Original subtitles

NARRATOR: A Russian passenger jet

crashes into the Volga River.

Rescuers are stunned to discover

that the plane was carrying some of the country's

most famous athletes.

I'm Galimov.

NARRATOR: The Lokomotiv Yaroslavl

hockey team is decimated.

Nearly the entire team is dead.

How can that happen to a team of

such young, talented, healthy guys

that had so much to offer?

NARRATOR: The president of Russia demands answers.

The Russian government was putting

pressure on the investigators trying to get results.

Why didn't they lift off?

NARRATOR: Investigators need to know--

Rotate.

NARRATOR: --why the jet struggled

to get off the ground.

That can be the moment, the split second when you might

have chosen life versus death.

Look what happened here.

NARRATOR: The reason is almost too simple to believe.

What are you doing?

Ladies and gentlemen, we are starting our approach.

We lost both engines.

Put the mask over your nose.

Emergency descent.

Brace for impact!

NARRATOR: September 7th, 2011.

A Yak-42 jet descends towards a Russian airport

on its way to pick up some very important passengers.

VICTOR ERMOLAEV: They were reliable, Soviet-built

airplanes that could land on shorter runways

and extend that airline service to smaller airports.

NARRATOR: This charter flight is operated

by Yak Service Airlines.

Only the crew is on board.

Flaps, 30.

NARRATOR: First Officer Igor Zhivelov

is the airline's vice president of flight operations.

In his nearly 30 years of flying,

he's racked up more than 13,000 hours in the air.

Flaps are 30.

NARRATOR: Beside him is Captain Andrei Solomentsev,

one of his closest friends.

NARRATOR: Flight engineer Vladimir Matyushin rounds out

the three-man cockpit crew.

Get down 3 green.

NARRATOR: Mechanic Alexander Sizov

flies with the plane to make sure it's in good working

order at all times.

VICTOR ERMOLAEV: It's important to get people

from A to B with, obviously, safe operation

and in good service.

In the charter world, maybe more so, because this is

the reputation of the company.

Will they call us again?

NARRATOR: The plane is just moments

from landing in Yaroslavl, a city

155 miles northeast of Moscow.

VICTOR ERMOLAEV: Touch down into Yaroslavl.

And it was a little bit rough touch down,

a bounced landing followed.

Whoa.

Little hairy there.

I must be nervous.

The president may be watching.

NARRATOR: Yaroslavl's airport is under tight security.

Some of Russia's top politicians

are attending an Economic Forum in town.

But it's not politicians who are preparing

to board the plane, it's another prestigious group

of passengers, the Lokomotiv Yaroslavl hockey team,

one of the most beloved sports teams in all of Russia.

MIKE FOUNTAIN: Their fans were fantastic.

They were loud in support of their team,

and they let you know when you were the opposing team.

NARRATOR: Mike Fountain is a former National

Hockey League goalie who was played

against Lokomotiv in Russia.

It created quite the atmosphere.

Whenever you went to that city, it was-- it's a hockey town.

They loved it.

VICTOR ERMOLAEV: Hockey is a religion in Russia.

People love hockey.

People love hockey players.

They are celebrities.

They are stars.

NARRATOR: Alexander Galimov off is

a right winger who has played for Lokomotiv

his entire career.

Born in Yaroslavl, he's a local hero.

Hey, coach.

This guy's like me on the forecheck.

NARRATOR: Canadian Brad McCrimmon

was an all-star NHL defenseman and assistant coach.

Now at age 52, he's looking forward

to his first regular season game

as a head coach in Russia.

For a coach like Brad McCrimmon with his record

of being an assistant coach with the Red Wings

and his playing career, for him to go over

to a team like Yaroslav with the passion those fans have,

I guarantee you, he was so excited to have

that opportunity to go and win that first game.

NARRATOR: Some of Russia's best players

are on this team, including team captain Ivan Tkachenko.

I had the opportunity to play against Ivan

Tkachenko for many years.

He was a fantastic hockey player.

And he is one of those guys that was always

in front of you in the game, always getting

an opportunity to score.

NARRATOR: In the pre-season, Lokomotiv

has been on a hot streak--

winning seven of nine pre-season games.

Fans believe this year, they have a very good shot

at winning the Gagarin Cup.

MIKE FOUNTAIN: They want you to win the championship that cup,

it's a big deal.

Hungry?

This year, we win it all.

Really?

Yeah.

NARRATOR: As a VP with the airline,

first officer Zhivelov has managed

to pull rank in order to fly with some of his heroes.

For this flight, captain Solomentsev

will take the controls while Zhivelov

handles the radio calls.

Is the call sign Tunoshna?

Yaroslavl.

Yaroslavl 42434 request engine start.

AIR TRAFFIC CONTROL: 42434 cleared to start.

NARRATOR: The crew starts the axe 3 engines.

Start number 3.

NARRATOR: And adjust the plane stabilizer for takeoff.

How much for you, 9?

Maybe 8, I think.

8 and 1/2.

Lops and slots in position.

NARRATOR: The flight is bound for Minsk,

two hours away in Belarus.

For the players, it's the first of many flights

they will have to make this season.

MIKE FOUNTAIN: The hockey players

are the same over in Russia as North America.

We've got the jokesters on the team.

You've got the guys that will maybe sit in the corner,

be a little more quiet.

You've got the guys that maybe went

out a little too much the night before

and has a story for you.

And it's kind of funny how that is an international thing.

Checking the flight's controls.

Start complete.

Thrust set.

NARRATOR: On September 7th, 2011,

just before 4:00 in the afternoon,

the plane starts down the runway.

Crew, we're taking off.

V1 is 190.

NARRATOR: The flight engineer watches the gauges.

It's his job to advise the captain when the plane

reaches takeoff speed.

The engine power should determine

just how fast you get.

And if it's done properly, and the flaps and slats are set

right, you will have the right lift generated by the speed

to get you off the ground safely,

as almost always happens.

Rotate.

The flight engineer called rotate,

and the captain displace the yoke to rotate the elevators

up to about 10 degrees.

This would have been sufficient for creating

that takeoff attitude and the airplane lifting off.

NARRATOR: But the plane stays on the ground.

VICTOR ERMOLAEV: Nothing happened.

The airplane did not react in any way

to the displacement of the yoke.

210.

Full power.

VICTOR ERMOLAEV: The captain calls for full power.

And again, nothing happens to the aircraft.

NARRATOR: Some of the passengers sense trouble.

MIKE FOUNTAIN: Planes in Russia are not

up to European and North American standards,

and it's a little bit scary for North

American and European players going over there.

NARRATOR: The runway is 3,280 yards long.

The crew must lift off before the 2,800 yard mark

or they won't be able to stop safely.

You probably set stabilizer too low.

Add some.

NARRATOR: Adjusting the stabilizer doesn't help.

What's happening?

You'll be fine.

NARRATOR: The plane has enough speed and should get airborne.

220.

NARRATOR: But instead of lifting off,

the Yak-42 keeps going past the end of the runway.

JAMES OBERG: Going off the runway at the end of a takeoff

roll is always dangerous-- full tank of gas,

people are still confused, you don't know how

far the clear spacing goes.

VICTOR ERMOLAEV: This is a nightmare for every pilot

because now they are plane is not flying,

and yet you're moving across the ground

at 142 miles an hour.

What are you doing?

NARRATOR: The crew struggles desperately to get

the plane of the ground.

Finally, they succeed.

The plane is airborne but not out of trouble.

Yak service flight 9633 isn't able to climb.

And the pilots lose control.

It crashes 500 yards from the end of the runway.

Local police patrolling the Volga

River are the first to reach the wreckage of the Yak-42.

Star player Alexander Galimov has survived the crash.

No, it's OK.

Help the others.

NARRATOR: Mechanic Alexander Sizov is also alive.

Over here.

Help!

Please!

NARRATOR: Rescuers are shocked to learn

the plane was carrying some of Russia's most famous athletes.

Thank you.

I'm Galimov.

NARRATOR: Twisted wreckage burns near the river's edge.

NARRATOR: Witness is record the horrific scene

minutes after impact.

Onlookers see no sign of more survivors

through the thick black smoke.

Dmitry Pushkov is a hospital pathologist

who rushes to the scene.

INTERPRETER: When we arrived at the crash site,

the ground was burned black.

Small pieces of wreckage and clothing fragments

were everywhere.

And in the middle of the field, the bodies of the dead hockey

players were stacked.

The smell of kerosene was very strong.

It tastes sweet.

I'll remember it forever.

NARRATOR: Within hours, Russian investigators

are also at the scene.

They must figure out what caused this accident.

Excuse me.

We'll be taking charge here now.

NARRATOR: James Oberg is an aviation consultant

and former NASA engineer.

The investigation team had a lot of experience,

sadly because there have been many accidents.

But that experience, as it turned out,

turned out to be critical to actually finding the cause

of this particular accident.

NARRATOR: Their first challenge is to secure the site.

Get these people out of here.

INTERPRETER: News of the tragedy

spread through the city, and fans, as well as

regular people, wanted to see.

Few could believe it.

So they wanted to see what happened and say

goodbye to the hockey players.

NARRATOR: Of the 45 people who boarded the flight,

43 are dead, including the pilots.

The Lokomotiv hockey team has been all but wiped out.

INTERPRETER: This was a tragedy for everyone in Yaroslavl.

Lots of people knew these guys, not just as hockey players

but personally.

That's why everybody took this loss very hard.

Hungry?

NARRATOR: Alexander Galimov and the mechanic Alexander Sizov

are the only two survivors.

They are both put into medically induced comas.

I knew that once I checked the players list,

I knew I would know players on that team, and it was-- it

was a, it was a tough feeling.

NARRATOR: The tragedy is felt around the world

and is among the worst in sports history.

I think the reaction across the world

was first of shock, disbelief.

You know, how can that happen to a team

of such young, talented, healthy, good family guys

that had so much to offer.

NARRATOR: In Moscow, fans are stunned

when a grim announcement interrupts

the Kontinental Hockey League season opening game.

MIKE FOUNTAIN: The president of the KHL

actually stopped a game that was in progress

after he heard about the accident, which

was a very touching move.

NARRATOR: More than 20 people saw the plane's

failed takeoff attempt.

So, what happened?

NARRATOR: Because the team is so well loved,

everyone wants answers.

Investigators focus in on a key question,

why couldn't the Yak-42 lift off the runway?

Three factors are essential for takeoff, first

is engine power.

You need enough thrust to reach takeoff speed.

Second is lift.

The wing flaps must be properly extended

to increase aerodynamic lift.

And finally, to achieve the proper angle, the plane's

horizontal stabilizer must be angled,

putting downward force on the tail and lifting the nose.

Investigators examined the wreckage,

trying to determine if the plane was properly

configured for takeoff.

Well, it looks like flaps were set at 20.

JAMES OBERG: On your way down the runway,

if your flaps and slats aren't set properly,

you may get too much drag.

It's a sweet spot of the settings,

and they have to be in that region.

If they are beyond that region, they

will not do what you want.

In fact, they'll do things you don't want.

NARRATOR: The flaps on the wing seem to be correctly

extended for takeoff.

On the tail, the horizontal stabilizer also appears

to be properly deflected.

It looks fine.

Everything appeared to be normal in terms of the lift.

NARRATOR: Investigators find nothing

to suggest the engines were providing enough thrust to get

the plane of the ground.

JAMES OBERG: You would look at the settings of the engines,

the quality of the jet fuel.

And those are the things you would look at first,

and they did look at them first.

NARRATOR: But the team can't confirm

proper engine performance until they have

the flight data recorder--

one of two black boxes that records flight details.

But they've been submerged in the Volga River,

and before they can be analyzed,

they must be slowly and carefully dried out.

OK, take them to Moscow immediately.

NARRATOR: As investigators try to determine

what caused the crash, they have another big question--

why didn't pilots stop at the first sign of trouble?

The question then is, what decisions

should the crew have made?

When would they have known enough to choose

to abort the takeoff?

NARRATOR: Meanwhile, a day after one

of his nation's worst tragedies,

Russian President Dmitry Medvedev

visits the crash site.

VICTOR ERMOLAEV: It was high profile because,

obviously, very famous club.

And any loss of life is tragic, in aviation especially.

And as I mentioned before, hockey is a main sport

in Russia, if you will.

And if you talk to Russian people, they would tell you,

we lost we lost part of a family.

NARRATOR: 2011 had already been a dismal year

for Russian aviation--

the Yaroslavl accident was the country's eighth fatal crash.

Less than three months earlier, 47 people died near an airport

403 miles north of Moscow.

RusAir flight 9605 slammed into a highway

while coming in for a landing late at night.

The Yaroslavl disaster has drawn critical attention

from around the world.

NARRATOR: President Medvedev announces

that radical changes are needed in Russian aviation.

The pressure on the team to investigate this and find

the correct answer to it is always high,

but when the president of the country

comes out and says you're going to do it right

because the country needs an answer,

I'm sure they felt the whole weight of their whole country

and of the families of all the victims looming over them.

We need to work faster.

NARRATOR: Investigators desperately

need to know what happened during the final moments

of flight 9633.

They catch a break when they learn that an airport security

camera off the end of the runway

recorded the Yak-42 as it finally lifted off.

The grainy image could provide a crucial lead.

Whoa.

Whoa.

Can you play that again?

NARRATOR: The video shows that the plane was properly

configured for takeoff.

But beyond that, it holds no new information,

no clue as to what went wrong.

OK, they started here.

They lift it off here.

NARRATOR: The airport runway wasn't the issue.

They had plenty of room to take off.

They had about 2,800 plus meters of runway available.

That's more than twice the distance they should need.

NARRATOR: Something kept the plane on the ground.

The question is, what.

They suspect the plane might simply have been too heavy.

JAMES OBERG: Aside from being harder to get in the air

if you weigh more, anything that weighs more

is going to be harder to accelerate.

NARRATOR: It's a lesson that was

learned nearly nine years earlier

in Charlotte, North Carolina.

All 21 people aboard a commuter plane

died when it crashed and burst into flames less

than a minute after takeoff.

The plane was 579 pounds above the allowed maximum.

Weight was also considered a key factor in the US Army's

deadliest peacetime crash.

On Arrow Air Flight 1285, the weight

of 248 soldiers equipped with heavy gear was underestimated.

Their DC-8 fell from the sky 2,900

feet beyond the end of the runway

in Gander, Newfoundland.

Everyone on board was killed.

If the weight is underestimated or not

calculated at all, you don't-- you just don't have

that clear picture of what exactly

to expect from the airplane.

They didn't know their weight.

NARRATOR: Concerns mount when investigators learned

that Yak's service didn't have baggage

scales at Yaroslavl's airport.

VICTOR ERMOLAEV: There was no way

to weigh the gear, the luggage, and the cargo that would

be loaded in the airplane.

So it was estimated.

NARRATOR: Investigators estimate

the weight of the team and their hockey gear.

Ultimately, they find the plane was not overloaded.

The weight is under the limit.

NARRATOR: It may not be the answer,

but it provides an important clue.

It does not appear that was a contributing

issue in this case, but it shows that the crew was not

properly preparing the information they would

need during the takeoff roll.

NARRATOR: Next, investigators focus on the plane's

speed in the engines.

They determine the speed needed for takeoff

was 133 miles per hour or 215 kilometers per hour.

Didn't they ever get to 215?

NARRATOR: If the engines weren't working properly,

it could explain the disaster.

It's very fortunate that the flight data recorders were

both recovered and functional, and that

isn't a universal factor in modern Russian aviation.

NARRATOR: The speed question is resolved when investigators

check the FDR data.

They find that the engines had powered the plane

well beyond takeoff speed.

Engines are working.

NARRATOR: Investigators are baffled.

They can find no reason for the failed takeoff.

And why didn't they lift off?

The airplane should fly.

The plane wants to fly.

In fact, at 210 kilometers per hour

with the stabilizers set at 7 degrees,

the Yak-42 will rotate on its own.

NARRATOR: On September 10th, 2011,

Russian prime minister Vladimir Putin

attends a memorial for the Lokomotiv players,

along with 40,000 grieving fans.

Two days later, Alexander Galimov,

the only team member to survive the crash,

dies from his injuries.

The Yaroslavl tragedy has now claimed 44 lives.

As the nation mourns their young athletes,

all eyes are on the air crash investigation team.

The Russian government was putting pressure

on the investigators trying to get results,

to get to the truth, what exactly was happening.

NARRATOR: Investigators scour the flight data

recording, again, for clues.

Finally, they spot something unusual.

Look at the acceleration.

NARRATOR: Despite full power from the engines,

the Yak-42 did not accelerate as quickly as it should.

During the takeoff roll when the aircraft should

be continuously accelerating, it was actually slowing down

toward the end of the roll.

And slowing down is a bizarre, unusual, and potentially

fatal development.

NARRATOR: A strange deceleration.

It could finally be the lead investigators

need to explain the crash to their grieving country.

The team pores over the possible cause

of the Russian plane's deceleration.

Suddenly, an idea.

Could the brakes be on?

Crew, we're taking off.

NARRATOR: It's a bizarre possibility

but could explain the plane's unusual behavior.

Something was breaking the aircraft

at a time when everything else was trying to speed it up.

NARRATOR: To test their theory, investigators

head to the Gromov flight Research

Institute near Moscow.

The length of the runway at Gromov

is probably around 5,000 meters or so.

It's very long.

It is suited for test flying.

NARRATOR: A test pilot will recreate the flight exactly

using data from the FDR.

First, they tried the flight with no brakes applied.

We have rotation speed.

NARRATOR: The test plane lifts off easily using just

a quarter of the long runway.

Then they try the flight again.

This time put the brake on.

They gradually applied the wheel brakes

to slow the aircraft down as you

are attempting to take off.

NARRATOR: With the brakes on, the plane still

has enough power to take off, but the distance

needed to reach takeoff speed more than doubles.

JAMES OBERG: What the flight test indicated

was that the four sets of brakes in the landing gear

were activated and were actively

slowing down the aircraft as it's rolling down the runway.

NARRATOR: The test flight evidence

is compelling it now seems almost

certain that the Yak-42 powered down

the runway with its brakes on.

Rotate.

NARRATOR: The puzzling question is why.

A bizarre situation.

And explaining it was a real challenge.

NARRATOR: Investigators listened to the cockpit voice

recording from flight 9633.

OK, go ahead.

NARRATOR: They hope the crew's conversation can help explain

how and why the plane's brakes were activated during takeoff.

Brakes.

Check on the left, functional.

Check on the left, functional.

NARRATOR: They hear the crew check

the brakes before takeoff.

The brake test was fine.

NARRATOR: It appears that the crew

had no concerns about their brakes

at the start of the flight.

Investigators now wonder if the braking system malfunctioned

and activated the brakes in error after the plane

began to move.

From the media coverage, we know that there were problems

with the braking system.

It's definitely a possibility.

NARRATOR: Digging into the history of brake malfunction

on the Yak-42, the investigative team

makes a disturbing find.

There have been at least five previous incidents

involving faulty brakes.

But things got really, really south

after the collapse of the Soviet Union,

and a lot of safety measures and normal training

and talented people all went by the wayside.

NARRATOR: To better understand what went wrong

with the brakes, investigators send the wheel

assemblies out for testing.

While they wait for results, they

shift their focus to another unanswered question--

Why they keep trying to get in the air long after?

In hindsight, it was clear they should not have.

NARRATOR: Perhaps the cockpit recording

will explain the crew's decision to continue

their troubled takeoff.

Full power.

NARRATOR: Investigators listen for the captain

to announce their abort speed, also known as V1.

Once the airplane approaches a V1 speed,

a captain of the aircraft needs to make

a decision to either continue takeoff or abort takeoff.

NARRATOR: But as they approach the critical speed.

Crew, we're taking off.

V1 is 119.

NARRATOR: The recording reveals a disturbing exchange.

We need 200 for V1.

No, Vr is 200.

We hear the captain announcing 190 kilometers

per hour as a V1 speed, and he's corrected

by the flight engineer.

NARRATOR: No air crew should be debating critical speeds

during a takeoff run.

They didn't know the abort speed.

NARRATOR: The abort speed should

have been determined before the plane even started to move.

OK, let me hear the briefing.

VICTOR ERMOLAEV: The departure briefing is very

important part of the flight.

It is done and conducted by the captain.

It has to be recorded on the cockpit voice recorder.

The heading 300.

Transition altitude is 700 meters take--

NARRATOR: A captain typically informs

his crew of the proper abort speed in a briefing

before takeoff.

Prior to reaching we

will the takeoff.

VICTOR ERMOLAEV: When he comes down to the V1 speed,

it's impossible to distinguish what exactly he's saying.

NARRATOR: Investigators suspect the crew did

not hear a V1 speed either.

Prior to reaching a speed of ..

NARRATOR: The three men never agreed

on the speed at which they could no

longer safely abort takeoff.

If you don't have your pre-planned criteria set up,

like the V speed, like other factors in the aircraft,

you don't have a one measurable gate

that can tell you at this point that you're good or not good.

Rotate.

Had they rejected takeoff 3 to 5 seconds

after attempting to rotate, they

would have still stopped in the clear way,

and everybody would have just walked away.

NARRATOR: Instead, they tried to troubleshoot the problem--

You probably set the stabilizer to low.

Add some.

NARRATOR: --until they run out of runway.

Calculations show that from the time

the pilots first attempted to lift off,

they had five seconds to decide whether to stop.

They had time to stop.

They allowed themselves to get to the point

where they no longer wanted to abort

and would rather have continued on, which they did.

VICTOR ERMOLAEV: In the cockpit,

there was a feel that the airplane

is going to get airborne any second now, any second.

A little bit more, a little bit more

speed, a little more speed and we're going to lift off.

NARRATOR: Investigators conclude

that continuing the takeoff was a fatal error by the crew.

They can only speculate why they did.

Perhaps the pilots felt pressure

to get their prestigious passengers

to their destination on time.

VICTOR ERMOLAEV: The crew, of course,

was trying to do their best and preform

this mission-- take them for their opening

game of the season.

If you have a maintenance delay,

doesn't quite look good.

And your company, will they call you again?

I don't know, maybe not.

NARRATOR: Meanwhile, results from the brake system analysis

are in.

There's no evidence of mechanical failure.

The brakes were fine.

They calculated that having them actually

fail independently, accidentally, all together,

the odds were literally a billion to one,

which will never happen.

NARRATOR: The finding moves the investigation closer

to a disturbing conclusion--

one of the pilots must have applied the brakes himself.

We need to take a closer look at the crew.

NARRATOR: Investigators are in a tough position.

The public will not want to hear that the crew

could have been at fault.

JAMES OBERG: There is a very common cultural thread

in Russia of blaming the people present for something

that goes wrong.

It helps to insulate those who put them there

or those decisions put them there, keeps them blameless.

NARRATOR: The Russian flight crew had a solid reputation.

It would be hard for people to believe one of them

accidentally hit the brakes.

Many eyebrows got raised within the Russian

airline industry.

We know that the first officer was very distinguished pilot,

and he had almost 13,000 hours as a first officer

and a captain.

NARRATOR: A review of the crew's flight records offers

up a clue--

both pilots routinely trained on

and flew two different versions of the Yak plane.

The Yak-40 is a much older regional jet that

carries up to 32 passengers.

The larger Yak-42, which the hockey team was on,

debuted in 1980.

With more powerful turbofan engines,

it can carry three times as many passengers

and fly longer routes.

Both pilots were more experienced

on the older Yak-40, but they also regularly

flew the newer Yak-42.

At most airlines, pilots are not allowed to switch from one

type of plane to another.

It is improper and incorrect to train a pilot to fly two

airplanes at the same time.

NARRATOR: It's beginning to look like the crew's habit

of flying two different but similar planes may have led

to confusion in the cockpit.

Focusing in on the brake pedals,

investigators spot a small but potentially

significant difference.

I want to see those pedals.

NARRATOR: On the older Yak-40, a pilot

rests his foot on the brake.

On the newer Yak-42, he must put his heel on the floor.

JAMES OBERG: They are flying back and forth these two

different kinds of aircraft which happened

to have different ways of putting

their feet on the brake pedal.

And that was when the a-ha started to appear.

NARRATOR: A pilot accustomed to flying the older Yak might

have placed his whole foot on the pedal, and as a result,

could have activated the brakes.

If you rest your feet on the Yak-42 pedals just like you

would in Yak-40, it is possible to create

a pressure on the top part of the pedal

and activate the wheel brakes.

It is possible.

NARRATOR: It's a promising theory, but questions remain.

Investigators can't understand why a pilot wouldn't

notice his mistake right away.

You would have to put about 10, 15, 20 pounds of pressure

onto the pedals, and that is a significant weight.

You would think a person would feel that.

NARRATOR: They find a clue in the crew's medical records.

First officer Igor Zhivelov had secretly been

treated for a nerve condition.

He should not have been certified to fly.

VICTOR ERMOLAEV: The first officer

had a neurological condition where the extremities

sort of lose sensitivity.

He was losing the sensations in his legs.

It was a medical development.

It was a slow development.

It didn't make him fall down, but it

made him less aware of feedback from feelings in his feet.

VICTOR ERMOLAEV: So the argument

was made that the first officer could

have been pressing on the brake pedals

without even realizing it.

Look.

Look what happened here.

NARRATOR: Then, investigators make

another startling discovery.

Full power.

NARRATOR: The brakes didn't just slow the plane down,

they also prevented lift off.

It's going to pitch you down because you

are being pushed by engines that are above the brakes.

It's going to give the aircraft a nose down pitch.

NARRATOR: By engaging the brakes

and the rotating wheels, the crew was actually

forcing the nose down.

The effect was like glue, sticking

the plane to the runway.

You probably set stabilizer too low.

Add some.

NARRATOR: The combined errors meant the plane was doomed--

Full power.

NARRATOR: --as soon as it was airborne.

At that point, the braking force of contact of the tires

with the runway now stops.

And all the other forces that you've

been putting into the aircraft-- pulling back

on the yoke, elevator trim, flaps just to get the nose up,

they are now no longer counteracted by the nose

down force of the braking.

The aircraft immediately goes into to nose up,

a high pitch rate, 20 degrees up in about two seconds.

And you can't stay in the air.

NARRATOR: The sudden nose up attitude

causes the wings to quickly lose lift.

Drag increases.

The speed drops.

The plane goes into a stall.

And you're just a big hunk of metal, and fuel, and flesh

just falling through the air.

NARRATOR: Digging further into the pilot's records,

investigators make another astonishing discovery.

Oh, whoa.

So he didn't complete the training?

JAMES OBERG: In the training reports of the two pilots,

it was discovered that, in many cases,

they had been certified as having accomplished certain

flight tasks and flight challenges

such as poor visibility, bad weather flying,

when they hadn't.

When the captain went through training,

then it was sort of put on hold,

and then went through training again,

and then switched employers.

But the training was done inconsistently

with breaks in between.

Some of the training documentation

for the first officer was not even available.

How much for you

Maybe 8 I think.

8.5?

NARRATOR: The crew while highly experienced

lacked the correct training to fly the Yak-42.

The federal air transport agency

immediately suspends the operating license

of Yak Service Airlines.

The fleet was grounded, and Yak Service, as a company,

was closed.

It was the people who had set up that disaster by not

properly training them, by not properly assigning them,

and by a whole series of regulatory failures

and procedural failures that set up this accident.

NARRATOR: There is one last thing

investigators want to examine.

The flight recorders reveal a puzzling exchange

between the captain and first officer just seconds

before impact.

What are you doing?

Full power!

NARRATOR: The team pores over this exchange,

trying to make sense of it.

What you're doing?

Full power!

NARRATOR: They know from the flight data there was

a momentary drop in engine thrust,

along with a brief deflection in the elevators.

Investigators synchronize the data

with the cockpit recording, and a tragic picture emerges.

After rolling off the runway, the captain moves his controls

to abort the takeoff.

The flight engineer follows his lead

and decreases engine power.

The flight engineer thinks they have aborted,

they are going to abort.

He sees a clue from the action of the pilot on the yoke

and puts the engines to neutral, actually

powers down the engines.

What are you doing?

NARRATOR: But the first officer disagrees, and the captain

reverses his decision.

Full power!

NARRATOR: He orders the engineer

to put the engines back at full power and tries to take off.

Running a safe cockpit requires there

to be a distinct chain of command,

and the captain is in charge.

But the problem with Yak Services

was that the first officer was actually, bureaucratically,

his boss because he was the director of flight services.

It was their last chance.

JAMES OBERG: Even a momentary hesitation

as to who's in charge and whose word goes,

that, in a case like this, can be the moment,

the split second when you might have chosen life versus death.

NARRATOR: Two months after the crash,

investigators release an initial report

outlining the causes.

The pilot's inadvertent braking is listed

as a main factor in the crash.

But the real blame, as the accident investigation came

to conclusion properly in my mind,

was that the people who put the crew in that position

were the ones to blame.

NARRATOR: The charter airline Yak Service

is also severely criticized.

The crew is doing things that you could have predicted

in advance they would have done,

and they were not doing things you could have predicted they

wouldn't have done because of the nature of the crew

training, their background, their experience, everything

that you could expect the pilot to do under those conditions.

NARRATOR: The sole survivor of the crash,

mechanic Alexander Sizov, requires ongoing treatment.

He no longer flies.

After suffering one of the worst tragedies in sports

history, Lokomotiv Yaroslavl cancels

their entire 2011 season.

The beauty of the Russian hockey system, I would say,

is that they do have a great feeder

program with those younger kids coming up.

They have a team called Yaroslavl Two

that is the next generation that would

be ready to make the step.

NARRATOR: The next year, the team

makes a triumphant return.

Once again, the city of Yaroslavl

has hopes of winning the cup.

The Lokomotiv fans would also come

to understand the true character of their late team

captain, Ivan Tkachenko.

For years, Ivan had been anonymously

donating millions of rubles to seriously ill children.

Minutes before takeoff, he made his last donation to

a 16-year-old cancer patient.

For some, there's hope that the Yaroslavl disaster will lead

to safer air travel in Russia.

MIKE FOUNTAIN: Through my years of playing there,

plane crashes were just, oh, Mike, it's Russia.

That was the attitude of the players I played

with in the organization.

It's just Russia.

And hopefully, unfortunately, a tragedy like this

can hopefully maybe wake some people up.

There is a push from the government

to clean up the industry from the small operators that

are not quite being controlled, if you will, or inspected

properly on a regular basis.

NARRATOR: The crash of flight 9633

shed a harsh light on commercial aviation in Russia.

Many believe that what's required now

is a strong effort to maintain a culture of safety

throughout the nation's aviation industry.

JAMES OBERG: There's hope we can establish control,

but it requires constant vigilance.

That's not something that procedures can fix.

Only a cultural change can fix it.

And getting it, getting that cultural change

is devilishly difficult. But if you don't do it,

then you pay--

you pay a devil's ransom.