Original subtitles

Singapore Six, you are cleared for takeoff, runway 05 left.

Singapore Six, you are cleared for takeoff, runway 05 left.

During the takeoff, your heartbeat goes up a bit.

OK, thrust left toga toga.

Taking off is a complex task.

Taking off is a complex task.

- Ignition? - Set.

Spoilers?

Armed.

Pilots need to carefully

execute multiple steps to get their plane into the air.

execute multiple steps to get their plane into the air.

100 knots.

But sometimes, mistakes are made...

But sometimes, mistakes are made...

They didn't follow procedures precisely.

...with tragic results.

...with tragic results.

In Taiwan, a 747 fails to take off in a typhoon.

In Taiwan, a 747 fails to take off in a typhoon.

I thought I was going to die.

A departure from Detroit goes horribly wrong.

A departure from Detroit goes horribly wrong.

Why didn't the pilots perform the task?

In a matter of seconds,

In a matter of seconds,

an MD82 is out of control in Madrid.

Fly the plane.

Fly it!

Fly it!

On three different flights,

small missteps ended in tragedy.

small missteps ended in tragedy.

Ladies and gentlemen,

we are starting our approach.

We lost both engines.

...bag over your nose,

...bag over your nose,

emergency descent.

Brace for impact!

...a loved one.

Investigators are starting to describe the...

Investigators are starting to describe the...

It's going to crash!

Taipei, Taiwan, Singapore

Taipei, Taiwan, Singapore

Airlines Flight 6 taxis to the runway

through heavy wind and rain.

through heavy wind and rain.

Typhoon Jianxin is closing in on Chiang Kai-Shek Airport.

Typhoon Jianxin is closing in on Chiang Kai-Shek Airport.

Flight 6 needs to get airborne before the storm hits.

Even a 747 can't take off in an actual typhoon.

Even a 747 can't take off in an actual typhoon.

It's the closer this storm gets, the more likely

it is that these guys are going to get stuck in Taipei.

it is that these guys are going to get stuck in Taipei.

There are 179 people on board the overnight flight

to Los Angeles.

to Los Angeles.

Singapore 6, for your information,

Singapore 6, for your information,

surface winds 020 at 24.

Casa 4-3.

Thank you, sir, Singapore 6.

Thank you, sir, Singapore 6.

Let me know when it's 30.

If the crosswinds reach 30 knots, or almost 35

If the crosswinds reach 30 knots, or almost 35

miles per hour, captain Fong Chee Kong

will have to abort the takeoff.

As we were taxiing down the runway, it was very windy,

As we were taxiing down the runway, it was very windy,

and the plane was moving left to right.

and the plane was moving left to right.

Singapore 6, you are cleared for takeoff, runway 05 left.

Singapore 6, you are cleared for takeoff, runway 05 left.

OK, thrust left toga toga.

OK, thrust left toga toga.

OK, my control.

OK, my control.

The 747 accelerates to reach the takeoff

speed of 180 miles an hour.

speed of 180 miles an hour.

V1.

V1.

As the plane was gaining

As the plane was gaining

speed to take off, at a certain time,

the plane kind of lost it.

What's happening?

I felt the airplane spinning around.

I felt the airplane spinning around.

I thought I was going to die.

After skidding down the runway...

After skidding down the runway...

...the 747 finally comes to a stop.

...the 747 finally comes to a stop.

Then I opened my eyes

Then I opened my eyes

and I saw a fireball coming at me.

Direct emergency vehicles to runway 05 left.

Direct emergency vehicles to runway 05 left.

Singapore 6, do you read?

Singapore 6?

Singapore 6?

Let's go, go, go.

The plane's tanks are fully

The plane's tanks are fully

loaded with tons of fuel...

...fuel for a fire that rescuers battle in this violent storm.

...fuel for a fire that rescuers battle in this violent storm.

It takes about 15 minutes to control the fire and 45 minutes

to extinguish all of them.

to extinguish all of them.

So it's a difficult task for the firefighters.

83 people have died.

There are 96 survivors, including the pilots.

One of Asia's busiest airports is immediately shut down.

One of Asia's busiest airports is immediately shut down.

It's now up to the Aviation Safety Council of Taiwan

It's now up to the Aviation Safety Council of Taiwan

to determine the cause of the disaster.

When I went to the crash site, I can see all the wreckage

When I went to the crash site, I can see all the wreckage

is spread the wrong way.

Flight 6 was cleared for takeoff on runway 5 left,

Flight 6 was cleared for takeoff on runway 5 left,

but much of the wreckage is spread over runway 5 right.

but much of the wreckage is spread over runway 5 right.

Investigators wonder whether the typhoon

blew the plane off its runway.

blew the plane off its runway.

When you're an investigator looking at a crash scene,

you have to keep an open mind.

you have to keep an open mind.

You have to assume it could be any conceivable factor

from the machinery, the human factors, to the weather,

from the machinery, the human factors, to the weather,

to who knows what?

As the investigators, we believe that we should

As the investigators, we believe that we should

interview pilots or operator as soon as possible,

because we believe that human memory will fade over time.

because we believe that human memory will fade over time.

Captain Fong Chee Kong is interviewed

within hours of the crash.

within hours of the crash.

What happened?

We collided with something on the runway.

We collided with something on the runway.

There's something there.

There was something on that runway.

Could you tell what it was?

No.

No.

We could not see all the way down the runway.

The focus shifts from the weather to the possibility

that there was an obstacle on the runway.

Investigators examine the wreckage for clues.

It's difficult for us to collect

all of the information, all of the wreckage,

because it's blown into everywhere.

because it's blown into everywhere.

Accidents during takeoff

can involve more than one aircraft.

can involve more than one aircraft.

In 1991, a SkyWest metroliner preparing for takeoff

In 1991, a SkyWest metroliner preparing for takeoff

from Los Angeles was crushed by a US Air 737 which was coming

from Los Angeles was crushed by a US Air 737 which was coming

in to land on the same runway.

34 people were killed.

34 people were killed.

Is that what happened to Singapore Airlines Flight 6?

Any signs of another plane?

Any signs of another plane?

And no other flights unaccounted for?

At Chiang Kai-Shek Airport,

At Chiang Kai-Shek Airport,

this theory is ruled out.

All of the debris appears to be from just one plane, Flight 6.

All of the debris appears to be from just one plane, Flight 6.

He didn't hit a plane.

Investigators worked through thousands

Investigators worked through thousands

of pieces of mangled wreckage.

Part of the flap assembly, the right wing.

Part of the flap assembly, the right wing.

They make an unexpected discovery.

They make an unexpected discovery.

Some wreckage doesn't belong to the shattered 747.

It looks more like construction equipment.

It looks more like construction equipment.

Chiang Kai-Shek airport has three runways.

Runway 5 left is the one Flight 6 was instructed to use.

Runway 5 left is the one Flight 6 was instructed to use.

Parallel to that is runway 5 right,

Parallel to that is runway 5 right,

a runway closed for construction.

Investigators consider the possibility

Investigators consider the possibility

that Flight 6 hit material from the construction site.

It wouldn't be hard to imagine some large object

It wouldn't be hard to imagine some large object

being blown into an engine or knocking out the windshield.

There's lots of things that could have happened.

There's lots of things that could have happened.

There's something there.

There's something there.

When investigators look at runway 5

When investigators look at runway 5

right adjacent to Flight 6's designated takeoff runway,

they see something that doesn't make any sense...

they see something that doesn't make any sense...

fresh tire tracks on a runway that is supposed to be closed.

We can actually see the time mark of this aircraft

We can actually see the time mark of this aircraft

starting from the takeoff point all the way

starting from the takeoff point all the way

to the first impact point.

The tire marks on runway 5

The tire marks on runway 5

right lead investigators to a startling conclusion.

This is our point of impact.

This is our point of impact.

It seems flight 6 was taking

off from the wrong runway.

off from the wrong runway.

But how could two experienced pilots make that mistake?

The only way to determine what went wrong

The only way to determine what went wrong

is with the data from the black boxes.

When we get information out of the recorder, we read it,

When we get information out of the recorder, we read it,

then we can know the exact position of the aircraft.

then we can know the exact position of the aircraft.

Investigators compare positioning information

from the flight data recorder to a satellite

from the flight data recorder to a satellite

image of the airport.

He's... he's lining up with the wrong runway.

He's... he's lining up with the wrong runway.

Somehow, the plane ended up on runway

5 right instead of 5 left.

5 right instead of 5 left.

He was supposed to be here.

He was supposed to be here.

How did they end up here instead?

1,243 meters down the runway, he collides

1,243 meters down the runway, he collides

with construction equipment.

It seems like the kind of thing that shouldn't happen

ever under any circumstances.

ever under any circumstances.

Investigators need to know why Singapore Airlines

Flight 6 tried to take off from the wrong runway at Taiwan

Flight 6 tried to take off from the wrong runway at Taiwan

Airport.

Investigator Thomas Wang interviews Captain Fong again.

Did you receive this notice?

Did you receive this notice?

He has questions about a notice

that runway 5 right was closed.

that runway 5 right was closed.

Of course I did.

Everyone did.

Everyone did.

We discussed it during our briefing.

Tell them we'll take 5 left.

Tell them we'll take 5 left.

So why didn't air traffic

controllers realize that the 747 had

turned on to the wrong runway?

turned on to the wrong runway?

I couldn't see them in that weather.

I couldn't see them in that weather.

When interviewed, the controller

said that night's storm limited visibility

to around 2,000 feet.

to around 2,000 feet.

And they confirmed runway 5 left.

And they confirmed runway 5 left.

That's the last I heard from them.

Hmm.

Hmm.

1,600 meters between the runway and the tower.

There's no way he saw them.

The crew assumed the tower was monitoring

their progress, but the controller

their progress, but the controller

had lost sight of the plane.

Investigators now try to determine

how the pilots lost their way.

how the pilots lost their way.

We couldn't see very far, but we could see far enough.

Co-pilot was studying the map while I

followed the taxi lights.

followed the taxi lights.

It led us directly to the runway.

OK, green lights are here.

OK, green lights are here.

It appears that the crew had no trouble

seeing their taxi route.

seeing their taxi route.

Was this the map you were using?

Yes.

Yes.

You didn't have any trouble reading it?

I wasn't reading it.

My first officer and relief pilot were following the map.

My first officer and relief pilot were following the map.

I only glanced at it when the route changed.

They changed the route?

They changed the route?

Yes.

Wang learns that the ground controller issued a last-minute

change to their taxi route.

change to their taxi route.

Singapore 6, request taxi.

Singapore 6 taxi to runway 06 via taxiway...

Singapore 6 taxi to runway 06 via taxiway...

correction, runway 05 left via taxiway 00

west cross and November papa.

west cross and November papa.

Pilots have to deal with last-minute

changes all the time.

The situation becomes complicated.

The situation becomes complicated.

It becomes hairy.

Now, you've got a typhoon bearing down on you.

You've got gusts, so you're under pressure.

You've got gusts, so you're under pressure.

Did additional workload in the cockpit

cause the pilots to make a fatal mistake?

cause the pilots to make a fatal mistake?

Investigators turn to the cockpit voice recorder.

Coming in fast.

Coming in fast.

The longer we delay, the worse it's going to get.

The CVR reveals that the crew

The CVR reveals that the crew

wanted to get off the ground before the weather closed in.

wanted to get off the ground before the weather closed in.

Singapore 6, runway 05 left, wind 020 at 28, gusts 50.

Singapore 6, runway 05 left, wind 020 at 28, gusts 50.

Cleared for takeoff.

Normally, a 747 taxi is about 25 knots.

Normally, a 747 taxi is about 25 knots.

On this night, they were going nine knots.

They were doing exactly what they should have

done, taking it nice and slow.

done, taking it nice and slow.

The pilots pass signs that

clearly identify the runways.

I'm going to go very slow here.

I'm going to go very slow here.

Otherwise, we'll skid.

Indeed, he's crawling.

Indeed, he's crawling.

020, from the left.

020.

The winds consume the crew's attention.

28.5.

It's getting close to 30, sir.

It's getting close to 30, sir.

OK.

The captain was taxiing the aircraft in very slow speed,

The captain was taxiing the aircraft in very slow speed,

and the first officer is doing the before takeoff checklist,

and the first officer is doing the before takeoff checklist,

and the relief pilot is working on the crosswind component.

So all pilot, they are occupied by something.

So all pilot, they are occupied by something.

They do not have enough attention

to actually check which runway they are taxiing onto.

to actually check which runway they are taxiing onto.

They believe they are making a right turn

They believe they are making a right turn

onto the correct runway.

Unfortunately, that's not the correct runway.

That's 05 right.

That's 05 right.

Captain Fong's extreme caution

might have worked against him.

might have worked against him.

OK, nine knots.

Because the turn took so long,

Because the turn took so long,

Captain Fong may have believed that he'd gone

further than he actually did.

So much time had passed that he may have thought he had

So much time had passed that he may have thought he had

actually reached runway 5 left.

The big irony of this crash is that they were taking off

The big irony of this crash is that they were taking off

in very dangerous circumstances near the limit of what their

in very dangerous circumstances near the limit of what their

plane was capable of handling.

But it wasn't the weather that did them in,

but rather the pressure of dealing

but rather the pressure of dealing

with the storm distracted them from what turned

out to be the real question.

Were they in the right place?

Were they in the right place?

V1.

V1.

There's something there.

One of the lessons of this accident

One of the lessons of this accident

is that you can have an exemplary crew performing

their duties with utmost care, and they still make a mistake

their duties with utmost care, and they still make a mistake

with fatal consequences.

Taiwan's Aviation Safety Council

recommends immediate changes to pilots'

recommends immediate changes to pilots'

procedures and training.

Currently turning

Currently turning

left onto taxiway November 1.

New checklists are designed that include

a visual step, obliging pilots to confirm

a visual step, obliging pilots to confirm

that they're on the correct runway before takeoff.

Singapore 006 reminded us again that if there is

Singapore 006 reminded us again that if there is

ambiguity in the cockpit and you're on the ground,

you need to resolve, and stop, and get that resolved,

you need to resolve, and stop, and get that resolved,

particularly in very, very inclement weather.

When visibility is reduced, you need to be

When visibility is reduced, you need to be

sure where the airplane is.

The crash of Singapore 6

isn't the first time a series of missteps during takeoff

isn't the first time a series of missteps during takeoff

leads to disaster.

Detroit Metropolitan Airport, more than 1,100 airplanes

Detroit Metropolitan Airport, more than 1,100 airplanes

used one of its four runways every day.

Northwest Airlines flight 255, an MD80,

is bound for Phoenix, Arizona.

is bound for Phoenix, Arizona.

There are 149 passengers on board.

Captain John Maus is in command.

A Las Vegas native, 57-year-old Maus is a veteran pilot.

A Las Vegas native, 57-year-old Maus is a veteran pilot.

His first officer is 35-year-old David

His first officer is 35-year-old David

Dodds of Galena, Illinois.

Look at this.

Look at this.

Today, storms darken the flight path

between Detroit and Phoenix.

between Detroit and Phoenix.

Several are moving quickly toward the airport.

Several are moving quickly toward the airport.

There's a line here and another one here

about 25 miles wide.

about 25 miles wide.

Well, if we get out of here pretty quick,

we won't have a delay.

Northwest 255, cleared to go.

Already running a half-hour late,

Already running a half-hour late,

Flight 255 is cleared to taxi to the runway.

OK, we're cleared to push.

Let's do the checklist.

Brakes?

Set.

Windshield heat?

It's on.

It's on.

Boost pumps?

We've got six.

Pumps and pressure?

Pumps and pressure?

On and checked.

Damn, it's starting to rain.

To beat the storms, they must leave immediately.

To beat the storms, they must leave immediately.

They're all on.

Before start checklist is complete.

Before start checklist is complete.

Flight 255 moves away from the gate

and toward the runway, but the bad weather...

and toward the runway, but the bad weather...

Northwest 255, no exit at Charlie runway, 3 center.

Northwest 255, no exit at Charlie runway, 3 center.

...forces a last-minute runway change.

OK.

To Charlie for 3 center, Northwest 255.

Charlie for 3 center right.

Charlie for 3 center right.

OK.

Ladies and gentlemen, we're currently

Ladies and gentlemen, we're currently

number one for departure.

We should be rolling in a couple of minutes.

Blacker than hell out there.

Where's Charlie at?

By the time they get to the new runway,

they are 45 minutes behind schedule.

they are 45 minutes behind schedule.

Northwest 255, runway 3 center, clear for takeoff.

Northwest 255, runway 3 center, clear for takeoff.

Flight 255 hurtles down runway 3C.

Flight 255 hurtles down runway 3C.

Clamp, a hundred knots.

V1, rotate.

The pilots angle the plane's nose up for liftoff.

But less than 50 feet off the ground,

But less than 50 feet off the ground,

flight 255 is in trouble.

Moments after takeoff...

Tower lifeguard copter 102.

Tower lifeguard copter 102.

...Northwest Airlines Flight 255 is out of control.

...Northwest Airlines Flight 255 is out of control.

The trail of debris is more than a mile long.

Remarkably, a four-year-old girl has survived the crash.

Rescuers spend hours searching the wreckage

for other survivors.

for other survivors.

But the young girl is the only one.

But the young girl is the only one.

154 people on board, including Captain

Maus and First Officer Dodds have been killed in the crash.

Maus and First Officer Dodds have been killed in the crash.

On the ground, two people died in their cars

On the ground, two people died in their cars

when they were hit by the plane.

Investigator Jack Drake and his team

from the National Transportation Safety Board

begin the search for clues.

begin the search for clues.

You know when you're at a crash site because you get

You know when you're at a crash site because you get

this combination of burned plastic, and kerosene,

and sometimes combined with fire retardant foam that

and sometimes combined with fire retardant foam that

has its own distinctive odor.

The cockpit voice recorder is intact,

The cockpit voice recorder is intact,

but the flight data recorder has been damaged in the crash.

Both recorders are sent to the NTSB Lab in Washington, DC.

Both recorders are sent to the NTSB Lab in Washington, DC.

John Clark is the team's flight performance engineer.

John Clark is the team's flight performance engineer.

He searches for ground scars and other impact marks

He searches for ground scars and other impact marks

and interviews witnesses to piece together

where the plane fell, and how.

where the plane fell, and how.

When I first started seeing the wreckage,

your mind immediately starts turning to sorting out where it

your mind immediately starts turning to sorting out where it

hit, how it hit... not where the wreckage ended up,

but those first few inches where the airplane was coming down.

but those first few inches where the airplane was coming down.

According to witnesses,

Flight 255 lifted off in a nose-high position,

Flight 255 lifted off in a nose-high position,

but then couldn't climb.

V1, rotate.

V1, rotate.

That clue could indicate that the plane didn't

have enough speed to get off the ground

or that high winds prevented it from lifting off.

or that high winds prevented it from lifting off.

Until technicians can decode the damaged FDR,

Until technicians can decode the damaged FDR,

the team must rely on physical evidence from the crash site.

the team must rely on physical evidence from the crash site.

Investigators study the cockpit center console.

One thing stands out...

Is this the way it was found?

Is this the way it was found?

...the lever that extends and retracts

the wing's flaps and slats.

the wing's flaps and slats.

Flaps and slats are extensions that slide out of the back

in front of the wing.

in front of the wing.

They make the wings larger, increasing the amount of lift

they can provide.

They must always be extended for takeoff.

They must always be extended for takeoff.

But the way the flap handle is damaged

suggests the plane's flaps were not extended when it crashed.

suggests the plane's flaps were not extended when it crashed.

The pin had left a mark.

The pin had left a mark.

This happens because the aircraft

comes to a very sudden stop and the handle jangles around...

comes to a very sudden stop and the handle jangles around...

metal-to-metal contact that's exaggerated by the impact.

metal-to-metal contact that's exaggerated by the impact.

That indicator was that the flaps

were zero, or fully retracted, and the slats

were zero, or fully retracted, and the slats

were retracted as well.

Even without data from the FDR,

investigators can determine the flap position at takeoff.

investigators can determine the flap position at takeoff.

B1, rotate.

Flaps and slats are moved

by cables running to the wings.

by cables running to the wings.

Each component of the slat system has its own drive

system, and one... one of those was

system, and one... one of those was

interrupted by the light pole that passed through the wing.

When they examine the left wing,

When they examine the left wing,

investigators see that the cable controlling the slats

sliced in two when the wing hit the pole.

sliced in two when the wing hit the pole.

By examining the cut cable, investigators

By examining the cut cable, investigators

can tell whether the slats and flaps were extended

or retracted.

or retracted.

It severed two cables.

It severed two cables.

If you lined up those two severed ends,

it corresponded with the slats being

in the full retracted position.

in the full retracted position.

When data is finally extracted from the FDR,

the report confirms what the cut cables suggested.

the report confirms what the cut cables suggested.

The flaps were not extended on takeoff.

It's a major breakthrough.

It's a major breakthrough.

Jack Drake now knows what brought down Flight 255.

Jack Drake now knows what brought down Flight 255.

But the flight data recorder can't answer

a more troubling question.

So why weren't the flaps deployed?

So why weren't the flaps deployed?

For some reason, a seasoned crew

allowed a critical misstep to occur while getting

allowed a critical misstep to occur while getting

their plane off the ground.

Why did the crew of Northwest Airlines Flight 255

fail to extend the flaps on takeoff?

fail to extend the flaps on takeoff?

Investigators listened to the cockpit voice recorder

again for answers.

again for answers.

It indicates that a last-minute runway change led

to confusion in the cockpit.

to confusion in the cockpit.

Northwest 255, no exit at Charlie runway, 3 center.

Did he say 3 center?

Did he say 3 center?

3 center, yeah.

That's why I was thinking we had to go that way.

I was thinking 2-1.

I was thinking 2-1.

Well, he made a wrong turn, which

might have been confusing because they

had to go a different route.

had to go a different route.

Ground, Northwest 255...

I guess we went by Charlie.

We're going to 3 center right.

Northwest 255, affirmative.

Northwest 255, affirmative.

Make a left turn.

They finally arrived at the runway 45 minutes late.

They finally arrived at the runway 45 minutes late.

We're OK for that center runway, aren't we?

We're OK for that center runway, aren't we?

Befoe they lost their way, the crew of Flight 255

carried out a number of checklists,

carried out a number of checklists,

but missed the taxi checklist.

They apparently didn't consider the checklist.

They apparently didn't consider the checklist.

And key in the checklist is the configuration

of the aircraft for departure.

of the aircraft for departure.

The first item on the taxi checklist is flaps.

And because they didn't run the checklist,

And because they didn't run the checklist,

the crew neglected to set their flaps to takeoff position.

I think Charlie was...

I think Charlie was...

No, it is Charlie.

Are you sure?

I think so.

I think so.

They hadn't done this checklist at the time

they normally would.

they normally would.

And as the activities piled up that were

potential distractions, they were further and further away

potential distractions, they were further and further away

from the point at which they would

normally perform that function.

After the checklists, there

After the checklists, there

is a last line of defense designed

to prevent pilots from taking off without flaps set.

to prevent pilots from taking off without flaps set.

An alarm should have sounded when

the pilot started down the runway with their flaps

retracted.

retracted.

Maybe it went off, but we just can't hear it.

But no alarm is heard on the CVR.

But no alarm is heard on the CVR.

When investigators consult other MD80 pilots,

they're told the takeoff configuration warning

they're told the takeoff configuration warning

was a nuisance at times.

Flaps.

Flaps.

Slats

Flaps.

If you're doing a single-engine taxi,

If you're doing a single-engine taxi,

you have to push the throttle up further to get a power to taxi,

and you set off the take-off warning system.

and you set off the take-off warning system.

And if it's going off routinely all the time,

it gets on their nerves.

So apparently, pilots were routinely silencing

So apparently, pilots were routinely silencing

those take-off warnings.

Investigators suspect that the crew of Flight 255

Investigators suspect that the crew of Flight 255

pulled a breaker to avoid the irritating take-off warning.

pulled a breaker to avoid the irritating take-off warning.

It is determined that the downing of Flight 255

was caused by pilot error.

The FAA orders a modification to the alarm

system of all commercial jetliners

to prevent nuisance alarms.

to prevent nuisance alarms.

I think a big lesson learned is

that a strict adherence to checklists is very important.

that a strict adherence to checklists is very important.

The checklist, in my mind, is kind of the fabric

The checklist, in my mind, is kind of the fabric

that holds a flight together.

It has to be religiously followed.

21 years after Flight 255's deadly crash,

21 years after Flight 255's deadly crash,

another tragedy shows flight crews were still missing

another tragedy shows flight crews were still missing

critical steps during takeoff.

Madrid-Barajas Airport, Spain.

Ladies and gentlemen, thank you for your patience.

Ladies and gentlemen, thank you for your patience.

We hope to be on the move again very soon.

At the last minute, Spanair Flight 5022 is delayed.

At the last minute, Spanair Flight 5022 is delayed.

There's a problem with a temperature probe.

There's a problem with a temperature probe.

While it's checked out, the air conditioning is turned off.

Passengers are sweltering in the heat.

Passengers are sweltering in the heat.

So we're done?

So we're done?

Yeah, pop the breaker, sir.

You're good to go.

OK, thanks.

OK, thanks.

After a delay of more than an hour,

Spanair Flight 5022 finally gets going.

Spanair Flight 5022 finally gets going.

There are 166 passengers on board

There are 166 passengers on board

the flight bound for the Canary Islands.

Today, Captain Antonio Luna is in command.

Today, Captain Antonio Luna is in command.

A former Spanish Air Force pilot, he's been

A former Spanish Air Force pilot, he's been

with Spanair for nine years.

Now's our time.

About an hour and a quarter behind schedule.

First Officer Francisco

First Officer Francisco

Mulet joined the company just a year and a half ago.

Spanair 5022, you're next in line on runway 36 left.

Spanair 5022, you're next in line on runway 36 left.

Spanair 5022, you're next in line on runway 36 left.

OK, here we go.

Preparing for takeoff is an extremely

busy time for the flight crew.

busy time for the flight crew.

They've got multiple checklists that they have to run.

The ignition.

Set.

Spoilers.

Armed.

Armed.

Make certain the aircraft is properly configured,

the thrust is set right, the brakes, et cetera.

the thrust is set right, the brakes, et cetera.

Air conditioning?

So there are a plethora of factors

that are all running through their mind simultaneously.

that are all running through their mind simultaneously.

Hey, Spanair 5022, you are cleared for takeoff,

runway 3-6, left.

runway 3-6, left.

Cleared for takeoff, Spanair 5022.

Just after 2 PM, the MD82 aircraft starts

Just after 2 PM, the MD82 aircraft starts

speeding down the runway.

speeding down the runway.

100.

The captain monitors their speed.

They can't lift off until they reach 157 knots,

They can't lift off until they reach 157 knots,

or almost 181 miles per hour.

or almost 181 miles per hour.

V1, rotate.

Suddenly, an alarm sounds.

Something is wrong.

Something is wrong.

Engine failure?

How the hell do you turn off that warning?

How the hell do you turn off that warning?

The plane is less than 40 feet off the ground.

Fly the plane.

Fly it.

Oh, oh, oh, damn.

Oh, oh, oh, damn.

Just seconds after takeoff,

Just seconds after takeoff,

Flight 5022 slams into a riverbank alongside the runway.

Airport fire crews race to the scene.

The plane with 172 people on board

is now shattered wreckage spread over half a mile.

is now shattered wreckage spread over half a mile.

Only 18 people survive the crash of Spanair Flight 5022.

Only 18 people survive the crash of Spanair Flight 5022.

147 passengers are dead.

147 passengers are dead.

So are both pilots.

It was a tremendous tragedy.

It was a tremendous tragedy.

All the country was affected by that.

Spain recruits an international team of experts

to investigate the country's worst

aviation disaster in 25 years.

aviation disaster in 25 years.

OK, people, it looks like we have our work cut out for us.

Marks on the ground paint a vivid picture...

Marks on the ground paint a vivid picture...

Here's our first impact.

...that reveals just how soon

flight 5022 hit the ground.

flight 5022 hit the ground.

The first impact marks are just 200 feet from the runway.

The first impact marks are just 200 feet from the runway.

The plane then passed over a road

and slid another 1,800 feet before crashing

and slid another 1,800 feet before crashing

on the far side of the river.

This airplane left a trail coming from the runway

This airplane left a trail coming from the runway

to the edge of the airport boundary.

So it was quite clear for the investigation

So it was quite clear for the investigation

that the airplane had big problems just on liftoff.

Investigators wonder if engine failure

Investigators wonder if engine failure

compromised the takeoff.

If we find mud, soil, or grass throughout the engine,

If we find mud, soil, or grass throughout the engine,

we can determine that the engine was fully operational

we can determine that the engine was fully operational

at the time of the accident.

Both engines are filled with debris

ingested during the crash.

ingested during the crash.

The finding means the engines were running

when the plane made impact.

The engines were fine.

But something stopped that plane from climbing.

But something stopped that plane from climbing.

Controllers working the day of the crash

Controllers working the day of the crash

present a potential lead.

They had some kind of maintenance issue right

before takeoff.

Madrid Spanair 5022, we have a slight problem.

Madrid Spanair 5022, we have a slight problem.

We have to exit the runway.

Investigators hear about the trouble

with the temperature sensor.

with the temperature sensor.

Oh, yeah.

I took a look, but it wasn't serious.

The sensor, called a REM air temperature probe,

The sensor, called a REM air temperature probe,

measures the outside air temperature

and feeds the information to the plane's computer during flight.

and feeds the information to the plane's computer during flight.

The sensor was sending out faulty readings.

MAINTENANCE MAN (ON RADIO): Check the ice

protection meter selector.

protection meter selector.

No, that didn't work either.

Without it, the automation that adjusts engine

Without it, the automation that adjusts engine

power won't function properly.

Look at that.

It says 104 degrees now.

It says 104 degrees now.

Maintenance workers were unable to repair

the faulty sensor.

MAINTENANCE MAN (ON RADIO): Sensor 29.

MAINTENANCE MAN (ON RADIO): Sensor 29.

All right, got it.

So they temporarily cut the power to the sensor,

thereby disabling it.

thereby disabling it.

So we're done?

Yeah.

I popped the breaker, so you're good to go.

OK, thanks.

OK, thanks.

Investigators wonder if the disabled temperature

probe is somehow linked to the crash.

probe is somehow linked to the crash.

I don't see how this could cause a problem.

I don't see how this could cause a problem.

But they quickly confirm

that the probe is not an essential piece of equipment.

The crew can keep track of the outside temperature

The crew can keep track of the outside temperature

themselves and then adjust engine power manually.

themselves and then adjust engine power manually.

Something else prevented the plane from climbing out.

What kind of wreckage have we recovered from the wings?

What kind of wreckage have we recovered from the wings?

Get me everything you have.

Investigators turn to the MD82's control surfaces.

They study the lever mechanism that pilots

use to adjust the flaps.

use to adjust the flaps.

The flap lever was very... an essential

The flap lever was very... an essential

part of the investigation.

Well, well, what have we here?

There's a deep scratch at the zero

There's a deep scratch at the zero

mark, the retracted position.

It's a startling finding, one that

It's a startling finding, one that

suggests the flaps on flight 5022

were not extended on takeoff.

were not extended on takeoff.

It's disturbingly similar to the crash of Northwest Airlines'

Flight 255, 21 years before.

Flight 255, 21 years before.

Did the pilots in Madrid, like those in Detroit,

fail to set the flaps properly before takeoff?

fail to set the flaps properly before takeoff?

V1.

What happened to prevent them from being

in the right position?

in the right position?

Rotate.

The answer to that question could

explain why 154 people died.

explain why 154 people died.

Investigators need to know

if the pilots of Spanair Flight 5022

took off without the flaps extended.

took off without the flaps extended.

They don't have a voice recording

for the first takeoff attempt.

for the first takeoff attempt.

It was erased when the MD82 left the runway

and powered down for maintenance.

and powered down for maintenance.

But they do have all the information

from the flight data recorder.

Flaps were set at 11 degrees on the first taxi,

exactly where they should be.

exactly where they should be.

The flight data recorder reveals that the flaps

were set correctly when the plane taxied onto the runway

were set correctly when the plane taxied onto the runway

the first time.

Then the pilots noticed that there's

a malfunctioning temperature probe.

a malfunctioning temperature probe.

Madrid Spanair 5022, we have a slight problem.

We have to exit the runway.

We have to exit the runway.

When the crew returned to the terminal for repairs,

they retracted the flaps.

they retracted the flaps.

The flaps and slats are retracted after coming off

the runway as part of standard operating procedure.

the runway as part of standard operating procedure.

- We're done? - Yeah.

We popped the breaker, so you're good to go.

Thanks.

Taxiing back to the runway,

Taxiing back to the runway,

the pilot should have extended the flaps for takeoff.

The MD82's preflight checklists direct

the crew to check the flaps and slats three times.

the crew to check the flaps and slats three times.

Ignition.

Off.

Air conditioning.

Set.

Set.

On the after start checklist, setting

the flaps is the final step.

the flaps is the final step.

Hydraulic pumps and valve?

Set and checked.

Set and checked.

Lights.

On.

Get permission from air traffic control to taxi,

Get permission from air traffic control to taxi,

will you?

Hold it, hold it, hold it.

Hold it, hold it, hold it.

What is he doing?

This is the worst possible time to interrupt him.

The CVR reveals that just as the first officer is

The CVR reveals that just as the first officer is

about to check the flaps and slats for the first time,

the captain instructs him to make a radio call.

the captain instructs him to make a radio call.

Ground, Spanair 5022 requesting taxi instructions.

Ground, Spanair 5022 requesting taxi instructions.

AIR CONTROLLER (ON RADIO): Spanair 5022.

He didn't return to the checklist

to finish that critical step.

to finish that critical step.

Humans are fallible.

And we know that when we're multitasking,

it's very easy to forget or miss a critical item.

it's very easy to forget or miss a critical item.

And they never set the flaps.

The captain and first officer then

failed to carry out this critical step

on the final two checklists.

on the final two checklists.

Transponder.

Set.

Cabin.

Hang on, stop.

Hang on, stop.

Where's the takeoff briefing?

Investigators now know what caused

Investigators now know what caused

the crash of Spanair 5022.

V1, rotate.

V1, rotate.

The pilots never extended their flaps

before takeoff, making it impossible for the plane

before takeoff, making it impossible for the plane

to climb.

And just as with Northwest Flight 255,

And just as with Northwest Flight 255,

investigators must answer a key question.

Where's the warning?

Where's the warning?

If the flaps were not in... set in the takeoff position,

there should be a very conspicuous sound

there should be a very conspicuous sound

saying that the aircraft is not ready for takeoff.

Once again, why didn't the alarm

Once again, why didn't the alarm

sound to warn the pilots that their flaps weren't set?

sound to warn the pilots that their flaps weren't set?

These failures have to be connected somehow.

Investigators look for a link

Investigators look for a link

between the failure of flight 5022's take-off warning...

OK, we have the relay switch.

...and the failed temperature sensor.

...and the failed temperature sensor.

...relay.

Look at that.

Look at that.

It says 104 degrees now.

Investigators trace the complex pathways

Investigators trace the complex pathways

for the temperature sensor and the take-off warning.

They make a critical discovery.

They make a critical discovery.

The sensor and the take-off warning

both pass through a single electronic relay,

the R25 relay.

the R25 relay.

It was very shocking to find out that two different systems,

like the take-off warning system and the RAM

like the take-off warning system and the RAM

air temperature probe heating, were

controlled by the same device.

Investigators suspect the m 25 relay failed,

disabling both the temperature sensor

disabling both the temperature sensor

and the take-off warning.

Technicians are not able to recreate

Technicians are not able to recreate

that failure in the lab.

But for one Carlos Lozano, the theory makes sense.

But for one Carlos Lozano, the theory makes sense.

That's it.

That's the link.

In my opinion, the relay 25 was the cause of the failure

In my opinion, the relay 25 was the cause of the failure

of the take-off warning system.

Right, got it.

With no take-off alarm,

the pilots lost a critical line of defense.

Just like the Northwest Airlines pilots in Detroit,

the Madrid crew's failure to follow the checklists

the Madrid crew's failure to follow the checklists

led to tragedy.

The single biggest failure in this accident is the failure

The single biggest failure in this accident is the failure

of the take-off warning system.

This system was designed considering that the humans can

This system was designed considering that the humans can

make mistakes.

And this is a clear example that the last line of defense fell.

And this is a clear example that the last line of defense fell.

After the crash of Spanair 5022,

After the crash of Spanair 5022,

Boeing revised its checklists again to make extending flaps

Boeing revised its checklists again to make extending flaps

and slats even more prominent.

Three disastrous take-offs lead to changes

that have made a critical period of flight much safer.

that have made a critical period of flight much safer.

Technology is helping us with all three of these accidents.

Technology is helping us with all three of these accidents.

The take-off warning systems are better on the more modern

airplanes so that if a crew attempts to take off,

airplanes so that if a crew attempts to take off,

they get very definite warnings.

they get very definite warnings.

Moving map displays that are now available for when you're

taxiing on low visibility, it physically shows the airplane

taxiing on low visibility, it physically shows the airplane

on an electronic map.

That reduces the ambiguity about your position.

So technology is helping us there,

So technology is helping us there,

but it still comes back to good decisions,

conservative decisions, and the adherence

conservative decisions, and the adherence

to standard operating practice.