1 00:00:02,751 --> 00:00:06,254 (narrator): Pilots of Colgan Air Flight 9446 fight for their lives 2 00:00:06,422 --> 00:00:08,757 as their plane dives towards the ground. 3 00:00:08,925 --> 00:00:12,053 - You pull for all you're worth. Just keep pulling for all you're worth. 4 00:00:12,178 --> 00:00:14,429 - Picture trying to do your day job 5 00:00:14,597 --> 00:00:16,598 while... deadlifting 250 pounds. 6 00:00:16,723 --> 00:00:19,851 (both groaning) - Oh, no! (TAWS): Pull up! 7 00:00:22,771 --> 00:00:24,774 (narrator): Both pilots are killed. 8 00:00:27,359 --> 00:00:30,195 The wreckage reveals very little. 9 00:00:31,322 --> 00:00:33,032 - That is a rat's nest. 10 00:00:33,157 --> 00:00:36,118 (narrator): The cockpit voice recording... (Captain): Got a runaway trim. 11 00:00:36,243 --> 00:00:37,661 (narrator): ...provides a key insight. 12 00:00:37,829 --> 00:00:40,289 - Listen to how exhausted they are, trying to keep the nose up. 13 00:00:40,456 --> 00:00:43,960 (narrator): But analysis of flight data turns the case on its head. 14 00:00:44,085 --> 00:00:47,713 - This doesn't look right. - Well, that was the huge aha moment for me. 15 00:00:48,339 --> 00:00:49,881 - How's that possible? 16 00:00:50,006 --> 00:00:52,717 - Everybody missed what was just... 17 00:00:52,844 --> 00:00:55,303 such a simple mistake. 18 00:00:57,764 --> 00:00:59,475 - Mayday, Mayday! 19 00:01:01,935 --> 00:01:03,645 - It's going up! 20 00:01:04,813 --> 00:01:06,898 (indistinct radio chatter) 21 00:01:22,163 --> 00:01:26,127 (narrator): A Colgan Air crew prepares for the last flight of the day 22 00:01:26,252 --> 00:01:28,753 in a recently serviced aircraft. 23 00:01:30,797 --> 00:01:33,133 - Weather looks good. Should be an easy ride. 24 00:01:33,925 --> 00:01:38,556 (narrator): Captain Scott Knabe has been with Colgan Air for more than two years. 25 00:01:39,306 --> 00:01:41,767 Six months ago, he was promoted to captain. 26 00:01:43,768 --> 00:01:48,648 - Scott Knabe was among the most careful and meticulous pilots. 27 00:01:51,568 --> 00:01:54,988 He was a very successful and very good accountant. 28 00:01:55,907 --> 00:01:57,783 But he had the aviation bug. 29 00:01:59,034 --> 00:02:02,830 - How's the paperwork? - Uh, weight and balance is checked and filed. 30 00:02:02,955 --> 00:02:06,041 (narrator): First Officer Steven Dean has been with the airline 31 00:02:06,166 --> 00:02:07,877 for less than a year. 32 00:02:09,629 --> 00:02:12,631 - Did you put in for that upgrade? - Actually, no, I didn't. 33 00:02:12,756 --> 00:02:16,052 I put in my notice. I can't afford to do this anymore. 34 00:02:17,218 --> 00:02:18,678 - Understood. 35 00:02:19,764 --> 00:02:22,766 - Being a young pilot moving his way up the ladder in the regionals, 36 00:02:22,933 --> 00:02:26,812 the first officer quickly discovered that his pay 37 00:02:26,938 --> 00:02:29,314 could not support his wife and daughter. 38 00:02:29,898 --> 00:02:34,403 So a week before this flight... he gave notice. 39 00:02:35,737 --> 00:02:38,407 - Don't mind these reposition flights. 40 00:02:40,575 --> 00:02:43,579 - Yeah, no passengers, no problems. 41 00:02:46,165 --> 00:02:49,961 (narrator): Colgan Air has a small fleet of Beech 1900s. 42 00:02:50,878 --> 00:02:54,255 The aircraft operate as part of US Air's regional arm. 43 00:02:55,466 --> 00:02:59,469 The Beechcraft is a smaller plane, popular for commuter flights. 44 00:03:02,348 --> 00:03:03,808 (Schiavo): They fly short distances. 45 00:03:03,974 --> 00:03:07,395 They fly into places that the big-name carriers... 46 00:03:07,520 --> 00:03:10,647 wouldn't be able to fill up or make a lot of money. 47 00:03:14,652 --> 00:03:18,571 - Maintenance log: checked. And aircraft is released. 48 00:03:19,824 --> 00:03:22,659 (narrator): After four days of routine maintenance in Hyannis, 49 00:03:22,826 --> 00:03:25,705 the plane is being returned to service. 50 00:03:26,664 --> 00:03:31,002 Colgan 9446 will fly empty to Upstate New York. 51 00:03:31,544 --> 00:03:35,088 - Sometimes we have to resort to these non-revenue flights 52 00:03:35,213 --> 00:03:39,135 to reposition the plane from one location to another. 53 00:03:39,302 --> 00:03:42,637 Occasionally that could also happen when you have to bring a plane 54 00:03:42,762 --> 00:03:44,557 to a specified maintenance facility. 55 00:03:45,182 --> 00:03:48,018 (narrator): Today's flight from Hyannis, Massachusetts, 56 00:03:48,184 --> 00:03:51,980 west to Albany, New York, should take 50 minutes. 57 00:03:53,273 --> 00:03:56,110 - Circuit breakers checked? - Checked. 58 00:03:56,861 --> 00:03:59,571 (narrator): The pilots perform their final checks. 59 00:04:03,867 --> 00:04:06,537 - Alright, I'm not getting any radios here. Anything in your headset? 60 00:04:06,704 --> 00:04:08,831 - Check, check, check. (blowing air) 61 00:04:10,040 --> 00:04:11,667 - What a cluster. 62 00:04:12,584 --> 00:04:14,836 - When an airplane is returned back to service, 63 00:04:14,961 --> 00:04:18,256 pilots will expect that all sub-systems are working. 64 00:04:18,381 --> 00:04:19,841 So you will show up to the airplane 65 00:04:20,009 --> 00:04:22,552 and expect that everything has been serviced accordingly 66 00:04:22,720 --> 00:04:25,096 and it's safe to return back to flying. 67 00:04:27,016 --> 00:04:30,353 (narrator): After a short delay because of a minor radio problem, 68 00:04:30,478 --> 00:04:33,730 Flight 9446 taxis for takeoff. 69 00:04:35,816 --> 00:04:38,944 - Takeoff trims are set. Cabin PA not required. 70 00:04:40,446 --> 00:04:43,574 - Tower, Colgan 9446. We're good to go: 24. 71 00:04:46,035 --> 00:04:48,287 - Uh, Colgan 9446, 72 00:04:48,412 --> 00:04:50,081 Runway 24... 73 00:04:50,247 --> 00:04:51,956 cleared for takeoff. 74 00:04:52,333 --> 00:04:54,084 - Cleared for takeoff: 24. 75 00:04:54,251 --> 00:04:55,877 Colgan 9446. 76 00:05:00,006 --> 00:05:01,675 - Set the power. 77 00:05:04,929 --> 00:05:06,179 - Power set. 78 00:05:06,930 --> 00:05:09,766 - The Beech 1900, being such a stable aircraft, 79 00:05:09,934 --> 00:05:12,393 as soon as it accelerates on the takeoff roll, 80 00:05:12,561 --> 00:05:17,400 it will reach flyable speeds in a distance as short as 4,000 feet. 81 00:05:17,566 --> 00:05:19,235 - Eighty knots. 82 00:05:20,110 --> 00:05:24,531 - And it will basically fly itself off the runway with very minimal pilot input. 83 00:05:25,949 --> 00:05:27,660 - V1, rotate. 84 00:05:29,453 --> 00:05:31,247 (narrator): At 3:38 p.m., 85 00:05:31,413 --> 00:05:34,208 Flight 9446 lifts off the runway... 86 00:05:35,376 --> 00:05:37,711 ...but it's barely gaining altitude. 87 00:05:38,629 --> 00:05:40,922 - We have a hot elevator trim. 88 00:05:42,091 --> 00:05:45,009 (narrator): The captain suspects there's an issue with the trim system, 89 00:05:45,136 --> 00:05:47,929 which is preventing the plane from climbing normally. 90 00:05:50,141 --> 00:05:55,103 Trim tabs on the elevator adjust the plane's pitch during takeoff. 91 00:05:55,771 --> 00:05:58,732 They're powered by a switch on the control column. 92 00:06:02,110 --> 00:06:05,280 But the captain's trim switch isn't working. 93 00:06:05,990 --> 00:06:09,410 - If you have a trim issue on takeoff, 94 00:06:09,535 --> 00:06:12,204 it is very difficult to overcome. 95 00:06:12,913 --> 00:06:17,792 You have seconds, not minutes, because you don't have any altitude. 96 00:06:19,252 --> 00:06:23,591 (narrator): Just 50 feet off the ground, the plane's nose is dropping. 97 00:06:25,341 --> 00:06:28,261 - Roll back, roll back, roll it back. - I got it. 98 00:06:30,221 --> 00:06:34,309 (narrator): Knabe instructs the first officer to adjust the trim manually. 99 00:06:37,480 --> 00:06:41,107 - The manual trim is a wheel located on the left side of the throttle quadrant 100 00:06:41,232 --> 00:06:44,819 that allows you to trim it into a nose-up attitude. 101 00:06:47,530 --> 00:06:49,324 (narrator): But that doesn't help. 102 00:06:50,158 --> 00:06:51,910 - Pull back. 103 00:06:52,035 --> 00:06:56,915 - An airplane that is nose-heavy will continuously require back pressure on the control yoke. 104 00:06:59,542 --> 00:07:01,920 (groaning) - It's heavy, buddy. 105 00:07:02,463 --> 00:07:04,088 (narrator): Using brute force, 106 00:07:04,215 --> 00:07:08,302 the pilots manage to raise the plane's nose and climb away from the runway, 107 00:07:08,427 --> 00:07:12,014 despite the plane's determination to pitch down. 108 00:07:15,309 --> 00:07:17,769 - Do the electric-trim disconnect? (grunting) 109 00:07:17,894 --> 00:07:21,105 (narrator): The captain wants to cut the power to the trim altogether. 110 00:07:21,232 --> 00:07:23,358 - Ah... (groaning) 111 00:07:23,526 --> 00:07:27,862 (narrator): But before the co-pilot can even find the right circuit-breaker... 112 00:07:28,739 --> 00:07:32,076 - Ah! Back, Steve! No, stay on the controls with me. 113 00:07:32,242 --> 00:07:35,037 (narrator): ...the nose drops again. 114 00:07:40,501 --> 00:07:42,211 - Put up our gear. 115 00:07:44,004 --> 00:07:45,838 - Selecting the gear-up in an airplane 116 00:07:45,965 --> 00:07:49,718 will reduce the amount of drag being exposed to the airstream, 117 00:07:49,884 --> 00:07:52,345 improving your climb performance. 118 00:07:53,264 --> 00:07:57,643 This would have made the pilots gain altitude at a faster rate. 119 00:07:58,352 --> 00:08:00,271 (narrator): Forty-five seconds into the flight, 120 00:08:00,437 --> 00:08:04,023 the pilots still can't get the plane to climb normally. 121 00:08:06,192 --> 00:08:09,655 - 9446 is requesting emergency back, sir. 122 00:08:10,530 --> 00:08:12,490 We got a runaway trim. 123 00:08:12,615 --> 00:08:15,160 (narrator): The captain wants to return to Hyannis Airport. 124 00:08:15,285 --> 00:08:17,870 - Colgan 9446, Roger. 125 00:08:17,996 --> 00:08:20,164 Right or left downwind. Your choice. 126 00:08:20,291 --> 00:08:22,334 Report midfield. 127 00:08:22,835 --> 00:08:24,544 - Okay, Roger. Will do. 128 00:08:25,211 --> 00:08:27,797 (narrator): Using all of their physical strength, 129 00:08:27,965 --> 00:08:30,967 the pilots manage to level off at 1,200 feet 130 00:08:31,134 --> 00:08:33,303 and start the turn back to Hyannis. 131 00:08:37,600 --> 00:08:39,518 - Alright. 132 00:08:40,811 --> 00:08:45,648 - We have a Beech 1900 aircraft that just took off reporting control problems. 133 00:08:45,816 --> 00:08:48,318 We need Fire and Rescue to Runway 33. 134 00:08:50,153 --> 00:08:53,323 (narrator): With brief respite from the struggle... 135 00:08:53,490 --> 00:08:55,868 - Can I pull the breaker? - Yeah. 136 00:08:55,993 --> 00:08:58,077 Pull the breaker, Steve. Pull the breaker. I have the yoke. 137 00:08:58,202 --> 00:09:01,123 (narrator): ...the pilots return to troubleshooting the trim issue. 138 00:09:01,248 --> 00:09:05,293 - Where is it? - Find it! (narrator): In the confusion, 139 00:09:05,418 --> 00:09:08,964 the first officer can't locate the breaker for the automatic trim. 140 00:09:09,840 --> 00:09:13,052 - Look left of the silver thing, Steve. Left of the silver thing. - Left of the silver thing? 141 00:09:13,177 --> 00:09:15,970 - Left of the silver thing. Ugh! The stick! 142 00:09:16,138 --> 00:09:18,264 Steve, stay with me! (groaning) 143 00:09:19,557 --> 00:09:23,227 (narrator): The second attempt to disconnect the trim system also fails. 144 00:09:25,230 --> 00:09:27,983 Less than two minutes after taking off, 145 00:09:28,108 --> 00:09:31,153 Colgan 9446 is losing altitude. 146 00:09:32,111 --> 00:09:33,489 (groaning) 147 00:09:34,615 --> 00:09:38,326 - You pull for all you're worth. Just keep pulling for all you're worth. 148 00:09:38,869 --> 00:09:41,830 - Really what he was saying is, "Pull for your life," 149 00:09:41,996 --> 00:09:44,582 because that was the only hope they had at that time. 150 00:09:44,707 --> 00:09:46,376 (groaning) 151 00:09:47,251 --> 00:09:49,212 (narrator): Five miles from the airport, 152 00:09:49,379 --> 00:09:52,257 the pilots struggle to return to Hyannis. 153 00:09:53,676 --> 00:09:57,345 - 9446 is requesting 33, sir. 154 00:09:58,221 --> 00:10:00,349 - 9446, Roger. 155 00:10:00,474 --> 00:10:02,850 Runway 33. Cleared to land. 156 00:10:03,018 --> 00:10:05,770 - We're gonna need both of us on this, Steve. 157 00:10:05,895 --> 00:10:08,315 (TAWS): Terrain. Terrain. Pull up! 158 00:10:08,440 --> 00:10:11,943 (narrator): The pilots use all their strength to keep their plane airborne... 159 00:10:12,068 --> 00:10:15,239 (TAWS): Terrain. Pull up! - Steve, keep-- - I'm pulling! 160 00:10:15,406 --> 00:10:17,865 (narrator): ...but it's still not enough. - Hold on, Steve! 161 00:10:21,744 --> 00:10:23,371 (groaning) (TAWS): Pull up! 162 00:10:23,538 --> 00:10:25,289 - Oh, no! (screaming) 163 00:10:35,426 --> 00:10:39,555 - We have a Beech 1900 aircraft down east of Point Gammon. 164 00:10:39,720 --> 00:10:41,974 Two pilots, no passengers. 165 00:10:43,975 --> 00:10:45,852 (narrator): Two minutes after takeoff, 166 00:10:45,977 --> 00:10:48,230 Colgan 9446 crashes 167 00:10:48,397 --> 00:10:52,192 3.5 miles from the airport in Hyannis, Massachusetts. 168 00:10:55,486 --> 00:10:58,240 - The Coast Guard was there almost immediately, 169 00:10:58,365 --> 00:11:02,411 but they were not able to save the pilot and the co-pilot. 170 00:11:03,244 --> 00:11:06,874 Hitting the water at a very high rate of speed... 171 00:11:07,707 --> 00:11:09,500 ...is like hitting cement. 172 00:11:11,003 --> 00:11:14,882 (narrator): The pilots' bodies are recovered from the wreckage within four hours. 173 00:11:21,596 --> 00:11:25,768 A team from the National Transportation Safety Board, the NTSB, 174 00:11:25,933 --> 00:11:28,979 arrives in Cape Cod to begin the investigation. 175 00:11:31,023 --> 00:11:33,233 - Keep me posted on the recovery process. 176 00:11:34,317 --> 00:11:37,946 (narrator): This is the second Beech 1900 to crash in six months. 177 00:11:39,239 --> 00:11:42,033 - There was the Air Midwest accident down in Charlotte. 178 00:11:42,158 --> 00:11:44,787 The big question was, you know: Is there anything related? 179 00:11:44,952 --> 00:11:46,955 Was there a fleet-wide problem? 180 00:11:51,585 --> 00:11:57,132 (narrator): NTSB investigators consider why Colgan Air Flight 9446 crashed 181 00:11:57,257 --> 00:12:00,384 so soon after takeoff, killing both pilots. 182 00:12:01,595 --> 00:12:05,139 It's similar to an Air Midwest crash in Charlotte, North Carolina, 183 00:12:05,264 --> 00:12:07,975 which took the lives of 21 people. 184 00:12:08,643 --> 00:12:10,645 - Witnesses reported that the aircraft... 185 00:12:10,770 --> 00:12:14,316 climbed for a few seconds... 186 00:12:14,983 --> 00:12:19,613 ...and then the nose pitched up high in the air, it edged over, 187 00:12:19,738 --> 00:12:22,282 and then literally tumbled... 188 00:12:22,407 --> 00:12:25,159 towards the ground into a building. 189 00:12:28,580 --> 00:12:32,709 (narrator): With hundreds of American-built Beech 1900s in service... 190 00:12:33,460 --> 00:12:36,337 ...investigators need to find out if there's a design fault 191 00:12:36,462 --> 00:12:40,008 with the aircraft that could put even more lives at risk. 192 00:12:43,553 --> 00:12:47,640 - Steve. Hey, great. You can set up over there. - Thanks, boss. 193 00:12:48,392 --> 00:12:51,519 (narrator): The NTSB calls in Steve Carbone, 194 00:12:51,687 --> 00:12:53,855 an investigator who has been working for months 195 00:12:54,022 --> 00:12:56,817 on the Beech 1900 accident in Charlotte. 196 00:12:58,568 --> 00:13:00,361 - What do we know so far about the cause 197 00:13:00,486 --> 00:13:03,657 of that other Beech 1900 crash, the one in Charlotte? 198 00:13:03,782 --> 00:13:05,658 - We think the plane was loaded wrong, 199 00:13:05,783 --> 00:13:07,786 and the pilots lost control of it. 200 00:13:08,703 --> 00:13:13,082 - A witness reported the Colgan Air 1900 seemed to struggle to hold altitude 201 00:13:13,249 --> 00:13:15,836 before descending into the water south of the airport. 202 00:13:16,586 --> 00:13:19,630 - Pilots understand that altitude is their best friend, 203 00:13:19,755 --> 00:13:22,592 and taking off from the airport and then... 204 00:13:22,759 --> 00:13:25,177 pretty much flying right into the ocean... 205 00:13:25,928 --> 00:13:28,807 ...is a sure sign that something was wrong. 206 00:13:30,142 --> 00:13:34,187 It could be control problems after takeoff in both accidents. 207 00:13:36,315 --> 00:13:39,109 The similarities between Colgan and Air Midwest 208 00:13:39,275 --> 00:13:43,029 wasn't just the fact that both were Beech 1900. 209 00:13:43,571 --> 00:13:47,908 In both instances, the attitude of the aircraft was uncontrollable. 210 00:13:50,119 --> 00:13:51,495 Charlotte. 211 00:13:51,621 --> 00:13:53,874 They lost control of the pitch. 212 00:13:54,249 --> 00:13:56,250 - Was it outside its centre of gravity? 213 00:13:58,669 --> 00:14:02,798 (narrator): The balancing point of an airplane is called its centre of gravity. 214 00:14:02,966 --> 00:14:07,553 Passengers and luggage must be carefully distributed from front to back 215 00:14:07,678 --> 00:14:10,807 to keep the plane stable in flight. 216 00:14:12,600 --> 00:14:14,101 In Charlotte, 217 00:14:14,268 --> 00:14:18,230 investigators believe the Beech 1900 may have been tail-heavy, 218 00:14:18,356 --> 00:14:20,984 which caused it to pitch up after takeoff. 219 00:14:23,653 --> 00:14:26,447 - The Colgan flight was empty. So without any passengers, 220 00:14:26,572 --> 00:14:29,493 maybe the centre of gravity was too far forward? 221 00:14:29,951 --> 00:14:31,662 - You can have an empty airplane 222 00:14:31,827 --> 00:14:35,331 and still be out of your centre of gravity. 223 00:14:36,082 --> 00:14:39,293 - The crew weight: 454 pounds. 224 00:14:42,004 --> 00:14:45,801 (narrator): They calculate Flight 9446's centre of gravity 225 00:14:45,966 --> 00:14:48,678 based on the distribution of the weight onboard. 226 00:14:48,845 --> 00:14:52,515 - And then the fuel weight was 3,291 pounds. 227 00:14:55,351 --> 00:14:57,019 That should do it. 228 00:15:01,942 --> 00:15:04,152 Look how far forward that is. 229 00:15:06,363 --> 00:15:09,115 - Yeah, but... it's within limits. 230 00:15:10,075 --> 00:15:11,951 (narrator): The team is now certain 231 00:15:12,076 --> 00:15:14,245 that whatever brought down Colgan 9446, 232 00:15:14,370 --> 00:15:17,164 it was not related to its centre of gravity. 233 00:15:20,335 --> 00:15:22,796 - With Colgan, centre of gravity... 234 00:15:22,921 --> 00:15:24,339 didn't turn out to be an issue, 235 00:15:24,505 --> 00:15:28,009 even though it did have to be eliminated as a possibility. 236 00:15:36,643 --> 00:15:38,227 - Thank you for meeting with me. 237 00:15:38,937 --> 00:15:41,773 (narrator): Investigators turn to the air-traffic controller for insight 238 00:15:41,898 --> 00:15:47,028 into why the pilots of Colgan 9446 lost control after takeoff. 239 00:15:48,654 --> 00:15:51,615 - Tell me about the flight. - It was a normal takeoff. 240 00:15:51,741 --> 00:15:55,619 Uh, about a minute after, they wanted to return to the airport. 241 00:16:00,167 --> 00:16:03,169 - 9446 is requesting emergency back, sir. 242 00:16:04,086 --> 00:16:06,715 We have a runaway trim. (sighing) 243 00:16:07,298 --> 00:16:10,302 - He told you a runaway trim? - Yeah. 244 00:16:11,177 --> 00:16:13,721 - The pilot reported a runaway trim to Air Traffic Control, 245 00:16:13,846 --> 00:16:17,057 which is a control issue, and so that information was very helpful. 246 00:16:17,225 --> 00:16:19,436 It helped us work smarter, not harder. 247 00:16:20,394 --> 00:16:26,400 (narrator): Runaway trim occurs when the motorized trim tabs on the elevator malfunction, 248 00:16:26,525 --> 00:16:30,238 causing the plane to pitch nose up or nose down. 249 00:16:31,281 --> 00:16:35,326 - Runaway trim close to the ground will be specifically challenging, 250 00:16:35,451 --> 00:16:37,745 because pilots will have very limited time 251 00:16:37,870 --> 00:16:42,249 to perform the required actions to safely control that aircraft. 252 00:16:42,374 --> 00:16:45,586 - Now, he came off of Runway 24... 253 00:16:47,379 --> 00:16:50,424 ...and reported his emergency about here. 254 00:16:51,384 --> 00:16:53,720 Turned back toward the airport. 255 00:16:54,220 --> 00:16:57,265 And the plane never got above 1,200 feet on my radar. 256 00:16:59,017 --> 00:17:01,478 And he hit the water... here. 257 00:17:04,396 --> 00:17:06,857 - If the pilot feels that he's having a trim runaway, 258 00:17:06,982 --> 00:17:08,777 there's something in the pitch system... 259 00:17:08,943 --> 00:17:10,945 that is clearly a problem. 260 00:17:11,488 --> 00:17:13,949 - This is very helpful. Thank you. 261 00:17:14,115 --> 00:17:16,535 - And we're certainly gonna investigate that. 262 00:17:16,660 --> 00:17:20,913 (narrator): Will the wreckage confirm what the pilots reported 263 00:17:21,038 --> 00:17:23,165 and help explain what brought down 264 00:17:23,333 --> 00:17:26,961 a widely used commuter aircraft in just over two minutes? 265 00:17:35,345 --> 00:17:36,846 - Good. You've got them. 266 00:17:37,346 --> 00:17:40,642 (narrator): The flight-data recorder and cockpit voice recorder 267 00:17:40,767 --> 00:17:43,143 of Colgan Air Flight 9446 268 00:17:43,310 --> 00:17:45,230 are recovered from the sea floor. 269 00:17:45,355 --> 00:17:47,065 - They are in good shape. 270 00:17:49,901 --> 00:17:51,528 Ship 'em to the lab. 271 00:17:51,694 --> 00:17:53,864 Maybe we'll get some answers from these. 272 00:17:54,905 --> 00:17:56,407 - We were lucky in some areas, 273 00:17:56,532 --> 00:18:00,327 where we had the flight-data recorder and the cockpit voice recorder. 274 00:18:02,038 --> 00:18:04,415 If we didn't have flight recorders on this one, 275 00:18:04,540 --> 00:18:06,293 boy, I don't know. 276 00:18:06,918 --> 00:18:08,627 - That is a rat's nest. 277 00:18:09,837 --> 00:18:12,632 (narrator): Investigators turn their attention to what remains 278 00:18:12,757 --> 00:18:14,800 of the control systems. 279 00:18:16,219 --> 00:18:18,888 - So there's a lot of cables that go to the tail. 280 00:18:19,055 --> 00:18:21,892 Cables that control the elevator, 281 00:18:22,057 --> 00:18:25,019 the trim, and the rudder, as well. 282 00:18:25,144 --> 00:18:28,731 - I see some of the trim cable in there. (camera shutter clicking) 283 00:18:28,899 --> 00:18:31,401 Let's find as many pieces of it as we can. 284 00:18:32,777 --> 00:18:34,863 - The trim cables are smaller and had fractured. 285 00:18:36,072 --> 00:18:41,201 And so it's a big puzzle to be able to track the cables from one end to the other. 286 00:18:42,370 --> 00:18:44,038 - Could take a while. 287 00:18:46,833 --> 00:18:51,211 (narrator): While one team looks for the cables connecting the trim system, 288 00:18:51,337 --> 00:18:55,049 another focuses on the maintenance history of Colgan 9446. 289 00:18:58,553 --> 00:19:01,221 - I'm gonna look into work done on the flight controls. 290 00:19:05,768 --> 00:19:08,855 The aircraft was brought into Hyannis four days before the accident 291 00:19:08,980 --> 00:19:11,066 for a regular phase inspection. 292 00:19:12,067 --> 00:19:14,318 (narrator): Could a faulty repair be connected 293 00:19:14,443 --> 00:19:17,072 to the pilot's report of runaway trim? 294 00:19:17,948 --> 00:19:19,907 - Check out which inspection they were in. 295 00:19:21,951 --> 00:19:26,748 (narrator): At Colgan Air, monthly routine inspections are divided into phases... 296 00:19:27,289 --> 00:19:29,459 ...focusing on different areas of the plane. 297 00:19:31,711 --> 00:19:34,422 - They were working on the tail. - Exactly. 298 00:19:35,257 --> 00:19:37,634 Which means they might've done work on the trim system. 299 00:19:37,800 --> 00:19:40,428 They flew in with no problems. 300 00:19:40,553 --> 00:19:44,223 And then, on the first flight out, they couldn't control it. 301 00:19:44,807 --> 00:19:47,352 Something happened that was detrimental 302 00:19:47,477 --> 00:19:49,645 to the safety of the aircraft. 303 00:19:50,355 --> 00:19:53,692 They spent at least four separate days on the inspection. 304 00:19:53,817 --> 00:19:55,527 - What took them so long? 305 00:19:59,655 --> 00:20:01,115 - It doesn't say. 306 00:20:01,657 --> 00:20:05,703 A phase check - in this case, what they call a detail check - 307 00:20:05,828 --> 00:20:08,080 you can do it within an eight-hour period, 308 00:20:08,205 --> 00:20:11,584 especially on a 1900, because it's a very simple aircraft. 309 00:20:12,168 --> 00:20:14,170 But the fact that it took four days 310 00:20:14,336 --> 00:20:17,589 led us to understand that there was something else that occurred. 311 00:20:19,843 --> 00:20:21,428 Mind if I record this? 312 00:20:21,553 --> 00:20:23,012 - Uh, sure. 313 00:20:26,932 --> 00:20:28,518 - I was wondering. 314 00:20:28,684 --> 00:20:31,645 Why did it take you so long to do your phase checks? 315 00:20:31,770 --> 00:20:34,982 - We definitely found a lot of stuff that we needed to replace. 316 00:20:41,823 --> 00:20:43,532 Can I have the flashlight? 317 00:20:47,370 --> 00:20:49,873 Just bring the light a little to my left? 318 00:20:52,959 --> 00:20:55,295 Yeah, the trim actuator is worn out. 319 00:20:56,503 --> 00:21:00,884 (narrator): Cables from the cockpit connect to the trim actuators... 320 00:21:01,759 --> 00:21:05,888 ...mechanical rods in the tail that move the trim tabs up or down. 321 00:21:06,806 --> 00:21:10,309 - What did you do when you found the problem with the actuators? 322 00:21:11,353 --> 00:21:15,315 - We removed the old ones, ordered new ones and installed them. 323 00:21:16,149 --> 00:21:20,194 - And the new ones went in easily and it worked fine? 324 00:21:21,112 --> 00:21:23,323 - Uh, well, not exactly. 325 00:21:28,411 --> 00:21:30,913 Okay, Bob, run the trim system, please? 326 00:21:33,916 --> 00:21:36,086 (static) - Did the actuators move? 327 00:21:37,045 --> 00:21:39,297 - No. Neither did the trim cable. 328 00:21:39,881 --> 00:21:43,593 (narrator): The test revealed problems with the actuator replacement. 329 00:21:44,426 --> 00:21:47,180 - When we replaced the actuator, we... 330 00:21:47,305 --> 00:21:51,058 we bent and kinked the cable that connects it to the cockpit controls. 331 00:21:51,183 --> 00:21:53,560 (stammering) It was just a dumb mistake. 332 00:21:55,563 --> 00:21:58,107 - If he's an experienced, competent mechanic, 333 00:21:58,274 --> 00:22:00,109 why would he do that? 334 00:22:00,276 --> 00:22:02,444 And the answer was he was not. 335 00:22:02,612 --> 00:22:05,781 He was a new hire, had never done this job before, 336 00:22:05,949 --> 00:22:11,246 and their training program allowed him to do this without any supervision. 337 00:22:11,413 --> 00:22:14,665 - I ordered a new cable and installed it. 338 00:22:15,791 --> 00:22:17,544 That's why it took four days. 339 00:22:18,545 --> 00:22:19,921 - And you tested it? 340 00:22:20,046 --> 00:22:21,713 - Yeah. Yup. 341 00:22:22,464 --> 00:22:25,175 (narrator): After the new cable was installed, 342 00:22:25,300 --> 00:22:28,054 maintenance workers performed a visual check. 343 00:22:28,762 --> 00:22:30,432 - Okay, let's give it a try. 344 00:22:30,973 --> 00:22:35,769 - When examining the paperwork after the accident, everything looked in order. 345 00:22:36,479 --> 00:22:39,231 - That's it. It's working. Thanks, man. 346 00:22:39,731 --> 00:22:41,942 - Yet we still had an issue, 347 00:22:42,109 --> 00:22:45,447 because it didn't explain what actually happened. 348 00:22:45,572 --> 00:22:47,449 (narrator): With no credible leads 349 00:22:47,574 --> 00:22:50,993 to explain why the pilots thought they had a trim issue, 350 00:22:51,161 --> 00:22:54,747 investigators must rely on what they learn from the CVR, 351 00:22:54,873 --> 00:22:56,499 the cockpit voice recorder. 352 00:22:56,665 --> 00:22:58,334 - Okay, let's hear it. 353 00:23:07,301 --> 00:23:09,095 - The recording runs about 17 minutes, 354 00:23:09,220 --> 00:23:12,015 from the moment the pilots powered up on the ground. 355 00:23:14,558 --> 00:23:16,685 (narrator): Could the pilots' communications reveal 356 00:23:16,853 --> 00:23:21,524 why Colgan Air Flight 9446 failed to maintain altitude? 357 00:23:24,152 --> 00:23:27,197 (Knabe): Hyannis Maintenance, this is Colgan 9446. 358 00:23:27,363 --> 00:23:30,950 Hey, I was told to stay in contact with you for the whole trip? 359 00:23:31,075 --> 00:23:35,454 - Yeah, they might call ya, turn you back, because they did find a problem. 360 00:23:35,579 --> 00:23:37,499 I don't know for sure. 361 00:23:39,083 --> 00:23:41,419 - Why would Maintenance want to turn them around? 362 00:23:41,544 --> 00:23:43,837 - Maybe there was something wrong with the plane. 363 00:23:44,422 --> 00:23:47,008 Somebody had doubts about the work they did? 364 00:23:49,719 --> 00:23:51,261 - I, as a mechanic, 365 00:23:51,386 --> 00:23:53,013 could not... 366 00:23:53,181 --> 00:23:55,349 ever release an aircraft... 367 00:23:55,517 --> 00:23:57,643 that there was a question of its airworthiness. 368 00:23:57,768 --> 00:24:02,147 You cannot say, well, you know, the wings are pretty... pretty strong on there. 369 00:24:02,272 --> 00:24:05,567 We're 90% positive they're not gonna fall off. 370 00:24:05,734 --> 00:24:07,194 You can't do that. 371 00:24:07,903 --> 00:24:11,950 - I prefer not to fly something if it's broken. I'd rather you do it, 372 00:24:12,075 --> 00:24:14,410 because you are the pilot in command. 373 00:24:14,576 --> 00:24:15,620 - Alright. 374 00:24:16,246 --> 00:24:20,374 - You know, a broken airplane? I wouldn't want to screw it up. (chuckling) 375 00:24:21,584 --> 00:24:24,295 - Okay, it'll be a standard Colgan takeoff. 376 00:24:24,420 --> 00:24:27,422 If things get spooky on the runway, we'll abort it. 377 00:24:29,842 --> 00:24:31,553 - Did he just say "spooky"? 378 00:24:32,220 --> 00:24:35,722 (narrator): As investigators continue to review the CVR... 379 00:24:36,473 --> 00:24:38,558 - A flight crew should not be that nervous. 380 00:24:38,684 --> 00:24:41,144 (narrator): ... they're surprised by the pilots' concern 381 00:24:41,270 --> 00:24:43,397 about the condition of their aircraft. 382 00:24:45,607 --> 00:24:48,152 - Sadly, the aircraft manuals... 383 00:24:48,278 --> 00:24:50,320 went down with the aircraft. 384 00:24:50,445 --> 00:24:53,449 So exactly what the maintenance personnel... 385 00:24:53,615 --> 00:24:57,662 put in those logbooks for the pilots to review, 386 00:24:57,787 --> 00:24:59,497 we will never know. 387 00:25:01,583 --> 00:25:04,919 - When did they first realize there was a serious issue with their aircraft? 388 00:25:05,795 --> 00:25:09,423 (sighing) - It looks like merely seconds after takeoff. 389 00:25:11,800 --> 00:25:13,553 - V1. Rotate. 390 00:25:17,307 --> 00:25:19,267 - We have a hot elevator trim. 391 00:25:19,433 --> 00:25:23,229 - They identified a trim issue seconds after takeoff, 392 00:25:23,354 --> 00:25:25,856 long before contacting the controller. 393 00:25:25,981 --> 00:25:28,192 - So what did they do about it? 394 00:25:30,403 --> 00:25:32,113 - Kill the trim, kill the trim. 395 00:25:33,197 --> 00:25:37,326 (narrator): The captain tries to disconnect the trim system on his yoke... 396 00:25:38,368 --> 00:25:40,246 ...but his attempts fail. 397 00:25:41,204 --> 00:25:43,999 - Roll back, roll back, roll it back. - I got it. 398 00:25:45,375 --> 00:25:46,626 (groaning) 399 00:25:47,753 --> 00:25:51,633 - They're commanding nose-up trim inputs, but it doesn't seem to help. 400 00:25:56,261 --> 00:25:59,265 - 9446 is requesting emergency back, sir. 401 00:26:00,182 --> 00:26:02,101 Got a runaway trim. 402 00:26:02,893 --> 00:26:05,229 - Okay, there it is. Runaway trim. 403 00:26:06,146 --> 00:26:08,066 Just like the controller said. 404 00:26:11,193 --> 00:26:13,320 - Did they try pulling the breaker? 405 00:26:13,488 --> 00:26:15,323 - Looks like it. 406 00:26:17,532 --> 00:26:20,827 - Pull the breaker, Steve. Pull the breaker. I have the yoke. Ah! 407 00:26:21,746 --> 00:26:24,707 - Listen to how exhausted they are, trying to keep the nose up. 408 00:26:25,458 --> 00:26:27,585 (FO): Where is it? (Captain): Find it! 409 00:26:28,586 --> 00:26:31,506 - The pilot was calling for the co-pilot to pull the circuit breakers, 410 00:26:31,672 --> 00:26:34,133 so they can stop these electrical signals 411 00:26:34,258 --> 00:26:36,760 that are commanding the runaway trim. 412 00:26:37,845 --> 00:26:40,682 But you have to have time to pull the circuit-breakers. 413 00:26:41,348 --> 00:26:44,602 - Look left of the silver thing, Steve. Left of the silver! - Left of the silver thing? 414 00:26:44,727 --> 00:26:47,814 - Left of the silver thing. Ugh! The stick! 415 00:26:47,939 --> 00:26:50,357 Steve, stay with me! (groaning) 416 00:26:50,942 --> 00:26:54,528 - The co-pilot had to abandon pulling the breaker in order to help the captain. 417 00:26:55,529 --> 00:26:57,615 - Steve, keep-- - I'm pulling! 418 00:26:57,865 --> 00:26:59,241 (alarm sounding) (groaning) 419 00:26:59,409 --> 00:27:01,743 - Oh, no! (screaming) 420 00:27:01,911 --> 00:27:03,578 (screaming) 421 00:27:09,000 --> 00:27:10,711 - Two minutes... 422 00:27:10,877 --> 00:27:12,797 from takeoff to impact. 423 00:27:14,632 --> 00:27:17,759 - Those guys fought the trim right until they hit the water. 424 00:27:19,511 --> 00:27:22,390 - We need to find out what's going on with that trim system. 425 00:27:24,599 --> 00:27:27,103 (narrator): Was there a mechanical issue with the trim 426 00:27:27,269 --> 00:27:29,396 that the pilots could not overcome? 427 00:27:33,733 --> 00:27:35,403 - Okay, let's have a look. 428 00:27:36,487 --> 00:27:39,656 - We were lucky we had a solid-state flight-data recorder. 429 00:27:39,781 --> 00:27:42,826 Some of the old, old flight recorders might only have 16 parameters. 430 00:27:42,951 --> 00:27:44,662 This one had a lot more. 431 00:27:45,663 --> 00:27:48,082 (narrator): Investigators examine the FDR, 432 00:27:48,249 --> 00:27:49,791 the flight-data recorder, 433 00:27:49,959 --> 00:27:53,503 to determine why the pilots reported a runaway trim. 434 00:27:55,714 --> 00:27:58,134 - This doesn't look right. - What do you mean? 435 00:27:58,675 --> 00:28:01,887 - This trim data is way out of calibration. 436 00:28:03,346 --> 00:28:05,807 - It either... wasn't maintained properly, 437 00:28:05,974 --> 00:28:08,059 or it was damaged in the accident. 438 00:28:08,185 --> 00:28:11,564 And so on this one, we didn't have exact... 439 00:28:11,689 --> 00:28:13,191 trim position. 440 00:28:13,649 --> 00:28:17,444 - If the FDR wasn't calibrated, those readings are worthless. 441 00:28:19,197 --> 00:28:21,115 (narrator): It's a major setback. 442 00:28:21,240 --> 00:28:22,700 Without the FDR data, 443 00:28:22,825 --> 00:28:25,202 the investigators may not be able to confirm 444 00:28:25,327 --> 00:28:27,829 the pilots' report of a runaway trim. 445 00:28:28,663 --> 00:28:32,250 - But we have all those other parameters: pitch, elevator. 446 00:28:33,044 --> 00:28:36,797 Let's ask the lab to try and calculate what the trim position would be. 447 00:28:37,882 --> 00:28:39,592 - Performance case study. 448 00:28:39,717 --> 00:28:41,426 That's a great idea. 449 00:28:42,260 --> 00:28:44,806 - A case study like this would help us to define... 450 00:28:45,431 --> 00:28:50,102 ...whether the elevator trim-tab cables had anything to do with the accident. 451 00:28:50,228 --> 00:28:53,105 It was one other thing that we could check into 452 00:28:53,230 --> 00:28:55,775 to verify the results we were finding. 453 00:28:55,900 --> 00:28:59,194 (narrator): Will the team be able to get accurate trim data... 454 00:28:59,362 --> 00:29:00,988 - Ah! Steve, keep-- - I'm pulling! 455 00:29:01,154 --> 00:29:03,657 (narrator): ...and explain why two experienced pilots 456 00:29:03,825 --> 00:29:06,243 were unable to keep their plane in the air? 457 00:29:06,368 --> 00:29:08,828 (groaning) - Oh, no! (screaming) 458 00:29:21,509 --> 00:29:25,136 - So... the lab took the control-column positions 459 00:29:25,262 --> 00:29:27,390 and extrapolated for trim. 460 00:29:28,098 --> 00:29:30,476 - I see. Excellent. 461 00:29:31,560 --> 00:29:34,814 (narrator): A performance study using the FDR data 462 00:29:34,939 --> 00:29:40,027 gives the NTSB a new look at the trim inputs on Flight 9446. 463 00:29:42,113 --> 00:29:45,115 - So they adjust the trim to take off right here. 464 00:29:45,825 --> 00:29:48,493 - Yeah. It's part of the Before Taxi checklist. 465 00:29:51,830 --> 00:29:53,665 - Before Taxi checklist. 466 00:29:54,916 --> 00:29:56,669 - Uh, Before Taxi. Weather radar. 467 00:29:57,420 --> 00:30:00,213 - On standby. - Trim set? 468 00:30:00,922 --> 00:30:03,550 - Point 5. Takeoff trim set. 469 00:30:06,011 --> 00:30:09,140 - The takeoff trim was set to. 5 nose down 470 00:30:09,265 --> 00:30:11,851 instead of. 5 nose up. 471 00:30:13,143 --> 00:30:14,686 - That's odd. 472 00:30:15,104 --> 00:30:16,730 When's the next input? 473 00:30:16,896 --> 00:30:18,566 - Right after takeoff. 474 00:30:19,482 --> 00:30:21,818 - That's right after he said... 475 00:30:22,903 --> 00:30:24,614 "We've got a hot elevator trim." 476 00:30:25,615 --> 00:30:28,366 - The plane's pitching down instead of up. 477 00:30:30,118 --> 00:30:31,787 - How's that possible? 478 00:30:32,579 --> 00:30:35,165 (narrator): Investigators discover the plane wasn't responding 479 00:30:35,290 --> 00:30:37,460 to the pilots' nose-up trim inputs. 480 00:30:38,251 --> 00:30:42,172 - And then happens again here, one last time, a few seconds later. 481 00:30:43,633 --> 00:30:46,344 - Roll back, roll back, roll it back. - I got it. 482 00:30:48,136 --> 00:30:52,266 (narrator): The more the first officer tries to manually trim the nose up... 483 00:30:52,391 --> 00:30:54,893 (groaning) ...the more the nose drops. 484 00:30:56,354 --> 00:30:58,355 - It's like the trim is reversed. 485 00:30:59,731 --> 00:31:01,817 (Gretz): A good analogy is learning to drive. 486 00:31:01,983 --> 00:31:03,443 Imagine how weird it would be... 487 00:31:03,568 --> 00:31:06,697 if you turned your steering wheel right and the car went left. 488 00:31:07,280 --> 00:31:09,157 - Talk about confusing. 489 00:31:10,201 --> 00:31:11,911 - And exhausting. 490 00:31:13,245 --> 00:31:16,499 - You pull for all you're worth. Just keep pulling for all you're worth. 491 00:31:16,665 --> 00:31:18,625 - They were dealing with a backwards trim, 492 00:31:18,750 --> 00:31:22,837 which I don't know how anyone would've ever fathomed that. 493 00:31:23,005 --> 00:31:24,714 (groaning) 494 00:31:24,839 --> 00:31:28,551 (narrator): Investigators calculate that within a minute of takeoff, 495 00:31:28,678 --> 00:31:33,015 the pilots would've required 250 pounds of force to hold the nose up. 496 00:31:33,973 --> 00:31:36,893 (TAWS): Terrain. Terrain. - Ah! Steve, keep-- - I'm pulling! 497 00:31:37,143 --> 00:31:38,813 (groaning) - Hold on, Steve! 498 00:31:38,938 --> 00:31:40,605 - Ah!!! 499 00:31:41,440 --> 00:31:45,486 - How on earth could they have wired a trim system backwards? 500 00:31:54,996 --> 00:31:58,374 - The team retrieved this from the wreckage. - Oh, great. 501 00:32:00,334 --> 00:32:05,006 (narrator): In an effort to prove the trim cables on Flight 9446 were reversed... 502 00:32:06,382 --> 00:32:11,345 ...investigators study a key piece of the trim system found in the wreckage. 503 00:32:12,179 --> 00:32:14,515 - Okay, the trim cable... 504 00:32:14,682 --> 00:32:17,518 is threaded and wrapped around this drum... 505 00:32:18,102 --> 00:32:21,646 ...and then runs in a loop from the cockpit to the tail. 506 00:32:27,819 --> 00:32:30,823 - Maybe they fed the cable incorrectly around the drum. 507 00:32:33,116 --> 00:32:34,993 - Let's check the installation manual. 508 00:32:46,713 --> 00:32:49,842 It looks like Maintenance threaded the drum correctly. 509 00:32:52,595 --> 00:32:53,720 - Yeah. 510 00:32:54,971 --> 00:32:56,723 But how did they install it? 511 00:32:58,183 --> 00:33:01,060 - The cable drum was one piece of the story that was telling us 512 00:33:01,228 --> 00:33:03,939 that it might've been incorrectly rigged, 513 00:33:04,105 --> 00:33:05,816 but we needed to dig deeper. 514 00:33:06,983 --> 00:33:09,319 - Okay, let's give this a try. 515 00:33:11,113 --> 00:33:15,451 (narrator): The NTSB considers how the maintenance crew installed the drum. 516 00:33:16,285 --> 00:33:17,912 - That's good. 517 00:33:20,538 --> 00:33:22,999 Here we go. Yeah, it's in. 518 00:33:32,093 --> 00:33:33,760 Well, that doesn't fit. 519 00:33:34,761 --> 00:33:35,930 Yeah. 520 00:33:43,394 --> 00:33:45,396 Yeah, the only way to install this thing... 521 00:33:49,777 --> 00:33:51,403 Like this. 522 00:33:51,528 --> 00:33:55,324 (narrator): Investigators discover that in order for the drum to fit the pin, 523 00:33:55,490 --> 00:33:58,911 it had to be flipped, thereby crossing the wires. 524 00:33:59,661 --> 00:34:01,956 - Well, that was the huge aha moment for me. 525 00:34:02,123 --> 00:34:05,960 - The manual, the way it was depicted at that time, 526 00:34:06,126 --> 00:34:07,920 it could mislead somebody. 527 00:34:08,045 --> 00:34:10,005 In this case, it did. 528 00:34:12,757 --> 00:34:14,677 - We have a hot elevator trim. 529 00:34:15,677 --> 00:34:17,679 (narrator): Because the wires were crossed, 530 00:34:17,847 --> 00:34:20,391 the trim tab operated in reverse. 531 00:34:23,686 --> 00:34:25,646 - Kill the trim, kill the trim. 532 00:34:28,356 --> 00:34:29,900 Pull back. 533 00:34:30,525 --> 00:34:32,152 - They knew they had a malfunction. 534 00:34:32,277 --> 00:34:35,114 They just couldn't figure out what it was. 535 00:34:36,824 --> 00:34:38,742 - There's only one explanation. 536 00:34:39,869 --> 00:34:41,786 The maintenance manual must be wrong. 537 00:34:42,621 --> 00:34:44,539 I'll check with the manufacturer. 538 00:34:45,081 --> 00:34:48,126 (narrator): But even if the manual is wrong, 539 00:34:48,251 --> 00:34:51,505 why didn't anyone notice the trim cables were crossed? 540 00:34:51,630 --> 00:34:53,215 - I'll check if the maintenance team 541 00:34:53,382 --> 00:34:55,675 got an inspector to sign off on the work. 542 00:34:56,802 --> 00:34:58,804 They are a second set of eyes. 543 00:34:59,345 --> 00:35:02,432 They have to be the one who is making sure that the job is done right. 544 00:35:02,891 --> 00:35:05,019 That is what an inspector does. 545 00:35:06,853 --> 00:35:09,731 After you installed the drum, did an inspector sign off on the work? 546 00:35:09,898 --> 00:35:13,110 - Yes, he did. In fact, he assisted with it. 547 00:35:15,403 --> 00:35:17,155 - He assisted? - Yeah. 548 00:35:18,072 --> 00:35:20,867 - The inspector cannot get in there with wrenches, 549 00:35:20,992 --> 00:35:24,454 he cannot get in there and tell you, "Okay, you gotta put this bolt here," 550 00:35:24,579 --> 00:35:26,498 or anything like that. 551 00:35:27,333 --> 00:35:28,791 - Thanks for your help tonight. 552 00:35:28,918 --> 00:35:32,545 - The thing is, with an inspector being part of the job, 553 00:35:32,713 --> 00:35:34,173 he's making the same mistakes 554 00:35:34,298 --> 00:35:37,760 the people that he's supposed to be overlooking are making, 555 00:35:37,927 --> 00:35:39,929 so he becomes part of the problem. 556 00:35:41,179 --> 00:35:44,141 (narrator): The inspector who helped with the installation 557 00:35:44,266 --> 00:35:46,393 didn't notice the crossed wires, 558 00:35:46,559 --> 00:35:48,686 and signed off on the work. 559 00:35:48,811 --> 00:35:51,398 - Uh, the last time we spoke, 560 00:35:51,565 --> 00:35:53,483 you said you tested it? 561 00:35:54,108 --> 00:35:55,735 - That's right. 562 00:35:56,527 --> 00:35:59,030 (narrator): After the new cable was installed... 563 00:35:59,155 --> 00:36:01,242 - Okay, let's give it a try. 564 00:36:01,407 --> 00:36:03,994 (narrator): ...maintenance workers performed a visual check. 565 00:36:04,119 --> 00:36:07,664 - Yeah, that's it. It's working. Yeah, thanks, man. 566 00:36:13,170 --> 00:36:15,130 - Yeah. It's coming in now. 567 00:36:17,132 --> 00:36:18,550 Thanks. 568 00:36:18,967 --> 00:36:20,552 (hanging up) 569 00:36:22,220 --> 00:36:24,097 - Hey. - Hey. 570 00:36:25,139 --> 00:36:26,516 What'd you find out? 571 00:36:26,641 --> 00:36:29,144 - The inspector helped with the installation, 572 00:36:29,311 --> 00:36:31,771 so not exactly an objective inspection. 573 00:36:31,938 --> 00:36:33,273 What about you? 574 00:36:33,440 --> 00:36:35,150 - Well, it's just like we thought. 575 00:36:36,402 --> 00:36:38,277 The drawing in the manual is wrong. 576 00:36:39,112 --> 00:36:43,367 This is how the drum should've been oriented when they threaded the cable. 577 00:36:44,367 --> 00:36:47,788 The manual shows the slots on the drum are facing out. 578 00:36:48,621 --> 00:36:50,291 But the correct way... 579 00:36:51,333 --> 00:36:54,503 ...to thread the cable is with the flat side facing out. 580 00:36:54,670 --> 00:36:56,088 - Here's what I don't get. 581 00:36:56,213 --> 00:36:59,215 They tested the trim system when the installation was complete 582 00:36:59,340 --> 00:37:01,010 and said it was working fine. 583 00:37:02,844 --> 00:37:04,637 - How's that possible? 584 00:37:05,306 --> 00:37:06,724 (sighing) 585 00:37:16,400 --> 00:37:18,652 - Long night? - Yeah. 586 00:37:19,320 --> 00:37:21,487 Found a recording of the trim check test. 587 00:37:21,655 --> 00:37:23,990 - You're kidding. - It's on the CVR, 588 00:37:24,157 --> 00:37:25,951 recorded well before their flight. 589 00:37:27,036 --> 00:37:30,956 - In order for the mechanics to do an operational check correctly, 590 00:37:31,081 --> 00:37:32,541 they had to power the airplane up. 591 00:37:32,708 --> 00:37:35,251 - Okay, Bob, run the trim system, please? 592 00:37:35,376 --> 00:37:39,465 - So the power was on, the CVR was on. It worked to our advantage. 593 00:37:40,048 --> 00:37:42,760 I think I know how the trim tabs passed the visual ground test 594 00:37:42,885 --> 00:37:44,887 even though they were running in reverse. 595 00:37:48,056 --> 00:37:51,018 (maintenance worker): Are you good in the cockpit? 596 00:37:51,143 --> 00:37:52,603 - Yeah. 597 00:37:53,311 --> 00:37:55,813 - Okay, let's give it a try. 598 00:37:56,481 --> 00:37:58,067 Trim nose up. 599 00:37:58,858 --> 00:38:00,527 - Trimming nose up. 600 00:38:01,862 --> 00:38:03,237 - Yeah, moving up. 601 00:38:03,405 --> 00:38:05,032 Looks good. 602 00:38:05,865 --> 00:38:07,617 Yeah, trim nose down? 603 00:38:08,284 --> 00:38:09,744 - Trimming down. 604 00:38:11,579 --> 00:38:14,458 - Okay. Yeah, that's it. That's working. 605 00:38:15,333 --> 00:38:16,751 Thanks, man. 606 00:38:18,628 --> 00:38:22,382 - Sounds like a normal test. - No. They got it backwards. 607 00:38:24,592 --> 00:38:26,719 We hear the cockpit call trim up, 608 00:38:26,844 --> 00:38:29,806 and the maintenance worker says he sees the trim tab move up. 609 00:38:29,931 --> 00:38:31,641 That is reversed. 610 00:38:32,226 --> 00:38:34,394 (narrator): If you trim nose up, 611 00:38:34,519 --> 00:38:36,563 the trailing edge moves down, 612 00:38:36,730 --> 00:38:38,565 in the opposite direction. 613 00:38:38,731 --> 00:38:41,527 The same is true for trimming the nose down. 614 00:38:43,987 --> 00:38:47,574 - It is counterintuitive... but you're right. 615 00:38:47,699 --> 00:38:49,742 It is an easy mistake to make. 616 00:38:50,494 --> 00:38:52,788 - Checking a trim system can be a little confusing. 617 00:38:52,954 --> 00:38:55,748 You have to make sure you're on the same page with the other person. 618 00:38:55,873 --> 00:38:58,501 Are you talking tab up or nose up? 619 00:38:59,128 --> 00:39:00,920 'Cause tab up is nose down. 620 00:39:01,797 --> 00:39:04,090 - The ground guys missed it, okay. 621 00:39:04,257 --> 00:39:06,050 Why didn't the pilots catch it? 622 00:39:07,927 --> 00:39:12,306 - Trim test is definitely a pre-takeoff checklist item. 623 00:39:12,474 --> 00:39:14,143 But did they run it? 624 00:39:18,063 --> 00:39:21,065 - According to the transcript, they ran the checklist. 625 00:39:24,152 --> 00:39:26,487 - Alright, Before Start checks. 626 00:39:27,030 --> 00:39:28,407 - Uh, parking brake? 627 00:39:28,532 --> 00:39:31,076 - It's set. - Pre-flight complete. 628 00:39:31,994 --> 00:39:35,621 - Before Taxi checklist. - Before Taxi. Weather radar. 629 00:39:38,416 --> 00:39:40,126 - They skipped the trim check. 630 00:39:42,503 --> 00:39:44,505 - I'm biased 'cause I have a pilot background. 631 00:39:44,673 --> 00:39:48,844 I feel like that first-flight- of-the-day checklist is crucial. That's where you can catch it. 632 00:39:50,637 --> 00:39:52,972 - Even if they had checked it, 633 00:39:53,139 --> 00:39:55,726 would they have known whether the trim system was reversed 634 00:39:55,851 --> 00:39:58,936 just by looking at the direction the trim wheel was spinning? 635 00:40:00,396 --> 00:40:01,815 - Good point. 636 00:40:02,356 --> 00:40:05,485 (narrator): Pilots test the trim by pressing the trim switch 637 00:40:05,652 --> 00:40:09,864 and monitoring the direction in which the manual trim wheel spins. 638 00:40:10,532 --> 00:40:13,744 To trim nose up, the wheel would turn backwards. 639 00:40:17,623 --> 00:40:20,501 Investigators recreate the reversed trim system 640 00:40:20,626 --> 00:40:23,545 on the same model of Beech 1900 that crashed 641 00:40:23,711 --> 00:40:28,175 to determine whether the pilots could've detected that the trim was reversed. 642 00:40:29,259 --> 00:40:31,010 - Let's give this a try. 643 00:40:33,889 --> 00:40:36,849 (narrator): Investigators trim the plane nose up. 644 00:40:38,809 --> 00:40:41,980 - The wheel is moving backwards, 645 00:40:42,105 --> 00:40:44,690 the way the pilots expected it to turn. 646 00:40:44,815 --> 00:40:47,360 (narrator): Even though the trim cable was reversed, 647 00:40:47,485 --> 00:40:50,697 the wheel still moves backwards as it should. 648 00:40:52,407 --> 00:40:56,202 - What is in error is the fact that the drum is upside down. 649 00:40:56,327 --> 00:41:00,248 It is now running the cables in the wrong direction. 650 00:41:00,414 --> 00:41:03,293 So everything in the cockpit is correct. 651 00:41:04,001 --> 00:41:07,880 (narrator): The test reveals the pilots of Colgan Flight 9446... 652 00:41:08,048 --> 00:41:09,550 - V1. Rotate. 653 00:41:10,092 --> 00:41:12,719 (narrator): ...wouldn't have realized the cables were reversed 654 00:41:12,844 --> 00:41:15,764 even if they had checked them prior to takeoff. 655 00:41:16,597 --> 00:41:18,559 - We have a hot elevator trim. 656 00:41:22,563 --> 00:41:24,146 (narrator): In their final report, 657 00:41:24,273 --> 00:41:27,150 the NTSB concludes the cause of the accident 658 00:41:27,275 --> 00:41:31,070 was the improper installation of the trim-cable system, 659 00:41:31,237 --> 00:41:35,117 and Beechcraft's erroneous depiction of the elevator trim drum 660 00:41:35,284 --> 00:41:37,077 in their maintenance manual. 661 00:41:37,994 --> 00:41:39,788 - Ugh! The stick! 662 00:41:40,038 --> 00:41:42,331 Steve, stay with me! (groaning) 663 00:41:42,456 --> 00:41:46,085 (narrator): These factors ended up sealing the pilots' fate. 664 00:41:47,003 --> 00:41:48,963 (TAWS): Terrain. Terrain. Pull up! 665 00:41:49,130 --> 00:41:51,675 - It's gonna take both of us on this, Steve. 666 00:41:54,469 --> 00:41:58,097 (TAWS): Terrain. Terrain. - Steve, keep-- - I'm pulling! 667 00:41:59,141 --> 00:42:00,601 (groaning) 668 00:42:00,726 --> 00:42:04,353 (narrator): The pilots' grueling efforts kept the plane in the air 669 00:42:04,478 --> 00:42:08,108 for more than two minutes. (TAWS): Pull up! (narrator): But in the end, 670 00:42:08,275 --> 00:42:13,030 the extreme stick pressures were too much for the pilots to overcome. 671 00:42:15,157 --> 00:42:18,784 - Picture trying to do your day job while deadlifting 250 pounds. 672 00:42:18,952 --> 00:42:22,289 (groaning) (TAWS): Pull up! - It's just too much. 673 00:42:22,831 --> 00:42:25,249 - Ah! Hold on, Steve! (screaming) 674 00:42:25,374 --> 00:42:26,668 (alarm sounding) 675 00:42:26,835 --> 00:42:29,838 - Oh, no! (TAWS): Pull up! (screaming) 676 00:42:40,766 --> 00:42:42,976 - This accident was 100% preventable. 677 00:42:43,393 --> 00:42:45,311 First and foremost is, 678 00:42:45,436 --> 00:42:48,065 your plane has to be flyable, 679 00:42:48,190 --> 00:42:50,233 and it's only flyable if the manuals 680 00:42:50,358 --> 00:42:54,112 and maintenance and pilot instructions make sense. 681 00:42:54,695 --> 00:42:58,574 (narrator): The Colgan Air 9446 report echoed similar findings 682 00:42:58,699 --> 00:43:04,331 to the other Beech 1900 crash months earlier in Charlotte, North Carolina. 683 00:43:05,164 --> 00:43:08,626 Improperly installed control cables were also a factor 684 00:43:08,751 --> 00:43:12,630 in the Air Midwest accident that killed 21 people. 685 00:43:13,130 --> 00:43:15,675 - If you looked up the term "maintenance accident" in the dictionary, 686 00:43:15,842 --> 00:43:17,969 those two accidents would be there. 687 00:43:18,719 --> 00:43:21,597 Colgan and Air Midwest were poster childs 688 00:43:21,722 --> 00:43:24,016 for maintenance accidents. 689 00:43:26,394 --> 00:43:29,563 If Colgan properly followed the maintenance program 690 00:43:29,731 --> 00:43:32,400 as dictated by the regulations, 691 00:43:32,567 --> 00:43:34,820 this accident never would've happened. 692 00:43:35,778 --> 00:43:39,824 (narrator): After the accident, Beechcraft's maintenance manuals were amended. 693 00:43:40,574 --> 00:43:44,079 And airlines adopted stricter procedures for airplane checks 694 00:43:44,246 --> 00:43:47,206 after undergoing routine maintenance. 695 00:43:47,916 --> 00:43:50,126 - The person in the cockpit missed it, 696 00:43:50,251 --> 00:43:53,170 the people on the elevators missed it, the inspector missed it. 697 00:43:53,922 --> 00:43:57,050 Everybody missed what was just... 698 00:43:57,217 --> 00:43:59,677 such a simple mistake. 699 00:44:30,876 --> 00:44:33,085 Subtitling: difuze