Original subtitles

Runway heading cleared for takeoff.

191.

191.

Commercial pilots receive extensive training...

Let's go flaps 10, and we'll configure early too.

Let's go flaps 10, and we'll configure early too.

...to help them react properly to an emergency.

We're climbing to 4,000, two, echo, X-ray.

We're climbing to 4,000, two, echo, X-ray.

But when that training is ignored...

Oh, yeah, there it is.

Approach lights in sight.

Approach lights in sight.

I don't see anything.

Why is the captain even looking for the approach lights?

...dangerous situations can become deadly.

...dangerous situations can become deadly.

100 knots?

That is weird with no lights.

Yeah.

What the heck is he talking about?

What the heck is he talking about?

This pilot was one of LA's top helicopter pilots.

How did he let himself get into this situation?

How did he let himself get into this situation?

He ignored all his training.

Investigators search for answers

when pilots of three aircraft skip protocols and crash.

when pilots of three aircraft skip protocols and crash.

When pilots don't follow the training that they've been given,

When pilots don't follow the training that they've been given,

this is not a place that you

want to be when you're sitting in the back as a passenger.

Ladies and gentlemen,

Ladies and gentlemen,

we are starting our approach.

We lost both engines.

Emergency descent.

Mayday. Mayday.

Mayday. Mayday.

Brace for impact!

I think I lost one.

I think I lost one.

It's gonna crash!

How's everyone doing today?

Helicopter charter pilot

Helicopter charter pilot

Ara Zobayan welcomes a familiar clan for today's flight...

basketball superstar Kobe Bryant.

basketball superstar Kobe Bryant.

Let's get going.

Let's get going.

Kobe, his daughter Gianna, and six others,

are flying out of Santa Ana, California,

are flying out of Santa Ana, California,

for a basketball tournament near Camarillo, 80 miles away.

for a basketball tournament near Camarillo, 80 miles away.

Hey, everyone.

It's about to get loud back there.

Zobayan is chief pilot for Island

Express, which flies VIPs around Southern California.

Express, which flies VIPs around Southern California.

Copter 7-2-Echo-X-ray, Island Express, for East 1 departure.

Copter 7-2-Echo-X-ray, Island Express, for East 1 departure.

Kobe and the pilot of this helicopter

had really become friends, because he had piloted him

so many times around Southern California

so many times around Southern California

that they developed a relationship.

They're flying in a luxury Sikorsky S-76B

They're flying in a luxury Sikorsky S-76B

configured to carry eight passengers.

The Sikorsky 76B is sort

The Sikorsky 76B is sort

of like an air limousine in that it's quite

common for VIP travel.

common for VIP travel.

Just after 9:00 AM, the helicopter

lifts off from Santa Ana.

lifts off from Santa Ana.

From here, Zobayan will navigate using the highways around Los

Angeles as a visual reference.

Landmarks for flying aircraft in LA is really important.

Landmarks for flying aircraft in LA is really important.

Burbank Helicopter, 7-2-Echo-X-ray Sikorsky

helicopter approaching the zoo for a 101 westbound transition.

13 minutes into the flight,

13 minutes into the flight,

Zobayan requests permission to pass through Burbank's airspace.

The controller denies his request because

The controller denies his request because

of low visibility, Burbank is only accepting flights where

pilots navigate solely on instruments,

pilots navigate solely on instruments,

and Zobayan is only authorized to fly

by visual flight rules or VFR.

by visual flight rules or VFR.

The threshold for the visual flight is normally 3 miles.

The threshold for the visual flight is normally 3 miles.

The Burbank Airport was 2 and 1/2 miles.

But Zobayan knows a way around this restriction.

But Zobayan knows a way around this restriction.

Asking for special VFR transition to the 101 westbound.

Asking for special VFR transition to the 101 westbound.

The controller authorizes the request,

allowing Zobayan through the low visibility airspace

allowing Zobayan through the low visibility airspace

once it's clear of traffic.

Copy that.

We'll maintain special VFR, copter 2-E-X-ray.

Zobayan will need to stay out of the clouds,

Zobayan will need to stay out of the clouds,

which are about 1,000 feet above the ground.

Where he went was the lowest route available because

Where he went was the lowest route available because

of the weather.

of the weather.

The controllers would not see him on radar, he was so low.

Kobe Bryant and the other passengers

Kobe Bryant and the other passengers

are less than 10 minutes from their destination.

are less than 10 minutes from their destination.

But now the visibility gets even worse.

But now the visibility gets even worse.

Zobayan radios the controller handling the last leg

of the flight to Camarillo for permission

to climb above the clouds.

to climb above the clouds.

We're going to go ahead and start our climb

to go above the layers.

2-Echo-X-ray, say intentions.

2-Echo-X-ray, say intentions.

We're climbing to 4,000, 2-Echo-X-ray.

And what are you going to do when you reach altitude?

And what are you going to do when you reach altitude?

Kobe Bryant, his daughter,

Kobe Bryant, his daughter,

Gianna, and the seven other people in the helicopter

are dead.

are dead.

I'm just at a loss for words right now.

You won't see another player like him again.

You won't see another player like him again.

He will be missed.

Why did a state of the art helicopter

crash just 24 miles from its destination?

crash just 24 miles from its destination?

It's up to investigators from the National Transportation

Safety Board to find the answer.

Safety Board to find the answer.

We need to cover all our bases on this one.

Knowing that there's a high-profile person

Knowing that there's a high-profile person

on board, obviously, NTSB responded with

a major investigations team.

a major investigations team.

They start by examining

the engines and rotors, as well as the helicopter's flight

the engines and rotors, as well as the helicopter's flight

instruments.

All the mechanical systems, electronic systems,

everything at that time appeared to be working fine.

everything at that time appeared to be working fine.

OK.

He takes off at 9:07.

He flies Northwest.

He flies Northwest.

Investigators can piece together a detailed flight

path from an ADS-B system installed

path from an ADS-B system installed

on the Sikorsky helicopter.

ADS-B data is like transponder data.

ADS-B data is like transponder data.

Controllers can see it and it's recorded your airspeed,

Controllers can see it and it's recorded your airspeed,

altitude, and headings.

He follows the I-5 to Van Nuys and then South to the 101,

He follows the I-5 to Van Nuys and then South to the 101,

which he follows until he makes this U-turn

straight into a hillside.

straight into a hillside.

You would see this turn

to the left, where he's coming back around or doing something.

to the left, where he's coming back around or doing something.

What's exactly the pilot doing here?

Let's take a look at the visibility.

Let's take a look at the visibility.

Investigators study visibility reports from weather

stations along the route.

They're a bit socked in near Burbank and Van Nuys,

They're a bit socked in near Burbank and Van Nuys,

but nothing you can't get through.

When he got near Burbank Airport, it

When he got near Burbank Airport, it

was 2 and 1/2 miles visibility.

That's still totally flyable for him.

That's still totally flyable for him.

They look into the career and background

of pilot Ara Zobayan.

More than 8,300 flying hours.

More than 8,300 flying hours.

Instructor on the S-76.

Chief pilot at Island Express.

Chief pilot at Island Express.

This pilot was not a rookie

who just got his license.

He was one of LA's top helicopter pilots

He was one of LA's top helicopter pilots

working for one of its top companies.

I get it if the visibility was down to zero,

I get it if the visibility was down to zero,

but this wasn't that bad.

So what happened to this guy?

So what happened to this guy?

Why do we have a high-time pilot, in an aircraft

that's capable of flight and visibility conditions

that's capable of flight and visibility conditions

he should have been able to handle,

either lose control or somehow inadvertently fly

either lose control or somehow inadvertently fly

his helicopter into the ground?

How's everyone doing today?

Records show that before he welcomed Kobe Bryant's

Records show that before he welcomed Kobe Bryant's

party on board, Zobayan checked the weather

and determined that even though there

and determined that even though there

were clouds blanketing the area, the flight was low-risk.

But the low clouds surrounding Los Angeles

But the low clouds surrounding Los Angeles

forced Zobayan to alter his usual, more direct route.

forced Zobayan to alter his usual, more direct route.

Because of the weather,

he flew more inland than he normally does.

he flew more inland than he normally does.

Based on the forecast, his plan was OK.

So what went wrong?

So what went wrong?

Investigators need to know

the exact conditions Zobayan flew into in the final moments

the exact conditions Zobayan flew into in the final moments

of the flight.

We need to figure out what he could actually see.

We need to figure out what he could actually see.

The NTSB obtains photos

that FNS captured the last moments before the crash.

OK.

OK.

You can just make him out here actually heading

into fairly heavy clouds.

Same camera, 3 seconds later, he's disappeared.

Same camera, 3 seconds later, he's disappeared.

They could collect data

in real time of what this pilot would have been encountering.

in real time of what this pilot would have been encountering.

So the cloud base was no more than 450 above the ground,

So the cloud base was no more than 450 above the ground,

not the 1,100 feet which was being reported along its route.

Surveillance data shows that the helicopter was

Surveillance data shows that the helicopter was

only 450 feet above the ground.

Investigators determined that, just over a minute

before the accident, Zobayan flew

into dense clouds, which would have reduced

into dense clouds, which would have reduced

his visibility to near zero.

Legally, he's not allowed to enter it.

Legally, he's not allowed to enter it.

He's only allowed to go in visual conditions only,

and yet he did.

and yet he did.

Flying into cloud banks with low visibility

is a leading cause of aviation accidents.

is a leading cause of aviation accidents.

In a helicopter, the consequences are often fatal.

You can't see where the horizon is,

You can't see where the horizon is,

and you can't see the sky from the ground.

Pilots like Zobayan are trained to do whatever they

Pilots like Zobayan are trained to do whatever they

can to avoid such conditions.

How did he let himself get into this situation?

Investigators take a closer look

at the speed the helicopter maintained

at the speed the helicopter maintained

while en route to Kobe Bryant's basketball academy at Camarillo.

while en route to Kobe Bryant's basketball academy at Camarillo.

He's bombing along here at about 140 knots.

He's bombing along here at about 140 knots.

Visibility is getting worse and worse,

but he's not slowing down.

He's not turning around.

He just keeps going.

He just keeps going.

Why?

He could have turned

around, landed at Van Nuys.

around, landed at Van Nuys.

He could have circled for a while near the airport waiting

for the conditions to improve.

for the conditions to improve.

For whatever reason we don't know,

he chose none of those options.

It doesn't take long for things to start going wrong as

It doesn't take long for things to start going wrong as

soon as he enters that cloud.

Instead of turning around,

Ara Zobayan decides to climb above the clouds.

Ara Zobayan decides to climb above the clouds.

We're going to go ahead and start our climb

to go above the layers.

He starts banking further and further left,

descends rapidly, hits the hill here.

descends rapidly, hits the hill here.

The helicopter's unusual movements

lead investigators to wonder about the level

lead investigators to wonder about the level

of training the pilot received.

They discover that Zobayan was well-trained to escape

They discover that Zobayan was well-trained to escape

the precise conditions he flew into.

More than that, he was

the chief pilot of the company.

the chief pilot of the company.

He set the safety standards for all the pilots,

and he trained them on how to deal with instrument conditions.

and he trained them on how to deal with instrument conditions.

It's one of the reasons

that Kobe Bryant flew with Zobayan so often.

that Kobe Bryant flew with Zobayan so often.

Director of operations says that Kobe's relationship with

Director of operations says that Kobe's relationship with

Ara was, quote, "warm and friendly,"

that he trusted Ara with his girls and his family,

that he trusted Ara with his girls and his family,

that they always wanted Ara.

A review of Zobayan's training

shows that he was taught to reduce speed, use

the autopilot to climb above the clouds,

the autopilot to climb above the clouds,

and then declare an emergency.

His training was good.

His training was good.

But did Zobayan follow that procedure?

Here he's entering an area of low visibility,

still flying well above 100 knots,

no evidence of slowing down.

no evidence of slowing down.

Look at that rate of climb...

1,500 feet a minute.

1,500 feet a minute.

Can't be the autopilot doing that.

That exceeds the authority

of the autopilot system.

of the autopilot system.

Therefore, this climb was being manually controlled.

The higher the helicopter

climbs into the dense clouds, the worse

climbs into the dense clouds, the worse

the visibility becomes.

But Zobayan never asks for help.

But Zobayan never asks for help.

He should have been saying mayday, mayday,

mayday, declaring an emergency.

mayday, declaring an emergency.

He didn't slow down, he didn't use his autopilot,

and never declared an emergency.

and never declared an emergency.

He ignored all his training.

There are basic procedures that should be

followed, and you have to have very

followed, and you have to have very

cautious approach to any sort of instrument conditions.

This was not evident in the way the pilot flew that day.

This was not evident in the way the pilot flew that day.

With no regard for protocol,

Zobayan continues a rapid climb with no visibility

Zobayan continues a rapid climb with no visibility

and without the help of the autopilot.

We're climbing to 4,000, 2-Echo-X-ray.

We're climbing to 4,000, 2-Echo-X-ray.

Did you hear that?

On the CVR,

investigators hear him report that he's climbing when he's

investigators hear him report that he's climbing when he's

actually descending rapidly.

The highway now veers off to the right,

The highway now veers off to the right,

but he's lost sight of it.

He's banking further and further to the left

without even realizing it.

without even realizing it.

There's no sign he ever figured out what was really happening.

We're climbing to 4,000, 2-Echo-X-ray.

We're climbing to 4,000, 2-Echo-X-ray.

We're climbing to 4,000, 2-Echo-X-ray.

Kobe Bryant and eight others die as a result

Kobe Bryant and eight others die as a result

of an all too common scenario...

a helicopter pilot flying into low visibility and becoming

a helicopter pilot flying into low visibility and becoming

disoriented.

The industry needs

to realize how common and sinister

to realize how common and sinister

these effects can be and develop better safety standards.

On the recommendation of the NTSB,

On the recommendation of the NTSB,

the Federal Aviation Administration

is evaluating tools that can be used to train more pilots

is evaluating tools that can be used to train more pilots

on how to recognize and cope with the effects

of disorientation.

The last thing the NTSB wants to do

is go back and investigate this kind of accident all over again.

is go back and investigate this kind of accident all over again.

The pilot of Kobe Bryant's helicopter

had all the training he needed to avoid

had all the training he needed to avoid

the situation altogether.

But that education was disregarded

But that education was disregarded

when it was needed most.

Training is an essential part of aviation at every level.

And when that training is ignored,

And when that training is ignored,

specifically ignored in a situation where

the training should be put to use in flight,

the training should be put to use in flight,

it could lead to an accident.

When pilots fail to follow every aspect

When pilots fail to follow every aspect

of their training...

I don't see anything.

Oh, yeah, there it is approach.

Oh, yeah, there it is approach.

Approach lights in sight.

...even the most routine procedures

can lead to disaster.

can lead to disaster.

No.

No!

Trees.

No, stop!

Oh, my god!

If we have to go missed we'll set max power.

If we have to go missed we'll set max power.

Flaps 10, positive rate, gear up.

The pilots of corporate Airlines Flight 5966

The pilots of corporate Airlines Flight 5966

conduct the approach briefing for Kirksville

Missouri Regional Airport.

Missouri Regional Airport.

Then we'll climb 3,000, then direct Kirksville VOR.

Captain Kim Sasse has been a pilot since the late

Captain Kim Sasse has been a pilot since the late

1980s, but only started flying professionally

in the last five years.

I'll ask you to walk me through that if we need it.

I'll ask you to walk me through that if we need it.

Roger that.

First officer Jonathan Palmer

has three years' professional flying experience

has three years' professional flying experience

with regional airlines.

The pilots viewed your time with the regionals

The pilots viewed your time with the regionals

as somewhat of the dues you pay to get to the airlines

or the high end corporate jobs.

or the high end corporate jobs.

There are 13 passengers on board

the 50-minute flight from Saint Louis to Kirksville, Missouri.

the 50-minute flight from Saint Louis to Kirksville, Missouri.

We're going into the crap.

Look, it's so eerie and creepy.

Look, it's so eerie and creepy.

The pilots are flying a Jetstream 32.

It's fuel-efficient and reliable.

It's fuel-efficient and reliable.

But this particular model has no autopilot.

The jetstream not having any autopilot

The jetstream not having any autopilot

made our days very long.

You had to constantly fly the airplane.

You had to constantly fly the airplane.

3,000 until established.

Clear for the approach.

The crew is flying a non-precision approach with

The crew is flying a non-precision approach with

no vertical landing guidance.

Let's go flaps 10 and we'll configure early too.

Let's go flaps 10 and we'll configure early too.

Configuring for landing early

reduces the workload as they near the airport.

reduces the workload as they near the airport.

In any non-precision approach,

you want to minimize the number of variables.

And one of the ways you do that is you

And one of the ways you do that is you

get the airplane in a position to land earlier than normal.

get the airplane in a position to land earlier than normal.

Let's make sure the lights are up, please.

All right.

The lights at Kirksville are pilot-activated.

Airports without a lot of traffic that goes in and out

Airports without a lot of traffic that goes in and out

of them... one of the ways that they reduce the cost

of running the airport is they don't have

the lights on all the time.

the lights on all the time.

The pilots have the ability to control those lights

with a series of microphone clicks

with a series of microphone clicks

on a specific radio frequency.

If those lights are not on, particularly when

If those lights are not on, particularly when

you fly with a low visibility and at night,

you won't see the runway.

you won't see the runway.

Kirksville ops, CorpEx 5966.

Kirksville ops, CorpEx 5966.

5966.

Yeah.

Could you tell me of the approach lights are up?

Could you tell me of the approach lights are up?

Lights are on.

Cool.

Thanks.

2 and 1/2 miles from the airport, the pilots

2 and 1/2 miles from the airport, the pilots

search for the runway.

400.

400.

It's very critical

to maintain that altitude because if you

don't see the runway you got to go missed.

don't see the runway you got to go missed.

Because you cannot land without seeing the runway.

350, here we are.

350, here we are.

At 2 miles from the runway,

the pilots are still looking for the approach lights.

I don't see anything.

I don't see anything.

You are flying 336 feet above the ground,

so there's not a lot of room for error.

so there's not a lot of room for error.

Oh, yeah, there it is.

Approach lights in sight.

Approach lights in sight.

Flaps 35?

Flaps 35?

No.

No!

Trees.

No, stop!

Oh, my god!

Holy crap!

Holy crap!

Corporate Airlines Flight 5966

has crashed a mile south of the airport at Kirksville, Missouri.

has crashed a mile south of the airport at Kirksville, Missouri.

Only two passengers survive.

The 11 other passengers and both pilots are dead.

The 11 other passengers and both pilots are dead.

For the pilot community,

this is something that is touching

this is something that is touching

us because that could be me.

We want to know what happened.

We want to know what happened.

NTSB investigators examine the wreckage.

Engines, controls, instruments all checked out.

It appeared that the airplane was fully functional at the time

It appeared that the airplane was fully functional at the time

it hit the ground.

The plane's working fine.

The plane's working fine.

What kind of an approach where they flying that night?

What kind of an approach where they flying that night?

A non-precision to runway 36.

Unfortunately, the accident rate

Unfortunately, the accident rate

for non-precision approaches is dramatically higher than

on those approaches with an instrument landing system.

on those approaches with an instrument landing system.

So they're flying blind through the clouds.

So they're flying blind through the clouds.

It's misty.

Visibility is poor.

Those are bad conditions for a non-precision approach.

Those are bad conditions for a non-precision approach.

You come down to the lowest altitude.

You come down to the lowest altitude.

You have to level off there.

And you fly along looking for the runway environment.

And you fly along looking for the runway environment.

Pilots of other flights

into Kirksville airport report that the weather

posed no problems for them.

posed no problems for them.

So why did flight 5966 crash on the same approach?

So why did flight 5966 crash on the same approach?

Looking at all the pieces, this accident

started to look like it was a human performance issue and not

started to look like it was a human performance issue and not

an airplane issue.

Let's see how they handled the approach.

By combining flight recorder data and radar returns,

By combining flight recorder data and radar returns,

investigators determine the flight's descent profile.

investigators determine the flight's descent profile.

So the plane was supposed to level off

at the minimum descent altitude before continuing

at the minimum descent altitude before continuing

to descend to the runway.

The minimum descent altitude is the lowest altitude

The minimum descent altitude is the lowest altitude

you're permitted to fly at until you see the runway environment.

Why would they blow right past the MDA

Why would they blow right past the MDA

like that?

Investigators turned to the cockpit

voice recorder for an answer.

Take it to when they near the MDA.

Take it to when they near the MDA.

If there's a big mistake, it'll likely be then.

400.

400.

350.

Here we are.

OK.

They're at the MDA.

It's decision time.

I don't see anything.

I don't see anything.

Oh, yeah, there it is.

Approach lights in sight.

They're 2 miles out, 300 feet up.

They're 2 miles out, 300 feet up.

They've just come out of the clouds.

With the mist that night, they probably

With the mist that night, they probably

couldn't see the runway lights.

There's only farmland

from here to the airport.

Why is the captain even looking for the approach lights?

Why is the captain even looking for the approach lights?

He shouldn't be doing that.

He shouldn't be doing that.

He should be totally focused inside the airplane.

The first officer is supposed to see the approach lights

The first officer is supposed to see the approach lights

and call out, "Approach lights in sight.

Continue."

Instead, they're both looking for the runway.

Instead, they're both looking for the runway.

And nobody is paying attention to the plane's

descent speed and altitude.

The flying pilot should have been monitoring

The flying pilot should have been monitoring

exclusively instruments.

And what sadly occurred was that the normal flight path continued

And what sadly occurred was that the normal flight path continued

below the minimum descent altitude,

below the minimum descent altitude,

and neither one of them caught it.

Captain's looking outside when he shouldn't.

The first officer doesn't challenge him.

The first officer doesn't challenge him.

Next thing, they're crashing.

It's surprising how

much the captain's performance suddenly fell apart at the end.

much the captain's performance suddenly fell apart at the end.

Investigators listened for clues in earlier cockpit

conversations to explain why the crew

conversations to explain why the crew

ignored established procedures during the flight's

final moments.

final moments.

I have a good time flying with you.

You got to have fun.

That's truth, man.

You got to have fun.

Too many of these jerks take themselves

way too seriously in this job.

I've flown with them, and it sucks.

I've flown with them, and it sucks.

All I want to strangle the jerk when I get to the ground.

The conversation raises a major concern

The conversation raises a major concern

for investigators.

The captain is essentially telling him how he wants

the first officer to behave.

the first officer to behave.

That's disturbing, and it sets a disturbing atmosphere.

That's disturbing, and it sets a disturbing atmosphere.

Cruise check. Power check.

Can you push his foot away?

Yes.

It's a relatively compact airplane,

It's a relatively compact airplane,

and the passengers in the front of the airplane

and the passengers in the front of the airplane

can sometimes put their foot into the cockpit area.

Cruise power.

Cruise power.

Cruise Check.

All you got to do is you open the curtain a little bit.

It's like, man...

It's like, man...

I dropped my book on him purposely one time, right

on top of the arch of the foot.

on top of the arch of the foot.

Oh.

OK, stop it.

The captain starts his cruise power checks,

The captain starts his cruise power checks,

but then interrupts himself to tell a story

but then interrupts himself to tell a story

about hurting a passenger.

Mm-hmm.

It's really inappropriate.

It's really inappropriate.

The lack of respect for passengers

is striking in his conversation.

is striking in his conversation.

All right.

Let's see if the first officer can get him back on track.

Let's see if the first officer can get him back on track.

How'd I get 2-niner-niner-zero?

'Cause you're an idiot.

Investigators now hear the captain teasing

Investigators now hear the captain teasing

the first officer while he's confirming

their altimeter setting.

their altimeter setting.

It should be 2-niner-niner-2.

You never set it when they cleared to the runway?

You never set it when they cleared to the runway?

And I've been sitting here living

a lie for the last 20 minutes.

Yeah, you lying scumbucket.

The captain's jokes have totally eroded procedure.

The captain's jokes have totally eroded procedure.

Even the first officer has given in

and turned his checklist into a joke.

and turned his checklist into a joke.

Did the captain's conduct

affect the first officer's actions at a critical moment?

affect the first officer's actions at a critical moment?

The kind of atmosphere he set up earlier, in making fun

The kind of atmosphere he set up earlier, in making fun

of other pilots and making fun of the passengers,

sets up the wrong tone.

It doesn't encourage the first officer to object.

It doesn't encourage the first officer to object.

When things were falling apart, he could have

stepped in and done something.

stepped in and done something.

It looks like a complete breakdown in command

structure led to this accident.

structure led to this accident.

The question is, why?

Got their personnel files.

Investigators studied the pilots' training

Investigators studied the pilots' training

and histories to determine if flight

5966 crew regularly deviated from airline procedures.

5966 crew regularly deviated from airline procedures.

Captain left a well-paying job to become a pilot.

Captain left a well-paying job to become a pilot.

Plenty of hours.

Passed all the checks.

Passed all the checks.

First officer checks out, too.

They were joking a fair bit, almost punch drunk.

They were joking a fair bit, almost punch drunk.

Do you think they may have been over-tired?

Do you think they may have been over-tired?

Fatigue is insidious in that,

once you are at a higher level of fatigue,

once you are at a higher level of fatigue,

performance impairment, it can be somewhat like alcohol.

We're going into the crap.

Look, it's so eerie and creepy.

Fatigue could explain why the pilots don't

Fatigue could explain why the pilots don't

rely on their training when confronted

with a changing situation.

People start to become giddy and are not

People start to become giddy and are not

critical enough or enough careful of their behavior.

Now, how much did these guys work before the accident fight?

Now, how much did these guys work before the accident fight?

Investigators check the crews duty

hours leading up to the flight.

The night of the flight, they had worked three days straight.

The night of the flight, they had worked three days straight.

That'll tire you out.

Yeah, well, they had 7 and 1/2 hours of available rest time

Yeah, well, they had 7 and 1/2 hours of available rest time

the night before the flight.

That day, they flew six flights an hour each,

and they were on duty for 14 hours straight,

starting at 5:45 AM.

Were the pilots made to work too many

Were the pilots made to work too many

hours without sufficient rest?

Check this out.

Pilots can't fly more than eight flight hours in a day.

I flew in those days, and you had a maximum number

I flew in those days, and you had a maximum number

of flight hours in a day.

But the number of duty hours and the time of day

was not even taken into consideration.

was not even taken into consideration.

Last time these regulations were updated, 1964.

Last time these regulations were updated, 1964.

The regulations needed to be updated to improve

the safety for everyone.

the safety for everyone.

The NTSB recommends an overhaul of the FAA's flight

The NTSB recommends an overhaul of the FAA's flight

and duty time regulations to consider the length of duty day,

and duty time regulations to consider the length of duty day,

start time, workload, and other factors

that can affect pilots' alertness.

that can affect pilots' alertness.

It's not always obvious when someone is tired,

and it's not obvious to them.

and it's not obvious to them.

Had the crew of flight 5966

been rested, they likely would have adhered to their training.

been rested, they likely would have adhered to their training.

And this tragedy might have been avoided.

When pilots don't follow the training that they've been

When pilots don't follow the training that they've been

given, basically, they are putting themselves

into a raw position of ignoring all

into a raw position of ignoring all

the lessons of the past that led to the construct

of that training.

This is not a place that you want to be when you're sitting

This is not a place that you want to be when you're sitting

in the back as a passenger.

Disaster doesn't just strike

when pilots breach protocols for in-flight procedures.

when pilots breach protocols for in-flight procedures.

All yours, Jim.

At your leisure, Comair 121.

At your leisure, Comair 121.

Ready to go.

Comair 191.

Sometimes critical mistakes

Sometimes critical mistakes

are made before the plane even leaves the ground.

Damn it!

It's close to 6:00 in the morning in Lexington,

Kentucky.

Comair flight 5191 prepares for takeoff.

Comair flight 5191 prepares for takeoff.

Ladies and gentlemen, we'd like

to take this time to welcome you on board Comair

Flight 5191 direct to Atlanta.

Flight 5191 direct to Atlanta.

There are 47 passengers and one flight

attendant on the Bombardier CRJ-100, a

attendant on the Bombardier CRJ-100, a

small twin-engine commuter jet.

In command is Captain Jeff Clay, an experienced pilot with

In command is Captain Jeff Clay, an experienced pilot with

more than 4,700 flight hours.

more than 4,700 flight hours.

You up for flying this leg?

Yeah, I'll take us to Atlanta.

First Officer James Polehinke is also a seasoned pilot

First Officer James Polehinke is also a seasoned pilot

with more than 6,500 hours.

Both the captain and the first officer

Both the captain and the first officer

were very highly regarded.

Right seat flex takeoff...

They had an outstanding professional reputation.

They had an outstanding professional reputation.

They're bound for Atlanta, Georgia...

a 67-minute flight south of the Lexington airport.

a 67-minute flight south of the Lexington airport.

Comair 181, taxi to runway 22.

Comair 181, taxi to runway 22.

Altimeter 3,000.

Winds are 200 at 8.

Winds are 200 at 8.

3-triple-0 and 22.

Comair 191.

Comair 191.

During the taxi out,

the first officer is running numerous checklists

the first officer is running numerous checklists

and verifying that the aircraft is safe for departure.

and verifying that the aircraft is safe for departure.

Lexington's air traffic controller clears

flight 5191 to the runway.

flight 5191 to the runway.

Cabin reports received.

Before takeoff checks complete.

Ready.

All set.

All set.

At your leisure, Comair 121.

Ready to go.

Comair 191.

Comair 191.

Lexingon Tower... fly runway heading clear for takeoff.

Ugh.

Ugh.

Runway heading clear for takeoff, 191.

Runway heading clear for takeoff, 191.

All yours, Jim.

Captain Clay hands over control of the aircraft

Captain Clay hands over control of the aircraft

to First Officer Polehinki.

My brakes, my controls.

Set thrust, please.

Set thrust, please.

Thrust set.

That is weird with no lights.

Yeah.

100 knots.

Checks.

Checks.

Whoa.

Whoa.

Damn it!

Damn it!

The plane hurtles past the runway...

...and bursts into flames.

...and bursts into flames.

49 people are dead after Comair flight 5191's

49 people are dead after Comair flight 5191's

disastrous takeoff attempt.

Only the first officer survives, but he's too injured

Only the first officer survives, but he's too injured

to assist with the NTSB investigation

into why the plane crashed less than half a mile

into why the plane crashed less than half a mile

from Lexington's Bluegrass Airport.

First impact point is there.

And the plane hit those trees over there.

His impact marks aren't more than 20 feet up those trunks.

The wreckage path tells

The wreckage path tells

investigators that the plane struggled to get airborne.

It looks like they took off from runway 26.

It looks like they took off from runway 26.

Well, hang on.

Well, hang on.

26 wasn't in use last night.

Investigators realized that flight 5191

Investigators realized that flight 5191

took off from the wrong runway.

But that alone doesn't explain why the plane couldn't lift off.

Maybe they were too heavy?

Maybe they were too heavy?

The plane weighed 49,087 pounds on that day.

The plane weighed 49,087 pounds on that day.

It's close, but it's within their limit.

The aircraft wasn't too heavy to take off.

The aircraft wasn't too heavy to take off.

How much runway would be needed to take off safely?

How much runway would be needed to take off safely?

The weight of the aircraft

affects how fast they have to be going to be able to lift off.

affects how fast they have to be going to be able to lift off.

And that is directly correlated to how

much runway it takes to be able to achieve that speed.

much runway it takes to be able to achieve that speed.

3,744 feet.

3,744 feet.

3,744 feet.

And runway 26 is...

3,501 feet.

They ran out of runway.

They now understand why the plane

They now understand why the plane

couldn't get airborne.

But a mystery remains.

But a mystery remains.

They're supposed to leave from runway 22 here,

They're supposed to leave from runway 22 here,

but they end up here.

but they end up here.

The question is, why?

Maybe there's something on the security footage.

Maybe there's something on the security footage.

Wait.

Stop it right there.

Stop it right there.

It looks like they've stopped at the hold

short line for runway 26.

Before takeoff.

Before takeoff.

Planes stop, or hold short of the runway,

until air traffic control clears them to proceed.

until air traffic control clears them to proceed.

Why the heck would they stop there?

We need to see the taxi route.

To better understand why the pilots of Comair

To better understand why the pilots of Comair

flight 5191 stopped at the hold short line

for the wrong runway...

All right, let's get started.

All right, let's get started.

...they retrace their taxi route.

Things that we're looking for during that taxi

Things that we're looking for during that taxi

demo were markings on the taxiway, the signage,

demo were markings on the taxiway, the signage,

whether it was illuminated or not.

I can clearly see the sign is telling us

I can clearly see the sign is telling us

that we're at the hold short line for runway 26.

I mean, it's hard to miss that.

Investigators discover the crew had

Investigators discover the crew had

clear cues that they were at the hold short line for runway 26,

clear cues that they were at the hold short line for runway 26,

not 22.

All the cues are right there in plain sight.

Then they uncover another disturbing fact.

Then they uncover another disturbing fact.

When we turned on to runway 26,

all of the lights on runway 26 were out.

all of the lights on runway 26 were out.

As an experienced pilot, I look at that

and say, why did this flight crew take off from this runway?

and say, why did this flight crew take off from this runway?

We need to know what was going on in that cockpit.

The cockpit voice recorder may hold the key.

OK.

OK.

Let's hear what we've got.

In this type of human factors accident,

In this type of human factors accident,

it's very difficult because we have to try to determine

what the pilots were thinking.

OK.

Here comes the taxi brief.

Here comes the taxi brief.

It's 22.

22.

The ILS is out on 22.

The ILS is out on 22.

Came in the other night and the runway

identifier lights were out all over the place.

All right.

22 is a short taxi.

22 is a short taxi.

Any questions?

No questions before starting

at your leisure.

Wait.

Stop it right there.

Stop it right there.

Is that not a short brief to you?

Mm-hmm.

There's no mention of crossing runways

There's no mention of crossing runways

or stopping to call ATC if they're

unsure of where they are.

unsure of where they are.

Investigators can't understand why the taxi brief

with eight checklist items, including a very crucial one,

with eight checklist items, including a very crucial one,

wasn't followed.

Yeah, they never briefed on the runway they had

to cross to get to runway 22.

to cross to get to runway 22.

The crew's abbreviated briefing

that morning was a deviation from standard operating

procedures that we identified.

procedures that we identified.

Had the crew performed a full taxi briefing,

Had the crew performed a full taxi briefing,

they would have discussed the need to cross

runway 26 on the way to 22.

OK, let's hear their taxi checklist.

Yeah, I

know three guys at Kennedy, or actually, two guys.

know three guys at Kennedy, or actually, two guys.

One went, but he didn't get through the sims.

Oh, really?

Then a first officer

from Cincinnati, he got through the second part

and that's as far as he got.

Stop it right there.

What the heck is he talking about?

What the heck is he talking about?

Instead of focusing on their checklists,

the crew of 5191 was having a casual conversation.

the crew of 5191 was having a casual conversation.

He skipped out at a briefing then,

for almost a minute, they violate

for almost a minute, they violate

the sterile cockpit rule.

The sterile cockpit rule requires that pilots refrain

The sterile cockpit rule requires that pilots refrain

from non-operational conversation during

significant portions of flight.

significant portions of flight.

Oh, OK.

The captain should be shouting this conversation down,

not encouraging it.

That non-pertinent conversation was in a critical

That non-pertinent conversation was in a critical

area when the flight crew was making their taxi out

area when the flight crew was making their taxi out

to the runway, where the flight crew needs

to be 100% flying the aircraft.

to be 100% flying the aircraft.

Could that period of inattention be the key

Could that period of inattention be the key

to this tragic accident?

Let's see what happens when they get here.

Investigators hope Comair flight 5191's CVR will

Investigators hope Comair flight 5191's CVR will

give some indication why the crew

turned onto the wrong runway.

turned onto the wrong runway.

Thrust reversers are armed.

Auto crossflow is manual.

Auto crossflow is manual.

Ignition is off.

Altimeters are 3-triple-zero across the board, cross-checked.

Altimeters are 3-triple-zero across the board, cross-checked.

I'll check in with the cabin.

I'll check in with the cabin.

That's it?

When they stopped their chit-chat,

they don't seem to recognize, know, or check where they are.

they don't seem to recognize, know, or check where they are.

Investigators are intrigued

by what they hear next.

by what they hear next.

At your leisure, Comair 121.

Ready to go.

Comair 191.

Comair 191.

Lexington Tower.

Fly runway heading, clear for takeoff.

They're completely relaxed when they ask for clearance.

They're completely relaxed when they ask for clearance.

In fact, so relaxed or distracted

that the first officer uses the wrong flight number.

that the first officer uses the wrong flight number.

These guys actually thought they were lined up for runway 22.

These guys actually thought they were lined up for runway 22.

The fact that they stopped at runway 26

and subsequently called for takeoff

and subsequently called for takeoff

indicates that they lost awareness that they

had not crossed runway 26.

had not crossed runway 26.

They turn onto runway 26.

Then what?

Keep going.

Keep going.

Weather checks completed.

All yours, Jim.

First officer takes the controls.

First officer takes the controls.

So he's looking ahead probably for the first time.

The captain transferred

The captain transferred

controls to the first officer.

So before this time, the first officer

was heads down in the cockpit.

My brakes, my controls.

When the first officer looked out,

When the first officer looked out,

he saw a runway.

He may not have perceived that it was a narrower

runway than runway 22.

They're looking down runway 26.

Why don't they see the sign for 22 off to the right?

Neither pilot cross-checked

Neither pilot cross-checked

their location at the time that they took the runway.

100 knots checks.

100 knots checks.

The pilots realize they're almost out of runway.

V1, rotate.

V1, rotate.

But they don't have the required speed to lift off.

Whoa.

Damn it!

The NTSB concludes that by ignoring their training,

The NTSB concludes that by ignoring their training,

the pilots lost track of their position on the way

the pilots lost track of their position on the way

to the runway.

Both crew members lost awareness of where they

were on that airport surface and made a mistake that

were on that airport surface and made a mistake that

was extremely consequential.

Among the NTSB's recommendations

is a technological change to prevent

is a technological change to prevent

pilots from getting lost.

Install moving map GPS displays in CRJ-100 cockpits.

Install moving map GPS displays in CRJ-100 cockpits.

The NTSB also makes recommendations

The NTSB also makes recommendations

for flight crews.

Require pilots to check that they

are at their assigned runway before crossing

are at their assigned runway before crossing

the hold short line.

This was a catastrophic accident.

This was a catastrophic accident.

It affected scores and scores of lives.

It affected scores and scores of lives.

But the legacy of this accident are the safety changes that have

But the legacy of this accident are the safety changes that have

been made to prevent this type of accident

from happening in the future.

Airline pilots expect the unexpected every day

Airline pilots expect the unexpected every day

they go to work.

But routine emergencies turn catastrophic

But routine emergencies turn catastrophic

when pilots disregard standard operating procedures

and allow a bad situation to get worse.

and allow a bad situation to get worse.

A lot of thought has gone into training modules.

And so if you ignore part of them

or just choose not to follow part of them,

or just choose not to follow part of them,

you are ignoring literally a whole body of knowledge that

has been put together to keep you safe

has been put together to keep you safe

and keep your passengers alive.