Original subtitles

*

Narrator: ON EVERY FLIGHT, PASSENGERS PLACE THEIR LIVES

IN THE HANDS OF THEIR CAPTAIN...

Captain: UNDERCARRIAGE UP.

Narrator: ...WHO CARRIES THEM INTO THE SKY...

Captain: CLEARED FOR TAKEOFF, THANK YOU.

Narrator: ...AND BRINGS THEM SAFELY BACK TO EARTH.

Captain: UP TO 6-0.

Narrator: AN EPIC ENDEAVOR CARRIED OUT

BY A HIGHLY TRAINED MAN OR WOMAN.

Man: THE IDEA OF THE COMMANDER BEING MORE OF A KING,

MORE OF A GOD-LIKE INDIVIDUAL WHO COULDN'T MAKE A MISTAKE,

AND NOBODY'S LIKE THAT.

Narrator: 1972, ENGLAND.

A PLANE CRASHES SHORTLY AFTER TAKEOFF.

Man: THAT CAN'T BE RIGHT.

Narrator: IN NORTHERN MINNESOTA,

A PILOT MISSES THE RUNWAY, KILLING EVERYONE ON BOARD.

Man: IT REALLY WAS ONE OF THE MOST DIFFICULT ACCIDENT SITES

I'D EVER BEEN TO.

Narrator: DURANGO, COLORADO.

Officer: DAMN! WE'RE TOO LOW.

Captain: PULL UP!

Man: THAT WAS GONNA BE THE BIG MYSTERY HERE

TO TRY TO UNDERSTAND.

Narrator: IF THE PERSON AT THE CONTROLS IS SO HIGHLY TRAINED,

THEN WHY DID THESE TRAGEDIES HAPPEN?

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 INTO THIS TRAGEDY...

Man: HE'S GONNA CRASH!

*

Narrator: PILOTS ARE TRAINED TO HANDLE

ALL SORTS OF EXTERNAL THREATS AND HAZARDS,

BUT SOMETIMES IT'S THE PERSONAL PROBLEMS--

IMPATIENCE, ARROGANCE, INCOMPETENCE--

THAT LEAD TO TRAGEDY.

IN 1972, THE HAWKER SIDDELEY TRIDENT

IS THE PRIDE OF BRITISH AVIATION.

Stanley Key: BEALINE 548 REQUESTING START.

Narrator: THE CREW OF BRITISH EUROPEAN AIRWAYS FLIGHT 548

IS COMPLETING FINAL PREPARATIONS FOR AN AFTERNOON FLIGHT

FROM LONDON'S HEATHROW AIRPORT TO BRUSSELS.

Jeremy Keighley: IT LOOKS LIKE THE WEATHER'S

GONNA GIVE US A BUMPY RIDE TODAY.

Controller: BEALINE 548 CLEARED FOR START.

Narrator: CAPTAIN STANLEY KEY WAS CALLED INTO WORK

ON HIS DAY OFF.

KEY IS A FORMER RAF PILOT

AND ONE OF THE AIRLINE'S MOST QUALIFIED CAPTAINS.

Key: STARTER MASTER, ON.

Colin Wright: CAPTAIN KEY HAD BEEN ON THE AIRCRAFT

FOR A LONG TIME, SO HE WAS VERY EXPERIENCED,

AND IF YOU EXPECTED TO FLY WITH HIM,

YOU EXPECTED TO FLY TO THE BOOK

AND TO DO IT ACCURATELY WITH NO ARGUING.

Narrator: TODAY, CAPTAIN KEY HAS HAD TO WAIT FOR ANOTHER CREW

CATCHING A LIFT TO BRUSSELS.

Key: HAVE A SEAT, CAPTAIN.

BEALINE 548 READY FOR TAKEOFF.

Controller: BEALINE 548 CLEAR FOR TAKEOFF.

Key: 548.

MAXIMUM THRUST.

[ENGINES WHIRRING]

Keighley: STOPWATCH ON.

Officer: ROTATE.

Narrator: ONCE THE TRIDENT HAS GAINED ENOUGH ALTITUDE,

THE CREW WILL HAVE TO THROTTLE BACK SLIGHTLY.

THEY'LL BE FLYING OVER THE SMALL TOWN OF STAINES,

WHICH LIES VERY CLOSE TO THE AIRPORT.

Wright: IT'S A VERY NOISY ENGINE

WITH A PARTICULARLY NASTY CRACKLE TO IT,

SO NOISE ABATEMENT WOULD BE AN ISSUE.

Narrator: CREWS ARE REQUIRED TO MINIMIZE AIRCRAFT NOISE

OVER POPULATED AREAS.

Key: UNDERCARRIAGE UP.

[BEEP]

Narrator: FIRST OFFICER JEREMY KEIGHLEY

PREPARES TO THROTTLE BACK THE ENGINES.

IF HE DOES IT TOO SOON,

THE PLANE WON'T HAVE ENOUGH POWER TO CLIMB.

Keighley: 75 SECONDS.

90 SECONDS.

Narrator: IF HE'S LATE, THE CREW WILL VIOLATE NOISE RESTRICTIONS.

RIGHT ON TIME, KEIGHLEY THROTTLES BACK.

Key: PASSING 1,500 FEET.

Narrator: THE TOWER CLEARS THEM TO A HIGHER ALTITUDE.

Key: UP TO 6-0.

[ALARM]

Narrator: SUDDENLY...

Officer: WHAT WAS THAT?

Narrator: THE PLANE BEGINS TO LOSE ALTITUDE

AND PLUMMETS LIKE A ROCK.

Officer: LOOK AT THE SPEED! LOOK AT THE SPEED!

Wright: THE AIRSPEED DROPPED QUITE RAPIDLY.

IT WAS IN A VERY HIGH RATE OF DESCENT.

THE PILOTS WERE JUST PASSENGERS IN THEIR OWN AIRCRAFT.

[SCREAMING]

[ALARM BUZZING]

[SCREAMING]

Narrator: ALL 118 PEOPLE ON BOARD ARE KILLED.

THE PLANE MISSED THE TOWN OF STAINES BY A FEW YARDS.

David Learmount: THIS ACCIDENT WAS PRETTY HORRIFYING

BECAUSE IT WAS THE WORST AIRLINE ACCIDENT

THAT BRITAIN HAD EVER EXPERIENCED,

AND BEA WAS RECKONED IN THOSE DAYS

TO BE THE KIND OF AIRLINE THAT JUST DIDN'T HAVE CRASHES,

AND THIS TIME THEY DID.

Newscaster: FLIGHT BE 548, EN ROUTE TO BELGIUM,

CRASHES IN A FIELD NOT FAR FROM HEATHROW

AND ONLY A FEW FEET FROM HOUSES AND THE MAIN ROAD.

Narrator: A TEAM FROM BRITAIN'S ACCIDENTS INVESTIGATION BRANCH

REACHES THE CRASH SITE.

INVESTIGATORS ARE STRUCK BY SOMETHING UNUSUAL.

IN MOST ACCIDENTS, MOMENTUM CARRIES THE WRECKAGE FORWARD

AFTER IT HITS THE GROUND.

THE CRASH AT STAINES IS DIFFERENT.

AFTER IMPACT, THE TAIL BARELY SLID FORWARD.

Chris Pollard: THE REST OF THE AIRCRAFT

PROBABLY HADN'T MOVED FORWARD MORE THAN ABOUT 50 YARDS,

YOU KNOW, WHICH FOR SUCH A HEAVY AIRPLANE

IS VERY, VERY LITTLE DISTANCE.

Narrator: IT'S A SURE SIGN THAT THE PLANE STALLED.

Learmount: AN AIRCRAFT STALLS WHEN IT'S FLYING TOO SLOWLY

TO GENERATE SUFFICIENT WIND OVER THE WINGS

TO GIVE IT LIFT.

WHEN THAT AIRCRAFT HIT THE GROUND,

IT WAS ACTUALLY SLIGHTLY NOSE UP.

IT WAS FALLING THROUGH THE SKY LIKE THAT.

Narrator: AN AIRPLANE CAN STALL FOR MANY DIFFERENT REASONS,

FROM ENGINE FAILURE TO PILOT ERROR.

TO DETERMINE THE CAUSE OF THE CRASH,

INVESTIGATORS FACE A HUGE HURDLE.

IN 1972, PLANES IN THE UNITED KINGDOM ARE NOT REQUIRED

TO CARRY COCKPIT VOICE RECORDERS.

INVESTIGATORS WILL HAVE TO RELY ON INFORMATION GLEANED

FROM THE TRIDENT'S FLIGHT RECORDERS

AND THE VAST JIGSAW PUZZLE OF DEBRIS

SALVAGED FROM THE WRECKAGE.

Peter Coombs: FOLLOWING AN IMPACT OF THIS SORT,

EVERYTHING IS COMPREHENSIVELY WRECKED AND JUMBLED UP,

AND MOST OF THE COMPONENTS ON THE AIRCRAFT,

PARTICULARLY THE ELECTRONIC COMPONENTS,

ALL LOOK VERY SIMILAR.

Narrator: EARLY IN THE INVESTIGATION,

SOMETHING DOESN'T MAKE SENSE.

Pollard: THAT CAN'T BE RIGHT.

Narrator: THE LEVER CONTROLS THE TRIDENT'S SLATS, OR DROOPS.

DROOPS INCREASE LIFT DURING TAKEOFF TO HELP THE PLANE CLIMB.

THEY SHOULD REMAIN EXTENDED UNTIL THE PLANE HAS REACHED

THE NECESSARY SPEED TO MAINTAIN LIFT.

BUT ACCORDING TO THE LEVER'S POSITION

AT THE TIME OF THE CRASH,

THE DROOPS HAD ALREADY BEEN RETRACTED INTO THE WING.

THIS WOULD HAVE BEEN TOO SOON

AND WOULD HAVE INSTANTLY PUT THE PLANE INTO A DANGEROUS STALL.

Coombs: HOW ON EARTH DID SOMEBODY MANAGE

TO RETRACT THE DROOP LEVER,

AND NOBODY NOTICED THAT THAT HAD HAPPENED?

AND IT DIDN'T MAKE A LOT OF SENSE.

Narrator: THERE'S NO WAY TO TELL

JUST BY LOOKING AT THE DROOP LEVER

WHETHER THE CREW RETRACTED IT BEFORE THE CRASH

OR IF IT WAS JOSTLED OUT OF PLACE

BY THE CRASH ITSELF.

IT MIGHT EVEN HAVE BEEN MOVED DURING RECOVERY OPERATIONS.

Pollard: HANG ON, WILL YOU?

WE HAD THE WHOLE OF THE DROOP SYSTEM LAID OUT ON TABLES

IN FRONT OF THE WING.

*

RETRACTED.

Learmount: THEY DETERMINED BY AN EXAMINATION OF THE WRECKAGE

THAT THE DROOPS HAD BEEN RETRACTED.

Narrator: THERE'S NO LONGER ANY DOUBT.

SOMEONE IN THE COCKPIT RETRACTED THE DROOP LEVER MUCH TOO SOON.

THIS PROMPTS URGENT QUESTIONS ABOUT THE CREW'S PERFORMANCE.

INVESTIGATORS FOCUS IN ON THE HIGHLY EXPERIENCED CAPTAIN KEY.

THEY STUDY THE CAPTAIN'S PREVIOUS FLIGHTS.

HE HAS AN IMPECCABLE REPUTATION, AT LEAST WITH MANAGEMENT.

Investigator: PUT UP THE PHOTO OF KEY.

NOW THE TRAY TABLE FROM THE WRECKAGE.

Narrator: THERE'S A PIECE OF WRECKAGE THAT RAISES QUESTIONS

ABOUT THE CAPTAIN'S REPUTATION WITH HIS COLLEAGUES.

Wright: AND THERE WAS SOME GRAFFITI SCRIBBLED,

WHICH GAVE A FEW RATHER FACETIOUS COMMENTS

OBVIOUSLY FROM A PILOT WHO'D BEEN SITTING IN THAT POSITION.

Key: BLOODY FOOLS.

Wright: IT SAID, "KEY MUST GO,"

AND THEN A FEW OTHER DEROGATORY COMMENTS ADDED AS WELL.

THERE WAS OVER 30 YEARS' DIFFERENCE BETWEEN CAPTAIN KEY

AND THE TWO OTHER MEMBERS OF HIS CREW,

AND THIS PRODUCES THE NATURAL DIFFERENCES

YOU HAVE BETWEEN A GENERATION,

ONE WHO REGARDS THE ELDERS AS OLD AND STUFFY

AND ONE WHO REGARD THE YOUNGSTERS

AS BEING YOUNG AND IRRESPONSIBLE.

THIS PRODUCED A GENERATIONAL GAP.

Narrator: DID SOME KIND OF GENERATIONAL FRICTION

ERUPT IN THE COCKPIT AND BRING THIS AIRPLANE DOWN?

[BEEPING]

INVESTIGATORS LOOKING AT THE CRASH OF BEA FLIGHT 548

WANT TO KNOW WHAT OTHER PILOTS THOUGHT

ABOUT CAPTAIN STANLEY KEY.

Investigator: I HEAR YOU'RE SOMEONE WE SHOULD TALK TO.

Pilot: YEAH. I NEED TO TELL YOU WHAT HAPPENED.

Narrator: PILOTS AT BRITISH EUROPEAN AIRWAYS

ARE ON THE VERGE OF A STRIKE.

CAPTAIN STANLEY KEY IS SEEN BY MANY AS A COMPANY MAN.

Wright: THERE WAS WORK-TO-RULE GOING ON.

MOST OF THE CO-PILOTS, WHICH INCLUDED ME,

WERE WORKING TO RULE,

AND HE THOROUGHLY DISAPPROVED OF THIS

AS NOT BEING A PROFESSIONAL WAY TO BEHAVE

AND WAS LEADING A CAMPAIGN AGAINST IT.

Narrator: ACCORDING TO WITNESSES,

THINGS CAME TO A HEAD 90 MINUTES BEFORE THE FLIGHT TO BRUSSELS.

Pilot: CAPTAIN KEY.

MAYBE THE BATTLE'S STARTING TO GO OUR WAY?

Key: WHAT DID YOU SAY?

Pilot: I, I JUST MEANT THAT...

Key: YOU KNOW THAT DURING THE WAR WE FLEW IN REAL BATTLES?

SELFISH, PAMPERED, IMMATURE CRYBABIES

MAKING A LOT OF RIDICULOUS DEMANDS.

Pilot: LOOK HERE, JUST BECAUSE YOUR LOT FLEW IN THE WAR--

Key: YOU UNGRATEFUL BASTARD!

IF YOU'RE FLYING THAT PLANE FOR MONEY,

THEN YOU'RE IN THE WRONG PROFESSION!

Pilot: I THINK WE BETTER AGREE TO DISAGREE.

Key: BUNCH OF FOOLS!

Narrator: THE ARGUMENT IS SO SEVERE

THAT INVESTIGATORS FACE A NEW POSSIBILITY.

DID THE CAPTAIN'S AGITATION INTERFERE WITH HIS ABILITY

TO FLY THE PLANE SAFELY?

Key: BLOODY FOOLS.

Controller: 548, CLIMB TO FLIGHT LEVEL 6-0, SQUAWK 6-6-1-5.

Narrator: POSSIBLY STILL ANGRY AND DISTRACTED...

Key: UP TO 6-0.

Narrator: ...HE MIGHT HAVE RETRACTED THE DROOP HANDLE

TOO EARLY WITHOUT BEING AWARE OF IT,

STALLING THE PLANE, TRIGGERING ALARMS.

Wright: IF YOU GO FROM WHAT IS APPARENTLY A NORMAL FLIGHT

INTO SOMETHING WHICH IS SERIOUSLY DANGEROUS,

IT WILL PRODUCE A SHOCK RESPONSE,

AND THAT MEANS YOUR ABILITY TO THINK CLEARLY

AND TO ACT DECISIVELY IS VERY DIFFICULT.

Narrator: THE TRIDENT IS NOT EQUIPPED

WITH A COCKPIT VOICE RECORDER,

SO INVESTIGATORS CAN'T KNOW FOR SURE

WHAT HAPPENED IN THE COCKPIT.

Key: BEALINE 548 READY FOR TAKEOFF.

Narrator: BUT THE CAPTAIN'S CONVERSATIONS

WITH AIR TRAFFIC CONTROL ARE RECORDED.

Controller: BEALINE 548, CLEAR FOR TAKEOFF 2-8 RIGHT.

Key: 548.

Narrator: THESE RECORDINGS DO NOT REVEAL

IF THE CAPTAIN RETRACTED THE DROOP LEVER TOO SOON,

BUT INVESTIGATORS NOTICE SOMETHING UNUSUAL.

Investigator: THE CAPTAIN SEEMS AWFULLY QUIET.

Key: UP TO 6-0.

Narrator: THE CAPTAIN'S RADIO CALLS

ARE SO INFREQUENT AND SO BRIEF,

THEY DON'T MEET AVIATION STANDARDS.

BUT THESE RECORDINGS PROVIDE NO CLUE

ABOUT WHY THE CAPTAIN SOUNDED SO RESTRAINED.

Investigator: WHAT WAS GOING ON IN THAT COCKPIT?

Narrator: THEN, A STARTLING DISCOVERY.

IT TURNS OUT CAPTAIN KEY HAD A SERIOUS HEART CONDITION

THAT HAD NOT SHOWN UP IN HIS REGULAR MEDICAL EXAMS.

Learmount: KEY HAD, WITHOUT EVEN KNOWING IT,

A CLOGGING OF THE CORONARY ARTERIES.

Key: YOU'RE NOT WORTHY OF THE WINGS ON YOUR UNIFORM!

Pilot: NOW, LOOK HERE, JUST BECAUSE YOUR LOT

FLEW IN THE WAR DOESN'T--

Key: YOU UNGRATEFUL BASTARD!

Narrator: AND THE AUTOPSY REVEALS SOMETHING ELSE.

PATHOLOGISTS BELIEVE THAT CAPTAIN KEY

SUFFERED HEART FAILURE SOMETIME WITHIN A TWO-HOUR WINDOW

BEFORE THE CRASH.

Key: UP TO 6-0.

Learmount: IF HIS BLOOD PRESSURE WAS PARTICULARLY HIGH

BECAUSE HE WAS AGITATED, IT MIGHT AFFECT HIS REASONING.

Coombs: HIS LEVEL OF PAIN WOULD HAVE INCREASED OVER THE PERIOD

UP TO A POINT WHERE HE WOULD HAVE BECOME

PARTLY OR TOTALLY INCAPACITATED.

Narrator: THE FORMER RAF PILOT WAS OLD SCHOOL.

IF HE WAS IN SEVERE PHYSICAL DISTRESS,

HE LIKELY CARRIED ON AND DID HIS DUTY,

NEVER ASKING HIS CREW FOR ANY HELP.

AND THIS RAISES A PARALLEL QUESTION.

THERE WERE OTHER QUALIFIED PILOTS IN THE COCKPIT THAT DAY.

[BEEPING]

Officer: WHAT WAS THAT?

Narrator: WHY DIDN'T ONE OF THEM DO SOMETHING TO SAVE THE PLANE?

Learmount: NEITHER CAPTAIN KEY NOR THE OTHER PILOTS

REALIZED THAT IT WAS THE RETRACTION OF THE DROOP

WHICH HAD CAUSED THE STALL

BECAUSE NOBODY ATTEMPTED TO PUT IT BACK DOWN AGAIN.

IF THEY HAD DONE, THEY COULD HAVE UN-STALLED THE AIRPLANE.

Narrator: INVESTIGATORS KEEP TURNING BACK

TO THAT ARGUMENT BEFORE TAKEOFF.

Pilot: LOOK HERE, JUST BECAUSE YOUR LOT--

Key: AND AS FOR YOUR REFUSAL TO FULFILL ALL OF YOUR DUTIES...

Narrator: INVESTIGATORS LEARN THAT AN HOUR AND A HALF

BEFORE TAKEOFF,

CO-PILOT JEREMY KEIGHLEY WITNESSED KEY'S OUTBURST.

Key: IF YOU'RE FLYING THAT PLANE FOR MONEY,

YOU'RE IN THE WRONG PROFESSION.

Narrator: THEY SUSPECT IT MADE A BIG IMPACT ON THE YOUNG PILOT.

Wright: HAVING WITNESSED AN OUTBURST LIKE THAT,

ONE CAN ONLY SURMISE THAT IF YOU ARE NEW TO THE FLEET,

YOU DON'T KNOW THE CAPTAIN,

YOU'RE SLIGHTLY UNCONFIDENT YOURSELF,

YOU MAY BE NERVOUS OF YOUR OWN PERFORMANCE.

Narrator: SHAKEN BY HIS CAPTAIN'S TEMPER...

Key: BUNCH OF FOOLS.

Narrator: ...KEIGHLEY MAY HAVE BEEN FAR LESS LIKELY

TO CORRECT HIS CAPTAIN'S ERRORS.

Learmount: IT WOULD CERTAINLY REINFORCE THE CONCEPT

THAT THE CAPTAIN WAS AUTHORITARIAN

AND NOT SOMEBODY THAT YOU SHOULD CHALLENGE LIGHTLY,

ESPECIALLY ON THAT DAY.

Narrator: THE CRASH OF BEA FLIGHT 548

WAS THE RESULT OF A TRAGIC COMBINATION OF HUMAN FACTORS

CENTERED AROUND THE CAPTAIN--

HEART FAILURE,

A LEVER MOVED TOO SOON,

AND CO-PILOT TOO JUNIOR OR TOO INTIMIDATED

TO STEP IN WHEN THINGS STARTED TO GO WRONG.

LESSONS LEARNED FROM BRITAIN'S DEADLIEST AIR DISASTER

HELPED TO CHANGE THE INDUSTRY.

COCKPIT VOICE RECORDERS ARE NOW STANDARD EQUIPMENT

IN ALMOST ALL COMMERCIAL PASSENGER PLANES.

Wright: THE MODERN AIRLINER IS OPERATED VERY, VERY DIFFERENTLY.

THE WAY THAT CREWS HANDLE THINGS IS IMPROVED.

IT'S A MUCH BETTER AND SAFER WORLD.

THE REGRET IS WE'VE HAD TO BUILD IT ON THE DEATH OF 118 PEOPLE.

Narrator: IN NORTHERN MINNESOTA,

A COMMUTER CRASH KILLS EVERYONE ON BOARD.

INVESTIGATORS THINK THE PROBLEM LIES IN THE COCKPIT.

Nance: YOU HAVE THE RESPONSIBILITY

AS A CAPTAIN OF CREATING AN INTERACTIVE TEAM

TO WHERE NO ONE ON THAT TEAM WOULD HESITATE TO SPEAK UP

IF YOU SAW, HEARD, FELT, OR EVEN INTUITED

THAT SOMETHING WAS WRONG.

Marvin Falitz: YOU DIDN'T CHECK THE DAMN EXTERIOR LIGHTS!

Narrator: NORTHWEST AIRLINK FLIGHT 5719

CRUISES ACROSS THE SKIES OF MINNESOTA.

FIRST OFFICER CHAD ERICKSON

IS TWO MONTHS INTO HIS FIRST AIRLINE JOB.

Craig Railsback: I'M SURE THAT CHAD WAS EXCITED.

THAT WAS THE FIRST STEP IN GETTING THE JOB

THAT WOULD LEAD YOU TO THE BIG JOB

TO FLY THE BIG IRON AT BIG AIRLINES.

Narrator: THIS IS THE FIRST TIME HE'S FLOWN A ROUTE

WITH AN OVERNIGHT STAY.

Chad Erickson: DO WE GET OUR OWN ROOM?

Falitz: NO, YOU'RE GONNA HAVE TO ROOM WITH ME.

AND IT'S ONLY A SINGLE BED,

SO YOU'LL HAVE TO CURL UP AT MY FEET.

OF COURSE YOU GET YOUR OWN ROOM.

YOU'RE UNDER CONTRACT NOW.

Narrator: ERICKSON'S CAPTAIN IS MARVIN FALITZ.

Malcolm Brenner: THE CAPTAIN GREW UP IN NEW YORK CITY.

HE WAS DESCRIBED AS HAVING A PERSONALITY

THAT WAS SOMEWHAT AT ODDS WITH A MIDWESTERN PERSONALITY.

Falitz: FREAKING COFFEE TASTES LIKE PISS.

Al Dickinson: HE HAD AN ISSUE WITH DEALING WITH OTHER PEOPLE.

Narrator: CAPTAIN FALITZ AND FIRST OFFICER ERICKSON

ARE FLYING A JETSTREAM BA-3100, A SMALL TWIN-ENGINE TURBOPROP.

Railsback: THE JETSTREAM WAS A HANDFUL TO FLY,

AND WE HAD TO FLY IT BY HAND ALL THE TIME.

Narrator: CRAIG RAILSBACK IS A FORMER NORTHWEST AIRLINK PILOT

WHO ALSO FLEW THE BA-3100.

Railsback: IT WAS FAIRLY UNSTABLE.

IT WAS LIKE BALANCING A BEACH BALL

ON TOP OF A COKE BOTTLE.

THE UPSIDE OF FLYING AN AIRPLANE LIKE THAT

WAS YOU WERE INCREDIBLY PROFICIENT.

I MEAN, YOU WERE, WE GOT TO BE REALLY GOOD

AT INSTRUMENT FLYING,

AND WE FLEW IN SOME REALLY, REALLY DIFFICULT,

CHALLENGING CONDITIONS,

WHICH, YOU KNOW, FOR A YOUNG GUY WAS GREAT FUN.

Narrator: FLIGHT 5719 LEFT MINNEAPOLIS JUST BEFORE 7 P.M.

FOR HIBBING, MINNESOTA, ABOUT AN HOUR AWAY.

THERE ARE 16 PASSENGERS ON BOARD.

AFTER THAT, IT'S SCHEDULED TO CONTINUE ON TO A FINAL STOP

IN INTERNATIONAL FALLS.

[RADIO CHATTER]

Controller: TWIN CITY 7-19.

HIBBING WEATHER-- SKY PARTIALLY OBSCURED,

FREEZING DRIZZLE.

John Cox: HIBBING'S A SMALL AIRPORT

THAT DOES NOT HAVE A CONTROL TOWER.

AT ABOUT THE 20 MILES FROM THE AIRPORT,

THEY'LL CLEAR YOU FOR THE INSTRUMENT APPROACH

IF THE WEATHER IS BELOW VISUAL LIMITS.

AND AT THAT POINT, ONCE YOU'RE CLEARED FOR THE APPROACH,

YOU'RE PRETTY MUCH ON YOUR OWN.

Falitz: WE CAN'T TAKE THE ILS 3-1.

Erickson: BECAUSE OF THE, UH, SNOW ON THE RUNWAY?

Falitz: WHAT?

Erickson: BECAUSE OF THE SNOW ON THE, UH, THE RUNWAY?

Falitz: I DON'T LIKE TO LAND WITH A TAILWIND ANYWAY.

TELL THEM WE'LL TAKE THE LOCALIZER BACK COURSE TO 1-3.

Narrator: HIBBING AIRPORT HAS TWO APPROACHES.

THE CAPTAIN DECIDES TO APPROACH

FROM WHAT'S CALLED THE BACK COURSE.

THIS APPROACH IS NOT EQUIPPED WITH THE INSTRUMENTS NEEDED

TO FULLY GUIDE THE PILOTS TO THE RUNWAY.

IT IS KNOWN AS A NON-PRECISION APPROACH.

Erickson: WE'D LIKE THE BACK COURSE UP TO 1-3.

Controller: ROGER. PROCEED, BUT YOU'RE ON YOUR OWN.

Cox: NON-PRECISION APPROACHES ARE, IN FACT,

MORE DEMANDING THAN THE PRECISION ONES

FOR THE REASON THAT YOU HAVE TO MONITOR THE DESCENT RATE,

THE DESCENT ALTITUDE,

THE NAVIGATION WHERE YOU ARE LATERALLY ACROSS THE GROUND,

SO THERE'S ACTUALLY QUITE A BIT MORE GOING ON.

Narrator: JUST BEFORE 7:50 P.M., FLIGHT 5719 STARTS DESCENDING

INTO THE BLOWING SNOW OF A COLD MINNESOTA NIGHT.

Falitz: GEAR DOWN.

Erickson: GEAR DOWN.

Falitz: DID YOU CLICK THE AIRPORT LIGHTS?

Cox: AN AIRPORT LIKE HIBBING

THAT DOES NOT HAVE A LOT OF TRAFFIC,

IN AN EFFORT TO SAVE MONEY,

BECAUSE THE LIGHT BULBS ARE VERY EXPENSIVE,

THEY ARE WHAT'S CALLED PILOT-CONTROLLED LIGHTING.

Falitz: YOU CLICK IT?

Erickson: UH, I, UM...

Cox: THE PILOTS, WITH A SERIES OF CLICKS FROM THEIR RADIOS,

CAN TURN THE LIGHTS UP AND DOWN.

Falitz: YOU CLICKED IT SEVEN TIMES.

Erickson: OKAY, I GOT IT NOW.

[CRASH]

[SCREAMING]

[ALARM BEEPING]

[SCREAMING]

[ALARM BEEPING]

[SCREAMING]

Narrator: IT TAKES ONE HOUR FOR EMERGENCY RESPONDERS

TO FINALLY LOCATE THE CRASH SITE,

TWO MILES NORTHWEST OF THE AIRPORT.

THERE ARE NO SURVIVORS.

*

THE NATIONAL TRANSPORTATION SAFETY BOARD

SENDS OUT INVESTIGATOR JOHN DeLISI.

John DeLisi: THE WRECKAGE WAS UP ON A HILL,

SO IT WAS IN A PRECARIOUS POSITION,

AND SOME OF THE BODIES HAD BEEN EJECTED.

MANY WERE STILL INSIDE THE FUSELAGE.

IT WAS THE HOLIDAY SEASON,

SO MANY FOLKS THAT WERE TRAVELING

HAD BROUGHT CHRISTMAS PRESENTS.

THEY WERE SCATTERED IN THE DEBRIS.

THERE WAS BLOOD IN THE SNOW.

IT REALLY WAS ONE OF THE MOST DIFFICULT ACCIDENT SITES

I'D EVER BEEN TO.

Narrator: DeLISI KNOWS THAT A PLANE THIS SIZE

WILL LIKELY BE EQUIPPED WITH ONLY ONE OF THE BLACK BOXES,

THE COCKPIT VOICE RECORDER.

DeLisi: HERE'S THE CVR.

AT THE TIME, COMMUTER AIRPLANE WITH 19 OR LESS SEATS

ONLY A REQUIREMENT FOR A COCKPIT VOICE RECORDER,

NOT A FLIGHT DATA RECORDER.

[HELICOPTER PASSES]

ALL RIGHT, LET'S GO.

Narrator: WITH NO FDR,

THE DIFFICULT JOB OF EXPLAINING THE CRASH JUST GOT HARDER.

DeLisi: WHEN THERE'S NO FLIGHT DATA RECORDER,

IT PUTS US IN A BIT

OF AN OLD-SCHOOL TYPE OF INVESTIGATION,

WHERE THE ANALYSIS OF THE PHYSICAL EVIDENCE

BECOMES SO MUCH MORE CRITICAL.

Narrator: DeLISI TURNS TO RADAR DATA FROM THE APPROACH CONTROL

TO TRACK THE PLANE'S DESCENT PATH.

IT'S VERY STEEP AND COMES LATE.

INVESTIGATORS CAN'T MAKE SENSE OF IT.

Dickinson: THE RATE OF DESCENT WAS DOUBLE

WHAT WE'D NORMALLY SEE.

IT SHOULD BE ABOUT 1,000 FEET PER MINUTE.

NOW, IN THIS CASE, IT WAS OVER 2,000,

SOMETIMES UP AT 2,200.

DeLisi: WHY DID THEY START THEIR DESCENT SO LATE?

Dickinson: ME AS A PILOT, IT DOES MAKE YOU WONDER,

BECAUSE THE LATER YOU START THE DESCENT,

THE FASTER YOU'RE GONNA HAVE TO DESCEND TO GET DOWN.

AND THE FASTER YOU DESCEND,

THE HARDER IT IS TO BREAK THAT RATE OF DESCENT.

Narrator: INVESTIGATORS WONDER IF ICE ON THE WINGS

CAUSED THE STEEP DESCENT AND CRASH.

DeLisi: BUILDUP OF ICE,

PARTICULARLY ON THE WINGS OF AN AIRPLANE,

CAN KILL THE LIFT THAT THE WINGS ARE CAPABLE OF GENERATING,

SO SOMETIMES AN AIRPLANE WITH A RAPID RATE OF DESCENT

MIGHT BE INDICATIVE OF AN OUT-OF-CONTROL MOTION

CAUSED BY A BUILDUP OF ICE.

DeLisi: I WAS WONDERING IF YOU HAVE A COUPLE OF MINUTES.

Narrator: INVESTIGATORS DETERMINE ICING CONDITIONS

WERE MODERATE AND COULD NOT HAVE CAUSED THE CRASH.

IF ICE DIDN'T BRING THE PLANE DOWN, WHAT DID?

DeLisi: IN TALKING TO OTHER PILOTS AT NORTHWEST,

WE BEGAN TO LEARN ABOUT WHAT THEY REFERRED TO

AS A SLAM DUNK APPROACH.

A SLAM DUNK APPROACH WAS DESCRIBED AS ONE IN WHICH,

WHILE YOU HAVE TO PASS THROUGH AN AREA OF ICING,

CREWS WANT TO MINIMIZE THE TIME THEY SPEND THERE,

SO THEY MAY HOLD THEIR ALTITUDE CLOSE IN TO THE AIRPORT

AND THEN VERY RAPIDLY DO A STEEP DESCENT

TO GET THROUGH THE ALTITUDES IN WHICH THERE WAS ICING

AS QUICKLY AS POSSIBLE.

THAT'S NOT A STANDARD TECHNIQUE,

BUT AS WE BEGAN TO HEAR ABOUT IT,

IT MATCHED WHAT WE WERE SEEING

ON THE AIR TRAFFIC CONTROL RADAR.

Cox: IT'S SOMETHING PROFESSIONAL PILOTS DEAL WITH A LOT,

AND IT REQUIRES A LOT OF SKILL IN AIRCRAFT HANDLING

TO GET THE AIRPLANE DOWN QUICKLY

WITHOUT HAVING THE SPEED GO UP TO AN UNACCEPTABLY HIGH LEVEL.

Narrator: MARVIN FALITZ WAS AN EXPERIENCED CAPTAIN.

HE SHOULD HAVE BEEN MORE THAN CAPABLE

OF SAFELY PERFORMING A SLAM DUNK APPROACH.

[CRASH]

SO, WHAT WENT WRONG ON FLIGHT 5719?

INVESTIGATORS EXAMINE HOW THE PILOTS

ON NORTHWEST AIRLINK FLIGHT 5719

PERFORMED A SO-CALLED SLAM DUNK APPROACH.

THEY HOPE THE COCKPIT VOICE RECORDING WILL SHED SOME LIGHT.

Erickson: BEFORE FINAL CHECKLIST COMPLETE.

Narrator: IT'S WHAT IS NOT SAID THAT ALARMS THEM THE MOST.

DeLisi: WHY ISN'T THE FIRST OFFICER

MAKING HIS ALTITUDE CALLOUTS?

WE DIDN'T HEAR THE REGULAR CALLOUTS

ABOUT 2,000, 1,000 FEET, DISTANCE FROM THE AIRPORT.

IT SEEMED AS IF THE FIRST OFFICER

DIDN'T REALLY KNOW WHAT WAS GOING ON IN THE APPROACH.

Erickson: GEAR DOWN. FLAPS 20.

DeLisi: HE NEVER TOLD THE CAPTAIN

HOW CLOSE THEY WERE GETTING TO THE GROUND.

Erickson: 1.93.

Narrator: INVESTIGATORS NEED TO KNOW WHAT WAS GOING ON

WITH THE NOVICE FIRST OFFICER.

WAS THIS TRAGEDY HIS FAULT?

THERE ARE NO RED FLAGS IN HIS OFFICIAL RECORD.

IN FACT, IT'S QUITE THE OPPOSITE.

Erickson: ATIS 119...

Dickinson: THIS GUY GRADUATED NUMBER ONE IN HIS CLASS.

Brenner: THE FIRST OFFICER HAD PREPARED INDEX CARDS

WITH AVIATION DATA FOR EVERY AIRPORT

THAT THE AIRLINE FLEW TO.

THIS WAS ABOVE AND BEYOND WHAT WAS NORMALLY REQUIRED.

HE WAS DOING SPECIAL STUDYING SO HE COULD BE PREPARED

AND BE A BETTER PILOT.

Dickinson: WHY WOULD HE NOT MAKE THOSE CALLOUTS?

WHAT WOULD CAUSE HIM NOT TO MAKE THOSE?

DeLisi: SO, WHAT DO WE KNOW ABOUT THE CAPTAIN?

Narrator: CAPTAIN FALITZ WAS AN EXPERIENCED SENIOR PILOT.

BUT A DEEPER LOOK REVEALS A MAN WITH A TROUBLING RECORD.

DeLisi: BOOM, BOOM, BOOM.

Brenner: SOON AFTER HE JOINED THE COMPANY,

HE FAILED HIS ORAL EXAM.

HE FAILED TWO MORE PROFICIENCY EXAMS IN HIS CAREER.

THAT'S UNUSUAL FOR A PROFESSIONAL PILOT

TO FAIL THAT MANY TIMES.

DeLisi: ARE ALL THESE FORMAL COMPLAINTS

AGAINST CAPTAIN FALITZ?

Railsback: MARVIN WAS THE FIRST CAPTAIN I FLEW WITH

AFTER MY IOE, MY INITIAL OPERATING EXPERIENCE,

AND HE TENDED TO BE A LITTLE BIT DOMINEERING

AND WOULD BERATE YOU AND WAS INTOLERANT OF MISTAKES

AND REALLY NOT A PARTICULARLY GREAT INSTRUCTOR PILOT.

DeLisi: HMM, WOW.

Narrator: PERHAPS THE MOST DISTURBING COMPLAINT

AGAINST CAPTAIN FALITZ

IS THAT HE ONCE STRUCK A COLLEAGUE IN ANGER.

IS THERE A LINK BETWEEN THE CAPTAIN'S BELLIGERENCE

AND THE FIRST OFFICER'S RETICENCE?

DeLisi: HELLO?

Narrator: INVESTIGATORS RECEIVE A PHONE CALL

FROM A RAMP SERVICE AGENT

AT MINNEAPOLIS-ST. PAUL INTERNATIONAL AIRPORT.

DeLisi: OKAY.

Falitz: WHY ISN'T THE EXTERIOR PREFLIGHT DONE?

Erickson: I WAS--

Falitz: YOU DIDN'T CHECK THE DAMN EXTERIOR LIGHTS!

Narrator: THE SERVICE AGENT WITNESSED CAPTAIN FALITZ

BERATING FIRST OFFICER ERICKSON OVER A PREFLIGHT CHECK.

Erickson: UH, I WAS GONNA CHECK THE LIGHTS

FROM INSIDE THE COCKPIT.

Falitz: THAT'S NOT HOW YOU DO IT!

YOU HAVE TO GO OUTSIDE AND SEE IT WITH YOUR OWN STUPID EYES!

DOES NORTHWEST EVEN SCREEN YOU GUYS ANYMORE?

YOU KNOW WHAT? SCREW IT. I'LL DO IT MYSELF.

Dickinson: THE CAPTAIN WAS BEING VERY, VERY CRITICAL

OF THE FIRST OFFICER,

AND THE FIRST OFFICER WAS A RELATIVELY NEW PILOT,

SO, YOU KNOW, YOU'RE GONNA MAKE MISTAKES,

SO THERE WAS A BETTER WAY TO HANDLE IT,

AND THE CAPTAIN DID NOT TAKE THE BETTER WAY.

Falitz: IF WE'RE LATE FOR DEPARTURE, IT'S ON YOU!

Dickinson: THIS HAPPENED IMMEDIATELY BEFORE THE FLIGHT,

SO IT SET THE TONE FOR THE TWO OF THEM WORKING TOGETHER,

WHICH WAS A BAD WAY TO DO THINGS.

DeLisi: OKAY, THANKS.

LET'S GET THAT CVR BACK IN HERE.

WE NEED TO FIND OUT WHAT WAS GOING ON

BETWEEN THOSE TWO PILOTS.

Falitz: CALL THE COMPANY AND TELL THEM WE NEED TO FUEL UP.

Brenner: IN LISTENING TO THE CVR,

THE CAPTAIN MAKES A LOT OF CORRECTIONS OR DIRECTIONS

TO THE FIRST OFFICER OF VERY SIMPLE THINGS.

Erickson: OPS 7-19...

Falitz: SAY HIBBING.

Hibbing Ops: HIBBING, GO AHEAD.

Erickson: UH, UH, HIBBING, UH...

Brenner: HE WAS INTIMIDATING AND NOT CONSTRUCTIVE.

Hibbing Ops: POSITIVE FUEL. SEE YOU IN A BIT.

Falitz: YOU CAN'T JUST SAY OPS.

YOU HAVE TO SPECIFY. WHO'S SUPPOSED TO ANSWER?

HIBBING? SIOUX CITY? DULUTH?

Railsback: BEFORE I WAS AN AIRLINE PILOT,

I WAS A FLIGHT INSTRUCTOR.

AND ONE GUARANTEED WAY TO HAVE THAT GUY SHUT DOWN

AND NOT BE ABLE TO PERFORM WAS TO BERATE THEM,

HUMILIATE THEM, EMBARRASS THEM.

DeLisi: HE WAS PARALYZED WITH FEAR.

THAT'S WHY HE DIDN'T MAKE HIS CALLOUTS TO THE CAPTAIN.

HE WAS, HE WAS TERRIFIED OF HIM.

Narrator: INVESTIGATORS FINALLY UNDERSTAND

WHY NORTHWEST AIRLINK FLIGHT 5719 ENDED IN TRAGEDY.

Falitz: YOU HAVE TO GO OUTSIDE

AND SEE IT WITH YOUR OWN STUPID EYES!

DeLISI: WELL, THIS ACCIDENT, IN MANY WAYS,

HAS BECOME A CASE STUDY IN JUST HOW VALUABLE IT IS

TO EMPOWER EITHER CREW MEMBER TO BE ASSERTIVE

AND TO SPEAK UP WHEN SOMETHING ISN'T GOING RIGHT.

*

Narrator: EVEN WHEN THE CAPTAIN ISN'T A BULLY,

HE CAN SUFFER FROM OTHER FLAWS HIDDEN FROM VIEW.

Stephen Silver: HEY, EVERYBODY SEATED?

Ralph Harvey: YEP, EVERYBODY'S IN.

Silver: FOLKS, THIS IS YOUR CAPTAIN SPEAKING.

WE'LL SOON BE LANDING IN DURANGO.

Narrator: EVENTUALLY THOSE FLAWS CAN LEAD TO TRAGEDY.

[SCREAMING]

John Nance: WE HAD SO MANY EXAMPLES OF PEOPLE

WHO COULD NOT OR WOULD NOT SPEAK UP,

BUT IT ALL CAME DOWN TO THE SHOULDERS OF THE CAPTAIN.

Controller: 2286, YOU ARE CLEARED FOR TAKEOFF.

Narrator: TRANS-COLORADO IS A SMALL REGIONAL CARRIER

THAT OPERATES FLIGHTS FOR CONTINENTAL AIRLINES.

Silver: 2286, CLEARED FOR TAKEOFF. THANK YOU.

Narrator: CAPTAIN STEPHEN SILVER IS IN COMMAND.

Brad Howard: STEVE WAS VERY HAPPY,

A JOVIAL, ENERGETIC PILOT.

UH, I ENJOYED FLYING WITH STEVE.

Silver: YOU'RE HANDLING FLYING THIS LEG, RIGHT?

Harvey: YOU BET.

Narrator: FIRST OFFICER RALPH HARVEY

WILL OPERATE THE CONTROLS FOR THIS FLIGHT,

LEAVING THE CAPTAIN FREE TO HANDLE RADIO CALLS.

Harvey: TAKEOFF POWER.

Cox: AIRLINE PILOTS ROUTINELY TRADE THE FLYING DUTIES.

PART OF IT IS FOR, UM, THE REDUCTION OF FATIGUE

SO THAT ONE PERSON'S NOT DOING ALL THE WORK,

BUT IT ALSO DIVIDES THE JOBS UP SO THAT FIRST OFFICERS

THAT WILL BE CAPTAINS ARE GAINING EXPERIENCE.

Silver: 100.

Narrator: THE CAPTAIN KEEPS AN EYE ON THE AIRSPEED

AS THEY ACCELERATE FOR TAKEOFF.

Silver: V-1.

AND ROTATE.

Narrator: THE CREW'S DAY BEGAN IN DENVER.

AFTER TWO SHORT HOPS TO RIVERTON AND CASPER, WYOMING,

THEY CIRCLED BACK TO DENVER.

NOW THEY'RE HEADED TO DURANGO,

A ROUTE THAT TAKES THEM OVER THE SOUTHERN ROCKY MOUNTAINS.

Silver: CONTROL, WE'LL PLAN ON A DME TO RUNWAY 2-0.

Controller: THAT'S APPROVED.

TRANS-COLORADO 2286 CLEARED FOR RUNWAY 2-0 APPROACH

AT DURANGO AIRPORT.

Narrator: LIKE MANY SMALL AIRPORTS IN AMERICA,

DURANGO DOES NOT HAVE ITS OWN AIR TRAFFIC CONTROL.

THE CONTROLLER IS IN DENVER, MORE THAN 200 MILES AWAY.

Howard: ONCE THEY CLEARED YOU FOR THAT APPROACH,

THEY BASICALLY GAVE YOU THE RESPONSIBILITY

TO GET THAT AIRPLANE DOWN ON THE GROUND.

Controller: RADAR COVERAGE TERMINATED.

PLEASE REPORT LANDING BY RADIO.

HAVE A GOOD NIGHT.

Harvey: GEAR DOWN.

Silver: GEAR DOWN.

THREE GREEN.

Harvey: DO YOU HAVE THE RUNWAY?

Narrator: SOMETHING'S WRONG. THE PILOTS CAN'T SEE THE RUNWAY.

Harvey: DAMN! WE'RE TOO LOW!

Silver: PULL UP!

Harvey: NO! NO, NO, NO, NO, NO!

Silver: HOLD ON!

[CRASH]

[SCREAMING]

Susie Welch: THERE WAS THIS JUST BIG BOOM.

I THOUGHT WE JUST HAD A ROUGH LANDING.

AND THE PLANE BEGAN TO DO A FLIP.

THAT'S WHEN I THOUGHT, IT'S HAPPENING. WE'RE CRASHING.

[CRASH]

THEY USUALLY SAY STAY WHERE YOU ARE,

SOMEONE WILL COME AND GET YOU,

BUT WE WERE OUT IN THE MIDDLE OF NOWHERE.

WE DIDN'T KNOW IF ANYBODY KNEW ANYTHING.

Knowlton: IT WAS A REMOTE AREA, AND SO IT MADE IT DIFFICULT

FOR THE EMERGENCY RESPONDERS TO GET THERE.

UM, IT TOOK US A LONG TIME

TO FIGURE OUT EXACTLY WHERE THE CRASH WAS.

Narrator: OF THE 17 PEOPLE ON BOARD,

THE CRASH HAS KILLED NINE, INCLUDING BOTH PILOTS.

*

TOM HAUETER OF THE NATIONAL TRANSPORTATION SAFETY BOARD

NOW FACES A HUGE TASK.

Tom Haueter: YEAH, THE LEFT WING TIP RIGHT HERE.

YEAH, THANKS, GUYS.

WE WERE HAVING A HARD TIME UNDERSTANDING

HOW THE CREW IMPACTED SO FAR SHORT OF THE AIRPORT.

THAT WAS GOING TO BE THE BIG MYSTERY HERE

TO TRY TO UNDERSTAND.

Narrator: INVESTIGATORS WONDER WHETHER THE APPROACH

INTO THE AIRPORT WAS TOO RISKY FOR THE CONDITIONS THAT NIGHT.

THE AIR TRAFFIC RECORDING REVEALS THAT THE CONTROLLER

GAVE THE CREW TWO OPTIONS.

THE FIRST WAS TO FLY

AN EASY PATH AROUND THE AIRPORT

TO A RUNWAY EQUIPPED WITH AN INSTRUMENT LANDING SYSTEM,

OR ILS, THAT GUIDES THE PILOTS DOWN.

IN THE SECOND, MORE CHALLENGING OPTION,

PILOTS MUST DESCEND IN STEEP STEPS

TO AVOID MOUNTAINS NORTH OF DURANGO.

Silver: UH, WE'LL PLAN ON USING THE 2-0. THANK YOU.

Haueter: WE HAVE HILLS HERE, HERE, AND HERE.

WHY DIDN'T THEY TAKE THE EASY WAY DOWN?

Narrator: IT'S THE CREW'S FOURTH FLIGHT OF THE DAY,

AND THEY'RE RUNNING LATE.

CAPTAIN SILVER DECIDES TO FLY THE STEEPER,

MORE DIFFICULT APPROACH.

Silver: LISTEN, WHEN WE GET TO DURANGO,

I'D LIKE TO GET IN THE AIR AGAIN AS QUICKLY AS POSSIBLE.

Harvey: IT SHOULDN'T BE A PROBLEM.

WE WON'T NEED TO REFUEL.

Silver: LET'S SEE WHAT ELSE WE CAN DO

TO GET THESE FOLKS BACK ON TIME.

Narrator: ESTIMATES SHOW THAT THE STRAIGHT-IN APPROACH

TO RUNWAY 2-0 SAVES ABOUT 10 MINUTES OF FLIGHT TIME.

Brenner: TO ME, IT SEEMS ALMOST INSTINCTIVE

THAT, THAT HE THOUGHT THIS IS HIS WAY TO CATCH UP

AND, AND GET IN FASTER.

Silver: FOLKS, THIS IS YOUR CAPTAIN SPEAKING.

WE'LL SOON BE LANDING IN DURANGO.

Narrator: THE INFORMATION EXPLAINS WHY CAPTAIN SILVER

CHOSE SUCH A CHALLENGING APPROACH ON A SNOWY NIGHT,

BUT IT DOESN'T EXPLAIN THE CRASH.

Haueter: TRICKY APPROACH,

BUT LOTS OF PILOTS SAY THEY DID IT ALL THE TIME.

Narrator: INVESTIGATORS COMPARE THE FLIGHT PATH

PILOTS ARE SUPPOSED TO FOLLOW FOR RUNWAY 2-0

TO THE ACTUAL DESCENT OF FLIGHT 2286.

Haueter: IT'S QUITE CLEAR THAT THE CREW DESCENDED

BELOW THE PUBLISHED APPROACH.

WHY EXACTLY, WE DON'T KNOW.

Narrator: IN DENVER, MALCOLM BRENNER

DIGS INTO THE QUALIFICATIONS OF THE TWO PILOTS

ON TRANS-COLORADO FLIGHT 2286.

THE FILE OF FIRST OFFICER RALPH HARVEY,

THE PILOT WHO WAS FLYING, IS CAUSE FOR REAL CONCERN.

Brenner: TESTED FOR CAPTAIN--FAILED.

PROFICIENCY TEST--FAILED.

INSTRUMENT FLYING-- BELOW AVERAGE.

Harvey: RUNWAY 2-0, SOUNDS GOOD.

Silver: NOTHING WE CAN'T HANDLE?

Narrator: BRENNER SUSPECTS THAT FLYING THE CHALLENGING APPROACH

TO DURANGO IN LIMITED VISIBILITY

WAS MORE THAN THE FIRST OFFICER COULD MANAGE.

Brenner: I THINK AS LONG AS THE WEATHER IS GOOD,

HE WOULD PROBABLY BE A VERY ADEQUATE PILOT.

HIS TROUBLE IS WHEN THINGS

START TO HAPPEN VERY FAST, IT SEEMS LIKE.

FOR SOME REASON, THE CAPTAIN DIDN'T TAKE OVER

AND SAVE THE PLANE. I NEED TO KNOW WHY.

Narrator: IF THE FIRST OFFICER WASN'T UP TO THE JOB,

THEN WHY DIDN'T CAPTAIN SILVER STEP IN AND TAKE OVER?

Harvey: DAMN!

Silver: PULL UP!

[SCREAMING]

Narrator: THE CAPTAIN AND THE FIRST OFFICER'S PERFORMANCE

ON TRANS-COLORADO FLIGHT 2286 BAFFLES INVESTIGATORS.

THEY CONTACT FRIENDS AND FAMILY,

TRYING TO PIECE TOGETHER WHAT THE PILOTS WERE DOING

IN THE HOURS LEADING UP TO THEIR LAST FLIGHT.

THEY'RE LOOKING FOR ANY SIGN OF STRESS OR FATIGUE.

BUT, AS FAR AS ANYONE CAN TELL,

CAPTAIN SILVER SPENT A QUIET EVENING WITH HIS FAMILY,

THEN WENT TO SLEEP.

Silver: WHAT A DAY.

Brenner: WHAT ARE WE MISSING HERE?

Narrator: THE CASE SEEMS TO HAVE HIT A DEAD END...

Brenner: HELLO?

Narrator: ...UNTIL A PHONE CALL CHANGES EVERYTHING.

Brenner: YES.

WHAT?

Silver: WHAT A DAY.

Narrator: INVESTIGATORS LEARN THAT ON THE EVE OF THE CRASH,

CAPTAIN SILVER MAY NOT HAVE SPENT

A QUIET NIGHT ALONE AFTER ALL.

Woman: TIME TO HAVE A BIT OF FUN.

Silver: NOW YOU'RE SPEAKING MY LANGUAGE.

Narrator: THEY HEAR A STORY ABOUT DRUG USE AND A WOMAN

WHO IS ALLEGED TO HAVE MADE A STUNNING ADMISSION.

Woman: I'M SURE GLAD WE BURIED HIM RIGHT AFTER THE ACCIDENT.

THE NIGHT BEFORE, WE'D DONE A BAG OF COCAINE.

[SNIFFS]

WE DID A BAG OF COCAINE.

WOULD YOU LIKE TO GO FIRST?

Silver: YEAH.

[SNIFFS]

Cox: THE BEST WAY I COULD DESCRIBE THE INVESTIGATORS

WAS ASTOUNDED.

Brenner: CALL THE LAB.

Narrator: TECHNICIANS CONDUCT TOXICOLOGY TESTS ON SAMPLES

FROM THE BODY OF THE DECEASED CAPTAIN OF FLIGHT 2286.

THE RESULTS LEAVE NO ROOM FOR DOUBT.

Brenner: HE WASN'T ASLEEP.

HE WAS UP, USING COCAINE.

HE WAS IN WITHDRAWAL BY THE TIME OF THE ACCIDENT.

Welch: I ALWAYS THOUGHT PILOTS WERE SQUEAKY CLEAN.

I MEAN, THEY ARE CARRYING PEOPLE'S LIVES.

THEY HAVE PEOPLE'S LIVES IN THEIR HANDS.

Narrator: A CAPTAIN SUFFERING WITHDRAWAL

IS ALSO UNDER THE GUN TO GET BACK ON SCHEDULE.

Silver: LISTEN, WHEN WE GET TO DURANGO,

I'D LIKE TO GET IN THE AIR AGAIN AS QUICKLY AS POSSIBLE.

Cox: BECAUSE OF HIS ACTIONS, HIS DELIBERATE ACTIONS,

HE PRESENTED HIMSELF FOR DUTY NOT QUALIFIED,

AND THAT, THAT GOES AGAINST EVERYTHING

THAT PROFESSIONAL PILOTS ARE TAUGHT.

Brenner: WHAT A HORRIBLE DECISION.

IN WITHDRAWAL, HE'S NOT, HE'S NOT HALF THE PILOT HE IS

WHEN, WHEN HE'S, WHEN HE'S ALERT.

Controller: TRANS-COLORADO 2286, FOR YOUR APPROACH TO DURANGO,

WOULD YOU RATHER SHOOT THE ILS,

OR WILL THE APPROACH TO RUNWAY 2-0 BE SUFFICIENT?

Silver: CONTROL, WE'LL PLAN ON A DME TO RUNWAY 2-0.

Narrator: ALREADY BEHIND SCHEDULE,

THE CAPTAIN'S HABIT OF RUSHING

LEADS HIM TO CHOOSE A CHALLENGING APPROACH

WHEN AN EASIER OPTION IS AVAILABLE.

THE STRUGGLING FIRST OFFICER IS SOON OVERWHELMED,

BUT THE CAPTAIN DOESN'T NOTICE...

Harvey: DO YOU HAVE THE RUNWAY?

Narrator: ...UNTIL IT'S FAR TOO LATE.

Harvey: DAMN! WE'RE TOO LOW.

Silver: PULL UP!

Harvey: NO, NO, NO, NO, NO!

Brenner: ONCE THEY LOST TRACK OF THEIR ALTITUDE,

THEY DIDN'T HAVE A CHANCE.

Narrator: THE NTSB'S FINAL REPORT

CITES THE FIRST OFFICER'S POOR FLYING

AND THE CAPTAIN'S USE OF COCAINE

AS CONTRIBUTING CAUSES TO THE TRANS-COLORADO CRASH.

THE FAA SOON IMPLEMENTS IMPORTANT CHANGES,

INCLUDING MORE FREQUENT DRUG TESTING FOR PILOTS.

Brenner: TO MY KNOWLEDGE,

THERE HAS NOT BEEN ANY OTHER CASE OF DRUGS

INVOLVED IN AN AIRLINE ACCIDENT.

Narrator: EGO...

Key: YOU UNGRATEFUL BASTARD!

Narrator: ...INTIMIDATION...

Falitz: THAT'S NOT HOW YOU DO IT!

YOU HAVE TO GO OUTSIDE AND SEE IT WITH YOUR OWN STUPID EYES!

Narrator: ...DERELICTION OF DUTY.

Woman: TIME TO HAVE A BIT OF FUN.

Narrator: THESE ARE THE HUMAN FLAWS

THAT HAVE BROUGHT DOWN AIRPLANES AND TAKEN LIVES.

THESE TRAGEDIES HAVE INSTIGATED A REVOLUTION IN THE RELATIONSHIP

BETWEEN THE CAPTAIN AND THE FLIGHT CREW.

THE GOD-LIKE FIGURE IS GONE,

AND NOW THE PLANE IS FLOWN BY A TRUE TEAM.

Nance: IT'S ALL BECAUSE WE FINALLY UNDERSTOOD US,

OUR FAILURE MODES AS HUMANS,

WHAT WE CAN DO CORRECTLY 100 PERCENT OF THE TIME

AND WHAT WE CAN'T, AND HOW TO USE TEAMWORK,

EVEN JUST A TEAM OF TWO,

TO REDUCE BY JUST AN INCREDIBLE AMOUNT

THE POTENTIAL FOR HUMAN ERROR METASTASIZING INTO AN ACCIDENT.