Original subtitles

Narrator: MORNING RUSH HOUR, CHARLOTTE, NORTH CAROLINA.

ITS BUSY AIRPORT IS ROCKED BY A MASSIVE EXPLOSION.

Man: THE FLAMES WERE COMING OVER THE FENCE, JUST TOTAL CRAZINESS,

EVERYBODY WAS JUST RUNNING FOR THEIR LIVES.

Narrator: FIREFIGHTERS RUSH TO ONE OF THE AIRPORT'S MAIN HANGARS.

THEY CONFRONT AN INFERNO.

Woman: IT WAS QUITE A WHILE

BEFORE WE REALIZED A PLANE HAD HIT THE HANGAR.

Narrator: A PACKED COMMUTER FLIGHT HAS PLUNGED TO THE GROUND

SHORTLY AFTER TAKEOFF.

EVERYONE ON BOARD IS KILLED.

Woman: WE KEPT SCRATCHING OUR HEAD WONDERING,

OKAY, THIS AIRPLANE FLEW NINE TIMES PREVIOUSLY,

AND WE HAD NO PROBLEMS.

Narrator: INVESTIGATORS UNCOVER A STRING OF ERRORS...

Woman: BILL, I HAVE AN IDEA.

Narrator: ...AND LEARN THAT PASSENGERS ON SMALL PLANES

HAVE ACTUALLY BEEN IN DANGER FOR YEARS.

Flight attendant: LADIES AND GENTLEMEN, WE ARE STARTING OUR APPROACH.

Pilot: WE LOST BOTH ENGINES!

Flight attendant: PUT THE MASK OVER YOUR NOSE.

EMERGENCY DESCENT.

Pilot: MAYDAY, MAYDAY.

Flight attendant: BRACE FOR IMPACT!

Controller: I THINK I LOST ONE.

Man: INVESTIGATION STARTING...

Man: HE'S GONNA CRASH!

Narrator: IT'S MORNING ON JANUARY 8, 2003,

IN CHARLOTTE, NORTH CAROLINA.

A CITY OF HALF A MILLION PEOPLE IS WAKING UP.

AT CHARLOTTE DOUGLAS INTERNATIONAL AIRPORT,

COMMERCIAL AIRLINE PILOT CAPTAIN KATIE LESLIE IS AT WORK EARLY.

ONLY 25 YEARS OLD, THIS TEXAS NATIVE

HAS BEEN FLYING FOR AIR MIDWEST FOR ALMOST THREE YEARS.

ONE OF THE YOUNGEST FLIGHT CAPTAINS AT HER AIRLINE...

Katie Leslie: HEY, TOM, HAVE A GREAT FLIGHT.

Narrator: SHE'S A TOP-RATED PILOT BUILDING HER CAREER

AT ONE OF THE FASTEST-GROWING AIRPORTS IN THE UNITED STATES.

THIS AIRPORT IS AN IMPORTANT DOMESTIC HUB FOR U.S. AIRWAYS,

WITH FLIGHTS TO MOST MAJOR CITIES

IN THE EASTERN UNITED STATES.

AIR MIDWEST RUNS A COMMUTER SERVICE AS U.S. AIRWAYS EXPRESS.

IT OPERATES A FLEET OF BEECHCRAFT 1900-D PLANES--

A 19-PASSENGER SHORT HAUL COMMUTER PLANE

AND A TRUSTED WORKHORSE IN THE INDUSTRY.

TODAY, CAPTAIN LESLIE IS IN COMMAND OF A 1900-D,

ON A 30-MINUTE HOP TO GREENVILLE-SPARTANBURG AIRPORT

IN GREER, SOUTH CAROLINA.

HER CO-PILOT IS 27-YEAR-OLD JONATHAN GIBBS.

Jonathan Gibbs: HOW'D YOU SLEEP LAST NIGHT?

Leslie: HAD A DREAM I WAS IN MIAMI.

Narrator: AMONG THE PASSENGERS FLYING TO GREER THIS MORNING,

18-YEAR-OLD CHRISTIANA SHEPHERD.

CHRISTIANA'S PARENTS, DOUG AND TEREASA,

ARE BAPTIST MISSIONARIES WORKING IN THE PORTUGUESE AZORES.

Tereasa Shepherd: CHRISTIANA LEFT THE 7th OF JANUARY

FROM THE AZORES, SPENT THE NIGHT IN THE AIRPORT IN BOSTON,

AND THEN FLEW THE NEXT MORNING

ON THE EARLY FLIGHT FROM BOSTON TO CHARLOTTE TO GREENVILLE.

SO SHE WAS ON HER WAY BACK TO COLLEGE.

Doug Shepherd: CHRISTIANA WAS VERY SPECIAL,

AND SHE WAS ONE THAT WOULD COME UP AND GIVE YOU A HUG,

AND SAY, YOU KNOW, SHE'D COME FOR NO REASON,

WOULD GIVE YOU A HUG, AND SAY, "DAD, I LOVE YOU."

Narrator: AT 8:00 IN THE MORNING,

CHRISTIANA BOARDS HER FLIGHT.

MEANWHILE, AS PART OF THEIR STANDARD CHECKLIST

BEFORE TAKEOFF, THE CREW CALCULATES THE WEIGHT

OF ALL THE BAGGAGE, PASSENGERS, AND FUEL ON THE PLANE.

THAT'S TO MAKE SURE THE PLANE ISN'T OVERWEIGHT,

AND THE WEIGHT IS SPREAD EVENLY.

IT'S A CALCULATION THAT'S MADE ON ALL COMMERCIAL AIRCRAFT.

Gibbs: SO, WE GOT A FULL HOUSE BACK THERE?

Leslie: YOU CAN COUNT 19 PEOPLE IN THE BACK,

DON'T KNOW THE BAGS YET.

Gibbs: OKAY.

Narrator: BUT BAGGAGE HANDLERS RAISE CONCERNS

THAT THE LUGGAGE THEY'RE LOADING MAY BE TOO HEAVY.

Worker: DAMN!

CAPTAIN, HOW MANY WE GOT TO TAKE OFF?

Leslie: WE'RE FIGURING IT OUT.

WE DON'T THINK WE'RE GOING TO HAVE TO TAKE ANYTHING OFF.

Gibbs: COOL, 17,018.

Leslie: 17,120 IS OUR WEIGHT, HUH?

Gibbs: YEAH, IS OUR MAX.

Leslie: SO, WE'RE COOL?

Gibbs: SO, YEAH.

Narrator: BEFORE TAKEOFF THE CREW CHECKS THE FLIGHT CONTROLS,

INCLUDING THE RUDDER AND ELEVATOR,

WHICH HELP CONTROL THE DIRECTION OF THE PLANE.

Gibbs: FLIGHT CONTROLS, FREE AND CORRECT.

Controller: AIR MIDWEST 5481, RUNWAY 18 RIGHT,

TAXI INTO POSITION AND HOLD.

Narrator: CAPTAIN LESLIE IS MOMENTS FROM TAKEOFF.

ON THE RUNWAY AHEAD OF THEM IS A BOMBARDIER CRJ

READY FOR DEPARTURE.

Gibbs: THAT CRJ SURE IS A GOOD-LOOKING PLANE, ISN'T IT?

Leslie: YEAH, WISH I WAS FLYING IT.

Narrator: WITH POWERFUL TURBULENCE RELEASED FROM THE CRJ,

CAPTAIN LESLIE MUST KEEP A SAFE DISTANCE.

Gibbs: THEY'RE GONNA BLAST US WITH HIS JET BLASTS.

Controller: AIR MIDWEST 5481, TURN RIGHT HEADING 230.

CLEARED FOR TAKEOFF.

Leslie: SET TAKEOFF POWER, PLEASE.

Gibbs: POWER IS SET.

80 KNOTS, CROSS-CHECK.

Narrator: AT 80 KNOTS, PILOTS CHECK

THAT KEY INSTRUMENTS ARE WORKING.

WITH NO SIGNS OF TROUBLE,

LESLIE AND GIBBS PROCEED WITH THEIR TAKEOFF.

TO AIR TRAFFIC CONTROL,

FLIGHT 5481's TAKEOFF ROLL IS PERFECTLY NORMAL.

Leslie: GEAR UP.

Gibbs: WHAT?

Leslie: OH!

Narrator: BUT WITHOUT WARNING,

THE PLANE'S NOSE PITCHES DRAMATICALLY UPWARD FROM SEVEN,

TO A STAGGERING 54 DEGREES.

Leslie: OH, HELP ME!

YOU GOT IT?

Gibbs: I'M TRYING!

Narrator: THE CREW STRUGGLES TO GET THE NOSE BACK DOWN AGAIN.

AIRFLOW OVER THE TOP OF THE WINGS CREATES LIFT.

BUT IF THE NOSE KEEPS RISING,

AIR WON'T FLOW SMOOTHLY OVER THE PLANE'S WINGS.

THE PLANE WILL LOSE ITS LIFT, STALL, AND PLUNGE FROM THE SKY.

Leslie: PUSH THE NOSE DOWN!

OH, MY GOD.

WE HAVE AN EMERGENCY FOR AIR MIDWEST 5481!

Controller: ALERT THREE STANDBY, RUNWAY 18 RIGHT.

Narrator: THE CONTROLLER HANDLING FLIGHT 5481

CALLS FOR EMERGENCY EQUIPMENT.

Leslie: OH, MY GOD.

Narrator: THE PLANE IS NOW JUST 1,150 FEET FROM THE GROUND.

IT STALLS, ROLLS TO THE LEFT, AND BEGINS FALLING FROM THE SKY.

CAPTAIN LESLIE PULLS ON HER CONTROL COLUMN

WITH ALL HER MIGHT.

IF SHE CAN'T GET THE PLANE TO CLIMB,

SHE'S GOING TO HIT THE GROUND.

Narrator: AIR TRAFFIC CONTROLLERS WATCH AS A 19-PASSENGER PLANE

PLUNGES TOWARD THE EARTH.

CAPTAIN KATIE LESLIE STRUGGLES DESPERATELY

TO GET HER PLANE TO CLIMB, BUT IT WON'T RESPOND.

THE PLANE HEADS TOWARDS A PACKED U.S. AIRWAYS HANGAR.

THE FLIGHT WAS LOADED WITH ALMOST 2,200 POUNDS

OF HIGHLY FLAMMABLE JET FUEL JUST BEFORE TAKEOFF.

THE FUEL IGNITES ON IMPACT.

NOW THE INTENSE FIRE THREATENS TO ENGULF THE HANGAR.

THERE ARE SEVERAL AIRPLANES

AND HUNDREDS OF PEOPLE WORKING INSIDE.

[TELEPHONE RINGS]

Man: FIRE STATION.

Woman: EMERGENCY-- A PLANE JUST CRASHED...

Man: AND THE PLANE JUST CRASHED?

Woman: YES, AT THE U.S. AIRWAYS MAINTENANCE.

FRONT END'S TOWARDS THE BUILDING, THERE'S A FIRE.

Man: WE GOT A CODE 10 HERE,

AIRCRAFT CRASHED AT THE SOUTH END OF RUNWAY 36 LEFT.

I REPEAT, A CONFIRMED AIRCRAFT CRASH ON FIRE.

Narrator: 38-YEAR-OLD FIRE CHIEF KEITH ROGERS IS DRIVING TO WORK

WHEN HE GETS A CODE 10 CALL.

Keith Rogers: A CODE 10 MEANS THAT THERE'S A CONFIRMED PLANE CRASH.

AND USUALLY THIS TYPE OF CALL

IS A ONCE-IN-A-CAREER TYPE OF INCIDENT.

[SIRENS]

Narrator: CINDY OVERCASH IS A FIREFIGHTER

WITH THE CHARLOTTE FIRE DEPARTMENT.

Cindy Overcash: YOU COULDN'T ACTUALLY SEE THE HANGAR

FROM HERE, BUT YOU JUST SAW A HUGE BLACK PLUME OF SMOKE,

AND WE KNEW, YOU KNOW, SOMETHING REALLY BAD IS HERE.

Radio: CODE 10 AT THE AIRPORT...

BATTALION ONE, BATTALION TWO...

Narrator: IN THE ADJACENT BUILDING,

SALES DIRECTOR DAVID ISOLA HEARS THE EXPLOSION.

David Isola: I WAS SITTING AT MY DESK,

AND I HEARD THIS LOUD BOOM.

AND ONE OF THE GUYS CAME IN FROM NEXT DOOR,

AND SAID THAT HE JUST SAW AN AIRPLANE CRASH.

AND SO I HOPPED IN MY TRUCK AND DROVE DOWN TO THE SITE.

IT LOOKED JUST LIKE HELL.

THE FLAMES WERE COMING OVER THE FENCE, JUST TOTAL CRAZINESS,

EVERYBODY WAS JUST RUNNING FOR THEIR LIVES.

[SIRENS]

Narrator: WHEN CHIEF KEITH ROGERS ARRIVES AT THE SCENE,

HE FINDS HIMSELF SWIMMING UPSTREAM AGAINST A MOB IN PANIC.

Rogers: AS I GOT ONTO THE AIRPORT PROPERTY,

AND GOT ONTO THE TARMAC, THE PEOPLE WERE EXITING THE HANGAR.

THOSE PEOPLE WERE RUNNING OUT IN FRONT OF THE FIRE TRUCKS,

THE FIRE CARS, THEY WOULD DRIVE WITH CAUTION.

THEY WERE GETTING OUT OF THE BUILDING AS FAST AS THEY COULD.

I THINK THEY DEFINITELY REALIZED THAT THIS WAS NOT A DRILL,

THIS WAS A REAL EMERGENCY.

Overcash: AND WE STILL WEREN'T SURE IF WE HAD A PLANE

INSIDE THE HANGAR THAT HAD CAUGHT ON FIRE,

OR IF THE HANGAR HAD CAUGHT ON FIRE.

IT WAS QUITE A WHILE BEFORE WE REALIZED

A PLANE HAD HIT THE HANGAR.

Narrator: CHIEF ROGERS IMMEDIATELY TAKES COMMAND

OF THE SCENE.

HE KNOWS THAT THERE ARE AIRCRAFT

PARKED INSIDE THE FLAMING HANGAR.

THEIR FUEL TANKS THREATEN TO BLOW.

Rogers: AND OUR CONCERN WAS ONE--

ABOUT THE PEOPLE THAT WERE ON BOARD THE AIRCRAFT,

TWO--FOR THE PEOPLE THAT WERE WORKING IN THE HANGAR,

AND THREE--WE HAD TO WORRY ABOUT THE AIRPLANES

THAT WERE IN FOR REPAIR, WERE THOSE AIRCRAFT ON FIRE?

SO WE HAD A LOT OF MAJOR ISSUES TO DEAL WITH.

Narrator: WITHIN MINUTES,

FIREFIGHTERS BEGIN TO GET THE INFERNO UNDER CONTROL.

THE HOPE NOW IS THAT SOMEWHERE INSIDE THE WRECK,

SURVIVORS ARE CLINGING TO LIFE.

CHIEF ROGERS SENDS A LINE OF FIREFIGHTERS

LED BY CINDY OVERCASH INTO THE HEART OF THE INFERNO.

Overcash: AS WE WALK UP ON THE SCENE, THE FIRE,

AND WE SEE THE--WHAT WE THINK ARE CRASH-TEST DUMMIES.

WE THOUGHT A PLANE HAD BLOWN UP INSIDE

AND BLEW THEIR TRAINING DUMMIES OUT.

AND THEN IT DAWNED ON ME--

UH-UH, THAT'S NOT A TRAINING DUMMY.

Rogers: IT TOOK THEM A FEW MINUTES

TO DETERMINE EXACTLY WHAT WAS HAPPENING.

AND ONCE THEY DID THAT,

IT WAS OBVIOUS THAT THERE WERE NO SURVIVORS.

Narrator: IT IS A TOTAL LOSS.

ALL 19 PASSENGERS,

AS WELL AS CAPTAIN LESLIE AND FIRST OFFICER GIBBS, ARE DEAD.

Man: AT ABOUT 8:53 THIS MORNING, WE HAD AN AIRCRAFT ACCIDENT.

IT HAD 19 PASSENGERS AND 2 CREW. THERE ARE NO SURVIVORS.

Rogers: WE HOPE THAT WE NEVER HAVE TO RESPOND TO A SITUATION

WITH SUCH A LARGE LOSS OF LIFE, BUT THAT IS OUR JOB.

THIS IS SOME OF THE MOST DIFFICULT DUTY AND TASK

THAT A FIREFIGHTER WILL EVER DO IN THEIR CAREER.

Narrator: FOR MEDICS AND RESCUE WORKERS, THE ORDEAL IS OVER.

BUT FOR FRIENDS AND FAMILY OF THE VICTIMS,

THE ANGUISH HAS JUST BEGUN.

T. Shepherd: I WAS WALKING THROUGH THE LIVING ROOM,

AND I STOPPED AND SAID--

MY HEART'S BEATING RIGHT NOW JUST THE WAY IT WAS THEN--

I SAID, HAS CHRISTIANA CALLED YET?

SHE SAID NO.

OKAY, AND I KNEW THEN WHAT HAD HAPPENED.

I JUST--I KNEW.

SO I WENT AND GOT THE TELEPHONE AND CALLED THE SCHOOL.

HE SAID, "YES, MRS. SHEPHERD, WE HAVE SOME SAD NEWS."

AND HE TOLD ME THAT THE PLANE HAD CRASHED ON TAKEOFF.

I ASKED IF THERE WERE ANY SURVIVORS, HE SAID NO.

SO THEN I KNEW I HAD TO GO TELL DOUG, AND HE WAS IN THE GARAGE.

D. Shepherd: IT'S SOMETHING YOU NEVER FORGET ABOUT.

I WAS CHANGING A FLUORESCENT BULB,

AND TEREASA CAME TO THE DOORWAY...

T. Shepherd: HOW DO YOU SAY THAT?

WHAT WORD--YOU USE WORDS EVERY SINGLE DAY.

HOW CAN YOU USE WORDS...

TO RUIN SOMEONE'S LIFE?

BUT I TOLD HIM.

I SAID, "DOUG, CHRISTIANA'S PLANE CRASHED."

D. Shepherd: AT THAT MOMENT MY WORLD FELL APART.

Narrator: NOW, THE SHEPHERDS AND THE FAMILIES OF THE OTHER 20 VICTIMS

WANT TO KNOW WHAT CAUSED THE DEATH OF THEIR LOVED ONES.

Narrator: AT THE CRASH SCENE, THE INVESTIGATION BEGINS.

WITH NO SURVIVORS TO RESCUE,

NEITHER BODIES NOR AIRPLANE PARTS ARE MOVED

FROM WHERE THEY FELL UNTIL THE ARRIVAL OF INVESTIGATORS

FROM THE NATIONAL TRANSPORTATION SAFETY BOARD.

WHILE MEDICAL EXAMINERS MARK THE LOCATION

OF HUMAN REMAINS IN RED,

NTSB INVESTIGATORS MARK SCRAPS OF METAL IN YELLOW,

LOOKING FOR CLUES TO WHAT CAUSED THE CRASH.

AMONG THOSE ASSIGNED TO THIS CASE,

LEAD INVESTIGATOR LORINDA WARD.

IT'S HER FIRST ASSIGNMENT AS THE LEAD INVESTIGATOR OF A CRASH.

Lorinda Ward: I CHECKED IN WITH THE FIRE DEPARTMENT

TO MAKE SURE THAT THE FIRES HAD BEEN PUT OUT.

AND THEN CALLED A MEETING WITH ALL THE FIRST RESPONDERS

TO SEE WHAT THEY HAD NOTICED

WHEN THEY CAME TO THE CRASH SITE.

Narrator: WARD ACTS FAST.

BECAUSE THERE ARE BODIES ENTANGLED WITH THE WRECKAGE,

SHE DECLARES THE CRASH SITE A POTENTIAL BIOHAZARD.

INVESTIGATORS WHO MIGHT COME IN CONTACT WITH THE WRECKAGE

MUST WEAR PROTECTIVE SUITS WHILE THEY EXAMINE THE WRECK

AND IDENTIFY THE VICTIMS' REMAINS.

WHILE WORK CONTINUES AT THE CRASH SITE...

Narrator: ...LORINDA WARD AND HER TEAM LOOK FOR CLUES NEARBY.

Ward: WE HAD THE FOLKS GO SHOULDER TO SHOULDER

ON THE RUNWAY THAT THE ACCIDENT CREW TOOK OFF ON

TO PICK UP ANYTHING THAT THEY SAW ON THE RUNWAY

TO SEE IF IT HAD ANY RELEVANCE TO THE ACCIDENT INVESTIGATION.

Narrator: RUNWAYS MUST BE CLEAR OF ALL DEBRIS.

THE SMALLEST OBJECT CAN BECOME A DEADLY PROJECTILE

IF IT STRIKES A PLANE ON TAKEOFF.

THREE YEARS EARLIER, A CONCORDE JET RAN OVER

A 40-CENTIMETER STRIP OF SCRAP METAL ON A PARIS RUNWAY.

THE PLANE'S FUEL TANK WAS PIERCED AND CAUGHT FIRE.

THE AIRCRAFT ROSE TO 200 METERS

BEFORE IT CRASHED INTO A NEARBY HOTEL.

109 PEOPLE ON BOARD AND 4 PEOPLE ON THE GROUND WERE KILLED.

AT CHARLOTTE DOUGLAS INTERNATIONAL,

INVESTIGATORS SCOUR THE AREA.

THEY FIND A FUEL CAP LYING DANGEROUSLY CLOSE TO THE RUNWAY.

Ward: WHAT DO YOU GOT?

IT COULD BE SUCKED IN, AND IT COULD DAMAGE AN ENGINE.

THE MAIN PART WOULD BE

THE DAMAGE THAT IT CAN DO TO AN ENGINE.

Narrator: THE DISCOVERY RAISES AN INTERESTING POSSIBILITY.

AS FLIGHT 5481 RACED DOWN THE RUNWAY AT TAKEOFF,

THE FUEL CAP COULD HAVE BOUNCED UP OFF THE TARMAC,

STRUCK THE ENGINE ROTORS,

AND BROUGHT CAPTAIN LESLIE'S AIRCRAFT CRASHING TO EARTH.

Ward: THIS WAS TO BE BROUGHT BACK TO SEE IF IT HAD

ANY RELEVANCE TO THE ACCIDENT INVESTIGATION.

WHETHER IT CAME OFF THE AIRPLANE ITSELF, OR IF IT COULD HAVE DONE

SOME TYPE OF DAMAGE TO THE AIRPLANE.

Narrator: A CLOSER EXAMINATION LEADS WARD AND HER TEAM

TO CONCLUDE THAT THE FUEL CAP

COULD NOT HAVE INTERFERED WITH THE PROPELLERS.

NOW NTSB AIR TRAFFIC CONTROL INVESTIGATOR BILL ENGLISH

EXPLORES ANOTHER SCENARIO.

Bill English: WHEN WE FIRST HEARD ABOUT THE ACCIDENT,

IT LOOKED LIKE THERE MIGHT BE THE POSSIBILITY

THAT WE'D WANT TO LOOK AT A WAKE TURBULENCE ENCOUNTER.

Narrator: THE WINGS OF A FAST-MOVING JET

DISTURB THE AIR AROUND THEM,

CREATING A TRAIL OF VIOLENTLY SWIRLING AIR.

NASA TESTS DECADES EARLIER HAD ILLUSTRATED THE POWER AND DANGER

OF WAKE TURBULENCE TO OTHER PLANES.

BILL ENGLISH EXAMINES RADAR RECORDS

FROM THE TIME OF THE ACCIDENT.

HE LEARNS THAT A MUCH HEAVIER BOMBARDIER REGIONAL JET, A CRJ,

TOOK OFF MOMENTS BEFORE THE BEECH.

Gibbs: THAT CRJ SURE IS A GOOD-LOOKING PLANE, ISN'T IT?

Leslie: YEAH, WISH I WAS FLYING IT.

English: THE WAKE TURBULENCE IS GENERATED

FROM THE WING TIPS OF ANY AIRPLANE.

AS SOON AS IT STARTS TO LIFT OFF THE GROUND,

IT MAKES WHAT PEOPLE SOMETIMES CALL HORIZONTAL TORNADOES--

VORTEXES OF AIR THAT CAN CREATE HAZARDOUS TURBULENCE.

Controller: RUNWAY 18 RIGHT, TAXI INTO POSITION...

English: AIR TRAFFIC CONTROLLERS DO HAVE STANDARD PROCEDURES

FOR SPACING OUT AIRPLANES, SO THAT THEY HAVE A CHANCE

TO AVOID THE WAKE TURBULENCE, OR LET THE WAKE DISSIPATE.

Narrator: ONE YEAR EARLIER, AN AMERICAN AIRLINES JET

TAKING OFF FROM NEW YORK ENCOUNTERED WAKE TURBULENCE.

THE PLANE CRASHED INTO A RESIDENTIAL NEIGHBORHOOD.

260 PEOPLE ON THE PLANE

AND FIVE PEOPLE ON THE GROUND WERE KILLED.

Gibbs: THEY'RE GONNA BLAST US WITH HIS JET BLASTS.

Controller: AIR MIDWEST 5481, CLEARED FOR TAKEOFF.

Leslie: OH!

Narrator: INVESTIGATOR BILL ENGLISH STUDIES THE FLIGHT PATH

OF CAPTAIN LESLIE'S PLANE AND FINDS IT CONSISTENT

WITH A PLANE FLYING INTO WAKE TURBULENCE.

English: PITCH-UP IS NOT UNHEARD OF IN A WAKE TURBULENCE ENCOUNTER,

WHERE THE AIRPLANE WILL SUDDENLY GO NOSE UP,

AND THE CREW HAS TROUBLE TO COUNTER THAT

AND GET THE NOSE BACK WHERE IT BELONGS.

Narrator: ENGLISH NEEDS TO KNOW HOW CLOSE THE AIR MIDWEST FLIGHT

GOT TO THE LARGER JET.

CHARLOTTE TOWER'S COMPUTER TRACKING SYSTEM

PROVIDES HIM WITH THE PRECISE LOCATION

OF THE PLANES AT LIFTOFF--AND HE MAKES A TELLING DISCOVERY.

THE SYSTEM GAVE BILL ENGLISH HIS ANSWER.

EVEN THOUGH BOTH PLANES USED THE SAME RUNWAY,

THEIR PATHS NEVER CROSSED.

English: THE RJ STARTED LIFTING OFF MUCH FARTHER DOWN THE RUNWAY

THAN THE ACCIDENT AIRPLANE DID,

AND THE CLIMB OUT ANGLE OF THE REGIONAL JET,

AND THE CLIMB OUT ANGLE OF THE ACCIDENT AIRPLANE

NEVER INTERSECTED.

SO, IF OUR AIRPLANE LIFTED OFF

AND CLIMBED ABOVE THE ANGLE OF THE PREVIOUS AIRPLANE,

WE KNEW THEN THAT IT COULDN'T POSSIBLY BE A FACTOR.

Narrator: THE WAKE VORTEX THEORY IS RULED OUT,

AND BILL ENGLISH'S WORK IS DONE.

NOW IT'S UP TO WARD AND HER CREW TO FIND CLUES

IN THE BURNT-OUT WRECKAGE OF THE PLANE.

WITHIN TWO DAYS HER INVESTIGATION WILL REVEAL

A STRING OF ERRORS AND FAULTY ASSUMPTIONS

THAT HAD BEEN PUTTING TENS OF THOUSANDS OF PASSENGERS

AT RISK FOR YEARS.

Narrator: WITHIN HOURS OF THE CRASH,

INVESTIGATORS FIND THE COCKPIT VOICE RECORDER

AND FLIGHT DATA RECORDER FROM AIR MIDWEST FLIGHT 5481.

THE RECORDERS ARE DESIGNED TO WITHSTAND TEMPERATURES

OF UP TO 2,000 DEGREES FAHRENHEIT.

IN THIS CRASH, PARTS OF THE VOICE RECORDER

HAD ACTUALLY MELTED.

THE DEVICES ARE PHOTOGRAPHED AND SENT FOR ANALYSIS.

THEN, AMONG THE TONS OF DEBRIS ON THE GROUND,

INVESTIGATORS DISCOVER THE SHREDDED REMAINS

OF THE ELEVATOR CONTROL CABLES.

VITAL TO FLIGHT CONTROL, THESE CABLES LINK

THE PILOT'S CONTROL COLUMNS TO THE FLIGHT ELEVATOR--

AN AERODYNAMIC PANEL THAT HELPS PILOTS CLIMB AND DESCEND.

TURNBUCKLES KEEP THE CABLES TAUT.

TO CLIMB, PILOTS PULL ON THE COLUMN--

THE CABLES PULL THE ELEVATOR UP, FORCING THE NOSE TO RISE.

TO DESCEND, PILOTS PUSH ON THE CONTROL COLUMN.

THE CABLES TILT THE ELEVATOR DOWN, AND THE NOSE FALLS.

BUT AS INVESTIGATORS EXAMINE THE BURNT-OUT CABLES AND TURNBUCKLES

ON CAPTAIN LESLIE'S PLANE, ALREADY SOMETHING LOOKS WRONG.

Ward: THEY LOOKED UNUSUAL, THEY WEREN'T IN THE NORMAL POSITION

THAT YOU WOULD FIND THEM.

IN THIS CASE, WE HAD ONE ADJUSTED ALL THE WAY OUT,

AND THEN ONE ADJUSTED ALL THE WAY IN.

SO THOSE WERE SET ASIDE FOR US TO LOOK AT LATER.

Narrator: WHILE THE LAB WORK CONTINUES,

NTSB INVESTIGATOR STEPHEN CARBONE

TRAVELS TO HUNTINGTON, VIRGINIA.

HE INTERVIEWS MECHANICS WHO WORKED ON THE PLANE

THE DAY BEFORE THE CRASH.

Stephen Carbone: AT THE TIME, WE HAD KNOWN THAT IT HAD JUST

COME OUT OF A DETAIL CHECK, WHICH IS A ROUTINE CHECK.

AND KNOWING THAT, WE WERE LOOKING INTO THE POSSIBILITY

THAT SOMETHING HAD BEEN DONE DURING THE CHECK

THAT NEEDED TO BE LOOKED AT FROM AN INVESTIGATION POINT OF VIEW.

Supervisor: THE CABLES NEEDED SERVICING.

MY GUY WROTE UP A SERVICE ORDER, AND I PUT HIM ON IT.

DON'T FORGET THE MANUAL.

Mechanic: GOT IT.

Narrator: EVERY 1,200 FLIGHT HOURS,

AIR MIDWEST PLANES GO IN FOR ROUTINE MAINTENANCE WORK.

THIS INCLUDES ADJUSTING THE CABLES

THAT CONTROL THE PLANE'S ELEVATOR.

Carbone: IN THE PROCESS OF DOING THIS CHECK,

HE FOUND THAT, THE MECHANIC HAD FOUND

THAT THE CABLES WERE OUT OF LIMITS, SO HE HAD WRITTEN UP

THAT HE WAS GOING TO CHECK THE CABLE TENSIONS,

AND THEN ADJUST THEM AS PER THE MANUAL.

Narrator: THE MECHANICS TELL CARBONE

THAT THE WORK WAS CHECKED AND STAMPED FOR QUALITY ASSURANCE.

Carbone: THEY BELIEVED THAT THE AIRCRAFT WAS PROPERLY RIGGED

AS PER THE MANUAL.

Narrator: AT FIRST GLANCE, THAT BELIEF APPEARS TO BE RIGHT.

AFTER MAINTENANCE, THIS BEECH AIRCRAFT TOOK OFF AND LANDED

NINE TIMES WITHOUT INCIDENT

BEFORE CAPTAIN LESLIE TOOK THE HELM.

INVESTIGATORS TURN TO THE FLIGHT DATA RECORDER

TO LEARN WHAT HAPPENED ON THOSE FLIGHTS.

THE FLIGHT DATA RECORDER STORES DATA FROM NUMEROUS FLIGHTS,

BOTH BEFORE AND AFTER THE PLANE'S CABLES WERE ADJUSTED.

NO ONE ON ANY OF THOSE FLIGHTS HAD ENCOUNTERED PROBLEMS

WITH THE PLANE'S ELEVATOR.

Ward: SO AT THE TIME WE DIDN'T KNOW HOW THAT AFFECTED

THE AIRPLANE, BECAUSE IT HAD FLOWN NINE TIMES SUCCESSFULLY

BEFORE THE ACCIDENT FLIGHT.

Narrator: WARD ALSO DISCOVERS THAT THE CREW TESTED

THEIR ELEVATOR CONTROLS BEFORE FLIGHT 5481 TOOK OFF.

Gibbs: FLIGHT CONTROLS, FREE AND CORRECT.

Controller: AIR MIDWEST 5481.

Narrator: WARD AND HER TEAM DIG DEEPER, LOOKING TO DISCOVER

IF THE UNUSUAL CONFIGURATION OF THE ELEVATOR CABLES

COULD HAVE PLAYED A ROLE IN THIS CRASH.

WHAT THEY FIND STRIKES AT THE VERY HEART OF WHAT WENT WRONG.

NORMALLY, BOTH TURNBUCKLES ARE ALMOST EXACTLY THE SAME LENGTH.

BUT ON CAPTAIN LESLIE'S PLANE,

ONE TURNBUCKLE IS NOTICEABLY LONGER THAN THE OTHER.

TO ESTABLISH THE CORRECT CABLE TENSION,

MECHANICS TIGHTEN THE TURNBUCKLES.

BUT TOO MUCH TIGHTENING OF A TURNBUCKLE SHORTENS THE CABLES

AND CUTS THE RANGE OF MOTION OF THE ELEVATOR CONTROL.

THE ELEVATOR SHOULD BE ABLE TO TILT

TO A NOSE-DOWN POSITION OF 14 DEGREES.

BUT THEIR DOWNWARD RANGE HAS ACTUALLY BEEN CUT IN HALF

TO ONLY SEVEN DEGREES.

THE RESULT IS DEADLY.

AS THE FLIGHT GOT UNDER WAY,

THE NOSE PITCHED UP AS EXPECTED DURING TAKEOFF...

Gibbs: WHAT?

Leslie: PUSH THE NOSE DOWN!

OH, MY GOD!

Narrator: BUT THE REDUCED RANGE IN THE ELEVATOR

MADE IT IMPOSSIBLE FOR THE PILOTS

TO BRING THE NOSE DOWN AGAIN.

Ward: DUE TO THE ADJUSTMENT THAT HAD BEEN DONE

AND THE MAINTENANCE A FEW NIGHTS EARLIER,

THERE'S NOTHING THAT THE CREW COULD HAVE DONE AT THAT TIME.

Narrator: UNABLE TO BRING THE NOSE DOWN,

THE PITCH OF THE WINGS BECAME TOO PRONOUNCED.

WITH NO AIR FLOWING OVER THE TOP OF THE WINGS,

THE PLANE LOST ITS LIFT AND BEGAN FALLING FROM THE SKY.

THE PILOT'S STRUGGLE WITH THE ELEVATOR

HELPS EXPLAIN WHY FLIGHT 5481 CRASHED THAT DAY.

SOMEHOW, THE ELEVATOR CABLES WERE IMPROPERLY ADJUSTED.

THE PILOTS SIMPLY COULD NOT CONTROL

THE PITCH OF THEIR AIRPLANE.

STEPHEN CARBONE WANTS TO KNOW

HOW MECHANICS HAD MADE SUCH A CRITICAL MISTAKE.

Mechanic: YEAH, I SEE THAT HERE.

Narrator: HE GOES BACK TO THE HANGAR

TO QUESTION THE MECHANICS ON DUTY THAT NIGHT,

AND THIS TIME, THEY TELL HIM A DIFFERENT STORY.

Supervisor: MOST OF THE GUYS WERE JUST LEARNING THE ROPES.

Carbone: THE MECHANICS WORKING ON THE AIRLINE

WERE SUBCONTRACTORS TO THE CONTRACT COMPANY,

AND THE MECHANICS WORKING ON THE AIRCRAFT THAT NIGHT

HAD LIMITED EXPERIENCE ON THE BEECH 1900-D,

AND THE PERSON PERFORMING THE RIG

WAS RECEIVING TRAINING THAT NIGHT ON THAT SPECIFIC TASK.

Supervisor: ONCE YOU HAVE THE RIG PIN SET,

ADJUST THE TURNBUCKLE BARRELS FOR MORE TENSION IN THE CABLE.

Mechanic: YEAH, I SEE THAT HERE.

Narrator: ADJUSTING THE ELEVATOR CABLES IS NOT A SIMPLE PROCESS.

IT'S A TIME-CONSUMING PROCEDURE

THAT INVOLVES 25 DIFFERENT STEPS.

Mechanic: GOT IT.

UH, WHAT ABOUT THE OTHER STEPS?

Supervisor: YEAH, UH, DON'T WORRY ABOUT THOSE.

JUST CHECK THE CABLE TENSION WHEN YOU'RE DONE,

AND WE'RE GOOD, THAT'S IT.

Carbone: THE QUALITY ASSURANCE INSPECTOR AND THE MECHANIC

TOOK IT UPON THEMSELVES TO DECIDE WHICH STEPS TO PERFORM,

BECAUSE THEY FELT THAT THE STEPS THEY WERE PERFORMING

WERE THE ONLY ONES NECESSARY TO GET THE TASK DONE.

Narrator: THE MECHANIC SKIPPED NINE STEPS THAT NIGHT.

ONE OF THOSE INVOLVED MANIPULATING THE ELEVATOR

THROUGH ITS FULL RANGE OF MOTION.

HAD THE MECHANIC TRIED TO DO THAT,

HE WOULD HAVE NOTICED THAT THE ELEVATOR'S MOTION

WAS RESTRICTED BY CABLES THAT HAD BEEN IMPROPERLY RIGGED.

Carbone: IF THEY HAD FOLLOWED THE STEPS

AS DESCRIBED IN THE MANUAL,

THEY WOULD HAVE FOUND THE PROBLEMS THAT HAD COME UP.

Narrator: BUT THERE WAS AN INSPECTOR SUPERVISING THE WORK.

CARBONE DISCOVERS THAT THE INSPECTOR WAS ACTUALLY

THE PERSON TEACHING THE MECHANICS HOW TO DO THE WORK.

Carbone: WELL, WHEN YOU PUT YOURSELF IN THAT POSITION,

YOU'RE ACTUALLY DOING THE TASK, BECAUSE EVEN AS A TEACHER,

YOU'RE PERFORMING THE TASK, AND THEN HE CAME IN BEHIND HIMSELF

AND THEN SIGNED OFF AS AN INSPECTOR, WHAT HE HAD DONE.

D. Shepherd: WHEN I FOUND OUT THAT THIS MECHANIC

HAD SKIPPED PROCEDURES...

I WAS UPSET.

THEY'RE PROCEDURES THAT AFFECTED OUR LIVES,

THAT AFFECTED THE LIVES OF 21 PEOPLE.

21 FAMILIES WERE DESTROYED.

BECAUSE YOU NEVER GET OVER SOMETHING LIKE THIS.

Narrator: THE SHEPHERDS SUE THE AIRLINE.

THEY ALSO DEMAND SOMETHING UNHEARD OF IN U.S. AVIATION--

AN APOLOGY.

Ron Goldman: THEY WANTED MORE THAN JUST TO ACHIEVE

A JUST SETTLEMENT IN MONETARY TERMS,

THEY HAD A NEED TO PRESS THE ISSUES

THAT HUMANIZE AND PUT A FACE ON

THE PEOPLE WHO ARE THE VICTIMS OF THESE TRAGEDIES.

Narrator: THE SHEPHERDS BELIEVE THAT THEIR BEST CHANCE

OF GETTING AN APOLOGY IS BY PUTTING A FACE

TO CHRISTIANA'S NAME.

D. Shepherd: SO WE DECIDE TO TAKE THIS PICTURE

TO SEND IT TO THOSE PEOPLE THAT WERE INVOLVED IN THE ACCIDENT,

IN THE INVESTIGATION, SO THAT CHRISTIANA WOULD NOT BE

JUST A NUMBER, OR A SEAT NUMBER, OR A TICKET NUMBER,

OR A SETTLEMENT AMOUNT,

SO THEY COULD ACTUALLY SEE THAT SHE WAS A PERSON.

Ward: IN THIS CASE, THE MECHANICS THOUGHT

THEY WERE DOING SOMETHING THAT WAS PERFECTLY REASONABLE.

THEY THOUGHT THIS WAS, YOU KNOW, ANOTHER DAY AT THE JOB.

AND THEN TO COME TO FIND OUT THAT NOW 21 PEOPLE

HAVE BEEN, YOU KNOW, KILLED DUE TO THEIR INADVERTENT ACT.

Narrator: FOR LORINDA WARD AND HER TEAM,

IT LOOKS LIKE THEY'VE FOUND THE PROBLEM.

BUT SOMETHING STILL DOESN'T ADD UP.

WHY DIDN'T THE PROBLEM WITH THE PLANE'S FAULTY RIGGING

SURFACE ON ANY OF ITS PREVIOUS FLIGHTS?

Ward: WE KEPT SCRATCHING OUR HEAD, WONDERING,

OKAY, THIS AIRPLANE FLEW NINE TIMES PREVIOUSLY,

AND WE HAD NO PROBLEMS.

SO WE'RE TRYING TO DECIDE,

WELL, WHAT WAS UNUSUAL ABOUT THIS FLIGHT?

Narrator: WARD HAS TO FIGURE OUT WHAT HAPPENED

IN THE HOURS AND MINUTES BEFORE THE CRASH.

Ward: DID YOU NOTICE ANYTHING UNUSUAL BEFORE TAKEOFF?

Worker: WELL, IT WAS SITTING LOW WHEN IT TAXIED OUT.

IT LOOKED HEAVY.

Ward: WE HAD A COUPLE OF WITNESSES THAT WERE IMPLYING

THAT WE HAD A VERY HEAVILY LOADED AIRPLANE.

THE BAGGAGE PEOPLE SAID THAT IT WAS HARD TO SHUT THE DOOR,

'CAUSE THEY THOUGHT BAGS WERE GONNA COME OUT.

Narrator: EACH PLANE HAS A MAXIMUM WEIGHT IT CAN HANDLE

BEFORE THE ENGINES CAN'T GET IT OFF THE GROUND.

BEFORE TAKEOFF, IT'S THE PILOTS' JOB

TO CALCULATE THE ONBOARD WEIGHT.

Gibbs: WE GOT A FULL HOUSE BACK THERE?

Worker: HOW MANY WE GOT TO TAKE OFF?

Leslie: WE'RE FIGURING IT OUT.

Narrator: THE CREW OF FLIGHT 5481 PERFORMED THAT CALCULATION.

Gibbs: COOL, 17,018.

Ward: WE HEAR THEM ON THE CVR GOING THROUGH THE NUMBERS

TO MAKE SURE THAT THEY HAVE THEIR CENTER GRAVITY

WITHIN THE RANGE FOR THEM TO TAKE OFF.

Leslie: 17,120 IS OUR WEIGHT, HUH?

Gibbs: YEAH, IS OUR MAX.

Narrator: ON ANY PLANE, LARGE OR SMALL,

THE WEIGHT OF CARGO AND PASSENGERS

HAS TO BE DISTRIBUTED EVENLY.

THE BALANCING POINT OF AN AIRPLANE

IS CALLED ITS CENTER OF GRAVITY.

FOR A PLANE TO FLY SAFELY, IT CAN NEITHER BE TOO FAR FORWARD,

NOR TOO FAR BACK OR AFT.

Leslie: SO, WE'RE COOL?

Gibbs: SO, YEAH.

Leslie: WE DON'T THINK WE'RE GOING TO HAVE TO TAKE ANYTHING OFF.

Narrator: AIR MIDWEST PILOTS ARE INSTRUCTED

HOW TO MAKE WEIGHT AND CENTER OF GRAVITY, OR CG, CALCULATIONS.

THEY USE AVERAGE WEIGHTS TO MAKE THAT CALCULATION--

175 POUNDS PER PASSENGER AND 20 POUNDS PER BAG.

Ward: THEY KNEW THAT THEY HAD A VERY AFT CG,

BUT DUE TO USING THE AVERAGE WEIGHTS

AND AVERAGE CALCULATIONS,

THE PAPERWORK SHOWED THEM BEING WITHIN THE RANGE

THAT THEY NEEDED TO TAKEOFF.

Narrator: BUT WARD NEEDS TO KNOW

IF THE PLANE REALLY WAS WITHIN THE PROPER RANGE

OF WEIGHT AND BALANCE BEFORE TAKEOFF.

Ward: WELL, WHAT WE DID WAS WE LOOKED AT THE WEIGHTS

OF THE ACTUAL BAGGAGE ITSELF THAT WAS ON BOARD

AND THEN THE WEIGHT OF THE PASSENGERS AND THE CREW.

Narrator: TECHNICIANS WEIGH THE REMAINS OF THE BURNT LUGGAGE

FROM THE WRECKAGE SITE...

Ward: DOCTOR, YES, COULD YOU TELL ME PLEASE

WHAT THE LAST RECORDED WEIGHT OF YOUR PATIENT...

Narrator: ...AND OBTAIN THE REAL WEIGHT OF PASSENGERS

ON BOARD THAT DAY.

Ward: 212, THANK YOU.

Narrator: WHEN ALL THE NUMBERS ARE IN,

WARD DISCOVERS THE REAL WEIGHT OF FLIGHT 5481

IS 17,700 POUNDS--

SOME 580 POUNDS OVER ITS MAXIMUM TAKEOFF WEIGHT.

Ward: THEY WOULD NOT HAVE BEEN ABLE TO TAKEOFF

IF THEY HAD USED ACTUAL WEIGHTS.

THEY WOULD'VE HAD TO PULL EITHER PASSENGERS OR BAGS OFF.

Narrator: BECAUSE OF THE HIGHER THAN EXPECTED WEIGHT

OF THE PASSENGERS AND BAGGAGE ON THE FLIGHT,

AND THE LARGE NUMBER OF BAGS STOWED IN THE REAR,

THE AIRPLANE WAS TAIL-HEAVY...

ITS CENTER OF GRAVITY EVER SO SLIGHTLY TOO FAR TO THE REAR.

WHICH WASN'T A PROBLEM, UNTIL THE LANDING GEAR WAS RAISED.

Leslie: GEAR UP.

Narrator: WHEN THE GEAR'S WEIGHT MOVED BACKWARDS FROM THE NOSE,

IT TIPPED THE BALANCE OF WEIGHT...

TOO FAR BACK.

THE PILOTS' EFFORTS TO REGAIN

CONTROL OF THE AIRCRAFT WERE FUTILE,

CRIPPLED BY THE AIRPLANE'S DEFECTIVE ELEVATOR CONTROLS.

Carbone: WHEN THE NOSE GEAR MOVED AFT,

THEY LOST THE ABILITY TO CONTROL THE AIRCRAFT,

BECAUSE ALL THE WEIGHT WENT BACK,

AND THEY HAD NO ELEVATOR MOVEMENT

ENOUGH TO BRING THE NOSE BACK DOWN.

AND AT THE HEIGHT THAT THEY WERE AT, THEY HAD NO RECOVERY.

Narrator: THE PASSENGERS AND CREW OF FLIGHT 5481

WERE DOOMED THE MOMENT THE PLANE LEFT THE GROUND.

THEY HAD NO WAY OF KNOWING THAT TWO UNRELATED PROBLEMS

WOULD COMBINE TO BRING DOWN THEIR PLANE.

BUT FAULTY MAINTENANCE AND ABOVE AVERAGE WEIGHTS

WEREN'T THE ONLY ISSUES

UNCOVERED BY LORINDA WARD'S INVESTIGATION.

Ward: HEY, YOU GOT A SEC? I HAVE AN IDEA.

Narrator: LORINDA WARD SUSPECTS THAT SHE'S UNCOVERED PROBLEMS

THAT DIDN'T JUST AFFECT THIS ONE FLIGHT,

BUT THAT ALSO AFFECT EVERY COMMUTER PLANE IN THE AIR.

Narrator: NTSB INVESTIGATORS SAY THAT EVERY PLANE CRASH

MAKES FLYING SAFER.

FLIGHT 5481 WAS NO EXCEPTION.

14 MONTHS AFTER THE ACCIDENT, LEAD INVESTIGATOR LORINDA WARD

AND HER TEAM FILE A COMPREHENSIVE REPORT

TO ENSURE THE MISTAKES THAT KILLED THOSE ABOARD FLIGHT 5481

ARE NEVER REPEATED.

AMONG WARD'S RECOMMENDATIONS--

THAT THE FAA REVIEW ITS AVERAGE PASSENGER AND BAGGAGE WEIGHTS--

AN AVERAGE THAT HAD NOT BEEN REVISED SINCE 1936.

AND SINCE STUDIES SUGGEST THAT AMERICANS AND OTHER ADULTS

WERE GETTING HEAVIER FROM YEAR TO YEAR,

WARD SUSPECTED THAT THE AVERAGES WERE OFF.

Ward: WE MADE A RECOMMENDATION TO THE FAA

TO HAVE THE OPERATORS GO OUT AND SURVEY THEIR OPERATIONS

BOTH SUMMER AND WINTER TIME TO SEE HOW ACCURATE

THESE AVERAGE WEIGHTS REFLECTED THE ACTUAL FLYING PUBLIC

THAT WAS GETTING ONTO THEIR AIRPLANES.

Narrator: AFTER CONDUCTING A SURVEY OF PASSENGERS,

THE FAA COMES TO A SHOCKING CONCLUSION.

THE AVERAGE WEIGHT OF ADULT AMERICAN PASSENGERS

WAS 195 POUNDS, NOT 175.

THE FAA ALSO DISCOVERED

THAT THE AVERAGE WEIGHT OF CARRY-ON LUGGAGE

WAS BEING UNDERESTIMATED BY FIVE POUNDS PER BAG.

Ward: WE HAD A AVERAGE WEIGHT,

THAT WERE BEING USED THAT NEED TO BE UPDATED.

Narrator: HAD THESE HIGHER AVERAGE WEIGHTS BEEN IN EFFECT

ON JANUARY 8, 2003,

FLIGHT 5481 WOULD NOT HAVE BEEN LEGAL FOR TAKEOFF.

CAPTAIN LESLIE WOULD HAVE HAD TO REMOVE BAGS AND PASSENGERS.

Gibbs: 48,107...COOL, 17,018.

Narrator: AIR MIDWEST PILOTS NOW USE AN AVERAGE WEIGHT

OF 200 POUNDS PER PASSENGER,

WHICH MEANS THAT THEIR BEECHCRAFT PLANES

CAN ONLY CARRY 17 PASSENGERS, NOT 19.

Narrator: BUT WARD'S REPORT GOES ON TO SAY

THAT EVEN WITH UPDATED INDUSTRY AVERAGES,

THERE IS STILL ROOM FOR ERROR.

HER REPORT STATES THAT FLYING SMALL AIRCRAFT

WILL BE SAFEST ONLY WHEN AIRLINES STOP USING

AVERAGE WEIGHT ASSUMPTIONS ALTOGETHER

AND CALCULATE THE REAL WEIGHT ON BOARD BEFORE TAKEOFF.

NEW TECHNOLOGIES ARE BEING DEVELOPED TO ALLOW AIR CARRIERS

TO MEASURE ACTUAL WEIGHT AND CONTROL BALANCE IN REAL TIME

AS THE PLANE IS LOADED.

KNOWING THE ACTUAL WEIGHT OF PASSENGERS AND BAGGAGE IS VITAL.

MORE AND MORE PEOPLE ARE FLYING ON SMALL COMMUTER JETS.

AS THE COST OF JET FUEL SOARS,

THE SMALLER FUEL-EFFICIENT PLANES

BECOME MORE ATTRACTIVE TO AIRLINES.

IN THE UNITED STATES ALONE, MORE THAN 10 MILLION PEOPLE A YEAR

BOARD PLANES WITH FEWER THAN 30 SEATS.

Ward: SMALLER AIRCRAFT ARE MORE SENSITIVE TO THE WEIGHT,

WEIGHT AND BALANCE ISSUE, THAN, SAY, A LARGER AIRPLANE.

Narrator: IN SPITE OF WARD'S RECOMMENDATIONS

AND THE AVAILABLE TECHNOLOGY,

ALMOST 70% OF SMALL PLANES ON SCHEDULED FLIGHTS

STILL USE AVERAGE INSTEAD OF ACTUAL WEIGHTS.

FOR DOUG AND TEREASA SHEPHERD,

THERE IS STILL ANOTHER DANGER THAT THREATENS TO STRIKE AGAIN.

T. Shepherd: IF THE FAA TOOK A VERY ACTIVE ROLE

IN THEIR REGULATION,

THEN SUBCONTRACTING COULD ACTUALLY BE A PLUS.

THE WAY IT'S HANDLED TODAY, THE MISTAKES WILL JUST CONTINUE.

Mechanic: WHAT ABOUT THE OTHER STEPS?

Supervisor: YEAH, UH, DON'T WORRY ABOUT THOSE.

JUST CHECK THE CABLE TENSION WHEN YOU'RE DONE,

AND WE'RE GOOD.

Narrator: IN HER REPORT, WARD STATES THAT

ALL AIR CARRIERS NEED TO PROVIDE DIRECT OVERSIGHT TO MAKE SURE

THAT EVEN SUBCONTRACTED WORK IS COMPLETED CORRECTLY.

Ward: THIS INVESTIGATION WAS UNIQUE TO ME, PERSONALLY,

BECAUSE IT WAS MY FIRST LAUNCH AS AN INVESTIGATOR IN CHARGE.

THIS WAS, IN MY MIND, A SIGNIFICANT INVESTIGATION

IN THE FACT THAT WE HAD THE 22 SAFETY RECOMMENDATIONS

THAT CAME OUT FROM A SMALL ACCIDENT INVESTIGATION.

Narrator: FOR THE SHEPHERDS, THE NTSB RECOMMENDATIONS COME TOO LATE.

BUT AFTER A LENGTHY LEGAL BATTLE,

AIR MIDWEST DOES DELIVER A RARE AND FORMAL APOLOGY

FOR THE MISTAKES THAT COST

18-YEAR-OLD CHRISTIANA SHEPHERD HER LIFE.

Goldman: MY NAME IS RON GOLDMAN, AND MY ROLE HERE TODAY

IS I WILL BE INTRODUCING THE PUBLIC APOLOGY,

AND THEN I'LL HAVE A FEW WORDS...

THE PUBLIC APOLOGY IS, IN AVIATION CASES, UNPRECEDENTED.

Greg Stephens: WE'RE HERE TODAY

TO REMEMBER THE VICTIMS

OF FLIGHT 5481,

AND TO OFFER OUR APOLOGIES, OUR CONDOLENCES,

AND SINCERE SYMPATHY TO THE SURVIVING FAMILY MEMBERS

OF THE PASSENGERS AND CREW WHO PERISHED IN THE JANUARY 8, 2003,

CRASH OF AIR MIDWEST FLIGHT NUMBER 5481.

Goldman: THE ACCEPTANCE OF ACCOUNTABILITY SUGGESTS

THAT THE RECOMMENDATIONS MADE BY THE SAFETY INVESTIGATORS

ARE NOT TO BE TAKEN AS A BOOK TO THROW IN A DRAWER

AND FORGET ABOUT, BUT ARE TO BE TAKEN SERIOUSLY,

BECAUSE IF YOU DON'T TAKE THEM SERIOUSLY,

THERE'S GOING TO BE PUBLIC ACCOUNTABILITY,

AS WELL AS PRIVATE ACCOUNTABILITY.

Ward: WHAT PEOPLE SHOULD NEVER FORGET IS THAT

AS WE'RE GOING ABOUT AND DOING OUR JOB DAY-TO-DAY,

WE NEED TO REMEMBER THE IMPORTANCE OF DOING OUR JOB.

IT DOESN'T MATTER WHERE WE'RE AT ON THE LADDER,

OR THE CORPORATE LADDER,

WHETHER WE'RE AT THE BOTTOM RUNG OR THE TOP RUNG,

WE HAVE RESPONSIBILITIES.

Narrator: IT TOOK A COMPLICATED STRING OF ERRORS

AND MISCALCULATIONS TO BRING DOWN FLIGHT 5481.

BUT SOME BELIEVE THERE WAS ONE PERSON

WHO PERFORMED ADMIRABLY THAT DAY, CAPTAIN KATIE LESLIE.

WITH AN UNBALANCED PLANE AND FAULTY CONTROLS,

CAPTAIN LESLIE COULD NOT HAVE SAVED THE FLIGHT.

BUT HER FINAL ACTIONS MAY HAVE SAVED SOME LIVES.

Overcash: YOU KNOW, SHE'S AN UNSUNG HERO TO ME.

SHE KEPT IT FROM, REALLY,

MORE OF A HEAD-ON HIT INTO THE HANGAR.

WHICH PROBABLY SAVED COUNTLESS OTHER PEOPLE

FROM PERISHING THAT DAY.

Narrator: IT WAS FIREFIGHTER CINDY OVERCASH

WHO FOUND THE BODY OF CAPTAIN KATIE LESLIE AMONG THE WRECKAGE.

TO THIS DAY, OVERCASH STILL FEELS A SPECIAL CONNECTION

TO THE YOUNG PILOT.

Overcash: I DON'T KNOW, I JUST FELT A KINSHIP,

I DON'T KNOW WHY, I DON'T KNOW, I--YOU KNOW.

IT COULD BE AS SIMPLE AS I FOUND HER,

AND I WAS THERE WHEN SHE LEFT THIS WORLD.

Narrator: LORINDA WARD'S INVESTIGATION COULD HAVE ENDED

WHEN SHE UNCOVERED THE ERRORS

THAT CAUSED THE CRASH OF FLIGHT 5481.

BUT BY DIGGING A BIT DEEPER,

SHE MADE FLYING SAFER FOR MILLIONS OF PEOPLE.