All language subtitles for M.2003-S24E08-Pitch.Battle.Colgan.Air.Flight.9446.WEBDL-1080pEAC3.5.1h264-NOGRP_track3_[eng]

(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