Original subtitles

You're going 120.

You can't keep decreasing your speed.

You can't keep decreasing your speed.

With no runway in sight...

It's more like 125,

which is the approach speed.

which is the approach speed.

...two pilots argue.

That doomed them.

Hey, what's going on?

A captain believes one signal...

A captain believes one signal...

Why is that ignition light on?

Did we just have a flameout?

...but ignores another.

...but ignores another.

Captain seems out of it.

They were just really flying sloppy.

They were just really flying sloppy.

Come on, come on, come on.

Level off, man.

Level off.

An exhausted pilot picks a disastrous time.

An exhausted pilot picks a disastrous time.

He's not gonna make it.

No way.

...to try a new approach.

These crashes could have been avoided.

These crashes could have been avoided.

They could see that the needle

was in the red band.

That captain should not have been flying passengers

That captain should not have been flying passengers

under any circumstances.

A debate about speed, a question about power,

A debate about speed, a question about power,

a case of fatigue.

Investigators ask how such experienced pilots

Investigators ask how such experienced pilots

could have been so careless.

Ladies and gentlemen,

we are starting our approach.

we are starting our approach.

We lost both engines.

Put the mask over your nose.

- Emergency descent. - Mayday. Mayday.

Brace for impact!

Brace for impact!

I think I lost one.

Investigation started.

Shrapnel.

He's gonna crash.

He's gonna crash.

ExecuFlight 1526 is climbing to cruising

ExecuFlight 1526 is climbing to cruising

altitude above the Midwest.

17,000 feet.

17,000 feet.

Roger.

17,000 feet, leveling off.

First Officer Renato Marchese is the pilot flying

the twin-engine Hawker 700.

the twin-engine Hawker 700.

He's logged more than 4,000 flying

hours on various private jets.

hours on various private jets.

Captain Oscar Chavez has over 6,000 hours on private

jets and cargo planes.

jets and cargo planes.

It's a 35-minute flight from Dayton,

northeast, to Akron, Ohio.

On board are seven executives from a Florida-based property

On board are seven executives from a Florida-based property

management company.

Cheers.

They've chartered the luxury jet

They've chartered the luxury jet

from ExecuFlight, a private carrier based

in Fort Lauderdale, Florida.

Zipline 1526, descend to 13,000.

Zipline 1526, descend to 13,000.

"Zipline" is the call sign for ExecuFlight.

Heading?

249.

ACTOR AS AKRON CONTROL Akron

ACTOR AS AKRON CONTROL Akron

visibility 1 and 1/2, mist.

Sky condition, overcast, 600 broken.

Sky condition, overcast, 600 broken.

The crew is advised that rain is reducing visibility

at their destination.

And there's another complication.

And there's another complication.

Zipline 1526, we do have another aircraft

Zipline 1526, we do have another aircraft

that's inbound to the airport that is slower than you.

A student pilot is practicing

a landing on the same runway assigned to Flight 1526.

a landing on the same runway assigned to Flight 1526.

a landing on the same runway assigned to Flight 1526.

Akron Control requests that they alter their course

and maintain altitude at 3,000 feet.

and maintain altitude at 3,000 feet.

Speed is 170 and 360, Zipline 1526.

Speed is 170 and 360, Zipline 1526.

Zipline 1526, the Piper is on the ground.

Zipline 1526, the Piper is on the ground.

You are cleared for localizer 2-5 approach.

Cleared for localizer 2-5.

Thank you.

Thank you.

Zipline 1526.

The plane is now 2 and 1/2 miles from the airport.

The plane is now 2 and 1/2 miles from the airport.

Clouds still obscure the runway.

Ground.

Keep going.

OK, OK, level out now!

OK, OK, level out now!

I got it.

I got it.

- ACTOR AS AUTOMATED - Pull up.

Pull up.

Hey, what's going on?

- ACTOR AS AUTOMATED - Pull up.

Pull up.

Pull up.

No, no, no, no, no, no, no, no, no, no!

ACTOR AS FIRST

We have a plane into a house.

Heavy fire.

We have a lot of wires down.

We have a lot of wires down.

ExecuFlight 1526 has crashed into a

ExecuFlight 1526 has crashed into a

two-story residential building.

Everyone on board is dead.

Fortunately, no one was inside the building.

Fortunately, no one was inside the building.

It's now up to the National Transportation Safety Board

It's now up to the National Transportation Safety Board

to determine what caused this fatal accident.

Yeah, it looks like the left wing hit first.

As investigators comb through the wreckage,

they make a crucial discovery.

they make a crucial discovery.

We found the angle of attack indicator

in the cockpit wreckage.

in the cockpit wreckage.

That's important because at a certain angle of attack,

the wing will stall.

What angle were you at?

What angle were you at?

They could see that the needle

was in the red band.

When the angle of attack

When the angle of attack

indicates it's in the red, you're stalled.

In other words, this wing was no longer flying.

In other words, this wing was no longer flying.

It's as simple as that.

Get that to Washington.

The cockpit voice recorder is sent to NTSB

The cockpit voice recorder is sent to NTSB

Headquarters for analysis.

The CVR is especially important, as the Hawker 700 isn't equipped

The CVR is especially important, as the Hawker 700 isn't equipped

with a flight data recorder.

In lieu of FDR data, the NTSB obtains valuable information

In lieu of FDR data, the NTSB obtains valuable information

from air traffic control.

A turning point in our investigation

came when our engineer was able to recreate

came when our engineer was able to recreate

our aircraft performance from the radar data.

The angle of attack, the attitude, the altitude, and rate

The angle of attack, the attitude, the altitude, and rate

of descent.

Investigators find nothing unusual about the flight

Investigators find nothing unusual about the flight

until its last two minutes.

until its last two minutes.

Look here.

The speed drops to 130 knots, and then

it keeps dropping to 98 knots.

it keeps dropping to 98 knots.

No wonder they stalled.

Airspeed is life.

Airspeed is life.

This is one of the most important

points in flying any airplane, but

especially, especially a jet.

especially, especially a jet.

Investigators review the plane's descent profile.

They level off at 9,000, 5,000, 4,000.

They level off at 9,000, 5,000, 4,000.

Look at that.

They hold at 3,000 feet for an entire two minutes.

They hold at 3,000 feet for an entire two minutes.

That's way too long.

And then they plunge steeply.

And then they plunge steeply.

Once they started diving the airplane down

Once they started diving the airplane down

to 2,000 feet a minute to get to that lower altitude,

that approach was unstable.

They should have executed a go around.

They should have executed a go around.

We really wondered, what is the situation

in the cockpit at that time?

They turned to the cockpit voice recorder

They turned to the cockpit voice recorder

to find out.

ACTOR AS AKRON

Zipline 1526, we do have an aircraft

Zipline 1526, we do have an aircraft

inbound to the airport that is slower than you.

OK.

I'll have to drag everything.

I'll have to drag everything.

Somebody lowered the landing gear

to start slowing the airplane up and creating drag to hopefully

to start slowing the airplane up and creating drag to hopefully

get a little bit more space in between them

and the other airplane.

and the other airplane.

Did you hear that?

Investigators hear the sound of the engine thrust

Investigators hear the sound of the engine thrust

decreasing.

The airspeed drops from 170 down to 140.

The airspeed drops from 170 down to 140.

That is way slower than he needs to be going.

ACTOR AS AKRON

Zipline 1526, the Piper is on the ground.

Zipline 1526, the Piper is on the ground.

You are cleared for localizer 2-5 approach.

Cleared for localizer 2-5.

ACTOR AS AKRON CONTROL Thank you.

ACTOR AS AKRON CONTROL Thank you.

Flight 1526 is now at 3,000 feet and flying

straight towards Akron.

straight towards Akron.

You're going 120.

You can't keep decreasing your speed.

Once the copilot received the warning

from the captain that they were too slow,

the copilot should have increased thrust significantly.

the copilot should have increased thrust significantly.

But instead, the pilots get into a debate.

But instead, the pilots get into a debate.

Oh, 120, where do you get 120?

It's more like 125, which is the approach speed.

It's more like 125, which is the approach speed.

But you've still got the flaps to go.

And when they go down...

This is what I'm saying.

If you continue decreasing your speed...

But why?

But why?

Because we're going to stall.

I don't want to stall.

How do we...

Stop.

Stop.

They are so busy arguing about their speed

that they forget to start their descent.

that they forget to start their descent.

You're diving.

Don't dive.

Don't dive.

You're with me there?

That delay of almost two minutes was critical.

He's already too slow and he's overflown

He's already too slow and he's overflown

the altitude he should be at.

And now they've got the chase the approach.

Now, he's got to get the airplane down fast.

Now, he's got to get the airplane down fast.

Investigators listened to the CVR

to find out how two experienced pilots could so

to find out how two experienced pilots could so

badly misjudge their situation.

OK.

OK.

What investigators hear next shocks them.

Full flaps.

Full flaps.

Full flaps at that speed, what was he thinking?

Full flaps at that speed, what was he thinking?

Bring up the altitude graph again.

Well, hey, that's why the plane

starts to drop like a rock.

Investigators finally understand

why Flight 1526 descended at twice the recommended rate.

why Flight 1526 descended at twice the recommended rate.

The airplane is too high,

it's too slow, and with full flaps rather than partial flaps.

it's too slow, and with full flaps rather than partial flaps.

And really, that is the turning point when we said,

this airplane is not configured properly for the approach.

this airplane is not configured properly for the approach.

And this puts the crew and passengers

in really a lot of danger.

He should have just called a missed approach, tried again.

The question is, why didn't he?

The question is, why didn't he?

Let's pick up where we left off,

the start of the final descent.

the start of the final descent.

While descending from 3,000 feet, the pilots

While descending from 3,000 feet, the pilots

begin their landing checklist.

Can you check if I've got everything, ignition?

Can you check if I've got everything, ignition?

Everything is all set.

Stand by.

Your damper, autopilot, main air valves.

Your damper, autopilot, main air valves.

He just stops in the middle of his landing checklist.

He just stops in the middle of his landing checklist.

Instead of completing the checklist,

the captain's focus turns to the plane's erratic descent.

the captain's focus turns to the plane's erratic descent.

You're diving.

Don't dive.

2,000 feet per minute.

2,000 feet per minute.

Buddy.

Yeah.

2,000 feet per minute.

Don't go 2,000 feet per minute.

Don't go 2,000 feet per minute.

You with me there?

This is the very serious portion of the approach.

This is the very serious portion of the approach.

You're gonna go down into weather that's very low.

Why wouldn't he take over?

Why wouldn't he take over?

By having the first officer fly, this captain

then was dividing his time being a captain

then was dividing his time being a captain

and also being an instructor.

We found he wasn't appropriately managing

We found he wasn't appropriately managing

the cockpit as a captain.

They're less than 500 feet off the ground.

They're less than 500 feet off the ground.

That's below their minimum descent altitude.

It's critical that you do not descend

It's critical that you do not descend

below that altitude until you have a visual view

of the airport or the runway.

of the airport or the runway.

Ground.

Ground.

Keep going.

The cockpit voice recording

makes it clear that the captain violated a fundamental rule

makes it clear that the captain violated a fundamental rule

of airmanship.

If you don't see the field, then you do a go around.

If you don't see the field, then you do a go around.

As he scanned for the airport,

he lost track of the plane's speed.

he lost track of the plane's speed.

OK, level up now.

Got it.

Up.

Up.

Pull up.

Pull up.

They'd been too slow for the last little while,

and they don't recognize, even with a stick

and they don't recognize, even with a stick

shaker banging away, that they are in an aerodynamic stall.

Pull up.

Pull up.

Pull up.

That doomed them.

No, no, no, no, no, no, no, no, no, no!

They broke so many rules.

They broke so many rules.

It makes you wonder who trained them.

The NTSB reviews the pilots' employment and training

records for the last five years.

records for the last five years.

What they find shocks them.

What they find shocks them.

The captain's termination notice.

It says that he was fired from his last job.

It says that he was fired from his last job.

Captain Chavez was dismissed because he

failed to show up for training.

failed to show up for training.

Get this.

The first officer was terminated because his performance

The first officer was terminated because his performance

was below standard.

So why did ExecuFlight hire these guys?

So why did ExecuFlight hire these guys?

Investigator Sathya Silva calls

the president of ExecuFlight.

He had hired the captain because

He had hired the captain because

of his extensive experience in the Hawker aircraft,

as well as flights that he had personally

as well as flights that he had personally

taken with the captain prior to his employment.

The first officer was hired based on a recommendation

The first officer was hired based on a recommendation

from another pilot, as well as one flight that he

from another pilot, as well as one flight that he

had taken with him personally.

He said they didn't contact their previous employers.

He said they didn't contact their previous employers.

ExecuFlight did give them CRM training.

ExecuFlight did give them CRM training.

Cockpit resource management training is teaching

pilots to work as a team.

pilots to work as a team.

Not much of a training manual.

Not much of a training manual.

What we found was their training

was insufficient and their evaluation of the crew

was not proper.

was not proper.

The NTSB investigation concludes

that the problems on board the private jet began on the ground.

that the problems on board the private jet began on the ground.

Both crew members had poor training records,

which their employer ignored.

which their employer ignored.

We determined that ExecuFlight did not enforce

We determined that ExecuFlight did not enforce

and did not make sure that the pilots were following

standard operating procedures.

standard operating procedures.

In its report, the NTSB

makes several recommendations for private operators,

makes several recommendations for private operators,

like ExecuFlight, including better training for pilots

like ExecuFlight, including better training for pilots

on nonprecision approaches, like the one into Akron,

and the installation of flight data recorders

and the installation of flight data recorders

that could monitor the progress of their flights.

After a deadly turboprop crash in the North Carolina woods,

After a deadly turboprop crash in the North Carolina woods,

investigators wonder why the pilots

reacted quickly to some signals, but ignored others.

reacted quickly to some signals, but ignored others.

When something happens, order a cup of coffee if you can

and think about it.

You can do that much more clearly

You can do that much more clearly

if everything you're doing is stable

and you're on the same page.

American Eagle Flight 3379 approaches Raleigh-Durham

American Eagle Flight 3379 approaches Raleigh-Durham

International Airport.

OK, can you do the descent checklist, please?

OK, can you do the descent checklist, please?

In the cockpit, Captain

Mike Hillis and First Officer Matthew

Mike Hillis and First Officer Matthew

Sailor prepare for landing.

Altimeter 30-31, set.

Cross-checked.

30-31 set.

30-31 set.

Cross-checked.

These were young pilots just starting off in their career.

These were young pilots just starting off in their career.

The pilots are flying a Jetstream

3201, a twin turboprop airplane designed for short flights.

3201, a twin turboprop airplane designed for short flights.

Flight 3379 took off at 6:00 PM from Greensboro, North Carolina.

Flight 3379 took off at 6:00 PM from Greensboro, North Carolina.

It's a 35-minute flight to Raleigh-Durham Airport.

It's a 35-minute flight to Raleigh-Durham Airport.

There are 18 passengers on board.

Ten miles from Raleigh-Durham, Flight 3379 is

cleared to begin its descent.

The crew reduces engine power.

And gear down.

And gear down.

Gear down.

Flaps 20.

Flaps 20.

Flaps 20.

Why is that ignition light on?

Did we just have a flameout?

Seeing the ignition light come on during approach

Seeing the ignition light come on during approach

would typically raise a concern.

If combustion is interrupted for any reason,

If combustion is interrupted for any reason,

it's what pilots call a flameout or an engine failure.

it's what pilots call a flameout or an engine failure.

I'm not sure what's going on with it.

If there is an engine failure,

If there is an engine failure,

the pilots need to consider making a go around.

Set max power.

Set max power.

At 1,500 feet, Captain Hillis aborts the landing.

At 1,500 feet, Captain Hillis aborts the landing.

When you have an engine failure,

you not only lost half your power, you

you not only lost half your power, you

lose 80% of your performance.

Flight 3379 isn't climbing and it's losing speed.

Flight 3379 isn't climbing and it's losing speed.

Lower the nose.

Lower the nose!

Now, it's stalling.

You got it?

Yeah.

They're unable to climb.

They're starting to lose directional control

They're starting to lose directional control

of the aircraft.

The plane is turning steadily to the left

The plane is turning steadily to the left

and veering further off course.

Lower the nose.

Lower the nose.

Things are getting bad real fast.

And they're running out of time.

And they're running out of time.

The Jetstream plows through the dense woods

The Jetstream plows through the dense woods

of North Carolina.

First responders are on the scene within minutes.

First responders are on the scene within minutes.

There are only five survivors.

There are only five survivors.

Fifteen people, including the pilots, are dead.

NTSB investigators are on site by morning.

They quickly notice that the plane's

They quickly notice that the plane's

landing gear is extended.

Do we know how the flaps are set?

Do we know how the flaps are set?

I'll check with our guy in the cockpit.

Stretch here.

What can you tell us about the flap selector?

ACTOR AS INVESTIGATOR

ACTOR AS INVESTIGATOR

The flap selector is fused in the a 20 degree position.

Copy that.

The flap extension was also

The flap extension was also

very interesting because it was in the landing configuration.

very interesting because it was in the landing configuration.

So he's four miles from the airport.

He's configured to land.

What happened?

Unless he veers off course.

Unless he veers off course.

He's off to the left.

Why?

OK, can you do the

OK, can you do the

descent checklist, please?

The team turns to the cockpit voice recorder,

The team turns to the cockpit voice recorder,

hoping to find an explanation for the unusual left turn.

Altimeter 30-31, set.

Altimeter 30-31, set.

Cross-checked.

Pressurization set and checked.

Pressurization set and checked.

Why is that ignition light on?

Did we just have a flameout?

We lost the left one?

Yeah.

A flameout moments from touchdown

should have prompted the pilots to take action.

should have prompted the pilots to take action.

Investigators need to find out why they didn't.

The cockpit voice recording from Flight 3379

suggests both pilots were unaware of the danger they

suggests both pilots were unaware of the danger they

were in.

An ignition light has illuminated.

An ignition light has illuminated.

The pilots have noticed it, but they are not taking any action.

You would expect during that period

You would expect during that period

that there would be some sort of confirmation.

Nothing happened other than absolute quiet.

Nothing happened other than absolute quiet.

We needed to try and figure out what was going on.

We needed to try and figure out what was going on.

These are the engine sound waves from when

the ignition light went on.

The CVR records more than voices.

The CVR records more than voices.

It also records the sound of the engines.

Call up the comparison.

Call up the comparison.

They compare the engine sounds from Flight 3379

to other engines operating at 100%.

to other engines operating at 100%.

They're almost identical.

They're almost identical.

Both engines were operating at full speed.

The ignition light must have misled the pilots into believing

the left engine flamed out.

the left engine flamed out.

We had a flameout.

He misdiagnosis the situation.

Well, surely he checks his engine's RPMs.

What do you want me to do?

Are you gonna continue?

OK, yeah, I'm gonna continue.

Just back me up.

Just back me up.

He's not even checking to see if there's

an actual engine failure.

If you don't know if you have an engine failure,

If you don't know if you have an engine failure,

but you're responding to a potential engine failure,

that's not very good.

that's not very good.

And that could very easily cause an accident.

Let's go missed approach.

Investigators wonder what action the pilots took

Investigators wonder what action the pilots took

to execute their go around.

to execute their go around.

OK, so how did they configure their plane

for their missed approach?

They set engine power to max.

They set engine power to max.

As they should have.

What else?

There's no mention

of reducing the flaps to 10 or retracting landing gear.

A go around would be done by informing

the other pilot, then apply max power, retract the gear,

the other pilot, then apply max power, retract the gear,

retract the flaps.

retract the flaps.

But the pilot's failure to raise the gear

or retract the flaps still can't explain the accident.

or retract the flaps still can't explain the accident.

Hard to believe that configuration

caused the plane to veer to the left and crash.

caused the plane to veer to the left and crash.

Well, there's only one way to find out.

We really wanted to figure out what the crew had

introduced in the configuration that

introduced in the configuration that

would make the aircraft deviate from this intended flight path.

would make the aircraft deviate from this intended flight path.

OK, let's go max power.

Investigators turned to test pilots for help.

Investigators turned to test pilots for help.

They'll push a Jetstream 3201 to its limits

to determine why the plane turned left on the go around.

to determine why the plane turned left on the go around.

Max power.

Flaps to 20.

Flaps to 20.

They start by duplicating

the configuration the pilots used for the missed approach.

Flaps 20.

Gear down.

OK, gear down.

OK, gear down.

OK, it's a bit slower than a regular missed approach,

but it's still doable.

but it's still doable.

Let's do the same configuration, but put max power

on the right engine but not the left.

Max power, right engine.

Max power, right engine.

Yawing to the left.

I can't climb like this.

It's the final piece of the puzzle.

It's the final piece of the puzzle.

Set max power.

Set max power.

Believing his left engine had failed,

the captain increases power to the right engine only.

the captain increases power to the right engine only.

Lower the nose.

Lower the nose!

The power imbalance reduces

The power imbalance reduces

airspeed and the lowered gear and extended flaps increase

airspeed and the lowered gear and extended flaps increase

drag.

The flight test told us

that an airplane with that configuration

could not have been flown safely.

could not have been flown safely.

It had to crash.

If the captain thought one of his engines failed,

they should have performed a single-engine missed approach.

He didn't do that either.

To come across an accident

To come across an accident

where a response was botched as poorly as this one,

it begs the question, how did he get there?

it begs the question, how did he get there?

The investigation digs into Captain Hillis's pilot records.

The investigation digs into Captain Hillis's pilot records.

Look at this.

Trainers evaluation.

Well, this is telling.

Well, this is telling.

He's messing up single-engine missed approaches.

When investigators ask American Eagle

When investigators ask American Eagle

about screening checks on Mike Hillis,

they're surprised at what they learn.

they're surprised at what they learn.

They did not go back and check with previous employers.

They did not go back and check with previous employers.

The NTSB does what American Eagle never did.

The NTSB does what American Eagle never did.

It requisitions Mike Hillis's file from his previous employer,

Comair.

"Moody, unpredictable, gets distracted.

Concerns about tunnel vision in an emergency situation."

Concerns about tunnel vision in an emergency situation."

Did American Eagle know about this guy's performance history?

It doesn't look like they asked.

It doesn't look like they asked.

That captain should not have been flying passengers

under any circumstances.

under any circumstances.

It turns out other American Eagle

pilots at Raleigh-Durham were well

aware of Hillis's deficiencies.

aware of Hillis's deficiencies.

Copilots were whispering to their colleagues

there was something not normal.

But was First Officer Sailor one of those copilots?

But was First Officer Sailor one of those copilots?

Lower the nose.

Lower the nose!

Investigators learned that Sailor

Investigators learned that Sailor

was new to the route.

So was he based out of Raleigh?

So was he based out of Raleigh?

No.

He worked out of Miami.

I think it was critical to this accident

I think it was critical to this accident

that the first officer was from a different base

than the captain.

This guy had no idea who he was flying with.

This guy had no idea who he was flying with.

If First Officer Sailor had known

about his captain's shortcomings,

he would likely have paid more attention to his conduct

he would likely have paid more attention to his conduct

during the approach.

The crash of Flight 3379 reveals deep flaws

The crash of Flight 3379 reveals deep flaws

in the hiring practices of US airline companies.

in the hiring practices of US airline companies.

Background information on pilots is almost

never shared between carriers.

In its final report, the NTSB recommends

In its final report, the NTSB recommends

that airlines conduct thorough background

checks on prospective pilots.

checks on prospective pilots.

In 1996, two years after the crash,

In 1996, two years after the crash,

Congress passes the Pilots Record Information Act to ensure

airlines have access to records from pilots' previous employers.

airlines have access to records from pilots' previous employers.

Carelessness in the cockpit is usually

Carelessness in the cockpit is usually

not something that happens on a single flight only.

It's usually a habit.

Those habits form over time.

Those habits form over time.

And if there's not proper oversight or some sort of check

and balance either in the cockpit

and balance either in the cockpit

or back in their training unit, then this could become the norm.

In other words, their normal flying

In other words, their normal flying

could be high-risk flying.

In an aviation milestone,

investigators sift through the wreckage

from another careless approach.

from another careless approach.

Guantanamo Bay, an isolated US

Navy base that sits on the southeast

Navy base that sits on the southeast

coast of the Island of Cuba.

American International Airways Flight 808,

a civilian DC-8 cargo plane, is on final approach

a civilian DC-8 cargo plane, is on final approach

to the Guantanamo airfield.

Here it comes.

Here it comes.

On 10.

On the flight deck are First Officer Thomas

Curran, Flight Engineer David Richmond,

Curran, Flight Engineer David Richmond,

and Captain James Chapo.

and Captain James Chapo.

The DC-8 is turning toward the runway.

But for some reason, it's banking steeply.

But for some reason, it's banking steeply.

No, he's not gonna make it.

No way.

No way.

The wings go about 90 degrees

relative to the horizon.

The nose pitched down and the airplane struck the ground.

Yeah, I don't remember the exact moment

Yeah, I don't remember the exact moment

of hitting the ground.

No.

Yeah, we were fortunate.

Yeah, we were fortunate.

You know, the DCA, they say, was built to separate at the cockpit

and cabin bulkhead.

And sure enough, that's where it busted apart.

And sure enough, that's where it busted apart.

And we rolled ahead of the airplane.

Can you move?

Can you move?

Yeah, man.

Yeah.

My memory of the actual accident itself is gone.

My memory of the actual accident itself is gone.

Please, help us.

I was told when the airplane hit the ground,

I was told when the airplane hit the ground,

a large boulder came through the cockpit by my rudder pedals,

and broke off the rudder pedals and severely damaged my legs.

and broke off the rudder pedals and severely damaged my legs.

The three injured pilots are transported

The three injured pilots are transported

to a hospital in Miami.

Within hours of the accident, a team

of investigators from the NTSB is on its way to Guantanamo.

of investigators from the NTSB is on its way to Guantanamo.

All right, let's see what we've got.

All right, let's see what we've got.

Greg Feith is the lead investigator for the team.

Both black boxes coming your way right now.

No, both slightly damaged.

Coming to you right now.

The black boxes are sent to the NTSB lab

The black boxes are sent to the NTSB lab

in Washington DC for analysis.

We've checked the entire site.

We've checked the entire site.

Correct.

Yeah.

Feith interviews two Navy

pilots who witnessed the crash.

pilots who witnessed the crash.

Come on, come on, come on.

Level off, man.

Level off.

Normally, you don't want to be turning more than about 10,

20 degrees on final approach.

20 degrees on final approach.

They watched this airplane as it went from 30 degrees to 40

degrees to 50 degrees, 60 degrees,

and they were really surprised.

Sounds like a wing stall.

Sounds like a wing stall.

Yes, sir.

It sure looked like it.

Yeah.

You understand how the aircraft struck the ground.

You understand how the aircraft struck the ground.

Now you have to determine why.

So did you pick up anything unusual in your conversation

So did you pick up anything unusual in your conversation

with the pilots?

When they talk to air traffic control,

investigators uncover an important piece of the puzzle.

investigators uncover an important piece of the puzzle.

GUANTANAMO CONTROL (OVER RADIO): Connie 808.

Guantanamo, go ahead.

Guantanamo, go ahead.

12 minutes before the crash, the crew

made an unusual request.

connie 808, requesting...

connie 808, requesting...

...we'd like to make the approach for 10 this afternoon.

They asked to change from their assigned

runway 2-8 to runway 10 or 1-0.

runway 2-8 to runway 10 or 1-0.

Guantanamo has a single runway with aircraft

Guantanamo has a single runway with aircraft

landing in either direction, 2-8 from

the east and 1-0 from the west.

the east and 1-0 from the west.

Normally, airplanes land on runway 2-8.

Normally, airplanes land on runway 2-8.

It's more or less a straight in approach, landing to the west.

Runway 1-0 is closer to the Cuban border.

Runway 1-0 is closer to the Cuban border.

To avoid Cuban territory, aircraft

To avoid Cuban territory, aircraft

must approach from the sea and then make a sharp right turn.

must approach from the sea and then make a sharp right turn.

Why would the crew of Flight 808 choose

the more difficult approach?

the more difficult approach?

Investigators try to interview the pilots,

but all three are in intensive care.

but all three are in intensive care.

Thanks very much.

Personnel records show that they

were all highly experienced.

You know that they can operate the airplane.

So now the question is, why didn't they?

The team reviews the plane's

flight data, which shows the plane's exact approach path.

flight data, which shows the plane's exact approach path.

OK, let's see the proper approach.

So they started their turn too late and never recovered.

So they started their turn too late and never recovered.

The pilot increased the bank,

trying to salvage that turn and get the airplane lined up.

trying to salvage that turn and get the airplane lined up.

But the steep bank hindered the plane's

ability to stay airborne.

ability to stay airborne.

The amount of lift it's producing to hold the airplane

The amount of lift it's producing to hold the airplane

in the air is compromised, because the wings

are at this high angle.

Now, all of a sudden,

Now, all of a sudden,

the airplane gets into an aerodynamic stall.

And because you're low to the ground,

you don't have sufficient altitude for proper recovery.

you don't have sufficient altitude for proper recovery.

Why do they start that turn so late?

The cockpit voice recording from Flight 808

is finally available.

GUANTANAMO CONTROL

GUANTANAMO CONTROL

Connie 808, you're required to remain within the airspace

designated by the strobe light.

The strobe light marks the base's

The strobe light marks the base's

border fence with Cuba.

It's a visual warning so pilots don't fly into Cuban airspace.

It's a visual warning so pilots don't fly into Cuban airspace.

Are they giving us 2-8?

Yeah, if it's available.

The CVR reveals why the captain

The CVR reveals why the captain

chose to land on runway 1-0.

Got to make that 1-0 approach just for the heck

Got to make that 1-0 approach just for the heck

of it and see how is.

If we miss it, we'll just come back around and land on 2-8.

For the heck of it.

For the heck of it.

That's why he's landing on runway 10?

You don't just do things for the heck of it

in an airplane of that size.

in an airplane of that size.

The captain seems out of it.

Where's the strobe?

Right over there.

Right over there.

Where?

Now, the captain struggles

Now, the captain struggles

to locate the strobe light that marks the Cuban border.

You know, we're not

getting air speed back there.

getting air speed back there.

The flight engineer comments

that the plane is flying more than 10 knots too slow.

Do you think you're gonna make this?

Do you think you're gonna make this?

The first officer and the flight engineer,

they only challenged the captain by what

they only challenged the captain by what

I call hinting and hoping, where they

would throw out a suggestion.

Do you think we're gonna make this?

Do you think we're gonna make this?

Yeah, if I can catch that strobe light.

But the captain isn't taking the hint.

But the captain isn't taking the hint.

As he begins his critical final turn,

he still can't see the runway.

he still can't see the runway.

He realizes he started the turn too late.

To compensate, he makes the turn even steeper.

To compensate, he makes the turn even steeper.

The plane needs an airspeed of 147 knots

The plane needs an airspeed of 147 knots

to stay airborne in the tight turn.

Watch.

Keep your airspeed up.

Keep your airspeed up.

140!

Suddenly, the stick shaker warning activates.

It shakes the control column to alert

It shakes the control column to alert

the pilot of an imminent stall.

Stall warning!

Stall warning!

Max power!

I got it!

Back off!

Back off!

There it goes!

No, no!

No!

He completely tuned out his crew.

He completely tuned out his crew.

We knew that there was

some bad decision-making going on in this particular cockpit.

some bad decision-making going on in this particular cockpit.

And the question was, why?

Greg Feith searches for clues

in the duty rosters and pilot logbooks of the DC-8's crew.

in the duty rosters and pilot logbooks of the DC-8's crew.

He learns that the day before the crash, the crew

He learns that the day before the crash, the crew

started flying from Dallas-Fort Worth at midnight

started flying from Dallas-Fort Worth at midnight

and flew all night.

They crossed the country before arriving back at their Atlanta

base just before 8:00 AM.

base just before 8:00 AM.

Thank you.

That was supposed to be the end of the crew's shift.

That was supposed to be the end of the crew's shift.

But they were called back for one last flight.

Guantanamo Bay, here we come.

Guantanamo Bay, here we come.

Nothing more I'd rather do.

By this point, each crew member has

been awake for about 15 hours.

been awake for about 15 hours.

They were now expected to fly to Virginia,

pick up cargo, then fly to Guantanamo

pick up cargo, then fly to Guantanamo

before returning to Atlanta.

Could the lengthy duty time have impaired

Could the lengthy duty time have impaired

the pilots' performance, leading them to take greater risks?

the pilots' performance, leading them to take greater risks?

Mark Rosekind, the head of NASA's Fatigue Countermeasures

Program, is brought in to help.

Program, is brought in to help.

We knew that fatigue was a risk.

So we knew bad stuff was already going on in flight.

The key was, how do you demonstrate fatigue actually

The key was, how do you demonstrate fatigue actually

played a role in that crash?

Rosekind discovers that the pilots' long work

Rosekind discovers that the pilots' long work

day wasn't the only reason they were fatigued.

They were all sleep-deprived.

The crew experienced lack of sleep

from two back-to-back night shifts before the crash.

from two back-to-back night shifts before the crash.

When you lose sleep,

it actually builds into what's called a sleep debt.

it actually builds into what's called a sleep debt.

And you should think about that just like a bank account.

It's like going in the red.

The captain's sleep debt was profound.

The captain's sleep debt was profound.

He had only 15 hours sleep in the previous 72.

He had only 15 hours sleep in the previous 72.

His behavior exhibits the symptoms of fatigue.

One was what we call cognitive fixation.

The captain just got stuck on finding a strobe light.

The captain just got stuck on finding a strobe light.

Where's the strobe?

What investigators have uncovered

raises a disturbing question.

raises a disturbing question.

Why did a sleep-deprived crew, suffering from fatigue,

accept the last-minute flight to Guantanamo?

Bring that over here.

Investigators are finally able to interview

the crew members.

the crew members.

ACTOR AS JAMES (OVER PHONE): I was tired.

We were all tired.

We were all tired.

You didn't have to accept the flight.

Technically, no, but we

didn't really have a choice.

didn't really have a choice.

The cargo industry is notorious as being

a cutthroat industry.

a cutthroat industry.

They will push the crews routinely to the edge

of duty time limits.

of duty time limits.

There's this fear of intimidation

and the loss of a job that if you don't do it,

and the loss of a job that if you don't do it,

I'll find somebody that will.

The fear of job loss almost cost them their lives.

Stall warning!

Stall warning!

It's fine.

Max power!

Max power!

I got it!

Back off!

There it goes!

At the very end, things happen very rapidly.

We were too low and our reactions were too slow.

We were too low and our reactions were too slow.

And I should have turned it over to Tom,

but I was already just sort of out of it.

but I was already just sort of out of it.

Ah, there it goes!

Ah, there it goes!

No!

It still... still gets to me because it still

It still... still gets to me because it still

boils down to the captain.

You know, the captain made the mistake.

And that's a... a hard thing to live with all the time.

And that's a... a hard thing to live with all the time.

Investigators discover one final tragic piece

Investigators discover one final tragic piece

of the puzzle.

The strobe light Captain Chapo was searching for

The strobe light Captain Chapo was searching for

was not operational that day.

There was no beacon to see.

There was no beacon to see.

No one thought to tell the controller

that the strobe was down.

So now they're trying to find something that doesn't exist.

So now they're trying to find something that doesn't exist.

And when they saw something flash out there, which they

And when they saw something flash out there, which they

thought was the strobe, it was actually the tin

roof on a little cabana.

roof on a little cabana.

In his final report on the crash of Flight 808,

Greg Feith emphasizes the central role played by fatigue.

Greg Feith emphasizes the central role played by fatigue.

This accident was precedent-setting.

This accident was precedent-setting.

It was the first commercial aviation accident

actually caused by fatigue.

And the industry took notice.

And the industry took notice.

In the aftermath of the Flight 808 crash,

the Federal Aviation Administration

the Federal Aviation Administration

tightens regulations on crew sleep requirements.

Airlines must now stay up to date

Airlines must now stay up to date

on sleep and fatigue research.

Managing rest times means pilots are less

Managing rest times means pilots are less

likely to make poor decisions.

When you're approaching a landing,

When you're approaching a landing,

if you don't feel that you have it all lined up, don't do it.

Go around, get your head together,

Go around, get your head together,

and make sure you're ready to do it, because it's the most

dangerous time of your flight.