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1
00:00:17,516 --> 00:00:20,018
On approach
to Cincinnati, Ohio.
2
00:00:23,731 --> 00:00:28,361
The pilots of Air Tahoma Flight
1-85, face disaster.
3
00:00:28,445 --> 00:00:31,321
- 23-hundred feet.
- Keep it steady.
4
00:00:31,405 --> 00:00:33,365
- The airplane will fall
like a rock.
5
00:00:34,075 --> 00:00:35,451
- My god.
6
00:00:35,576 --> 00:00:38,746
The plane crashes
into a golf course.
7
00:00:39,789 --> 00:00:41,832
Only the captain survives.
8
00:00:41,915 --> 00:00:44,710
- He did not remember much
of the flight.
9
00:00:44,793 --> 00:00:47,255
When you have a tragic
event happen,
10
00:00:47,380 --> 00:00:49,173
the memories are not there.
11
00:00:49,256 --> 00:00:52,093
The wrecked engines
provide investigators
12
00:00:52,218 --> 00:00:53,552
with their first clue.
13
00:00:53,636 --> 00:00:55,012
- There's no evidence
of burning or charring.
14
00:00:55,095 --> 00:00:57,390
Both engines flamed out
before the crash.
15
00:00:57,515 --> 00:00:59,725
But according
to the gauges,
16
00:00:59,808 --> 00:01:01,936
there was ample fuel
for the flight.
17
00:01:02,561 --> 00:01:04,897
- If there was still 56-hundred
pounds of fuel
18
00:01:05,022 --> 00:01:08,192
in the right tank, why didn't
that fuel feed the engines?
19
00:01:09,109 --> 00:01:12,030
- That was certainly something
that I had not seen before.
20
00:01:35,344 --> 00:01:40,141
Air Tahoma Flight
1-85 is cruising at 15,000 feet.
21
00:01:40,808 --> 00:01:44,019
It's headed for Cincinnati
Northern Kentucky
22
00:01:44,144 --> 00:01:45,772
International Airport.
23
00:01:47,774 --> 00:01:50,150
- The coffee's still hot
if you want some?
24
00:01:50,275 --> 00:01:52,861
- No, thanks.
I'm well rested.
25
00:01:52,986 --> 00:01:56,615
Captain Bruno
Pichelli is an experienced pilot
26
00:01:56,698 --> 00:01:58,367
who has flown all over the world
27
00:01:58,492 --> 00:02:02,329
and also worked as a firefighter
in British Columbia, Canada.
28
00:02:02,454 --> 00:02:05,959
Convair-5-80 pilot
Bruno St. Jacques
29
00:02:06,084 --> 00:02:08,836
has flown alongside
Captain Pichelli.
30
00:02:08,961 --> 00:02:13,007
- He was a very good person,
easy to get along with.
31
00:02:13,133 --> 00:02:14,967
He flew well.
32
00:02:15,050 --> 00:02:18,930
Me and him, it was a very good
joint venture.
33
00:02:21,014 --> 00:02:25,103
Michael Gelwicks has
logged nearly 25 hundred hours
34
00:02:25,186 --> 00:02:26,770
as a pilot and flight engineer
35
00:02:26,854 --> 00:02:30,608
and is now a first officer
for Air Tahoma.
36
00:02:31,693 --> 00:02:33,902
Tonight's flight
from Memphis, Tennessee
37
00:02:34,027 --> 00:02:37,323
to Cincinnati, Ohio
is 80 minutes.
38
00:02:37,407 --> 00:02:39,658
- This was the first leg
of a round trip
39
00:02:39,783 --> 00:02:42,996
and was done every weeknight
by Air Tahoma.
40
00:02:45,122 --> 00:02:47,834
They're flying
a Convair 5-80,
41
00:02:47,917 --> 00:02:52,379
a twin turboprop aircraft used
for short-haul flights.
42
00:02:53,173 --> 00:02:57,009
- The Convair 5-80 is about
50 years old,
43
00:02:57,092 --> 00:03:00,013
was used in passenger service
for a long time,
44
00:03:00,096 --> 00:03:02,973
and then transitioned
to cargo service.
45
00:03:05,643 --> 00:03:09,688
- It was always reputed to be a
very stable, reliable airplane.
46
00:03:13,776 --> 00:03:16,486
- So, what was it like flying
as a firefighter?
47
00:03:16,570 --> 00:03:19,741
- Well, uh, long hours.
48
00:03:20,532 --> 00:03:22,075
Same plane as this.
49
00:03:22,200 --> 00:03:23,828
Different cargo, of course.
50
00:03:25,413 --> 00:03:28,457
There are five
pallets containing mail
51
00:03:28,582 --> 00:03:32,753
and parcels from the courier DHL
Express onboard the aircraft.
52
00:03:42,722 --> 00:03:44,598
- How's the paperwork?
53
00:03:45,349 --> 00:03:46,768
- Almost done.
54
00:03:51,939 --> 00:03:53,733
- The captain was focused
on some paperwork
55
00:03:53,858 --> 00:03:56,276
that he needed to complete
before he landed in Cincinnati,
56
00:03:56,401 --> 00:03:58,070
which he did.
57
00:04:01,241 --> 00:04:03,241
- Okay.
58
00:04:05,118 --> 00:04:08,413
You know what? I'm just gonna
balance out the fuel here.
59
00:04:10,290 --> 00:04:12,293
Captain Pichelli
notices
60
00:04:12,418 --> 00:04:15,921
that one of his fuel tanks
has more fuel than the other.
61
00:04:17,214 --> 00:04:21,177
- The Convair 5-80 has two tanks
and you can use one tank
62
00:04:21,302 --> 00:04:25,807
to feed both engines until both
tanks are even.
63
00:04:28,810 --> 00:04:30,560
One hour into
the flight,
64
00:04:30,644 --> 00:04:32,605
the crew receives
a weather update.
65
00:04:32,689 --> 00:04:35,149
- Tahoma 1-85.
The winds are kinda weird today.
66
00:04:35,274 --> 00:04:37,526
Suggest 10 left to Cincinnati
when able.
67
00:04:37,985 --> 00:04:41,656
- Okay, 10 degrees left
to Cincinnati when able.
68
00:04:41,781 --> 00:04:44,658
1-85, thank you.
- I already had it.
69
00:04:45,158 --> 00:04:46,786
Right on the money.
70
00:04:47,995 --> 00:04:51,749
As Air Tahoma 1-85
begins its descent,
71
00:04:51,833 --> 00:04:54,961
the first officer detects
a change in the controls.
72
00:04:55,043 --> 00:04:57,254
- The yoke feels funny.
73
00:04:58,714 --> 00:05:00,132
- Say again?
74
00:05:00,591 --> 00:05:02,343
- It feels like I need
a lot of force.
75
00:05:06,180 --> 00:05:08,516
- It's pushing to the right
for some reason.
76
00:05:08,641 --> 00:05:10,310
I don't know why.
77
00:05:13,103 --> 00:05:15,648
- The Convair doesn't use
hydraulics
78
00:05:15,773 --> 00:05:18,067
to move the control surfaces.
79
00:05:18,192 --> 00:05:21,321
The pilot must use a lot
of arm strength
80
00:05:21,446 --> 00:05:23,906
when the autopilot is not on.
81
00:05:25,908 --> 00:05:27,869
- Four in the box.
82
00:05:31,079 --> 00:05:32,956
Thirty miles
from the airport,
83
00:05:33,040 --> 00:05:35,918
the controller provides
an update on the approach.
84
00:05:36,043 --> 00:05:40,255
- Tahoma 1-85, fly heading
0-9-0 maintain 4,000.
85
00:05:40,380 --> 00:05:43,050
- Maintain 4,000, 1-85.
86
00:05:43,175 --> 00:05:46,637
- They're packed tonight so
we're gonna go bang bang bang.
87
00:05:46,721 --> 00:05:48,514
- Got it.
88
00:05:49,348 --> 00:05:52,142
- There was pressure on it,
because if you get late
89
00:05:52,225 --> 00:05:57,482
in the sequence of the other
aircraft landing in the airport,
90
00:05:57,564 --> 00:06:00,860
you're slowing down all
the airplanes behind you.
91
00:06:00,942 --> 00:06:03,612
- Tahoma 1-85,
92
00:06:03,737 --> 00:06:05,740
cleared for visual approach,
3-6 right.
93
00:06:05,865 --> 00:06:07,367
Keep your speed up.
94
00:06:07,492 --> 00:06:08,408
- Visual approach.
95
00:06:08,533 --> 00:06:12,497
3-6 right. Keep the speed
up, 1-85. Thank you.
96
00:06:12,579 --> 00:06:16,041
As the crew receives
clearance for a visual approach,
97
00:06:16,125 --> 00:06:19,002
the aircraft continues pulling
to the right.
98
00:06:19,086 --> 00:06:21,923
- What in the world is going on
with this plane?
99
00:06:22,048 --> 00:06:24,091
This sucker is acting so funny.
100
00:06:24,925 --> 00:06:27,261
- We'll do a full-control check
on the ground.
101
00:06:28,762 --> 00:06:31,723
Point it down at 3,000
as quick as you can.
102
00:06:34,644 --> 00:06:39,232
- Usually, an airplane flies
straight and wings level.
103
00:06:39,314 --> 00:06:41,733
It wouldn't give you a nice
feeling to fly the plane,
104
00:06:41,858 --> 00:06:44,653
which always want to turn on
one side.
105
00:06:44,778 --> 00:06:48,740
- 1-85, runway 3-6 right,
cleared to land.
106
00:06:48,865 --> 00:06:52,077
- Cleared to land, 3-6 right,
1-85.
107
00:06:52,870 --> 00:06:54,579
- Runway's in sight.
108
00:06:54,663 --> 00:06:57,290
- Alright, I'll give you
the in-range.
109
00:06:58,793 --> 00:07:02,129
- In-range check...
cabin pressure.
110
00:07:02,254 --> 00:07:03,047
- Set.
111
00:07:03,130 --> 00:07:06,216
- Bypass is down.
Hydraulic pressure.
112
00:07:06,300 --> 00:07:07,509
Quantity checks.
113
00:07:07,634 --> 00:07:10,555
As the crew runs
the in-range checklist.
114
00:07:11,139 --> 00:07:13,932
- AC pump is on.
Green light.
115
00:07:14,057 --> 00:07:15,267
Boost pumps on.
116
00:07:15,392 --> 00:07:18,228
The plane continues
to handle poorly.
117
00:07:18,312 --> 00:07:21,774
- Man, I'm telling you,
what is wrong with this plane?
118
00:07:21,899 --> 00:07:23,442
It is really funny.
119
00:07:25,026 --> 00:07:27,447
Then, less than
5 miles from the airport.
120
00:07:29,865 --> 00:07:33,494
And just 23 hundred
feet above the ground,
121
00:07:33,619 --> 00:07:36,038
both engines lose power.
122
00:07:45,839 --> 00:07:48,216
- The airplane will fall like
a rock,
123
00:07:48,341 --> 00:07:52,930
because it needs at least
one engine in good shape
124
00:07:53,014 --> 00:07:55,641
to bring them to the runway.
125
00:07:55,725 --> 00:08:01,146
Twenty-three hundred feet...
my God.
126
00:08:02,189 --> 00:08:04,983
- Cincinnati control,
Tahoma 1-85,
127
00:08:05,067 --> 00:08:06,610
we're having engine problems.
128
00:08:06,694 --> 00:08:10,238
- Tahoma 1-85, do you
require emergency support?
129
00:08:14,785 --> 00:08:15,995
- Negative.
130
00:08:19,372 --> 00:08:21,666
- I think the reason
he said no,
131
00:08:21,791 --> 00:08:24,795
was he was still hoping
that somehow
132
00:08:24,879 --> 00:08:25,795
he could get to the airport.
133
00:08:25,879 --> 00:08:27,507
- Pull up.
134
00:08:27,632 --> 00:08:28,841
Pull up.
135
00:08:28,966 --> 00:08:30,175
- Keep it steady.
136
00:08:30,300 --> 00:08:31,927
But they're dropping
too fast
137
00:08:32,052 --> 00:08:34,138
to make it to the airport.
138
00:08:34,221 --> 00:08:35,181
- Come on!
139
00:08:35,306 --> 00:08:37,475
They see
an opening ahead.
140
00:08:37,557 --> 00:08:40,977
- There's no time at all to
raise the gear, raise the flap,
141
00:08:41,062 --> 00:08:44,105
restart the engine before you
touch the ground.
142
00:08:44,231 --> 00:08:47,985
Their only option was to go
straight to the safest place
143
00:08:48,068 --> 00:08:53,282
to put down the plane,
and hope for the best.
144
00:08:54,033 --> 00:08:56,785
- Tahoma 1-85, please respond.
145
00:08:57,577 --> 00:08:59,496
- They were at low altitude.
- Hold it up.
146
00:08:59,580 --> 00:09:02,667
- They were short of the runway.
It was dark outside.
147
00:09:02,750 --> 00:09:04,418
- Tahoma 1-85,
do you copy?
148
00:09:04,543 --> 00:09:06,461
- The situation was very,
very dire.
149
00:09:06,586 --> 00:09:09,465
- Trees!
- Pull up.
150
00:09:09,590 --> 00:09:11,424
- Pull up. Pull up.
151
00:09:18,265 --> 00:09:19,808
They make it
through the trees.
152
00:09:19,933 --> 00:09:22,102
- Come on. Come on!
153
00:09:25,105 --> 00:09:27,692
But can't keep
the plane on the ground.
154
00:09:56,136 --> 00:09:59,432
Emergency vehicles
soon arrive at the crash site,
155
00:09:59,557 --> 00:10:01,517
just 1. 2 miles
156
00:10:01,642 --> 00:10:03,769
south of Cincinnati's
International Airport.
157
00:10:07,648 --> 00:10:09,817
The body of First officer
Gelwicks
158
00:10:09,942 --> 00:10:11,735
is found in the wreckage.
159
00:10:15,530 --> 00:10:19,368
Incredibly,
Captain Pichelli has survived.
160
00:10:22,663 --> 00:10:26,958
the National Transportation
Safety Board, or NTSB,m
161
00:10:27,083 --> 00:10:30,629
rush to Cincinnati and begin
looking into the crash
162
00:10:30,754 --> 00:10:33,298
of Air Tahoma Flight 1-85.
163
00:10:33,381 --> 00:10:35,509
- So, what have we got so far?
164
00:10:35,634 --> 00:10:38,011
- Both black boxes have been
sent to Washington for analysis.
165
00:10:38,136 --> 00:10:40,514
- Good.
Structural failure?
166
00:10:40,639 --> 00:10:41,849
- Take a look.
167
00:10:43,058 --> 00:10:49,273
- When we first arrived what we
typically do is to look for the
four corners of the airplane,
168
00:10:49,356 --> 00:10:52,567
to be able to rule out some sort
of structural failure
169
00:10:52,692 --> 00:10:55,153
or a part or piece
of the airplane
170
00:10:55,236 --> 00:10:58,032
departing prior to impact
with the ground.
171
00:11:00,868 --> 00:11:03,245
- We found all four corners
of the plane.
172
00:11:03,703 --> 00:11:04,830
We found the tail here.
173
00:11:04,955 --> 00:11:07,832
We located both wing tips,
here and here.
174
00:11:07,917 --> 00:11:10,293
And the nose was essentially
split in half
175
00:11:10,378 --> 00:11:12,129
and fractured into small pieces.
176
00:11:12,212 --> 00:11:15,131
- If it wasn't structural
failure then what?
177
00:11:15,216 --> 00:11:16,634
What did the captain
have to say?
178
00:11:16,716 --> 00:11:18,594
- He's still recovering
in hospital,
179
00:11:18,719 --> 00:11:20,428
but I did speak
with the air traffic controller.
180
00:11:20,553 --> 00:11:21,764
- And?
181
00:11:21,889 --> 00:11:23,724
- She says the crew reported
having engine problems
182
00:11:23,849 --> 00:11:25,350
just before crashing.
183
00:11:34,402 --> 00:11:37,738
- When we heard that the crew
had reported engine problems,
184
00:11:37,863 --> 00:11:40,115
it made us think,
as investigators,
185
00:11:40,240 --> 00:11:42,158
whether it was one engine
or two engines.
186
00:11:42,243 --> 00:11:44,245
And that would be a big
difference.
187
00:11:45,287 --> 00:11:48,874
With one engine they would still
be able to make the airfield.
188
00:11:50,042 --> 00:11:54,504
- Tahoma 1-85,
we're having engine problems.
189
00:11:59,719 --> 00:12:03,264
If the engines
were operating before the crash,
190
00:12:03,389 --> 00:12:08,018
investigators expect to find
burnt debris inside the engine.
191
00:12:08,101 --> 00:12:10,270
- There's no evidence
of burning or charring.
192
00:12:11,938 --> 00:12:14,316
I don't think we had combustion
on this engine.
193
00:12:14,442 --> 00:12:16,485
- Ditto with engine two.
194
00:12:18,403 --> 00:12:21,240
- So both engines flamed out
before the crash.
195
00:12:23,116 --> 00:12:26,202
- With a dual engine failure,
that's not common,
196
00:12:26,287 --> 00:12:30,374
so we would think immediately
about something with the fuel,
197
00:12:30,457 --> 00:12:32,000
either the loss of fuel
198
00:12:32,125 --> 00:12:34,836
or maybe even contamination
within the fuel.
199
00:12:35,754 --> 00:12:40,301
Was the fuel onboard
Flight 1-85 contaminated?
200
00:12:41,092 --> 00:12:44,179
- Fuel contamination is a danger
to flight safety
201
00:12:44,304 --> 00:12:47,307
because it can affect both
engines at the same time.
202
00:12:48,267 --> 00:12:50,477
- Do we have the results
of that fuel testing?
203
00:12:50,602 --> 00:12:52,104
- Yeah, right here.
204
00:12:53,980 --> 00:12:56,066
Fuel checks out.
205
00:12:57,234 --> 00:12:59,486
- Well, maybe they ran
out of fuel?
206
00:12:59,611 --> 00:13:01,113
- Well, it's possible.
207
00:13:02,155 --> 00:13:07,327
In 1978, pilots
of United Airlines Flight 1-73
208
00:13:07,452 --> 00:13:09,913
ran out of fuel while
troubleshooting
209
00:13:09,996 --> 00:13:12,041
a landing gear issue.
210
00:13:13,417 --> 00:13:15,753
The DC-8 crashed into
a neighborhood
211
00:13:15,836 --> 00:13:16,836
in Portland, Oregon.
212
00:13:20,508 --> 00:13:24,845
Ten of the 189 people
onboard were killed.
213
00:13:25,929 --> 00:13:30,308
- To explore the possibility
of whether the airplane
ran out of fuel,
214
00:13:30,433 --> 00:13:32,937
we wanted to look initially
at the fuel quantity indicators
215
00:13:33,019 --> 00:13:34,687
in the flight deck.
216
00:13:34,812 --> 00:13:38,567
Investigators
recover Flight 1-85's
instrument panel.
217
00:13:38,692 --> 00:13:42,278
They focus on the left and right
fuel tank indicators.
218
00:13:42,904 --> 00:13:46,366
- Zero and 56-hundred pounds.
219
00:13:49,787 --> 00:13:51,663
That's odd.
220
00:13:51,788 --> 00:13:53,206
- The expectation would be
221
00:13:53,331 --> 00:13:56,376
that both would be approximately
the same value.
222
00:13:56,501 --> 00:14:00,172
That one of them was at zero
wasn't surprising, I suppose,
223
00:14:00,255 --> 00:14:02,383
but the other one being
so much different
224
00:14:02,508 --> 00:14:05,510
was certainly something that
I had not seen before.
225
00:14:05,635 --> 00:14:08,681
- Okay, so they didn't exactly
run out of fuel,
226
00:14:08,764 --> 00:14:10,515
but why are the tanks so uneven?
227
00:14:11,225 --> 00:14:13,351
- Maybe some kind of problem
in the fuel system
228
00:14:13,476 --> 00:14:15,937
stopped fuel from flowing
to the engines.
229
00:14:16,062 --> 00:14:18,065
- See what you can salvage
in terms of fuel pumps
230
00:14:18,190 --> 00:14:21,360
and piping from the wreckage,
and we'll have a look.
231
00:14:24,321 --> 00:14:26,282
- While looking at all
the different elements
232
00:14:26,407 --> 00:14:31,035
of the fuel system, the hope
was that you would be able to
document something going wrong,
233
00:14:31,160 --> 00:14:34,248
either loss of fuel
or fuel starvation.
234
00:14:35,081 --> 00:14:37,710
Investigators slowly
piece together
235
00:14:37,835 --> 00:14:39,879
elements of the plane's fuel
system.
236
00:14:40,004 --> 00:14:41,922
- So these are the crossfeed
pipe and valves?
237
00:14:43,673 --> 00:14:45,216
- Check it out.
238
00:14:49,429 --> 00:14:51,889
The crossfeed valves
allow the pilot
239
00:14:52,015 --> 00:14:54,058
to provide both engines
with fuel
240
00:14:54,183 --> 00:14:57,605
from only one tank when
there's a fuel imbalance.
241
00:15:01,692 --> 00:15:03,318
- Both valves are open.
242
00:15:03,443 --> 00:15:05,278
That means they were
crossfeeding fuel
243
00:15:05,403 --> 00:15:07,239
before the crash.
244
00:15:07,364 --> 00:15:10,116
- When we found that the
crossfeed valves were open,
245
00:15:10,241 --> 00:15:12,244
that was a huge discovery.
246
00:15:12,369 --> 00:15:15,831
We wondered if that may have
some sort of connection
247
00:15:15,956 --> 00:15:18,417
between the left tank having
no fuel
248
00:15:18,500 --> 00:15:21,253
and the right tank
having excessive fuel.
249
00:15:21,961 --> 00:15:24,340
- But why would the crew be
crossfeeding fuel
250
00:15:24,465 --> 00:15:25,633
so close to landing?
251
00:15:25,758 --> 00:15:27,967
Did they make a mistake?
252
00:15:28,092 --> 00:15:29,761
- Only one person knows.
253
00:15:30,553 --> 00:15:33,057
Let's see if the captain
can talk to us yet.
254
00:15:34,932 --> 00:15:36,309
- The good thing in
this accident
255
00:15:36,434 --> 00:15:38,187
was that the captain
did survive.
256
00:15:38,312 --> 00:15:40,773
He was able to talk with us in
the hospital
257
00:15:40,898 --> 00:15:43,024
because he only had
minor injuries.
258
00:15:43,817 --> 00:15:45,568
- How are you feeling?
259
00:15:46,445 --> 00:15:48,447
- Okay. Thanks.
260
00:15:52,201 --> 00:15:55,037
- Can you tell me what you
remember of the flight?
261
00:15:55,620 --> 00:15:57,413
Every detail counts.
262
00:16:00,750 --> 00:16:02,461
What is
wrong with this plane?
263
00:16:02,586 --> 00:16:03,796
It is really funny.
264
00:16:03,921 --> 00:16:05,798
- I remember...
265
00:16:06,673 --> 00:16:09,634
- Visual approach. 36 right.
Keep the speed up.
266
00:16:09,759 --> 00:16:12,846
I remember talking
on the radio.
267
00:16:12,971 --> 00:16:15,640
- Tahoma 1-85, you're
cleared for visual approach.
268
00:16:15,765 --> 00:16:19,311
Keep your speed up.
- I saw the approach lights.
269
00:16:19,394 --> 00:16:21,647
Then we weren't getting power.
270
00:16:27,277 --> 00:16:29,654
Then the next thing I remember
is the impact.
271
00:16:29,738 --> 00:16:31,155
- Keep it steady.
272
00:16:37,705 --> 00:16:39,498
- And then...
273
00:16:41,750 --> 00:16:43,668
I was standing outside.
274
00:16:49,716 --> 00:16:51,427
- One more thing.
275
00:16:51,552 --> 00:16:55,096
We found the crossfeed
valves open.
276
00:16:56,597 --> 00:16:59,559
Do you remember crossfeeding
fuel during the flight?
277
00:16:59,684 --> 00:17:03,355
- I'm... I'm sorry.
278
00:17:03,480 --> 00:17:05,106
I don't.
279
00:17:08,484 --> 00:17:10,988
- He did not remember much
of the flight
280
00:17:11,070 --> 00:17:13,990
because when you have a tragic
event happen,
281
00:17:14,074 --> 00:17:16,410
the memories are not there.
282
00:17:19,328 --> 00:17:22,540
Investigators search
the wreckage for clues
283
00:17:22,624 --> 00:17:26,252
that could explain why the two
crossfeed valves were open.
284
00:17:28,422 --> 00:17:30,715
- It's the weight and balance
form for the flight.
285
00:17:30,840 --> 00:17:32,175
- Hm.
286
00:17:32,259 --> 00:17:34,219
- The weight and balance
form reflects
287
00:17:34,344 --> 00:17:36,137
where the cargo pallets
are located,
288
00:17:36,262 --> 00:17:37,847
whether they're towards
the front of the airplane
289
00:17:37,931 --> 00:17:39,266
or towards the back
of the airplane,
290
00:17:39,391 --> 00:17:42,810
and that determines whether
the airplane is nose heavy,
291
00:17:42,935 --> 00:17:45,730
or tail heavy, or right where it
should be in the middle.
292
00:17:47,273 --> 00:17:48,567
- That's strange.
293
00:17:48,650 --> 00:17:52,153
It looks like the captain
was revising his calculations,
294
00:17:52,278 --> 00:17:53,363
possibly during the flight.
295
00:17:53,446 --> 00:17:55,740
- Well, this is stranger.
296
00:17:55,824 --> 00:17:57,742
Here's a second one.
297
00:17:59,368 --> 00:18:02,789
- This one has no corrections
and the captain signed it.
298
00:18:03,499 --> 00:18:06,167
- Finding two weight and balance
sheets for the same flight
299
00:18:06,292 --> 00:18:08,796
with different data on it
at the accident site
300
00:18:08,921 --> 00:18:10,923
raised lots of questions for us.
301
00:18:11,548 --> 00:18:13,800
What was the captain doing
during the fight?
302
00:18:14,926 --> 00:18:17,762
- So it looks like the captain
was revising his numbers
303
00:18:17,887 --> 00:18:20,891
on this first form almost using
it like a working copy.
304
00:18:20,973 --> 00:18:22,934
And this was his hard copy
to hand in.
305
00:18:23,977 --> 00:18:27,230
Did the captain's
weight and balance calculations
306
00:18:27,314 --> 00:18:29,398
play a role in the crash?
307
00:18:29,900 --> 00:18:32,861
- Well, the center of gravity
limits were within the envelope.
308
00:18:32,986 --> 00:18:35,696
- So a mistake in his weight
and balance calculations
309
00:18:35,823 --> 00:18:37,281
didn't bring down the plane.
310
00:18:37,406 --> 00:18:38,616
- Well, whatever his process,
311
00:18:38,700 --> 00:18:40,911
he was supposed to hand this
in before departure.
312
00:18:43,497 --> 00:18:44,957
- Check with the airline.
313
00:18:45,082 --> 00:18:48,626
See if the captain handed
in his numbers before takeoff.
314
00:18:50,378 --> 00:18:52,588
- Taking off without having
computed the weight
315
00:18:52,673 --> 00:18:56,801
and balance limits
is against procedures.
316
00:18:56,884 --> 00:18:58,804
It cuts the safety margin.
317
00:18:59,721 --> 00:19:01,097
- You're sure?
318
00:19:01,181 --> 00:19:02,641
Okay, thanks.
319
00:19:03,182 --> 00:19:04,977
- The airline just confirmed,
320
00:19:05,059 --> 00:19:07,229
the plane departed without
the captain leaving a weight
321
00:19:07,354 --> 00:19:08,939
and balance form behind
in Memphis.
322
00:19:09,021 --> 00:19:14,778
- So... why did our captain
depart before completing
his paperwork?
323
00:19:23,369 --> 00:19:25,663
- Would you like coffee?
- I'm fine, thanks.
324
00:19:25,747 --> 00:19:29,625
Investigators
reinterview Captain
Bruno Pichelli
325
00:19:29,710 --> 00:19:32,546
to find out why he didn't follow
proper procedure
326
00:19:32,671 --> 00:19:35,007
before Flight
1-85's departure.
327
00:19:35,089 --> 00:19:39,845
- So, we found some weight and
balance forms in the wreckage.
328
00:19:39,928 --> 00:19:43,015
Why didn't you complete
them before taking off?
329
00:19:44,974 --> 00:19:49,104
- What can I say?
I ran out of time.
330
00:19:50,230 --> 00:19:54,358
Normally I fill out the form
using their handheld computer.
331
00:19:54,442 --> 00:19:58,446
It had been acting up,
now it was just dead.
332
00:19:59,280 --> 00:20:01,700
I'm not used to filling out
that form manually.
333
00:20:01,825 --> 00:20:05,037
Frankly, I'd never been
trained to.
334
00:20:05,119 --> 00:20:08,164
So, I thought I'd finish
it en route.
335
00:20:10,250 --> 00:20:13,336
Captain Pichelli
explains how he determined
336
00:20:13,420 --> 00:20:16,506
that Flight 1-85 was safe
to take off.
337
00:20:17,633 --> 00:20:19,468
- I did my own assessment.
338
00:20:21,053 --> 00:20:24,431
I checked that the plane's
maximum weight was acceptable.
339
00:20:24,556 --> 00:20:27,893
I saw that the position
of the cargo pallets
340
00:20:28,018 --> 00:20:30,061
were evenly balanced.
341
00:20:30,938 --> 00:20:34,523
I also looked at the nose
landing gear strut.
342
00:20:36,067 --> 00:20:38,069
And the plane sat
properly on it.
343
00:20:39,779 --> 00:20:41,490
- If the nose wheel strut
was compressed,
344
00:20:41,615 --> 00:20:44,034
that would be nose heavy,
and if it were extended,
345
00:20:44,116 --> 00:20:46,536
it would be tail heavy.
But it was in a normal position.
346
00:20:46,619 --> 00:20:50,249
So on that basis, he decided
that the airplane
347
00:20:50,332 --> 00:20:52,834
was actually within its weight
and balance limits.
348
00:20:52,960 --> 00:20:55,503
- From your corrections,
349
00:20:55,628 --> 00:20:58,048
it looks like your numbers
weren't adding up.
350
00:20:59,508 --> 00:21:04,136
- That's true. Yeah.
At first they didn't.
351
00:21:04,261 --> 00:21:06,472
So I had to keep working
on them.
352
00:21:08,016 --> 00:21:10,143
Yeah, it took me a while
to get them right.
353
00:21:15,606 --> 00:21:17,276
- How long did it take?
354
00:21:17,401 --> 00:21:18,818
- I don't know.
355
00:21:18,943 --> 00:21:20,653
- Did it interfere with
your workflow?
356
00:21:20,778 --> 00:21:25,450
- It was stressful. I mean,
I was buried in paperwork.
357
00:21:26,410 --> 00:21:27,952
- Right.
358
00:21:30,329 --> 00:21:33,040
- So even though the weight and
balance was not an issue
359
00:21:33,165 --> 00:21:34,584
with the operation
of the engines,
360
00:21:34,667 --> 00:21:38,462
it did raise questions with
regard to the crew activity.
361
00:21:40,464 --> 00:21:42,049
- Hey. Any news?
362
00:21:42,174 --> 00:21:44,260
With no explanation
for the cause
363
00:21:44,344 --> 00:21:46,555
of Flight 185's engine failure,
364
00:21:46,680 --> 00:21:49,307
the investigation finally
gets a break.
365
00:21:49,391 --> 00:21:51,684
- Great.
Send it to us right away.
366
00:21:53,060 --> 00:21:55,814
The lab just finished
transcribing the CVR.
367
00:21:55,896 --> 00:21:57,732
We've got good data.
368
00:21:57,857 --> 00:22:00,986
But we don't have impact.
369
00:22:01,068 --> 00:22:03,989
The recording stops just
before the crash.
370
00:22:04,114 --> 00:22:05,324
- Well, if the recording
stopped,
371
00:22:05,449 --> 00:22:07,034
that means the plane must
have lost power.
372
00:22:07,159 --> 00:22:08,160
- It looks like it.
373
00:22:08,285 --> 00:22:11,371
And it supports a dual
engine flameout.
374
00:22:18,336 --> 00:22:21,673
- Having the CVR stop about
two minutes prior to impact
375
00:22:21,798 --> 00:22:25,009
is another indication that
we lost both engines
376
00:22:25,134 --> 00:22:28,387
because we likely had a rollback
of both engines
377
00:22:28,512 --> 00:22:31,391
and therefore a change
in electrical configuration.
378
00:22:31,892 --> 00:22:33,352
- When you're ready.
379
00:22:33,434 --> 00:22:36,730
Investigators listen
to the cockpit voice recording,
380
00:22:36,855 --> 00:22:40,776
or CVR, to determine why
the engines flamed out
381
00:22:40,901 --> 00:22:43,987
even though the plane still
had plenty of fuel.
382
00:22:44,070 --> 00:22:46,198
How's
the paperwork?
383
00:22:47,531 --> 00:22:48,700
- Almost done.
384
00:22:52,953 --> 00:22:54,830
Okay.
385
00:22:56,833 --> 00:22:58,542
You know what?
386
00:22:59,544 --> 00:23:02,381
I'm just gonna balance out
the fuel here.
387
00:23:09,930 --> 00:23:12,557
- The captain wanted to balance
his fuel tanks.
388
00:23:12,682 --> 00:23:15,309
But he didn't remember
that at his interview.
389
00:23:15,434 --> 00:23:20,565
That must be when he opened the
crossfeed valves at 12:17 a.m.
390
00:23:23,442 --> 00:23:27,655
- Question is: Did he forget
to close them?
391
00:23:27,780 --> 00:23:29,406
- Let's find out.
392
00:23:32,285 --> 00:23:36,205
Okay ten degrees left
to Cincinnati when able.
393
00:23:36,288 --> 00:23:38,458
1-85, thank you.
394
00:23:38,583 --> 00:23:40,210
I already
had it.
395
00:23:40,292 --> 00:23:42,253
Right on the money.
396
00:23:42,336 --> 00:23:45,173
The team pays close
attention to any mention
397
00:23:45,298 --> 00:23:47,550
of the crossfeed valves
being closed.
398
00:23:47,634 --> 00:23:51,887
- The captain doesn't indicate
that he's stopping the crossfeed
399
00:23:51,971 --> 00:23:53,347
or even mention it.
400
00:23:53,472 --> 00:23:56,143
It made me wonder if they
had forgotten
401
00:23:56,268 --> 00:23:58,603
that the crossfeeding operation
was going on.
402
00:23:59,770 --> 00:24:03,191
Then, just minutes
before the flight's
scheduled arrival.
403
00:24:03,316 --> 00:24:06,111
- AC pump is on.
Green light.
404
00:24:06,236 --> 00:24:08,738
Boost pumps on.
405
00:24:09,530 --> 00:24:10,906
Man,
I'm telling you,
406
00:24:10,990 --> 00:24:15,162
what is wrong with this plane?
It is really funny.
407
00:24:25,337 --> 00:24:27,548
- Yeah.
- Can you feel it?
408
00:24:27,673 --> 00:24:30,719
It feels like it's swinging
back and forth.
409
00:24:34,597 --> 00:24:37,142
- Yeah, we've got an imbalance
410
00:24:37,267 --> 00:24:39,685
on this darn crossfeed
I left open.
411
00:24:41,104 --> 00:24:44,607
The captain finally
realizes he forgot to stop
412
00:24:44,691 --> 00:24:47,193
crossfeeding fuel from
the left tank.
413
00:24:47,318 --> 00:24:48,653
- Is that what it is?
414
00:24:49,863 --> 00:24:51,280
- Yeah.
415
00:24:51,990 --> 00:24:53,490
- Oh, damn.
416
00:24:53,575 --> 00:24:55,326
I see.
417
00:24:58,538 --> 00:25:01,875
- The crossfeed's been going
on for almost half an hour.
418
00:25:02,709 --> 00:25:05,170
- It looks like he never shut
the crossfeed valves.
419
00:25:05,295 --> 00:25:06,837
- He forgot to close it.
420
00:25:06,922 --> 00:25:09,673
That explains why the plane
was so hard to handle.
421
00:25:14,011 --> 00:25:17,848
With the crossfeed
valves open for 29 minutes,
422
00:25:17,973 --> 00:25:20,852
only the left fuel tank fed
both engines.
423
00:25:20,977 --> 00:25:24,230
As the tank emptied,
it created an imbalance,
424
00:25:24,355 --> 00:25:26,816
which made it difficult
to control the aircraft.
425
00:25:26,900 --> 00:25:29,818
- That also explains why
the left tank was empty.
426
00:25:30,487 --> 00:25:33,365
- Yeah, but if there was still
56-hundred pounds of fuel
427
00:25:33,448 --> 00:25:37,493
in the right tank, why didn't
that fuel feed the engines?
428
00:25:42,249 --> 00:25:44,875
- Do you have the list?
Thanks.
429
00:25:48,087 --> 00:25:50,339
- Alright, let's figure
this out.
430
00:25:50,423 --> 00:25:54,301
Did the pilots
of Air Tahoma Flight 1-85
431
00:25:54,426 --> 00:25:58,597
follow the correct procedure
for balancing their fuel?
432
00:25:58,722 --> 00:26:02,184
- The question that it raised,
for me in the investigation is:
433
00:26:02,269 --> 00:26:04,563
If there is ample fuel
in the right tank,
434
00:26:04,645 --> 00:26:06,897
why did both engines fail?
435
00:26:07,022 --> 00:26:10,067
- Alright, to crossfeed fuel
from the left tank
436
00:26:10,192 --> 00:26:12,112
to both engines first
the crew has to open
437
00:26:12,237 --> 00:26:15,073
the crossfeed valves here
and here.
438
00:26:15,155 --> 00:26:18,826
Investigators
consult the wreckage inventory.
439
00:26:18,951 --> 00:26:20,036
- And we know from the wreckage
440
00:26:20,119 --> 00:26:21,663
the crew did the first
step correctly.
441
00:26:21,788 --> 00:26:23,539
The valves were open.
442
00:26:23,623 --> 00:26:28,086
- Second, they're supposed to
close the right fuel pump here.
443
00:26:28,169 --> 00:26:31,798
- Got it. It was turned off at
the time of the crash.
444
00:26:33,340 --> 00:26:34,593
- Step three:
445
00:26:34,718 --> 00:26:35,926
they were supposed to close
446
00:26:36,010 --> 00:26:39,055
the right tank fuel
shutoff valve here.
447
00:26:40,472 --> 00:26:42,474
- It looks like the right one
was left open.
448
00:26:42,601 --> 00:26:44,394
- They didn't shut the valve.
449
00:26:44,477 --> 00:26:47,021
- So they did the procedure
incorrectly.
450
00:26:48,772 --> 00:26:50,357
- So the question we had was,
451
00:26:50,482 --> 00:26:52,777
by leaving the right fuel
tank valve open,
452
00:26:52,902 --> 00:26:55,904
did that somehow lead
to the engine failure?
453
00:26:55,989 --> 00:26:58,782
- I know they made a mistake,
but I'm still confused.
454
00:26:58,866 --> 00:27:00,993
If they didn't close the valve
455
00:27:01,118 --> 00:27:03,872
why wasn't fuel flowing from
the right tank
456
00:27:03,997 --> 00:27:06,374
all the way to both engines?
457
00:27:07,334 --> 00:27:09,501
And why would the engines
flame out?
458
00:27:12,130 --> 00:27:14,465
- There's only one way
to find out.
459
00:27:18,345 --> 00:27:20,805
- As the investigation
progressed,
460
00:27:20,888 --> 00:27:23,057
we decided to run a test
to determine
461
00:27:23,182 --> 00:27:26,269
what occurred during
the accident flight.
462
00:27:27,228 --> 00:27:29,396
Investigators build
a replica
463
00:27:29,521 --> 00:27:33,151
of Flight 1-85's fuel system
to better understand
464
00:27:33,276 --> 00:27:35,778
how both engines
could have failed.
465
00:27:35,862 --> 00:27:37,489
- Lets simulate what
the captain did.
466
00:27:38,365 --> 00:27:42,160
Step one: open the
crossfeed valves.
467
00:27:47,164 --> 00:27:48,665
- Crossfeed valves open.
468
00:27:48,750 --> 00:27:52,753
- Alright. Step two: turn off
the right fuel pump.
469
00:27:52,878 --> 00:27:54,963
- Right fuel pump off.
470
00:27:55,673 --> 00:27:57,884
- Step three:
471
00:27:58,009 --> 00:28:00,804
he didn't close the right fuel
tank shutoff valve.
472
00:28:00,886 --> 00:28:03,347
- So we've got this in
the open position.
473
00:28:05,642 --> 00:28:06,893
- Let's see what happens.
474
00:28:15,067 --> 00:28:16,693
- Okay.
475
00:28:17,487 --> 00:28:20,073
It looks like the left fuel pump
is sending fuel
476
00:28:20,198 --> 00:28:22,701
from the left fuel tank
to both engines.
477
00:28:22,826 --> 00:28:25,119
So that part's working
out just fine.
478
00:28:28,373 --> 00:28:31,792
- Yeah, but fuel from the left
fuel tank
479
00:28:31,917 --> 00:28:34,211
is also flowing
to the right tank.
480
00:28:39,049 --> 00:28:41,635
With the right shut
off valve open,
481
00:28:41,760 --> 00:28:45,722
the left pump supplied fuel
not only to both engines
482
00:28:45,848 --> 00:28:48,393
but also to the right fuel tank.
483
00:28:53,940 --> 00:28:56,483
- Look how quickly the left fuel
tank emptied.
484
00:28:57,777 --> 00:28:59,278
- This was new to me.
485
00:28:59,403 --> 00:29:04,075
I had never seen a case where
fuel is transferred to the point
486
00:29:04,159 --> 00:29:06,286
of the one tank being emptied.
487
00:29:07,287 --> 00:29:10,248
- So the left tank ran dry.
488
00:29:10,330 --> 00:29:12,959
And with that pump
still running,
489
00:29:13,084 --> 00:29:14,836
that means that air
was likely being pumped
490
00:29:14,961 --> 00:29:16,503
through the whole system.
491
00:29:17,672 --> 00:29:20,174
Investigators
now understand
492
00:29:20,299 --> 00:29:24,554
why the plane's engines flamed
out just before the crash.
493
00:29:28,474 --> 00:29:30,852
Once the left tank was empty,
494
00:29:30,977 --> 00:29:33,229
air was pumped into
the fuel system,
495
00:29:33,313 --> 00:29:36,607
causing both engines
to flame out.
496
00:29:36,732 --> 00:29:40,236
- Turbine engines require
a steady flow of fuel.
497
00:29:41,653 --> 00:29:44,281
When you start entering air
into the system,
498
00:29:44,406 --> 00:29:47,576
the air bubbles then cause
the interruption
499
00:29:47,660 --> 00:29:49,621
of the ignition of the fuel,
500
00:29:49,746 --> 00:29:53,790
and that will cause the engines
to roll back and stop.
501
00:29:55,167 --> 00:29:57,170
- So if the captain had just
followed procedure
502
00:29:57,295 --> 00:29:59,130
and shut off that valve...
503
00:29:59,213 --> 00:30:02,217
- If he had, there would have
been enough fuel
504
00:30:02,342 --> 00:30:05,135
in the left fuel tank to power
both engines to the airport.
505
00:30:06,512 --> 00:30:09,265
- I'm just gonna balance out
the fuel here.
506
00:30:10,682 --> 00:30:12,977
The captain's
failure to close
507
00:30:13,060 --> 00:30:17,315
the right fuel tank shutoff
valve, sealed their fate.
508
00:30:17,941 --> 00:30:20,527
- So, why didn't
he follow procedure?
509
00:30:25,990 --> 00:30:28,034
- As the investigation
progressed
510
00:30:28,159 --> 00:30:30,537
and new information
came to light,
511
00:30:30,662 --> 00:30:32,538
it was helpful to go back
to the captain
512
00:30:32,663 --> 00:30:34,874
to discuss his recall
of what happened.
513
00:30:36,000 --> 00:30:38,795
- In your airline's handbook,
they instruct pilots
514
00:30:38,877 --> 00:30:44,299
to shut the right tank valve
during the crossfeed procedure.
515
00:30:44,384 --> 00:30:46,760
You didn't shut the valve.
516
00:30:46,885 --> 00:30:51,932
- I don't... I don't remember
doing a crossfeed on the day,
517
00:30:52,892 --> 00:30:56,604
but, uh, typically when
I do the procedure,
518
00:30:57,313 --> 00:30:59,856
I leave the tank valve open.
519
00:31:01,108 --> 00:31:02,777
- Really?
520
00:31:03,736 --> 00:31:07,531
- This was a surprise because
that is totally contrary
521
00:31:07,656 --> 00:31:09,616
to the flight operating manual.
522
00:31:09,741 --> 00:31:13,413
- I heard if you shut that valve
it might fail.
523
00:31:13,538 --> 00:31:15,789
Then you have no access
to your fuel.
524
00:31:16,457 --> 00:31:18,459
- So you've heard
the valve is faulty?
525
00:31:18,585 --> 00:31:19,626
- I sure have.
526
00:31:19,751 --> 00:31:23,381
And my old employer allowed me
to do it this way.
527
00:31:27,175 --> 00:31:29,095
- Previous employers
had told him
528
00:31:29,220 --> 00:31:31,931
it was the captain's discretion
whether he closes
529
00:31:32,056 --> 00:31:33,516
the shutoff valve or not.
530
00:31:33,599 --> 00:31:37,394
And we confirmed that that was
their position.
531
00:31:38,938 --> 00:31:40,480
Was there a history
532
00:31:40,606 --> 00:31:43,233
of fuel tank shutoff
valves failing?
533
00:31:44,109 --> 00:31:49,406
- I've gone through the FAA's
Service Difficulty Reports
database and I found nothing.
534
00:31:49,490 --> 00:31:51,409
- I can't find anything either.
535
00:31:51,534 --> 00:31:54,703
- I don't think that valve
has ever failed.
536
00:31:58,499 --> 00:32:02,336
- There was no evidence
of the valve getting stuck.
537
00:32:02,461 --> 00:32:06,089
This was a fiction that had
somehow spread
538
00:32:06,214 --> 00:32:07,717
among the pilot community
539
00:32:07,799 --> 00:32:10,636
that simply did not have
an accurate basis.
540
00:32:10,761 --> 00:32:12,721
- This is the part I don't get.
541
00:32:13,681 --> 00:32:16,433
So, what were they doing
for 29 minutes?
542
00:32:18,894 --> 00:32:22,898
- Twenty-nine minutes
is a long time to miss
543
00:32:22,981 --> 00:32:25,401
that there's
a crossfeed problem,
544
00:32:25,484 --> 00:32:27,694
especially when the first
officer reports
545
00:32:27,819 --> 00:32:30,073
that there are handling
difficulties as well.
546
00:32:30,656 --> 00:32:33,116
And so it was very important
to look into
547
00:32:33,201 --> 00:32:34,868
what might have caused this.
548
00:32:34,993 --> 00:32:36,244
- Keep it steady.
549
00:32:42,376 --> 00:32:47,048
- Alright, the captain started
the crossfeed at 12:17 a.m.
550
00:32:47,173 --> 00:32:50,801
He didn't notice the mistake
until 29 minutes later.
551
00:32:50,926 --> 00:32:52,886
What happened in between?
552
00:32:53,011 --> 00:32:57,099
Investigators return
to Flight 1-85's CVR
553
00:32:57,182 --> 00:32:59,810
to determine why the pilots
didn't notice
554
00:32:59,935 --> 00:33:02,605
that there was a growing
fuel imbalance.
555
00:33:03,855 --> 00:33:07,151
- It looks like the captain
finished his paperwork
at 12:26 a.m.,
556
00:33:07,276 --> 00:33:10,320
but he kept talking about it.
557
00:33:13,281 --> 00:33:15,076
- All this time I couldn't
figure out why
558
00:33:15,201 --> 00:33:16,243
on the landing I was out,
559
00:33:16,368 --> 00:33:18,371
and I was okay on
the takeoff.
560
00:33:18,496 --> 00:33:20,914
And it was my chicken scratch.
- Ah.
561
00:33:21,039 --> 00:33:24,210
- Yeah.
The momentum is 1-6-6-7,
562
00:33:24,335 --> 00:33:28,839
but I thought my chicken scratch
I put 1-0-6-7.
563
00:33:28,964 --> 00:33:30,717
I couldn't work it out.
- Ah.
564
00:33:30,842 --> 00:33:33,803
- It was my own doing.
- Ah damn.
565
00:33:33,885 --> 00:33:36,722
I had it all along.
566
00:33:36,847 --> 00:33:39,683
We were okay all along.
567
00:33:39,767 --> 00:33:41,477
- Is that right?
- Yeah.
568
00:33:41,560 --> 00:33:43,186
- Oh, man.
569
00:33:44,521 --> 00:33:46,982
- Okay, first he's distracted
by his paperwork
570
00:33:47,066 --> 00:33:48,734
and then he keeps talking
about it.
571
00:33:49,568 --> 00:33:53,364
- Yeah. The captain's focus is
on his paperwork for a while
572
00:33:53,448 --> 00:33:55,741
instead of monitoring
the flight.
573
00:33:55,866 --> 00:33:58,536
- What about after that?
Any mention of the fuel gauges?
574
00:34:04,959 --> 00:34:06,376
- What about the first officer?
575
00:34:06,501 --> 00:34:08,295
How come he didn't pick
up on this?
576
00:34:10,130 --> 00:34:12,215
- Twenty minutes after
the crossfeed was opened,
577
00:34:12,300 --> 00:34:14,802
the first officer knew something
was wrong.
578
00:34:14,927 --> 00:34:16,387
- The yoke feels funny.
579
00:34:16,512 --> 00:34:18,056
- Say again?
580
00:34:18,556 --> 00:34:21,016
- It feels like I need
a lot of force.
581
00:34:22,851 --> 00:34:26,731
It's pushing to the right for
some reason, I don't know why.
582
00:34:26,813 --> 00:34:29,150
I'm trying to...
583
00:34:29,275 --> 00:34:31,235
I'm not sure what's going on.
584
00:34:33,570 --> 00:34:37,699
- Alright, the first officer
reports a problem with
the flight controls,
585
00:34:37,784 --> 00:34:41,244
but he doesn't check his fuel
gauges for an imbalance. Why?
586
00:34:42,288 --> 00:34:43,581
- Well, according
to his work record,
587
00:34:43,706 --> 00:34:46,458
he was still pretty new
at flying the plane.
588
00:34:46,583 --> 00:34:49,545
Plus he'd only been with
the airline three months.
589
00:34:52,340 --> 00:34:55,592
- To his credit,
he was assertive
590
00:34:55,675 --> 00:34:58,512
that he was having difficulty
in the handling characteristics.
591
00:34:58,637 --> 00:35:01,516
So he was completely appropriate
in asking for help.
592
00:35:01,641 --> 00:35:04,434
And unfortunately,
the captain did not respond
593
00:35:04,518 --> 00:35:07,355
as a pilot in command would
be expected.
594
00:35:09,023 --> 00:35:10,775
- It feels like I need
a lot of force.
595
00:35:10,858 --> 00:35:16,030
- Tahoma 1-85, fly heading
0-9-0 maintain 4,000.
596
00:35:16,155 --> 00:35:20,284
- 0-9-0, 4,000, 1-85.
Thank you.
597
00:35:21,869 --> 00:35:24,121
0-9-9, 4,000.
598
00:35:27,333 --> 00:35:30,503
- How many times did he alert
the captain to the problem?
599
00:35:31,295 --> 00:35:36,467
- He repeated his concerns
at least seven times.
600
00:35:38,344 --> 00:35:40,972
Finally, the captain replied.
601
00:35:41,847 --> 00:35:44,224
- We'll do a full-control check
on the ground then.
602
00:35:52,023 --> 00:35:54,735
- He missed the cues
from his co-pilot.
603
00:35:55,527 --> 00:35:57,280
- How long has he been
a captain?
604
00:35:57,362 --> 00:35:58,739
- Here's the thing.
605
00:35:59,532 --> 00:36:01,992
He's been in a cockpit
for over 20 years,
606
00:36:02,117 --> 00:36:04,661
but only 100 hours
or so as a captain.
607
00:36:06,956 --> 00:36:10,251
- As captain, we would expect
him to actually help
608
00:36:10,376 --> 00:36:16,007
the first officer troubleshoot
why the aircraft was flying
609
00:36:16,090 --> 00:36:17,592
in a non-normal state.
610
00:36:17,717 --> 00:36:22,262
- Still, wouldn't they have
caught this mistake
611
00:36:22,387 --> 00:36:24,181
during the in-range checklist?
612
00:36:24,306 --> 00:36:25,849
- That's a good point.
613
00:36:27,226 --> 00:36:31,521
- The purpose of the in-range
checklist is to prepare
the airplane for landing.
614
00:36:31,646 --> 00:36:34,733
And that includes a review
of the cockpit instruments,
615
00:36:34,858 --> 00:36:36,693
including the fuel gauges.
616
00:36:37,737 --> 00:36:40,447
- So, did they perform
the in-range checklist?
617
00:36:41,532 --> 00:36:45,202
- Yup. They started
the checklist at 12:45 a.m.
618
00:36:45,327 --> 00:36:47,829
- I'll give you the in-range.
619
00:36:48,496 --> 00:36:52,626
AC pump is on.
Green light. Fuel panel.
620
00:36:52,751 --> 00:36:54,711
Boost pumps on.
621
00:36:54,836 --> 00:36:58,798
- Man, I'm telling you what
is wrong with this plane?
622
00:36:58,925 --> 00:37:01,302
It is really funny.
623
00:37:08,768 --> 00:37:09,893
- Yeah.
624
00:37:09,976 --> 00:37:13,856
We have an imbalance on this
darn crossfeed I left open.
625
00:37:16,483 --> 00:37:17,860
- Is that what it is?
626
00:37:18,985 --> 00:37:20,445
- Yeah.
627
00:37:21,864 --> 00:37:23,074
- Oh damn.
628
00:37:23,199 --> 00:37:24,909
I see.
- Yeah.
629
00:37:25,701 --> 00:37:29,454
- We're gonna flameout
if we don't, aren't we?
630
00:37:36,170 --> 00:37:38,797
- Ten seconds later,
the engines flamed out.
631
00:37:39,798 --> 00:37:41,300
- Wow.
632
00:37:41,425 --> 00:37:43,969
The plane had become
one gigantic glider
633
00:37:44,094 --> 00:37:45,679
about to hit the ground.
634
00:37:47,264 --> 00:37:49,432
- They were too late to save it.
635
00:37:50,476 --> 00:37:53,521
- They found out about
the crossfeed issue
636
00:37:53,646 --> 00:37:56,398
at the same time
they lost their engines.
637
00:38:00,568 --> 00:38:02,822
- Did they start the checklist
too late?
638
00:38:03,822 --> 00:38:06,909
- They were at about 3,000 feet
when they started.
639
00:38:13,581 --> 00:38:16,793
- According to the airline's
operating manual,
640
00:38:16,876 --> 00:38:18,920
they should have started
the checklist at 12,000 feet.
641
00:38:23,134 --> 00:38:25,469
- They should have started
at least 10 minutes earlier.
642
00:38:25,594 --> 00:38:27,471
- If they had, they would have
caught their mistake
643
00:38:27,554 --> 00:38:29,514
with enough time to save
the plane.
644
00:38:33,351 --> 00:38:35,646
- If you're not monitoring
the fuel gauges,
645
00:38:35,730 --> 00:38:39,025
when you run the in-range
checklist that will remind you.
646
00:38:39,150 --> 00:38:40,650
But they waited
until it was so late,
647
00:38:40,775 --> 00:38:44,822
they didn't have time to prevent
the engines from flaming out.
648
00:38:48,159 --> 00:38:49,952
- It still bugs me.
649
00:38:50,744 --> 00:38:54,081
Even with all the distractions
and the inexperience,
650
00:38:54,206 --> 00:38:56,375
all professional pilots
651
00:38:56,500 --> 00:38:58,585
are trained to scan
their instruments.
652
00:38:59,878 --> 00:39:01,380
Why didn't they?
653
00:39:02,715 --> 00:39:05,760
- Maybe the fuel gauges
are hard to see?
654
00:39:09,637 --> 00:39:12,849
- Could the pilots actually see
the fuel gauges
655
00:39:12,974 --> 00:39:15,603
from the seating positions
that they were at?
656
00:39:20,565 --> 00:39:24,527
- Alright, so both our seats
are fully forward.
657
00:39:24,612 --> 00:39:28,657
Investigators now
visit a Convair 5-80 cockpit
658
00:39:28,740 --> 00:39:32,702
to determine if its layout
somehow prevented the pilots
659
00:39:32,827 --> 00:39:34,914
from monitoring
their fuel gauges.
660
00:39:35,039 --> 00:39:37,333
- So both fuel gauges
are visible.
661
00:39:38,708 --> 00:39:42,003
But is that the case
for every seat position?
662
00:39:42,088 --> 00:39:44,590
- Let's make an adjustment.
663
00:39:54,641 --> 00:39:56,018
- Wow.
664
00:39:56,684 --> 00:39:59,730
From this angle, the fuel gauges
are much harder to see.
665
00:40:04,068 --> 00:40:06,570
The throttle control console
is in the way.
666
00:40:12,242 --> 00:40:15,036
- It depended on what position
the seat was in.
667
00:40:15,121 --> 00:40:16,996
When the seat was aft it was
more difficult to see
668
00:40:17,123 --> 00:40:19,333
the fuel gauges.
669
00:40:19,458 --> 00:40:22,253
- So the degree to which the
fuel gauges are obscured changes
670
00:40:22,335 --> 00:40:24,380
depending on the seat position.
671
00:40:26,047 --> 00:40:28,342
Hard to say if it played a role.
672
00:40:29,844 --> 00:40:33,179
- Unfortunately, because of the
destruction of the aircraft,
673
00:40:33,304 --> 00:40:36,266
the wreckage did not allow us
to determine
674
00:40:36,391 --> 00:40:40,271
whether the captain's seat was
forward or aft.
675
00:40:41,021 --> 00:40:43,898
- What in the world is going on
with this plane?
676
00:40:43,983 --> 00:40:46,360
This sucker is acting so funny.
677
00:40:47,610 --> 00:40:50,947
- In this case there was a
concern about the fuel gauges
678
00:40:51,030 --> 00:40:52,407
and their location
679
00:40:52,490 --> 00:40:54,452
and whether they could be seen
by the pilots.
680
00:40:58,414 --> 00:41:00,708
- Yes, he would have to rise up
just a little bit
681
00:41:00,833 --> 00:41:03,751
to look over the thrust levers
to be able to see the gauges,
682
00:41:03,835 --> 00:41:07,422
but it's your job to know
what those instruments
are saying at all times.
683
00:41:09,550 --> 00:41:12,887
- I've been told some pilots
put this sign up
684
00:41:13,012 --> 00:41:15,639
during a crossfeed
as a reminder.
685
00:41:17,849 --> 00:41:19,976
Investigators have
pieced together
686
00:41:20,059 --> 00:41:23,063
what led to the crash
of Flight 1-85.
687
00:41:29,945 --> 00:41:31,237
- You know what?
688
00:41:31,362 --> 00:41:32,614
I'm just gonna balance out
the fuel here.
689
00:41:32,697 --> 00:41:35,826
When the captain
decides to even out
690
00:41:35,951 --> 00:41:39,788
the fuel in the tanks, he skips
a key step in the procedure
691
00:41:39,871 --> 00:41:43,333
and leaves the right fuel tank
shutoff valve open.
692
00:41:43,416 --> 00:41:46,211
- If the captain had shut
the right fuel tank valve,
693
00:41:46,336 --> 00:41:50,007
there may have been enough fuel
to complete the flight.
694
00:41:50,090 --> 00:41:52,760
It's my chicken scratch.
695
00:41:52,885 --> 00:41:54,302
I had it all along.
696
00:41:54,385 --> 00:41:57,056
Then, he forgets
to close the crossfeed valves.
697
00:41:57,181 --> 00:42:00,518
- It was my own doing.
- Oh, man.
698
00:42:00,643 --> 00:42:03,311
- There are priorities
when you're flying
699
00:42:03,394 --> 00:42:05,356
and you don't wanna
be distracted
700
00:42:05,438 --> 00:42:08,192
by something like doing
paperwork that's overdue.
701
00:42:09,193 --> 00:42:10,527
- Yoke feels funny.
702
00:42:10,652 --> 00:42:13,155
As fuel drained out
of the left fuel tank...
703
00:42:13,239 --> 00:42:14,907
- Say again?
704
00:42:15,574 --> 00:42:17,451
- It feels like I need
a lot of force.
705
00:42:17,576 --> 00:42:20,621
...the plane
became unbalanced.
706
00:42:20,746 --> 00:42:22,831
- It's pushing to the right
for some reason.
707
00:42:22,914 --> 00:42:25,041
I don't know why.
708
00:42:28,586 --> 00:42:30,672
- When you have a flight
control problem,
709
00:42:30,755 --> 00:42:32,967
that's an urgent problem.
710
00:42:33,092 --> 00:42:35,094
You have to deal
with it immediately.
711
00:42:35,219 --> 00:42:37,096
- The runway's in sight.
712
00:42:37,221 --> 00:42:39,472
- I'll give you the in-range.
713
00:42:39,597 --> 00:42:42,893
Then the pilots
started the in-range checklist
714
00:42:43,018 --> 00:42:44,811
later than required.
715
00:42:51,777 --> 00:42:52,945
- Yeah.
716
00:42:53,070 --> 00:42:57,032
We've got an imbalance on that
darn crossfeed I left open.
717
00:42:58,659 --> 00:43:03,831
When the captain
finally realized there was a
fuel problem, it was too late.
718
00:43:12,463 --> 00:43:15,884
- Fuel is life in an airplane.
719
00:43:15,967 --> 00:43:17,469
You have no more fuel,
720
00:43:17,594 --> 00:43:20,097
there's only one way
you're gonna go and it's down.
721
00:43:20,179 --> 00:43:23,851
- Pull up.
- Keep it steady.
722
00:43:23,976 --> 00:43:25,686
- Pull up. Pull up.
723
00:43:31,483 --> 00:43:34,027
- I think the lesson
to be learned is that
724
00:43:34,152 --> 00:43:37,072
regardless of the airplane
that you're flying
725
00:43:37,155 --> 00:43:41,909
and the conditions, that you
should adhere to the procedures
726
00:43:41,994 --> 00:43:43,786
as they're provided to you.
727
00:43:53,297 --> 00:43:56,007
In its report
on Flight 1-85,
728
00:43:56,132 --> 00:44:01,847
the NTSB makes a recommendation
to all Convair 5-80 operators.
729
00:44:03,181 --> 00:44:04,766
- One of the main
recommendations
730
00:44:04,849 --> 00:44:07,143
was to inform pilots that
they should shut off
731
00:44:07,268 --> 00:44:10,648
the fuel shutoff valves
if they are crossfeeding.
732
00:44:10,773 --> 00:44:13,733
Ultimately, if flight crews
follow the procedures
733
00:44:13,858 --> 00:44:18,237
that they are given, they will
get on the ground safely.
734
00:44:23,327 --> 00:44:25,496
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