Original subtitles

OK, and we're marker inbound.

Don't forget to give me my call outs.

Captain and first officer have to work together as a team.

Captain and first officer have to work together as a team.

But cockpits containing...

Tony, what did you do?

Tony, what did you do?

...domineering captains...

Heading 230, understand?

...poor communicators...

...poor communicators...

No!

All he had to say was, stop, you're turning the wrong way.

...and intimidated rookies...

...and intimidated rookies...

I did nothing.

...let the personal...

Don't be so stupid.

...get in the way of the professional...

...get in the way of the professional...

There were words that you wouldn't

expect to hear in a professional crew environment.

...and doomed many lives.

...and doomed many lives.

Investigators must now unravel three needless tragedies...

Investigators must now unravel three needless tragedies...

He made a habit of failing his checkrides.

...stemming from...

We're crashing!

We're crashing!

...bad pilot pairings.

Ladies and gentlemen,

we are starting our approach.

We lost both engines.

AIRCRAFT CREW (OVER PA): Emergency descent.

Brace for impact!

In Douala, Cameroon, Kenya Airways Flight 507

is waiting for a bad storm to pass.

is waiting for a bad storm to pass.

Ladies and gentlemen, we are going

to wait for the weather conditions

to wait for the weather conditions

to improve before we take off.

There are 108 passengers on board

There are 108 passengers on board

the new Boeing 737-800.

the new Boeing 737-800.

Flight 507 began in Abidjan earlier in the day.

It's stopping over at Douala and flying on to Nairobi, Kenya.

It's stopping over at Douala and flying on to Nairobi, Kenya.

But the storm has caused an hour's delay.

But the storm has caused an hour's delay.

Captain Francis Wamwea is in command.

Let's see what this storm is doing.

Let's see what this storm is doing.

He's got more than 8,000 flying hours.

He's got more than 8,000 flying hours.

23-year-old Andrew Kiuru is the first officer.

There might be a way around it.

Tower, Kenya 507.

Looks like there's a break in the weather.

Looks like there's a break in the weather.

Requesting startup.

OK, 507.

OK, 507.

Startup approved.

Startup checklist.

Quickly, please.

Generators on.

OK, request taxi clearance.

OK, request taxi clearance.

As the plane taxis to the runway,

As the plane taxis to the runway,

the first officer focuses on takeoff preparations.

Wait till we line up.

Wait till we line up.

OK.

Usually, things happen quickly, though.

Usually, things happen quickly, though.

Right.

OK.

Try to keep up.

Captain Wamwea verifies the position

Captain Wamwea verifies the position

of a thunderstorm...

Let's have a look.

...before confirming a route around it.

...before confirming a route around it.

Tower, Kenya 507.

After departure, we would like to maintain

After departure, we would like to maintain

a heading slightly left of runway due to weather ahead.

a heading slightly left of runway due to weather ahead.

Right.

Sorry, slightly right.

Sorry, slightly right.

Approved.

OK, takeoff thrust is set.

Speed building on both.

Check.

80 knots.

Check.

V1 rotate.

Just after midnight, Kenya Airways

Flight 507 finally takes off.

Flight 507 finally takes off.

Get up.

OK.

1,000 feet and climbing.

1,000 feet and climbing.

The 737 begins turning to avoid the storm.

The 737 begins turning to avoid the storm.

N1.

After reaching 1,500 feet, the captain calls for...

After reaching 1,500 feet, the captain calls for...

OK, command.

...the autopilot to be engaged.

So should I remain on this heading?

Yep.

2,400 feet and climbing.

2,400 feet and climbing.

Now we're getting into it.

Now we're getting into it.

Bank angle, bank angle.

Bank angle, bank angle.

Suddenly, the 737 rolls dangerously to the right.

Suddenly, the 737 rolls dangerously to the right.

Bank angle, bank

angle, bank angle, bank angle.

The captain struggles to level the plane.

The captain struggles to level the plane.

Bank angle, bank angle.

Bank angle, bank angle.

Bank angle.

We're crashing!

Yeah, we are crashing.

Left, left!

Left, left!

Bank angle, bank angle.

Left correction!

Bank angle, bank angle.

Bank angle, bank angle.

Bank angle, bank angle.

Bank angle.

Flight 507 has plunged into a swamp.

Flight 507 has plunged into a swamp.

Search teams spend two days looking for the wreckage.

Search teams spend two days looking for the wreckage.

It's found in a mangrove swamp southeast of the airport.

All 114 people on board the 737 are dead.

All 114 people on board the 737 are dead.

An international air accident team arrives in Cameroon

An international air accident team arrives in Cameroon

to investigate the case.

This was the toughest accident scene I've been on in my career

This was the toughest accident scene I've been on in my career

at Boeing.

With so much of the physical evidence obliterated,

With so much of the physical evidence obliterated,

investigators face a huge challenge.

investigators face a huge challenge.

The team gets a break when the 737's flight

data recorder is recovered.

Well, looks pretty good, considering.

Well, looks pretty good, considering.

The search for the cockpit voice recorder

The search for the cockpit voice recorder

continues.

In the meantime, investigators can search

In the meantime, investigators can search

the flight data for clues.

They hope it will reveal why a new Boeing aircraft

They hope it will reveal why a new Boeing aircraft

crashed so soon after takeoff.

Let's see what we've got.

The data showed us the airplane was behaving

as we would expect it to.

It was a perfectly airworthy aircraft.

It was a perfectly airworthy aircraft.

There's no question about it.

As investigators examine the data...

As investigators examine the data...

Look at this.

...the pilot's control wheel inputs after takeoff

attract their attention.

attract their attention.

Rotate.

They make a surprising discovery.

They make a surprising discovery.

He was turning left from the moment they left the ground.

That information showed us that right after takeoff

the aircraft started to roll to the right a little bit,

the aircraft started to roll to the right a little bit,

and the pilot corrected it.

And then he keeps making corrections to the left.

And then he keeps making corrections to the left.

It looks like he's trying to keep the plane level.

It looks like he's trying to keep the plane level.

Investigators wonder what caused the aircraft's

slight roll to the right.

They dig deeper into the flight data.

They dig deeper into the flight data.

Bingo.

It's the way the flaps are rigged,

It's the way the flaps are rigged,

gave it a slight right roll.

On this particular 737,

On this particular 737,

the left flap provided slightly more

lift than the one on the right.

While climbing, pilots needed to compensate for the difference

While climbing, pilots needed to compensate for the difference

by making constant adjustments to the roll.

It's similar to driving down the freeway in your car

It's similar to driving down the freeway in your car

and just letting go of the wheel.

and just letting go of the wheel.

Then it'll start to drift off one way or another.

That's the way the airplane was slowly and naturally banking.

That's the way the airplane was slowly and naturally banking.

The discovery explains why the captain kept

his control column turned to the left immediately after takeoff.

his control column turned to the left immediately after takeoff.

Well, that's weird.

Well, that's weird.

But it doesn't account for some readings

in the flight data.

Look at this.

Look at this.

The captain's control wheel inputs seem to stop.

It's like he just let go of it.

It's like he just let go of it.

Six degrees right, he does nothing.

11 degrees, 15 degrees, 20 degrees,

11 degrees, 15 degrees, 20 degrees,

30 degrees and still nothing.

Why did the crew stop leveling

the plane despite banking further

and further to the right?

and further to the right?

Bank angle, bank angle.

The airplane just continues to roll right

up to 110 degrees of bank.

The crew didn't recover it before impact.

The data paints a baffling

picture of the short flight.

Who flies like that?

Who flies like that?

With little physical evidence to go on

and perplexing flight data, the team

is eager to locate the plane's cockpit voice recorder.

is eager to locate the plane's cockpit voice recorder.

It may be all they have to solve the mystery

It may be all they have to solve the mystery

of Flight 507's crash.

It takes five weeks for searchers

to recover Kenya Airways Flight 507's

to recover Kenya Airways Flight 507's

cockpit voice recorder from a swamp near Douala International

Airport.

Airport.

Started.

Investigators hope it will reveal why the pilots

didn't take action until the aircraft reached

didn't take action until the aircraft reached

an extreme right bank angle.

Selected.

Check.

N1.

FIRST OFFICER (ON TAPE): OK, command.

That's the call to activate the autopilot.

So should I remain on this heading?

Yep.

Yep.

Flight data confirms that the captain released

the control column after calling for the autopilot

the control column after calling for the autopilot

to be engaged.

But investigators spot a problem.

The autopilot didn't come on.

The autopilot didn't come on.

He thought the 737 was flying itself.

Investigators are stunned.

Investigators are stunned.

After the captain released the control column,

55 seconds passed before pilots noticed

55 seconds passed before pilots noticed

the plane was out of control.

There was nobody flying the controls,

There was nobody flying the controls,

so nothing was controlling the airplane.

The chilling discovery gives

the investigation a new focus.

the investigation a new focus.

N1.

OK, command.

Why didn't the autopilot turn on?

Why didn't the autopilot turn on?

The captain calls for the autopilot to be engaged.

The captain calls for the autopilot to be engaged.

But the first officer does not respond.

Investigators suspect that the first officer was so

Investigators suspect that the first officer was so

focused on inputting the route around the storm

that he never engaged the autopilot.

that he never engaged the autopilot.

Now we're getting into it.

It seems the captain assumed

the autopilot was controlling the aircraft and

the autopilot was controlling the aircraft and

the pre-selected right turn.

Bank angle, bank angle.

Bank angle, bank angle.

Bank angle, bank angle.

The pilots only noticed

there was a problem when the bank angle warning sounded.

there was a problem when the bank angle warning sounded.

This means the plane exceeded a 35-degree roll

This means the plane exceeded a 35-degree roll

and was flying into danger.

We're crashing!

Yet, the 737's bank angle

Yet, the 737's bank angle

warning is designed to give pilots

enough time to regain control.

enough time to regain control.

So why didn't the crew recover?

They should have been trained for such a scenario.

Investigators dig into the pilots' backgrounds for clues.

Wait.

Wait.

Look at this.

They find serious shortcomings in the captain's

training records.

Inadequate knowledge of systems and procedures,

insufficient flight discipline, poor cockpit scans,

insufficient flight discipline, poor cockpit scans,

below standard.

Yikes.

Yikes.

Get up.

OK.

We discovered that captain had a history of training

difficulties and lack of systems knowledge

difficulties and lack of systems knowledge

for autoflight systems and so forth.

So he had some red flags in his history.

So he had some red flags in his history.

The first officer's report isn't any better.

The first officer's report isn't any better.

The first officer was young and fairly inexperienced.

He had had some training feedback, like you

He had had some training feedback, like you

need to be more proactive about calling out deviations

and so forth.

Not an A-level crew.

Not an A-level crew.

It's a troubling discovery,

but it still doesn't add up.

but it still doesn't add up.

It should have been a simple recovery.

Even a less experienced captain

and a novice first officer would have had

and a novice first officer would have had

basic upset recovery skills.

Was there something here that we are

missing in the investigation?

missing in the investigation?

They returned to the flight data and the voice

recording for additional clues.

recording for additional clues.

Bank angle.

When the bank warning came on and the aircraft was

When the bank warning came on and the aircraft was

in a right roll, the captain turned it further to the right,

in a right roll, the captain turned it further to the right,

which aggravated the situation.

When he realized the autopilot was disengaged,

When he realized the autopilot was disengaged,

the captain activated it.

But when the plane didn't level immediately,

But when the plane didn't level immediately,

he turned the control column erratically.

Those inputs overrode the autopilot.

Those inputs overrode the autopilot.

22 degrees to the right, 20 left,

45 right, then 11 to the left.

45 right, then 11 to the left.

That's not helping.

That's not helping.

We're crashing!

Yeah, we are crashing.

Then, "yes, we are crashing."

Then, "yes, we are crashing."

Left, left, left corrections.

Left correction!

Left correction!

The timing of the first officer's response

is significant.

is significant.

It took him ten seconds to speak up.

The first officer read the situation correctly.

The first officer read the situation correctly.

We're crashing!

Yeah, we are crashing.

The pilots needed to turn left.

The pilots needed to turn left.

Left, left!

Bank angle.

Left correction!

So why did First Officer Kiuru stay silent?

So why did First Officer Kiuru stay silent?

They go back to the first leg of the flight from Abidjan

They go back to the first leg of the flight from Abidjan

to Douala on the recording for clues.

Let's hear it.

Let's hear it.

FIRST OFFICER (ON TAPE): Sorry, Did you

say an altitude of 14,000 feet?

say an altitude of 14,000 feet?

Yes, don't be so stupid.

Write it down if you can't remember.

Write it down if you can't remember.

Wow.

There were words like "stupid," "shut up,"

stuff like that that you wouldn't

stuff like that that you wouldn't

expect to hear in a professional crew environment.

What is wrong with you?

What is wrong with you?

Did you not hear the instruction?

The first officer seemed to shut down.

Heading 2-3-0.

Heading 2-3-0.

Understand?

Investigators believe the captain's

Investigators believe the captain's

intimidating manner prevented the first officer

from speaking up sooner.

Bank angle, bank angle.

The captain's behavior toward the first officer

on the first flight likely caused

on the first flight likely caused

him to adopt a passive role.

You need both pilots actively engaged in checking each other

You need both pilots actively engaged in checking each other

and catching errors.

So a heightened ego?

So a heightened ego?

Really?

History with him.

Captain Wamwea's treatment of his first officer

Captain Wamwea's treatment of his first officer

leads investigators to delve deeper into the captain's

professional history.

professional history.

He had a lot of concerning things in his training files

about being overbearing, being authoritarian

about being overbearing, being authoritarian

in terms of how he dealt with other crew members.

So we have our young, reserved first officer

and an overbearing captain.

and an overbearing captain.

A lethal combination.

So should I remain on this heading?

Yep.

In the end, investigators

In the end, investigators

conclude that one major mistake lay

at the heart of the tragedy...

the crew's failure to ensure the autopilot was engaged.

the crew's failure to ensure the autopilot was engaged.

Additionally, the pairing of a domineering, verbally abusive

Additionally, the pairing of a domineering, verbally abusive

captain with an apprehensive young pilot

compounded the danger.

Bank angle, bank angle.

In the wake of Flight 507's crash,

Cameroon's commission of inquiry made a series

Cameroon's commission of inquiry made a series

of recommendations, including regularly updating

of recommendations, including regularly updating

safety manuals relating to cockpit procedures

and crew responsibility...

and crew responsibility...

They made changes to the standard operating procedures

about who's responsible for engaging the autopilot.

about who's responsible for engaging the autopilot.

...and improved pilot training with a focus

on upset recovery.

on upset recovery.

Communication in the cockpit is like the fabric that

holds a good flight together.

holds a good flight together.

And when these break down, then you may be in trouble.

And when another professional mismatch

leads to panic in the cockpit...

leads to panic in the cockpit...

Left, left, left!

...a short commuter flight goes horribly wrong.

...a short commuter flight goes horribly wrong.

It's a cold and rainy night at Zurich International Airport.

Passengers on board Crossair Flight 498

Passengers on board Crossair Flight 498

are waiting for takeoff to Dresden, Germany.

Captain Pavel Gruzin is in command.

Captain Pavel Gruzin is in command.

And ready?

And Rastislav Kolesar is first officer.

And Rastislav Kolesar is first officer.

Checklist completed.

Both

Pilots came from Eastern Europe

to work in Switzerland.

to work in Switzerland.

Set takeoff power.

Takeoff power set.

Tonight, they're flying a Saab 340 turboprop.

Tonight, they're flying a Saab 340 turboprop.

Get up.

Before the aircraft clears the clouds,

the controller makes a slight change to the flight path.

the controller makes a slight change to the flight path.

498, turn left to Zurich East.

Turning left to Zurich East.

Turning left to Zurich East.

Crossair Four-niner-eight.

The new route takes the plane south of the airport

The new route takes the plane south of the airport

over a navigation beacon and on to Dresden.

As the plane begins to turn, the first officer

notices something wrong.

notices something wrong.

Turning... turning left to Zurich East.

We should left!

No, no.

Crossair 498, confirm you are turning left.

Please, standby.

Please, standby.

The plane should be turning left,

but instead it's banking to the right.

but instead it's banking to the right.

OK, continue right to Zurich East.

No!

Left, left, left!

Left, left, left!

No!

Flight 498 slams into the ground

just four miles from the airport.

just four miles from the airport.

All seven passengers and three crew die on impact.

All seven passengers and three crew die on impact.

The next morning, investigators inspect the wreckage.

The next morning, investigators inspect the wreckage.

The crash site itself provides them with their first lead.

The crash site itself provides them with their first lead.

If you can't see a bigger structure of an aircraft

and you see a crater, that leads you to the idea

and you see a crater, that leads you to the idea

that this aircraft has to come quite steep into the ground.

that this aircraft has to come quite steep into the ground.

The debris field tells investigators the direction

the plane was flying.

the plane was flying.

They discover it was turning in the opposite direction

to its designated flight path.

to its designated flight path.

They question air traffic controllers working

the night of the accident.

the night of the accident.

Why weren't they flying the standard departure?

498 turn left to Zurich East.

498 turn left to Zurich East.

Air traffic controllers

tell investigators Crossair 498 turned right

tell investigators Crossair 498 turned right

and not left as instructed.

Crossair 498, confirm you are turning left.

Crossair 498, confirm you are turning left.

Please, standby.

The controller assumed the captain

wanted to follow a different route

wanted to follow a different route

and approved the course change.

OK, continue right to Zurich East.

Moments later, the plane spiraled out of control.

Moments later, the plane spiraled out of control.

A steep right turn developed, which led to a collision

with ground.

But there was no indication about the reason for that.

The team hopes the black boxes will

The team hopes the black boxes will

help focus the investigation.

While experts recover the recorders' data,

While experts recover the recorders' data,

crash site debris provides a big lead...

a pilot's mostly intact flight bag.

It belonged to Captain Gruzin, and its contents

It belonged to Captain Gruzin, and its contents

are disturbing.

There were some personal items in there,

and with them we found this medication.

and with them we found this medication.

No label or box with it.

No label or box with it.

It is quite uncommon that you find some medication

in a pilot's bag.

in a pilot's bag.

Turning left to Zurich East.

We should left!

We should left!

Investigators consider a deeply troubling scenario.

Was a drug-impaired captain at the controls

Was a drug-impaired captain at the controls

on the night of the crash?

It is always of great concern because we all

It is always of great concern because we all

know that we're not supposed to take any kind of drugs

when we go flying.

The team must identify the medication

The team must identify the medication

and determine whether Captain Gruzin took any before stepping

into the cockpit.

into the cockpit.

Get this to the lab.

OK.

The test results identify

The test results identify

phenazepam, a powerful sedative similar to Valium.

The drug is often used to treat anxiety disorders.

The drug is often used to treat anxiety disorders.

In this case, there was a medication

which was very strong, and which can

which was very strong, and which can

have an effect on your capability to fly an airplane.

have an effect on your capability to fly an airplane.

Investigators must wait for the results

of the tissue analysis.

Could an impaired pilot be the reason

Could an impaired pilot be the reason

10 people lost their lives in a tragic accident?

The investigation into the crash of Crossair Flight 498

The investigation into the crash of Crossair Flight 498

comes to a dead end with the results

comes to a dead end with the results

from the tissue analysis.

Though Captain Gruzin had traces of a sedative in his system,

Though Captain Gruzin had traces of a sedative in his system,

the tests don't reveal if the amount was sufficient to affect

his flying.

We were not able to rule out this effect in the accident,

We were not able to rule out this effect in the accident,

but we were also not sure that this medication

but we were also not sure that this medication

had an effect for sure.

had an effect for sure.

With the data from the black boxes now available,

the team turns to the cockpit voice recording for answers.

the team turns to the cockpit voice recording for answers.

FIRST OFFICER (ON TAPE): Tail is up.

They listen to the pilots' conversation

in the cockpit alongside the flight data.

in the cockpit alongside the flight data.

Right here the turn is starting to get very steep.

Right here the turn is starting to get very steep.

Oh, no, no!

The captain's sudden agitated reaction

provides a clue.

provides a clue.

That timing can't be coincidence.

That timing can't be coincidence.

Investigators know that the captain's

flight display changes the moment

a turn becomes too steep.

The system is designed that if you go into an abnormal bank

The system is designed that if you go into an abnormal bank

or pitch angle, he removes unnecessary information

or pitch angle, he removes unnecessary information

to make the recovery easier for the pilot.

The timing of the captain's remark

The timing of the captain's remark

convinces investigators his instruments were working.

But for some reason, the pilot turned further to the right.

But for some reason, the pilot turned further to the right.

Left!

I think the problem was that he was

I think the problem was that he was

not aware of what was going on.

What so confused an experienced pilot

What so confused an experienced pilot

that he was unable to distinguish left from right?

The team examines the pilot's records at Crossair.

The team examines the pilot's records at Crossair.

Nothing yet.

Nothing yet.

You?

Investigators need to dig deeper

into the crew's training.

into the crew's training.

The search for an answer takes them to Russia, where

Captain Gruzin learned to fly.

Captain Gruzin learned to fly.

Thank you for seeing us.

Captain Gruzin was trained

on Soviet-era aircraft, the first officer

on Soviet-era aircraft, the first officer

on Western planes.

Investigators learned that both pilots completed

Investigators learned that both pilots completed

their training successfully.

But then Russian experts share a troubling cluster

But then Russian experts share a troubling cluster

of similar accidents.

Pilots trained on Soviet-era aircraft were

Pilots trained on Soviet-era aircraft were

becoming confused by a crucial flight

instrument on Western planes...

the attitude indicator, or artificial horizon.

the attitude indicator, or artificial horizon.

This was very surprising for us

because this problem was not well

because this problem was not well

known at this time in the Western part of aviation.

known at this time in the Western part of aviation.

Pilots in the former Soviet Union

were trained to fly using an attitude

indicator that looks very different from the ones

indicator that looks very different from the ones

in Western planes.

Turning left to Zurich East, Crossair four-niner-eight.

Turning left to Zurich East, Crossair four-niner-eight.

In the West, the aircraft symbol at the center

In the West, the aircraft symbol at the center

is static while the background moves.

Soviet or Eastern attitude indicators

work in the opposite way.

work in the opposite way.

The aircraft symbol moves, and the horizon remains static.

The aircraft symbol moves, and the horizon remains static.

It's easy to see how a pilot might get confused.

This discovery was really crucial for a probable cause

This discovery was really crucial for a probable cause

of this accident.

Under stress and possibly

Under stress and possibly

affected by a sedative, Captain Gruzin

may have reverted to what he learned

may have reverted to what he learned

when he first became a pilot.

No!

In his confusion, he became convinced

In his confusion, he became convinced

he was in a steep left turn, so he

turned right, putting the aircraft

turned right, putting the aircraft

into a deadly, spiraling dive.

But a question remains unanswered... what prevented

But a question remains unanswered... what prevented

the first officer from noticing his captain's

mistake before it was too late?

mistake before it was too late?

Climbing level 110, Crossair four-niner-eight.

It was the first officer's

job to monitor the instruments.

job to monitor the instruments.

Investigators reconstruct the flight

to see what the first officer was doing when

to see what the first officer was doing when

things started to go wrong.

OK, let's begin.

In the air.

In the air.

Crossair 498, climb to flight level 110.

Climbing level 110.

Crossair four-niner-eight.

Crossair four-niner-eight.

Investigators discover the first officer must have

Investigators discover the first officer must have

been looking down to adjust some settings

or was focused on the overhead panel.

or was focused on the overhead panel.

Bleeds are on.

Set climb power.

Set climb power.

Coming.

These duties keep a pilot's gaze well away

from the attitude indicator.

By the time the first officer could see what was happening,

By the time the first officer could see what was happening,

the plane was already in a steep right bank.

the plane was already in a steep right bank.

Turning left to Zurich East.

We should left!

Crossair 498, confirm you are turning left.

Crossair 498, confirm you are turning left.

Please, standby.

No!

No!

The stress in the first officer's voice

suggests he knew there was a serious problem,

but was unable to communicate it clearly.

but was unable to communicate it clearly.

Left, left!

And the captain, thinking his plane was already

turning left, didn't understand what his first officer

turning left, didn't understand what his first officer

was trying to tell him.

Left!

Their English was basically aviation English.

Their English was basically aviation English.

Ah!

And it is hard to communicate fluently

and to communicate concerns well enough.

and to communicate concerns well enough.

All he had to say was stop, you're turning the wrong way.

All he had to say was stop, you're turning the wrong way.

In the end, the pairing

of two pilots with very limited English language skills

proved lethal.

proved lethal.

After the crash of Flight 498, the aviation industry worldwide

After the crash of Flight 498, the aviation industry worldwide

improved training for pilots from former Soviet bloc

countries, and passing an English language proficiency

countries, and passing an English language proficiency

test became a requirement.

Recommendations did arise from the accident.

People upgrading to Western machines

People upgrading to Western machines

received much more training on the differences between Western

and Eastern Bloc aircraft.

and Eastern Bloc aircraft.

But when mistrust in the cockpit reaches a fever pitch...

But when mistrust in the cockpit reaches a fever pitch...

Yaw damper.

Autopilot all the way.

Don't touch.

...a straightforward landing turns into a disaster.

...a straightforward landing turns into a disaster.

Tony, what did you do?

I did nothing.

United Express Flight 6291

United Express Flight 6291

is en route from Washington Dulles Airport

to Columbus, Ohio.

A winter cold front is dropping temperatures

below freezing in the region.

Cold enough for you?

Cold enough for you?

Captain Derek White is in the cockpit.

Actually, I kind of like it.

Really?

Really?

Anthony Samuels is his first officer.

He's been with United Express for three months.

He's been with United Express for three months.

Starting to get the hang of it?

Oh, yeah.

Oh, yeah.

They're piloting a brand new Jetstream 4100,

a small twin-engine turboprop.

There are only five passengers plus a flight

attendant in the cabin.

attendant in the cabin.

Flight 6291 is cruising at an altitude of 14,000 feet.

Flight 6291 is cruising at an altitude of 14,000 feet.

United Express 6291, be advised,

United Express 6291, be advised,

we just had a report of some icing at 1,400.

we just had a report of some icing at 1,400.

Indianapolis Center, United Express 6291,

can we get 1,500 for a while?

can we get 1,500 for a while?

United Express 6291, climb and maintain 1,500.

United Express 6291, climb and maintain 1,500.

1,500, United Express 6291.

1,500, United Express 6291.

After flying for several minutes

After flying for several minutes

above the bad weather...

I made the approach turn.

...the pilots are ready to begin their descent.

...the pilots are ready to begin their descent.

United Express 6291, reduce speed to 1-7-0 knots.

United Express 6291, reduce speed to 1-7-0 knots.

The plane needs to slow

down to make a safe approach.

down to make a safe approach.

Reduce speed to 170 knots, United Express 6291.

Reduce speed to 170 knots, United Express 6291.

United Express 6291, Columbus Tower, runway

United Express 6291, Columbus Tower, runway

2-8 left cleared to land.

Wind 3-0-0 at 4 knots.

Wind 3-0-0 at 4 knots.

OK, if you have all the speeds,

don't worry about it anymore.

The ref is 112, but I got to input that.

The ref is 112, but I got to input that.

I did it for you.

OK, and we're marker inbound.

Roger.

Don't forget to give me my call-outs.

Don't forget to give me my call-outs.

The captain reminds the first officer

to report the altitude and airspeed readings.

As the plane pushes through the mist and drizzle,

the runway comes into view.

the runway comes into view.

Flaps 15, landing checks.

Flaps 15, landing gear down, three green.

Flaps 15, landing gear down, three green.

Yaw damper.

Tony, what did you do?

I did nothing.

Oh!

Give me flaps up.

No, no, no.

Hold it, hold it.

Hold it, hold it.

They're up.

Give me flaps up.

Hold tight!

Ah!

Ah!

Flight 6291 crashes into a warehouse only

a mile short of the runway.

a mile short of the runway.

Follow me right behind.

A family of three escapes the fiery wreckage.

They are the only ones to survive.

They are the only ones to survive.

After sunrise, lead investigator Al Dickinson and his team

After sunrise, lead investigator Al Dickinson and his team

from the National Transportation Safety Board are on the scene.

The fire was very intense, and it

The fire was very intense, and it

made it hard just to try to identify the different pieces.

made it hard just to try to identify the different pieces.

Yes, now, that's what I wanted to see.

Yes, now, that's what I wanted to see.

The flight data recorder

and cockpit voice recorder are found

buried deep in the wreckage.

Using Flight 6291's airspeed and altitude,

Using Flight 6291's airspeed and altitude,

the team tracks the plane's descent.

the team tracks the plane's descent.

OK, this is the ice that they flew through.

The data gives the investigators a lead.

Wow, 240 knots.

Wow, 240 knots.

They are screaming through this.

And it looks like a slam dunk.

And it looks like a slam dunk.

A slam dunk is when a plane approaches high and then

descends rapidly to the runway.

descends rapidly to the runway.

It's usually done to get through bad weather quickly,

but it's a risky maneuver.

You can fly really fast to get through ice,

You can fly really fast to get through ice,

but if you don't look well ahead of the aircraft,

you can easily slam it right into the Earth.

you can easily slam it right into the Earth.

Here they're going so fast, the controller

has to slow them down.

United Express 6291, reduce speed to 1-7-0 knots.

United Express 6291, reduce speed to 1-7-0 knots.

In response, the crew moves the thrust to idle

and doesn't adjust it again.

and doesn't adjust it again.

Investigators discover the plane dropped to 100 knots,

Investigators discover the plane dropped to 100 knots,

well below 130 knots, which is the minimum speed

to prevent a stall.

to prevent a stall.

So they go from way too fast to way too slow.

So they go from way too fast to way too slow.

Why would pilots reduce

their speed so dangerously low?

Sifting through United Express Flight 6291's...

Sifting through United Express Flight 6291's...

It's here.

It's here.

...the investigators make a surprising discovery.

They were doing all this with the autopilot on.

So right up until before they crashed,

they were using the autopilot to help them land?

they were using the autopilot to help them land?

While an aircraft on autopilot

While an aircraft on autopilot

can follow the descent path perfectly,

the captain still needs to monitor

and control the airspeed.

and control the airspeed.

That's why pilots almost always land manually.

So they move thrust to idle, the plane

slows down below the safe approach

slows down below the safe approach

speed, which makes it descend.

speed, which makes it descend.

And the autopilot tries to climb.

Because Flight 6291 drops

Because Flight 6291 drops

below the prescribed descent path, or glide slope,

the autopilot pitches the nose up to regain altitude.

the autopilot pitches the nose up to regain altitude.

But this slows the plane even more and takes it into a stall.

But this slows the plane even more and takes it into a stall.

Tony, what did you do?

Tony, what did you do?

I did nothing.

Investigators now know the sequence of events that led

to the crash, but they still don't know

to the crash, but they still don't know

why the pilots didn't increase their airspeed

to save the plane.

to save the plane.

OK, let's go.

The team listens to the cockpit

voice recording for clues.

voice recording for clues.

United Express 6291, reduce speed to 1-7-0 knots.

United Express 6291, reduce speed to 1-7-0 knots.

Reduce speed to 170 knots.

Just as the pilots are cleared to land,

investigators hear things going wrong.

investigators hear things going wrong.

OK, if you have all the speeds,

don't worry about it anymore.

FIRST OFFICER (ON TAPE): Ref is 112.

FIRST OFFICER (ON TAPE): Ref is 112.

I got to input that.

I did it for you.

Now, there's definitely tension in the cockpit.

OK, and we're marker inbound.

OK, and we're marker inbound.

Roger.

Don't forget to give me my call-outs.

FIRST OFFICER (ON TAPE): OK, flaps nine.

Geared up.

Geared up.

Flaps, nine waiting for three green.

Flaps 15, landing checks.

FIRST OFFICER (ON TAPE): Flaps 15,

FIRST OFFICER (ON TAPE): Flaps 15,

landing gear down, three green.

Wait.

Wait.

Did anyone hear any call-outs?

He should have been calling out altitudes.

He should have been calling out airspeeds,

but he wasn't doing any of that.

but he wasn't doing any of that.

The first officer's omission is revealing.

Yaw damper.

Yaw damper.

Autopilot all the way.

Don't touch.

Don't touch, holding on the yaw damper.

Disconnecting the yaw damper

Disconnecting the yaw damper

would turn off the autopilot.

He doesn't want to lose the autopilot.

This heated exchange tells investigators the captain

This heated exchange tells investigators the captain

has little faith in his own skills to land manually,

and even less faith in his first officer's abilities.

and even less faith in his first officer's abilities.

The captain's comment "yaw damper, don't touch,"

and the first officer response, "don't touch,"

and the first officer response, "don't touch,"

told us a lot about the dynamics between the captain

and first officer.

It illustrated the tension between the two of them

and the lack of trust.

OK, that's the stick shaker.

It's stalling.

It's stalling.

That only happens when the airspeed

is approaching the stall speed.

They must take immediate action, or

They must take immediate action, or

the airplane will likely crash.

Tony, what did you do?

I did nothing.

I did nothing.

Rather than increase airspeed, as he should have

done, the captain wasted precious seconds

chastising his first officer.

chastising his first officer.

His first assumption was that the first officer

had done something wrong, which wasn't the case.

had done something wrong, which wasn't the case.

I was dumbfounded.

Give me flaps up.

No, no, no, hold it.

Hold it.

Give me flaps up.

Give me flaps up.

Flaps up in a stall?

What were these guys thinking?

What were these guys thinking?

There is no training that involves flaps up during any

There is no training that involves flaps up during any

kind of a go-around situation.

With its flaps up, the plane needs more speed

than usual to pull out of a stall,

than usual to pull out of a stall,

yet the crew doesn't notice their airspeed is already

too slow.

too slow.

Up until that time, he could have recovered.

But after that, he was along for the ride.

But after that, he was along for the ride.

It's pretty clear that the captain did not feel he could

rely on the first officer.

It's also clear the first officer did not diagnose

It's also clear the first officer did not diagnose

the need for the captain to increase

the airspeed as he should have.

the airspeed as he should have.

And therefore, it's pretty clear that the team

of the captain and first officer was ineffective.

of the captain and first officer was ineffective.

Investigators wonder how

these pilots ended up together in the cockpit

in the first place.

They study the pair's professional histories

for answers.

I got the captain's records and the first officer's.

I got the captain's records and the first officer's.

The first officer's airline

records are surprisingly thin.

That's it?

That's it?

This guy's totally green.

Hired six months before the accident,

and he's only got 2.5 hours of line experience

on the Jetstream 4100.

on the Jetstream 4100.

The captain's records also raise serious questions.

Look at this.

Look at this.

He made a habit of failing his checkrides.

He made a habit of failing his checkrides.

Checkrides verify a pilot's competency and skill.

It's very rare that a captain or first officer

will fail the checkride.

will fail the checkride.

This captain failed two check rides within about a year.

Investigators then talked to other first officers

Investigators then talked to other first officers

who have flown with the captain to find out more

about his habits when landing.

about his habits when landing.

So he usually used the autopilot while he was landing?

Thank you.

Thank you.

When a pilot constantly uses autopilot, in reality,

When a pilot constantly uses autopilot, in reality,

he doesn't have confidence in himself to fly approaches.

And pilots need to have that confidence.

And pilots need to have that confidence.

Investigators conclude that United Express should not

Investigators conclude that United Express should not

have paired a novice first officer and a captain

with a history of failures on the 4100.

with a history of failures on the 4100.

Unfortunately, the organization

needed pilots to fly the 4100 because they

needed pilots to fly the 4100 because they

had been expanding.

And they chose to pair this pair up,

And they chose to pair this pair up,

and it wasn't a good pairing.

The NTSB recommends more training to enable pilots

The NTSB recommends more training to enable pilots

to recognize and recover from a stall

and to manage high speed approaches.

and to manage high speed approaches.

Today, many more factors are considered before pilots are

Today, many more factors are considered before pilots are

placed in the cockpit together.

This cockpit resource management training now

has moved great bounds so that the first officer

has moved great bounds so that the first officer

feels he can question a decision from his captain.

feels he can question a decision from his captain.

He can suggest solutions to a situation,

He can suggest solutions to a situation,

and he will be listened to.

We're crashing!

Left, left!

Left, left!

Three bad pilot pairings

that ended in disaster.

No!

Each a lesson for greater scrutiny of a pilot's

Each a lesson for greater scrutiny of a pilot's

history and the creation of compatible partnerships

in the cockpit.

in the cockpit.

We put 93,000 flights in the air over the Earth every day

We put 93,000 flights in the air over the Earth every day

and get every one of them back almost all the time

without anything going seriously wrong.

And teamwork is what gets airplanes with people

And teamwork is what gets airplanes with people

back on the ground safely.