre of gravity.

Passengers and luggage must be carefully distributed from front to back

to keep the plane stable in flight.

In Charlotte,

investigators believe the Beech 1900 may have been tail-heavy,

which caused it to pitch up after takeoff.

- The Colgan flight was empty. So without any passengers,

maybe the centre of gravity was too far forward?

- You can have an empty airplane

and still be out of your centre of gravity.

- The crew weight: 454 pounds.

(narrator): They calculate Flight 9446's centre of gravity

based on the distribution of the weight onboard.

- And then the fuel weight was 3,291 pounds.

That should do it.

Look how far forward that is.

- Yeah, but... it's within limits.

(narrator): The team is now certain

that whatever brought down Colgan 9446,

it was not related to its centre of gravity.

- With Colgan, centre of gravity...

didn't turn out to be an issue,

even though it did have to be eliminated as a possibility.

- Thank you for meeting with me.

(narrator): Investigators turn to the air-traffic controller for insight

into why the pilots of Colgan 9446 lost control after takeoff.

- Tell me about the flight. - It was a normal takeoff.

Uh, about a minute after, they wanted to return to the airport.

- 9446 is requesting emergency back, sir.

We have a runaway trim. (sighing)

- He told you a runaway trim? - Yeah.

- The pilot reported a runaway trim to Air Traffic Control,

which is a control issue, and so that information was very helpful.

It helped us work smarter, not harder.

(narrator): Runaway trim occurs when the motorized trim tabs on the elevator malfunction,

causing the plane to pitch nose up or nose down.

- Runaway trim close to the ground will be specifically challenging,

because pilots will have very limited time

to perform the required actions to safely control that aircraft.

- Now, he came off of Runway 24...

...and reported his emergency about here.

Turned back toward the airport.

And the plane never got above 1,200 feet on my radar.

And he hit the water... here.

- If the pilot feels that he's having a trim runaway,

there's something in the pitch system...

that is clearly a problem.

- This is very helpful. Thank you.

- And we're certainly gonna investigate that.

(narrator): Will the wreckage confirm what the pilots reported

and help explain what brought down

a widely used commuter aircraft in just over two minutes?

- Good. You've got them.

(narrator): The flight-data recorder and cockpit voice recorder

of Colgan Air Flight 9446

are recovered from the sea floor.

- They are in good shape.

Ship 'em to the lab.

Maybe we'll get some answers from these.

- We were lucky in some areas,

where we had the flight-data recorder and the cockpit voice recorder.

If we didn't have flight recorders on this one,

boy, I don't know.

- That is a rat's nest.

(narrator): Investigators turn their attention to what remains

of the control systems.

- So there's a lot of cables that go to the tail.

Cables that control the elevator,

the trim, and the rudder, as well.

- I see some of the trim cable in there. (camera shutter clicking)

Let's find as many pieces of it as we can.

- The trim cables are smaller and had fractured.

And so it's a big puzzle to be able to track the cables from one end to the other.

- Could take a while.

(narrator): While one team looks for the cables connecting the trim system,

another focuses on the maintenance history of Colgan 9446.

- I'm gonna look into work done on the flight controls.

The aircraft was brought into Hyannis four days before the accident

for a regular phase inspection.

(narrator): Could a faulty repair be connected

to the pilot's report of runaway trim?

- Check out which inspection they were in.

(narrator): At Colgan Air, monthly routine inspections are divided into phases...

...focusing on different areas of the plane.

- They were working on the tail. - Exactly.

Which means they might've done work on the trim system.

They flew in with no problems.

And then, on the first flight out, they couldn't control it.

Something happened that was detrimental

to the safety of the aircraft.

They spent at least four separate days on the inspection.

- What took them so long?

- It doesn't say.

A phase check - in this case, what they call a detail check -

you can do it within an eight-hour period,

especially on a 1900, because it's a very simple aircraft.

But the fact that it took four days

led us to understand that there was something else that occurred.

Mind if I record this?

- Uh, sure.

- I was wondering.

Why did it take you so long to do your phase checks?

- We definitely found a lot of stuff that we needed to replace.

Can I have the flashlight?

Just bring the light a little to my left?

Yeah, the trim actuator is worn out.

(narrator): Cables from the cockpit connect to the trim actuators...

...mechanical rods in the tail that move the trim tabs up or down.

- What did you do when you found the problem with the actuators?

- We removed the old ones, ordered new ones and installed them.

- And the new ones went in easily and it worked fine?

- Uh, well, not exactly.

Okay, Bob, run the trim system, please?

(static) - Did the actuators move?

- No. Neither did the trim cable.

(narrator): The test revealed problems with the actuator replacement.

- When we replaced the actuator, we...

we bent and kinked the cable that connects it to the cockpit controls.

(stammering) It was just a dumb mistake.

- If he's an experienced, competent mechanic,

why would he do that?

And the answer was he was not.

He was a new hire, had never done this job before,

and their training program allowed him to do this without any supervision.

- I ordered a new cable and installed it.

That's why it took four days.

- And you tested it?

- Yeah. Yup.

(narrator): After the new cable was installed,

maintenance workers performed a visual check.

- Okay, let's give it a try.

- When examining the paperwork after the accident, everything looked in order.

- That's it. It's working. Thanks, man.

- Yet we still had an issue,

because it didn't explain what actually happened.

(narrator): With no credible leads

to explain why the pilots thought they had a trim issue,

investigators must rely on what they learn from the CVR,

the cockpit voice recorder.

- Okay, let's hear it.

- The recording runs about 17 minutes,

from the moment the pilots powered up on the ground.

(narrator): Could the pilots' communications reveal

why Colgan Air Flight 9446 failed to maintain altitude?

(Knabe): Hyannis Maintenance, this is Colgan 9446.

Hey, I was told to stay in contact with you for the whole trip?

- Yeah, they might call ya, turn you back, because they did find a problem.

I don't know for sure.

- Why would Maintenance want to turn them around?

- Maybe there was something wrong with the plane.

Somebody had doubts about the work they did?

- I, as a mechanic,

could not...

ever release an aircraft...

that there was a question of its airworthiness.

You cannot say, well, you know, the wings are pretty... pretty strong on there.

We're 90% positive they're not gonna fall off.

You can't do that.

- I prefer not to fly something if it's broken. I'd rather you do it,

because you are the pilot in command.

- Alright.

- You know, a broken airplane? I wouldn't want to screw it up. (chuckling)

- Okay, it'll be a standard Colgan takeoff.

If things get spooky on the runway, we'll abort it.

- Did he just say "spooky"?

(narrator): As investigators continue to review the CVR...

- A flight crew should not be that nervous.

(narrator): ... they're surprised by the pilots' concern

about the condition of their aircraft.

- Sadly, the aircraft manuals...

went down with the aircraft.

So exactly what the maintenance personnel...

put in those logbooks for the pilots to review,

we will never know.

- When did they first realize there was a serious issue with their aircraft?

(sighing) - It looks like merely seconds after takeoff.

- V1. Rotate.

- We have a hot elevator trim.

- They identified a trim issue seconds after takeoff,

long before contacting the controller.

- So what did they do about it?

- Kill the trim, kill the trim.

(narrator): The captain tries to disconnect the trim system on his yoke...

...but his attempts fail.

- Roll back, roll back, roll it back. - I got it.

(groaning)

- They're commanding nose-up trim inputs, but it doesn't seem to help.

- 9446 is requesting emergency back, sir.

Got a runaway trim.

- Okay, there it is. Runaway trim.

Just like the controller said.

- Did they try pulling the breaker?

- Looks like it.

- Pull the breaker, Steve. Pull the breaker. I have the yoke. Ah!

- Listen to how exhausted they are, trying to keep the nose up.

(FO): Where is it? (Captain): Find it!

- The pilot was calling for the co-pilot to pull the circuit breakers,

so they can stop these electrical signals

that are commanding the runaway trim.

But you have to have time to pull the circuit-breakers.

- Look left of the silver thing, Steve. Left of the silver! - Left of the silver thing?

- Left of the silver thing. Ugh! The stick!

Steve, stay with me! (groaning)

- The co-pilot had to abandon pulling the breaker in order to help the captain.

- Steve, keep-- - I'm pulling!

(alarm sounding) (groaning)

- Oh, no! (screaming)

(screaming)

- Two minutes...

from takeoff to impact.

- Those guys fought the trim right until they hit the water.

- We need to find out what's going on with that trim system.

(narrator): Was there a mechanical issue with the trim

that the pilots could not overcome?

- Okay, let's have a look.

- We were lucky we had a solid-state flight-data recorder.

Some of the old, old flight recorders might only have 16 parameters.

This one had a lot more.

(narrator): Investigators examine the FDR,

the flight-data recorder,

to determine why the pilots reported a runaway trim.

- This doesn't look right. - What do you mean?

- This trim data is way out of calibration.

- It either... wasn't maintained properly,

or it was damaged in the accident.

And so on this one, we didn't have exact...

trim position.

- If the FDR wasn't calibrated, those readings are worthless.

(narrator): It's a major setback.

Without the FDR data,

the investigators may not be able to confirm

the pilots' report of a runaway trim.

- But we have all those other parameters: pitch, elevator.

Let's ask the lab to try and calculate what the trim position would be.

- Performance case study.

That's a great idea.

- A case study like this would help us to define...

...whether the elevator trim-tab cables had anything to do with the accident.

It was one other thing that we could check into

to verify the results we were finding.

(narrator): Will the team be able to get accurate trim data...

- Ah! Steve, keep-- - I'm pulling!

(narrator): ...and explain why two experienced pilots

were unable to keep their plane in the air?

(groaning) - Oh, no! (screaming)

- So... the lab took the control-column positions

and extrapolated for trim.

- I see. Excellent.

(narrator): A performance study using the FDR data

gives the NTSB a new look at the trim inputs on Flight 9446.

- So they adjust the trim to take off right here.

- Yeah. It's part of the Before Taxi checklist.

- Before Taxi checklist.

- Uh, Before Taxi. Weather radar.

- On standby. - Trim set?

- Point 5. Takeoff trim set.

- The takeoff trim was set to. 5 nose down

instead of. 5 nose up.

- That's odd.

When's the next input?

- Right after takeoff.

- That's right after he said...

"We've got a hot elevator trim."

- The plane's pitching down instead of up.

- How's that possible?

(narrator): Investigators discover the plane wasn't responding

to the pilots' nose-up trim inputs.

- And then happens again here, one last time, a few seconds later.

- Roll back, roll back, roll it back. - I got it.

(narrator): The more the first officer tries to manually trim the nose up...

(groaning) ...the more the nose drops.

- It's like the trim is reversed.

(Gretz): A good analogy is learning to drive.

Imagine how weird it would be...

if you turned your steering wheel right and the car went left.

- Talk about confusing.

- And exhausting.

- You pull for all you're worth. Just keep pulling for all you're worth.

- They were dealing with a backwards trim,

which I don't know how anyone would've ever fathomed that.

(groaning)

(narrator): Investigators calculate that within a minute of takeoff,

the pilots would've required 250 pounds of force to hold the nose up.

(TAWS): Terrain. Terrain. - Ah! Steve, keep-- - I'm pulling!

(groaning) - Hold on, Steve!

- Ah!!!

- How on earth could they have wired a trim system backwards?

- The team retrieved this from the wreckage. - Oh, great.

(narrator): In an effort to prove the trim cables on Flight 9446 were reversed...

...investigators study a key piece of the trim system found in the wreckage.

- Okay, the trim cable...

is threaded and wrapped around this drum...

...and then runs in a loop from the cockpit to the tail.

- Maybe they fed the cable incorrectly around the drum.

- Let's check the installation manual.

It looks like Maintenance threaded the drum correctly.

- Yeah.

But how did they install it?

- The cable drum was one piece of the story that was telling us

that it might've been incorrectly rigged,

but we needed to dig deeper.

- Okay, let's give this a try.

(narrator): The NTSB considers how the maintenance crew installed the drum.

- That's good.

Here we go. Yeah, it's in.

Well, that doesn't fit.

Yeah.

Yeah, the only way to install this thing...

Like this.

(narrator): Investigators discover that in order for the drum to fit the pin,

it had to be flipped, thereby crossing the wires.

- Well, that was the huge aha moment for me.

- The manual, the way it was depicted at that time,

it could mislead somebody.

In this case, it did.

- We have a hot elevator trim.

(narrator): Because the wires were crossed,

the trim tab operated in reverse.

- Kill the trim, kill the trim.

Pull back.

- They knew they had a malfunction.

They just couldn't figure out what it was.

- There's only one explanation.

The maintenance manual must be wrong.

I'll check with the manufacturer.

(narrator): But even if the manual is wrong,

why didn't anyone notice the trim cables were crossed?

- I'll check if the maintenance team

got an inspector to sign off on the work.

They are a second set of eyes.

They have to be the one who is making sure that the job is done right.

That is what an inspector does.

After you installed the drum, did an inspector sign off on the work?

- Yes, he did. In fact, he assisted with it.

- He assisted? - Yeah.

- The inspector cannot get in there with wrenches,

he cannot get in there and tell you, "Okay, you gotta put this bolt here,"

or anything like that.

- Thanks for your help tonight.

- The thing is, with an inspector being part of the job,

he's making the same mistakes

the people that he's supposed to be overlooking are making,

so he becomes part of the problem.

(narrator): The inspector who helped with the installation

didn't notice the crossed wires,

and signed off on the work.

- Uh, the last time we spoke,

you said you tested it?

- That's right.

(narrator): After the new cable was installed...

- Okay, let's give it a try.

(narrator): ...maintenance workers performed a visual check.

- Yeah, that's it. It's working. Yeah, thanks, man.

- Yeah. It's coming in now.

Thanks.

(hanging up)

- Hey. - Hey.

What'd you find out?

- The inspector helped with the installation,

so not exactly an objective inspection.

What about you?

- Well, it's just like we thought.

The drawing in the manual is wrong.

This is how the drum should've been oriented when they threaded the cable.

The manual shows the slots on the drum are facing out.

But the correct way...

...to thread the cable is with the flat side facing out.

- Here's what I don't get.

They tested the trim system when the installation was complete

and said it was working fine.

- How's that possible?

(sighing)

- Long night? - Yeah.

Found a recording of the trim check test.

- You're kidding. - It's on the CVR,

recorded well before their flight.

- In order for the mechanics to do an operational check correctly,

they had to power the airplane up.

- Okay, Bob, run the trim system, please?

- So the power was on, the CVR was on. It worked to our advantage.

I think I know how the trim tabs passed the visual ground test

even though they were running in reverse.

(maintenance worker): Are you good in the cockpit?

- Yeah.

- Okay, let's give it a try.

Trim nose up.

- Trimming nose up.

- Yeah, moving up.

Looks good.

Yeah, trim nose down?

- Trimming down.

- Okay. Yeah, that's it. That's working.

Thanks, man.

- Sounds like a normal test. - No. They got it backwards.

We hear the cockpit call trim up,

and the maintenance worker says he sees the trim tab move up.

That is reversed.

(narrator): If you trim nose up,

the trailing edge moves down,

in the opposite direction.

The same is true for trimming the nose down.

- It is counterintuitive... but you're right.

It is an easy mistake to make.

- Checking a trim system can be a little confusing.

You have to make sure you're on the same page with the other person.

Are you talking tab up or nose up?

'Cause tab up is nose down.

- The ground guys missed it, okay.

Why didn't the pilots catch it?

- Trim test is definitely a pre-takeoff checklist item.

But did they run it?

- According to the transcript, they ran the checklist.

- Alright, Before Start checks.

- Uh, parking brake?

- It's set. - Pre-flight complete.

- Before Taxi checklist. - Before Taxi. Weather radar.

- They skipped the trim check.

- I'm biased 'cause I have a pilot background.

I feel like that first-flight- of-the-day checklist is crucial. That's where you can catch it.

- Even if they had checked it,

would they have known whether the trim system was reversed

just by looking at the direction the trim wheel was spinning?

- Good point.

(narrator): Pilots test the trim by pressing the trim switch

and monitoring the direction in which the manual trim wheel spins.

To trim nose up, the wheel would turn backwards.

Investigators recreate the reversed trim system

on the same model of Beech 1900 that crashed

to determine whether the pilots could've detected that the trim was reversed.

- Let's give this a try.

(narrator): Investigators trim the plane nose up.

- The wheel is moving backwards,

the way the pilots expected it to turn.

(narrator): Even though the trim cable was reversed,

the wheel still moves backwards as it should.

- What is in error is the fact that the drum is upside down.

It is now running the cables in the wrong direction.

So everything in the cockpit is correct.

(narrator): The test reveals the pilots of Colgan Flight 9446...

- V1. Rotate.

(narrator): ...wouldn't have realized the cables were reversed

even if they had checked them prior to takeoff.

- We have a hot elevator trim.

(narrator): In their final report,

the NTSB concludes the cause of the accident

was the improper installation of the trim-cable system,

and Beechcraft's erroneous depiction of the elevator trim drum

in their maintenance manual.

- Ugh! The stick!

Steve, stay with me! (groaning)

(narrator): These factors ended up sealing the pilots' fate.

(TAWS): Terrain. Terrain. Pull up!

- It's gonna take both of us on this, Steve.

(TAWS): Terrain. Terrain. - Steve, keep-- - I'm pulling!

(groaning)

(narrator): The pilots' grueling efforts kept the plane in the air

for more than two minutes. (TAWS): Pull up! (narrator): But in the end,

the extreme stick pressures were too much for the pilots to overcome.

- Picture trying to do your day job while deadlifting 250 pounds.

(groaning) (TAWS): Pull up! - It's just too much.

- Ah! Hold on, Steve! (screaming)

(alarm sounding)

- Oh, no! (TAWS): Pull up! (screaming)

- This accident was 100% preventable.

First and foremost is,

your plane has to be flyable,

and it's only flyable if the manuals

and maintenance and pilot instructions make sense.

(narrator): The Colgan Air 9446 report echoed similar findings

to the other Beech 1900 crash months earlier in Charlotte, North Carolina.

Improperly installed control cables were also a factor

in the Air Midwest accident that killed 21 people.

- If you looked up the term "maintenance accident" in the dictionary,

those two accidents would be there.

Colgan and Air Midwest were poster childs

for maintenance accidents.

If Colgan properly followed the maintenance program

as dictated by the regulations,

this accident never would've happened.

(narrator): After the accident, Beechcraft's maintenance manuals were amended.

And airlines adopted stricter procedures for airplane checks

after undergoing routine maintenance.

- The person in the cockpit missed it,

the people on the elevators missed it, the inspector missed it.

Everybody missed what was just...

such a simple mistake.

Subtitling: difuze