All language subtitles for Air.Disasters.S02E12.Deadly.Reputation.1080p.PMTP.WEB-DL.DDP5.1.H.264-maldini_track3_[eng]

Every flight
begins and ends here--

a strip of asphalt

scorched by jet engines
and marred with rubber.

But not all runways
are created equal.

One of the world's
most notorious is runway 35-L

at Congonhas Airport in Brazil.

It could surprise
you at any moment.

In July 2007,

TAM Airlines flight 3054
becomes its latest victim.

Decelerate!

Decelerate!

It can't! It can't!

The runway claims 199 lives.

It would be carefully
scrutinized,

its history reviewed.

Investigators desperately
need to know

why runway 35-L
is so dangerous...

Before more lives are lost.

Ladies and gentlemen,

we are starting our approach.

We lost both engines!

Put the mask over your nose.

Emergency descent.

Mayday, mayday.

Brace for impact!

I think I lost one.

Investigation starting...

He's gonna crash!

Heavy rains pound
Brazil's largest city.

Sao Paulo sees this kind
of deluge regularly

during the winter rains.

The downpour snarls traffic
to and from Congonhas Airport.

Almost 500 miles away,

TAM Airlines flight 3054
is en route

from the southern Brazilian city
of Porto Alegre.

The Airbus A320
is headed for Sao Paulo,

90 minutes away.

For the 181 passengers on board,

it's a routine domestic flight.

But there's been
an unexpected development

for Captain
Henrique Stephanini di Sacco.

He and his First Officer
Kleyber Lima

have just learned
that the heavy rain

has temporarily shut down
runway 35-L--

the main runway
at their destination.

Did they say
when it would reopen?

No.

Let's prepare
an alternate, just in case.

Ladies and gentlemen,

it looks like,
due to the weather,

we may not be able to land
at Congonhas as planned.

I will keep you advised
as I get more information.

Congonhas Airport is
one of the busiest in the world.

Planes take off and land here
every 90 seconds,

carrying a steady stream
of people and cargo

into the country's economic hub.

But Congonhas is also notorious
among pilots.

The airport lies
at the heart of the city,

crowded on all sides
by apartment buildings,

offices, and roadways.

Runway 35-L is
less than 6,500 feet long--

short for large jets.

Even worse,
it's built on a hilltop

with a sharp drop-off
on all sides.

The risk the airport poses,

due to its construction,
due to its geography,

it does not allow
for simple mistakes.

Captain Carlos Camacho

is the flight safety director

of the Brazilian Pilots Union.

As you approach the runway,

your adrenaline
is really pumping.

For us pilots, it's like landing
on an aircraft carrier.

It makes Congonhas

one of the most treacherous
airports in the world.

In fact, a Pantanal Airlines
commuter plane

spun out of control
while landing

just the day before.

And a few months ago,
disaster was narrowly averted

when a Boeing 737
came skidding to a stop,

just inches
before the steep embankment

at the end of runway 35-L.

When pilots
begin landing at Congonhas,

they're more worried

than when operating
at any other national airport.

Flight 3054
is at cruising altitude

south of Sao Paulo

when the crew gets news

that runway 35-L
is back in operation.

3054,
35-L is the active runway.

There's no need to divert.

Ladies and gentlemen,

this is your captain speaking.

I have some good news for you.

The runway at Congonhas
has reopened.

We'll arrive as scheduled,
shortly before 7 p.m.

The relief of the passengers

is not shared by the pilot.

Stephanini has an additional
challenge on this flight.

Remember,
we only have one reverser.

Yes.

Only the left.

He will have to land

at one of the world's
most challenging airports

with less than the usual amount
of stopping power.

One of the Airbus'
two thrust reversers

isn't working.

The devices are designed
to slow the aircraft on landing

by reversing engine thrust.

If I was the pilot that day,

I would be extremely concerned

knowing that one of my reversers
wasn't functioning.

TAM 3054,
35-L clear to land.

Stephanini
will be landing

on the infamous runway 35-L.

The runway is wet,
and it's slippery.

The wind is 330 at 8 knots.

The crew was informed

of poor braking conditions
on the runway.

The Airbus is on final approach.

Even though the autopilot could
get the plane to the runway,

the captain decides to take over
the controls himself.

Land green, manual flight.

He wants to bring the plane in

as close to the runway threshold
as possible.

He needs every inch of runway
he can get.

35-L. 35-L.

The concern
was that after touching down,

the pilots needed to be sure

that they would be able
to stop their plane

before the end of the runway.

The passengers only know

that they'll soon be landing.

300. 300.

Now they are only 300
feet above the city.

The Airbus is lined up
with the center of the runway.

Middle.

Runway conditions.

200. 200.

100. 100.

One dot now, okay?

The plane's wheels

will touch the Congonhas tarmac
in seconds.

20. Retard.

As the plane touches down,

their worries about landing
are only just beginning.

Captain Stephanini
applies reverse thrust

to the A320's
only working reverser.

The pilot would have to

activate the reverser,

on the engine
that had a working reverser,

as fast as possible
to initiate deceleration.

But the plane
is not slowing down.

Reverse number one only.

At this rate,

it will use nearly
the entire 6,400 feet of runway

in less than 30 seconds.

Decelerate!

It can't!

The pilots operated

the foot brakes with the pedals,

pressing on them
for a long time.

Look at this.

Now...the aircraft
mysteriously pulls to the left.

Turn! Turn!

It's almost as if
it has a mind of its own.

Oh, my god! Oh, my god!

Flight 3054 has slammed

into a TAM Airlines building

and an adjacent gas station.

Nearly 200 firefighters
descend on the scene.

They face a raging fuel fire

burning at over
1,800 degrees Fahrenheit.

The devastation horrifies
Dr. Douglas Ferrari.

The explosion spread fire

throughout the entire area.

There was a fire
in the gas station,

killing the people who
were filling up their tanks,

burning the whole structure,

turning it unrecognizable.

He had hoped
to treat survivors,

but now he fears
there might not be any.

We had
three, four cars on fire.

In one of these cars,
I saw a mother with her child...

Dead.

The entire plane
is engulfed in flames.

There's little hope
for anyone inside.

But now there is a new danger.

Huge quantities of fuel

in the storage tanks
beneath the gas station

could blow up at any moment.

The aircraft broke

its wings on impact

and spilled fuel
throughout the entire area.

There was a risk
of the gas station exploding.

Rescuers hope
they can save people

in the TAM Airlines building.

But with the fire
raging out of control,

they will have to act fast.

We tried to rescue the people

from inside the building.

I was anxious to help them.

Dr. Ferrari makes a grim find

inside the TAM Airlines offices.

The airplane wing
blocked the way.

It prevented people
from escaping.

I was behind the firefighter
accompanying me

while he moved bodies
to the sidewalk.

It was a horrible feeling.

But they do locate
some office workers

in another part of the building

and rush them to safety.

On the
right side of the building,

where there was no obstruction,

there was time
for people to get out.

About ten or twenty people
made it.

No one
in the aircraft has survived.

199 people are dead,

including a dozen people
in the gas station

and the TAM building.

It's the worst aviation accident
in South American history.

The black boxes will not
last long in the heat!

Lieutenant colonel
Fernando Camargo

is an accident investigator
with Cenipa,

the country's
aviation safety agency.

In modern aircraft,

the recorders are the core
of any investigation.

So when we arrived
at the crash site

and we saw
that strong fire,

we got really concerned about
the integrity of the data.

He knows the intense
heat could already be damaging

the plane's
data and voice recorders--

valuable evidence that could
help explain the crash

may already be lost.

Colonel Camargo and his team
know that just the day before,

another plane
slid off runway 35-L.

We knew that we
would have to run

a complete investigation
on the runway.

If a rain-slicked
runway caused this crash,

disaster could
strike again soon.

The pressure is on to figure out

exactly what happened
to flight 3054.

I knew that there was a video

from the surveillance system.

That's the time of the accident.
That must be it.

The airport surveillance system

captured the doomed Airbus
speeding down the runway.

This video could solve
a lot of issues.

Let's see it again, please.

But the crash was outside

the range of the cameras.

Can we look at this
from a different angle?

Even without the crash on tape,

the video could hold
important clues.

Do you have tape
of other A320s landing?

Okay, go ahead
and play it now.

We compared these timeframes

from one aircraft to another.

Nine seconds.

A regular landing,

the aircraft would take
something about nine seconds

to pass over this camera.

Okay, now
the crash plane, please.

And the accident aircraft
took three seconds.

Three seconds?

That puzzled us a little bit.

Why was the crash plane
going three times faster

than the regular A320 landing?

Four hours after the accident,

firefighters are still battling
the intense blaze.

The fire was a strong fire,

with a lot of fuel
to keep it burning.

Camargo is desperate

to gain access to
the tail section,

which contains
the two black boxes.

They concentrated
the fight in the rear

of the aircraft.

Finally, firefighters
beat back the flames enough

to get at the recorders.

But it may be too late.

They can be submitted to fire

until a certain temperature.

After that there's no guarantee

that data will be preserved.

The recorders
will be sent to Washington

to be examined at the national
transportation safety board.

Now investigators can focus

on the infamous runway 35-L.

They examine
the surface for clues

that might explain why 3054
went so badly out of control.

We walked through the runway,

searching for evidence,
marks of the aircraft,

the point where it
veered off the runway.

It's still wet!

The water is pooling,
creating puddles.

That shouldn't happen
on a modern runway.

When this water gets in contact

with the landing gear,
the tires,

it can generate
what we call hydroplaning,

and this is a problem

because a pilot will have little
or no control of his aircraft.

Camargo and his team wonder

why water is pooling
on the runway.

They study files

from the government agency
that runs Congonhas Airport.

They learn that runway 35-L
had been completely resurfaced

just one month
before the accident.

In 2007,

the runway at Congonhas
underwent repairs.

It had been offering
a very low level of traction.

There were many reports
of skids.

For years,
pilots had been complaining

about the slippery conditions.

They knew that the pavement

needed to be reconstructed...

Because the surface allowed

the water to accumulate.

35-L. 35-L.

The runway had been resurfaced.

That should have solved
the water problem.

It reopened
just weeks before the crash.

The new surface seemed to be
a major improvement.

The airport
operated for about a month

in dry weather,
with no problems.

But then,
three days before the crash,

heavy rains began.

And with the rain,

older problems
that were supposed to be solved

came back.

On the night of the accident,

the biggest problem
was still the water.

Aircraft were still reporting
difficulties braking.

The runway's wet,
and it's slippery.

In theory,

there was no more depressions
on the runway

to accumulate water.

So what could cause water
to accumulate?

He discovers
that the repair work

lacked a critical
safety feature.

"Grooving to be done
at a later date."

no wonder it was wet.

Special grooves
that carry away rainwater.

Without them,
rain would collect in puddles.

The repairs still lacked

the necessary upgrade.

It was very difficult

to interrupt the operation
of the main runway

in order to install the grooves.

Evidence is mounting

that a compromised surface
on runway 35-L

played a key role in Brazil's
worst airline accident.

Colonel Camargo is concerned
that Brazil's notorious rains

may bring more runway disasters.

Soon after the accident,

we recommended the suspension
of the operations

of regular aircraft
in rainy conditions.

The airport authority complies,

shutting down runway 35-L
until answers are found.

But the main runway at one
of the world's busiest airports

can't stay closed for long.

They must find out
what caused this accident

as soon as possible.

Their focus turns to the A320's
thrust reversers.

The plane's maintenance records

reveal why only one of them
was working.

Four days before the crash,

mechanics deactivated the right
engine's thrust reverser

for routine maintenance.

But the aircraft had then flown
without incident for four days.

"No action required"?

Not only had
the plane landed repeatedly

with one thrust reverser...

It had even landed safely
on runway 35-L.

This plane landed
on the same runway,

on the same runway that day,
with the same problems,

had only one thrust reverser,

just one thrust reverser.

No issues whatsoever.

So why had this
landing gone so wrong?

Colonel Fernando Camargo

travels to Washington, D.C.

Technicians at the National
Transportation Safety Board

will help him
try to recover data

stored in flight 3054's
badly burned flight recorders.

First, they look for
a temperature-sensitive chip

that could provide a clue

as to how bad
the heat damage might be.

There is an indicator
that turns the color

if it was exposed

to a temperature

above that one that it was

manufactured to support.

Even though
the boxes are designed

to survive a fierce fire of
up to 1,800 degrees Fahrenheit,

the chip's appearance
is worrying news.

These boards were submitted

to a fire that exceeded
its limitation.

They test the circuit board

to see if any
of the memory survived.

Without the data,

the investigation
into flight 3054

would be effectively crippled.

Colonel Camargo may never know
why 199 people died

at Brazil's busiest airport.

But the circuit board test
provides some hope.

Okay, we got something.

Fortunately,
everything works okay.

We could recover
100% of the data.

Here we go.

The information paints

a picture of the plane's
performance...

The speed is fine...

...in the critical
seconds before the crash.

They came down fine.

Brakes were engaged.
The brakes were engaged.

The data confirms

that the foot brakes
were working properly

and that the A320
did not skid or slide.

Here.

Then Camargo discovers

that the plane's two engines

were inexplicably operating
against each other.

The plane's left engine
was in reverse

to help slow the aircraft down.

But the right engine,

the one with
the disabled thrust reverser,

was doing the opposite.

It's powering up
for takeoff.

It's supposed to be idling.

Instead of winding down,

it was accelerating
to climb power.

-Decelerate!
-It can't!

- Decelerate!
-It can't!

With one engine
at full power,

the pilots didn't have a chance
to stop their aircraft in time.

This aircraft was braking.

But it would take
around one more kilometer

for it to stop.

The lopsided thrust pushed

the plane to the left.

The right engine really

was increasing thrust.

There was no means available

for the pilot
to avoid the aircraft

to veer off to the left.

So engine two
was thrusting

when it should have
been idling.

That would explain
the veer-off to the left, right?

So what does this mean?

Now colonel Camargo
needs to figure out

why the right engine
was at full power

when it should have been
in reverse.

At that time,
we could establish, roughly,

two main lines
of investigation:

One, mechanical failure;

and the other one...

Pilot error.

Colonel Camargo

brings in
human factors investigators

Lieutenant Colonel Marcia Fajer

and First Lieutenant
Vanessa Dias.

The pilot is
Henrique Stephanini di Sacco,

age 53, from Sao Paulo.

13,654 flight hours.

The pilot who was in command

was a very experienced pilot.

He knew the aircraft very well.

His first officer
was Aguiar Kleyber Lima,

age 54, from Porto Velho.

14,760 flight hours.

He had enough
training to do a good job,

including
in an emergency situation.

Their job is to determine

if the crew
somehow made an error

that could have
caused one engine

to stay at full power.

Machines are straightforward

because they work
in predictable ways.

Humans are infinitely
more complex

in the way they think and act.

It's much harder to analyze
their behavior in an accident.

You know, but I just...
I can't believe

that this pilot would make
that kind of mistake.

Okay.

The human factors team

must now conduct a psychological
study of the crew

to understand how they might
have committed a fatal misstep.

We attempted to reconstruct

the individual history
of each crew member

and their experience.

Ladies and gentlemen,

this is your captain speaking.

I have some good news for you.

And tried to create a picture

that could help us explain
what happened in the cockpit.

Colonel Camargo still believes

a mechanical failure
is more likely.

He now turns his attention
to the complicated mechanics

that link the thrust levers
to the engines.

He must determine
if a failure there

led to the mysterious
power surge.

We began studying
this thrust system,

each and every component
of the system,

from the lever to the engine.

We've been through it...

There's nothing wrong
with the engines.

That leaves only one component

that could have caused
the problem:

The mechanism that links
the throttles to the engines--

a device called
an artificial feel unit,

or AFU.

Investigators wonder
if that device failed,

leaving the engines
at full power

even though the pilots
set the lever to idle.

But such a failure
is highly unlikely.

It's really
a remote possibility--

400 billion hours of flight

for us to have
one occurrence of that.

Still, he needs
to rule out the AFU

as a possible cause
of the crash.

But he's not sure the unit
can even be found

amongst the wreckage.

Computers,
all the avionics...

Everything was gone.

Luckily,

one of the few pieces
to have survived the fire

is the piece
investigators now need:

The AFU.

It's sent to a specialized
laboratory

that can scan the metal
for microscopic markings.

It got melted in such a way

that you can work with it.

So we could check something.

The 3-D scanner

allows them to look
for nicks or scratches

that would indicate
the unit failed.

I'm looking for any...

Any unusual marks
in this area.

If we could find out any mark,
any evidence

of the position of this gear,

we could go after the lever

and find out the real position
of the thrust lever.

But they can find no evidence

that the AFU malfunctioned.

Ok, pack it up.
Let's go home.

We found nothing.

No mark. No evidence.

Colonel Camargo concludes

mechanical failure
was not to blame

for the improper power setting
on the right engine.

He has to assume
that for some reason

the crew left the right engine
lever at full power

after the Airbus landed.

Oh, my god!

Turn! Turn! Turn! Turn!

Back in Sao Paulo,

the human factors team turns
to the cockpit voice recorder,

or CVR.

They need to understand
the pilots' state of mind

as they approached Sao Paulo
the night of the crash.

The CVR
enables us to get an idea

of the interaction
between crew members.

They learn
that captain Stephanini

was quite concerned
about the runway conditions.

Ask them about the
rain, the runway conditions,

if the runway's slippery.

TAM on final approach.

Two miles away.

Could you confirm conditions?

It's wet,
and it's slippery, 3054.

Wet and slippery.

The pilot is already tense,

and then he finds out

that runway conditions
are worse than usual--

slippery and rainy.

The tension can affect
the pilot's perception,

his concentration.

35-L, 35-L.

It now appears that
Stephanini's anxiety about 35-L,

and not the runway itself,

was the main cause
of this crash.

Camargo now focuses
on the crew's actions.

I think it's ready, sir.

Thank you.

He needs to understand

how the power levers were
handled before the crash.

Using data
from the flight recorder,

investigators focus first

on the landing just prior
to the one at Congonhas.

We discover

that the same pilot,
the captain,

was the one
operating the aircraft

in the previous land
and in Congonhas.

First, how did they land
in Porto Alegre?

Okay.

Both levers full forward
during approach.

They learn

that during the previous landing
in Porto Alegre,

captain Stephanini pulled back
both thrust levers...

...exactly the right procedure

for landing
with only one reverser.

And now,
both levers to reverse.

At the time
of the accident,

the correct procedure

was for the pilot to take
both throttles to idle

and both throttles to reverse,

as if you had no problem
with the reversers.

They've established
that captain Stephanini

carried out
the correct procedure

for landing
with one thrust reverser

on the day of the crash.

No reverser number two.

Auto brakes on.

And speed is dropping.

It puzzled me

because of the fact

that the captain
knew the procedure.

He performed
the correct procedure

hours before
in the previous landing.

So what did he do differently

two and a half hours later
in Sao Paulo?

- Okay.
-Okay, now Congonhas.

Left lever to idle.

The data shows

that captain Stephanini's
handling of the thrust levers...

Then reverse.

...was very different
on his landing in Sao Paulo.

Instead of throttling back
both levers,

he only put the left engine
in idle,

leaving the right one
at full power.

Then, once the aircraft
had touched down,

he activated
only the left reverser,

again leaving
the right engine at full.

That is quite different.

I don't get it.

How could a guy
that knew the aircraft,

that knew the correct procedure,

that executed
a correct procedure,

how could he

do something different?

It doesn't seem to make sense...

We could really use
your help on this.

...until Camargo enlists

the help of another pilot.

It's only then that he discovers
an important detail

that could explain
what the captain did.

It turns out there was
an older, outdated procedure

for landing an A320
with a single thrust reverser.

Could you
demonstrate it for me, please?

It starts out the same,

but then there's
an important difference.

The former procedure

was taking

both levers to idle

and then just the lever
corresponding to the engine

with the reverser
operating normally--

that would be taken
to reverse position.

But that is not
what captain Stephanini did.

He left the right engine
at full power

instead of bringing it to idle.

If he was attempting
the old procedure,

he got it wrong.

Investigators learn
that captain Stephanini

would not have been
the first pilot

to make that mistake.

There had been several accidents
around the world.

The cause was identical:

Pilots mishandling the procedure

for landing
with a disabled reverser,

inadvertently leaving
one thrust lever at full power.

That old procedure

led pilots to error.

Airbus finally
modified the procedure

to reduce the risk
of precisely that error.

The manufacturer changed

the procedure and determined
that both levers

would come down together

to the idle position,

and then,
right after touching the ground,

both would come down
to the reverser position.

Captain Stephanini was familiar

with both the old
and the new procedure

for landing
with a disabled reverser.

Retard. Retard.

It now seems on flight 3054

he may have tried
to use the old one.

The question for investigators
is why?

Investigators
still can't understand

why the crew of flight 3054

left an engine at full power
after touching down.

Did they get it wrong?

But after
interviewing other pilots,

they do understand
why using the older procedure

would have made sense
that rainy day at Congonhas.

It would bring the plane
to a stop much more quickly

than the new one.

That could explain

why the captain would go

for a former procedure

that he knew was more efficient

than the current one.

Investigators
theorize that in reaction

to deteriorating conditions
at Congonhas...

Wet runway? One reverser?

I'm gonna buy us some runway
and use the old procedure.

He was trying to ensure

that he'd have
as much distance as possible

to stop on the notorious
runway 35-L.

But he made a costly error.

Under those circumstances...

Remember,
we only have one reverser...

One reverser...
Manual flight...

Wet and slippery...
One reverser...one reverser...

Manual flight.

It is completely understandable

that he had tried
a former procedure,

and, under such a pressure,

made a mistake.

Lieutenant Vanessa Dias

re-creates the final moments
of the flight

in a simulator.

Okay, engine one to idle.
Engine two stays at climb.

She notices
that in a dark cockpit,

it would have been difficult

to see the position
of the thrust levers.

20. Retard. Retard.

Engine one to reverse.
Don't touch number two.

Brakes.

Okay, so...wow.

In the simulator,

we were able to program in
every known factor:

The chronology of events,

whether it was
cloudy or raining,

the wet surface,
the slippery surface,

the position of the levers.

We also went off the runway

and had an accident
in the simulator.

Lieutenant Dias believes

she now understands why
TAM Airlines flight 3054

ended in tragedy.

Captain Stephanini had done
everything he could

to ensure the A320
would touch down on runway 35-L

with as much room ahead of him
as possible.

Land green.
Manual flight.

But the prospect of landing

on the treacherous runway
had so unnerved him

that he bungled
a simple procedure.

It's possible that tension

might block
a crucial motor response.

It can affect
the pilot's ability to react.

There was no alarm to warn them

that one engine was speeding up
while the other was in reverse.

First officer Lima tried to
figure out what was going wrong.

Decelerate.

But in a dark cockpit...

It can't.

Overwhelmed
by a landing going badly...

He didn't notice the abnormal
thrust lever settings.

Decelerate! Decelerate!

The pilots
were unable to understand

what was happening
to their aircraft.

Ah...look at this!

A runway
with a dangerous reputation

so unnerved a crew

that they made a mistake...

That ended up killing
199 people.

Oh, my god! Oh, my god!

Since the crash
of flight 3054,

the runways at Congonhas
have been grooved

and are regularly inspected.

New rules are in place dictating

wet-weather landing procedures.

In rainy weather,

you need to have
all of your reversers operating.

But despite these efforts

to improve safety at Congonhas,

many pilots
doubt it's any better.

Congonhas is not safer today.

It continues to be
a dangerous airport.

Only a total ban on operations
in wet or rainy conditions

would improve the safety
of this airport.

What's clear

is that even today,

35-L is a runway that cannot

shake its dangerous reputation.

35-L. 35-L.