1 00:00:01,455 --> 00:00:04,295 Pilots of Colganair Flight 900446 fight 2 00:00:04,335 --> 00:00:06,311 for their lives as their plane dives 3 00:00:06,383 --> 00:00:09,231 towards the ground. You pull for all your 4 00:00:09,263 --> 00:00:10,567 worth. Just keep pulling for all your 5 00:00:10,591 --> 00:00:13,175 worth. Picture trying to do your day job 6 00:00:13,295 --> 00:00:16,955 while deadlifting 250 pounds. Oh no. 7 00:00:21,055 --> 00:00:22,795 Both pilots are killed. 8 00:00:25,375 --> 00:00:27,675 The wreckage reveals very little. 9 00:00:29,095 --> 00:00:32,359 That is a rat's nest. The cockpit voice 10 00:00:32,447 --> 00:00:34,287 recording got a runaway trip. Provides a 11 00:00:34,311 --> 00:00:36,023 key insight. Listen how exhausted they 12 00:00:36,039 --> 00:00:38,487 are. Trying to keep the nose up but 13 00:00:38,551 --> 00:00:41,207 analysis of flight data turns the case on 14 00:00:41,231 --> 00:00:43,383 its head. This doesn't look right. Well, 15 00:00:43,399 --> 00:00:45,463 that was the huge ah ha moment for me. 16 00:00:45,639 --> 00:00:48,407 How'that possible? Everybody missed what 17 00:00:48,431 --> 00:00:52,115 was just such a simple mistake. 18 00:01:18,165 --> 00:01:20,717 A Colgan Air crew prepares for the last 19 00:01:20,781 --> 00:01:23,005 flight of the day in a recently serviced 20 00:01:23,045 --> 00:01:26,961 aircraft. Weather looks 21 00:01:26,993 --> 00:01:30,065 good. Should be an easy ride. Captain 22 00:01:30,145 --> 00:01:32,481 Scott Knnabbe has been with Colganair for 23 00:01:32,513 --> 00:01:35,761 more than two years. Six months ago he was 24 00:01:35,793 --> 00:01:39,937 promoted to Captain Scott Kanabe 25 00:01:40,001 --> 00:01:43,561 was among the most careful and meticulous 26 00:01:43,633 --> 00:01:47,153 pilots. He was a very 27 00:01:47,249 --> 00:01:49,685 successful and very good accountant. 28 00:01:50,145 --> 00:01:53,809 But he had the aviation bug. How's the 29 00:01:53,817 --> 00:01:55,689 paperwork? Weight and balance is checked 30 00:01:55,697 --> 00:01:59,337 and filed. First officer Stephen Dean has 31 00:01:59,361 --> 00:02:00,953 been with the airline for less than a 32 00:02:00,969 --> 00:02:04,337 year. Did you put in for that 33 00:02:04,361 --> 00:02:07,089 upgrade? Actually no I didn't. I put in my 34 00:02:07,097 --> 00:02:09,765 notice. I can't afford to do this anymore. 35 00:02:10,265 --> 00:02:13,945 I understood. Being a young pilot 36 00:02:14,025 --> 00:02:15,881 moving his way up the ladder in the 37 00:02:15,913 --> 00:02:18,665 regionals, the first officer quickly 38 00:02:18,705 --> 00:02:21,555 discovered that his pay could not his wife 39 00:02:21,595 --> 00:02:24,811 and daughter. So a week before 40 00:02:25,003 --> 00:02:27,535 this flight he gave notice. 41 00:02:28,435 --> 00:02:30,335 Don't mind these reposition flights. 42 00:02:33,715 --> 00:02:36,175 Yeah, no passengers, no problems. 43 00:02:38,675 --> 00:02:42,375 Knair has a small fleet of BEEC 1900s 44 00:02:42,755 --> 00:02:45,411 the aircraft oper as part of USAir's 45 00:02:45,483 --> 00:02:48,835 regional arm. The Beechcraft is a 46 00:02:48,875 --> 00:02:50,675 smaller plane popular for commuter 47 00:02:50,715 --> 00:02:51,335 flights. 48 00:02:54,355 --> 00:02:56,851 They fly short distances. They fly into 49 00:02:56,883 --> 00:02:59,243 places that the big name carriers wouldn't 50 00:02:59,259 --> 00:03:01,575 be able to fill up or make a lot of money. 51 00:03:05,755 --> 00:03:09,059 Maintenance log checked and aircraft is 52 00:03:09,107 --> 00:03:12,747 released. After four days of routine 53 00:03:12,811 --> 00:03:15,451 maintenance in Hyanis, the plane is being 54 00:03:15,523 --> 00:03:19,003 returned to service. Colgan 9446 55 00:03:19,059 --> 00:03:21,695 will fly empty to upstate New York. 56 00:03:22,235 --> 00:03:24,635 Sometimes we have to resort to these non 57 00:03:24,675 --> 00:03:26,915 revenue flights to reposition the plane 58 00:03:26,955 --> 00:03:29,499 from one location to another. 59 00:03:29,667 --> 00:03:31,547 Occasionally that could also happen when 60 00:03:31,571 --> 00:03:33,315 you have to bring the plane to a specified 61 00:03:33,355 --> 00:03:36,731 maintenance facility. Today's flight from 62 00:03:36,763 --> 00:03:39,707 Hyanis, Massachusetts west to Albany, New 63 00:03:39,731 --> 00:03:41,815 York should take 50 minutes. 64 00:03:43,435 --> 00:03:46,707 Circuit breakers checked. Checked. The 65 00:03:46,731 --> 00:03:48,775 pilots perform their final checks. 66 00:03:52,955 --> 00:03:54,331 All right. I'm not getting any radios 67 00:03:54,363 --> 00:03:55,387 here. Have you get anything in your heads, 68 00:03:55,411 --> 00:03:56,895 sir? Check, check, check. 69 00:03:58,955 --> 00:04:02,211 What a cluster. When an airplane is 70 00:04:02,243 --> 00:04:04,523 let's return back to service. Pilots will 71 00:04:04,579 --> 00:04:06,941 expect that all subsistence are working. 72 00:04:07,083 --> 00:04:08,953 So you will show up to the airplane and 73 00:04:09,009 --> 00:04:10,625 expect that everything has been service 74 00:04:10,665 --> 00:04:12,137 accordingly and it's safe to return back 75 00:04:12,161 --> 00:04:15,801 to flying after 76 00:04:15,833 --> 00:04:18,113 a short delay because of a Minor radio 77 00:04:18,169 --> 00:04:21,925 problem. Flight 900446 taxis for takeoff. 78 00:04:23,625 --> 00:04:26,001 The afterions are set. Cabin PA not 79 00:04:26,033 --> 00:04:28,737 required. Tower cold. 80 00:04:28,801 --> 00:04:34,069 9446 we're good to go. 24 Colgan 81 00:04:34,117 --> 00:04:37,837 9004 and 46 Runway 24 cleared for 82 00:04:37,861 --> 00:04:40,389 takeoff. Clear for takeoff. 83 00:04:40,437 --> 00:04:47,317 24 Kgan 9446 set 84 00:04:47,341 --> 00:04:48,065 the power. 85 00:04:51,405 --> 00:04:54,589 Power set. The beach 1900 86 00:04:54,637 --> 00:04:56,949 being as such a stable aircraft as soon as 87 00:04:56,957 --> 00:04:59,451 it accelerates on the takeoff roll it will 88 00:04:59,483 --> 00:05:01,883 reach fliable speeds in a distance as 89 00:05:01,939 --> 00:05:05,379 short as 4,000ft 80 knots and 90 00:05:05,427 --> 00:05:07,507 it will basically fly itself off the 91 00:05:07,531 --> 00:05:10,295 ramway with very minimal pilot input. 92 00:05:11,715 --> 00:05:13,215 V1 rotate. 93 00:05:15,075 --> 00:05:18,891 At 3:38pm Flight 9446 lifts 94 00:05:18,923 --> 00:05:21,971 off the Runway but it's barely gaining 95 00:05:22,003 --> 00:05:25,935 altitude. We have a hot elevator trim. 96 00:05:26,705 --> 00:05:28,793 The captain suspects there's an issue with 97 00:05:28,809 --> 00:05:30,657 the trim system which is preventing the 98 00:05:30,681 --> 00:05:32,325 plane from climbing normally. 99 00:05:35,625 --> 00:05:37,897 Trim tabs on the elevator adjust the 100 00:05:37,921 --> 00:05:40,689 plane's pitch during takeoff. They're 101 00:05:40,737 --> 00:05:43,205 powered by a switch on the control column 102 00:05:46,825 --> 00:05:49,041 but the captain's trim switch isn't 103 00:05:49,113 --> 00:05:52,755 working. If you have a trim issue on 104 00:05:52,795 --> 00:05:56,375 takeoff it is very difficult to overcome. 105 00:05:56,755 --> 00:05:59,763 You have seconds not minutes because you 106 00:05:59,779 --> 00:06:04,155 don't have any altitude. Just 50ft 107 00:06:04,195 --> 00:06:06,419 off the ground the plane's nose is 108 00:06:06,467 --> 00:06:09,835 dropping. Roll back. Roll back. 109 00:06:09,875 --> 00:06:11,255 Roll it back. I got it. 110 00:06:13,475 --> 00:06:15,827 Kanaabbe instructs the first officer to 111 00:06:15,851 --> 00:06:17,455 adjust the trim manually. 112 00:06:20,455 --> 00:06:22,423 The manual trim is a wheel located on the 113 00:06:22,439 --> 00:06:24,391 left side of the throttle quadrant that 114 00:06:24,423 --> 00:06:26,519 allows you to trim it into a nose up 115 00:06:26,567 --> 00:06:30,479 addite. But that 116 00:06:30,527 --> 00:06:34,583 doesn't help pull back an 117 00:06:34,599 --> 00:06:36,111 airplane that is nose heavy will 118 00:06:36,183 --> 00:06:38,535 continuously require back pressure on the 119 00:06:38,575 --> 00:06:39,475 control yoke. 120 00:06:42,135 --> 00:06:46,091 It's everybody. Using brute force the 121 00:06:46,123 --> 00:06:48,187 pilots manage to raise the plane's nose 122 00:06:48,251 --> 00:06:50,739 and climb away from the Runway. Despite 123 00:06:50,787 --> 00:06:57,003 the plane's determination to pitch down do 124 00:06:57,019 --> 00:06:59,587 the electric trim disconnect. The captain 125 00:06:59,651 --> 00:07:01,331 wants to cut the power to the trim 126 00:07:01,403 --> 00:07:02,255 altogether. 127 00:07:05,035 --> 00:07:07,411 But before the co pilot can even find the 128 00:07:07,443 --> 00:07:10,735 right circuit breaker back 129 00:07:10,815 --> 00:07:13,711 Steve no, stay the controls with me. The 130 00:07:13,743 --> 00:07:15,155 nose drops again. 131 00:07:20,655 --> 00:07:21,795 Put up our gear. 132 00:07:24,135 --> 00:07:26,751 Selecting the gear up in an airplane will 133 00:07:26,903 --> 00:07:28,663 reduce the amount of starac being exposed 134 00:07:28,719 --> 00:07:31,679 to the airstriam improving your climb 135 00:07:31,727 --> 00:07:34,183 performance. This would have make the 136 00:07:34,199 --> 00:07:36,935 pilots gain altitude at a faster rate. 137 00:07:38,395 --> 00:07:40,931 45 seconds into the flight the pilots 138 00:07:41,003 --> 00:07:42,739 still can't get the plane to climb 139 00:07:42,787 --> 00:07:43,535 normally. 140 00:07:45,755 --> 00:07:48,775 9446 is requesting emergency back sir. 141 00:07:49,555 --> 00:07:52,523 Got a runaway Trim, the captain wants to 142 00:07:52,579 --> 00:07:54,419 return to Hyanis Airport. 143 00:07:54,587 --> 00:07:58,139 Colgan9446, Roger. Right a left downwind. 144 00:07:58,187 --> 00:08:00,455 Your choice. Report midf field. 145 00:08:01,255 --> 00:08:04,983 Okay, roger. We will do. Using all of 146 00:08:04,999 --> 00:08:07,079 their physical strength, the pilots 147 00:08:07,167 --> 00:08:10,159 managed to level off at,200ft and start 148 00:08:10,207 --> 00:08:11,995 the turn back to Hyanis. 149 00:08:15,575 --> 00:08:19,167 Allgh, we have 150 00:08:19,191 --> 00:08:21,791 a beach. 1900 aircraft that just took off 151 00:08:21,863 --> 00:08:24,151 reporting control problems. We need fire 152 00:08:24,183 --> 00:08:28,523 and rescue to Runway three three with 153 00:08:28,579 --> 00:08:31,499 brief respite from the struggle. Can I 154 00:08:31,507 --> 00:08:33,747 pull the breaker? Yeah, pull the breaker. 155 00:08:33,771 --> 00:08:36,195 See? Pull the breaker. The ye. The pilots 156 00:08:36,275 --> 00:08:38,563 return to troubleshooting the trim issue. 157 00:08:38,699 --> 00:08:42,227 Where is it? Find it. In the confusion, 158 00:08:42,291 --> 00:08:44,515 the first officer can't locate the breaker 159 00:08:44,555 --> 00:08:47,299 for the automatic trim. Look. Left of the 160 00:08:47,307 --> 00:08:48,467 silver thing, Steve. Left of the silver 161 00:08:48,491 --> 00:08:49,699 thing. Left of the silver thing. Left of 162 00:08:49,707 --> 00:08:53,277 the silver thing. This dick seeve. 163 00:08:53,381 --> 00:08:56,477 Stay with me. The second attempt to 164 00:08:56,501 --> 00:08:59,145 disconnect the trim system also fails. 165 00:09:01,645 --> 00:09:03,957 Less than two minutes after taking off, 166 00:09:04,061 --> 00:09:07,185 Colga 9446 is losing altitude. 167 00:09:10,605 --> 00:09:12,357 You pull for all your worth. Just keep 168 00:09:12,381 --> 00:09:15,053 pulling for all your worth. Really what he 169 00:09:15,069 --> 00:09:17,533 was saying is pull for your life. Because 170 00:09:17,549 --> 00:09:19,085 that was the only hope they had at that 171 00:09:19,125 --> 00:09:19,705 time. 172 00:09:22,545 --> 00:09:25,065 Five miles from the airport, the pilots 173 00:09:25,145 --> 00:09:27,205 struggle to return to Hyanis. 174 00:09:28,825 --> 00:09:31,805 9446 is requesting 33, sir. 175 00:09:32,745 --> 00:09:36,657 9446 roger. Runway 33 cleared 176 00:09:36,681 --> 00:09:39,297 the land. You're gonna need both of us on 177 00:09:39,321 --> 00:09:40,045 this, Steve. 178 00:09:42,785 --> 00:09:45,305 The pilots use all their strength to keep 179 00:09:45,345 --> 00:09:48,429 their plane airborne. Steve. Ke I'm 180 00:09:48,477 --> 00:09:50,945 pulling but it's still not enough. 181 00:10:08,645 --> 00:10:11,605 We have a beach. 1900 aircraft down east 182 00:10:11,645 --> 00:10:14,875 of Point Gamon. Two pilots, no passengers. 183 00:10:16,775 --> 00:10:19,735 Two minutes after takeoff, KGAN 9004 and 184 00:10:20,235 --> 00:10:22,487 46 crashes three and a half miles from the 185 00:10:22,511 --> 00:10:24,635 airport in Hayanis, Massachusetts. 186 00:10:27,855 --> 00:10:29,783 The Coast Guard was there almost 187 00:10:29,839 --> 00:10:32,279 immediately, but they were not able to 188 00:10:32,327 --> 00:10:35,671 save the pilot and the co pilot. Hitting 189 00:10:35,703 --> 00:10:39,167 the water at a very high rate of speed is 190 00:10:39,191 --> 00:10:43,047 like hitting cement. The pilot's 191 00:10:43,071 --> 00:10:44,879 bodies are recovered from the wreckage 192 00:10:44,967 --> 00:10:46,115 within four hours. 193 00:10:52,935 --> 00:10:54,959 A team from the National Transportation 194 00:10:55,047 --> 00:10:58,423 Safety Board, the NTSB arrives in Cape Cod 195 00:10:58,479 --> 00:11:02,487 to begin the investigation can be posted 196 00:11:02,511 --> 00:11:05,091 on under recovery process. This is the 197 00:11:05,123 --> 00:11:08,335 second beach 1900 to crash in six months. 198 00:11:09,795 --> 00:11:11,619 There was the Air Midwest accident down in 199 00:11:11,667 --> 00:11:14,147 Charlotte. The big question was, you know, 200 00:11:14,211 --> 00:11:15,843 is there anything related? Was there a 201 00:11:15,859 --> 00:11:16,935 fleet wide problem? 202 00:11:21,515 --> 00:11:24,859 NTSB investigators consider why Colgan Air 203 00:11:24,907 --> 00:11:28,395 Flight 9446 crashed so soon after takeoff, 204 00:11:28,475 --> 00:11:31,703 killing both pilots. It's similar to 205 00:11:31,719 --> 00:11:33,839 an Air Midwest crash in Charlotte, North 206 00:11:33,887 --> 00:11:36,399 Carolina which took the lives of 21 207 00:11:36,447 --> 00:11:38,991 people. Witnesses reported that the 208 00:11:39,023 --> 00:11:42,311 aircraft climbed for a 209 00:11:42,463 --> 00:11:45,471 Few seconds and then the nose pitched up 210 00:11:45,543 --> 00:11:49,263 high in the air. It edged over and then 211 00:11:49,439 --> 00:11:52,263 literally tumbled towards the ground into 212 00:11:52,279 --> 00:11:53,155 a building. 213 00:11:56,915 --> 00:11:59,131 With hundreds of American built beach 214 00:11:59,203 --> 00:12:02,467 1900s in service, investigators need 215 00:12:02,491 --> 00:12:04,683 to find out if there's a design fault with 216 00:12:04,699 --> 00:12:06,675 the aircraft that could put even more 217 00:12:06,715 --> 00:12:07,855 lives at risk. 218 00:12:11,195 --> 00:12:13,763 Steve. Hey, great. You can set up over 219 00:12:13,779 --> 00:12:17,251 there. Thanks, boss. The NTSB calls 220 00:12:17,283 --> 00:12:20,227 in Steve Carbone, an investigator who has 221 00:12:20,251 --> 00:12:22,619 been working for months on the beach 1900 222 00:12:22,667 --> 00:12:24,095 accident in Charlotte. 223 00:12:25,505 --> 00:12:27,513 What do we know so far about the cause of 224 00:12:27,529 --> 00:12:30,137 that other BE 1900 crash, the one in 225 00:12:30,161 --> 00:12:32,121 Charlotte? We think the plane was loaded 226 00:12:32,153 --> 00:12:34,325 wrong and the pilots lost control of it. 227 00:12:35,385 --> 00:12:38,017 A witness reported that Colgan Air 1900 228 00:12:38,081 --> 00:12:40,209 seemed to struggle to hold altitude before 229 00:12:40,257 --> 00:12:41,633 descending into the water south of the 230 00:12:41,649 --> 00:12:44,801 airport. Pilots understand that altitude 231 00:12:44,833 --> 00:12:47,169 is their best friend. And taking off from 232 00:12:47,217 --> 00:12:50,123 the airport and then pretty much flying 233 00:12:50,219 --> 00:12:53,427 right into the ocean is a sure sign that 234 00:12:53,491 --> 00:12:57,243 something was wrong. Could be 235 00:12:57,299 --> 00:12:59,099 controlled problems after takeoff in both 236 00:12:59,147 --> 00:13:02,843 accidents, the similarities 237 00:13:02,939 --> 00:13:05,819 between Kogan and Air Midwest wasn't just 238 00:13:05,947 --> 00:13:09,387 the fact that Both were beach 1900. In 239 00:13:09,411 --> 00:13:11,067 both instances, the attitude of the 240 00:13:11,091 --> 00:13:13,015 aircraft was uncontrollable. 241 00:13:15,415 --> 00:13:18,515 Charlotte. They lost control of the pitch. 242 00:13:19,255 --> 00:13:20,915 Was it outside its center? Gravity? 243 00:13:23,335 --> 00:13:25,495 The balancing point of an airplane is 244 00:13:25,535 --> 00:13:28,527 called its center of gravity. Passengers 245 00:13:28,591 --> 00:13:30,799 and luggage must be carefully distributed 246 00:13:30,847 --> 00:13:32,935 from front to back to keep the plane 247 00:13:33,015 --> 00:13:34,235 stable in flight. 248 00:13:36,775 --> 00:13:39,047 In Charlotte, investigators believe the 249 00:13:39,071 --> 00:13:41,809 beach 1900 may have been tail heavy, 250 00:13:41,927 --> 00:13:44,545 which caused it to pitch up after takeoff. 251 00:13:47,285 --> 00:13:49,317 The Colgan flight was empty. So without 252 00:13:49,341 --> 00:13:50,749 any passengers. Maybe the center of 253 00:13:50,757 --> 00:13:53,621 gravity was too far forward. You could 254 00:13:53,653 --> 00:13:56,629 have an empty airplane and still be out of 255 00:13:56,677 --> 00:14:01,509 your center of gravity. Crew weight 454 256 00:14:01,557 --> 00:14:05,897 pounds. They calculate Flight 257 00:14:06,048 --> 00:14:08,681 9446's center of gravity based on the 258 00:14:08,713 --> 00:14:11,681 distribution of the weight on board. And 259 00:14:11,713 --> 00:14:15,165 then the fuel weight was 3,271 pounds. 260 00:14:17,905 --> 00:14:19,125 That should do it. 261 00:14:24,385 --> 00:14:26,085 Look how far from it that is. 262 00:14:28,145 --> 00:14:30,805 Yeah, but it's within limits. 263 00:14:31,665 --> 00:14:33,785 The team is now certain that whatever 264 00:14:33,825 --> 00:14:36,897 brought down Colgan 9446, it was not 265 00:14:36,961 --> 00:14:38,765 related to its center of gravity. 266 00:14:41,465 --> 00:14:44,537 With Kogan, center of gravity didn't turn 267 00:14:44,561 --> 00:14:46,433 out to be an issue, even though it did 268 00:14:46,489 --> 00:14:48,725 have to be eliminated as a possibility. 269 00:14:56,985 --> 00:14:58,365 Thank you for meeting with me. 270 00:14:59,185 --> 00:15:01,081 Investigators turned to the air traffic 271 00:15:01,153 --> 00:15:03,521 controller for insight into why the pilots 272 00:15:03,553 --> 00:15:07,245 of Colgan 9446 lost control after takeoff. 273 00:15:08,745 --> 00:15:11,401 Tell me about the flight. It'a normal 274 00:15:11,433 --> 00:15:14,553 takeoff. About a minute after they wanted 275 00:15:14,569 --> 00:15:15,725 to return to the airport. 276 00:15:19,745 --> 00:15:22,725 9446 is requesting emergency back. Sir. 277 00:15:23,825 --> 00:15:27,121 We have a runaway trim. He told 278 00:15:27,153 --> 00:15:29,565 you a runaway Trim? Yeah. 279 00:15:30,465 --> 00:15:32,697 Pilot reported a runaway trim to air 280 00:15:32,721 --> 00:15:34,485 traffic control, which is a control issue. 281 00:15:34,625 --> 00:15:36,533 And so that information was very helpful. 282 00:15:36,589 --> 00:15:38,705 It helped us work smarter, not harder. 283 00:15:40,005 --> 00:15:42,485 Runaway trim occurs when the motorized 284 00:15:42,565 --> 00:15:45,213 trim tabs on the elevator malfunction, 285 00:15:45,349 --> 00:15:47,973 causing the plane to pitch nose up or nose 286 00:15:48,029 --> 00:15:51,397 down. Aroundeight trim close to the 287 00:15:51,421 --> 00:15:53,245 ground will be specifically challenging 288 00:15:53,325 --> 00:15:56,053 because pilots will have very limited time 289 00:15:56,109 --> 00:15:59,077 to perform the required actions to safely 290 00:15:59,141 --> 00:16:02,047 control that aircraft. Now, he came off a 291 00:16:02,071 --> 00:16:05,527 Runway 24 and reported his 292 00:16:05,551 --> 00:16:08,075 emergency here. 293 00:16:08,895 --> 00:16:11,195 Turned back toward the airport, 294 00:16:11,775 --> 00:16:13,847 and the plane never got above 1200ft on my 295 00:16:13,871 --> 00:16:17,595 radar and he hit the water 296 00:16:17,975 --> 00:16:18,715 here. 297 00:16:21,375 --> 00:16:23,415 If the pilot feels that he's having a trim 298 00:16:23,455 --> 00:16:24,991 runaway, there's something in the pitch 299 00:16:25,063 --> 00:16:27,895 system that is clearly a problem. 300 00:16:28,755 --> 00:16:31,275 This is very helpful. Thank you. And we're 301 00:16:31,315 --> 00:16:34,035 certainly going to investigate that. Will 302 00:16:34,075 --> 00:16:36,091 the wreckage confirm what the pilots 303 00:16:36,163 --> 00:16:38,491 reported and help explain what brought 304 00:16:38,523 --> 00:16:41,291 down a widely used commuter aircraft in 305 00:16:41,323 --> 00:16:42,935 just over two minutes? 306 00:16:50,675 --> 00:16:53,739 Good. You got them. The flight data 307 00:16:53,827 --> 00:16:55,971 recorder and cockpit voice Recorder of 308 00:16:56,003 --> 00:16:58,987 Colganair Flight 9446 are recovered from 309 00:16:59,011 --> 00:17:01,455 the sea floor. They are in good shape. 310 00:17:04,675 --> 00:17:07,163 Ship them to the lab. Mean we'get some 311 00:17:07,179 --> 00:17:10,507 answers from these. We were lucky in 312 00:17:10,531 --> 00:17:12,211 some areas where we had the flight data 313 00:17:12,283 --> 00:17:14,019 recorder and we had the cockpit force 314 00:17:14,067 --> 00:17:17,403 recorder. If we didn't have flight 315 00:17:17,459 --> 00:17:20,004 recorders on this one, boy, I don't know. 316 00:17:21,064 --> 00:17:22,604 That is a rat's nest. 317 00:17:24,264 --> 00:17:26,488 Investigators turn their attention to what 318 00:17:26,536 --> 00:17:29,856 remains of the control systems. So there's 319 00:17:29,880 --> 00:17:32,404 a lot of cables that go to the tail, 320 00:17:32,744 --> 00:17:36,284 cables that control the elevator, the trim 321 00:17:36,944 --> 00:17:39,696 and the rudder as well. I see some of the 322 00:17:39,720 --> 00:17:42,656 trim cable in there. Let's find as many 323 00:17:42,680 --> 00:17:45,901 pieces of it as we can. The trim cables 324 00:17:45,933 --> 00:17:49,109 are smaller and head fractured, and so 325 00:17:49,197 --> 00:17:51,901 it's a big puzzle to be able to track the 326 00:17:51,933 --> 00:17:55,261 cables from one end to the other. Could 327 00:17:55,293 --> 00:17:56,145 take a while. 328 00:17:59,365 --> 00:18:01,413 While one team looks for the cables 329 00:18:01,469 --> 00:18:03,749 connecting the trim system, another 330 00:18:03,797 --> 00:18:05,821 focuses on the maintenance history of 331 00:18:05,853 --> 00:18:07,625 Colgan9004.46, 332 00:18:10,825 --> 00:18:12,153 I'm going to look into work done on the 333 00:18:12,169 --> 00:18:13,125 flight controls. 334 00:18:17,585 --> 00:18:19,561 The aircraft was brought into has four 335 00:18:19,593 --> 00:18:21,585 days before the accident for regular phase 336 00:18:21,625 --> 00:18:25,017 inspection. Could a faulty repair 337 00:18:25,121 --> 00:18:27,025 be connected to the pilot's report of 338 00:18:27,065 --> 00:18:30,233 runaway trim? Check out which inspection 339 00:18:30,289 --> 00:18:34,281 they were in. At Colnair, 340 00:18:34,393 --> 00:18:36,665 monthly routine inspections are divided 341 00:18:36,745 --> 00:18:39,385 into phases, focusing on different areas 342 00:18:39,425 --> 00:18:40,325 of the plane. 343 00:18:42,905 --> 00:18:45,001 They were working on the tail. Exactly. 344 00:18:45,153 --> 00:18:46,497 Which means they might have done work on 345 00:18:46,521 --> 00:18:49,705 the trim system. They flew in with no 346 00:18:49,745 --> 00:18:52,585 problems, and then on the first flight 347 00:18:52,625 --> 00:18:55,489 out, they couldn't control it. Something 348 00:18:55,537 --> 00:18:58,649 happened that was detrimental to safety of 349 00:18:58,657 --> 00:19:01,385 the aircraft. They spent at least four 350 00:19:01,425 --> 00:19:04,197 separate days on the inspection ###n take 351 00:19:04,221 --> 00:19:05,065 them so long? 352 00:19:08,845 --> 00:19:12,285 It doesn't say a phase check. 353 00:19:12,365 --> 00:19:14,165 In this case, what they call a detail 354 00:19:14,205 --> 00:19:16,661 check, you can do it within an eight hour 355 00:19:16,733 --> 00:19:19,213 period, especially on a 1900, because it's 356 00:19:19,229 --> 00:19:22,077 a very simple aircraft. But the fact that 357 00:19:22,101 --> 00:19:24,525 it took four days led us to understand 358 00:19:24,565 --> 00:19:25,781 that there was something else that 359 00:19:25,813 --> 00:19:29,831 occurred. Mind if I record this? 360 00:19:30,013 --> 00:19:30,735 Sure. 361 00:19:35,195 --> 00:19:38,027 I was wondering why did it take you so 362 00:19:38,051 --> 00:19:40,427 long to do your face checks? No, we 363 00:19:40,451 --> 00:19:41,603 definitely found a lot of stuff that we 364 00:19:41,619 --> 00:19:42,535 need to replace. 365 00:19:49,955 --> 00:19:51,335 I got the flashlight. 366 00:19:54,995 --> 00:19:56,735 Just bring the light a up to my left. 367 00:20:00,155 --> 00:20:02,575 Yeah. The trim actuator is worn out. 368 00:20:04,155 --> 00:20:06,491 Cables from the cockpit connect to the 369 00:20:06,523 --> 00:20:09,947 trim actuators. Mechanical rods 370 00:20:10,011 --> 00:20:12,307 in the tail that move the trim tabs up or 371 00:20:12,331 --> 00:20:15,667 down. What did you do when you found the 372 00:20:15,691 --> 00:20:18,963 problem with the actuators? We removed the 373 00:20:18,979 --> 00:20:21,307 old ones, ordered new ones and installed 374 00:20:21,331 --> 00:20:24,727 them. And the new ones went in 375 00:20:24,751 --> 00:20:28,055 easily and it worked fine. U well, 376 00:20:28,135 --> 00:20:29,155 not exactly. 377 00:20:34,175 --> 00:20:36,395 Okay, Bob, run the trim system, please. 378 00:20:40,015 --> 00:20:43,239 Did the actuators move? No. 379 00:20:43,407 --> 00:20:45,951 Neither did the trim cable. The test 380 00:20:46,023 --> 00:20:47,975 revealed problems with the actuator 381 00:20:48,015 --> 00:20:50,853 replacement. When we replaced the 382 00:20:50,869 --> 00:20:54,053 actuator, we bent and kinked the cable 383 00:20:54,109 --> 00:20:56,225 that connects it to the cockpit controls. 384 00:20:56,925 --> 00:21:01,173 It was just a dumb mistake. If he's an 385 00:21:01,269 --> 00:21:03,557 experienced, competent mechanic, why would 386 00:21:03,581 --> 00:21:06,865 he do that? And the answer was he was not. 387 00:21:07,245 --> 00:21:09,341 He was. A new hire, had never done this 388 00:21:09,373 --> 00:21:12,085 job before. And their training program 389 00:21:12,205 --> 00:21:14,637 allowed him to do this without any 390 00:21:14,701 --> 00:21:18,035 supervision. I ordered a new cable and 391 00:21:18,075 --> 00:21:20,051 installed it. That's why it took four 392 00:21:20,083 --> 00:21:23,819 days. And you tested it? 393 00:21:23,987 --> 00:21:27,091 Yeah. Yep. After the 394 00:21:27,123 --> 00:21:29,379 new cable was installed, maintenance 395 00:21:29,467 --> 00:21:31,375 workers performed a visual check. 396 00:21:32,395 --> 00:21:35,371 Okay, let's give it a try. When examining 397 00:21:35,403 --> 00:21:37,363 the paperwork after the accident, 398 00:21:37,539 --> 00:21:40,131 everything looked in order. That's it. 399 00:21:40,163 --> 00:21:43,263 It's working. Thanks, man. Yet we still 400 00:21:43,319 --> 00:21:46,743 had an issue because it didn't explain 401 00:21:46,839 --> 00:21:49,823 what actually happened. With no credible 402 00:21:49,879 --> 00:21:51,991 leads to explain why the pilots thought 403 00:21:52,023 --> 00:21:54,671 they had a trim issue, investigators must 404 00:21:54,703 --> 00:21:57,351 rely on what they learn from the cvr. The 405 00:21:57,383 --> 00:22:00,715 cockpit voice recorder. Okay. Hear it. 406 00:22:08,675 --> 00:22:10,723 The recording runs about 17 minutes from 407 00:22:10,739 --> 00:22:12,347 the moment the pilots powered up on the 408 00:22:12,371 --> 00:22:12,935 ground. 409 00:22:15,795 --> 00:22:18,211 Could the pilot's communications reveal 410 00:22:18,283 --> 00:22:21,307 why Colganair Flight 9446 failed to 411 00:22:21,331 --> 00:22:22,615 maintain altitude? 412 00:22:24,875 --> 00:22:27,644 Hi, its maintenance. This is Colan 9004 413 00:22:27,729 --> 00:22:30,331 46. Hey, I was told to stay in contact 414 00:22:30,363 --> 00:22:32,387 with you for the whole trip. Yeah, they 415 00:22:32,411 --> 00:22:34,235 might call you and turn you back. Because 416 00:22:34,275 --> 00:22:36,447 they did find a problem. I don't know for 417 00:22:36,471 --> 00:22:40,215 sure. Why would maintenance 418 00:22:40,255 --> 00:22:42,375 want to turn them around? Maybe there was 419 00:22:42,415 --> 00:22:44,927 something wrong with the plane. Somebody 420 00:22:44,951 --> 00:22:46,555 had doubts about the work. They did. 421 00:22:49,735 --> 00:22:53,295 I, as a mechanic could not ever 422 00:22:53,415 --> 00:22:55,151 release an aircraft that there was a 423 00:22:55,183 --> 00:22:57,087 question of its airwortthhiness. You 424 00:22:57,111 --> 00:23:00,375 cannot say. Well, you know, the wings aret 425 00:23:00,455 --> 00:23:03,175 pretty strong on there. We're 90% positive 426 00:23:03,215 --> 00:23:05,257 they're not going to fall off. You can't 427 00:23:05,281 --> 00:23:08,153 do that. I d prefer not to fly something 428 00:23:08,169 --> 00:23:10,753 if it's broken. I'd rather you do it 429 00:23:10,929 --> 00:23:13,353 because you are the pilot in command. All 430 00:23:13,369 --> 00:23:16,753 right. Broken airplane. I wouldn't 431 00:23:16,769 --> 00:23:17,765 want to screw it up. 432 00:23:20,385 --> 00:23:22,905 Okay. It'll be a standard Coolan takeoff. 433 00:23:22,985 --> 00:23:24,713 If things get spooky on the Runway, we'll 434 00:23:24,729 --> 00:23:27,953 abort it. Did you 435 00:23:27,969 --> 00:23:31,853 just say spooky? As investigators continue 436 00:23:31,909 --> 00:23:35,093 to review, the CVR flight crew should 437 00:23:35,109 --> 00:23:37,933 not be that nervous. They're surprised by 438 00:23:37,949 --> 00:23:39,693 the pilots's concern about the condition 439 00:23:39,749 --> 00:23:40,945 of their aircraft. 440 00:23:43,045 --> 00:23:46,373 Sadly, the aircraft manuals went down with 441 00:23:46,389 --> 00:23:49,557 the aircraft. So exactly what 442 00:23:49,661 --> 00:23:51,909 the maintenance personnel put in those log 443 00:23:51,957 --> 00:23:54,613 books for the pilots to review we will 444 00:23:54,669 --> 00:23:55,585 never know. 445 00:23:58,385 --> 00:23:59,913 When did they first realize there was a 446 00:23:59,929 --> 00:24:01,445 serious issue with their aircraft? 447 00:24:03,385 --> 00:24:06,045 Looks like merely seconds after takeoff. 448 00:24:08,305 --> 00:24:09,965 V1 rotate. 449 00:24:13,265 --> 00:24:16,313 We have a hot elevator trim. They 450 00:24:16,369 --> 00:24:18,401 identified a trim issue seconds after 451 00:24:18,433 --> 00:24:20,809 takeoff, long before contacting the 452 00:24:20,857 --> 00:24:24,005 controller. So what do they do about it? 453 00:24:26,145 --> 00:24:29,617 Kill the trim. Kill the trim. The captain 454 00:24:29,681 --> 00:24:32,065 tries to disconnect the trim system on his 455 00:24:32,105 --> 00:24:35,085 yoke, but his attempts fail. 456 00:24:36,465 --> 00:24:38,313 Roll back. Roll back. Roll it back. I got 457 00:24:38,329 --> 00:24:38,885 it. 458 00:24:43,345 --> 00:24:45,313 Their commanding nos up trim inputs, but 459 00:24:45,329 --> 00:24:46,525 it doesn't seem to help. 460 00:24:50,765 --> 00:24:53,785 9446 is requesting emergency back, sir. 461 00:24:54,525 --> 00:24:58,189 Got a runaway trim. Okay, there it 462 00:24:58,197 --> 00:25:01,245 is. Runaway trip, just like the controller 463 00:25:01,285 --> 00:25:01,865 said. 464 00:25:04,965 --> 00:25:08,077 Did they try pulling the breaker? Looks 465 00:25:08,101 --> 00:25:08,825 like it. 466 00:25:11,485 --> 00:25:13,029 Pull the br ste. Pull the breaker at the 467 00:25:13,037 --> 00:25:16,281 yoke. Listen how exhausted 468 00:25:16,313 --> 00:25:17,965 they are. Trying to keep the nose up. 469 00:25:18,785 --> 00:25:22,233 Where is it? Find it. The pilot was 470 00:25:22,289 --> 00:25:24,097 calling for the co pilot to pull the 471 00:25:24,121 --> 00:25:26,201 circuit breaker so they can stop these 472 00:25:26,273 --> 00:25:28,337 electrical signals that are commanding the 473 00:25:28,361 --> 00:25:32,065 runaway tram. But you have to have time to 474 00:25:32,105 --> 00:25:34,809 pull the circuit breakers. Look. Left of 475 00:25:34,817 --> 00:25:35,833 the silver things, Steve. Left of the 476 00:25:35,849 --> 00:25:37,273 silver. Left of the silver thing. Left to 477 00:25:37,289 --> 00:25:40,873 the silver thing. O this dick. See? 478 00:25:40,969 --> 00:25:44,313 Stay with me. The coal pilot had to 479 00:25:44,329 --> 00:25:45,649 abandon pull in the breaker in order to 480 00:25:45,657 --> 00:25:49,085 help the captain. Steve, keep pulling. 481 00:25:51,625 --> 00:25:52,725 Oh, no. 482 00:26:00,465 --> 00:26:03,805 Two minutes from takeo the impact. 483 00:26:06,045 --> 00:26:08,093 Those guys fought the trim right until 484 00:26:08,109 --> 00:26:11,277 they hit the water. We need to find 485 00:26:11,301 --> 00:26:13,105 out what's going on with that trim system. 486 00:26:15,565 --> 00:26:17,933 Was there a mechanical issue with the trim 487 00:26:17,989 --> 00:26:20,065 that the pilots could not overcome? 488 00:26:24,165 --> 00:26:27,549 Okay, let's have a look. We were lucky we 489 00:26:27,557 --> 00:26:29,909 had a solid state flight data recorder. 490 00:26:30,077 --> 00:26:31,821 Some of the old, old flight recorders 491 00:26:31,853 --> 00:26:33,617 might only have 16 parameters. This one 492 00:26:33,641 --> 00:26:37,425 had a lot more. Investigators examined the 493 00:26:37,465 --> 00:26:40,673 fdr, the flight data recorder to determine 494 00:26:40,729 --> 00:26:43,325 why the pilots reported a runaway trim. 495 00:26:45,545 --> 00:26:47,805 This doesn't look right. What do you mean? 496 00:26:48,185 --> 00:26:50,481 This trimmed. That is way out of 497 00:26:50,513 --> 00:26:54,201 calibration. It either wasn't 498 00:26:54,233 --> 00:26:56,393 maintained properly or it was damaged in 499 00:26:56,409 --> 00:26:59,193 the accident and so on. This one we didn't 500 00:26:59,249 --> 00:27:02,005 have exact treosition. 501 00:27:03,185 --> 00:27:04,961 If the FDR wasn't calibrated, those 502 00:27:04,993 --> 00:27:08,441 readings are worthless. It's a 503 00:27:08,513 --> 00:27:11,441 major setback. Without the FDR data, 504 00:27:11,553 --> 00:27:13,641 the investigators may not be able to 505 00:27:13,713 --> 00:27:15,849 confirm the pilot's report of a runaway 506 00:27:15,897 --> 00:27:18,313 trim. But we have all those other 507 00:27:18,329 --> 00:27:20,605 parameters. Pitch elevator. 508 00:27:21,305 --> 00:27:23,121 Let's ask the lab to try and calculate 509 00:27:23,153 --> 00:27:24,565 what the trim position would be. 510 00:27:25,705 --> 00:27:28,865 Performance case study. It's a great idea. 511 00:27:29,765 --> 00:27:31,861 A case study like this would help us to 512 00:27:31,893 --> 00:27:35,125 define whether the elevator trim tape of 513 00:27:35,165 --> 00:27:37,021 cables had anything to do with the 514 00:27:37,053 --> 00:27:39,253 accident. It was one other thing that we 515 00:27:39,269 --> 00:27:42,293 could check into to verify the results we 516 00:27:42,309 --> 00:27:44,957 were finding. Will the team be able to get 517 00:27:44,981 --> 00:27:48,325 accurate trim data? Steve KE I'm pulling. 518 00:27:48,405 --> 00:27:50,773 And explain why two experienced pilots 519 00:27:50,829 --> 00:27:52,613 were unable to keep their plane in the 520 00:27:52,629 --> 00:27:54,505 air. Oh no. 521 00:28:07,925 --> 00:28:10,389 So the lab took the control column 522 00:28:10,437 --> 00:28:13,781 positions and extrapolated for trim. I 523 00:28:13,813 --> 00:28:17,709 see. Excellent. A performance 524 00:28:17,797 --> 00:28:21,333 study using the FDR data gives the NTSB 525 00:28:21,389 --> 00:28:23,661 a new look at the trim inputs on Flight 526 00:28:23,733 --> 00:28:25,105 9446. 527 00:28:26,995 --> 00:28:29,771 So they adjust the trim to take off right 528 00:28:29,803 --> 00:28:32,147 here? Yepah. It's part of the before taxi 529 00:28:32,171 --> 00:28:32,895 checklist. 530 00:28:36,515 --> 00:28:40,267 Before taxi checklists. Before taxi 531 00:28:40,331 --> 00:28:45,851 Weather radar on standby. Trim set.5 532 00:28:45,963 --> 00:28:47,295 Takeo trim set. 533 00:28:49,915 --> 00:28:53,027 The takeoff trim was set to 0.5 nose down 534 00:28:53,091 --> 00:28:55,255 instead of.5 nose up. 535 00:28:56,675 --> 00:28:59,775 That's odd. When's the next input? 536 00:29:00,315 --> 00:29:03,939 Right after takeoff. That's right after 537 00:29:03,987 --> 00:29:07,107 he said. We've got a hot elevator 538 00:29:07,131 --> 00:29:10,843 trim. Plane is pitching down instead of 539 00:29:10,859 --> 00:29:14,175 up. How's that possible? 540 00:29:15,075 --> 00:29:17,267 Investigators discover the plane wasn't 541 00:29:17,331 --> 00:29:19,467 responding to the pilots's nose up trim 542 00:29:19,531 --> 00:29:22,981 inputs. And it happens again here, one 543 00:29:23,013 --> 00:29:26,605 last time a few seconds later. Roll back. 544 00:29:26,645 --> 00:29:28,465 Roll back. Roll it back. I got it. 545 00:29:30,485 --> 00:29:32,541 The more the first officer tries to 546 00:29:32,573 --> 00:29:35,813 manually trim the nose up, the more the 547 00:29:35,829 --> 00:29:39,301 nose drops. It's like the trim is 548 00:29:39,333 --> 00:29:42,685 reversed. A good analogy is 549 00:29:42,765 --> 00:29:44,629 learning to drive. Imagine how weird it 550 00:29:44,637 --> 00:29:46,789 would be if you turned your steering wheel 551 00:29:46,877 --> 00:29:49,305 right and the car went left. Talk about 552 00:29:49,345 --> 00:29:52,645 confusing and exhausting. 553 00:29:54,665 --> 00:29:56,377 You pull for all your worth. Just keep 554 00:29:56,401 --> 00:29:57,817 pulling for all your wor. They were 555 00:29:57,841 --> 00:30:01,849 dealing with the backwards trim, which I 556 00:30:01,857 --> 00:30:03,385 don't know how anyone would have ever 557 00:30:03,465 --> 00:30:07,273 fathomed that. Investigators calculate 558 00:30:07,329 --> 00:30:09,529 that within a minute of takeoff the pilots 559 00:30:09,577 --> 00:30:13,105 would have required £250 of force to hold 560 00:30:13,145 --> 00:30:14,125 the nose up. 561 00:30:16,105 --> 00:30:19,037 I'm. Hold on, 562 00:30:19,101 --> 00:30:19,705 Steve. 563 00:30:22,085 --> 00:30:23,861 How on earth can they have wired a trim 564 00:30:23,933 --> 00:30:24,865 system backwards? 565 00:30:34,485 --> 00:30:36,613 The team retrieved this from the wreckage. 566 00:30:36,749 --> 00:30:40,053 O great. In an 567 00:30:40,069 --> 00:30:42,461 effort to prove the trim cables on Flight 568 00:30:42,533 --> 00:30:44,545 9446 were reversed, 569 00:30:45,875 --> 00:30:48,011 investigators study a key piece of the 570 00:30:48,043 --> 00:30:50,215 trim system found in the wreckage. 571 00:30:51,115 --> 00:30:54,491 Okay. The trim cable is threaded and 572 00:30:54,523 --> 00:30:57,483 wrapped around this drum and then runs in 573 00:30:57,499 --> 00:31:00,055 a loop from the cockpit to the tail. 574 00:31:05,955 --> 00:31:07,923 Maybe they fed the cable incorrectly 575 00:31:07,979 --> 00:31:11,543 around the drum. Let's check the 576 00:31:11,559 --> 00:31:12,755 installation manual. 577 00:31:24,615 --> 00:31:26,375 Looks like maintenance threaded the drum 578 00:31:26,415 --> 00:31:27,235 correctly. 579 00:31:29,415 --> 00:31:33,315 Yeah, but how did they install it? 580 00:31:34,775 --> 00:31:36,999 The cable drum is one piece of the story 581 00:31:37,047 --> 00:31:38,607 that was telling us that it might have 582 00:31:38,631 --> 00:31:41,397 been incorrectly rigged, but we needed to 583 00:31:41,421 --> 00:31:44,149 dig deeper. Okay, 584 00:31:44,277 --> 00:31:48,677 let's give this a try. The NTSB 585 00:31:48,781 --> 00:31:50,437 considers how the maintenance crew 586 00:31:50,501 --> 00:31:53,225 installed the drum. It's good. 587 00:31:56,605 --> 00:31:58,865 We. Yep. It's. 588 00:32:07,665 --> 00:32:09,005 Well, that doesn't fit. 589 00:32:18,505 --> 00:32:20,565 Yeah. The only way to install this thing 590 00:32:24,465 --> 00:32:27,993 like this. Investigators discover that in 591 00:32:28,009 --> 00:32:30,465 order for the drum to fit the pin, it had 592 00:32:30,505 --> 00:32:33,445 to be flipped, thereby crossing the wires. 593 00:32:33,765 --> 00:32:36,105 Well, that was the huge aha moment for me. 594 00:32:36,485 --> 00:32:38,733 The manual, the way it was depicted at 595 00:32:38,749 --> 00:32:42,517 that time, it could mislead somebody. 596 00:32:42,701 --> 00:32:44,025 In this case, it did. 597 00:32:46,485 --> 00:32:48,225 We have a hot elevator trim. 598 00:32:49,685 --> 00:32:52,053 Because the wires were crossed, the trim 599 00:32:52,109 --> 00:32:53,905 tab operated in reverse. 600 00:32:57,005 --> 00:32:58,665 Give a trim, kill the trim, 601 00:33:01,425 --> 00:33:04,449 pull back. They knew they had a 602 00:33:04,457 --> 00:33:07,225 malfunction. They just couldn't figure out 603 00:33:07,265 --> 00:33:11,165 what it was. There's only one explanation. 604 00:33:12,145 --> 00:33:14,085 The maintenance manual must be wrong. 605 00:33:15,425 --> 00:33:18,313 I'll check with the manufacturer. But even 606 00:33:18,329 --> 00:33:21,073 if the manual is wrong, why didn't anyone 607 00:33:21,129 --> 00:33:23,525 notice the trim cables were crossed? 608 00:33:23,945 --> 00:33:25,481 I'll check to see if the maintenance team 609 00:33:25,513 --> 00:33:27,485 got inspector to sign off on the work. 610 00:33:28,845 --> 00:33:31,357 They are a second set of eyes. They have 611 00:33:31,381 --> 00:33:33,277 to be the one who is making sure that the 612 00:33:33,301 --> 00:33:35,213 job is done right. That is what an 613 00:33:35,229 --> 00:33:38,997 inspector does. After you installed 614 00:33:39,021 --> 00:33:41,093 the drum, did an inspector sign off on the 615 00:33:41,109 --> 00:33:44,141 work? Yes, he did. In fact, he assisted 616 00:33:44,173 --> 00:33:47,589 with it. He assisted? 617 00:33:47,757 --> 00:33:50,989 Yep. The inspector cannot get in there 618 00:33:51,037 --> 00:33:53,341 with wrenches. He cannot get in there and 619 00:33:53,373 --> 00:33:55,021 tell you, okay, you got to put this bolt 620 00:33:55,053 --> 00:33:58,429 here or anything like that. Thanks for 621 00:33:58,437 --> 00:34:01,005 your help tonight. The thing is, with an 622 00:34:01,045 --> 00:34:03,581 inspector being part of the job, he's 623 00:34:03,613 --> 00:34:05,533 making the same mistakes that the people 624 00:34:05,589 --> 00:34:07,669 that he's supposed to be overlooking are 625 00:34:07,717 --> 00:34:10,465 making. So he becomes part of the problem. 626 00:34:11,445 --> 00:34:13,421 The inspector who helped with the 627 00:34:13,453 --> 00:34:15,669 installation didn't notice the crossed 628 00:34:15,717 --> 00:34:18,345 wires and signed off on the work. 629 00:34:19,525 --> 00:34:21,837 The last time we spoke, you said you 630 00:34:21,861 --> 00:34:24,395 tested it. That's right. 631 00:34:26,135 --> 00:34:29,263 After the new cable was installed. Okay, 632 00:34:29,279 --> 00:34:32,031 let's give it a try. Maintenance workers 633 00:34:32,103 --> 00:34:34,943 performed a visual check. That's it. It's 634 00:34:34,999 --> 00:34:36,875 working. Yeah. Thanks, man. 635 00:34:41,895 --> 00:34:44,155 Yeah, that's coming in now. 636 00:34:45,735 --> 00:34:46,515 Thanks. 637 00:34:50,155 --> 00:34:53,675 Hey. Hey. What did 638 00:34:54,175 --> 00:34:56,043 d you find out? The inspector helped with 639 00:34:56,059 --> 00:34:58,003 the installation. So not exactly an 640 00:34:58,019 --> 00:35:00,895 objective inspection. What about you? 641 00:35:01,475 --> 00:35:04,467 Well, it's just like we thought. No 642 00:35:04,491 --> 00:35:07,819 drawing in the manuals. Rm this is 643 00:35:07,867 --> 00:35:09,883 how the drum should have been oriented 644 00:35:09,939 --> 00:35:12,675 when they threaded the cable. The manual 645 00:35:12,715 --> 00:35:14,571 shows the slots on the drum are facing 646 00:35:14,603 --> 00:35:19,067 out. But the correct way to 647 00:35:19,091 --> 00:35:20,595 thread the cable is with the flat side 648 00:35:20,635 --> 00:35:23,635 facing out. Here's what I don't get. They 649 00:35:23,675 --> 00:35:25,283 tested the trim system when the 650 00:35:25,299 --> 00:35:26,963 installation was complete and said it was 651 00:35:27,019 --> 00:35:30,735 working fine. How's that possible? 652 00:35:42,335 --> 00:35:46,071 Long night? Yeah. Found a recording 653 00:35:46,103 --> 00:35:48,495 of the trim check test. You're kidding. 654 00:35:48,655 --> 00:35:50,847 It's on the cvr. Recorded well before 655 00:35:50,871 --> 00:35:54,103 their flight. In order for the mechanics 656 00:35:54,159 --> 00:35:56,551 to do an operational check correctly, 657 00:35:56,663 --> 00:35:58,791 they had to power the airplane up. Okay, 658 00:35:58,823 --> 00:36:01,127 Bob, run the trim system, please. So the 659 00:36:01,151 --> 00:36:03,399 power was on. The CVR was on. It worked to 660 00:36:03,407 --> 00:36:06,175 our advantage. I think I know how the trim 661 00:36:06,215 --> 00:36:08,023 tabs pass the visual ground tests even 662 00:36:08,039 --> 00:36:09,595 though they were running in reverse. 663 00:36:13,215 --> 00:36:14,835 Arey you good in the cockpit? 664 00:36:16,215 --> 00:36:19,675 Yeah. Okay, let's give it a try. 665 00:36:20,975 --> 00:36:26,479 Trim nose up. Trimming thosese upe. 666 00:36:26,527 --> 00:36:30,135 Moving up. Looks good. That trim 667 00:36:30,175 --> 00:36:33,195 Nose down. Trimming down. 668 00:36:35,195 --> 00:36:38,723 Okay, that's it. That's working. 669 00:36:38,899 --> 00:36:39,815 Thanks, man. 670 00:36:42,275 --> 00:36:45,323 Sounds like a normal test. No, they got it 671 00:36:45,339 --> 00:36:48,579 backwards. We hear the cockpit 672 00:36:48,667 --> 00:36:50,595 call trim up and the maintenance worker 673 00:36:50,635 --> 00:36:53,571 says he sees the trim tab move up. That is 674 00:36:53,603 --> 00:36:57,203 reversed. If you trim nose up, 675 00:36:57,339 --> 00:36:59,787 the trailing edge moves down in the 676 00:36:59,811 --> 00:37:02,567 opposite direction. The same is true for 677 00:37:02,591 --> 00:37:03,955 trimming the nose down. 678 00:37:06,815 --> 00:37:09,635 It is counterintuitive, but you're right. 679 00:37:10,095 --> 00:37:13,263 It is an easy mistake to make. Checking a 680 00:37:13,279 --> 00:37:14,839 trim system can be a little confusing. 681 00:37:14,967 --> 00:37:16,631 You have to make sure you're on the same 682 00:37:16,663 --> 00:37:18,287 page with the other person. Are you 683 00:37:18,311 --> 00:37:21,487 talking tab up or nose up? Because tab up 684 00:37:21,511 --> 00:37:24,583 is nose down. The ground guys missed it. 685 00:37:24,599 --> 00:37:27,115 Okay. Why didn't the pilots? 686 00:37:29,475 --> 00:37:32,491 Trim test is definitely a pre takeo 687 00:37:32,603 --> 00:37:35,095 checklist item. But then they run it 688 00:37:39,595 --> 00:37:41,307 according to the transcript. They ran the 689 00:37:41,331 --> 00:37:42,135 checklist. 690 00:37:44,675 --> 00:37:47,095 All the four start checks. 691 00:37:47,955 --> 00:37:51,123 Parking brake. It's set. Pre flight 692 00:37:51,179 --> 00:37:54,551 complete before taxi. Checklists before 693 00:37:54,583 --> 00:37:56,075 taxi. Weather radar. 694 00:37:58,575 --> 00:38:00,155 They skipped the trim check. 695 00:38:02,415 --> 00:38:03,631 I'm biased because I have a pilot 696 00:38:03,663 --> 00:38:05,407 background. I feel like that first flight 697 00:38:05,431 --> 00:38:07,567 of the day checklist is crucial. That's 698 00:38:07,591 --> 00:38:08,755 where you can catch it. 699 00:38:10,375 --> 00:38:13,183 Even if they had checked it, would they 700 00:38:13,199 --> 00:38:14,871 have known whether the trim system was 701 00:38:14,903 --> 00:38:16,655 reversed just by looking at the direction 702 00:38:16,695 --> 00:38:18,155 the trim wheel was spinning? 703 00:38:19,635 --> 00:38:23,411 Good. Point pilots test the trim 704 00:38:23,483 --> 00:38:25,771 by pressing the trim switch and monitoring 705 00:38:25,803 --> 00:38:27,779 the direction in which the manual trim 706 00:38:27,827 --> 00:38:30,659 wheel spins. To trim nose up, 707 00:38:30,787 --> 00:38:32,615 the wheel would turn backwards. 708 00:38:36,435 --> 00:38:38,731 Investigators recreate the reverse trim 709 00:38:38,803 --> 00:38:41,115 system on the same model of Beach 1900 710 00:38:41,155 --> 00:38:43,507 that crashed to determine whether the 711 00:38:43,531 --> 00:38:45,379 pilots could have detected that the trim 712 00:38:45,427 --> 00:38:48,815 was reversed. Let's give this a try. 713 00:38:52,115 --> 00:38:54,575 Investigators trim the plane nose up. 714 00:38:56,875 --> 00:39:00,459 The wheel is moving backwards the 715 00:39:00,467 --> 00:39:02,811 way the pilots expected it to turn. Even 716 00:39:02,843 --> 00:39:05,131 though the trim cable was reversed, the 717 00:39:05,163 --> 00:39:07,975 wheel still moves backwards as it should. 718 00:39:09,035 --> 00:39:12,267 What is in error is the fact that the drum 719 00:39:12,331 --> 00:39:15,611 is upside down. It is now running the 720 00:39:15,643 --> 00:39:17,435 cables in the wrong direction. So 721 00:39:17,475 --> 00:39:19,735 everything in the cockpit is correct. 722 00:39:20,675 --> 00:39:23,299 The test reveals the pilots of Kgan Air 723 00:39:23,347 --> 00:39:27,235 Flight 9446B1 rotate wouldn't have 724 00:39:27,275 --> 00:39:29,763 realized the cables were reversed even if 725 00:39:29,779 --> 00:39:31,895 they had checked them prior to takeoff. 726 00:39:32,595 --> 00:39:34,335 We have a hot elevator trim. 727 00:39:38,635 --> 00:39:41,971 In their final report, the NTSB concludes 728 00:39:42,043 --> 00:39:44,331 the cause of the accident was the improper 729 00:39:44,403 --> 00:39:47,315 installation of the trim cable system and 730 00:39:47,355 --> 00:39:49,387 Beechcraft's erroneous depiction of the 731 00:39:49,411 --> 00:39:51,643 elevator trim drum in their maintenance 732 00:39:51,699 --> 00:39:54,975 manual. The stick. 733 00:39:55,915 --> 00:39:59,339 Stay with me. These factors ended up 734 00:39:59,387 --> 00:40:04,307 sealing the pilots's fate'n 735 00:40:04,331 --> 00:40:05,695 take both of us on under Steve. 736 00:40:10,935 --> 00:40:12,755 Steve. Keith. I'm pulling. 737 00:40:14,815 --> 00:40:17,391 The pilot's grueling efforts kept the 738 00:40:17,423 --> 00:40:19,135 plane in the air for more than two 739 00:40:19,175 --> 00:40:22,687 minutes. P But in the end, 740 00:40:22,791 --> 00:40:25,159 the extreme stick pressures were too much 741 00:40:25,207 --> 00:40:28,847 for the pilots to overcome. Picture trying 742 00:40:28,871 --> 00:40:32,715 to do your day job while deadlifting £250. 743 00:40:33,735 --> 00:40:35,675 It's just too much. 744 00:40:37,055 --> 00:40:38,355 Hold on, Steve. 745 00:40:40,775 --> 00:40:41,515 No. 746 00:40:52,535 --> 00:40:56,231 This accident was 100% preventable. First 747 00:40:56,263 --> 00:40:59,999 and foremost is your plane has to be 748 00:41:00,087 --> 00:41:02,495 flyable. And it's only flyable if the 749 00:41:02,535 --> 00:41:04,479 manuals and maintenance is and pilot 750 00:41:04,527 --> 00:41:07,927 instructions make sense. The Colganair 751 00:41:07,991 --> 00:41:11,487 9446 report echoed similar findings to 752 00:41:11,511 --> 00:41:14,447 the other Beach 1900 crash months earlier 753 00:41:14,511 --> 00:41:16,315 in Charlotte, North Carolina. 754 00:41:17,375 --> 00:41:19,687 Improperly installed control cables were 755 00:41:19,751 --> 00:41:21,943 also a factor in the Air Midwest accident 756 00:41:21,999 --> 00:41:25,407 that killed 21 people. If you looked 757 00:41:25,431 --> 00:41:26,847 up the term maintenance accident and 758 00:41:26,871 --> 00:41:28,767 dictionary, those two accents would be 759 00:41:28,791 --> 00:41:32,155 there. Colgan and Air Midwest were poster 760 00:41:32,195 --> 00:41:34,975 childs for maintenance accidents. 761 00:41:35,875 --> 00:41:39,347 If Colgan properly followed the 762 00:41:39,451 --> 00:41:41,787 maintenance program as dictated by the 763 00:41:41,811 --> 00:41:44,283 regulations, this accident never would 764 00:41:44,299 --> 00:41:47,611 have happened. After the accident, 765 00:41:47,683 --> 00:41:49,651 Beechcraft'maintenance manuals were 766 00:41:49,683 --> 00:41:52,755 amended and airlines adopted stricter 767 00:41:52,795 --> 00:41:55,323 procedures for airplane checks. After 768 00:41:55,379 --> 00:41:58,459 undergoing routine maintenance, the person 769 00:41:58,507 --> 00:42:00,523 in the cockpit missed it. The people on 770 00:42:00,539 --> 00:42:02,275 the elevators missed it. The inspector 771 00:42:02,315 --> 00:42:06,411 missed it. Everybody missed what was just 772 00:42:06,523 --> 00:42:08,235 such a simple mistake.