1 00:00:02,000 --> 00:00:05,000 The pilots of Air Transport International Flight 782 2 00:00:05,000 --> 00:00:08,000 prepare to depart from Kansas City 3 00:00:08,000 --> 00:00:10,000 with just three of their four working engines. 4 00:00:10,000 --> 00:00:13,000 - A three-engine ferry. - It's a difficult maneuver. 5 00:00:14,000 --> 00:00:16,000 - 100 knots. - Okay. 6 00:00:17,000 --> 00:00:18,000 Their takeoff goes tragically wrong. 7 00:00:19,000 --> 00:00:21,000 - We're off the runway. - Go max power. 8 00:00:22,000 --> 00:00:23,000 - You got it! 9 00:00:26,000 --> 00:00:28,000 This accident of course was very tragic. 10 00:00:28,000 --> 00:00:29,000 and they did not make it. 11 00:00:30,000 --> 00:00:32,000 Examination of the wrecked reveals very little. 12 00:00:33,000 --> 00:00:35,000 Stem to stern, wingtip to wingtip, was airworthy. 13 00:00:35,000 --> 00:00:39,000 But when investigators visit the simulator used to train the pilots, 14 00:00:39,000 --> 00:00:41,000 This is not how their aircraft would have behaved. 15 00:00:41,000 --> 00:00:44,000 They begin to understand the origins of this accident. 16 00:00:45,000 --> 00:00:47,000 The simulators are extremely accurate. 17 00:00:48,000 --> 00:00:51,000 We were shocked that this one was not. 18 00:01:25,000 --> 00:01:29,000 Air Transport International Flight 782 19 00:01:29,000 --> 00:01:30,000 has been canceled. 20 00:01:30,000 --> 00:01:32,000 One of its four engines won't start. 21 00:01:34,000 --> 00:01:37,000 Maintain directional control using rudder and nose wheel steering. 22 00:01:38,000 --> 00:01:42,000 The replacement crew is taking the cargo plane for repairs 23 00:01:42,000 --> 00:01:44,000 to a maintenance facility in Massachusetts. 24 00:01:45,000 --> 00:01:47,000 The only crews that are permitted to do a three engine ferry 25 00:01:47,000 --> 00:01:50,000 are the very experienced crews because it is very dangerous. 26 00:01:51,000 --> 00:01:53,000 It does not happen very often. 27 00:01:55,000 --> 00:01:58,000 Captain Walter Meagher has worked his way up from flying the DC-6 28 00:01:58,000 --> 00:02:03,000 and DC-7 and is now Captain on the airlines DC-8 aircraft. 29 00:02:05,000 --> 00:02:08,000 The Captain had about 4,000 hours in the DC-8. 30 00:02:08,000 --> 00:02:10,000 He'd been flying the DC-8 for years. 31 00:02:13,000 --> 00:02:16,000 Max wind for takeoff, crosswinds ten knots, tailwinds five knots. 32 00:02:16,000 --> 00:02:18,000 Okay. Let's check the weather on that. 33 00:02:20,000 --> 00:02:22,000 First Officer Mark Almer is new to the company 34 00:02:22,000 --> 00:02:25,000 and the plane, but he's been flying for 14 years. 35 00:02:26,000 --> 00:02:28,000 He only had about 200 hours in the DC-8. 36 00:02:29,000 --> 00:02:33,000 However, he was commended for being enthusiastic, 37 00:02:33,000 --> 00:02:36,000 for trying to learn and being an important part of the crew. 38 00:02:37,000 --> 00:02:40,000 There's a third crew member on board, Flight Engineer 39 00:02:40,000 --> 00:02:41,000 Kerry Hardy. 40 00:02:43,000 --> 00:02:46,000 Flight Engineer had more than 4,000 hours of flight time 41 00:02:46,000 --> 00:02:48,000 and in large airplanes. 42 00:02:49,000 --> 00:02:50,000 He was a very experienced pilot. 43 00:02:52,000 --> 00:02:55,000 It's a two-hour flight from Kansas City to Chicopee, 44 00:02:55,000 --> 00:02:58,000 Massachusetts, where the engine is to be repaired. 45 00:02:59,000 --> 00:03:00,000 - Here you go. 46 00:03:02,000 --> 00:03:04,000 The crew has concerns about their schedule. 47 00:03:09,000 --> 00:03:11,000 There is a curfew on the airport in Massachusetts. 48 00:03:12,000 --> 00:03:14,000 The airline had told the crew that they needed to land by 49 00:03:14,000 --> 00:03:17,000 11 p.m. because that is when that airport would close. 50 00:03:21,000 --> 00:03:23,000 What we're going to need to do is get as much direct as we can. 51 00:03:24,000 --> 00:03:26,000 That'll allow us to fly a little bit better than the 280 knots 52 00:03:26,000 --> 00:03:27,000 indicated. 53 00:03:29,000 --> 00:03:31,000 Well, as pilots, we're always trying to hurry. 54 00:03:32,000 --> 00:03:35,000 The crew had decided that they wanted to fly a more direct route 55 00:03:35,000 --> 00:03:36,000 at a faster speed. 56 00:03:37,000 --> 00:03:39,000 So we'll be using one nine right? 57 00:03:39,000 --> 00:03:42,000 First Officer Almer wants the longest runway for their takeoff. 58 00:03:44,000 --> 00:03:46,000 I'm going to request right because we'll get an extra 1,300 feet. 59 00:03:50,000 --> 00:03:54,000 In order to take off, the DC-8 needs power from at least 60 00:03:54,000 --> 00:03:55,000 three of its four engines. 61 00:03:57,000 --> 00:04:01,000 You always want the longest runway that you can get with a takeoff 62 00:04:02,000 --> 00:04:05,000 like this so that you have more room to get the airplane up to 63 00:04:05,000 --> 00:04:06,000 the proper speeds. 64 00:04:06,000 --> 00:04:09,000 Kansas City, this is Air Transport 782, 65 00:04:11,000 --> 00:04:13,000 We're going to be a three-engine departure. 66 00:04:16,000 --> 00:04:19,000 Flight 782 checks with Air Traffic Control about their 67 00:04:19,000 --> 00:04:20,000 runway assignment. 68 00:04:21,000 --> 00:04:25,000 Air Transport 782 South on Bravo, taxi Runway one left. 69 00:04:27,000 --> 00:04:31,000 Okay, South on Bravo, taxi one left, Air Transport 782. 70 00:04:33,000 --> 00:04:36,000 - Winds 240 at 4. - Roger. 71 00:04:37,000 --> 00:04:38,000 - That's a tailwind, right? - Yeah. 72 00:04:40,000 --> 00:04:43,000 You don't want a tailwind with a three-engine takeoff because it's 73 00:04:43,000 --> 00:04:44,000 going to take more runway. 74 00:04:45,000 --> 00:04:47,000 240 and we're running it to what? 75 00:04:48,000 --> 00:04:50,000 - 4. - Four knots. 76 00:04:53,000 --> 00:04:56,000 The tailwind was acceptable. The maximum tailwind allowed was five 77 00:04:56,000 --> 00:04:57,000 knots and they had four knots. 78 00:04:59,000 --> 00:05:02,000 Flight 782 taxis to the longer runway. 79 00:05:04,000 --> 00:05:05,000 Takeoff data. 80 00:05:06,000 --> 00:05:08,000 Okay, this is max power takeoff. 81 00:05:09,000 --> 00:05:12,000 The pilots review the required speeds for the three-engine takeoff. 82 00:05:13,000 --> 00:05:18,000 Okay, I got VMCG of 107, 123 for VR, 140 for V2 83 00:05:19,000 --> 00:05:20,000 and 210 for the cleanup. 84 00:05:23,000 --> 00:05:27,000 This takeoff requires raising both inboard engines, engine two 85 00:05:27,000 --> 00:05:29,000 and engine three, to max power. 86 00:05:29,000 --> 00:05:33,000 Only when the plane reaches a certain speed can the third working 87 00:05:33,000 --> 00:05:35,000 engine, engine four, be increased to max power. 88 00:05:37,000 --> 00:05:40,000 Controlling the airplane on the runway while you are adding the power 89 00:05:40,000 --> 00:05:41,000 from the third engine is vital. 90 00:05:42,000 --> 00:05:46,000 It must be done slowly, and you must be able to keep control of the 91 00:05:46,000 --> 00:05:47,000 airplane at all times. 92 00:05:48,000 --> 00:05:51,000 And of course, we'll all be watching real close for loss of directional 93 00:05:54,000 --> 00:05:58,000 Two engines on the right side are going to cause the aircraft 94 00:05:58,000 --> 00:06:02,000 to veer to the left. It's only going to have one engine operating 95 00:06:03,000 --> 00:06:06,000 on the left side. So directional control is the critical issue 96 00:06:06,000 --> 00:06:08,000 on that three-engine takeoff like this. 97 00:06:11,000 --> 00:06:13,000 Number one engine is inoperative. So what we're going to do 98 00:06:14,000 --> 00:06:16,000 is set max power on number two and number three. 99 00:06:16,000 --> 00:06:17,000 - Right. - Right. 100 00:06:17,000 --> 00:06:21,000 As the crew nears the end of the taxi, they finalize the takeoff plan. 101 00:06:23,000 --> 00:06:24,000 Okay. Then I'll ease in number four. 102 00:06:25,000 --> 00:06:26,000 - And I'll call increments of 0.1. - Yeah. 103 00:06:31,000 --> 00:06:33,000 Flight 782 is now ready for takeoff. 104 00:06:39,000 --> 00:06:41,000 Okay, coming up on two and three. 105 00:06:45,000 --> 00:06:49,000 The crew lets the inboard engines spool up before the plane starts 106 00:06:50,000 --> 00:06:53,000 - Set max power. - Max power two and three. 107 00:06:55,000 --> 00:06:59,000 At 8:20 p.m., Air Transport International Flight 782 108 00:06:59,000 --> 00:07:01,000 begins its takeoff. 109 00:07:08,000 --> 00:07:11,000 0.3, 0.4. 110 00:07:11,000 --> 00:07:13,000 The flight engineer closely monitors engine power. 111 00:07:14,000 --> 00:07:15,000 - Air speeds alive. - 0.6. 112 00:07:19,000 --> 00:07:20,000 - 90 knots. 113 00:07:21,000 --> 00:07:24,000 But 20 seconds into the takeoff roll, the plane veers left 114 00:07:24,000 --> 00:07:25,000 of the center line. 115 00:07:27,000 --> 00:07:29,000 0.8, 100 knots. 116 00:07:30,000 --> 00:07:33,000 The Captain uses his rudder to redirect the plane to the 117 00:07:34,000 --> 00:07:36,000 center of the runway, but it doesn't work. 118 00:07:38,000 --> 00:07:39,000 Abort. 119 00:07:43,000 --> 00:07:44,000 Spoilers. 120 00:07:45,000 --> 00:07:47,000 Air Transport 782 aborting takeoff. 121 00:07:50,000 --> 00:07:53,000 Flight 782 aborts its three-engine takeoff. 122 00:07:55,000 --> 00:07:59,000 Air Transport 782, Roger, when able, turn right off the runway. 123 00:08:00,000 --> 00:08:02,000 - Do you need any assistance? - Negative assistance. 124 00:08:02,000 --> 00:08:04,000 - No, negative. - Negative assistance, Air Transport 125 00:08:07,000 --> 00:08:09,000 The crew considers what went wrong. 126 00:08:12,000 --> 00:08:15,000 We were at 0.16 and then power went all the way up to 190 127 00:08:15,000 --> 00:08:16,000 as you ran it up. 128 00:08:17,000 --> 00:08:18,000 So it went up real fast. 129 00:08:19,000 --> 00:08:21,000 And number four jerked up while I was trying to ease it in. 130 00:08:22,000 --> 00:08:24,000 You brought it up too fast or it jerked up or what? 131 00:08:25,000 --> 00:08:27,000 The power on it just came on too fast. 132 00:08:33,000 --> 00:08:35,000 Hardy proposes a solution. 133 00:08:37,000 --> 00:08:39,000 If you want to try it again, I could try adding the power if you like. 134 00:08:41,000 --> 00:08:42,000 Okay, let's do it that way. 135 00:08:44,000 --> 00:08:47,000 It was decided that the flight engineer would help the Captain 136 00:08:48,000 --> 00:08:51,000 and he would add the power on the third engine for the second takeoff. 137 00:08:52,000 --> 00:08:55,000 Tell him we want to taxi back and have another try at it. 138 00:08:56,000 --> 00:09:00,000 Kansas City Ground Air Transport 782 would like to taxi back 139 00:09:00,000 --> 00:09:01,000 to depart one left again. 140 00:09:02,000 --> 00:09:05,000 - Air Transport 782, Roger, - Taxi one left. 141 00:09:11,000 --> 00:09:15,000 While returning to the runway, the crew revisits the takeoff procedure. 142 00:09:16,000 --> 00:09:18,000 Okay, when do I have to have max power in on the outboard engine? 143 00:09:21,000 --> 00:09:22,000 107. 144 00:09:29,000 --> 00:09:32,000 Flight 782 is again ready for takeoff. 145 00:09:35,000 --> 00:09:38,000 Kansas City Control, Air Transport 782 ready to go at the end of 146 00:09:38,000 --> 00:09:40,000 one left, a three-engine takeoff. 147 00:09:41,000 --> 00:09:47,000 Air Transport 782 heavy, Control one left. Turn right 030. 148 00:09:47,000 --> 00:09:48,000 Clear for takeoff. 149 00:09:51,000 --> 00:09:53,000 I've lined up just to the right of the center line here. 150 00:09:57,000 --> 00:09:59,000 The Captain did line up on the right side of the runway because... 151 00:10:01,000 --> 00:10:03,000 They veered off to the left on the first takeoff. 152 00:10:03,000 --> 00:10:06,000 And he wanted to give himself more runway width available 153 00:10:07,000 --> 00:10:09,000 in order to do the second takeoff. 154 00:10:10,000 --> 00:10:12,000 Okay, make sure the two and three are set. 155 00:10:12,000 --> 00:10:13,000 Max power. 156 00:10:15,000 --> 00:10:17,000 At 8:26 in the evening, 157 00:10:17,000 --> 00:10:20,000 Flight 782 begins its second takeoff attempt. 158 00:10:30,000 --> 00:10:31,000 One four. 159 00:10:34,000 --> 00:10:35,000 One five. 160 00:10:36,000 --> 00:10:37,000 One six. 161 00:10:44,000 --> 00:10:45,000 Air speeds alive. 162 00:10:45,000 --> 00:10:50,000 Ten seconds into the takeoff roll, the plane again starts veering to the left. 163 00:10:51,000 --> 00:10:52,000 One seven. 164 00:10:54,000 --> 00:10:57,000 The captain tries to direct it back to the centerline with the rudder. 165 00:11:01,000 --> 00:11:03,000 God, bless it. 166 00:11:07,000 --> 00:11:09,000 - Keep it going, keep it going? - Yeah. 167 00:11:11,000 --> 00:11:13,000 Eighty knots, 90 knots. 168 00:11:14,000 --> 00:11:16,000 The captain attempts to get airborne. 169 00:11:23,000 --> 00:11:24,000 We're off the runway! 170 00:11:24,000 --> 00:11:26,000 But he doesn't have the speed. 171 00:11:26,000 --> 00:11:27,000 Go max power! 172 00:11:30,000 --> 00:11:32,000 He tries to salvage the takeoff. 173 00:11:33,000 --> 00:11:35,000 Flight 782 is barely in the air. 174 00:11:37,000 --> 00:11:38,000 Get the nose down! 175 00:11:39,000 --> 00:11:40,000 Go max power! 176 00:11:40,000 --> 00:11:41,000 You got it! 177 00:11:42,000 --> 00:11:43,000 Max power! 178 00:11:58,000 --> 00:12:01,000 Alert three, runway zero one, North End. 179 00:12:01,000 --> 00:12:02,000 DC-8 on takeoff. 180 00:12:05,000 --> 00:12:09,000 Air Transport International Flight 782 has crashed 181 00:12:09,000 --> 00:12:11,000 beside the runway at Kansas City Airport. 182 00:12:13,000 --> 00:12:16,000 Fire and rescue units are nearby on a night training exercise. 183 00:12:17,000 --> 00:12:18,000 They rush to the crash site. 184 00:12:20,000 --> 00:12:22,000 We heard a real loud boom like something hit the dock real hard. 185 00:12:22,000 --> 00:12:25,000 Take long for fire rescue crews to arrive on the scene I'm assuming. 186 00:12:25,000 --> 00:12:27,000 No, just a matter of 60 seconds. 187 00:12:29,000 --> 00:12:31,000 All three crew members are dead. 188 00:12:34,000 --> 00:12:38,000 The National Transportation Safety Board, or NTSB, is notified. 189 00:12:38,000 --> 00:12:41,000 And Bob Benson is named lead investigator. 190 00:12:41,000 --> 00:12:45,000 The aircraft had broken apart although it was in three large pieces. 191 00:12:46,000 --> 00:12:49,000 The fuselage behind the wings seemed to be reasonably intact. 192 00:12:50,000 --> 00:12:52,000 The wing assembly itself seemed to be in one piece. 193 00:12:54,000 --> 00:12:56,000 The question Benson must answer, 194 00:12:57,000 --> 00:13:02,000 why was the crew unable to execute this takeoff, not once, but twice? 195 00:13:04,000 --> 00:13:06,000 We were aware that it was an attempted three-engine takeoff. 196 00:13:07,000 --> 00:13:11,000 And because that is an unusual maneuver, we wondered if that could have been 197 00:13:11,000 --> 00:13:13,000 part of the reason the aircraft crashed. 198 00:13:14,000 --> 00:13:15,000 Thanks for taking the time to meet. 199 00:13:17,000 --> 00:13:21,000 While the plane wreckage is collected, investigators speak to the controller 200 00:13:21,000 --> 00:13:22,000 to learn more about the crash. 201 00:13:23,000 --> 00:13:26,000 When did you realize there was an issue with Flight 782? 202 00:13:28,000 --> 00:13:30,000 I guess the first thing that caught my attention was that 203 00:13:31,000 --> 00:13:32,000 they aborted their first takeoff. 204 00:13:34,000 --> 00:13:36,000 I was told the plane veered left on the runway. 205 00:13:39,000 --> 00:13:43,000 They lined up for their next takeoff and the same thing happened, only worse. 206 00:13:45,000 --> 00:13:49,000 The plane veered left, and this time they rotated awkwardly, nose high. 207 00:13:51,000 --> 00:13:53,000 There was a fire coming out of one of the engines, 208 00:13:53,000 --> 00:13:54,000 and then there was a loud bang. 209 00:13:58,000 --> 00:14:02,000 Then the plane stalled, rolled left and crashed. 210 00:14:13,000 --> 00:14:14,000 The fire, what side? 211 00:14:14,000 --> 00:14:15,000 Left. 212 00:14:17,000 --> 00:14:18,000 That had to be engine number two. 213 00:14:24,000 --> 00:14:26,000 Plane engines are numbered from left to right. 214 00:14:27,000 --> 00:14:31,000 For Flight 782, the number one engine was inoperative. 215 00:14:31,000 --> 00:14:36,000 If engine two failed, the crew would be left with only the right engines. 216 00:14:36,000 --> 00:14:39,000 We knew because this was a three-engine takeoff attempt. 217 00:14:40,000 --> 00:14:43,000 And if we'd lost any more power on the left side of the aircraft, 218 00:14:43,000 --> 00:14:46,000 it may have caused an immediate crash. 219 00:14:49,000 --> 00:14:50,000 What have you got? 220 00:14:51,000 --> 00:14:55,000 Investigators examine engine number two after its recovery 221 00:14:57,000 --> 00:14:59,000 Uh, no penetration on the nose cow. 222 00:15:01,000 --> 00:15:03,000 Fuel is present throughout. 223 00:15:04,000 --> 00:15:06,000 Compressor bleed valve is closed. 224 00:15:06,000 --> 00:15:10,000 They discover that it was operative, and it didn't fail on takeoff. 225 00:15:12,000 --> 00:15:15,000 That fire in the engine was probably a compressor surge. 226 00:15:18,000 --> 00:15:22,000 A compressor surge is a phenomenon that occurs when the tilt of the engine 227 00:15:22,000 --> 00:15:27,000 is, is high enough that it disturbs the air flow going into 228 00:15:27,000 --> 00:15:31,000 the intake and causes a big bang, flames coming out both ends perhaps. 229 00:15:32,000 --> 00:15:37,000 But technically the, the, the, the engine isn't damaged at all. 230 00:15:40,000 --> 00:15:41,000 No unusual wear. 231 00:15:43,000 --> 00:15:45,000 If all three remaining engines were working, 232 00:15:46,000 --> 00:15:49,000 could one of the brakes have locked, causing the plane to veer left? 233 00:15:50,000 --> 00:15:53,000 Treads look almost new, no flat spots. 234 00:15:53,000 --> 00:15:56,000 The tires show no sign of abnormal breaking. 235 00:15:59,000 --> 00:16:00,000 Okay. 236 00:16:01,000 --> 00:16:02,000 Let's have a look at the brakes. 237 00:16:04,000 --> 00:16:06,000 We thought that because they had aborted the earlier takeoff, 238 00:16:07,000 --> 00:16:11,000 maybe they, uh, uh, they used the brakes very heavily 239 00:16:11,000 --> 00:16:15,000 and caused them to, uh, uh, fail frankly, or weaken, 240 00:16:16,000 --> 00:16:18,000 and then failed completely during the second takeoff. 241 00:16:25,000 --> 00:16:26,000 Brake stack assembly looks fine. 242 00:16:29,000 --> 00:16:31,000 No discoloration or pitting on the pads. 243 00:16:32,000 --> 00:16:34,000 Discs are clean, no signs of overheating. 244 00:16:38,000 --> 00:16:39,000 We looked at the brakes very carefully. 245 00:16:40,000 --> 00:16:44,000 Uh, we found nothing really physically wrong. There was no overheating 246 00:16:44,000 --> 00:16:48,000 or melding together. So in, in essence, the brake system 247 00:16:48,000 --> 00:16:49,000 did not become an issue. 248 00:16:51,000 --> 00:16:55,000 The NTSB is still unable to determine why the crew lost control. 249 00:16:56,000 --> 00:16:57,000 Let's check out the rudder. 250 00:17:00,000 --> 00:17:03,000 The rudder plays a massive role in a three-engine takeoff. 251 00:17:04,000 --> 00:17:06,000 It is the key to keeping the airplane going straight and being safe. 252 00:17:08,000 --> 00:17:13,000 Three-engine takeoffs require the two inboard engines to reach VMCG, 253 00:17:14,000 --> 00:17:15,000 or minimum control speed on the ground. 254 00:17:17,000 --> 00:17:21,000 Only then can the rudder counteract the directional force of the third 255 00:17:21,000 --> 00:17:22,000 working engine as it's powered up. 256 00:17:25,000 --> 00:17:29,000 The faster you are going, the more rudder control you have, 257 00:17:29,000 --> 00:17:33,000 and you need that rudder control to be able to keep the airplane 258 00:17:39,000 --> 00:17:40,000 How's the rudder control cable look? 259 00:17:41,000 --> 00:17:45,000 Did the rudder malfunction, causing the crew to lose control 260 00:17:46,000 --> 00:17:49,000 Cable severed in several different places, see? 261 00:17:49,000 --> 00:17:52,000 There's no corrosion or fraying. Probably severed in the crash. 262 00:17:53,000 --> 00:17:54,000 Agreed. 263 00:17:56,000 --> 00:17:57,000 Assess the rudder. 264 00:17:58,000 --> 00:18:02,000 We looked very carefully at the cabling that we used in the rudder system, 265 00:18:03,000 --> 00:18:06,000 and the only thing we did note were simple breaks in the cables 266 00:18:07,000 --> 00:18:10,000 because of overload, instant overload, which occurred during the crash. 267 00:18:14,000 --> 00:18:15,000 Good to go. 268 00:18:16,000 --> 00:18:20,000 If the rudder cables didn't fail, then could the rudder itself have 269 00:18:21,000 --> 00:18:22,000 Okay, deflect left? 270 00:18:24,000 --> 00:18:26,000 Investigators test its movement. 271 00:18:27,000 --> 00:18:28,000 Turning to the left. 272 00:18:31,000 --> 00:18:33,000 But the rudder moves freely. 273 00:18:36,000 --> 00:18:39,000 Occasionally in previous accidents, rudders have locked up, 274 00:18:40,000 --> 00:18:43,000 or become blocked by some, some broken part. 275 00:18:44,000 --> 00:18:47,000 And we found that this did not occur during this, this event. 276 00:18:49,000 --> 00:18:53,000 The mystery of Flight 782's crash deepens. 277 00:18:55,000 --> 00:18:59,000 And in the end, we look at the entire wreckage very, very carefully 278 00:19:00,000 --> 00:19:02,000 from stem to stern, wing tip to wing tip. 279 00:19:03,000 --> 00:19:04,000 And determined that it was airworthy. 280 00:19:06,000 --> 00:19:08,000 We had to look into other areas to determine what happened. 281 00:19:13,000 --> 00:19:16,000 Okay, we found skid marks on the runway for the first takeoff, 282 00:19:17,000 --> 00:19:18,000 starting here, 283 00:19:19,000 --> 00:19:20,000 all the way to here. 284 00:19:21,000 --> 00:19:22,000 Then they aborted. 285 00:19:23,000 --> 00:19:27,000 Investigators now turn to evidence left behind by Flight 782, 286 00:19:28,000 --> 00:19:29,000 to determine why it veered off the runway. 287 00:19:30,000 --> 00:19:34,000 In the second takeoff, the skid starts even earlier. Here. 288 00:19:35,000 --> 00:19:36,000 And the marks last 289 00:19:42,000 --> 00:19:46,000 Skid marks were there, indicating that although the aircraft was 290 00:19:47,000 --> 00:19:49,000 rolling forward, it was skidding to the left side of the runway. 291 00:19:50,000 --> 00:19:52,000 The skid marks are a tell-tale sign. 292 00:19:53,000 --> 00:19:55,000 It looks like they had too much power to the right side of the plane. 293 00:19:57,000 --> 00:19:59,000 And it happened early on. Look, on both. 294 00:20:00,000 --> 00:20:01,000 takeoffs. 295 00:20:01,000 --> 00:20:03,000 They skid it to the left after 296 00:20:03,000 --> 00:20:04,000 only 500 feet. 297 00:20:09,000 --> 00:20:11,000 So maybe there was an issue with the 298 00:20:11,000 --> 00:20:12,000 power in that third working engine. 299 00:20:12,000 --> 00:20:13,000 Let's find out. 300 00:20:14,000 --> 00:20:17,000 We discovered that the engine 301 00:20:17,000 --> 00:20:18,000 operation would probably be some 302 00:20:18,000 --> 00:20:19,000 kind of an issue. 303 00:20:19,000 --> 00:20:21,000 And the only way we could determine 304 00:20:21,000 --> 00:20:23,000 that was to go to the flight data 305 00:20:24,000 --> 00:20:27,000 Did engine number four somehow 306 00:20:27,000 --> 00:20:29,000 cause the plane to veer too far 307 00:20:32,000 --> 00:20:33,000 There's the air speed data there. 308 00:20:34,000 --> 00:20:37,000 Investigators examined the flight 309 00:20:37,000 --> 00:20:39,000 data recorder to learn how the crew 310 00:20:39,000 --> 00:20:40,000 managed their engines. 311 00:20:40,000 --> 00:20:41,000 Looks like we have a glitch here. 312 00:20:44,000 --> 00:20:46,000 To learn more about how the crew 313 00:20:46,000 --> 00:20:47,000 manipulated the throttles, 314 00:20:47,000 --> 00:20:49,000 we needed two parameters from the FDR. 315 00:20:49,000 --> 00:20:52,000 Air speed and the engine pressure 316 00:20:52,000 --> 00:20:53,000 ratio or the EPR. 317 00:20:53,000 --> 00:20:56,000 We had air speed, but unfortunately 318 00:20:56,000 --> 00:20:59,000 this FDR did not record correctly 319 00:21:00,000 --> 00:21:02,000 We need a work around to get that 320 00:21:02,000 --> 00:21:03,000 engine data. 321 00:21:04,000 --> 00:21:06,000 What about a sound spectrum analysis? 322 00:21:08,000 --> 00:21:09,000 Sure, let's give it a shot. 323 00:21:13,000 --> 00:21:15,000 Okay, coming up on two and three. 324 00:21:19,000 --> 00:21:22,000 There's a microphone in the cockpit. 325 00:21:23,000 --> 00:21:25,000 that records every sound. 326 00:21:25,000 --> 00:21:28,000 And they can record and hear the 327 00:21:28,000 --> 00:21:30,000 engines as they are increased 328 00:21:30,000 --> 00:21:31,000 or decreased. 329 00:21:31,000 --> 00:21:32,000 and they're very accurate. 330 00:21:42,000 --> 00:21:44,000 The team conducts a digital 331 00:21:44,000 --> 00:21:46,000 analysis of the engine sounds. 332 00:21:48,000 --> 00:21:49,000 Done. Great work. 333 00:21:52,000 --> 00:21:54,000 Let's compare the third working 334 00:21:54,000 --> 00:21:56,000 engine, engine four, 335 00:21:57,000 --> 00:21:58,000 with the plane's overall air speed 336 00:21:58,000 --> 00:21:59,000 data. 337 00:21:59,000 --> 00:22:02,000 In the end, we use both the FDR 338 00:22:02,000 --> 00:22:04,000 and the CVR to determine the air 339 00:22:04,000 --> 00:22:05,000 speed throughout the entire flight, 340 00:22:05,000 --> 00:22:08,000 and the power setting for all, 341 00:22:08,000 --> 00:22:10,000 all three of the operating engines. 342 00:22:14,000 --> 00:22:17,000 It looks like 343 00:22:18,000 --> 00:22:19,000 the third working engine, 344 00:22:19,000 --> 00:22:22,000 engine number four, almost reaches 345 00:22:22,000 --> 00:22:23,000 max power in ten seconds, 346 00:22:23,000 --> 00:22:25,000 when the air speed is only about 347 00:22:28,000 --> 00:22:29,000 That seems awfully slow. 348 00:22:32,000 --> 00:22:35,000 Was the power to engine four 349 00:22:35,000 --> 00:22:36,000 increased too soon in the takeoff 350 00:22:36,000 --> 00:22:37,000 roll? 351 00:22:38,000 --> 00:22:39,000 Let's check the three engine takeoff 352 00:22:39,000 --> 00:22:40,000 chart. 353 00:22:41,000 --> 00:22:43,000 Investigators examined the chart 354 00:22:43,000 --> 00:22:45,000 used by the crew to determine 355 00:22:45,000 --> 00:22:47,000 the speed they needed to reach 356 00:22:47,000 --> 00:22:49,000 before applying max power to engine 357 00:22:51,000 --> 00:22:52,000 What was their weight? 358 00:22:53,000 --> 00:22:55,000 Uh, their weight was 220,000 359 00:22:55,000 --> 00:22:57,000 pounds. Temperature is zero degrees. 360 00:23:00,000 --> 00:23:02,000 They shouldn't have put the third 361 00:23:02,000 --> 00:23:03,000 working engine to max power until 362 00:23:03,000 --> 00:23:05,000 they reached 116 knots. 363 00:23:05,000 --> 00:23:06,000 That's the target speed. 364 00:23:08,000 --> 00:23:10,000 At 65 knots, it was way too much 365 00:23:10,000 --> 00:23:11,000 power too soon. 366 00:23:14,000 --> 00:23:16,000 One three, one four, one five, 367 00:23:20,000 --> 00:23:21,000 Air speed's alive. 368 00:23:22,000 --> 00:23:23,000 One seven. 369 00:23:23,000 --> 00:23:25,000 Investigators conclude engine 370 00:23:25,000 --> 00:23:27,000 four was powered up too fast, 371 00:23:27,000 --> 00:23:29,000 pushing the plane to the left. 372 00:23:34,000 --> 00:23:36,000 They never reached the speed they 373 00:23:36,000 --> 00:23:38,000 needed for the rudder to counteract 374 00:23:38,000 --> 00:23:39,000 the power of both engines on the 375 00:23:39,000 --> 00:23:40,000 right side of the plane. 376 00:23:42,000 --> 00:23:43,000 That's why they veered off the runway. 377 00:23:46,000 --> 00:23:48,000 Why did the pilots increase power 378 00:23:48,000 --> 00:23:50,000 to the right outboard engines 379 00:23:53,000 --> 00:23:55,000 We knew that the issue here was 380 00:23:55,000 --> 00:23:59,000 reaching VMCG at exactly the right 381 00:23:59,000 --> 00:24:01,000 time with the correct air speed and 382 00:24:01,000 --> 00:24:02,000 everything. But the crew didn't do 383 00:24:02,000 --> 00:24:03,000 that and that would became the big 384 00:24:03,000 --> 00:24:05,000 question. Why? Why didn't they do 385 00:24:11,000 --> 00:24:12,000 Whenever you're ready. 386 00:24:13,000 --> 00:24:16,000 Benson's team listens to the cockpit 387 00:24:16,000 --> 00:24:18,000 voice recorder, or CVR, to better 388 00:24:18,000 --> 00:24:20,000 understand how the pilots of Flight 389 00:24:20,000 --> 00:24:22,000 782 performed the three-engine 390 00:24:22,000 --> 00:24:23,000 procedure. 391 00:24:23,000 --> 00:24:25,000 Okay, this is max power takeoff 392 00:24:26,000 --> 00:24:30,000 speeds. VR 123, 140 393 00:24:30,000 --> 00:24:33,000 and 210. VMCG of 107. 394 00:24:35,000 --> 00:24:38,000 Okay, I got VMCG of 107, VR 395 00:24:38,000 --> 00:24:40,000 of 123, 140 for V2, and 396 00:24:40,000 --> 00:24:41,000 210 on the cleanup. 397 00:24:46,000 --> 00:24:49,000 Both pilots think the VMCG is 398 00:24:49,000 --> 00:24:51,000 107 knots. It should be 116. 399 00:24:52,000 --> 00:24:55,000 Yep. VMCG is 116 knots. 400 00:24:56,000 --> 00:24:57,000 So how did the flight engineer get 401 00:24:57,000 --> 00:24:58,000 that wrong? 402 00:25:01,000 --> 00:25:03,000 Wait a minute. Check this out. 403 00:25:04,000 --> 00:25:07,000 107 is the speed for a temperature 404 00:25:10,000 --> 00:25:11,000 Celsius. 405 00:25:15,000 --> 00:25:17,000 Investigators discover the flight 406 00:25:17,000 --> 00:25:19,000 engineer used the speed for a 407 00:25:19,000 --> 00:25:21,000 temperature of 30 degrees Celsius. 408 00:25:22,000 --> 00:25:24,000 But on the night of the crash it was 409 00:25:24,000 --> 00:25:27,000 30 degrees Fahrenheit, approximately 410 00:25:31,000 --> 00:25:33,000 That C for Celsius is so small. 411 00:25:33,000 --> 00:25:35,000 He must have used 30 Celsius, 412 00:25:35,000 --> 00:25:37,000 thinking the chart is in Fahrenheit. 413 00:25:45,000 --> 00:25:48,000 They selected the wrong line to get 414 00:25:48,000 --> 00:25:49,000 their V speeds. 415 00:25:51,000 --> 00:25:52,000 Thanks. 416 00:25:55,000 --> 00:25:58,000 They were nine knots off on what 417 00:25:58,000 --> 00:25:59,000 VMCG should have been. 418 00:26:03,000 --> 00:26:05,000 It's happened before. Four years 419 00:26:05,000 --> 00:26:07,000 earlier, a flight engineer on 420 00:26:07,000 --> 00:26:09,000 another air transport DC-8 421 00:26:09,000 --> 00:26:11,000 miscalculated the plane's weight, 422 00:26:11,000 --> 00:26:13,000 providing the captain with the wrong 423 00:26:13,000 --> 00:26:14,000 takeoff speeds. 424 00:26:15,000 --> 00:26:17,000 I was one of the first investigators 425 00:26:17,000 --> 00:26:19,000 from the NTSB to arrive on scene. 426 00:26:19,000 --> 00:26:21,000 When I went into the cockpit, 427 00:26:22,000 --> 00:26:24,000 it didn't take any smarts at all 428 00:26:24,000 --> 00:26:27,000 to see the takeoff data was 429 00:26:27,000 --> 00:26:28,000 100,000 pounds too low. 430 00:26:29,000 --> 00:26:31,000 As a result, the company very 431 00:26:31,000 --> 00:26:33,000 seriously began to emphasize the 432 00:26:34,000 --> 00:26:35,000 need to check those calculations 433 00:26:35,000 --> 00:26:36,000 and make sure they're accurate. 434 00:26:37,000 --> 00:26:39,000 And so it's disturbing that in this 435 00:26:39,000 --> 00:26:40,000 accident that did not happen. 436 00:26:41,000 --> 00:26:42,000 Is that the only thing the pilots 437 00:26:53,000 --> 00:26:54,000 A question to consider, Captain. 438 00:26:56,000 --> 00:26:58,000 Once we get near VMCG, if we've used 439 00:26:58,000 --> 00:26:59,000 all the rudder control, you might 440 00:26:59,000 --> 00:27:00,000 want to consider a board. 441 00:27:01,000 --> 00:27:02,000 Because when we get higher, we're 442 00:27:02,000 --> 00:27:03,000 going to be in worse trouble, correct? 443 00:27:04,000 --> 00:27:05,000 That's correct. Absolutely. 444 00:27:10,000 --> 00:27:13,000 The CVR of Flight 782 reveals 445 00:27:13,000 --> 00:27:15,000 that the captain and first officer 446 00:27:15,000 --> 00:27:17,000 were uncertain about the impact of 447 00:27:17,000 --> 00:27:19,000 VMCG speed on rudder control. 448 00:27:20,000 --> 00:27:22,000 The first officer made the comment 449 00:27:22,000 --> 00:27:25,000 that you have rudder control is 450 00:27:25,000 --> 00:27:27,000 less effective once you go beyond 451 00:27:27,000 --> 00:27:30,000 VMCG. And actually the opposite 452 00:27:30,000 --> 00:27:31,000 is true. 453 00:27:34,000 --> 00:27:35,000 Uh, no, actually. 454 00:27:36,000 --> 00:27:38,000 The flight engineer realizes their 455 00:27:39,000 --> 00:27:41,000 Above VMCG, rudder has more authority. 456 00:27:41,000 --> 00:27:42,000 It's helping you more. 457 00:27:43,000 --> 00:27:44,000 I understand. 458 00:27:45,000 --> 00:27:47,000 But the captain fails to acknowledge 459 00:27:47,000 --> 00:27:48,000 the correction. 460 00:27:49,000 --> 00:27:50,000 The flight engineer had the right 461 00:27:51,000 --> 00:27:52,000 answer that the faster the airplane 462 00:27:53,000 --> 00:27:55,000 goes, the more effective the rudder 463 00:27:55,000 --> 00:27:56,000 becomes and you need that 464 00:27:57,000 --> 00:27:58,000 effectiveness to keep the airplane 465 00:27:58,000 --> 00:27:59,000 on the runway. 466 00:28:01,000 --> 00:28:04,000 Why didn't the crew stop and discuss 467 00:28:04,000 --> 00:28:05,000 it until they reached a consensus? 468 00:28:05,000 --> 00:28:06,000 That's the advantage of having three 469 00:28:06,000 --> 00:28:07,000 people in the cockpit. 470 00:28:10,000 --> 00:28:12,000 The right answer generally exists 471 00:28:12,000 --> 00:28:14,000 somewhere in the cockpit and in this 472 00:28:14,000 --> 00:28:16,000 instance the flight engineer had 473 00:28:16,000 --> 00:28:18,000 Maybe their lack of understanding 474 00:28:18,000 --> 00:28:20,000 about the procedure caused them to 475 00:28:20,000 --> 00:28:21,000 abort their first takeoff. 476 00:28:21,000 --> 00:28:22,000 It's possible. 477 00:28:29,000 --> 00:28:30,000 Check that out. 478 00:28:34,000 --> 00:28:36,000 Power went all the way up to 190 479 00:28:37,000 --> 00:28:38,000 So when it flew fast. 480 00:28:39,000 --> 00:28:41,000 And number four jerked up while 481 00:28:41,000 --> 00:28:42,000 I was trying to ease it in. 482 00:28:43,000 --> 00:28:44,000 You brought it up too fast? 483 00:28:45,000 --> 00:28:47,000 Investigators learned that the 484 00:28:47,000 --> 00:28:49,000 captain struggled with engine four's 485 00:28:49,000 --> 00:28:50,000 thrust during the first takeoff 486 00:28:50,000 --> 00:28:51,000 roll. 487 00:28:52,000 --> 00:28:54,000 Power on it just came on too fast. 488 00:28:54,000 --> 00:28:55,000 It's what happened. 489 00:28:58,000 --> 00:28:59,000 If you want to try it again, I could 490 00:28:59,000 --> 00:29:00,000 try adding the power if you like. 491 00:29:01,000 --> 00:29:03,000 The flight engineer proposes an 492 00:29:03,000 --> 00:29:05,000 unorthodox change to the procedure. 493 00:29:06,000 --> 00:29:07,000 Okay, let's do it that way. 494 00:29:10,000 --> 00:29:12,000 The flight engineer took over 495 00:29:12,000 --> 00:29:13,000 control of engine four. 496 00:29:13,000 --> 00:29:14,000 That's crazy. 497 00:29:16,000 --> 00:29:18,000 They couldn't have understood the 498 00:29:18,000 --> 00:29:19,000 difficulty of the procedure if they 499 00:29:19,000 --> 00:29:20,000 split the responsibility. 500 00:29:22,000 --> 00:29:24,000 The core problem is the captain 501 00:29:24,000 --> 00:29:25,000 could not tell how much rudder he's 502 00:29:26,000 --> 00:29:27,000 going to need because he wasn't the 503 00:29:27,000 --> 00:29:29,000 one adding the thrust to the 504 00:29:29,000 --> 00:29:31,000 airplane. It's like trying to 505 00:29:31,000 --> 00:29:33,000 have two people drive a stick shift 506 00:29:33,000 --> 00:29:35,000 car. One doing the steering, one 507 00:29:35,000 --> 00:29:36,000 doing the shifting. It just doesn't 508 00:29:37,000 --> 00:29:38,000 work. You need to have one person 509 00:29:38,000 --> 00:29:40,000 in control at one time. 510 00:29:42,000 --> 00:29:44,000 The flight engineer and the captain 511 00:29:44,000 --> 00:29:45,000 thought they could coordinate the 512 00:29:45,000 --> 00:29:46,000 takeoff together. 513 00:29:49,000 --> 00:29:50,000 Let's figure out how they did. 514 00:29:53,000 --> 00:29:54,000 We worked with the Douglas Aircraft 515 00:29:54,000 --> 00:29:56,000 Company and they produced the a 516 00:29:56,000 --> 00:29:59,000 graph of what an ideal three-engine 517 00:29:59,000 --> 00:30:00,000 takeoff should... 518 00:30:00,000 --> 00:30:04,000 look like with airspeed and engine speed. 519 00:30:04,000 --> 00:30:06,000 We compared that with what actually happened 520 00:30:07,000 --> 00:30:09,000 So this is what the crew was supposed to fly. 521 00:30:10,000 --> 00:30:12,000 Seems like the power and speed rise steadily 522 00:30:12,000 --> 00:30:14,000 in unison until they reach VMCG. 523 00:30:16,000 --> 00:30:18,000 Very, very smooth and synchronized. 524 00:30:18,000 --> 00:30:20,000 But in the accident flight, 525 00:30:20,000 --> 00:30:23,000 the flight engineer brings up power to the engine number 526 00:30:23,000 --> 00:30:25,000 four really quickly. 527 00:30:28,000 --> 00:30:30,000 The plane begins to veer left 528 00:30:30,000 --> 00:30:31,000 off the runway. 529 00:30:32,000 --> 00:30:36,000 Then he brings down the power abruptly here. 530 00:30:37,000 --> 00:30:39,000 Probably in reaction to the plane being out of control. 531 00:30:41,000 --> 00:30:44,000 The most probable thing we think happened was that the flight engineer 532 00:30:44,000 --> 00:30:47,000 saw the aircraft going off to the left of the runway 533 00:30:48,000 --> 00:30:51,000 and kind of panicked and tried to pull the engines back a little bit. 534 00:30:52,000 --> 00:30:54,000 ♪ Fly, bless it. ♪ 535 00:30:59,000 --> 00:31:01,000 Keep it going! Keep it going! Yeah. 536 00:31:01,000 --> 00:31:04,000 Instead of aborting, the Captain attempts to get airborne because 537 00:31:04,000 --> 00:31:06,000 they're about to veer off the runway. 538 00:31:06,000 --> 00:31:10,000 He was countermanded by the Captain who said, "Don't, no, keep going." 539 00:31:10,000 --> 00:31:11,000 So the engines went back up. 540 00:31:12,000 --> 00:31:14,000 We're off the runway! Go max power! 541 00:31:18,000 --> 00:31:22,000 Then the Captain insists that he goes to max power a few seconds later. 542 00:31:23,000 --> 00:31:24,000 They don't have enough speed for takeoff. 543 00:31:25,000 --> 00:31:27,000 The Captain never decided to abort, 544 00:31:27,000 --> 00:31:31,000 and it appeared to be that he thought he could get the airplane in the air. 545 00:31:32,000 --> 00:31:33,000 We will never know. 546 00:31:36,000 --> 00:31:39,000 The Captain and the flight engineer 547 00:31:39,000 --> 00:31:40,000 could never coordinate their actions. 548 00:31:46,000 --> 00:31:49,000 One, two, one, three. 549 00:31:49,000 --> 00:31:53,000 Why did the crew fail to execute a takeoff procedure that they were 550 00:31:53,000 --> 00:31:55,000 specifically sent to Kansas City to perform? 551 00:31:58,000 --> 00:31:59,000 You got it! 552 00:32:06,000 --> 00:32:07,000 Find anything? 553 00:32:08,000 --> 00:32:13,000 Investigators review the work history of Flight 782's crew to determine 554 00:32:13,000 --> 00:32:15,000 their experience with three-engine takeoffs. 555 00:32:16,000 --> 00:32:20,000 Our flight engineer and our first officer were new hires. 556 00:32:21,000 --> 00:32:22,000 They were still on probation. 557 00:32:22,000 --> 00:32:25,000 It's almost certain that neither had performed a three-engine takeoff. 558 00:32:26,000 --> 00:32:27,000 And the Captain? 559 00:32:33,000 --> 00:32:36,000 He'd done it three times, but only as first officer. 560 00:32:37,000 --> 00:32:39,000 He'd never actually flown as a Captain. 561 00:32:40,000 --> 00:32:41,000 They were all green. 562 00:32:43,000 --> 00:32:47,000 The closest the Captain came to flying this type of takeoff was in a simulator. 563 00:32:48,000 --> 00:32:49,000 He only trained on it twice. 564 00:32:55,000 --> 00:32:59,000 Investigators traveled to Colorado to assess the simulator the airline 565 00:32:59,000 --> 00:33:02,000 used to train its pilots to perform three-engine takeoffs. 566 00:33:04,000 --> 00:33:05,000 Okay. 567 00:33:07,000 --> 00:33:10,000 This is a three-engine takeoff, and we're watching for directional control. 568 00:33:11,000 --> 00:33:15,000 Did the pilots have sufficient training to perform this difficult procedure? 569 00:33:16,000 --> 00:33:18,000 I'll call it engine power until you get to max. 570 00:33:18,000 --> 00:33:22,000 Part of the examination was to see if the simulator accurately portrayed 571 00:33:23,000 --> 00:33:25,000 what a three-engine takeoff should entail. 572 00:33:25,000 --> 00:33:27,000 Okay. Let me give this a try. 573 00:33:30,000 --> 00:33:32,000 Engines two and three are spoold up. 574 00:33:32,000 --> 00:33:34,000 Engine four is set. Here we go. 575 00:33:38,000 --> 00:33:40,000 Slowly bringing up four. 576 00:33:44,000 --> 00:33:47,000 One, five, one, six. 577 00:33:50,000 --> 00:33:51,000 One, seven. 578 00:33:52,000 --> 00:33:54,000 I am barely using my rudder. 579 00:33:54,000 --> 00:33:56,000 There is no force pushing me off the runway. 580 00:33:58,000 --> 00:34:00,000 One, eight. 581 00:34:00,000 --> 00:34:04,000 We have VMCG. Max power to Engine four. 582 00:34:04,000 --> 00:34:06,000 And rotate. 583 00:34:07,000 --> 00:34:11,000 In the simulator, the three-engine takeoff is no different from 584 00:34:11,000 --> 00:34:12,000 a regular takeoff. 585 00:34:12,000 --> 00:34:13,000 Okay, cut. 586 00:34:17,000 --> 00:34:21,000 The simulator was not calibrated properly and it did not require the 587 00:34:21,000 --> 00:34:25,000 normal amount of rudder that would be required with a three-engine takeoff. 588 00:34:26,000 --> 00:34:28,000 This is not how their aircraft would have behaved. 589 00:34:29,000 --> 00:34:30,000 Not a chance. 590 00:34:32,000 --> 00:34:35,000 Simulators are for the most part extremely accurate. 591 00:34:36,000 --> 00:34:40,000 And in this particular case, we were frankly shocked that this one was not. 592 00:34:41,000 --> 00:34:44,000 It also happened to be the one the crew trained on. 593 00:34:45,000 --> 00:34:49,000 And this would really give them, I think, a false sense of security when it came to 594 00:34:50,000 --> 00:34:52,000 the difficulty of making a three-engine takeoff. 595 00:34:54,000 --> 00:34:55,000 I'm calling from the NTSB. 596 00:34:56,000 --> 00:35:01,000 How did Air Transport International, or ATI, compare to other cargo 597 00:35:01,000 --> 00:35:03,000 operators on three-engine takeoffs? 598 00:35:04,000 --> 00:35:05,000 I'd like to talk to your chief pilot. 599 00:35:07,000 --> 00:35:11,000 We checked with the other cargo operators who were operating the DC-8. 600 00:35:13,000 --> 00:35:15,000 So only your most qualified pilots do it, huh? 601 00:35:17,000 --> 00:35:22,000 The vast majority of them use the most experienced crews and limited the 602 00:35:22,000 --> 00:35:25,000 operation to daytime in good weather. 603 00:35:26,000 --> 00:35:30,000 Now, this led us to believe that the industry as a whole 604 00:35:31,000 --> 00:35:34,000 understood the danger and the difficulty of a three-engine takeoff 605 00:35:35,000 --> 00:35:36,000 better than ATI did. 606 00:35:37,000 --> 00:35:41,000 Why did the airline choose such an inexperienced crew for such a difficult 607 00:35:42,000 --> 00:35:43,000 I think it's time we asked them that. 608 00:35:46,000 --> 00:35:50,000 Our team went to Little Rock, which was the headquarters of the ATI operation. 609 00:35:51,000 --> 00:35:53,000 And we met with all of the key people there. 610 00:35:55,000 --> 00:35:56,000 Thanks for meeting with me. 611 00:35:57,000 --> 00:36:01,000 So, I've been told that you didn't use your most experienced crew. 612 00:36:01,000 --> 00:36:02,000 Why not? 613 00:36:02,000 --> 00:36:04,000 I needed my experienced crew for a revenue flight. 614 00:36:06,000 --> 00:36:09,000 The Flight 782 crew is only legal for a non-revenue flight. 615 00:36:10,000 --> 00:36:11,000 How so? 616 00:36:12,000 --> 00:36:14,000 They'd only had enough rest for a non-revenue flight. 617 00:36:15,000 --> 00:36:16,000 You don't say. 618 00:36:17,000 --> 00:36:21,000 They discover that the crew was selected because of a critical regulation 619 00:36:22,000 --> 00:36:24,000 governing non-revenue flights and rest times. 620 00:36:26,000 --> 00:36:29,000 Normal flights, where the company makes revenue, are covered by flight 621 00:36:29,000 --> 00:36:31,000 and duty time regulations. 622 00:36:32,000 --> 00:36:35,000 For safety reasons, they have to provide a crew that has been properly 623 00:36:35,000 --> 00:36:38,000 rested. But there is a loophole. 624 00:36:38,000 --> 00:36:41,000 That if the flight is not revenue, 625 00:36:42,000 --> 00:36:44,000 then there are no flight and duty time regulations. 626 00:36:45,000 --> 00:36:49,000 In theory, a crew could fly non-revenue flights indefinitely. 627 00:36:54,000 --> 00:36:59,000 Investigators now wonder how rested the crew was when Flight 782 628 00:36:59,000 --> 00:37:00,000 prepared for takeoff. 629 00:37:03,000 --> 00:37:05,000 So, take us through this. 630 00:37:08,000 --> 00:37:12,000 Investigators closely examined the crew of Flight 782's recent flight 631 00:37:13,000 --> 00:37:15,000 Okay, the morning before the accident, 632 00:37:16,000 --> 00:37:18,000 our crew lands in Germany after a seven-hour flight. 633 00:37:21,000 --> 00:37:22,000 From Delaware. 634 00:37:25,000 --> 00:37:26,000 And how many time zones did they cross? 635 00:37:28,000 --> 00:37:29,000 Six. 636 00:37:30,000 --> 00:37:33,000 Later that same day, they returned, 637 00:37:34,000 --> 00:37:35,000 landing first in Gander, Newfoundland, 638 00:37:38,000 --> 00:37:39,000 then another flight to Delaware. 639 00:37:41,000 --> 00:37:44,000 So they crossed another six time zones heading back. 640 00:37:46,000 --> 00:37:51,000 We were aware that their circadian rhythm had to be pretty much out of sync. 641 00:37:53,000 --> 00:37:54,000 That's simply not a good thing. 642 00:37:56,000 --> 00:37:59,000 Fatigue is not easy to recognize, 643 00:38:00,000 --> 00:38:06,000 but it degrades all aspects of thinking, decision-making and performance. 644 00:38:08,000 --> 00:38:11,000 They got into their hotel in Delaware at 2:40 a.m. on the day of the crash. 645 00:38:12,000 --> 00:38:15,000 How much uninterrupted rest did the Captain get? 646 00:38:17,000 --> 00:38:18,000 Less than five hours. 647 00:38:19,000 --> 00:38:22,000 So they didn't have enough rest to fly anything except this flight. 648 00:38:23,000 --> 00:38:27,000 And they were sent despite lacking the training and experience they needed. 649 00:38:35,000 --> 00:38:40,000 The NTSB concludes its investigation, outlining the fateful steps that caused 650 00:38:40,000 --> 00:38:41,000 the crash of Flight 782. 651 00:38:42,000 --> 00:38:44,000 It begins with the poorly rested crew. 652 00:38:46,000 --> 00:38:52,000 One of the consistent findings of fatigue research is that people tend 653 00:38:52,000 --> 00:38:53,000 to underestimate how tired they are. 654 00:38:54,000 --> 00:38:57,000 Much of the time, you can conduct a safe flight doing that. 655 00:38:58,000 --> 00:39:00,000 But if something unexpected happens, 656 00:39:01,000 --> 00:39:03,000 you're at a real disadvantage. 657 00:39:03,000 --> 00:39:08,000 In this case, the takeoff procedure was much more complicated than the 658 00:39:08,000 --> 00:39:10,000 crew had been trained to expect. 659 00:39:12,000 --> 00:39:13,000 Thanks. 660 00:39:14,000 --> 00:39:19,000 The flight engineer makes an error in a calculation that the other pilots 661 00:39:20,000 --> 00:39:23,000 Once we get near VMCG, if we've used all our rudder control, we might want to 662 00:39:24,000 --> 00:39:26,000 consider aborting, because when we get higher, we're going to be in worse 663 00:39:27,000 --> 00:39:28,000 That's correct. Absolutely. 664 00:39:30,000 --> 00:39:33,000 The pilots are confused about the takeoff procedure. 665 00:39:34,000 --> 00:39:35,000 I know, actually. 666 00:39:36,000 --> 00:39:38,000 Above VMCG, rudder has more authority. 667 00:39:41,000 --> 00:39:45,000 This was a very delicate procedure, and they seemed to think otherwise. 668 00:39:47,000 --> 00:39:49,000 If you want to try it again, I could try adding the power if you like. 669 00:39:50,000 --> 00:39:51,000 Okay, let's do it that way. 670 00:39:52,000 --> 00:39:55,000 A decision to improvise a difficult takeoff 671 00:39:57,000 --> 00:39:59,000 leads to the plane veering out of control. 672 00:40:00,000 --> 00:40:03,000 Very bad decision to improvise on this procedure because 673 00:40:03,000 --> 00:40:09,000 only the person operating the rudder can tell how effective that is 674 00:40:09,000 --> 00:40:10,000 when advancing the throttle. 675 00:40:10,000 --> 00:40:11,000 Okay? 676 00:40:12,000 --> 00:40:15,000 The captain decides not to abort a second time. 677 00:40:19,000 --> 00:40:22,000 The plane lacks enough speed to safely get airborne. 678 00:40:23,000 --> 00:40:24,000 We're off the runway. 679 00:40:25,000 --> 00:40:26,000 Go max power. 680 00:40:33,000 --> 00:40:35,000 It's hard to say what was going through his mind, but 681 00:40:35,000 --> 00:40:38,000 I think he believed he could get the aircraft airborne. 682 00:40:40,000 --> 00:40:44,000 In their report, the NTSB makes several key recommendations. 683 00:40:44,000 --> 00:40:48,000 One is to revise the training procedures for three engine takeoffs. 684 00:40:51,000 --> 00:40:53,000 The crew not only was not trained well, it was inexperienced 685 00:40:53,000 --> 00:40:56,000 in the particular maneuver they were talking about, 686 00:40:56,000 --> 00:40:58,000 and they were tired. 687 00:41:00,000 --> 00:41:04,000 Closing the loopholes that allow flight crews to perform non-revenue 688 00:41:04,000 --> 00:41:07,000 flights without adequate rest is another recommendation. 689 00:41:08,000 --> 00:41:12,000 The reason this is relevant is because the company elected to have 690 00:41:12,000 --> 00:41:17,000 this tired crew fly the three-engine ferry, rather than the rested crew 691 00:41:17,000 --> 00:41:19,000 that was already present in Kansas City. 692 00:41:20,000 --> 00:41:22,000 It was legal, but 693 00:41:22,000 --> 00:41:24,000 it was not a good idea. 694 00:41:25,000 --> 00:41:30,000 The NTSB also recommends that three-engine ferry flights be assigned 695 00:41:30,000 --> 00:41:32,000 to specially designated experienced crews. 696 00:41:33,000 --> 00:41:37,000 Training instructors advised pilots of the simulator's shortcomings 697 00:41:37,000 --> 00:41:38,000 for three-engine takeoffs. 698 00:41:39,000 --> 00:41:42,000 Company exceeded the board's requests. 699 00:41:42,000 --> 00:41:45,000 They really took it very seriously and did change their whole procedure 700 00:41:45,000 --> 00:41:46,000 to prevent this. 701 00:41:47,000 --> 00:41:50,000 The airline industry as a whole does not follow suit. 702 00:41:51,000 --> 00:41:55,000 Non-revenue flights remain exempt from flight and duty time regulations. 703 00:41:55,000 --> 00:41:59,000 There should be no difference with safety whether there are 704 00:41:59,000 --> 00:42:02,000 people on the airplane, freight on the airplane, or the airplane is empty. 705 00:42:03,000 --> 00:42:07,000 One rest rule requirement should apply to everybody every time everywhere.