Original subtitles

Laredo International Airport, Texas.

Continental Express is such a watershed moment

for accident investigation.

Outside looks good.

Okay. I've done the cockpit scans.

We're set for the before-start checklist.

Continental Express flight 2574.

It happened extremely fast.

The force was so violent.

The plane was unflyable.

Oh, my god. Look.

I was a little bit scared when I first saw the wreckage.

I told them that I thought it was bomb went off.

Kaboom!

The wreckage will tell a chilling story...

If they had strictly followed those procedures,

this accident should not have happened.

...of good intentions gone terribly wrong.

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!

Jetlink 2574.

They're going to bring everybody in on 26 or 27.

Okie-dokie.

Autopilot off.

Continental Express flight 2574

and its 11 passengers nears the end of its one-hour flight

from Laredo to Houston, Texas.

It's the second flight of the day for this crew.

They have already flown from Houston to Laredo.

Now they're on their way back.

15,000 feet below, it's a warm late summer morning

on the farms and cattle ranches of southern Texas.

Captured on the right.

The pilots prepare the Embraer 120 Brasilia

for another routine landing.

Captain Brad Patridge is just 29 years old.

43-year-old first officer Clint Rodosovich is very close

to becoming a captain himself.

They are less than 70 miles from Houston,

home for both pilots.

Pushing this descent.

Making like the space shuttle.

High speed. High speed.

In the blink of an eye,

the plane is plummeting towards the ground.

It drops 2,000 feet in just a few seconds.

Stall.

Far below, Cary Labay and his brother Clifton

are working on their farm.

My brother and I heard an explosion.

We both looked up in the air and it was, "oh, my god. Look."

Seen the plane coming out of the air.

The plane was spiraling.

Flight 2574 plummets to the ground

at more than 300 miles an hour.

Engine.

Autopilot.

autopilot, autopilot.

Unit one channel. Unit one channel.

When it hit the ground, there was a massive explosion.

My brother said, "let's go."

and I said, "man, I really don't think there's anything

I want to see there."

When I made the 911 call, they were asking for directions,

and I told them, I said,

"all you have to do is follow the smoke."

What we see on the ground is not recognizable

in any shape, form or fashion as having been an airplane.

Firefighters find the smoldering

wreckage of the aircraft

in the middle of a farmer's field

near Eagle Lake, Texas, just 68 miles west of Houston.

As we went there you--

if you wouldn't have knew it was an airplane,

you would have just thought it was a pile of trash,

it was burnt so far.

10 bodies were found inside the wreckage,

four outside.

All 14 people on board,

including Patridge and Rodosovich, are dead.

Accident investigators must now figure out

why lives were lost on a popular commuter flight.

Whenever one passenger dies

in a scheduled flight,

we launch an entire team, that's understood.

We have about 12 specialties that form the go-team.

And we have to be prepared to launch

on three to four hours notice.

Jim Ritter is an engineer

who specializes in airplane mechanics.

One of the key things that we do

in every accident investigation is we try to figure out

why did the airplane behave the way it did?

Was it normal performance, or was there a malfunction

that can explain what caused the accident?

I was a little bit scared when I first saw the wreckage.

The airplane was destroyed, and there wasn't a lot to go on.

Deepak Joshi is an expert

on the structure of the aircraft itself.

I went straight to the main wreckage,

where I found most of the airplane.

My first order of business

was to locate the four corners of the airplane.

The small plane was a Brazilian-made twin turboprop,

the Embraer 120.

Its size and speed have made it popular

with regional airlines in the U.S.

The Continental Express fleet includes 34 of the aircraft.

The first day when we got down there,

I led the group in terms of interviewing six witnesses.

And one of them reported that the airplane appeared to be

in a routine descent to the airport,

and as he watched it, he saw that there was an explosion.

There was an explosion.

I told him that I thought it was a bomb went off.

And it was spiraling as it went down.

When it hit the ground, there was a secondary explosion.

And kaboom!

The primary explosion's what caused us to go, "oh, my god."

I could see a hole in it.

It looked like it had a hole in it

about the size of a Volkswagen.

The eyewitnesses were unanimous

that the airplane was on fire before it reached the ground.

I seen this plane.

Saw the fire, just the outside wings, and going straight down.

The wing was blown completely off.

And it was just dangling there.

The eyewitness testimony is compelling.

An onboard explosion caused by a bomb

seems like a very real possibility.

Agents from the Federal Bureau of Investigation

are quickly on the scene looking for evidence of foul play.

The FAA said that they believe

that there had been a midair explosion,

and it went off, it went off the screen very rapidly.

The FBI had gotten a report

that someone had placed a bomb on the aircraft,

and they were being very careful

and making sure that there was no evidence of any kind of bomb

or criminal activity.

The NTSB has heard reports

of a federally protected witness

testifying in a Laredo drug trial

who was reportedly booked on the continental flight.

The suspect missed the flight after the trial ran late.

What I'm telling you is our investigators

have nothing on that.

I don't know how much more clear I can be on that.

The wreckage itself gives the investigators

an immediate clue about the crash.

I saw the cockpit was there.

The fuselage was there.

The left wing had folded under the right wing.

And a portion of the vertical stabilizer was there.

But the horizontal stabilizer was missing.

The Embraer 120 is what's called a T-tail airplane.

The horizontal stabilizer sits

on top of the vertical stabilizer.

And then I wondered, where could it be?

218 yards away, well back from the main wreckage,

Joshi finds the missing tail section.

Can someone help me get a bearing on this?

That made me believe that

there is definitely an in-flight breakup of an airplane.

All right.

A lot of the various pieces were scattered around,

so one of the key questions that we kept asking ourselves

was what happened first?

What initiated this event?

I'm guessing that tail came off at about 9,000 feet.

There's something there that,

something speaking to us in that evidence.

Deciphering the message won't be easy.

But as the story of flight 2574 unfolds,

investigators will uncover a shocking accident scenario

unlike anything seen before.

All 14 people aboard were killed,

among them the pilot, captain Brad Patridge of Kingwood.

NTSB investigators recover the black boxes

from the rear fuselage of Continental Express flight 2574.

The recorders are pivotal in our work.

It's really what gives us a window into what happened.

If we didn't have the flight data recorder,

or we don't have the cockpit voice recorder,

we don't have a lot of information to go on.

The black boxes will be rushed to Washington

for analysis.

Investigators focus next on the plane's severed tail.

There is a missing piece of the puzzle,

and it does not reach the main wreckage.

That's where the focus tends to go.

From its position 218 yards back

from the rest of the wreckage,

investigators can tell it was one of the first parts

to come off the plane.

They wonder if corrosion or metal fatigue

may have weakened the tail to the point of failure.

When a piece of metal bends back and forth over time,

it eventually snaps.

Called fatigue, that failure is identified

by a smooth, clean break.

We started to look at the fracture surfaces

of the vertical stabilizer.

But the edges of the tail section aren't smooth.

They're jagged.

In this particular accident,

we did not see any brown color, rust.

No corrosion. No fatigue.

The fracture surfaces clearly indicate

that the tail was ripped off suddenly.

In Washington,

NTSB technicians open the black boxes.

The cockpit voice recorder is

our single most important piece of evidence.

It records everything that's said, all sounds in the cockpit

for the last half hour before impact.

You can hear cockpit sounds that can be very helpful.

So you can hear what the engines are doing.

You can hear a whole bunch of things.

We do analysis on that.

But no voice recorder comes with a guarantee.

It's a complicated piece of electronics

hooked up to several microphones.

After slamming into the ground at more than 300 miles an hour,

there's a chance the recording may be damaged or lost.

In Texas, the FBI field unit finishes testing

remnants of the plane for any residue from explosives.

I think it was a bomb went off.

The results are conclusive.

There was no bomb on board flight 2574.

It became pretty obvious

that we had a structural reason for the accident

and not really a bomb or any kind of criminal event.

The fire and a midair explosion reported by witnesses

were likely caused when the wing broke off,

igniting the fuel inside.

Investigators discover that the tail section

did not fall off in one piece.

I noticed that the leading edge

on the left side horizontal stabilizer was missing.

This is very unusual.

Maybe a small section of the leading edge would be missing,

but not the whole, complete 10-foot section.

The leading edge on the right side

is still attached to the stabilizer,

but the one on the left is missing entirely.

So when did this piece break off?

A key question there is,

what was the first part that came off of the airplane?

Because, a lot of times,

the initiating event is going to be found in those early parts

that break from the airplane in an in-flight breakup.

It's now vitally important

for investigators to find the missing leading edge.

It's a piece of molded composite material three yards long.

Its rounded shape allows air to pass

smoothly over the stabilizer.

But the missing piece can't be found anywhere

near the crash site.

We really needed it,

and there was a growing frustration,

because we thought this part was critical.

Without it,

they don't have all the pieces of the aircraft.

More importantly, they're missing the piece

that most likely came off first.

That piece of evidence was very, very important

for this investigation.

And we made our best effort to find this leading edge.

The FAA asked us to assist in the search.

We walked our property.

I knew every bit of that property.

As searchers comb the area,

Jim Ritter receives a copy of the CVR data

from the lab in Washington.

The good news is the recording is intact.

The pilots' final moments have been clearly captured.

Radio check.

Ritter wants to see if

they discussed a developing crisis,

or perhaps were forced to make a sudden maneuver

to avoid an oncoming obstacle.

That the airplanes are flying within

6,000 to 8,000 feet,

you know, you might have some involvement of birds.

But the twin turboprop

was flying much higher,

well above any threat of a bird strike.

Radio check.

I can hear you loud and clear.

As you, also.

But the CVR is mostly filled

with the sound of controllers

giving the pilots routine instructions...

Jetlink 2574, say your heading.

050.

Jetlink 2574, roger.

Fly heading 030.

...and normal conversation between the pilots.

I've got a few days off coming up.

I'm gonna head down to the coast,

a little r-and-r, a little golf.

There are no hints of trouble on this flight

until the first officer pushes his plane into a rapid descent

towards Houston.

Pushing this descent.

Making like the space shuttle.

Well, the CVR showed us that the flight crew

was totally professional.

I mean, they were not doing anything

that they shouldn't have been doing.

Investigators listen for any other clues--

the sounds of objects being upset in the cockpit.

The engines suddenly screaming.

The blare of flight warning alarms.

Stall.

Stall, stall.

But there's no more conversation at all.

The recording tells investigators

that Patridge and Rodosovich had absolutely no advance warning

of their plane's sudden plunge.

The event happened extremely fast.

I don't think there was anything that the crew could have done.

An analysis of the flight data recorder

comes to the same conclusion.

We didn't see anything unusual

about the accident flight

until the very instant that we had the pitch down.

Until the plane went into a dive near top speed

and broke up, there was nothing abnormal about this flight.

The cause of the crash remains a mystery.

Finding the one missing piece of the tail

is now more important than ever.

We were doing marches through the area,

and after several days went by, it was difficult.

We had flights by the local volunteer groups

were flying over the site.

They're searching a four-square-mile area

for a three-yard-long composite piece.

Finding it is a long shot.

There was this growing theme

that we have to find that part.

And there was a frustration

that it was way more difficult than we thought.

We had engineers from the aircraft manufacturer

helping to tell us how heavy the parts were...

Do you have the weight of the piece?

...the dimensions of the parts, so that we could figure out

what drag levels we might see.

Ritter logs the coordinates of the crash site.

He studies the weather patterns from the day of the accident.

So I took that information, put it together,

and calculated where the leading edge radius should be.

Finally, he comes up with a possible location

for the missing piece.

I think it's somewhere in here.

Over the next couple of days, we went to that area,

and we laid out a grid to search for it.

We searched for it on, in the four-wheelers,

and in the helicopter.

On the third day of the search,

some good news.

We were flying over the Texas countryside,

Big Cattle Country, suddenly the pilot sitting next to me said,

"I think I see it."

The piece is in the area predicted,

but it's so well camouflaged,

it was nearly impossible to spot.

People had walked by it hundreds of times,

but it just happened to blend in with the cattle fence.

Hey, Jim, we found it, and it's just where you said it was.

Of course it is,

you just weren't looking hard enough.

We had spent several days all day long,

long days and nights calculating where to look,

and so I was elated when we finally found the part.

Now that the leading edge has been found,

investigators believe they finally have

all the pieces of the plane.

We were really excited, because it's important.

You want to do your best

to understand what happened in an accident.

And if you didn't have the key part,

there would always be questions.

Right away, they notice something unusual.

The evidence indicated that

the leading edge upper surface holes were absolutely clean.

No elongation. No damage.

But the holes that hold the piece

to the bottom of the stabilizer look quite different.

The lower surface holes onto the leading edge

were elongated.

They were cracked,

as if you have pulled it through the fasteners.

The missing piece was found

over 1,000 yards southwest of the tail section.

There is no question it was the first piece

to fall off the plane.

Look here, look here-- absolutely perfect on top,

but destroyed at the bottom.

The fact that the screw holes

on the top of the leading edge aren't damaged

presents a frightening prospect.

It looked like there was no screws

attached onto the top surface

of the horizontal stabilizer leading edge.

The discovery presents the team

with two important questions.

Why were the screws missing? And...

Could losing this

actually cause the plane to crash?

The leading edge improves the aerodynamics

of the plane.

But it's not a moving part that controls direction.

It's hard to see how losing it

would cause the plane to plummet from the sky.

At that time, I was kind of surprised

that losing a composite leading edge

would actually cause such a severe impact.

Now that all the pieces of the plane

have been found,

the investigation moves to NTSB headquarters in Washington, D.C.

Well, we were just trying to put

all the pieces of the puzzle together

and try to make sure that we understood

what the motion of the airplane was

after the leading edge radius broke off.

The horizontal stabilizer is

like an upside down wing.

It pushes the tail down while the wings lift it up.

Reducing the force on the stabilizer

lifts the tail and makes the flight unstable.

There were still questions about

maybe it would still be controllable.

And so we did an engineering simulation

to try to see if maybe there was a way

that the airplane could still fly

after it lost the leading edge.

But we found that it really was not a controllable situation.

After the leading edge radius broke off of the airplane,

it was a negative five-G pitch over.

Once the angle of attack exceeded the negative limits,

it actually broke the wing apart.

So it was not a survivable event.

The simulations are conclusive.

Losing just one leading edge along the horizontal stabilizer

will send the plane into a catastrophic nosedive...

...precisely what witnesses say happened to flight 2574.

If there is any component of the wing

that you don't want to lose, it's the leading edge.

The team now knows what triggered the crash--

the loss of the stabilizer's leading edge.

But what they still don't know

is why the part seems not to have been properly attached.

Examining the maintenance records for the aircraft,

Brenner makes a disturbing find.

A maintenance crew worked on the horizontal stabilizer

the night before the accident.

The evidence was mounting

that we really needed to look in-depth

at the maintenance procedures done the night before

and the maintenance area.

Continental Express is

one of the most popular carriers

in the United States.

The lives of thousands of passengers depend on

the entire fleet of aircraft being properly maintained.

Investigators urgently need to find out what went wrong

in the hours leading up to the crash.

NTSB investigator Malcolm Brenner

travels to Houston Intercontinental Airport

to talk with the maintenance crew

that worked on the plane the night before it crashed.

In general, we wanted to visit the facility,

to see what the facility looked like,

and then to go through specifically what had been done

the evening before.

Now, many times,

a lot of work happens on these overnight shifts,

and they have to get an airplane back out to fly the next day.

Terry von Thaden teaches aviation safety.

She uses flight 2574 as a case study.

So there's a push

to turn this aircraft around quickly.

Sometimes you can get the work done, sometimes you can't.

In preparation for winter,

Continental Express had been inspecting and repairing

the deice boots on its fleet of Embraer 120's.

The deice boot is a rubber bladder

that can be inflated by the pilots

to break up ice on the wings and tail.

We wanted to interview every mechanic, supervisor,

and inspection person who took part in that activity.

Brenner is particularly

interested in three employees.

Shift supervisor Adam Dillon...

Troy Anderson, an inspector responsible for checking

the work of the mechanics,

and the evening shift supervisor who started the job,

John Lepage.

Thanks for taking the time.

So what was the plan for the night?

We had about 10 hours to change both boots.

Replacing the boot involves

removing the leading edge, stripping the old boot off it,

and putting on a new one.

The entire piece gets screwed back

onto the horizontal stabilizer.

This is a big job to do all in one night.

It was scheduled to have these replaced

during the midnight shift.

Somehow the evening shift had some extra time

and decided they can help out get this airplane out,

so we'll get it started.

Grab what you need. I'll get the boots.

Watching over the work being done by the mechanics

is inspector Troy Anderson.

I had some time to lend a hand.

We went up to the stabilizer to start the job.

The mechanic started working on the bottom.

The inspector volunteered to climb up on top of the thing

and get the top ones.

The evening shift, the second shift of the day,

was going to remove the screws

holding the leading edge in place.

The rest of the work would be done by the midnight shift.

At 10:00 pm, Adam Dillon takes over

as supervisor for the midnight shift.

Hey-hey, finishing a AC-check,

engine maintenance, and a boot swap.

-Both sides? - Yup.

A shift change is such a crucial time,

because we're taking work that's halfway done,

and we have to be very, very specific

about what's been done

and what the other people are taking over.

When I came on to my shift,

I asked how far they got on the deice boots.

The mechanics find

that many of the screws are stripped.

Getting them out takes longer than expected.

I found out they were still trying to remove

the leading edge on the right side.

And it was looking like

they weren't going to get both sides done.

Then a crucial decision is made.

Have you started on the left side yet?

No.

The crew that started work on the deice boots

went home at 10:30.

There was no way we were going to get both sides done,

so I decided to just do the right side that night.

Investigators learn

that the supervisor of the midnight shift decided

there wasn't enough time to do both sides.

Guys, forget the left side for tonight,

and let's get this plane out of here.

So the guys, they spent most of their shift

replacing the right side boot.

A few hours later,

mechanics finished changing the deice boot

and reinstalled the right side leading edge.

So your mechanics didn't do any work at all

on the left side?

No. We didn't touch it.

After having changed just the right deice boot,

airplane 701 is rolled out to the gate

for the first flight of the day.

Three hours later, the left leading edge rips off the tail,

causing the aircraft to plummet

almost 12,000 feet to the ground.

Back in Washington,

NTSB investigators try to piece together

the information they've gathered so far.

...and Lepage.

The individual mechanics, the supervisors,

in general, I thought we had good cooperation.

They did describe what they were doing.

I think they, they were credible.

I believe they were trying to help.

Where was Anderson if he was helping?

We had about 10 hours...

No way we're going to get both sides done.

I had some time to lend a hand.

The second shift...

Investigators are almost certain

that the screws were removed

from the top of the left side leading edge and never replaced.

But maintenance workers insist

they only worked on the right side.

Investigators are puzzled.

So the second shift started the job.

These guys, they started on the right side.

Their inspector, he helped them.

It's always dangerous

when you change from one shift to another shift.

And that's why there are very strict procedures about that.

They were bypassing them.

The inspector jumped in to get this airplane moving.

That was all disturbing.

Did he ever say what he did up there?

Yeah, that's great, let me see that.

"Helped the mechanics remove the deice boots."

What does that mean?

Malcolm Brenner returns to Houston

to try to determine precisely what work inspector Anderson

performed on the doomed plane.

"Helped mechanics remove deice boots."

it's a very simple statement.

It's not specific as to what was taken off the aircraft,

what was done, where the maintenance stood

at that time of the shift turnover.

"Helped the mechanics remove the deice boots."

What did you do?

Well, it wasn't that busy,

so I offered to help the guys.

The inspector went up on the man lift

and started helping the mechanics.

That's not his job.

He said he wasn't too busy and they needed help.

They're going to turn this around.

It wasn't his role.

It wasn't a good idea.

So which side did you work on, Troy?

Just the right?

Both.

Look.

When I left, the plan was to do both sides.

For me, the most disturbing was the inspector.

He was up there,

and he was the one who actually took the screws off.

Part of the philosophy of maintenance

is that you have one group that does the work.

And then you have another group,

the best of the best, the cream of the cream,

who are then inspecting the work.

And their function is to sign off

and make sure that this work is being done properly.

He had a bag of 40 screws.

And he left the bag of 40 screws that he took out

on the man lift for the oncoming shift.

Have you started the left side yet?

No.

I spoke with the second shift supervisor.

We decided to skip the left side.

So he asked the supervisor,

"have you done any work on the left side?"

the supervisor looked up and said, "no.

No, not that I know of."

Guys, forget the left side for tonight,

and let's get this plane out of here.

No one on the midnight shift

knew that Anderson had started pulling screws

from the left side.

The work records weren't done.

And the procedures, even though they're in place

and should have worked, they weren't followed.

Did you give your mechanics the paperwork

to fill out on the job?

No.

Sometimes the paperwork takes longer than the job itself.

On a shift turnover,

that's one of the critical things that you have.

You have a written record that anyone can go back to.

It wasn't done.

None of the mechanics from the evening shift

filled in the cards that detailed the work they'd done

for the next shift.

Paperwork is never fun.

And then when you're describing something you've already done,

people don't necessarily want to do that.

I've already done it. I did it.

I don't necessarily want to go back

and write it down that I did it.

And we asked the supervisor why wasn't it done,

and he said, "well, it's a simple procedure,

and sometimes it's not worth doing.

If you take out a bunch of screws,

you wouldn't issue the work cards.

It's more trouble than to do it."

that was disturbing.

And inspector Troy Anderson was vague

about the work he did.

His write up didn't really describe

the fact that he took the screws out on the left.

He did not see his role as a mechanic

on that aircraft.

So I think perhaps he didn't take writing on those cards

as seriously as he should have,

because that was the mechanic's job to do that.

A failure in routine maintenance

caused the crash of flight 2574.

But there is still one lingering question.

Captured on the right.

The plane flew nearly 500 miles

before the leading edge tore off.

It is pretty amazing that the horizontal tail

stayed intact for that first flight.

The deadly failure came

near the end of the crew's second flight that day.

Pushing this descent.

Making like the space shuttle.

Why didn't it happen sooner?

Investigators pore over the recorded data from both flights.

They compare flight parameters like speed, heading, altitude,

in search of anything that might provide an answer.

It was a question of, you know,

how much the forces would have changed.

They zero in on the plane's airspeed during descent.

Just before its fatal dive,

flight 2574 hit a speed of 260 knots.

Though safe under normal conditions,

that's close to top speed

and 44 knots faster than the previous descent.

They conduct a study to confirm suspicions

that those 44 extra knots were enough to trigger disaster.

The leading edge stays on at 216 knots--

the plane's maximum speed during the first flight.

The aerodynamic forces never quite rose

to the level that they did on the accident flight.

But an increase of 44 knots drastically increases

the amount of drag on the leading edge.

Once the plane got up near its maximum speed,

it had this failure waiting to happen.

The tragic significance

of first officer Rodosovich's last words

is now clear to investigators.

Pushing this descent.

Making like the space shuttle.

His high-speed descent

sealed the fate of flight 2574.

The airplane broke apart

at the highest speed that it reached

since the maintenance was done the night before.

The aerodynamic forces were very high,

and so eventually they were enough

to bend the leading edge radius downward,

because it wasn't attached anymore

on the top of the horizontal tail.

And they bent it downward to the point where finally,

the oncoming air was powerful enough to break it off.

At 260 knots, the leading edge rips off.

When that part failed, the plane was unflyable.

High speed.

High speed.

I mean, the force was so violent.

Engine.

Engine.

On the cockpit voice recording,

the pilots don't say anything after it happens.

They were probably incapacitated.

It's that violent.

The massive negative G-force

would have instantly sent blood rushing to the brains

of the passengers and crew, rendering them unconscious.

One channel.

Unit one channel.

Unit one channel.

Unit one channel.

Unit one channel.

The NTSB blames the accident

on the failure to reinsert all the screws

holding the left leading edge to the tail.

My heart reached out to the people

that had worked on the airplane,

because I knew that this was a human error.

And whoever had been involved in that maintenance,

I'm sure was going to feel very badly about the situation.

The safety board also takes the unprecedented step

of faulting Continental Express for not making sure

all maintenance procedures were followed.

In particular, the failure to ensure

the mechanics and inspectors completed the proper paperwork.

Sometimes the paperwork takes longer

than the job itself.

This was a preventable accident.

If they had strictly followed those procedures,

this accident should not have happened.

The Continental Express accident

is such a watershed moment for accidents

and accident investigation in particular,

because it's one of the first times

that the culture of the organization was mentioned

in an accident investigation.

Never before has the NTSB cited

an airline's senior management

for allowing a climate where rules get bent.

Leadership needs to understand

their accountability in these accidents

and have more commitment towards the people on the line,

so that they can do their jobs properly and effectively.

As a result of the crash,

airlines now put much greater emphasis

on making sure all safety procedures are followed.

They use computerized systems

to more precisely track mechanics' work.

But better technology is only part of the solution.

One of the things we try

and get people on the front line to do is talk.

We try and encourage them to speak up,

that there are no stupid questions.

Every question is important.

This is a case where small deviations...

By many people...

Where cutting corners in small ways

that appear small to each person,

can accumulate to cause this horrible accident,

a horrible and preventable accident.