Original subtitles

NARRATOR: A deadly air crash in Brazil

leaves a neighborhood in flames.

INTERPRETER: It looked like a bomb had gone off.

NARRATOR: The Black box data is baffling.

Look at engine number 2.

The power is all over the place.

I was amazed because that's just not supposed to happen.

NARRATOR: To solve the crash of TAM 402,

investigators will need to try something different.

Let's see what we got.

NARRATOR: Something that's never been done before.

And it proved to be very revealing.

Oh, no.

Don't tell me.

ANNOUNCER: Ladies and gentlemen,

we are starting our approach.

We lost both engines.

Keep your mask up your nose.

Emergency descend. - Mayday!

Mayday!

Brace for impact!

He's the last one.

Investigation started in 2004.

He's going to crash.

NARRATOR: Sao Paulo, Brazil, is the largest

city in South America.

With 16 million residents, morning rush hour

is always a crawl.

The traffic overhead is busy too.

Residential neighborhoods are packed

tied around Congonhas Airport, one of Brazil's busiest hubs.

Jorge da Silva and his family lived

just a stone's throw away from the airport terminal.

INTERPRETER: My family has always

lived in this neighborhood, all of us,

even after we grew up and got married.

When we left our parents' homes,

we bought houses in the surrounding area.

NARRATOR: Every day, more than 500 flights

come and go from this airport.

INTERPRETER: When we were kids, watching a plane go by

would give us a feeling of freedom, a desire to fly.

Seeing those machines in flight is a fantastic thing.

NARRATOR: Today, 89 passengers are

getting ready for a short hop from Sao Paulo

to Rio de Janeiro.

They're flying on TAM airlines.

The Brazilian company has just won

an award for best regional carrier

and wants everyone to know it.

INTERPRETER: The number one painted on the plane

was part of an ad campaign TAM had underway at the time,

promoting its business and its aircraft.

No problem, but I should go.

I'm on board right now.

NARRATOR: Regina Lemos is a Brazilian journalist.

She's on her way to Rio to cover a fashion show.

INTERPRETER: My sister was a standout in her field.

She'd been an editor at Marie Claire Magazine

and was working on the launch of a new magazine.

She traveled a lot, covering stories,

reporting, interviewing.

Good morning. How are you doing?

Great.

NARRATOR: One of TAM's most experienced pilots

is in command.

José Antonio Moreno has almost 6,500 flight hours.

Before we start, checklist?

Yes, captain.

Already done.

Good.

Go ahead and call the tower so we

can get these engines started.

You got it.

NARRATOR: First officer Ricardo Luis

Gomes is less experienced.

The 27-year-old has only been qualified to fly

the Fokker 100 for one week.

Sao Paulo TAM 402, we're ready to go

and requesting engine start.

AIR TRAFFIC CONTROLLER: TAM 402, you're clear to start.

Fire them up.

Starting number one, starting engine two.

NARRATOR: The short-haul jet is powered

by twin Rolls-Royce engines.

Yeah.

All right, I'll put it away now.

NARRATOR: Ronaldo Jenkins is not only Regina's brother.

He's also an aviation expert.

INTERPRETER: It's a short flight, 35 minutes normally

from Sao Paulo to Rio, and you have approximately

five flights every hour.

So it's a very busy route.

AIR TRAFFIC CONTROLLER: TAM 402, you're cleared

for takeoff runway 17, right.

OK.

Here we go.

Take off the rust.

NARRATOR: It's 8:26 AM, flight 402 is underway.

Well, as you roll down the runway,

we typically will accelerate the aircraft to a point

that we call V1, that is a decision speed at which

the flight crew makes the decision to either reject

the takeoff, that is to abort the takeoff

or continue it with the amount of runway remaining.

NARRATOR: As they accelerate down the runway,

the crew gets a warning.

Hey, this is what?

It's out.

See, the autothrottle is up.

A single chime warning is really of no consequence

during the takeoff roll.

At that point, it wasn't something that they would

have rejected the takeoff for.

NARRATOR: Two more beeps tell them the problem is affecting

their other engine as well.

The autothrottle is out.

Manual thrust.

NARRATOR: They'll have to adjust engine power by hand.

They could certainly continue to take

off in the manual mode.

Nothing to be alarmed with at that point.

V1 rotate.

NARRATOR: It seems like a routine takeoff.

At that moment, the aircraft's climbing.

The nose attitude of the aircraft is raising.

The aircraft is accelerating, and the altitude

is increasing.

Those are all good positive parameters.

No, no, no, no.

NARRATOR: Then, less than 50 feet in the air,

the plane rolls dangerously right.

The captain needs to level the plane fast.

The timing of this could not have been worse.

The aircraft is dissipating energy, airspeed at a rate

of about two knots per second.

Speed is life.

So the resolution of this malfunction

is super critical in terms of time.

NARRATOR: The captain's efforts start to pay off.

The wings move back towards level.

What was that?

NARRATOR: It's a brief reprieve.

The airspeed is dropping dangerously low.

Worse, the captain can't keep the plane level.

DEVICE: Terrain.

Terrain.

It has to be an absolutely sick feeling for that flight

crew at that point.

DEVICE: Terrain.

Terrain

NARRATOR: Just 25 seconds after takeoff, flight 402

hits the ground.

In an instant, the Jabaquara neighborhood is in ruins.

A passenger jet has fallen from the sky.

Houses are crushed, streets are in flames.

Emergency crews respond quickly,

but there's little hope any of the 95 people on board

have survived.

There are also expected to be many casualties on the ground.

News of the horrific crash spreads quickly.

INTERPRETER: My brother phoned me and said

a plane fell in your house.

Come quickly.

NARRATOR: Jorge da Silva races home, unsure what to expect.

INTERPRETER: My brother is a bit of a joker.

I didn't believe him at first, but I could

hear the fear in his voice.

NARRATOR: Jorge's parents are trapped

at the center of the disaster.

The elderly couple finds their way is blocked,

their escape route engulfed in fire.

INTERPRETER: My father looked back and saw

the room being destroyed.

So they rushed downstairs to the ground floor,

and he saw flames in front of them.

NARRATOR: If they don't get out soon, it could be too late.

Jorge da Silva arrives home to a scene of devastation.

His neighborhood is in flames, and he

has no idea if his parents are alive or dead.

My parents, have you seen them?

INTERPRETER: It looked like a bomb had gone off.

There was fire burning throughout the whole street,

tall flames, lots of smoke, and twisted metal.

It was terrible, like something I'd

only ever seen in war movies.

NARRATOR: The plane's jet fuel has ignited an inferno.

INTERPRETER: There was a river of fire,

a line of flames down the middle of the street

burning all the parked cars.

It was hard to believe it was real that it

was actually happening.

NARRATOR: That as Silvas make a narrow escape out

of the back of their house.

They are later reunited with their family.

INTERPRETER: It was a very emotional moment

that's difficult to describe.

In a short time, I went from a sensation

of having lost them that they were dead to having

found them again.

That was a rebirth.

It was fantastic.

NARRATOR: Others are not so lucky.

Many of Jorge's neighbors are injured, four of them fatally.

The crash has also killed all 95 people who were on board

the plane.

INTERPRETER: I got a call from my son

saying that he'd seen on TV that Regina, my sister,

was on the plane.

I knew there were no survivors.

That's when I realized she was dead.

NARRATOR: Shortly after the disaster,

Jenkins is asked to investigate the TAM crash

for an insurance company.

The death of his sister makes that impossible.

INTERPRETER: I had to contact the insurance company

to say that I just couldn't do the job

since I was now emotionally involved in the case.

NARRATOR: Across Brazil, the enormity of the disaster

sinks in.

It's the worst air crash in Sao Paulo's history.

INTERPRETER: This tragedy was a critical event in the history

of Brazil because it was in a city,

especially the biggest city in the country,

it affected everyone.

NARRATOR: Air crash investigators

from the Brazilian Air Force arrive at the crash site.

Major Carlos da Conceicao leads the team.

INTERPRETER: When I got there, it was really

a scene of total devastation.

The plane took down everything in its path,

houses, cars, everything.

It was like a war zone.

NARRATOR: He immediately realizes

the accident could have been even more devastating.

At least the kids were already in school.

NARRATOR: Flight 402 has crashed less than 60 feet

from an elementary school where 800 students were

attending morning classes.

INTERPRETER: It was truly surprising

that the streets were empty and there were so few victims.

For some strange reason, at that moment,

there weren't many people on the street.

Take your time.

We don't want to miss anything.

NARRATOR: Recovering all the wreckage

will be a lengthy process.

But for investigators, it's a crucial step.

INTERPRETER: First of all, you have to find

the pieces of the aircraft.

The engines, landing gear, the right wing, the left wing,

the tail section.

Is the airplane all there, or did a part

come off before the crash?

And you start to put together this puzzle.

NARRATOR: At the home of Jorge da Silva's parents,

the recovery team makes an incredible find.

The plane's landing gear has smashed through the roof

and crushed the da Silva's bed.

INTERPRETER: It was a miracle that they survived.

The landing gear of the plane, I learned later,

weighs about two tons.

If my parents had been there, they would have been killed.

NARRATOR: Piece by piece, all the major components

of the plane are found at the crash site.

OK, looks like we have the whole plane here.

NARRATOR: It's important confirmation

that the plane didn't lose any pieces while in the air.

We know that the aircraft departed control flight

at a very, very low altitude.

The first culprit in that type of instance

would be loss of thrust.

NARRATOR: Da Conceicao examines the Rolls-Royce

engines at the crash site looking for signs of failure.

But damage deep inside both engines

tells him they were spinning at high speed

when the plane hit the ground.

Burning and turning.

These engines were fine.

NARRATOR: Ruling out a potential cause

is a step in the right direction.

But investigators will need more

evidence before they can zero in on what

brought down flight 402.

We're going to head maybe just over there.

Can you keep those people back, please?

NARRATOR: Onlookers crowd the Sao Paulo crash site where

99 people lost their lives.

The city has declared three days of mourning.

Brazil's president pledges a safety

review of all city airports.

The pressure for answers is intense.

INTERPRETER: It was the first time I had ever

investigated a crash like this, and it

was really very difficult.

OK, so it was definitely rolling right like like this.

NARRATOR: Witnesses tell investigators

the plane was banking steeply to the right

just before the crash.

Any time you have witness statements that describe

the aircraft rolling or pitching

or observation of any moving flight control surface,

it perks the interest of the investigator.

NARRATOR: Shattered wreckage at the Jabaquara crash site

confirms the witness statements.

INTERPRETER: The right wing was found stuck in a building.

The aircraft sliced into it at an angle like a knife.

NARRATOR: A steep right roll would

have caused the wings to lose lift

and put the plane into a dive.

But why was the plane rolling so steeply?

Investigators wonder if there is a problem with the plane's

control surfaces, the flaps, and slats that pilots extend

from the wings during takeoff.

If the crew didn't set the flaps properly,

it might explain flight 402's fatal trajectory.

We do know that failure to deploy the flaps

or configure the aircraft properly for takeoff

has been involved with many, many mishaps.

NARRATOR: They focus on the mechanism that

moves the flaps in and out.

Precise measurements should tell them if the TAM

crew made a deadly error.

What they find rules out that possibility.

8 degrees, right where it should be.

NARRATOR: The plane was configured

properly for takeoff.

OK, mark it down.

8 degrees.

This is not-- this is not helping us.

Investigators will need to look elsewhere.

Yeah.

Check the records.

I want to know everything the pilots

did in the last 24 hours.

How well was a pilot trained?

Was he rested?

Had he eaten within the last several hours?

Everything that makes the man-machine interaction work,

we want to find out what went into that machine

prior to the mishap.

The records look fine.

NARRATOR: A comprehensive review of the cruise records

turns up no red flags.

The crew was well-rested and fully

qualified to fly the plane.

A good investigator will take every bit of evidence

he can put together and make a puzzle

and fit the piece of the puzzle,

so it fits the scenario rather than the scenario

trying to fit the malfunction.

NARRATOR: Investigators hope the black boxes will

fill in some missing pieces.

This one's in good shape.

NARRATOR: The cockpit voice recorder looks promising,

but the flight data recorder, which

tracks the operation of aircraft systems,

is badly burned.

Let's hope this isn't as bad as it looks.

INTERPRETER: It was no longer that orange color, which is

characteristic of black boxes.

It was completely gray from all of the fire damage.

I was really anxious to know if the data had survived or not.

OK, come on.

I need to get these to the states.

NARRATOR: Brazil doesn't have a lab equipped to analyze

the damaged recorder.

So they need to be sent somewhere that does.

It was a US-manufactured flight recorder,

so it was obvious to bring the recorder to the United

States for analysis.

NARRATOR: Dennis Grossi is quickly recruited to the team.

He's an investigator with the National

Transportation Safety Board.

Thanks for helping us.

Of course.

Sure.

Happy to help.

NARRATOR: He's also one of the world's leading experts

on flight recorders.

Let's see if this will work like it's supposed to.

NARRATOR: But with this recorder,

he faces a new challenge.

It's a digital device.

And at 1996, digital technology is not very common.

We had a long experience with tape recorders,

but we had no experience with solid-state recorders.

And it was heavily fire-damaged.

So we thought it was prudent to take it to the manufacturer

to use their expertise in opening it and accessing

the solid-state memory.

OK.

Here we go.

NARRATOR: The data inside could be a huge windfall

for the investigation.

Nice and easy.

NARRATOR: But getting to it is a delicate matter.

There's always that anticipation.

Is it going to be destroyed, or is it pristine?

What condition is the memory in?

Are we going to come up empty-handed,

or are we going to have a viable piece of evidence here?

It looks promising.

Fingers crossed.

The vulnerabilities was the chips breaking.

If you crack a chip, it's done.

Or if the chips come off the board,

and then you have to do a chip-level recovery,

which is very, very difficult.

NARRATOR: They hook the card up to a computer

and attempt to download.

Does it always take this long?

NARRATOR: The data has survived.

Never had a moment's doubt.

The fire protection and the crash impact

protection worked.

We were very happy at that point.

NARRATOR: All of Brazil wants to know

why flight 402 crashed.

Somewhere in the download data, investigators

may now have the answer.

It's been three days since TAM flight 402 crashed on takeoff.

Now with the help of black box data,

investigators may soon know why.

The flight recorder has captured

dozens of parameters about the Fokker 100 short flight.

INTERPRETER: This specific recorder

has 106 parameters, 106 sensors on the aircraft,

which give us information.

So it's important, very important, to have

this initial information in our job.

No, no, no, no.

NARRATOR: But will it be enough to tell

them why the plane rolled so suddenly out of control?

As they study the data, investigators immediately

noticed something unusual.

Look at Engine number two.

The power's all over the place.

The fact that the thrust was was increasing and decreasing,

increasing, decreasing, and then finally full thrust

was very confusing.

Why would this happen?

NARRATOR: After fluctuating several times,

the engine finally reaches full power,

the usual setting for takeoff.

It wasn't clear exactly what was causing this.

Could it be a automated system that

was malfunctioning and causing this to happen,

or was it some crew activity?

Can you bring up all the data on the thrust reversers?

NARRATOR: There's another parameter investigators

are eager to see.

OK, so you saw something moving

at the back of the engine?

NARRATOR: A witness told investigators

he saw one of the plane's thrust reversers

operating just before the crash.

Thrust reversers are buckets deployed

on landing to redirect the flow of engine exhaust,

pushing it forward to help the plane slow down.

Pilots never used them in the air.

Witnesses saw that the buckets

opening and closing, opening and closing,

and then finally opening.

INTERPRETER: This was a real surprise to everyone

because the reverser is an aerodynamic brake,

which is used on landing.

Why would it open during takeoff?

NARRATOR: If a thrust reversers did somehow deploy in flight,

it could easily cause the type of steep right

roll that doomed flight 402.

For investigators, witness accounts aren't enough.

They need hard evidence.

They soon find it in the flight data.

There.

NARRATOR: Just after takeoff, the right thrust

reversers moves back and forth twice

and then stays in the dangerous deployed position.

This shouldn't even be possible.

I was amazed because that's just not supposed

to happen, especially in a critical phase

of flight like takeoff.

NARRATOR: The thrust reversers system

includes a safety feature designed

to prevent accidental deployment in the air.

The plane's wheels must be firmly on the ground

before the buckets will open.

There's a switch called a weight and wheel switch

that, once it was compressed, once the aircraft touched

down, would allow the pilots to manually

open the thrust reversers.

That was by design.

NARRATOR: Airlines all over the world fly Fokker airplanes.

If there's a design flaw in the reversers system,

the lives of thousands of passengers could be in danger.

It's extremely important that the operators know

of any malfunctions so they may apply

that knowledge to how they're operating

their particular fleet.

American Airlines, US Airways were

big operators of the F-100.

It was critical that information

was disseminated worldwide to all the operators.

NARRATOR: Investigators test the actuators that

move the reversers, looking for a failure

that might explain why one of them opened during flight.

But there's no sign of any malfunction.

The movement of the thrust reversers

it was a big mystery at first.

NARRATOR: They also test the electronics

that detect when the plane's wheels

are safely on the ground.

They need to check every circuit.

The exhaustive effort pays off with the discovery

of a faulty sensor.

It was failing intermittently, signaling the reverse

here to open and close.

The result was chaos in the cockpit.

The sensor failure was intermittent.

So the buckets opened and closed and opened again.

Every time those buckets would open and close,

a different yaw moment would be applied to the aircraft.

Every one of those yaw moments would have to be

countered by the captain.

It was very, very involved and very dynamic situation

at a very low altitude and very low airspeed environment.

NARRATOR: But there's one big problem with what

investigators have uncovered.

The Fokker 100 has an additional safety net

that should have kept the plane safe

even after the sensor failed.

If a faulty thrust reversers deploys on takeoff,

power to the affected engine is supposed

to drop to idle automatically to prevent the reversal

from acting as a brake.

No alarm sounds in the cockpit, but the safety

system kicks in immediately.

The pilots don't have to do a thing.

If there is an uncommanded trust reversal deployment,

the system would automatically retard

the thrust level back to idle without any crew involvement.

The Fokker 100 has more than enough power to climb

safely on just one engine.

So the question remains, why didn't flight 402 make

it safely away from Congonhas?

OK.

Go ahead, please.

The cockpit voice recording may be investigators only hope

of finding the answer.

OK, here we go.

Takeoff thrust.

Clearing for takeoff.

NARRATOR: Investigators listen intently

to the sounds captured in the cockpit of flight 402.

INTERPRETER: When we started listening to the tape,

everything seemed normal during the beginning of the takeoff.

The equipment, the pilots, everything

was as it should be.

Hey, this is what?

NARRATOR: Then, four seconds later,

the crew gets a warning.

PILOT ANTONIO MORENO (ON RECORDER): It's out.

See, the autothrottle is out.

It's a minor issue.

It shouldn't matter.

INTERPRETER: Captain Moreno speaks

calmly to the co-pilot, who he realized

was new to this plane.

He calmly tells him that the autothrottle is out and keeps

going with the takeoff.

Why is he so calm and not doing anything?

Because the disconnection of the autothrottle

does not impede takeoff.

NARRATOR: As the plane accelerates down the runway,

the pilots seem perfectly in control.

Rotate.

NARRATOR: But not long after liftoff,

the mood in the cockpit changes dramatically.

PILOT ANTONIO MORENO (ON RECORDER): No, no, no, no.

He sounds like he's fumbling with something.

It's locked.

What's locked?

PILOT ANTONIO MORENO (ON RECORDER):

Turn it off up there, autothrottle.

Pull here.

FIRST OFFICER GOMES (ON RECORDER): It's off.

It sounds like the crew thought the problem

was the autothrottle.

NARRATOR: The pilots don't mention the reverser at all.

They're focused on the autothrottle

and seem to be struggling with cockpit controls.

Turn it off up there.

Here too.

It's off!

It's off!

NARRATOR: There was no alarm to tell

them a reverser had deployed.

DEVICE: Terrain.

Terrain.

Those guys had no idea what was going on.

NARRATOR: It's clear to investigators

that the crew was confused, but they still

don't know what the crew was doing

in those crucial last seconds.

You want to get clear what, in fact, happened so

that this won't happen again.

NARRATOR: To build a more detailed picture,

Dennis Grossi tries something new.

He combines the flight data with the cockpit

voice recording to create a real-time animation

of the flight.

OK.

Take up speed was 127 knots.

It's something that, at that point, the NTSB had never done

and it proved to be very revealing.

Let's see what we got.

INTERPRETER: You can evaluate second by second what happened

during the accident, which helps us a lot

in recreating the events.

NARRATOR: The new animation reveals an astounding

detail about how the crew reacted

when the reverse are deployed.

PILOT ANTONIO MORENO (ON RECORDER): No, no, no, no.

It's locked.

Hold it.

He must be reacting to the movement of the thrust lever.

No, no, no, no.

The automation just moved it to idle

just like it's supposed to.

NARRATOR: The sudden loss of thrust in the right engine

indicates that the safety system responded correctly

when the reverser deployed.

Turn it off up there, autothrottle.

Pull here.

It's off.

But the pilots misinterpret the lever's movement.

Oh, no.

Don't tell me.

NARRATOR: They think it's a malfunction

that a faulty autothrottle is cutting engine power.

Tragically, they tried to override the system.

I think the first officer is deliberately putting

the engine back to full power.

They, in fact, had ended up with the thrust reverse fully

open and with full thrust on that engine where the thrust

reversers were open.

Turn it off up there. Here too.

It's off.

It off.

NARRATOR: With one engine at full forward power

and the other in full reverse, the plane

quickly rolls uncontrollably into a fatal dive.

DEVICE: Terrain.

Terrain.

Once you put the engine back to full power,

they didn't stand a chance.

NARRATOR: The animation helps reveal

that the crew's actions played a tragic part

in the crash of TAM 402.

But it raises new questions as well.

Why was the crew so confused about an automated system

designed to help save their plane?

There's still a missing piece to this puzzle.

The thought came, why?

How did this happen?

How did the crew not understand what was happening to them?

Let's see how much time these guys spent training for this.

NARRATOR: da Conceicao wants to know how the airline

trains its pilots to deal with accidental

reversal deployments.

INTERPRETER: We found out that TAM had consulted with Fokker

to find out whether there was any need

to train for a reverser deployment during takeoff.

NARRATOR: Fokker's response is a key piece of this puzzle.

A failure so rare they decided not to train for it.

INTERPRETER: Fokker formally responded,

saying the training was not necessary

that the probability that the reversers would open

during takeoff was very small, and this training

was not necessary.

NARRATOR: Fokker estimated the chance of such a failure

was less than 1 per billion flight hours.

Turn it off up there, autothrottle.

Pull here.

It's off.

NARRATOR: The pilot's confusion starts to make sense.

For the crew not to know that the thrust of reverser

deployment would, in fact, pull the throttle back,

in this case, that lack of training

really put the flight crew in a bad situation.

Turn it off up there.

Here too. - It's off.

It's off.

NARRATOR: Confused and untrained,

the first officer restores the full power he

thinks they need for takeoff.

Unfortunately, they didn't have

enough information to make the right decisions

at the right time.

NARRATOR: There's another troubling mystery to solve.

What went wrong with this safety system?

NARRATOR: That safety system should be foolproof.

The first officer should not have been able to overpower

the automation and push the thrust lever to full power,

yet somehow he did exactly that.

The question is how.

The levers are here.

NARRATOR: Investigators trace the components of the safety

system, including the cable that

pulls the thrust lever back during

an accidental deployment.

It runs from the thrust lever all the way to the reverser.

It was very important to, in fact, examine the cable.

What condition was it in?

And the seeing why their throttles

behaved the way they did and the thrust behaved the way

it did.

This connects to the faulty reverser?

NARRATOR: The cable is in good condition,

except for one problem.

It has come apart at a connection point.

It's a baffling discovery.

The cable is designed to withstand an overwhelming 632

pounds of force.

I don't see how a pilot could pull that hard.

Let's set up a test.

There's something I want to try.

NARRATOR: Investigators decide to put an identical cable

to the test.

They pull against the cable from both ends.

Not only where it connects to the thrust levers

but also from the opposite end where it attaches

to the thrust reversers.

They'll soon know exactly how strong

the cable system really is.

The safety cable system from the Fokker 100 strains as it's

pulled apart with more and more force.

Then at over 900 pounds of force, it can take no more.

The cable actually failed at a quick disconnect that

was supplied to allow for maintenance so you could

disconnect and reconnect fairly fast,

and that actually turned out to be

the weak point in the system.

NARRATOR: But even with the weak link,

the cable withstood more force than the first officer

alone could have applied.

Then, in terms of design limits,

one of the first questions I would have

is how were they exceeded?

How did this component actually fail?

NARRATOR: Investigators propose an astonishing new hypothesis

to explain what happened.

It began with the electrical failure.

NARRATOR: A failed sensor disables

the lock on the right-side thrust reverser.

The autothrottle disconnects so that the safety

system can assume control of engine power.

After takeoff, the reverser deploys.

No, no, no, no.

NARRATOR: The safety system pulls back the engine power,

but the crew doesn't know what's happening,

and there's no cockpit alarm.

PILOT ANTONIO MORENO (ON RECORDER):

Turn it off up there. Here too.

FIRST OFFICER GOMES (ON RECORDER): It's off.

It off.

PILOT ANTONIO MORENO (ON RECORDER): Oh, God.

Three times, the safety system pulls back the power,

and three times the first officer puts the engines back

to full power.

NARRATOR: Investigators conclude that when the thrust

lever snaps to idle for the last time,

the first officer holds it forward with all his might.

It's a natural response.

The object is to get the airplane as high

and fast as you possibly can.

Given the information that this flight crew had,

I would venture to say that 99% of all flight crews

would have reacted exactly the same way.

NARRATOR: With the throttle held forward, the next time

the reverse cycles open, the first officer

is pushing while the automation is pulling.

The combined force is stronger than the designers

ever anticipated.

It pulls the cable apart.

You had the thrust reversal buckets

fully deployed and full thrust on one

engine in reverse and full thrust on the other engine

in forward.

NARRATOR: The plane rolls violently to the right.

The captain fights to level the plane,

but his years of experience aren't enough.

INTERPRETER: Once the cable breaks,

the accident is inevitable.

At that point, they had no options.

They did everything they humanly could.

NARRATOR: Investigators conclude

the crash was caused by a rare combination of failures.

All of them contributing to an accident that

should have been impossible.

INTERPRETER: The first thing to learn from this investigation

is that nothing is fail-safe.

We need to have guidelines, information, and training

to help pilots respond to an emergency situation,

no matter how unlikely that emergency might be.

NARRATOR: After the crash, TAM airlines added new training

to teach its pilots how to respond if a reversal

deploys during takeoff.

Fokker improved its thrust reversal system.

They also modified the cockpit alarm

so that pilots will now get a warning if a reverse air

deploys on takeoff.

INTERPRETER: An investigation from which nothing is learned

has no value.

The importance is in learning and improving what we do.

INTERPRETER: Whenever we investigate accidents,

we are always searching to understand why.

We want to try and make sure such accidents never

happen again.