All language subtitles for Mayday.Air.Disaster.S25E07.Deadly.Climb.1080p.AMZN.WEB-DL.DDP5.1.H.264-BLOOM_track3_[eng]

- I remember being amazed
how quickly

the accident took place.

They were flying and the next
thing you know,

the airplane's lost.

Midwest Express
Flight 1-0-5

crashes seconds after taking
off from Milwaukee, Wisconsin.

All 31 people on board
are killed.

And what do you say
to the public

about the crashes that we've
been having?

1985 becomes one
of the deadliest years

in civil aviation.

It's up to investigators to put
the public at ease.

- This is how the plane hit
the ground.

When they examine
the engines,

they find a component
prone to failure.

Well, when we had
heard that this part

had failed 45 times before,
that's a big deal.

But the flight data
turns the investigation
on its head.

- So the ruptured right engine
didn't bring down this plane.

- It did not.

- Mayday! Mayday!

There are 27
passengers boarding

Midwest Express Airlines
Flight 1-0-5,

a commuter flight from
Milwaukee, to Atlanta.

Many are employees

of the manufacturer
Kimberley Clark.

- Midwest Express Airlines used
the slogan:

"Best Care in the Air," and
they really meant it

because they had as close
to an all-business aircraft

as you could have.

- Treats for when we're
airborne.

- And they also baked fresh
cookies on board

and made the place smell amazing
when you walked on.

- Midex 1-0-5 requesting
IFR clearance to Atlanta.

Both pilots
on this flight are captains

with the airline.

They've already flown two
flights together today.

- Midex 1-0-5, cleared
to Atlanta,

climb and maintain 5000.

- Climb and maintain 5000.
Midex 1-0-5.

For this leg
of the flight,

Danny Martin will be
the acting captain

and Bill Weiss,
the first officer.

- You had two captains
and they... they literally

could switch seats
because of that.

And they did do that over
the course of two days,

flipping out who was the pilot
flying

and who was the pilot
not flying.

- Uh, our alternate will be DCA
if we can't make Atlanta.

There are
thunderstorms in Atlanta,

so the crew has taken
on additional fuel

in case they have to divert
to another airport.

- Takeoff weight is 7-7-1-2-2
pounds. Set stab trim 2.2.

Just past 3
in the afternoon,

the pilots start the engines.

- Starting number one.

The DC-9 used
for today's flight

is powered by two
Pratt and Whitney engines

mounted on the fuselage
at the rear of the plane.

- Because the engines
were in the back,

they were close together, which
made for a little bit easier

flying in emergency situations.

Second of all, for
the passengers, it's quieter.

- Thank you.

Can I put that up here for you?

Thank you.

The plane is loaded
and ready to depart on schedule.

- Airspeed bug, 1-33 set.

And, ah, 1.9 on the EPR

- Okay.

Ladies and gentlemen,

we are number one for departure
so we should be airborne

within one minute.

Flight attendants please
be seated.

- Midex 1-0-5 cleared
for takeoff.

- Midex 1-0-5.

- Here we go. Spooling up.

- This was a very
normal morning,

for a very normal flight.

It was a gorgeous blue sky,
September day.

There was a little bit
of gusty winds,

but it was nothing
for Milwaukee.

- Power normal. One hundred.

The pilots need
to reach a speed of 127 knots
for take-off.

- V-1. Rotate.

At 3:21
in the afternoon,

Flight 1-0-5 begins its journey.

The flight plan calls
for the plane to climb

to an altitude of 33 000 feet
for the 2-hour trip to Atlanta.

- Gear Up.

Just 450 feet
above the ground...

What the hell was that?

...the pilots lose
power in one of the engines.

- It's a critical situation
because if you don't do

something about it immediately,
you won't have time

to do anything about it.
Altitude is your friend.

Midex 1-0-5,

turn left heading 1-7-5.

- What have we got here, Bill?
Here!

- Midex 1-0-5 roger,
ah we got an emergency here.

- Midex 1-0-5, roger.

The plane begins
rolling to the right

and dropping.

- Oh crap!

The DC-9
is stalling.

- Get your heads down.

Heads down! Heads down!

Less than a minute
after takeoff,

Flight 1-0-5 is diving towards
the ground

at more than 170 miles an hour.

The plane hits
the ground

less than 17-hundred feet
from the runway.

- A DC-9 has crashed southwest
of runway 1-9-right.

All 31 people
on board have been killed.

The crash of Midwest Express
Flight 1-0-5

is the third major accident
in the United States this year

and the eighth accident
worldwide.

With more than 12-hundred people
killed, this is becoming

one of the deadliest years
in the history

of civil aviation.

Passengers are unnerved.

Everyone says:
"My God, another one."

What do you say to the public
about the crashes

that we've been having?

- Well, insofar as the National
Transportation Safety Board

is concerned, we are sparing
no effort to determine the cause

of each one of them and we will
make the necessary

recommendations to keep
any repeat of any one of them

from happening.

- Can you show me where
it started to bank?

Investigators from
the NTSB begin by interviewing

witnesses of Midwest Express
Flight 1-0-5's fatal dive.

They either came
forward or we tracked them down.

We ended up making out
a questionnaire

with 40 or 50 questions on it
to kind of cover all the bases.

- OK, got it.

While the witness
accounts differ in detail,

they all describe more or less
the same thing.

- I saw a couple of puffs
of black smoke come out

and I, I just figured that
they had gunned the engines

a little bit. An instant later
the left wing rolls up

and it tipped over and it went
nose first into the trees here.

Most of
the witnesses agree that takeoff

appeared normal until
the airplane was about 300 feet

from the ground.

Almost all report smoke and fire
coming from the right engine

several remember
loud bangs.

Most said that the plane
then rolled abruptly

into a steep right bank,
went into a nose-low spin
and crashed.

- The value of having
so many witness statements

to look at was that they gave us
a picture of what happened

right at the end, a loss
of control, a fire,

and, of course,
the impact itself.

Investigators must
now determine

what could have caused such
a catastrophic loss of control

so soon after takeoff.

- I'm guessing this was made
by the right wing.

- Yup, agreed.

- Let's see what we can
figure out.

After securing
the crash site

of Midwest Express Flight 1-0-5,
investigators begin mapping

the wreckage field.

I think the whole
length of the impact site

was about 295 feet, not much
more than two times

the length of the airplane.

So the airplane hit pretty
steeply and didn't go very far.

- Right-wing tip here, and
horizontal stabilizer here.

This is how the plane hit
the ground.

A 90-degree right roll,
and a right yaw.

Can you grab a picture?
- You got it.

The wreckage path
confirms eyewitness reports.

It very definitely
indicates right up front

that you've got a loss
of control.

It doesn't suggest why you had
the loss of control.

It kind of opens the door
to a lot of different

investigative avenues.

- Yeah, it's fire damage for
sure, but it looks like

all the pieces are here.

Investigators study
the plane's control surfaces,

starting with the ailerons.

The ailerons on each wing direct
the plane's roll.

If an aileron malfunctions and
gets stuck in one position,

it could cause a devastating
lack of control.

- Control tabs are in place.
They seem to be intact.

We didn't find
a problem with other components

that are part of that system.

With the ailerons
ruled out,

investigators turn
their attention

to the rudder system.

- The dampers are still working.
The hinges are intact.

The fractures look like
overload, not stress.

I don't think the rudder
is our culprit.

- We didn't find
anything wrong with any

of the control systems based
on that preliminary look-see.

Could the engines
provide insight into the crash

of Midwest Express Flight 1-0-5?

If the engines
were, well, obviously banged up,

they were fire-damaged,
and they were along

the wreckage path,
which is always good,

it means they didn't
fall off somewhere earlier.

- There's a spacer missing here.

And most of the blades
from this stage are gone.

The team finds
damage inside the right engine

that could not have been caused
on impact.

The missing engine pieces
include a spacer

and the compressor blades

from the 9th and 10th
compressor stages.

They're found more than
half a mile

from the main wreckage site.

- Finding any part
of the airplane

short of where the airplane
crashed was a suggestion

of a malfunction or failure that
had occurred in-flight

and required further
investigation.

The engine and
the pieces are moved

to a nearby warehouse where
they can be more closely
examined.

In the end,
though, we ended up finding

about 90% by weight
of the spacer,

so, that was a big boon
to the investigation.

Investigators study
the recovered spacer

to determine why it failed
on Midwest Express Flight 1-0-5.

- All along the pedestal, here.

It's definitely not overstress.

They discover
a tell-tale crack on the spacer

that appears to have spread
over time,

what's called
"progressive cracking."

- There may be stress marks.
There may be, uh, cracks.

There, there may be things that,
that suggest a direction

of failure and, and a timeframe

where the fracture would
have occurred.

It doesn't occur all
at one time.

- Can we determine how long that
crack has been spreading for?

- I'll see what I can do.

- We became interested
not just in detailing

that but trying to find whether
this was a fracture

that could have been detected
previously.

A closer look
at the crack on the steel spacer

reveals it is filled
with nickel.

A light-weight nickel coating
is applied to certain

vital engine pieces like
the compressor spacers

and blades to prevent corrosion.

- The compressor was brought
in to be refurbished in 1981.

Coating stripped, spacer
examined and, oh, here we go,

re-plated.

- That was 4 years ago.

The maintenance
records tell investigators

that work had been done
on the spacer

that failed on Midwest Express
Flight 1-0-5.

Nickel cadmium
plating is the last step

of the refurbishment process
that would have been done

by the maintenance facility
that was involved

with essentially the overhaul
of that part.

Four years before
the accident,

the spacer was removed from
the engine,

stripped of its coating,
and examined for cracks.

The inspector reported
no cracks and sent the part

to be re-plated with nickel.

Since nickel was found inside
the crack,

it must have been present when
the nickel was applied.

The DC-9 flew about 25-hundred
flights over the next 4 years

with the damaged spacer until
it finally ruptured

on Flight 1-0-5.

- This should have
been caught during an overhaul,

but it wasn't.

And so the crack kept growing
and growing

until it finally hit
its failure point.

Investigators wonder
what caused the crack to form

on the spacer
in the first place.

- These spacers have been used
inside the JT8D

for more than 20 years.

This can't be the first
one to break.

There are identical
spacers in more than

1400 J-T-8-D engines used
on airplanes around the world.

Is there any history of similar
failures?

And it turns out
that Pratt and Whitney

were well aware of the spacer
failures that occurred before.

And so we started to wonder,
what have they done about it?

- It seems to happen a lot.

While researching
spacer issues in other aircraft,

investigators uncover 45 similar
failures

prior to Midwest Express
Flight 1-0-5's accident.

- Well, when we heard
that this part had failed

45 times before, we kind
of looked askance

a bit at the manufacturer.
It's a big deal.

But of all
the failures uncovered

by the NTSB...

- Not a single loss of aircraft
or even a single injury.

- Well, that says something.

...in every
previous incident,

the plane landed safely.

So why did the rupture
of a spacer

on Flight 1-0-5 cause the plane
to become uncontrollable

and crash?

- Well, we knew that none
of the previous failures

had led to an accident,
so one of the questions was:

"What made this one different?"

- Let's see what got hit.

Investigators
consider the possibility

that pieces of the ruptured
spacer on Flight 1-0-5

punctured the plane's fuselage
and damaged vital

control systems such as cables
or hydraulic lines.

When a part like
a spacer or a fan disc breaks

under a lot of stress it's...

it's almost like a small
explosion going off.

You have fragments of metal
flying at very, very

high speeds.

- OK, let's see 8 9 4.

They study
the location and pattern of all

the puncture marks found
on the skin of the plane

to see if any were near vital
control links.

- No control cables.
No hydraulics.

10, 12.

No control cables,
no hydraulics.

What about the pieces
of the plane

that we haven't
been able to find?

There are many
critical pieces of the plane

that have not been recovered
or are too badly damaged
to study.

- Is it possible to figure out
if they could have been hit

by the engine pieces?

- We have what we need to run
a trajectory analysis.

- Alright.

- We were looking at could
these parts

that have left the engine, uh,
strike a control surface,

or the hydraulic system
or anything else

where they could have done
secondary damage

that would have compounded
the situation

the pilots were facing.

Knowing the plane's
velocity, angle of ascent,

and the wind speed at the time
the engine failed,

the team calculates the path
of debris ejected

from the engine.

- The smallest piece we found
was about half an ounce.

The largest piece was just over
a pound.

- So everything moves away from
the plane. Nothing hits it.

The trajectory
analysis tells investigators

that none of the ejected engine
pieces would have struck

the airplane with enough force
to cause substantial damage

to the control systems.

- The analysis indicated that
it was so unlikely

that we considered
it an impossibility,

that those parts leaving
the engine in the direction

they went and the size that
they had could have caused

secondary damage that would
cause loss of control.

If spacer fragments
didn't hit vital components

and cause the loss of control,

perhaps the initial explosive
force opened the cowling,

or engine cover, affecting
the plane's aerodynamics.

- If the cowling had been blown
open, it would cause

a lot of drag. It might cause
the airplane to roll.

It might cause the airplane
to become uncontrollable.

- There's a hole in the cowling.

It looks to be about
2 square inches.

The team finds
evidence that the cowling

was pierced by fragments ejected
from the engine.

- But all four latches, 1, 2,
3, 4, they're all latched.

- It can't have opened
in flight.

- They found them all either
latched or fully intact

with no damage at all.

So that scenario kind of went
out the window.

- So the ruptured right engine
didn't bring down this plane.

- It did not.

Reasonably early
in the investigation

the team figured out that
a spacer had failed

and the engine had failed.

And now we had the rest
of the accident to figure out.

Why would that cause a crash?

Flight 1-0-5's flight data
ex recorder in hopes

of understanding how the loss
of the right engine

caused the death of 31 people.

- It doesn't give us much,

but it's all we've got
to work with.

It was only
recording

four flight parameters.

It had airspeed, altitude,
uh, heading

and vertical acceleration.

- Right here.

A sudden deceleration
at 450 feet.

This must be where
the right engine failed.

- Well, that's consistent with
what the witnesses told us.

The engine failure
we know occurred

above the airport,
so the airplane

had only been airborne
for a few seconds.

- But their heading doesn't
change when the engine fails.

They must be applying left
rudder to compensate.

- Dead right engine, left
rudder. That's the right move.

When the right
engine fails,

the remaining engine should
force the plane to the right.

To counteract that, a pilot
would apply left rudder

to keep the plane flying
straight.

- What the hell was that?

The data shows
that's precisely

what Captain Martin did
in response

to Flight 105's engine failure.

After
a few seconds,

they start this yaw
to the right.

- So, right rudder?

Four seconds after
the failure of the right engine,

the FDR data indicates that
the pilot moved the rudder

from left to right.

That forced the plane into
a sudden yaw to the right.

- He's in a sideslip.

And he's deviating further
and further to the right.

And then he starts to lose
altitude.

148 knots.

He's in a high-speed stall.

- How'd they let that happen?

He went into
a right skid, and then followed

by an abrupt right turn
and dive.

That would be consistent
with a stall.

But the airspeeds indicated
were high enough

that you wouldn't normally
have a stall at those speeds.

- They've clearly lost control
of the plane.

Five seconds later,
they hit the ground.

The flight data
tells investigators that it took

only 10 seconds for the pilots
to lose control of the plane

after the failure
of the right engine.

I have never
seen an accident sequence

that brief, um, before or since.

- So, he responds correctly
at first with left rudder

and nose down pitch.

Then he inexplicably switches
to right rudder?

- And that's what leads
to the yaw,

the right roll
and the eventual stall.

- Right rudder. It makes
no sense.

- It was clear,
from all the data,

that the pilot didn't understand
what happened.

He responded inappropriately,
and within seconds,

the airplane was lost,
and everybody on board

was killed in the accident.

Was there something
about the DC-9's handling
characteristics

that led the pilots to input
the right rudder?

- So, it was relatively
easy to control then?

Just with the control wheel?

Investigators
interview DC-9 pilots

to determine how the plane
handles with only one engine.

- The DC-9 pilots that we talked
to, it was overwhelmingly

described as a very easy,
docile aircraft

to handle in those situations.

- Oh, this has been extremely
helpful. Thanks. OK. Bye.

They all say the same thing.

It's no big deal with
one engine.

Because the DC-9's
engines are mounted

on the fuselage instead
of the wings,

when one engine fails
it does not force the plane

into a severe turn.

- The DC-9 is almost
a centerline thrust aircraft.

So if you lose one engine
on either side,

there's not that much excess
yawing

or controllability
problems at all.

How easy is
it to handle a DC-9

in the situation the pilots
of Flight 1-0-5

found themselves in?

- It was valuable to do
a simulation or test flight,

to get a better idea of exactly
how the airplane performed

under the circumstances
of the accident

but at a higher altitude.

- OK, when we get to 10 000
feet I'm going to cut power

to the right leaving the left
at takeoff power.

Keep the flaps at 20.
Target speed is 170 knots.

They tried
to match the parameters

of the airplane in terms
of the flaps, gear, uh...

and airspeed and then proceeded
to cut the engine power.

- OK, cutting power.

OK, thank you.
Let's go around for another.

The flight
demonstrations showed that

the pilot didn't have
to input rudder at all.

If he had only used
the ailerons,

he could have safely
flown out of it.

- OK, this time no reaction.
Let's see what the plane does.

With no input from
the pilot after the loss

of the right engine, the plane
rolls right and the nose drops.

- OK, you can recover?

Even with
no immediate action,

the pilot is easily able
to recover the plane.

- OK, I think we have
what we need.

- That may have actually been
the best thing to do was...

was to do nothing, watch
the airplane's response,

understand the airplane's
response

and respond appropriately
to the nature of the emergency.

- What the hell was that?

If the DC-9
is so easy to control,

why were two experienced pilots
unable to recover

from the loss
of their right engine?

- OK, we kpt with the airline.

But how much experience
did they actually have?

Investigators look
into the backgrounds

of the pilots of Midwest Express
Flight 1-0-5

to understand why they didn't
recover from

a single-engine failure.

- Neither had a lot of turbo
jet experience.

One was
upgraded to captain

with 600 hours on the DC-9,
the other with only 500.

- It doesn't seem like
a whole lot.

- Advancement to captain
happened within a year

for both of these pilots,
at Midwest Express Airlines

at that time.

And the reason why was it was
a small airline.

It was growing quickly.
They were adding airplanes.

They consult large US airlines
to determine

their qualifications
for an upgrade.

- Ok. Thanks.

- It's the same for both
airlines: 10 years seniority

and 75-hundred hours as DC-9
first officer

to be considered for an upgrade.

- You know, these guys weren't
anywhere near that.

While the pilots may
have been experienced,

neither had spent much time
piloting the DC-9

before they were promoted
to captain.

The more
experience someone has

exercising command, the more
likely they are to exercise

that command in situations
that call for calm thinking,

for rational response and so on.

- So how much training did these
guys get on engine failures?

To understand why
the pilots of Flight 1-0-5

were not able to control
their plane

following an engine failure,

investigators look
at their training records.

What was
their experience?

What kind of pilots were they?

How did they respond to unusual
events?

Did they seem self-confident?
How well did they work together?

- OK, so the captain's practiced
12 engine failures

on takeoff in the simulator.
The first officer, 15 sessions.

They discover
that both pilots

had been extensively trained
to cope with engine failure

on take-off...

- It's precisely the type
of emergency they faced

on Flight 1-0-5.

...but what
exactly were they taught?

- We looked very closely
at the training these pilots

received and interviewed
the flight instructor

who oversaw their training
in the DC-9 for Midwest Express.

- Tell me what you can remember
about captains Martin and Weiss.

- They were both excellent
pilots, trained to proficiency.

- Lots of simulator training
on engine failure.

- You bet. We ran them through
all sorts of scenarios.

- Let's focus on takeoff
with simulated engine failure.

What were they taught?

- Pay attention to your yaw.
It's your best cue.

Yawing right.
Applying left rudder.

- Control wheel as needed.
Keep the plane level.

Nice and easy.
That's a good job.

- Got it.

Captain Martin was
trained to pay close attention

to the plane's yawing motion
when identifying

and correcting
an engine failure.

- It looks like they had
excellent training.

Thanks for the insight.

We found
the instructor,

uh, to be very capable,
very dedicated,

and we found the simulators
to be... to be okay,

uh, for that time.

If Captain Martin
was extensively trained to cope

with engine failure on take-off,

why didn't he do
what he was trained to do.

- Most of their training was for
an engine failure at take-off.

Pretty easy to identify
which way you're yawing.

Yeah.

- Investigators consider
the timing

of the engine failure.

If you're
closer to the ground,

there are much more visual cues
available from the ground

to see what the airplane
is encountering.

Not so easy
when you're already

in a steep climb.

- Right.

As Flight 1-0-5 was
climbing, only blue sky

would have been visible
to the pilots,

making it more difficult
to identify

the direction of the yaw.

- What the hell was that?

With no outside
visual cues,

investigators believe Captain
Martin's initial response

was a spontaneous reaction
to the plane's changing motion

and not the result
of an analysis of the situation.

But what triggered the incorrect
rudder application

a few seconds later,

that resulted in a total
loss of control?

- Alright, let's see what
these guys were doing.

Midex
1-0-5, cleared for takeoff.

Midex 1-0-5.

Here we go.

Investigators pin
their hopes on the CVR

to explain Captain Martin's
actions.

Spooling up.

Power normal.

100.

V-1. Rotate.

Gear up.

- The spacer?

(controller on CVR:
Midex 1-0-5,

turn left heading 1-7-5.

What have we got here, Bill?

Here!

Midex 1-0-5 roger,

ah we got an emergency here.

Midex 1-0-5 roger.

Oh crap.

Get your heads down. Heads down!

- I've never heard an accident
unfold so quickly.

Holy smokes.

And I remember
just being amazed

how quickly the accident
took place.

It was like they're...
they were flying.

You hear the engine fail,

uh, and the next thing you know,
the airplane's lost.

- OK, so what did we hear?

- It sure happened fast.

- Yup, 15 seconds from the sound
of the engine exploding

to the end of the recording.

Astonishing.

What else?

- "What was that?
What have we got?"

The captain seemed uncertain.

- Agreed.

- What have we got here, Bill?

- Well, it was clear from
the cockpit voice recorder

that the pilot didn't recognize
what had happened.

He articulates that.

"What was that? What have we got
here, Bill?"

- What the hell was that?

The sound
of the engine,

the sensation of the right yaw,
and the instruments

should have told Captain Martin
that he was dealing

with a failure of his
right engine.

- Anything else on that tape?

- Not a lot of troubleshooting
or communication

between them really.

- Actually none.

- What have we got here, Bill?
Here!

- Midex 1-0-5 roger,
ah we got an emergency here.

Investigators hear
Captain Martin

asking his first officer
for assistance in assessing
the situation,

but First Officer Weiss
never replies.

- That was troubling to me
because I would have expected

that in an emergency situation
and especially

when asked for help, that
the other crew member

would have helped if he could.

So that prompted some further
investigation.

- OK, let's start with that:
Why was the Captain confused

about what had happened?

- It should have been obvious.

46-hundred flight hours:

but he's never experienced
an actual engine failure.

NTSB Investigators
looking into the crash

of Midwest Express Flight 1-0-5
have learned that

Captain Martin's only
experience

with a single-engine
failure was in a simulator.

- Yaw and deceleration don't
feel the same,

plus all the sounds
are different.

- It's not the same as
the real thing.

- It was a catastrophic engine
failure where they had thrust

and then they didn't.
It was immediate. Uh...

I don't think they were trained
in that kind of scenario.

- What have we got here, Bill?

The limitations
of the simulator may explain

Captain Martin's initial
confusion,

but it does not explain
the first officer's
unusual silence.

- Let's have another listen.

They return
to the cockpit voice recording

to better understand how
First Officer Weiss

reacted to the emergency.

What the hell was that?

- That's one.

Midex 1-0-5,

turn left heading 1-7-5.

What have we got here, Bill?

- That's two.
- Here!

- That's three.

He asks for help three times,

but the FO says absolutely
nothing to him the entire time.

- Not even "I'm not sure,"
or "I don't know."

Not a word.

- In this situation,
seconds were critical.

Had he said right away,
"I don't know," then the captain

would immediately have tried
to rely on his own understanding

of the situation, rather than
expect the first officer

to come up with an explanation
of what he had.

What could have
caused the first officer's
silence?

- Hang on. What altitude where
they at when the engine failed?

- 450 feet.

- This could be it then.

Pilots say they were taught
not to make callouts

or even verbalize the nature
of an emergency

after 100 knots, before
reaching 800 feet.

- Let me see.

Not even to identify
a failed engine.

No communication at all
until 800 feet.

I couldn't imagine
a management team

at Midwest Express thinking
this silent cockpit business

made any sense.

It just flies in the face
of communication,

which is kind of the fabric that
holds a safe flight together.

So it just blew my mind,
frankly.

- What the hell was that?

Investigators think
First Officer Weiss

may have been following
a Midwest Express unwritten rule

of not discussing emergencies
until the plane reaches
800 feet.

It's important
during an emergency

for people to talk to each other
because they both may not be

looking at the same instrument.

They both may not be looking
at the same thing outside.

You have to talk.
You have to talk.

One last thing
troubles investigators.

In spite of his first officer's
silence, Captain Martin

could have easily identified
which engine had failed

simply by looking
at his instruments.

Both pilots
had visual information

from the engine flight
instruments,

the bank turn indicator
and so on,

that would have told
them um...

what was going on in terms
of the loss of thrust.

- I don't think either of them
were scanning the instruments.

- Agreed.

They never saw which engine
had failed,

the direction of the yaw
or the severity of the roll.

The NTSB concludes
that the pilots' failure

to monitor their instruments
contributed to Captain Martin's

incorrect rudder application.

With the lack
of visual cues,

the only sure way they would
have had to recognize

which engine failed would
be to look at the instruments.

The pilots' lack of
awareness ultimately led

to the stall that brought down
Flight 1-0-5.

- Up until here he should
be fine.

But then there's no
communication

and no instrument scanning.

And this, this is what
dooms them.

He puts in right rudder,
which sends them

into a sideslip, an extreme
right roll and a stall.

- If they had talked
to each other,

scanned their instruments
you don't get this accident.

- The reality of the situation
is the mismanagement

inside the cockpit caused
the accident,

not the engine failure.

The NTSB's final
report

makes several key
recommendations to prevent

this type of accident
from happening again.

They recommend a directive
requiring airlines

to replace the existing spacers
with a new type of spacer

which is less likely to fail.

They also recommend that
airlines are advised

to teach their pilots
to communicate

during on-board emergencies.

It should never be
overstated the importance

of crew coordination.

Every crew member has something
valuable to add.

Anything that is an abnormality
needs to be discussed

at the proper time.

They also suggest
that airlines review

their simulator training
to ensure pilots are taught

to use their instruments
to assess the nature

of engine failures.

- I think this accident still
has an impact today

because it's such a clear
illustration of what happens

when you don't do what you
should to do in an emergency.

Any time there's an emergency,

you should have the exact
same procedures,

and you should run right
to them.

Midwest Express
Airlines continued to operate

until 2009.

It merged with
Frontier Airlines in 2010.

Subtitling: difuze