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[dramatic music]
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Mayday, mayday,
engine flameout.
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NARRATOR: A dash cam video
captures the last moments
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00:00:14,381 --> 00:00:15,682
of a horrific plane crash.
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A minor flight issue--
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[alarm beeping]
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Right engine oil pressure.
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NARRATOR: --turns into a crisis.
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PAUL STASSEN: Gerrit, Gerrit.
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TODD CURTIS: There was several
places where the airplane
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could have been saved.
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Fire.
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NARRATOR: A revolutionary
new aircraft breaks
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up during a critical flight.
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Three tragedies caused
by fateful decisions
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made in the heat of the moment.
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JOHN NANCE: The tendency
is always, let's solve
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the problem right this minute.
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And we've lost a lot
of airplanes that way.
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FLIGHT ATTENDANT:
Ladies and gentlemen,
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we are starting our approach.
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LIU TZE-CHUNG: We
lost both engines.
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WOMAN 1: The last--
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emergency descend.
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WOMAN 2: Brace for impact.
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MAN: It's going to crush.
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[explosion booming]
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[calm music]
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NARRATOR: Taipei,
capital city of Taiwan.
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Near its center lies
Songshan Airport.
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The next plane scheduled
for departure this morning
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is TransAsia Flight 235.
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The first officer
is Liu Tze-chung.
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He has almost 7,000
hours of flying time.
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Oil pressure.
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Check.
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NARRATOR: The captain,
Liao Chien-tsung,
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is a former military pilot.
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A third pilot is
observing today's flight.
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TransAsia 235 is a one hour
commuter flight from Taipei
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to the Taiwanese
island of Kinmen,
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just off the coast
of mainland China.
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TransAsia 235, runway 10,
wind 100 degree, nine are not,
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cleared for takeoff.
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LIAO CHIEN-TSUNG: OK,
cleared for takeoff.
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[engine accelerating]
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NARRATOR: Immediately
after takeoff, the captain
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engages the autopilot.
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Gear up.
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LIU TZE-CHUNG: Gear up.
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NARRATOR: Flight 235 climbs
over metropolitan Taipei,
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home to more than
seven million people.
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Seconds later, the
Master Warning sounds.
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The Master Warning is
indicative of an emergency
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situation requiring
an immediate response.
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NARRATOR: TransAsia
235 has lost an engine.
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The captain disengages
the autopilot.
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I have control.
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You have control.
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Heading mode?
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NARRATOR: He needs a
heading back to the airport.
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Below 2,500 feet.
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Turn to heading, it's--
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Come on!
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Zero, zero niner five.
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Check.
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PETER RENSHAW: When you lose
an engine in a twin engine
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aircraft, you need to
be able to maintain
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your client performance.
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LIU TZE-CHUNG: OK,
engine flameout check.
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Check.
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NARRATOR: The speed and
climb rate are dropping fast.
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Watch the speed.
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STALL WARNING:
Stall, stall, stall.
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NARRATOR: The Stall Warning
indicates the plane is flying
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too slowly to maintain lift.
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PETER RENSHAW: The Stall
Warning at low altitudes,
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a critical situation that no
pilot ever wants to end up in.
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Terrain ahead.
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LIU TZE-CHUNG:
Tower, TransAsia 235.
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Mayday, mayday, engine flameout.
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[suspenseful music]
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Engine flameout, both sides.
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HUNG PING-CHUNG: How
is this possible?
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PETER RENSHAW: The crew was
surrounded by high density
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housing, high rise
apartment blocks,
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a heavily populated area.
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Impact, brace for impact!
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Oh, no!
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LIU TZE-CHUNG: Oh.
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Oh no!
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STALL WARNING: Pull up.
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[plane crashing]
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[mournful music]
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NARRATOR: TransAsia
flight 235 has
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gone down in the Keelung River.
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Suspend all takeoff
and landing operations.
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Begin emergency procedures.
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NARRATOR: Rescuers
rushed to the scene.
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[helicopter blades whirring]
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00:05:16,115 --> 00:05:22,922
Of the 58 people on board,
only 15 make it out alive.
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All three pilots are dead.
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[investigative music]
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Investigators from Taiwan's
Aviation Safety Council
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need to start collecting
evidence at the scene.
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But even before they
leave headquarters--
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INVESTIGATOR 1:
Take a look at this.
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NARRATOR: --a stunning piece
of evidence from a dashboard
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camera surfaces.
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What?
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What was happening
on that plane?
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INVESTIGATOR 1:
What do you think?
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Left engine?
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When we watched
the video clip,
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we know there's something
wrong about the engine.
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The prop seems very slow.
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Is this the left engine?
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Uh, yes.
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00:06:23,616 --> 00:06:26,586
NARRATOR: Investigators can
see in the dash cam video
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that the plane was banked
steeply to the left.
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A faulty left engine is
the most likely suspect.
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But the recovered engine
shows no sign of a fault.
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Left engine
completely operational.
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00:06:47,473 --> 00:06:47,940
Ah, strange.
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00:06:52,645 --> 00:06:55,648
NARRATOR: When they study the
right engine, what they find
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00:06:55,648 --> 00:06:57,016
is equally mystifying.
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Look at the blades.
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00:07:03,656 --> 00:07:04,657
They're feathered.
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00:07:08,494 --> 00:07:12,565
NARRATOR: Feathered is a
propeller's fail safe position.
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00:07:12,565 --> 00:07:15,501
When a propeller engine
loses power in flight,
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the blades automatically rotate
parallel to the airstream
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00:07:19,105 --> 00:07:20,973
to reduce drag and
allow the plane
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to operate with one engine.
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00:07:23,943 --> 00:07:26,078
Why would the right
engine be feathered
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00:07:26,078 --> 00:07:27,980
when the dash cam
video clearly shows
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00:07:27,980 --> 00:07:29,949
the plane banking to the left?
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00:07:29,949 --> 00:07:32,218
It doesn't make any sense.
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00:07:32,218 --> 00:07:35,021
Let's have a look.
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00:07:35,021 --> 00:07:38,825
When we discover a
feathered of the propeller,
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we know there
should be something
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wrong about the engine.
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00:07:43,262 --> 00:07:45,865
NARRATOR: But their inspection
shows the right engine
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is also in working condition.
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00:07:47,967 --> 00:07:50,837
If both engines
were operational,
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00:07:50,837 --> 00:07:52,705
why did this plane crash?
146
00:07:55,274 --> 00:07:56,542
[suspenseful music]
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00:07:56,542 --> 00:07:59,579
NARRATOR: Investigators hope the
plane's flight data recorder,
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which records dozens of flight
parameters, can tell them more.
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00:08:05,518 --> 00:08:08,621
But all data points indicate
the plane was operating
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00:08:08,621 --> 00:08:10,957
normally, except for one.
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Take a look at this.
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00:08:14,060 --> 00:08:15,261
The torque is all
over the place.
153
00:08:19,999 --> 00:08:21,934
NARRATOR: Torque is
the twisting rotational
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00:08:21,934 --> 00:08:24,704
force created by the engine.
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00:08:24,704 --> 00:08:28,007
It increases and decreases
during specific phases
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00:08:28,007 --> 00:08:31,277
of flight, but it's not
supposed to fluctuate
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00:08:31,277 --> 00:08:32,912
in such rapid bursts.
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00:08:32,912 --> 00:08:34,814
Why is it doing that?
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00:08:34,814 --> 00:08:36,215
NARRATOR: They dig
deeper, studying
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00:08:36,215 --> 00:08:39,285
how the Pratt & Whitney
engine measures torque.
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00:08:39,285 --> 00:08:42,021
THOMAS WANG: So we try
to find out the design
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logic for the system.
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00:08:44,223 --> 00:08:46,826
What's the connection
between the torque
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and the feather propellers?
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00:08:50,930 --> 00:08:52,698
NARRATOR: They learned
that the engine's
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00:08:52,698 --> 00:08:56,269
auto feathering system includes
an electronic torque sensor.
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00:08:56,269 --> 00:09:00,940
It measures how much rotational
force the engine is producing.
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00:09:00,940 --> 00:09:03,342
An extremely low torque
reading indicates
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00:09:03,342 --> 00:09:07,013
that the engine has failed and
triggers automatic feathering.
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00:09:11,017 --> 00:09:12,885
But investigators
have already concluded
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the engine was operational.
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They need to find the
reason incorrect torque
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readings would cause the
right engine to feather.
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00:09:20,626 --> 00:09:24,797
Maybe the sensor is sending
a faulty reading, triggering
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00:09:24,797 --> 00:09:26,065
the auto feathering unit.
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00:09:29,068 --> 00:09:30,803
NARRATOR: Investigators
find the circuit
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00:09:30,803 --> 00:09:32,004
board from the right engine.
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00:09:32,004 --> 00:09:34,240
Took a look underneath.
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00:09:34,240 --> 00:09:36,142
NARRATOR: And look
for any defects
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00:09:36,142 --> 00:09:39,378
that could have caused the
propeller to feather in flight.
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00:09:39,378 --> 00:09:42,181
INVESTIGATOR 1: It's
a broken solder.
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00:09:42,181 --> 00:09:44,784
NARRATOR: They discover
microscopic faults
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00:09:44,784 --> 00:09:45,584
in the circuit board.
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00:09:51,257 --> 00:09:53,659
With a broken circuit
board, the sensor
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00:09:53,659 --> 00:09:56,796
couldn't detect torque
even though the engine
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was functioning perfectly.
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00:09:58,731 --> 00:10:01,834
So the system automatically
feathered the propeller.
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00:10:03,903 --> 00:10:05,004
LIU TZE-CHUNG: OK.
189
00:10:05,004 --> 00:10:06,639
Engine flameout check.
190
00:10:06,639 --> 00:10:07,873
Check.
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00:10:07,873 --> 00:10:10,409
NARRATOR: They now understand
why the right-side propeller
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00:10:10,409 --> 00:10:11,377
feathered.
193
00:10:11,377 --> 00:10:15,214
Investigators now face
an even bigger mystery.
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00:10:15,214 --> 00:10:17,283
Losing thrust in
the right engine
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00:10:17,283 --> 00:10:22,788
should cause a right bank,
but the dash cam video clearly
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00:10:22,788 --> 00:10:26,092
shows the plane banking left.
197
00:10:26,092 --> 00:10:28,794
The power lever angle.
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00:10:28,794 --> 00:10:30,997
NARRATOR: When investigators
check the throttle settings
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00:10:30,997 --> 00:10:33,833
on the left or
number one engine,
200
00:10:33,833 --> 00:10:36,335
they make a stunning discovery.
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00:10:36,335 --> 00:10:38,237
Unbelievable.
202
00:10:38,237 --> 00:10:42,041
The power of the
number one engine
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00:10:42,041 --> 00:10:45,177
was gradually being
reduced, reduced,
204
00:10:45,177 --> 00:10:47,279
and eventually being shut off.
205
00:10:51,017 --> 00:10:53,853
NARRATOR: On this
ATR 72, the throttles
206
00:10:53,853 --> 00:10:55,254
can only be moved by hand.
207
00:11:00,126 --> 00:11:03,229
It had to have been shut
down by one of the pilots.
208
00:11:03,229 --> 00:11:04,697
THOMAS WANG: So we
start to wondering,
209
00:11:04,697 --> 00:11:08,034
why the pilot was shut
down the good engine.
210
00:11:08,034 --> 00:11:09,201
That's crazy.
211
00:11:16,217 --> 00:11:18,820
HUNG PING-CHUNG: How
is this possible?
212
00:11:18,820 --> 00:11:21,723
NARRATOR: Investigators turned
to the cockpit voice recording
213
00:11:21,723 --> 00:11:25,927
to help explain why
TransAsia flight 235 crashed
214
00:11:25,927 --> 00:11:28,296
in Taipei's Keelung River.
215
00:11:28,296 --> 00:11:30,432
AIR TRAFFIC CONTROLLER:
TransAsia 235,
216
00:11:30,432 --> 00:11:34,936
contact approach a one, one,
niner decimal seven, good day.
217
00:11:34,936 --> 00:11:39,441
We still have number one
engine produce power normally,
218
00:11:39,441 --> 00:11:41,943
but for some reason
the pilot decided
219
00:11:41,943 --> 00:11:44,012
to shut down the good engine.
220
00:11:44,012 --> 00:11:46,347
We have to find out why.
221
00:11:46,347 --> 00:11:47,782
[alarm ringing]
222
00:11:47,782 --> 00:11:49,017
What's that sound?
223
00:11:49,017 --> 00:11:52,120
It must be the
engine Default Warning.
224
00:11:52,120 --> 00:11:53,421
NARRATOR: Investigators
already know
225
00:11:53,421 --> 00:11:56,224
a faulty torque sensor
caused the right engine
226
00:11:56,224 --> 00:12:00,061
to feather and lose thrust.
227
00:12:00,061 --> 00:12:02,130
This is a crucial moment.
228
00:12:02,130 --> 00:12:04,365
Let's hear what they're
going to do next.
229
00:12:04,365 --> 00:12:05,767
LIAO CHIEN-TSUNG:
I have control.
230
00:12:05,767 --> 00:12:07,168
NARRATOR: Investigators
hear the sound
231
00:12:07,168 --> 00:12:09,237
of the autopilot turning off.
232
00:12:09,237 --> 00:12:11,105
He's disengaging
the autopilot.
233
00:12:11,105 --> 00:12:12,240
He shouldn't be doing that.
234
00:12:16,544 --> 00:12:21,549
He just made a
difficult situation worse.
235
00:12:21,549 --> 00:12:23,785
LIU TZE-CHUNG: OK,
engine flameout check.
236
00:12:23,785 --> 00:12:25,286
Check.
237
00:12:25,286 --> 00:12:29,324
There's a checklist
procedure on the screen.
238
00:12:29,324 --> 00:12:33,161
If they follow the procedure,
do everything correctly,
239
00:12:33,161 --> 00:12:38,266
they should be able to fly back
to land without any problem.
240
00:12:38,266 --> 00:12:39,801
NARRATOR: But
instead of following
241
00:12:39,801 --> 00:12:41,836
the emergency checklist--
242
00:12:41,836 --> 00:12:43,571
Watch the speed.
243
00:12:43,571 --> 00:12:46,040
NARRATOR: --the captain
does something inexplicable.
244
00:12:46,040 --> 00:12:47,342
Pull back number one.
245
00:12:50,512 --> 00:12:53,515
NARRATOR: Both engines are
capable of producing power,
246
00:12:53,515 --> 00:12:55,850
but because the right
engine has feathered,
247
00:12:55,850 --> 00:13:00,889
it has lost thrust behaving
like a car in neutral gear.
248
00:13:00,889 --> 00:13:04,459
When the captain then pulls
back the left engine throttle,
249
00:13:04,459 --> 00:13:08,463
he leaves himself
with no thrust at all.
250
00:13:08,463 --> 00:13:10,465
How could he do such a thing?
251
00:13:10,465 --> 00:13:13,268
NARRATOR: The
captain of Flight 235
252
00:13:13,268 --> 00:13:17,972
has shut down the plane's
only working engine.
253
00:13:17,972 --> 00:13:20,308
No, wait a
second, cross-check.
254
00:13:20,308 --> 00:13:22,210
PETER RENSHAW: The pilot
monitoring, to his credit,
255
00:13:22,210 --> 00:13:25,847
did try to stop the pilot flying
from manipulating the engine
256
00:13:25,847 --> 00:13:28,883
number one power
lever and he announced
257
00:13:28,883 --> 00:13:29,484
he wanted to cross check.
258
00:13:32,120 --> 00:13:34,055
Heading mode.
259
00:13:34,055 --> 00:13:35,890
NARRATOR: But the captain
interrupted the first officer
260
00:13:35,890 --> 00:13:37,959
to ask for a new heading.
261
00:13:37,959 --> 00:13:39,327
Come on!
262
00:13:39,327 --> 00:13:41,596
LIU TZE-CHUNG: Zero,
zero niner five.
263
00:13:41,596 --> 00:13:42,797
LIAO CHIEN-TSUNG: Check.
264
00:13:42,797 --> 00:13:45,333
PETER RENSHAW: All of a sudden
they've got a dual engine
265
00:13:45,333 --> 00:13:48,202
failure and the pilot
monitoring I think
266
00:13:48,202 --> 00:13:50,371
has been caught off guard.
267
00:13:50,371 --> 00:13:53,107
And he's not really
sure what's going on.
268
00:13:53,107 --> 00:13:54,309
Restart the engine.
269
00:13:54,309 --> 00:13:55,944
I can't restart the engine!
270
00:13:55,944 --> 00:13:58,246
NARRATOR: When the captain
realizes his mistake--
271
00:13:58,246 --> 00:14:02,083
Oh, well, I shut
off the wrong engine.
272
00:14:02,083 --> 00:14:04,252
NARRATOR: --there's no
time to restart the engine.
273
00:14:08,423 --> 00:14:10,458
HUNG PING-CHUNG: Impact,
brace for impact!
274
00:14:10,458 --> 00:14:12,160
Oh, no!
275
00:14:12,160 --> 00:14:14,262
[plane crashing]
276
00:14:16,531 --> 00:14:18,299
NARRATOR: Investigators
now have an even more
277
00:14:18,299 --> 00:14:21,035
puzzling question to answer.
278
00:14:21,035 --> 00:14:24,238
Why didn't the captain
understand what he was doing?
279
00:14:24,238 --> 00:14:26,908
[speculative music]
280
00:14:26,908 --> 00:14:29,444
NARRATOR: Did taking
manual control of the plane
281
00:14:29,444 --> 00:14:34,582
distract the pilot from
verifying which engine failed?
282
00:14:34,582 --> 00:14:36,417
[alarm blaring]
283
00:14:36,417 --> 00:14:37,452
LIU TZE-CHUNG: Watch the speed.
284
00:14:42,090 --> 00:14:45,927
He could have been suffering
from change blindness.
285
00:14:45,927 --> 00:14:48,596
PETER RENSHAW: Change blindness,
people are focused or fixated
286
00:14:48,596 --> 00:14:51,399
on another item or
area of interest
287
00:14:51,399 --> 00:14:53,968
and so they miss what
would be considered
288
00:14:53,968 --> 00:14:56,404
a very distinguishable
change in the environment,
289
00:14:56,404 --> 00:14:58,206
but they don't perceive it.
290
00:14:58,206 --> 00:15:00,208
[alarm blaring]
291
00:15:01,309 --> 00:15:02,243
I will pull back
engine one throttle.
292
00:15:05,279 --> 00:15:09,150
Even when all the systems were
telling him it was engine two,
293
00:15:09,150 --> 00:15:14,255
his perception told him he
was doing the right thing.
294
00:15:14,255 --> 00:15:15,289
Change blindness.
295
00:15:19,093 --> 00:15:22,230
NARRATOR: Investigators finally
understand what went wrong
296
00:15:22,230 --> 00:15:26,734
aboard TransAsia Flight 235.
297
00:15:26,734 --> 00:15:29,437
A microscopic crack
in a circuit board
298
00:15:29,437 --> 00:15:31,606
disabled a sensor
in the right engine,
299
00:15:31,606 --> 00:15:34,442
causing the system to
incorrectly determine
300
00:15:34,442 --> 00:15:35,610
that the engine had failed.
301
00:15:38,012 --> 00:15:41,516
This was a series of mistakes
on the part of the captain.
302
00:15:41,516 --> 00:15:43,685
When engine two
feathered, the captain
303
00:15:43,685 --> 00:15:46,487
reacted before he had properly
assessed the situation.
304
00:15:52,260 --> 00:15:56,130
NARRATOR: The captain should
have followed a checklist.
305
00:15:56,130 --> 00:15:57,365
I have control.
306
00:15:57,365 --> 00:15:58,566
NARRATOR: But in the
heat of the moment,
307
00:15:58,566 --> 00:16:01,035
he turned off the
autopilot and reduced
308
00:16:01,035 --> 00:16:03,471
power in the wrong engine.
309
00:16:03,471 --> 00:16:04,672
I will pull back
engine one throttle.
310
00:16:08,342 --> 00:16:11,512
He shut down their
only working engine.
311
00:16:11,512 --> 00:16:17,285
By the time he
realizes, it's too late.
312
00:16:17,285 --> 00:16:18,486
LIAO CHIEN-TSUNG:
Restart the engine!
313
00:16:18,486 --> 00:16:21,122
I can't restart the engine.
314
00:16:21,122 --> 00:16:23,224
Wow, I shut off the engine.
315
00:16:26,594 --> 00:16:28,796
NARRATOR: The
crash of Flight 235
316
00:16:28,796 --> 00:16:33,668
would be the last accident
for TransAsia Airways.
317
00:16:33,668 --> 00:16:36,637
In November 2016, the
company went out of business.
318
00:16:40,174 --> 00:16:43,244
When you talk about the
TransAsia situation in Taipei,
319
00:16:43,244 --> 00:16:45,813
we've got a situation there
where if they had just delayed
320
00:16:45,813 --> 00:16:49,083
until they had enough altitude
and air speed doing anything,
321
00:16:49,083 --> 00:16:50,418
they would have probably lived.
322
00:16:54,822 --> 00:16:56,724
[exciting music]
323
00:16:56,724 --> 00:16:57,959
Runway in sight.
324
00:16:57,959 --> 00:17:01,395
NARRATOR: But sometimes when a
split second decision is made--
325
00:17:01,395 --> 00:17:02,730
GERRIT LIEVAAR: Steer, steer!
326
00:17:02,730 --> 00:17:07,435
NARRATOR: --even a minor
issue can turn deadly.
327
00:17:07,435 --> 00:17:09,303
PAUL STASSEN: Gerrit!
328
00:17:09,303 --> 00:17:12,440
[plane exploding]
329
00:17:16,744 --> 00:17:19,514
NARRATOR: It's
Easter Monday, 1994,
330
00:17:19,514 --> 00:17:22,150
at Amsterdam Schiphol Airport.
331
00:17:22,150 --> 00:17:24,819
Set torque.
332
00:17:24,819 --> 00:17:26,387
My controls.
333
00:17:26,387 --> 00:17:28,790
NARRATOR: KLM
Cityhopper Flight 433
334
00:17:28,790 --> 00:17:33,127
is preparing to fly from
Amsterdam to Cardiff, Wales.
335
00:17:33,127 --> 00:17:36,130
Torque set.
336
00:17:36,130 --> 00:17:38,733
NARRATOR: Flying time is
an hour and 20 minutes.
337
00:17:42,603 --> 00:17:47,341
PAUL STASSEN: V1, rotate.
338
00:17:47,341 --> 00:17:51,579
NARRATOR: The plane is a Saab
340B, a dual turboprop designed
339
00:17:51,579 --> 00:17:53,080
for short regional flights.
340
00:17:56,217 --> 00:18:01,689
The captain on Flight 433 is
37-year-old Gerrit Lievaart.
341
00:18:01,689 --> 00:18:04,458
The first Officer
Paul Stassen is 34.
342
00:18:07,795 --> 00:18:09,797
There are 21
passengers on board.
343
00:18:17,305 --> 00:18:20,641
Amsterdam KLM 433.
344
00:18:20,641 --> 00:18:22,610
AIR TRAFFIC CONTROLLER:
Go ahead, 433.
345
00:18:22,610 --> 00:18:24,412
Is flight level 200 available?
346
00:18:27,315 --> 00:18:28,683
Climb to 200.
347
00:18:28,683 --> 00:18:31,485
You are recleared
flight level 200.
348
00:18:31,485 --> 00:18:32,653
Thank you, sir.
349
00:18:32,653 --> 00:18:39,827
Climbing flight
level 200, KLM 433.
350
00:18:39,827 --> 00:18:42,296
NARRATOR: But on the
way up to 20,000 feet.
351
00:18:42,296 --> 00:18:44,765
[alarm ringing]
352
00:18:46,734 --> 00:18:48,436
Right engine oil pressure.
353
00:18:48,436 --> 00:18:49,270
GERRIT LIEVAAR: Check.
354
00:18:49,270 --> 00:18:49,937
Take action.
355
00:18:49,937 --> 00:18:52,240
Copy, taking action.
356
00:18:52,240 --> 00:18:54,675
NARRATOR: First Officer
Stassen consults the Engine
357
00:18:54,675 --> 00:18:56,878
Oil Pressure Warning checklist.
358
00:18:56,878 --> 00:18:58,446
There are several
reasons where oil pressure
359
00:18:58,446 --> 00:19:00,348
could drop in an engine.
360
00:19:00,348 --> 00:19:03,651
Primarily due to leaks or
some sort of damaging event
361
00:19:03,651 --> 00:19:05,453
in the engine system.
362
00:19:05,453 --> 00:19:10,391
Emergency checklist for engine
and propeller oil pressure low.
363
00:19:10,391 --> 00:19:11,959
NARRATOR: The
checklist tells him
364
00:19:11,959 --> 00:19:15,897
to monitor the Warning Light
and the oil pressure gauges.
365
00:19:15,897 --> 00:19:20,701
If the Warning Light is
on or the gauge is below 30,
366
00:19:20,701 --> 00:19:22,837
then you can continue.
367
00:19:22,837 --> 00:19:26,407
But if you have both,
then shut down the engine.
368
00:19:26,407 --> 00:19:29,277
That's not the case.
369
00:19:29,277 --> 00:19:33,381
NARRATOR: The crew decides
it's safe to keep flying.
370
00:19:33,381 --> 00:19:35,249
But then.
371
00:19:35,249 --> 00:19:40,421
GERRIT LIEVAART: OK, we're
not climbing anymore.
372
00:19:40,421 --> 00:19:42,323
NARRATOR: Approaching
17,000 feet
373
00:19:42,323 --> 00:19:44,825
captain Lievaart notices
the plane is not climbing
374
00:19:44,825 --> 00:19:47,295
as quickly as it should be.
375
00:19:47,295 --> 00:19:47,962
No.
376
00:19:51,399 --> 00:19:54,669
We need to return to
Amsterdam, make a pan call,
377
00:19:54,669 --> 00:19:57,772
request to maintain
flight level 160.
378
00:19:57,772 --> 00:19:59,941
Tell them we have
a technical issue.
379
00:19:59,941 --> 00:20:02,877
TODD CURTIS: A pan call means
there is an unusual situation.
380
00:20:02,877 --> 00:20:05,613
Please pay attention to
us, we need extra help.
381
00:20:05,613 --> 00:20:10,284
Amsterdam KLM 433,
pan-pan, pan-pan, pan-pan.
382
00:20:10,284 --> 00:20:12,753
We have an engine problem
and we'd like to maintain
383
00:20:12,753 --> 00:20:16,290
160 for return to Schiphol.
384
00:20:16,290 --> 00:20:17,525
That's copy sir.
385
00:20:17,525 --> 00:20:18,759
You may turn right
heading to Schiphol.
386
00:20:24,765 --> 00:20:27,435
KLM 433, 3 can you
give me any details?
387
00:20:27,435 --> 00:20:30,604
GERRIT LIEVAART: KLM 433,
situation's under control.
388
00:20:30,604 --> 00:20:34,342
We have an engine oil pressure
problem in engine number two.
389
00:20:34,342 --> 00:20:39,613
Yes, OK, we can bring you
in 406, you're our number one.
390
00:20:39,613 --> 00:20:41,482
NARRATOR: Five minutes
later, the plane
391
00:20:41,482 --> 00:20:43,451
lines up with a runway.
392
00:20:43,451 --> 00:20:45,386
PAUL STASSEN: Runway in sight.
393
00:20:45,386 --> 00:20:47,621
Flaps 20.
394
00:20:47,621 --> 00:20:51,058
Flaps 20, out of marker.
395
00:20:51,058 --> 00:20:52,927
Check.
396
00:20:52,927 --> 00:20:58,432
NARRATOR: KLM 433 is just
500 feet above the ground.
397
00:20:58,432 --> 00:21:00,334
Watch your speed.
398
00:21:00,334 --> 00:21:01,769
NARRATOR: The plane
has slowed to the point
399
00:21:01,769 --> 00:21:04,338
that it could stall.
400
00:21:04,338 --> 00:21:06,407
I'm on it.
401
00:21:06,407 --> 00:21:10,411
NARRATOR: Suddenly the
plane banks to the right.
402
00:21:10,411 --> 00:21:11,512
Going around.
403
00:21:11,512 --> 00:21:14,515
Set torque, flaps
seven, gear up.
404
00:21:14,515 --> 00:21:16,584
NARRATOR: Captain Lievaart
attempts to go around.
405
00:21:18,819 --> 00:21:20,921
But the plane keeps
banking right.
406
00:21:25,826 --> 00:21:27,895
GERRIT LIEVAART:
Steer, steer, steer.
407
00:21:27,895 --> 00:21:29,930
PAUL STASSEN: Gerrit,
Gerrit, Gerrit!
408
00:21:33,601 --> 00:21:36,837
[plane exploding]
409
00:21:41,409 --> 00:21:44,712
Crash, crash, crash, runway
06, emergency, runway 06.
410
00:21:52,119 --> 00:21:55,489
NARRATOR: KLM Flight 433
has crashed in a field next
411
00:21:55,489 --> 00:21:55,990
to the runway.
412
00:21:59,393 --> 00:22:02,496
Of the 24 people on board,
two passengers and the captain
413
00:22:02,496 --> 00:22:03,564
are dead.
414
00:22:06,033 --> 00:22:09,003
Eight passengers and the first
officer are seriously injured.
415
00:22:12,406 --> 00:22:15,042
Investigators from the
Netherlands Aviation Safety
416
00:22:15,042 --> 00:22:17,545
Board recover the
plane's black boxes
417
00:22:17,545 --> 00:22:19,046
and send them off
for processing.
418
00:22:22,149 --> 00:22:24,819
[investigative music]
419
00:22:26,587 --> 00:22:29,657
Meanwhile, lead investigator Ben
Groenendijk is eager to speak
420
00:22:29,657 --> 00:22:31,158
with air traffic control.
421
00:22:31,158 --> 00:22:34,762
BEN GROENENDIJK: We go
to the tower and approach
422
00:22:34,762 --> 00:22:39,567
and we get the
first information.
423
00:22:39,567 --> 00:22:41,936
They issued a pan call, we're
coming back to the airport.
424
00:22:41,936 --> 00:22:46,941
Amsterdam KLM 433,
pan-pan, pan-pan, pan-pan.
425
00:22:46,941 --> 00:22:49,443
We have an engine problem
and we'd like to maintain
426
00:22:49,443 --> 00:22:50,911
160 for return to Schiphol.
427
00:22:55,116 --> 00:22:57,051
Did they tell you
what the problem was?
428
00:22:57,051 --> 00:23:00,888
Yeah, they said it had to
do with the oil pressure.
429
00:23:00,888 --> 00:23:03,757
KLM 433, situation's
under control.
430
00:23:03,757 --> 00:23:09,130
We have an engine oil pressure
problem in engine number two.
431
00:23:09,130 --> 00:23:10,764
Next thing I knew
they were going around.
432
00:23:14,635 --> 00:23:16,003
Going around.
433
00:23:16,003 --> 00:23:19,573
Set torque, flap seven, gear up.
434
00:23:19,573 --> 00:23:21,742
NARRATOR: Pilots conduct a
go around if their landing
435
00:23:21,742 --> 00:23:24,612
becomes unstable.
436
00:23:24,612 --> 00:23:27,114
TODD CURTIS: They increase
the power, they gain altitude.
437
00:23:27,114 --> 00:23:31,986
They circle around and they try
a second time for that landing.
438
00:23:31,986 --> 00:23:34,588
Right before the aircraft
is about to touch down--
439
00:23:34,588 --> 00:23:35,990
GERRIT LIEVAAR: Steer, steer.
440
00:23:35,990 --> 00:23:37,791
TODD CURTIS: --the
potential for danger
441
00:23:37,791 --> 00:23:39,760
is much much higher
than if the same problem
442
00:23:39,760 --> 00:23:43,497
happened at altitude.
443
00:23:43,497 --> 00:23:46,934
[plane exploding]
444
00:23:51,105 --> 00:23:53,140
NARRATOR: In a hangar
at Schiphol Airport
445
00:23:53,140 --> 00:23:55,176
the investigators
try to determine
446
00:23:55,176 --> 00:23:57,144
the nature of the
oil pressure problem
447
00:23:57,144 --> 00:23:59,079
and if it contributed
to the crash.
448
00:24:02,116 --> 00:24:06,687
He could have the seizure
of an engine or overheating
449
00:24:06,687 --> 00:24:10,791
because the oil is not there.
450
00:24:10,791 --> 00:24:13,961
Hm, turbines are moving.
451
00:24:13,961 --> 00:24:16,697
NARRATOR: But curiously,
they find no evidence
452
00:24:16,697 --> 00:24:18,999
of any oil pressure issues.
453
00:24:18,999 --> 00:24:25,272
Any damages from the
impact, not from oil pressure.
454
00:24:25,272 --> 00:24:27,107
NARRATOR: It seems
the pilots reported
455
00:24:27,107 --> 00:24:29,143
a problem that didn't exist.
456
00:24:33,647 --> 00:24:34,815
Why would they
report a problem
457
00:24:34,815 --> 00:24:36,884
if they didn't have one?
458
00:24:36,884 --> 00:24:38,552
What were they looking at?
459
00:24:38,552 --> 00:24:41,555
NARRATOR: Investigators
now wonder, did the cockpit
460
00:24:41,555 --> 00:24:45,793
instruments on KLM Flight
433 somehow malfunction
461
00:24:45,793 --> 00:24:47,261
and mislead the pilots?
462
00:24:47,261 --> 00:24:49,029
[alarm ringing]
463
00:24:49,029 --> 00:24:50,998
Right engine oil pressure.
464
00:24:50,998 --> 00:24:52,933
Check, take action.
465
00:24:52,933 --> 00:24:54,101
Copy, taking action.
466
00:24:57,238 --> 00:25:01,942
NARRATOR: When investigators
test the oil pressure system
467
00:25:01,942 --> 00:25:03,043
one thing jumps out.
468
00:25:06,580 --> 00:25:12,853
Ah, OK, there's a short
circuit in the switch.
469
00:25:12,853 --> 00:25:16,156
NARRATOR: Now they understand
what the pilots were seeing,
470
00:25:16,156 --> 00:25:17,625
a false warning.
471
00:25:17,625 --> 00:25:20,094
[alarm ringing]
472
00:25:21,795 --> 00:25:24,098
Right engine oil pressure.
473
00:25:24,098 --> 00:25:25,699
NARRATOR: But a
false warning alone
474
00:25:25,699 --> 00:25:27,167
is not enough to cause a crash.
475
00:25:31,038 --> 00:25:33,240
Investigators turned to
the cockpit voice recorder.
476
00:25:36,343 --> 00:25:37,211
OK, let's hear it.
477
00:25:39,780 --> 00:25:42,316
NARRATOR: They hope it will tell
them how a false warning, which
478
00:25:42,316 --> 00:25:45,886
required no action, still
led the pilots to turn
479
00:25:45,886 --> 00:25:48,255
back to Schiphol Airport.
480
00:25:48,255 --> 00:25:48,789
[alarm ringing]
481
00:25:48,789 --> 00:25:50,224
There's the warning.
482
00:25:50,224 --> 00:25:52,926
PAUL STASSEN: Right
engine oil pressure.
483
00:25:52,926 --> 00:25:56,063
Let's see how they handle it.
484
00:25:56,063 --> 00:25:57,865
Check, take action.
485
00:25:57,865 --> 00:26:01,669
Copy, taking action.
486
00:26:01,669 --> 00:26:04,204
NARRATOR: The pilots consult an
emergency checklist that should
487
00:26:04,204 --> 00:26:07,308
help them solve the problem.
488
00:26:07,308 --> 00:26:09,276
PAUL STASSEN: If the
Warning Light is on
489
00:26:09,276 --> 00:26:15,282
or the gauge is below 30,
then you can continue.
490
00:26:15,282 --> 00:26:17,117
TODD CURTIS: On Saab
340, the Warning
491
00:26:17,117 --> 00:26:19,720
System and the Oil
Measuring System
492
00:26:19,720 --> 00:26:21,322
are two separate systems.
493
00:26:21,322 --> 00:26:23,223
And if there is a
confusion between the two,
494
00:26:23,223 --> 00:26:25,092
the guidance on the
emergency checklist
495
00:26:25,092 --> 00:26:27,094
is to continue
normal operations.
496
00:26:27,094 --> 00:26:30,130
So the light is on,
but we're above 30 PSI.
497
00:26:30,130 --> 00:26:30,764
So--
498
00:26:30,764 --> 00:26:32,599
Continue normal operation.
499
00:26:35,269 --> 00:26:37,971
NARRATOR: The recording reveals
that the pilots knew it was
500
00:26:37,971 --> 00:26:39,606
safe to continue their flight.
501
00:26:44,678 --> 00:26:46,280
Why the heck did they
decide to turn back?
502
00:26:51,752 --> 00:26:54,121
GERRIT LIEVAART: OK, we're
not climbing anymore.
503
00:26:54,121 --> 00:26:54,955
Ah.
504
00:26:54,955 --> 00:26:56,090
GERRIT LIEVAART: No.
505
00:26:56,090 --> 00:26:58,325
That must be why
they turned back.
506
00:26:58,325 --> 00:27:00,994
Engines are fine.
507
00:27:00,994 --> 00:27:02,162
Why are they not climbing?
508
00:27:06,300 --> 00:27:08,969
NARRATOR: Investigators now turn
to the flight data recorder.
509
00:27:12,940 --> 00:27:14,174
What's going on here?
510
00:27:18,278 --> 00:27:23,250
Right-side engine
thrust, it's dropping.
511
00:27:23,250 --> 00:27:25,753
NARRATOR: It's a
major discovery.
512
00:27:25,753 --> 00:27:29,189
It suggests pilot error may
have caused the deadly disaster.
513
00:27:32,393 --> 00:27:35,295
Right here, right
after the alarm goes off,
514
00:27:35,295 --> 00:27:37,064
he actually pulls
the power back.
515
00:27:40,033 --> 00:27:41,235
All the way to idle.
516
00:27:45,305 --> 00:27:47,040
NARRATOR: The captain
may have been trying not
517
00:27:47,040 --> 00:27:49,977
to further damage what he
thought was a crippled engine
518
00:27:49,977 --> 00:27:50,978
when he powered back.
519
00:27:54,348 --> 00:27:56,884
And look, he keeps sitting
idle for the remainder
520
00:27:56,884 --> 00:27:59,019
of the flight.
521
00:27:59,019 --> 00:28:00,187
Well, no wonder
they couldn't climb.
522
00:28:04,391 --> 00:28:09,096
Did having an idle engine
cause this accident?
523
00:28:09,096 --> 00:28:12,866
Let's see the data from
the final approach.
524
00:28:12,866 --> 00:28:15,068
NARRATOR: The data shows
how the right engine being
525
00:28:15,068 --> 00:28:18,205
at idle affected the landing.
526
00:28:18,205 --> 00:28:21,008
At this point,
they are too slow.
527
00:28:21,008 --> 00:28:24,912
[suspenseful music]
528
00:28:24,912 --> 00:28:27,347
Watch your speed.
529
00:28:27,347 --> 00:28:28,215
I'm on it.
530
00:28:34,955 --> 00:28:38,125
NARRATOR: The captain advances
power to the left engine,
531
00:28:38,125 --> 00:28:39,426
pushing the aircraft
to the right
532
00:28:39,426 --> 00:28:42,229
because the right engine
isn't producing thrust.
533
00:28:50,337 --> 00:28:52,105
Now at this point
there's no way they're
534
00:28:52,105 --> 00:28:53,474
going to make the landing.
535
00:28:53,474 --> 00:28:56,376
So they have no choice but
to attempt to go around.
536
00:28:56,376 --> 00:28:57,077
Going around.
537
00:28:57,077 --> 00:29:01,281
Set torque, flap seven, gear up.
538
00:29:01,281 --> 00:29:03,917
NARRATOR: To climb, the
captain pushes the left engine
539
00:29:03,917 --> 00:29:07,788
to maximum power, but that only
sends the plane into an even
540
00:29:07,788 --> 00:29:10,524
steeper right bank.
541
00:29:10,524 --> 00:29:13,093
Oh, steer, steer.
542
00:29:13,093 --> 00:29:17,064
Gerrit, Gerrit, Gerrit.
543
00:29:17,064 --> 00:29:20,400
[plane exploding]
544
00:29:26,073 --> 00:29:27,140
INVESTIGATOR 2: What a blunder.
545
00:29:30,444 --> 00:29:32,346
NARRATOR: Investigators
finally understand
546
00:29:32,346 --> 00:29:34,181
the sequence of
events that brought
547
00:29:34,181 --> 00:29:37,851
down KLM Cityhopper Flight 433.
548
00:29:37,851 --> 00:29:40,254
[alarm ringing]
549
00:29:42,189 --> 00:29:43,323
Right engine oil pressure.
550
00:29:43,323 --> 00:29:45,025
GERRIT LIEVAAR:
Check, take action.
551
00:29:45,025 --> 00:29:46,560
Taking action.
552
00:29:46,560 --> 00:29:48,328
NARRATOR: In the
heat of the moment,
553
00:29:48,328 --> 00:29:50,864
the captain reduces
right engine power
554
00:29:50,864 --> 00:29:54,034
before his first officer has a
chance to read the checklist.
555
00:29:54,034 --> 00:29:57,204
This fools them both into
thinking they have an engine
556
00:29:57,204 --> 00:29:58,939
problem when they don't.
557
00:29:58,939 --> 00:30:02,209
KAS BEUMKES: The right power
lever remained in the position
558
00:30:02,209 --> 00:30:04,978
of flight idle, and
I didn't discuss
559
00:30:04,978 --> 00:30:06,446
the consequences of that.
560
00:30:10,484 --> 00:30:12,152
Going around.
561
00:30:12,152 --> 00:30:15,455
Set torque, flaps
seven, gear up.
562
00:30:15,455 --> 00:30:18,191
NARRATOR: Attempting a go
around using just one engine
563
00:30:18,191 --> 00:30:20,193
is the final mistake.
564
00:30:20,193 --> 00:30:22,896
Steer, steer, steer.
565
00:30:22,896 --> 00:30:27,534
Gerrit, Gerrit, Gerrit!
566
00:30:27,534 --> 00:30:30,504
[plane exploding]
567
00:30:37,344 --> 00:30:39,313
NARRATOR: The Netherlands
Aviation Safety Board
568
00:30:39,313 --> 00:30:41,348
determines that the
cause of those errors
569
00:30:41,348 --> 00:30:42,516
goes beyond the cockpit.
570
00:30:46,620 --> 00:30:50,424
The final report recommends
KLM review pilot testing
571
00:30:50,424 --> 00:30:54,428
techniques, establish
cockpit management training,
572
00:30:54,428 --> 00:30:58,565
and improve guidance on
flying with an idle engine.
573
00:30:58,565 --> 00:31:02,002
There's an old adage in
aviation about the level
574
00:31:02,002 --> 00:31:04,938
of forgiveness of an airplane,
but one of the things it's not
575
00:31:04,938 --> 00:31:08,241
going to forgive is failing
to do the things that are
576
00:31:08,241 --> 00:31:09,576
in the checklist appropriately.
577
00:31:09,576 --> 00:31:13,680
Checklists are
there for a reason.
578
00:31:13,680 --> 00:31:16,350
NARRATOR: It's an adage that
holds for even the best pilots
579
00:31:16,350 --> 00:31:18,518
in the most advanced planes.
580
00:31:18,518 --> 00:31:21,121
[alarm blaring]
581
00:31:21,121 --> 00:31:23,523
[calm music]
582
00:31:23,523 --> 00:31:27,394
At the Mojave Air & Space
Port in Southern California,
583
00:31:27,394 --> 00:31:30,097
a revolutionary new aircraft
is about to undertake
584
00:31:30,097 --> 00:31:30,564
a test flight.
585
00:31:34,267 --> 00:31:36,136
It's called SpaceshipTwo.
586
00:31:42,609 --> 00:31:44,511
System booting.
587
00:31:44,511 --> 00:31:46,146
NARRATOR: The
spaceship is designed
588
00:31:46,146 --> 00:31:48,415
by American Aerospace
company Scaled
589
00:31:48,415 --> 00:31:52,219
Composites for Virgin Galactic.
590
00:31:52,219 --> 00:31:54,721
Showing green
across the board.
591
00:31:54,721 --> 00:31:55,589
Copy that.
592
00:32:00,961 --> 00:32:01,695
[applause]
593
00:32:03,597 --> 00:32:05,732
NARRATOR: Virgin Galactic's
owner, Sir Richard Branson,
594
00:32:05,732 --> 00:32:08,602
hopes this unique craft will
soon carry paying customers
595
00:32:08,602 --> 00:32:11,738
to the edge of space and back.
596
00:32:11,738 --> 00:32:16,343
Together we can make space
accessible in a way that
597
00:32:16,343 --> 00:32:19,713
has only been dreamed
of before now.
598
00:32:19,713 --> 00:32:22,015
NARRATOR: The success of
this stage of the program
599
00:32:22,015 --> 00:32:24,484
rests on the shoulders
of these two test pilots.
600
00:32:27,154 --> 00:32:31,658
43-year-old Peter Siebold is
an award-winning engineer.
601
00:32:31,658 --> 00:32:35,262
He's piloted 11 different
types of experimental aircraft.
602
00:32:38,465 --> 00:32:41,301
His co-pilot,
39-year-old Mike Alsbury,
603
00:32:41,301 --> 00:32:45,272
is also a seasoned test pilot
and an aeronautical engineer.
604
00:32:49,042 --> 00:32:53,380
They've spent almost nine months
training for this mission.
605
00:32:53,380 --> 00:32:55,182
ERIK SEEDHOUSE: These
guys are test pilots,
606
00:32:55,182 --> 00:32:56,516
very, very experienced pilots.
607
00:32:56,516 --> 00:32:57,617
These are the best of
the best of the best.
608
00:33:00,620 --> 00:33:02,389
NARRATOR: The rocket
powered spaceship
609
00:33:02,389 --> 00:33:08,395
is suspended from a jet powered
plane with a 140-foot wingspan.
610
00:33:08,395 --> 00:33:10,530
The launch plane is
called White Knight 2.
611
00:33:13,233 --> 00:33:19,406
White Knight 2 will carry the
spaceship up to 46,000 feet.
612
00:33:19,406 --> 00:33:23,744
At that altitude, SpaceShipTwo
will detach from the airplane,
613
00:33:23,744 --> 00:33:27,681
fire its rocket motor, and
climb another 100,000 feet
614
00:33:27,681 --> 00:33:30,817
up into the Earth's atmosphere.
615
00:33:30,817 --> 00:33:34,488
Flying four times higher than
a typical commercial aircraft,
616
00:33:34,488 --> 00:33:36,656
it will then glide
back to Earth.
617
00:33:40,527 --> 00:33:43,530
Monitoring today's flight
is a flight director.
618
00:33:43,530 --> 00:33:45,432
He communicates with
a team of flight
619
00:33:45,432 --> 00:33:47,267
engineers and the four pilots.
620
00:33:49,836 --> 00:33:51,404
At 9:20 AM.
621
00:33:51,404 --> 00:33:56,810
White Knight 2, you are go.
622
00:33:56,810 --> 00:33:59,379
[engine accelerating]
623
00:34:00,714 --> 00:34:03,383
NARRATOR: Takeoff
speed is 150 knots.
624
00:34:11,758 --> 00:34:15,228
Once SpaceShipTwo is
released, Captain Siebold
625
00:34:15,228 --> 00:34:18,431
will take the control column,
while co-pilot Alsbury
626
00:34:18,431 --> 00:34:20,467
monitors the instruments
and configures
627
00:34:20,467 --> 00:34:21,635
the craft for its descent.
628
00:34:26,606 --> 00:34:28,875
You are clear to
arm a time-on release.
629
00:34:28,875 --> 00:34:31,411
I'll call fire.
630
00:34:31,411 --> 00:34:32,712
NARRATOR: In the
minutes before launch,
631
00:34:32,712 --> 00:34:34,748
the pilots review
the flight checklists
632
00:34:34,748 --> 00:34:39,252
they've been training
for months to memorize.
633
00:34:39,252 --> 00:34:46,793
Can't pitch up, pitch down,
trim feather unlock 1.4.
634
00:34:46,793 --> 00:34:48,461
ERIK SEEDHOUSE: Things happen
very, very, very quickly.
635
00:34:48,461 --> 00:34:51,498
They do not have the time
physically to go and pull out
636
00:34:51,498 --> 00:34:53,834
the checklist and
read the checklist
637
00:34:53,834 --> 00:34:55,769
because these things are
happening second after second
638
00:34:55,769 --> 00:34:56,636
after second.
639
00:34:58,772 --> 00:35:03,310
Glide trim's good,
green for release.
640
00:35:03,310 --> 00:35:04,277
PETER SIEBOLD: OK.
641
00:35:04,277 --> 00:35:06,179
Here we go.
642
00:35:06,179 --> 00:35:08,448
Stick.
643
00:35:08,448 --> 00:35:10,417
Let's take us forward.
644
00:35:10,417 --> 00:35:18,358
MAN 2: And 5, 4,
3, 2, 1, release.
645
00:35:18,358 --> 00:35:21,328
NARRATOR: As SpaceShipTwo
drops from its carry plane--
646
00:35:21,328 --> 00:35:23,363
Clean release.
647
00:35:23,363 --> 00:35:26,199
NARRATOR: --Mike Alsbury engages
the experimental rocket motor.
648
00:35:26,199 --> 00:35:27,834
MICHAEL ALSBURY: Arm.
649
00:35:27,834 --> 00:35:28,635
Fire.
650
00:35:28,635 --> 00:35:29,703
MICHAEL ALSBURY: Fire.
651
00:35:33,607 --> 00:35:35,675
NARRATOR: 6,000 pounds
of thrust propel them
652
00:35:35,675 --> 00:35:36,910
towards the speed of sound.
653
00:35:40,213 --> 00:35:42,282
Good light.
654
00:35:42,282 --> 00:35:45,518
ERIK SEEDHOUSE: SpaceShipTwo,
its top speed as close to three
655
00:35:45,518 --> 00:35:47,487
Mach, so three times
a speed of sound,
656
00:35:47,487 --> 00:35:49,356
over 2,000 miles per hour.
657
00:35:49,356 --> 00:35:50,490
Yeehaw.
658
00:35:52,859 --> 00:35:54,794
ERIK SEEDHOUSE: It's a
very, very rough ride.
659
00:35:54,794 --> 00:35:56,029
So you think about
the worst turbulence
660
00:35:56,029 --> 00:36:00,867
you've been in an aircraft liner
and then magnify that by 10.
661
00:36:00,867 --> 00:36:03,703
It was supposed to be a 38
second burn of the engine.
662
00:36:06,740 --> 00:36:11,578
NARRATOR: But just 14
seconds after ignition
663
00:36:11,578 --> 00:36:15,282
something goes terribly wrong.
664
00:36:15,282 --> 00:36:17,717
[alarm ringing]
665
00:36:22,398 --> 00:36:25,568
SpaceShipTwo lies in
pieces after breaking up
666
00:36:25,568 --> 00:36:28,638
over California's Mojave desert.
667
00:36:28,638 --> 00:36:30,873
Co-pilot Mike Alsbury
was killed in the crash.
668
00:36:36,212 --> 00:36:39,482
Amazingly, Captain Pete
Siebold parachuted to safety.
669
00:36:42,652 --> 00:36:44,820
He's badly injured, but alive.
670
00:36:48,924 --> 00:36:53,362
Emergency responders
rushed him to the hospital,
671
00:36:53,362 --> 00:36:56,432
while a team from the NTSB
Combs through the wreckage
672
00:36:56,432 --> 00:36:57,700
spread over the Mojave Desert.
673
00:37:01,404 --> 00:37:03,272
LORENDA WARD: One of the things
that we were able to tell
674
00:37:03,272 --> 00:37:06,776
by being on scene was that
the motor was not an issue
675
00:37:06,776 --> 00:37:08,611
as to why the vehicle broke up.
676
00:37:12,348 --> 00:37:15,351
NARRATOR: Investigators hope
the craft's external cameras
677
00:37:15,351 --> 00:37:17,486
will provide vital information.
678
00:37:17,486 --> 00:37:19,288
See here?
679
00:37:19,288 --> 00:37:22,024
The tailbone folded in on
the aircraft along the hinge
680
00:37:22,024 --> 00:37:23,759
of the feather system.
681
00:37:23,759 --> 00:37:25,461
It went into feather mode?
682
00:37:27,863 --> 00:37:30,466
NARRATOR: Feather mode refers
to the defining feature
683
00:37:30,466 --> 00:37:33,302
of SpaceShipTwo's design.
684
00:37:33,302 --> 00:37:37,640
The spaceship actually
changes shape during flight.
685
00:37:37,640 --> 00:37:41,944
After reaching maximum altitude
the pilots rotate twin rudders
686
00:37:41,944 --> 00:37:44,613
into the feather
position to increase drag
687
00:37:44,613 --> 00:37:45,815
and slow their descent.
688
00:37:48,551 --> 00:37:51,887
The craft can then drop safely
back into Earth's atmosphere
689
00:37:51,887 --> 00:37:53,823
before gliding to a runway.
690
00:38:00,296 --> 00:38:04,767
Lorenda Ward reviews the
video from a cockpit camera.
691
00:38:04,767 --> 00:38:07,036
So he unlocked
the feather system?
692
00:38:07,036 --> 00:38:09,805
Correct.
693
00:38:09,805 --> 00:38:12,475
But did he actually deploy it?
694
00:38:12,475 --> 00:38:13,743
No.
695
00:38:13,743 --> 00:38:14,710
That's a weird thing.
696
00:38:14,710 --> 00:38:18,013
No one touched the handle.
697
00:38:18,013 --> 00:38:21,917
NARRATOR: There are two steps
to feathering the spaceship.
698
00:38:21,917 --> 00:38:24,987
First, the pilots unlock
the feather system.
699
00:38:24,987 --> 00:38:28,924
So the tail boom can
pivot when commanded.
700
00:38:28,924 --> 00:38:32,361
Second, the pilots must pull
the feather handle to actually
701
00:38:32,361 --> 00:38:35,464
deploy the tail boom.
702
00:38:35,464 --> 00:38:38,868
LORENDA WARD: So we have the
video of the copilot unlocking,
703
00:38:38,868 --> 00:38:43,038
but we never see him actually
operate the feathers.
704
00:38:43,038 --> 00:38:48,410
But we know from external
video that the feathers moved.
705
00:38:48,410 --> 00:38:53,949
So we knew that we had a
performance or a dynamic issue.
706
00:38:53,949 --> 00:38:56,886
NARRATOR: Somehow the system
designed to slow the craft
707
00:38:56,886 --> 00:38:59,855
on descent deployed while
the crew was accelerating
708
00:38:59,855 --> 00:39:00,990
toward the speed of sound.
709
00:39:04,026 --> 00:39:06,595
To learn more about
the feather system,
710
00:39:06,595 --> 00:39:10,699
investigators consult engineers
at Scaled Composites, the firm
711
00:39:10,699 --> 00:39:12,902
that designs SpaceShipTwo.
712
00:39:12,902 --> 00:39:14,937
So when is supposed to
unlock the feather system?
713
00:39:17,840 --> 00:39:22,711
Between Mach 1.4 and 1.8.
714
00:39:22,711 --> 00:39:23,679
You want to play that?
715
00:39:27,583 --> 00:39:28,951
48, unlocking.
716
00:39:32,855 --> 00:39:36,559
The co-pilot had
actually unlocked
717
00:39:36,559 --> 00:39:40,162
the feather system early.
718
00:39:40,162 --> 00:39:43,632
Isn't it safer to unlock
it at lower speeds?
719
00:39:43,632 --> 00:39:44,733
No, ma'am.
720
00:39:44,733 --> 00:39:46,936
It can be catastrophic.
721
00:39:46,936 --> 00:39:48,103
ERIK SEEDHOUSE: In
the transonic phase,
722
00:39:48,103 --> 00:39:52,441
you get a huge amount of
upward force on the tail boom,
723
00:39:52,441 --> 00:39:55,411
on the tail of the
spacecraft, and the feather
724
00:39:55,411 --> 00:39:59,014
system was not designed to
deal with that sort of load.
725
00:40:01,684 --> 00:40:03,018
NARRATOR: It's a
devastating discovery
726
00:40:03,018 --> 00:40:05,087
that points to pilot error.
727
00:40:05,087 --> 00:40:06,288
Unlocking.
728
00:40:06,288 --> 00:40:09,425
NARRATOR: When co-pilot Mike
Alsbury unlocked the feather
729
00:40:09,425 --> 00:40:13,796
system 16 seconds early,
aerodynamic forces
730
00:40:13,796 --> 00:40:15,965
were so strong they
pulled the tail
731
00:40:15,965 --> 00:40:19,034
into the feathered position
and tore the aircraft apart.
732
00:40:23,906 --> 00:40:26,475
But why would a highly
experienced test pilot
733
00:40:26,475 --> 00:40:29,979
like Mike Alsbury, who had
already carried out eight
734
00:40:29,979 --> 00:40:32,448
previous flights
on SpaceShipTwo,
735
00:40:32,448 --> 00:40:37,086
unlock the tail boom at the
deadliest possible moment?
736
00:40:37,086 --> 00:40:42,091
The team pores over
training materials.
737
00:40:42,091 --> 00:40:44,493
We need to figure out what
they were told about unlocking
738
00:40:44,493 --> 00:40:45,427
the feather system early.
739
00:40:49,965 --> 00:40:51,500
NARRATOR: Record
show that co-pilot
740
00:40:51,500 --> 00:40:55,137
Alsbury flew 112 simulator
runs for this mission.
741
00:40:58,007 --> 00:41:00,843
Never once did the co-pilot
unlock the feather early.
742
00:41:04,146 --> 00:41:05,080
Hold on now.
743
00:41:08,117 --> 00:41:10,920
NARRATOR: But the records do
reveal that on one occasion
744
00:41:10,920 --> 00:41:14,056
he unlocked the
feather too late.
745
00:41:14,056 --> 00:41:15,591
12 degrees.
746
00:41:15,591 --> 00:41:17,092
MICHAEL ALSBURY: Feather unlock.
747
00:41:17,092 --> 00:41:18,093
14 degrees.
748
00:41:18,093 --> 00:41:19,995
MICHAEL ALSBURY: Mission
abort, mission abort.
749
00:41:23,032 --> 00:41:25,200
LORENDA WARD: If they
didn't unlock by 1.8,
750
00:41:25,200 --> 00:41:28,537
they would have had
to aborted the flight.
751
00:41:28,537 --> 00:41:30,873
NARRATOR: Aborting a
mission is not fatal,
752
00:41:30,873 --> 00:41:33,575
but it could be a major
setback for the program.
753
00:41:33,575 --> 00:41:35,511
0.8.
754
00:41:35,511 --> 00:41:37,980
NARRATOR: Investigators wonder,
did this error in training
755
00:41:37,980 --> 00:41:40,049
months ago lead Alsbury--
756
00:41:40,049 --> 00:41:42,551
MICHAEL ALSBURY: Mission
abort, mission abort.
757
00:41:42,551 --> 00:41:43,819
I'll call fire.
758
00:41:43,819 --> 00:41:45,788
NARRATOR: to act prematurely?
759
00:41:45,788 --> 00:41:48,190
Investigators
believe a time crunch
760
00:41:48,190 --> 00:41:50,926
may be one reason Mike
Alsbury decided to unlock
761
00:41:50,926 --> 00:41:52,528
the feather system early.
762
00:41:52,528 --> 00:41:53,896
Unlocking.
763
00:41:56,532 --> 00:41:57,900
ERIK SEEDHOUSE: If
they don't unlock
764
00:41:57,900 --> 00:42:00,569
the feather mechanism
by Mach 1.8,
765
00:42:00,569 --> 00:42:01,837
then the flight is aborted.
766
00:42:01,837 --> 00:42:02,871
So obviously that's
going to be weighing
767
00:42:02,871 --> 00:42:04,106
on the co-pilot's mind.
768
00:42:04,106 --> 00:42:07,142
You want to get
that out of the way.
769
00:42:07,142 --> 00:42:11,313
NARRATOR: Then they
make another discovery.
770
00:42:11,313 --> 00:42:13,582
Can I see that
simulator video again?
771
00:42:13,582 --> 00:42:16,819
[suspenseful music]
772
00:42:19,154 --> 00:42:20,589
NARRATOR: The
training simulator did
773
00:42:20,589 --> 00:42:23,926
not vibrate or mimic G-Forces.
774
00:42:23,926 --> 00:42:26,729
The pilots didn't feel
the actual sensation
775
00:42:26,729 --> 00:42:27,529
of a powered flight.
776
00:42:30,332 --> 00:42:32,768
Yeehaw.
777
00:42:32,768 --> 00:42:35,004
ERIK SEEDHOUSE: Even if you're
a very, very good test pilot,
778
00:42:35,004 --> 00:42:36,772
that has to be a little
bit unnerving to get all
779
00:42:36,772 --> 00:42:39,875
this vibration, and G loads, and
the speed, and everything else.
780
00:42:43,178 --> 00:42:46,749
NARRATOR: Investigators
finally know what happened.
781
00:42:46,749 --> 00:42:51,220
He had a lot to do, made
a decision to unlock early,
782
00:42:51,220 --> 00:42:56,291
perhaps not realizing
the deadly implications.
783
00:42:56,291 --> 00:42:59,228
NARRATOR: The NTSB
faults Scaled Composites
784
00:42:59,228 --> 00:43:02,097
for not ensuring pilots
understood the consequences
785
00:43:02,097 --> 00:43:04,666
of unlocking the
feather system early
786
00:43:04,666 --> 00:43:08,203
and for failing to take steps
to prevent that from happening.
787
00:43:08,203 --> 00:43:09,471
Catch up!
788
00:43:09,471 --> 00:43:13,275
LORENDA WARD: Even just having a
sensor that physically prevents
789
00:43:13,275 --> 00:43:15,611
them from unlocking
until it passes
790
00:43:15,611 --> 00:43:19,148
the appropriate threshold would
have prevented this accident.
791
00:43:21,817 --> 00:43:24,219
NARRATOR: In its
final report, the NTSB
792
00:43:24,219 --> 00:43:26,388
states the probable
cause of the disaster
793
00:43:26,388 --> 00:43:29,625
was a failure to protect
against the possibility
794
00:43:29,625 --> 00:43:33,128
that a single human error
could trigger a catastrophe.
795
00:43:36,131 --> 00:43:38,400
The common thread in
all of these tragedies
796
00:43:38,400 --> 00:43:40,736
is that people took
action without really
797
00:43:40,736 --> 00:43:43,972
examining what action was
needed and they moved too fast.
798
00:43:43,972 --> 00:43:48,277
MICHAEL ALSBURY: 0.8, unlocking.
799
00:43:48,277 --> 00:43:50,345
JOHN NANCE: We do know
how to prevent them,
800
00:43:50,345 --> 00:43:53,315
and that is by sitting on
your hands in most cases
801
00:43:53,315 --> 00:43:55,717
until you are sure you
need to take action.
802
00:43:55,717 --> 00:43:58,420
You don't take action because
if you take the wrong action,
803
00:43:58,420 --> 00:44:01,190
it can lead you into a
major problem or a disaster.
61247
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