The pilots of Air Transport International Flight 782
prepare to depart from Kansas City
with just three of their four working engines.
- A three-engine ferry. - It's a difficult maneuver.
- 100 knots. - Okay.
Their takeoff goes tragically wrong.
- We're off the runway. - Go max power.
- You got it!
This accident of course was very tragic.
and they did not make it.
Examination of the wrecked reveals very little.
Stem to stern, wingtip to wingtip, was airworthy.
But when investigators visit the simulator used to train the pilots,
This is not how their aircraft would have behaved.
They begin to understand the origins of this accident.
The simulators are extremely accurate.
We were shocked that this one was not.
Air Transport International Flight 782
has been canceled.
One of its four engines won't start.
Maintain directional control using rudder and nose wheel steering.
The replacement crew is taking the cargo plane for repairs
to a maintenance facility in Massachusetts.
The only crews that are permitted to do a three engine ferry
are the very experienced crews because it is very dangerous.
It does not happen very often.
Captain Walter Meagher has worked his way up from flying the DC-6
and DC-7 and is now Captain on the airlines DC-8 aircraft.
The Captain had about 4,000 hours in the DC-8.
He'd been flying the DC-8 for years.
Max wind for takeoff, crosswinds ten knots, tailwinds five knots.
Okay. Let's check the weather on that.
First Officer Mark Almer is new to the company
and the plane, but he's been flying for 14 years.
He only had about 200 hours in the DC-8.
However, he was commended for being enthusiastic,
for trying to learn and being an important part of the crew.
There's a third crew member on board, Flight Engineer
Kerry Hardy.
Flight Engineer had more than 4,000 hours of flight time
and in large airplanes.
He was a very experienced pilot.
It's a two-hour flight from Kansas City to Chicopee,
Massachusetts, where the engine is to be repaired.
- Here you go.
The crew has concerns about their schedule.
There is a curfew on the airport in Massachusetts.
The airline had told the crew that they needed to land by
11 p.m. because that is when that airport would close.
What we're going to need to do is get as much direct as we can.
That'll allow us to fly a little bit better than the 280 knots
indicated.
Well, as pilots, we're always trying to hurry.
The crew had decided that they wanted to fly a more direct route
at a faster speed.
So we'll be using one nine right?
First Officer Almer wants the longest runway for their takeoff.
I'm going to request right because we'll get an extra 1,300 feet.
In order to take off, the DC-8 needs power from at least
three of its four engines.
You always want the longest runway that you can get with a takeoff
like this so that you have more room to get the airplane up to
the proper speeds.
Kansas City, this is Air Transport 782,
We're going to be a three-engine departure.
Flight 782 checks with Air Traffic Control about their
runway assignment.
Air Transport 782 South on Bravo, taxi Runway one left.
Okay, South on Bravo, taxi one left, Air Transport 782.
- Winds 240 at 4. - Roger.
- That's a tailwind, right? - Yeah.
You don't want a tailwind with a three-engine takeoff because it's
going to take more runway.
240 and we're running it to what?
- 4. - Four knots.
The tailwind was acceptable. The maximum tailwind allowed was five
knots and they had four knots.
Flight 782 taxis to the longer runway.
Takeoff data.
Okay, this is max power takeoff.
The pilots review the required speeds for the three-engine takeoff.
Okay, I got VMCG of 107, 123 for VR, 140 for V2
and 210 for the cleanup.
This takeoff requires raising both inboard engines, engine two
and engine three, to max power.
Only when the plane reaches a certain speed can the third working
engine, engine four, be increased to max power.
Controlling the airplane on the runway while you are adding the power
from the third engine is vital.
It must be done slowly, and you must be able to keep control of the
airplane at all times.
And of course, we'll all be watching real close for loss of directional
Two engines on the right side are going to cause the aircraft
to veer to the left. It's only going to have one engine operating
on the left side. So directional control is the critical issue
on that three-engine takeoff like this.
Number one engine is inoperative. So what we're going to do
is set max power on number two and number three.
- Right. - Right.
As the crew nears the end of the taxi, they finalize the takeoff plan.
Okay. Then I'll ease in number four.
- And I'll call increments of 0.1. - Yeah.
Flight 782 is now ready for takeoff.
Okay, coming up on two and three.
The crew lets the inboard engines spool up before the plane starts
- Set max power. - Max power two and three.
At 8:20 p.m., Air Transport International Flight 782
begins its takeoff.
0.3, 0.4.
The flight engineer closely monitors engine power.
- Air speeds alive. - 0.6.
- 90 knots.
But 20 seconds into the takeoff roll, the plane veers left
of the center line.
0.8, 100 knots.
The Captain uses his rudder to redirect the plane to the
center of the runway, but it doesn't work.
Abort.
Spoilers.
Air Transport 782 aborting takeoff.
Flight 782 aborts its three-engine takeoff.
Air Transport 782, Roger, when able, turn right off the runway.
- Do you need any assistance? - Negative assistance.
- No, negative. - Negative assistance, Air Transport
The crew considers what went wrong.
We were at 0.16 and then power went all the way up to 190
as you ran it up.
So it went up real fast.
And number four jerked up while I was trying to ease it in.
You brought it up too fast or it jerked up or what?
The power on it just came on too fast.
Hardy proposes a solution.
If you want to try it again, I could try adding the power if you like.
Okay, let's do it that way.
It was decided that the flight engineer would help the Captain
and he would add the power on the third engine for the second takeoff.
Tell him we want to taxi back and have another try at it.
Kansas City Ground Air Transport 782 would like to taxi back
to depart one left again.
- Air Transport 782, Roger, - Taxi one left.
While returning to the runway, the crew revisits the takeoff procedure.
Okay, when do I have to have max power in on the outboard engine?
107.
Flight 782 is again ready for takeoff.
Kansas City Control, Air Transport 782 ready to go at the end of
one left, a three-engine takeoff.
Air Transport 782 heavy, Control one left. Turn right 030.
Clear for takeoff.
I've lined up just to the right of the center line here.
The Captain did line up on the right side of the runway because...
They veered off to the left on the first takeoff.
And he wanted to give himself more runway width available
in order to do the second takeoff.
Okay, make sure the two and three are set.
Max power.
At 8:26 in the evening,
Flight 782 begins its second takeoff attempt.
One four.
One five.
One six.
Air speeds alive.
Ten seconds into the takeoff roll, the plane again starts veering to the left.
One seven.
The captain tries to direct it back to the centerline with the rudder.
God, bless it.
- Keep it going, keep it going? - Yeah.
Eighty knots, 90 knots.
The captain attempts to get airborne.
We're off the runway!
But he doesn't have the speed.
Go max power!
He tries to salvage the takeoff.
Flight 782 is barely in the air.
Get the nose down!
Go max power!
You got it!
Max power!
Alert three, runway zero one, North End.
DC-8 on takeoff.
Air Transport International Flight 782 has crashed
beside the runway at Kansas City Airport.
Fire and rescue units are nearby on a night training exercise.
They rush to the crash site.
We heard a real loud boom like something hit the dock real hard.
Take long for fire rescue crews to arrive on the scene I'm assuming.
No, just a matter of 60 seconds.
All three crew members are dead.
The National Transportation Safety Board, or NTSB, is notified.
And Bob Benson is named lead investigator.
The aircraft had broken apart although it was in three large pieces.
The fuselage behind the wings seemed to be reasonably intact.
The wing assembly itself seemed to be in one piece.
The question Benson must answer,
why was the crew unable to execute this takeoff, not once, but twice?
We were aware that it was an attempted three-engine takeoff.
And because that is an unusual maneuver, we wondered if that could have been
part of the reason the aircraft crashed.
Thanks for taking the time to meet.
While the plane wreckage is collected, investigators speak to the controller
to learn more about the crash.
When did you realize there was an issue with Flight 782?
I guess the first thing that caught my attention was that
they aborted their first takeoff.
I was told the plane veered left on the runway.
They lined up for their next takeoff and the same thing happened, only worse.
The plane veered left, and this time they rotated awkwardly, nose high.
There was a fire coming out of one of the engines,
and then there was a loud bang.
Then the plane stalled, rolled left and crashed.
The fire, what side?
Left.
That had to be engine number two.
Plane engines are numbered from left to right.
For Flight 782, the number one engine was inoperative.
If engine two failed, the crew would be left with only the right engines.
We knew because this was a three-engine takeoff attempt.
And if we'd lost any more power on the left side of the aircraft,
it may have caused an immediate crash.
What have you got?
Investigators examine engine number two after its recovery
Uh, no penetration on the nose cow.
Fuel is present throughout.
Compressor bleed valve is closed.
They discover that it was operative, and it didn't fail on takeoff.
That fire in the engine was probably a compressor surge.
A compressor surge is a phenomenon that occurs when the tilt of the engine
is, is high enough that it disturbs the air flow going into
the intake and causes a big bang, flames coming out both ends perhaps.
But technically the, the, the, the engine isn't damaged at all.
No unusual wear.
If all three remaining engines were working,
could one of the brakes have locked, causing the plane to veer left?
Treads look almost new, no flat spots.
The tires show no sign of abnormal breaking.
Okay.
Let's have a look at the brakes.
We thought that because they had aborted the earlier takeoff,
maybe they, uh, uh, they used the brakes very heavily
and caused them to, uh, uh, fail frankly, or weaken,
and then failed completely during the second takeoff.
Brake stack assembly looks fine.
No discoloration or pitting on the pads.
Discs are clean, no signs of overheating.
We looked at the brakes very carefully.
Uh, we found nothing really physically wrong. There was no overheating
or melding together. So in, in essence, the brake system
did not become an issue.
The NTSB is still unable to determine why the crew lost control.
Let's check out the rudder.
The rudder plays a massive role in a three-engine takeoff.
It is the key to keeping the airplane going straight and being safe.
Three-engine takeoffs require the two inboard engines to reach VMCG,
or minimum control speed on the ground.
Only then can the rudder counteract the directional force of the third
working engine as it's powered up.
The faster you are going, the more rudder control you have,
and you need that rudder control to be able to keep the airplane
How's the rudder control cable look?
Did the rudder malfunction, causing the crew to lose control
Cable severed in several different places, see?
There's no corrosion or fraying. Probably severed in the crash.
Agreed.
Assess the rudder.
We looked very carefully at the cabling that we used in the rudder system,
and the only thing we did note were simple breaks in the cables
because of overload, instant overload, which occurred during the crash.
Good to go.
If the rudder cables didn't fail, then could the rudder itself have
Okay, deflect left?
Investigators test its movement.
Turning to the left.
But the rudder moves freely.
Occasionally in previous accidents, rudders have locked up,
or become blocked by some, some broken part.
And we found that this did not occur during this, this event.
The mystery of Flight 782's crash deepens.
And in the end, we look at the entire wreckage very, very carefully
from stem to stern, wing tip to wing tip.
And determined that it was airworthy.
We had to look into other areas to determine what happened.
Okay, we found skid marks on the runway for the first takeoff,
starting here,
all the way to here.
Then they aborted.
Investigators now turn to evidence left behind by Flight 782,
to determine why it veered off the runway.
In the second takeoff, the skid starts even earlier. Here.
And the marks last
Skid marks were there, indicating that although the aircraft was
rolling forward, it was skidding to the left side of the runway.
The skid marks are a tell-tale sign.
It looks like they had too much power to the right side of the plane.
And it happened early on. Look, on both.
takeoffs.
They skid it to the left after
only 500 feet.
So maybe there was an issue with the
power in that third working engine.
Let's find out.
We discovered that the engine
operation would probably be some
kind of an issue.
And the only way we could determine
that was to go to the flight data
Did engine number four somehow
cause the plane to veer too far
There's the air speed data there.
Investigators examined the flight
data recorder to learn how the crew
managed their engines.
Looks like we have a glitch here.
To learn more about how the crew
manipulated the throttles,
we needed two parameters from the FDR.
Air speed and the engine pressure
ratio or the EPR.
We had air speed, but unfortunately
this FDR did not record correctly
We need a work around to get that
engine data.
What about a sound spectrum analysis?
Sure, let's give it a shot.
Okay, coming up on two and three.
There's a microphone in the cockpit.
that records every sound.
And they can record and hear the
engines as they are increased
or decreased.
and they're very accurate.
The team conducts a digital
analysis of the engine sounds.
Done. Great work.
Let's compare the third working
engine, engine four,
with the plane's overall air speed
data.
In the end, we use both the FDR
and the CVR to determine the air
speed throughout the entire flight,
and the power setting for all,
all three of the operating engines.
It looks like
the third working engine,
engine number four, almost reaches
max power in ten seconds,
when the air speed is only about
That seems awfully slow.
Was the power to engine four
increased too soon in the takeoff
roll?
Let's check the three engine takeoff
chart.
Investigators examined the chart
used by the crew to determine
the speed they needed to reach
before applying max power to engine
What was their weight?
Uh, their weight was 220,000
pounds. Temperature is zero degrees.
They shouldn't have put the third
working engine to max power until
they reached 116 knots.
That's the target speed.
At 65 knots, it was way too much
power too soon.
One three, one four, one five,
Air speed's alive.
One seven.
Investigators conclude engine
four was powered up too fast,
pushing the plane to the left.
They never reached the speed they
needed for the rudder to counteract
the power of both engines on the
right side of the plane.
That's why they veered off the runway.
Why did the pilots increase power
to the right outboard engines
We knew that the issue here was
reaching VMCG at exactly the right
time with the correct air speed and
everything. But the crew didn't do
that and that would became the big
question. Why? Why didn't they do
Whenever you're ready.
Benson's team listens to the cockpit
voice recorder, or CVR, to better
understand how the pilots of Flight
782 performed the three-engine
procedure.
Okay, this is max power takeoff
speeds. VR 123, 140
and 210. VMCG of 107.
Okay, I got VMCG of 107, VR
of 123, 140 for V2, and
210 on the cleanup.
Both pilots think the VMCG is
107 knots. It should be 116.
Yep. VMCG is 116 knots.
So how did the flight engineer get
that wrong?
Wait a minute. Check this out.
107 is the speed for a temperature
Celsius.
Investigators discover the flight
engineer used the speed for a
temperature of 30 degrees Celsius.
But on the night of the crash it was
30 degrees Fahrenheit, approximately
That C for Celsius is so small.
He must have used 30 Celsius,
thinking the chart is in Fahrenheit.
They selected the wrong line to get
their V speeds.
Thanks.
They were nine knots off on what
VMCG should have been.
It's happened before. Four years
earlier, a flight engineer on
another air transport DC-8
miscalculated the plane's weight,
providing the captain with the wrong
takeoff speeds.
I was one of the first investigators
from the NTSB to arrive on scene.
When I went into the cockpit,
it didn't take any smarts at all
to see the takeoff data was
100,000 pounds too low.
As a result, the company very
seriously began to emphasize the
need to check those calculations
and make sure they're accurate.
And so it's disturbing that in this
accident that did not happen.
Is that the only thing the pilots
A question to consider, Captain.
Once we get near VMCG, if we've used
all the rudder control, you might
want to consider a board.
Because when we get higher, we're
going to be in worse trouble, correct?
That's correct. Absolutely.
The CVR of Flight 782 reveals
that the captain and first officer
were uncertain about the impact of
VMCG speed on rudder control.
The first officer made the comment
that you have rudder control is
less effective once you go beyond
VMCG. And actually the opposite
is true.
Uh, no, actually.
The flight engineer realizes their
Above VMCG, rudder has more authority.
It's helping you more.
I understand.
But the captain fails to acknowledge
the correction.
The flight engineer had the right
answer that the faster the airplane
goes, the more effective the rudder
becomes and you need that
effectiveness to keep the airplane
on the runway.
Why didn't the crew stop and discuss
it until they reached a consensus?
That's the advantage of having three
people in the cockpit.
The right answer generally exists
somewhere in the cockpit and in this
instance the flight engineer had
Maybe their lack of understanding
about the procedure caused them to
abort their first takeoff.
It's possible.
Check that out.
Power went all the way up to 190
So when it flew fast.
And number four jerked up while
I was trying to ease it in.
You brought it up too fast?
Investigators learned that the
captain struggled with engine four's
thrust during the first takeoff
roll.
Power on it just came on too fast.
It's what happened.
If you want to try it again, I could
try adding the power if you like.
The flight engineer proposes an
unorthodox change to the procedure.
Okay, let's do it that way.
The flight engineer took over
control of engine four.
That's crazy.
They couldn't have understood the
difficulty of the procedure if they
split the responsibility.
The core problem is the captain
could not tell how much rudder he's
going to need because he wasn't the
one adding the thrust to the
airplane. It's like trying to
have two people drive a stick shift
car. One doing the steering, one
doing the shifting. It just doesn't
work. You need to have one person
in control at one time.
The flight engineer and the captain
thought they could coordinate the
takeoff together.
Let's figure out how they did.
We worked with the Douglas Aircraft
Company and they produced the a
graph of what an ideal three-engine
takeoff should...
look like with airspeed and engine speed.
We compared that with what actually happened
So this is what the crew was supposed to fly.
Seems like the power and speed rise steadily
in unison until they reach VMCG.
Very, very smooth and synchronized.
But in the accident flight,
the flight engineer brings up power to the engine number
four really quickly.
The plane begins to veer left
off the runway.
Then he brings down the power abruptly here.
Probably in reaction to the plane being out of control.
The most probable thing we think happened was that the flight engineer
saw the aircraft going off to the left of the runway
and kind of panicked and tried to pull the engines back a little bit.
♪ Fly, bless it. ♪
Keep it going! Keep it going! Yeah.
Instead of aborting, the Captain attempts to get airborne because
they're about to veer off the runway.
He was countermanded by the Captain who said, "Don't, no, keep going."
So the engines went back up.
We're off the runway! Go max power!
Then the Captain insists that he goes to max power a few seconds later.
They don't have enough speed for takeoff.
The Captain never decided to abort,
and it appeared to be that he thought he could get the airplane in the air.
We will never know.
The Captain and the flight engineer
could never coordinate their actions.
One, two, one, three.
Why did the crew fail to execute a takeoff procedure that they were
specifically sent to Kansas City to perform?
You got it!
Find anything?
Investigators review the work history of Flight 782's crew to determine
their experience with three-engine takeoffs.
Our flight engineer and our first officer were new hires.
They were still on probation.
It's almost certain that neither had performed a three-engine takeoff.
And the Captain?
He'd done it three times, but only as first officer.
He'd never actually flown as a Captain.
They were all green.
The closest the Captain came to flying this type of takeoff was in a simulator.
He only trained on it twice.
Investigators traveled to Colorado to assess the simulator the airline
used to train its pilots to perform three-engine takeoffs.
Okay.
This is a three-engine takeoff, and we're watching for directional control.
Did the pilots have sufficient training to perform this difficult procedure?
I'll call it engine power until you get to max.
Part of the examination was to see if the simulator accurately portrayed
what a three-engine takeoff should entail.
Okay. Let me give this a try.
Engines two and three are spoold up.
Engine four is set. Here we go.
Slowly bringing up four.
One, five, one, six.
One, seven.
I am barely using my rudder.
There is no force pushing me off the runway.
One, eight.
We have VMCG. Max power to Engine four.
And rotate.
In the simulator, the three-engine takeoff is no different from
a regular takeoff.
Okay, cut.
The simulator was not calibrated properly and it did not require the
normal amount of rudder that would be required with a three-engine takeoff.
This is not how their aircraft would have behaved.
Not a chance.
Simulators are for the most part extremely accurate.
And in this particular case, we were frankly shocked that this one was not.
It also happened to be the one the crew trained on.
And this would really give them, I think, a false sense of security when it came to
the difficulty of making a three-engine takeoff.
I'm calling from the NTSB.
How did Air Transport International, or ATI, compare to other cargo
operators on three-engine takeoffs?
I'd like to talk to your chief pilot.
We checked with the other cargo operators who were operating the DC-8.
So only your most qualified pilots do it, huh?
The vast majority of them use the most experienced crews and limited the
operation to daytime in good weather.
Now, this led us to believe that the industry as a whole
understood the danger and the difficulty of a three-engine takeoff
better than ATI did.
Why did the airline choose such an inexperienced crew for such a difficult
I think it's time we asked them that.
Our team went to Little Rock, which was the headquarters of the ATI operation.
And we met with all of the key people there.
Thanks for meeting with me.
So, I've been told that you didn't use your most experienced crew.
Why not?
I needed my experienced crew for a revenue flight.
The Flight 782 crew is only legal for a non-revenue flight.
How so?
They'd only had enough rest for a non-revenue flight.
You don't say.
They discover that the crew was selected because of a critical regulation
governing non-revenue flights and rest times.
Normal flights, where the company makes revenue, are covered by flight
and duty time regulations.
For safety reasons, they have to provide a crew that has been properly
rested. But there is a loophole.
That if the flight is not revenue,
then there are no flight and duty time regulations.
In theory, a crew could fly non-revenue flights indefinitely.
Investigators now wonder how rested the crew was when Flight 782
prepared for takeoff.
So, take us through this.
Investigators closely examined the crew of Flight 782's recent flight
Okay, the morning before the accident,
our crew lands in Germany after a seven-hour flight.
From Delaware.
And how many time zones did they cross?
Six.
Later that same day, they returned,
landing first in Gander, Newfoundland,
then another flight to Delaware.
So they crossed another six time zones heading back.
We were aware that their circadian rhythm had to be pretty much out of sync.
That's simply not a good thing.
Fatigue is not easy to recognize,
but it degrades all aspects of thinking, decision-making and performance.
They got into their hotel in Delaware at 2:40 a.m. on the day of the crash.
How much uninterrupted rest did the Captain get?
Less than five hours.
So they didn't have enough rest to fly anything except this flight.
And they were sent despite lacking the training and experience they needed.
The NTSB concludes its investigation, outlining the fateful steps that caused
the crash of Flight 782.
It begins with the poorly rested crew.
One of the consistent findings of fatigue research is that people tend
to underestimate how tired they are.
Much of the time, you can conduct a safe flight doing that.
But if something unexpected happens,
you're at a real disadvantage.
In this case, the takeoff procedure was much more complicated than the
crew had been trained to expect.
Thanks.
The flight engineer makes an error in a calculation that the other pilots
Once we get near VMCG, if we've used all our rudder control, we might want to
consider aborting, because when we get higher, we're going to be in worse
That's correct. Absolutely.
The pilots are confused about the takeoff procedure.
I know, actually.
Above VMCG, rudder has more authority.
This was a very delicate procedure, and they seemed to think otherwise.
If you want to try it again, I could try adding the power if you like.
Okay, let's do it that way.
A decision to improvise a difficult takeoff
leads to the plane veering out of control.
Very bad decision to improvise on this procedure because
only the person operating the rudder can tell how effective that is
when advancing the throttle.
Okay?
The captain decides not to abort a second time.
The plane lacks enough speed to safely get airborne.
We're off the runway.
Go max power.
It's hard to say what was going through his mind, but
I think he believed he could get the aircraft airborne.
In their report, the NTSB makes several key recommendations.
One is to revise the training procedures for three engine takeoffs.
The crew not only was not trained well, it was inexperienced
in the particular maneuver they were talking about,
and they were tired.
Closing the loopholes that allow flight crews to perform non-revenue
flights without adequate rest is another recommendation.
The reason this is relevant is because the company elected to have
this tired crew fly the three-engine ferry, rather than the rested crew
that was already present in Kansas City.
It was legal, but
it was not a good idea.
The NTSB also recommends that three-engine ferry flights be assigned
to specially designated experienced crews.
Training instructors advised pilots of the simulator's shortcomings
for three-engine takeoffs.
Company exceeded the board's requests.
They really took it very seriously and did change their whole procedure
to prevent this.
The airline industry as a whole does not follow suit.
Non-revenue flights remain exempt from flight and duty time regulations.
There should be no difference with safety whether there are
people on the airplane, freight on the airplane, or the airplane is empty.
One rest rule requirement should apply to everybody every time everywhere.