All language subtitles for M.2003-S24E09-Deadly.Departure.Air.Transport.International.Flight.782.WEBDL-1080pEAC3.5.1h264-NOGRP_track3_[eng]

(narrator): The Pilots of Air
Transport International

Flight 7-82 prepare to depart
from Kansas City

with just three of their four
working engines.

- A three-engine ferry,
it's a difficult manoeuvre.

- A hundred knots...
- Okay.

(narrator): Their takeoff
goes tragically wrong.

- We're off the runway.

- Go max power!

- You got it!

(crashing)

- This accident, of course,
was very tragic

and they did not make it.

(narrator): Examination of the
wreckage reveals very little.

- From stem to stern, wingtip
to wingtip, it was airworthy.

(narrator): But when
investigators

visit the simulator used
to train the pilots...

- This is not how their
aircraft would have behaved.

(narrator): ...they begin
to understand

the origins of this accident.

- The simulators are
extremely accurate.

We were shocked that this
one, uh, was not.

(intro)

- Okay, first things first,

let's review our three-engine
ferry procedure.

- Sure thing.
- Yup.

(narrator): Air Transport
International Flight 7-82

has been cancelled.

One of its four engines
won't start.

- Maintain directional control
using rudder

and nose wheel steering.

(narrator): The replacement
crew is taking the cargo plane

for repairs to a maintenance
facility in Massachusetts.

- The only crews that
are permitted to do

a three-engine ferry are
the very experienced crews,

because it is very dangerous.

It does not happen very often.

(narrator): Captain Walter Miga
has worked his way up

from flying the DC-6 and DC-7

and is now captain on the
airline's DC-8 aircraft.

- The captain had about four
thousand hours in the DC-8.

He'd been flying
the DC-8 for years.

- Max wind for takeoff
crosswinds 10 knots,

tailwinds 5 knots.
- Okay,

let's check the weather on that.

(narrator): First Officer
Mark Ulmer is new to the company

and the plane, but he's been
flying for 14 years.

- He only had about two hundred
hours in the DC-8.

However, uh, he was commended
for being enthusiastic,

for trying to learn, and being
an important part of the crew.

(narrator): There's a third
crew member onboard:

Flight Engineer Kerry Hardy.

- The flight engineer had more
than 4,000 hours of flight time,

and in large airplanes.

He was a very experienced pilot.

(narrator): It's a two-hour
flight from Kansas City

to Chicopee, Massachusetts where
the engine is to be repaired.

- Here you go.

- Thank you.

(narrator): The crew has
concerns about their schedule.

- There was a curfew on the
airport in Massachusetts.

The airline had told the crew

that they needed to land
by 11 p.m.

because that is when
that airport would close.

- What we're gonna need to do
is get as much direct as we can.

That will allow us to fly
a little bit better

than the 2-88 knots
indicated.

- Well, as pilots,
we're always trying to hurry.

The crew had decided that
they wanted to fly

a more direct route
at a faster speed.

- So, we'll be using
1-9, right?

(narrator): First Officer Ulmer
wants the longest runway

for their takeoff.

- I'm gonna request right

because we'll get an extra
13,000 feet.

- Okay.

(narrator): In order to take
off, the DC-8 needs power

from at least three
of its four engines.

- You always want the longest
runway that you can get

with a takeoff like this
so that you have more room

to get the airplane up to
the proper speeds.

- Kansas City, this is Air
Transport 7-82 ready to taxi.

We're gonna be a three-engine
departure.

(narrator): Flight 7-82 checks
with Air Traffic Control

about their runway assignment.

- Air Transport, 7-82, south on
bravo taxi runway one left.

- Okay, south on bravo taxi
one left, Air Transport 7-82.

What's the winds?

- Winds 240 at 4.

- Roger.
- That's a tailwind, right?

- Yeah.

- You don't want a tailwind
with a three-engine takeoff

because it's going to take more
runway.

- 240 and running into what?

- Four.

- Four knots.

- The tailwind was acceptable.

The maximum tailwind allowed
was five knots,

and they had four knots.

(narrator): Flight 7-82 taxis
to the longer runway.

- Takeoff data?

- Okay, this is a max power
takeoff.

(narrator): The pilots review
the required speeds

for the three-engine takeoff.

- Okay. I got VMCG of 1-0-7,
1-23 for VR,

1-40 for V2,
and 2-10 for the cleanup.

- Set.

(narrator): This takeoff
requires raising both
inboard engines,

Engine 2 and Engine 3,
to max power.

Only when the plane reaches
a certain speed

can the third working engine,
Engine 4,

be increased to max power.

- Controlling the airplane on
the runway

while you are adding the power
from the third engine is vital.

It must be done slowly and you
must be able to keep control

of the airplane at all times.

- And of course, we'll all
be watching real close

for loss of directional control.

- The two engines
on the right side

are gonna cause the aircraft
to veer to the left.

It's only gonna have one engine
operating on the left side,

so directional control
is the critical issue

on a three-engine takeoff
like this.

- Number 1 engine
is inoperative.

So what we're gonna do is set
max power on number 2

and number 3.
- Right.

(narrator): As the crew nears
the end of the taxi,

they finalize the takeoff plan.

- Okay, then I'll ease
in number 4.

- And I'll call increments
of point one.

- Yeah.

(narrator): Flight 7-82
is now ready for takeoff.

(whirring)

- Okay, coming up
on 2 and 3.

(narrator): The crew lets
the inboard engines spool up

before the plane starts moving.

- Set max power.

- Max power 2 and 3.

(narrator): At 8:20 p.m.,

Air Transport International
Flight 7-82 begins its takeoff.

(tense music)

- One point three....
point four...

(narrator): The flight engineer
closely monitors engine power.

- Airspeed's alive.
- ...one point six.

- Eighty knots.

(grunts)
- Ninety knots.

(narrator): But 20 seconds
into the takeoff roll,

the plane veers left of
the centreline.

- One point eight.

- A hundred knots.

(narrator): The captain
uses his rudder

to redirect the plane to the
centre of the runway,

but it doesn't work.

- Abort.

(tense music)

Spoilers.

- Air Transport 7-82
aborting takeoff.

(narrator): Flight 7-82 aborts
its three-engine takeoff.

- Air Transport 7-82, roger.

When able, turn right
off the runway.

Do you need any assistance?

- Negative assistance?
- No. Negative.

- Negative assistance,
Air Transport 7-82.

(narrator): The crew considers
what went wrong.

- We were at 1.6 and then
power went all the way up

to 190 as you ran it up,
so it went up real fast.

- And number 4 jerked up

while I was trying
to ease it in.

- You brought it up too fast,
or it jerked up, or what?

- The power on it just came on
too fast, that's what happened.

(narrator): Hardy proposes
a solution.

- If you want to try it again,

I can try adding the power
if you like.

- Okay, let's do it that way.

- It was decided that
the flight engineer

would help the captain
and he would add the power

on the third engine for
the second takeoff.

- Tell them we wanna taxi back
and have another try at it.

- Kansas City ground,
Air Transport 7-82

we'd like to taxi back to depart
one left again.

- Air Transport 7-82,
roger, taxi one left.

- Okay.

(narrator): While returning
to the runway,

the crew revisits
the takeoff procedure.

- Okay, when do I have to have
max power

in on the outboard engine?

- One hundred and seven.

(tense music)

(narrator): Flight 7-82
is again ready for takeoff.

- Kansas City control,
Air transport 7-82,

ready to go at the end of one
left, a three-engine takeoff.

- Air Transport 7-82 heavy,
control, one left,

turn right 030,
cleared for takeoff.

- I've lined up just to the
right of the centreline here.

- That's a good idea.

- The captain did line up on
the right side of the runway

because they veered off to
the left on the first takeoff

and he wanted to give himself
more runway width available

in order to do the second
takeoff.

- Okay, make sure that
2 and 3 are set...

- Max power?

- Yeah.

(narrator): At 8:26 in
the evening,

Flight 7-82 begins
its second takeoff attempt.

- One one... one two...

(whirring)

one three...

One four...

One five...

One six...

- Airspeed's alive.

(narrator): Ten seconds
into the takeoff roll,

the plane again starts veering
to the left.

- One seven.

(narrator): The captain tries
to direct it back

to the centreline with
the rudder.

- God bless it.

(tense music)

- Keep it goin'.
- Keep it goin'?

- Yeah.

- Eighty knots, ninety knots...
- Okay.

(narrator): The captain
attempts to get airborne...

- We're off the runway.

(narrator): ...but he doesn't
have the speed.

- Go max power!

(narrator): He tries
to salvage the takeoff.

Flight 7-82 is barely
in the air.

- Get the nose down!

- Go max power.
- You got it!

- Max power!

(crash, explosion)

- Alert 3. Runway 0-1,
north end, DC-8 on takeoff.

(narrator): Air Transport
International Flight 7-82

has crashed beside the runway
at Kansas City Airport.

Fire and rescue units are nearby
on a night-training exercise.

They rush to the crash site.

- We heard a real loud boom
like something hit
the dock real hard.

- It didn't take long for fire
rescue crews to arrive
on the scene, I'm assuming?

- No, no. Just in a matter of
about 60 seconds.

(sirens)

(narrator): All three
crew members are dead.

The National Transportation
Safety Board, or NTSB,

is notified, and Bob Benzon
is named Lead Investigator.

- The aircraft had broken apart,
although it three large pieces.

The fuselage, behind the wings
seemed to be reasonably intact.

The wing assembly itself seemed
to be in one piece.

(narrator): The question
Benzon must answer:

Why was the crew unable to
execute this takeoff,

not once, but twice?

- We were aware that it was an
attempted three-engine takeoff.

And because that is an unusual
manoeuvre,

we wondered if that could
have been part of the reason

the aircraft crashed.

- Thanks for taking
the time to meet.

(narrator): While the plane
wreckage is collected,

investigators speak
to the controller,

to learn more about the crash.

- When did you realize there
was an issue with Flight 7-8-2?

- I guess the first thing
that caught my attention

was that they aborted
their first takeoff.

- Why?

- I was told the plane veered
left on the runway.

- And then?

- They lined up
for their next takeoff

and the same thing happened.
Only worse.

- The plane veered left,

and this time they rotated
awkwardly, nose high.

- There was a fire coming out
of one of the engines.

And then there was a loud bang.

Then the plane stalled,
rolled left, and crashed.

(foreboding music)

(crash, explosion)

- The fire, what side?

- Left.

- That had to be
engine number 2.

(narrator): Plane engines are
numbered from left to right.

For Flight 7-82, the number one
engine was inoperative.

If engine two failed,

the crew would be left with only
the right engines.

- We knew because this was a
three-engine takeoff attempt,

and if we'd lost any more power
on the left side of the aircraft

it may have caused an
immediate crash.

- What have you got?

(narrator): Investigators
examine engine number 2

after its recovery from
the crash site.

- Ah, no penetration
on the nose cowl.

Fuel is present throughout.

Compressor bleed
valve was closed.

(narrator): They discover
that it was operative

and it didn't fail on takeoff.

- That fire in the engine was
probably a compressor surge.

- Hmm.

- A compressor surge
is a phenomenon

that occurs when the tilt
of the engine is high enough

that it disturbs the airflow
going into the intake

and causes a big bang, flames
coming out both ends perhaps.

But technically the... the
engine isn't damaged at all.

- No unusual wear.

(narrator): If all three
remaining engines were working,

could one of the brakes
have locked,

causing the plane
to veer left?

- The treads look almost new.

No flat spots.

(narrator): The tires show
no sign of abnormal braking.

- Okay, let's have
a look at the brakes.

- We thought that because they
had aborted the earlier takeoff,

maybe they, uh, they used
the brakes very heavily

and caused them to, uh, fail,
frankly, or weaken,

and then fail completely during
the second takeoff.

- Brake stack assembly
looks fine.

- No discolouration
or pitting on the pads.

- Discs are clean.

No signs of overheating.

- We looked at brakes
very carefully.

Uh, we found nothing really
physically wrong.

There was no overheating
or melding together.

So in essence the brake
system did not become an issue.

(narrator): The NTSB is still
unable to determine

why the crew lost control.

- Let's check out the rudder.

- The rudder plays a massive
role in a three-engine takeoff.

It is the key to keeping
the airplane going straight

and being safe.

(narrator): Three-engine
takeoffs

require the two inboard
engines

to reach V-M-C-G, or Minimum
Control Speed on the Ground.

Only then can the rudder
counteract the directional force

of the third working engine
as it's powered up.

(whirring)

- The faster you are going, the
more rudder control you have,

and you need that rudder
control to be able to keep

the airplane on the runway.

- How's the rudder control
cable look?

(narrator): Did the rudder
malfunction,

causing the crew to lose control
of the plane?

- The cable is severed in
several different places, see.

- There's no corrosion
or fraying.

Probably severed in the crash.

- Agreed.

Let's test the rudder.

- We looked very carefully
at the cabling

used in the rudder system.

And the only thing we did note
were simple breaks in the cables

because of overload,
instant overload,

which occurred during the crash.

- Control cable ready?

- Good to go.

(narrator): If the rudder
cables didn't fail,

then could the rudder itself
have malfunctioned.

- Okay, deflect left.

(narrator): Investigators
test its movement.

- Turning to the left.

(narrator): But the
rudder moves freely.

- We're good.

- On occasion in previous
accidents rudders have locked up

or become blocked by some...
some broken part.

And we found that, uh, this did
not occur during this event.

(narrator): The mystery of
Flight 7-82's crash deepens.

- In the end, uh, we looked
at the entire wreckage

very, very carefully, uh,
from stem to stern,

wingtip to wingtip,

and determined that it was
airworthy.

We had to look into other areas
to determine what happened.

- Okay, we found skid marks
on the runway

for the first takeoff.

Starting here all
the way to here.

Then they aborted.

(narrator): Investigators now
turn to evidence left behind

by Flight 7-82 to determine
why it veered off the runway.

- In the second takeoff, the
skid starts even earlier: here.

And the marks last...

...until here.

- The skid marks were there
indicating that,

although the aircraft was
rolling forward,

it was skidding to the left side
of the runway.

(narrator): The skid marks
are a telltale sign.

- It looks like they had
too much power

to the right side
of the plane.

And it happened early on.
Look.

On both takeoffs, they skidded
to the left after only 500 feet.

- Correct.

So maybe there was an issue
with the power

in that third working engine.

- Let's find out.

- We discovered
that the engine operation

would probably be some kind
of an issue.

And the only way we could
determine that

was to go to the flight data
recorder.

(narrator): Did engine number 4

somehow cause the plane to veer
too far to the left?

- There's the airspeed
data there.

(narrator): Investigators
examine the flight data recorder

to learn how the crew
managed their engines.

- It looks like we had
a glitch here.

- To learn more about how the
crew manipulated the throttles,

we needed parametres
from the FDR:

airspeed and the engine pressure
ratio, or the EPR.

We had airspeed,
but unfortunately,

this FDR did not record
correctly the EPR.

- We need a workaround
to get that engine data.

- What about a sound
spectrum analysis?

- Sure, let's give it a shot.

- Okay.
Coming up on 2 and 3.

(powering up)

- There's a microphone
in the cockpit.

It records every sound.

And it can record and hear
the engines

as they are increased
or decreased.

And they're very accurate.

(narrator): The team conducts
a digital analysis

of the engine sounds.

- Done. Great work.

- Let's compare the third
working engine, Engine 4,

with the plane's overall
airspeed data.

- In the end, we used both
the FDR and the CVR

to determine the airspeed
throughout the entire flight,

and the power setting, for all
three of the operating engines.

- It looks like...

...the third working engine,
engine number 4,

almost reaches max power
in 10 seconds

when the airspeed is only about
65 knots.

- That seems awfully slow.

(narrator): Was the power
to engine 4

increased too soon
in the takeoff roll?

- Let's check the three-engine
takeoff chart.

(narrator): Investigators
examine the chart

used by the crew to determine
the speed they needed to reach

before applying max power
to engine number 4.

- What was their weight?

- Ah, their weight
was 220,000 pounds.

Temperature was zero degrees.

- They shouldn't have put
the third working engine

to max power until they reached
116 knots.

That's the target speed.

- At 65 knots, it was way
too much power, too soon.

- One three, one four,
one five, one six.

- Airspeed's alive.

- One seven.

(narrator): Investigators
conclude engine 4

was powered up too fast,
pushing the plane to the left.

- They never reached the speed
they needed

for the rudder to counteract
the power of both engines

on the right side of the plane.

- That's why they veered
off the runway.

(narrator): Why did the pilots
increase power

to the right outboard engine
so quickly?

- We knew that the issue here
was reaching VMCG

at exactly the right time,
with the correct airspeed,

and everything.
But the crew didn't do that

and that one became the big
question.

Why? Why didn't they do that?

- Whenever you're ready.

(narrator): Benzon's team
listens to the cockpit voice
recorder, or CVR,

to better understand how
the pilots of Flight 7-82

performed the three-engine
procedure.

(Captain): Okay, this is a max
power takeoff.

Speeds: VR 1-23, 1-40 and 2-10.

VMCG of 1-0-7.

- Okay, I got VMCG of 1-0-7,

VR of 1-23, 1-40 for V2,
and 2-10 on the cleanup.

- Both pilots think
the VMCG is 107 knots.

It should be 116.

- Yup, VMCG is 116 knots.

- So, how did the flight
engineer get that wrong?

- What a minute.

Check this out.

107 is the speed for a
temperature of 30 degrees...

Celsius.

(narrator): Investigators
discover the flight engineer

used the speed for a temperature
of 30 degrees Celsius,

but on the night of the crash
it was 30 degrees Fahrenheit,

approximately zero degrees
Celsius.

- That C for Celsius
is so small.

He must have used 30 Celsius

thinking the chart is in
Fahrenheit.

(somber music)

- They selected the wrong line
to get their V speeds.

- Here you go.

- Thanks.

- They were nine knots off on
what VMCG should have been.

(narrator): It's happened
before.

Four years earlier,
a flight engineer

on another Air Transport DC-8

miscalculated the plane's
weight,

providing the captain
with the wrong takeoff speeds.

- I was one of the first
investigators

from the NTSB to arrive
on scene.

When I went into the cockpit,

it didn't take any smarts
at all to see the takeoff data

was 100,000 pounds too low.

- And as a result, the company
very seriously

began to emphasize the need
to check those calculations

and make sure they're accurate.

And so it's disturbing
that in this accident,

that did not happen.

- Was that the only thing
the pilots missed?

(tapes whirring)

- A question to consider,
Captain,

once we get near VMCG, if we've
used all our rudder control,

you might wanna consider abort,
because when we get higher,

we're gonna be in worse trouble,
correct?

- That's correct, absolutely.

(narrator): The CVR of Flight
7-82

reveals that the captain
and first officer

were uncertain about the impact
of VMCG speed on rudder control.

- The first officer made
the comment that you have...

rudder control is less effective
once you go beyond VMCG,

when actually the opposite
is true.

- Uh, no, actually.

(narrator): The flight engineer
realizes their mistake.

- Above VMCG, your rudder
has more authority.

It's helping you more.

- I understand.

(narrator): But the captain
fails to acknowledge

the correction.

- The flight engineer had
the right answer

that the faster the airplane
goes,

the more effective
the rudder becomes,

and you need that effectiveness

to keep the airplane
on the runway.

- Why didn't the crew stop

and discuss it until they
reached a consensus?

- That's the advantage
of having three people
in the cockpit.

- The right answer generally
exists somewhere in the cockpit.

In this instance the flight
engineer had the right answer.

- Maybe their lack
of understanding

about the procedure caused them
to abort their first takeoff.

- It's possible.

- Here it is.

Check that out.

- The power went all the way up
to 190 as you ran it up,

so it went up real fast.

- And number 4 jerked up while
I was trying to ease it in.

- You brought it up too fast?

(narrator): Investigators learn
that the captain struggled

with engine 4's thrust during
the first takeoff roll.

- The power on it just came on
too fast, it's what happened.

- If you wanna try it again,
I can try adding the power,

if you like.

(narrator): The flight engineer
proposes an unorthodox change

to the procedure.

- Okay, let's do it that way.

- The flight engineer took
over control of engine 4?

- That's crazy.

- They couldn't have understood
the difficulty of the procedure

if they split the
responsibility.

- The core problem is
the captain could not tell

how much rudder he was going
to need

because he wasn't the one adding
the thrust to the airplane.

It's like trying to have two
people drive a stick shift car,

one doing the steering,
one doing the shifting.

It just doesn't work.

You need to have one person
in control at one time.

- The flight engineer
and the captain thought

they could coordinate
the takeoff together.

Let's figure out how they did.

- We worked with the Douglas
Aircraft Company

and they produced a, uh, a graph
of what an ideal

three-engine takeoff should
look like with airspeed

and engine speed.

We compared that with
what actually happened.

- So this is what the crew
was supposed to fly.

- It seems like the power
and speed rise steadily,

in unison until they reach VMCG.

- Very, very smooth
and synchronized.

But in the accident flight,
the flight engineer

brings up power to the engine
number 4 really quickly.

(narrator): The plane begins
to veer left, off the runway.

- Then, he brings down
the power abruptly, here.

Probably in reaction to the
plane being out of control.

- The most probable thing
we think happened

was that the flight engineer
saw the aircraft going off

to the left of the runway
and kinda panicked

and tried to pull the engines
back a little bit.

- God bless it.

(whirring)

- Keep it goin'.

- Keep it goin'?
- Yeah.

(narrator): Instead
of aborting,

the captain attempts
to get airborne

because they're about to veer
off the runway.

- He was countermanded
by the captain, who said,

"No, no, keep going."
So the engines went back up.

- We're off the runway.
- Go max power!

- Then the captain insists

that he goes to max power
a few seconds later.

- They don't have enough
speed for takeoff.

- The captain never decided
to abort

and it appeared to be that
he thought

he could get the airplane
in the air.

We will never know.

- The captain
and the flight engineer

could never coordinate
their actions.

- One two...

One three.

(narrator): Why did the crew
fail to execute

a takeoff procedure
that they were specifically sent

to Kansas City to perform?

(tense music)

- You got it!

- Find anything?

(narrator): Investigators
review the work history

of Flight 7-82's crew to
determine their experience

with three-engine takeoffs.

- Our flight engineer and our
first officer were new hires.

They were still on probation.

It's almost certain
that neither

had performed
a three-engine takeoff.

- And the captain?

- He'd done it three times,
but only as first officer.

He'd never actually
flown as a captain.

- They were all green.

(narrator): The closest
the captain came

to flying this type of takeoff
was in a simulator.

He only trained on it twice.

Investigators travel to
Colourado to assess the
simulator

the airline used to train
its pilots

to perform three-engine
takeoffs.

- Okay...

This is a three-engine takeoff,

and we are watching
for directional control.

(narrator): Did the pilots have
sufficient training

to perform this difficult
procedure?

- I'll call out engine power
until you get to max.

- Part of the examination
was to see if the simulator

accurately portrayed what
a three-engine takeoff
should entail.

- Okay, let me give this a try.

Engines 2 and 3 are spooled up.

Engine 4 is set.

Here we go.

Slowly bringing up 4.

(powering up)

- One five...

One six...

One seven...

- I am barely using my rudder.

There is no force pushing
me off the runway.

- One eight.

- We have VMCG.

Max power to engine 4 and...

rotate.

(narrator): In the simulator,
the three-engine takeoff

is no different from a regular
takeoff.

- Okay, cut.

- The simulator was not
calibrated properly

in that it did not require
the normal amount of rudder

that would be required with a
three-engine takeoff.

- This is not how their
aircraft would have behaved.

- Not a chance.

- Simulators are for the most
part extremely accurate,

and in this particular case,
we were...

frankly, shocked that this one
was not.

It also happened to be the
one the crew trained on.

And this would really give
them, I think,

a false sense of security
when it came to the difficulty

of making a three-engine
takeoff.

- I'm calling from the NTSB.

(narrator): How did Air
Transport International,

or ATI, compared to other
cargo operators

on three-engine
takeoffs?

- I'd like to talk
to your chief pilot.

- And we checked with the other
cargo operators

who were operating the DC-8.
There were nine of them.

- So only your most qualified
pilots do it, huh?

- The vast majority of them used
their most experienced crews

and limited the operation
to daytime in good weather.

Now, this led us to believe
that the industry, as a whole,

understood the danger
and the difficulty

of a three-engine takeoff
better than ATI did.

- Why did the airline choose
such an inexperienced crew

for such a difficult flight?

- I think it's time
we asked them that.

- Our team went to Little Rock,

which was the headquarters
of the ATI operation,

and we met with all of the key
people there.

- Thanks for meeting with me.

So, I've been told

that you didn't use your most
experienced crew.

Why not?

- I needed my experienced
crew for a revenue flight.

The Flight 7-8-2 crew was only
legal for a non-revenue flight.

- How so?

- They'd only had enough rest
for a non-revenue flight.

- You don't say.

(narrator): They discover that
the crew was selected

because of a critical regulation

governing non-revenue flights
and rest times.

- Normal flights where
the company makes revenue

are covered by flight and duty
time regulations.

For safety reasons, they have
to provide a crew

that has been properly rested.
But there is a loophole

that if the flight
is not revenue,

then there are no flight
and duty time regulations.

In theory, a crew could
fly non-revenue flights
indefinitely.

- Abort.

(narrator): Investigators now
wonder how rested the crew was

when Flight 7-82 prepared
for takeoff.

- So, take us through this.

(narrator): Investigators
closely examine

the crew of Flight 7-82's recent
flight assignments.

- Okay, the morning before
the accident,

our crew lands in Germany after
a seven-hour flight...

...from Delaware.

- And how many time zones
did they cross?

- Six.

Later that same day,
they return,

landing first in Gander,
Newfoundland.

Then, another flight
to Delaware.

(scoffs)

- So, they cross another six
time zones heading back?

- We were aware that their
circadian rhythm had to be

pretty much out of sync.

It's simply not a good thing.

- Fatigue is not easy
to recognize,

but it degrades all aspects
of thinking,

decision-making
and performance.

- They got into their hotel
in Delaware at 2:40 a.m.

on the day of the crash.

- How much uninterrupted rest
did the captain get?

- Less than 5 hours.

- So, they didn't have enough
rest to fly anything

except this flight,
and they were sent,

despite lacking the training
and experience they needed.

(narrator): The NTSB concludes
its investigation,

outlining the fateful steps that
caused the crash of Flight 7-82.

It begins with the poorly
rested crew.

- One of the consistent
findings of fatigue research

is that people tend
to underestimate

how tired they are.

Much of the time you can conduct
a safe flight doing that.

But if something
unexpected happens,

you're at a real disadvantage.

In this case, the takeoff
procedure

was much more complicated

than the crew had been trained
to expect.

- Here you go.
- Thanks.

(narrator): The flight engineer
makes an error in a calculation

that the other pilots
don't catch.

- Once we get near VMCG,

if we've used all our rudder
control

you might wanna consider abort,

because when we get higher,

we're gonna be in worse
trouble, correct?

- That's correct, absolutely.

(narrator): The pilots
are confused

about the takeoff
procedure.

- Uh, no, actually.

- Above VMCG your rudder
has more authority.

It's helping you more.

- This was a very delicate
procedure

and they seemed
to think otherwise.

- If you wanna try it again,
I can try adding the power,

if you like.
- Okay, let's do it that way.

(narrator): A decision to
improvise a difficult takeoff

leads to the plane veering
out of control.

- It was a very bad decision
to improvise on this procedure

because only the person
operating the rudder

can tell how effective that
is when advancing the throttle.

- Okay.

(narrator): The captain decides
not to abort a second time.

The plane lacks enough speed to
safely get airborne.

(shaking)

- We're off the runway.

- Go max power!

(whirring, crash)

- It's hard to say what was
going through his mind,

but I think he believed he could
get the aircraft airborne.

(narrator): In their report,

the NTSB makes several key
recommendations.

One is to revise the training
procedures

for three-engine takeoffs.

- The crew not only was
not trained well,

it was inexperienced
in the particular manoeuvre

they were talking about,
and they were tired.

(narrator): Closing
the loopholes

that allow flight crews
to perform non-revenue flights

without adequate rest is another
recommendation.

- The reason this is relevant
is because the company

elected to have this tired
crew fly the three-engine ferry

rather than the rested crew
that was already present
in Kansas City.

It was legal.

But it was not a good idea.

(narrator): The NTSB
also recommends

that three-engine ferry flights

be assigned to specially
designated, experienced crews.

Training instructors
advised pilots

of the simulator's shortcomings
for three-engine takeoffs.

- The company exceeded
the Board's requests.

They really took it
very seriously

and did change their whole
procedure to prevent this.

(narrator): The airline industry
as a whole does not follow suit.

Non-revenue flights remain
exempt from flight

and duty time regulations.

- There should be no difference
with safety

whether there are people
on the airplane,

freight on the airplane,
or the airplane is empty.

One rest rule requirement
should apply to everybody,

every time, everywhere.

Subtitling: difuze