All language subtitles for Mayday.S05E04.Dead.Weight.1080p.AMZN.WEB-DL.DD+2.0.H.264-playWEB_track3_[eng]

Morning rush hour,
Charlotte, North Carolina.

Its busy airport is rocked
by a massive explosion.

The flames were coming
over the fence.
Just total craziness.

Everyone was just
running for their lives.

Firefighters rushed
to one of the airport's
main hangars.

They confront an inferno.

It was quite a while
before we realized
a plane had hit the hangar.

A packed commuter
flight has plunged to the ground
shortly after takeoff.

Everyone on board is killed.

We kept scratching our head,
wondering, okay, this airplane

flew nine times previously
and we had no problems.

Investigators uncover
a string of errors.

Bill, I have an idea.

And learn that
passengers on small planes

have actually been in danger
for years.

Mayday! Mayday! Mayday!

It's morning
on January the 8th, 2003,
in Charlotte, North Carolina.

A city of half a million wakes.

At Charlotte Douglas
International Airport,

commercial airline pilot
Captain Katie Leslie
is at work early.

Only 25 years old,
this Texas native
has been flying

for Air Midwest
for almost three years.

One of the youngest
flight captains at her airline.

Hey, Tom. Have a great flight.

She's a top-rated pilot,
building her career

at one of the fastest
growing airports
in the United States.

This airport is an important
domestic hub for US Airways,

with flights to most
major cities
in the eastern United States.

Air Midwest runs
a commuter service
as US Airways Express.

It operates a fleet
of Beechcraft 1900D planes,

a 19 passenger short-haul
commuter plane

and a trusted workhorse
in the industry.

Today, Captain Leslie
is in command of a 1900D

on a 30-minute hop to
Greenville-Spartanburg Airport
in Greer, North Carolina.

Her co-pilot is 27-year-old
Jonathan Gibbs.

How did you sleep last night?

Had a dream I was in Miami.

Attention, ladies and gentlemen,
this is the final boarding call

for Air Midwest Flight 5481
to Greenville-Spartanburg.

All passengers wishing to board
should make their way...

Among the passengers
flying to Greer this morning,

18-year-old Christiana Shepherd.

Christiana's parents,
Doug and Tereasa,

are Baptist missionaries working
in the Portuguese Azores.

Christiana left
the seventh of January
from the Azores,

spent the night in the airport
in Boston.

And then flew the next morning
on the early flight from Boston

to Charlotte to Greenville.

So, she was on her way
back to college.

Christiana was very special
and she was one
that would come up

and give you a hug and say...
You know, she'd come
for no reason.

She would give you a hug
and say, "Dad, I love you."

At 8:00 in the morning,
Christiana boards her flight.

Meanwhile,
as part of their standard

checklist before takeoff,
the crew calculates

the weight of all the baggage,
passengers and fuel
on the plane.

That's to make sure
the plane isn't overweight
and the weight is spread evenly.

It's a calculation that's made
on all commercial aircraft.

So, we got a full house
back there?

You can count 19 people
in the back.

- I don't know the bags yet.
- Okay.

But baggage handlers
raise concerns

that the luggage they're loading
may be too heavy.

Damn. Captain,
how many we got to take off?

We're figuring it out.

We don't think we're gonna
have to take anything off.

Cool. Seventeen thousand
eighteen.

Seventeen thousand
one hundred and twenty
is our weight, huh?

Yeah, as our max.

So, we're cool.

So, yeah.

Good morning. Welcome aboard
US Airways Express Service
to Greenville-Spartanburg.

It's a very short flight,
maybe 30 minutes gate to gate.

So, sit back, relax,

and we'll have you there
in a few minutes.

Before takeoff,
the crew checks
the flight controls,

including the rudder
and elevator,

which help control
the direction of the plane.

Flight controls
free and correct.

Air Midwest 5481,
Runway 18 right.

Taxi into position and hold.

Captain Leslie
is moments from takeoff.

On the runway, ahead of them
is a Bombardier CRJ
ready for departure.

That CRJ sure is
a good looking plane, isn't it?

Yeah. I wish I was flying it.

With powerful turbulence
released from the CRJ,

Captain Leslie
must keep a safe distance.

They're gonna blast us
with his jet blast.

Air Midwest 5481.
Turn right, heading 230.
Cleared for takeoff.

Set takeoff power, please.

Power is set.

Eighty knots. Cross-check.

At 80 knots,
pilots check that key
instruments are working.

With no signs of trouble,
Leslie and Gibbs
proceed with their take off.

To air traffic control,
Flight 5481's takeoff roll
is perfectly normal.

Gear up.

What?

Oh!

But without warning,
the plane's nose

pitches dramatically upward
from seven
to a staggering 54 degrees.

Help me.

- You got it?
- I'm trying.

The crew struggles
to get the nose back down again.

Airflow over the top
of the wings creates lift,
but if the nose keeps rising,

air won't flow smoothly
over the plane's wings.

The plane will lose its lift,
stall, and plunge from the sky.

Push the nose down.

Oh, my God. We have an emergency
on Air Midwest 5481.

Alert 3.
Standby Runway 18 right.

The controller
handling Flight 5481
calls for emergency equipment.

Oh, my God.

The plane is now
350 meters from the ground.

It stalls, rolls to the left
and begins falling from the sky.

Captain Leslie
pulls on her control column
with all her might.

If she can't get
the plane to climb,
she's going to hit the ground.

Air traffic controllers watch

as a 19-passenger plane
plunges towards the earth.

Captain Katie Leslie
struggles desperately
to get her plane to climb,

but it won't respond.

The plane heads towards
a packed US Airways hangar.

The flight was loaded
with almost 1,000 kg

of highly flammable jet fuel
just before takeoff.

The impact instantly
ignites all that fuel.

Now the intense fire
threatens to engulf the hangar.

There are several airplanes
and hundreds of people
working inside.

Fire station.
Emergency.

- A plane just crashed.
- There's a plane
that's crashed.

Yes. At the US Airways
entry.

Right at the corner
of the building,
there's a fire.

We got a Code 10,
aircraft crash at the south end
of runway 36 left.

I repeat, a confirmed
aircraft crash, on fire.

Thirty-eight-year-old
Fire Chief Keith Rogers

is driving to work
when he gets a Code 10 call.

A Code 10 means that

there is a confirmed
plane crash.

But usually this type of call
is a once in a career
type of incident.

Cindy Overcash
is a firefighter with
the Charlotte Fire Department.

You couldn't actually
see the hangar from here,

but you just saw a huge
black plume of smoke.

And we knew, you know,
something really bad is here.

In the adjacent building,

Sales Director David Isola
hears the explosion.

I was sitting at my desk
and I heard this, uh...
This loud boom.

And, uh, one of the guys
came in from next door

and said that, uh,
he just saw an airplane crash.

And, uh, so I hopped in my truck
and drove down to the site.

From 60 meters away,

Isola records
the opening moments
of the tragedy.

There was a lot of smoke
and, uh, it was just...
Just like hell.

Looked just like hell.

The flames were coming
over the fence.

Just total craziness.

Everyone was just
running for their lives.

When Chief Keith Rogers
arrives at the scene,

he finds himself
swimming upstream
against a mob in panic.

As I got onto
the airport property
and got onto the tarmac,

uh, the people
were exiting the hangar.

Those people were running out
in front of the fire trucks
and the fire cars.

So, we had to drive
with caution.

They were getting
out of the building
as fast as they could

because I think
they definitely realized
that this was not a drill,

this was a real emergency.

And we still weren't sure
if we had a plane
inside the hangar

that had caught on fire
or if the hangar
had caught on fire.

It was quite a while
before we realized
a plane had hit the hangar.

Chief Rogers
immediately takes command
of the scene.

He knows that
there are aircraft parked
inside the flaming hangar.

Their fuel tanks
threaten to blow.

And our concern
was, one, about the people

that were on board the aircraft.
Two, for the people that were
working in the hangar.

And three, we had to worry
about the airplanes

that were in for repair,
were those aircraft on fire.

So, we had a lot of
major issues to deal with.

Within minutes,
firefighters begin to get
the inferno under control.

The hope now is that
somewhere inside the wreck,
survivors are clinging to life.

The main thing probably
was on anybody's mind

once we realized what we had
was survivors.

Chief Rogers sends
a line of firefighters,

led by Cindy Overcash
into the heart of the inferno.

Cindy Overcash
and two of her team

make their way
into the wreckage,

carefully putting out
spot fires along the way.

As we walk up on
the scene of the fire,

and we see the...
What we think
are crash-test dummies,

we thought a plane
had blown up inside

and blew their
training dummies out.

And then it dawned on me.

Uh-uh. That's not
a training dummy.

It took them
a few minutes in determining
exactly what was happening.

And once they did that,
it was obvious that
there were no survivors.

It's a total loss.

All 19 passengers,

as well as Captain Leslie
and First Officer Gibbs
are dead.

At about 8:53 this morning,
uh, we had an aircraft accident.

It had 19 passengers
and two crew.

There are no survivors.

And we hope
that we never have to respond

to a situation
with such a large loss of life.

But that is our job.

This is some of the most
difficult duty and tasks

that a firefighter
will ever do in their career.

For medics
and rescue workers,
the ordeal is over.

But for friends
and family of the victims,
the anguish has just begun.

I was walking
through the living room,

and I stopped and said...
My heart's beating right now

just the way it was then.

I said, "Has Cristiana
called yet?" She said no.

Okay. And I knew then
what had happened.

I just... I knew.

So, I went and got the telephone
and called the school.

He said, "Yes, Mrs. Shepherd,
we have some sad news."

And he told me that
the plane crashed on takeoff.

I asked if there were
any survivors.

He said no.

So then I knew
I had to go tell Doug,
and he was in the garage.

Yeah, it's something you...
You never forget about.

Uh, I was changing
a fluorescent bulb,

and, uh, Tereasa came
to the... to the doorway.

How do you say that?
What word...

You use words every single day.

How can you use words...

...to ruin
someone's life.

But I told him. I said, "Doug,
Christiana's plane crashed."

At that moment, uh, my...
my world fell apart.

Now, the Shepherds
and the families
of the other 20 victims

want to know what caused
the deaths of their loved ones.

It's been
almost five hours

since Flight 5481
crashed into a hangar

in Charlotte, North Carolina.

With no survivors to rescue,

neither bodies
nor airplane parts
are moved from where they fell

until the arrival
of investigators

from the National Transportation
Safety Board.

While medical examiners
mark the location
of human remains in red,

NTSB investigators mark
scraps of metal in yellow,

looking for clues
to help them figure out

what happened aboard
Flight 5481.

Among those
assigned to this case,
lead investigator Lorinda Ward.

This is her first assignment
as the lead investigator
of a crash.

But today,
she's not feeling her best.

That day, I was a little bit
under the weather.

I was fighting off a cold.

You have the adrenaline
that shoots through your body
at the time.

And so, that actually
makes up for when
you're not feeling well.

And I knew that
the other people on my team
were experienced,

so I felt comfortable
going to Charlotte.

At Charlotte Douglas Airport,

Ward takes the first steps
towards solving this accident.

I checked in
with the fire department

to make sure that the fires
had been put out.

And then called a meeting
with all the first responders

to see what they had noticed
when they came
to the crash site.

Ward acts fast.

Because there are bodies
entangled with the wreckage,

she declares the crash site
a potential biohazard.

Investigators who might come
in contact with the wreckage

must wear protective suits
while they examine the wreck

and identify
the victims' remains.

When we arrived on scene,

the accident site did not look
like an airplane was there.

Uh, due to the fire,
the post-crash fire,

um, when you initially
walked up to it,

it was hard to identify
that you had an airplane
that could hold 21 people.

While work continues
at the crash site...

All right, let's go.

Lorinda Ward and her team
look for clues nearby.

We had the folks
go shoulder to shoulder

on the runway that
the accident crew took off on

to pick up anything that
they saw on the runway.

To see if it had any relevance
to the accident investigation.

Runways must be clear
of all debris.

The smallest object
can become a deadly projectile

if it strikes a plane
on takeoff.

Three years earlier,
a Concorde jet

ran over a 40 centimeter
strip of scrap metal
on a Paris runway.

The plane's fuel tank
was pierced and caught fire.

The aircraft rose to 200 meters
before it crashed
into a nearby hotel.

One hundred
and nine people on board

and four people on the ground
were killed.

At Charlotte
Douglas International,
investigators scour the area.

They find a fuel cap
lying dangerously close
to the runway.

What do we got?

It could be sucked in
and it could damage an engine.

But the main part
would be the damage
that it could do to an engine.

The discovery raises
an interesting possibility.

As Flight 5481 raced down
the runway at takeoff,

the fuel cap
bounced up off the tarmac,

struck the engine rotors...

Oh!

...and brought
Captain Leslie's aircraft
crashing to earth.

This was to be brought back
to see if it had any relevance
to the accident investigation.

Uh, whether it came off
the airplane itself,

or if it could have done
some type of damage
to the airplane.

A closer examination
leads Ward and her team
to conclude

that the fuel cap could not have
interfered with the propellers.

Investigators discover no other
relevant debris on the runway.

The runway debris theory
is ruled out.

Now, NTSB Air Traffic Control
Investigator Bill English
explores another scenario.

When we first heard
about the accident,
it looked like there might be

the possibility, uh,
that we'd want to look
at a wake-turbulence encounter.

The wings
of a fast moving jet
disturb the air around them,

creating a trail
of violently swirling air.

NASA tests decades earlier
had illustrated
the power and danger

of wake turbulence
to other planes.

We had to see...
did another airplane
depart before it.

That's where wake-turbulence
hazard would come from.

And we wanted to look at
what kind of airplane
departed ahead of it.

Uh, larger, heavier airplanes

are the more risky
wake turbulence, uh,
creating airplanes,

Bill English
examines radar records
from the time of the accident.

He learns that a much heavier
Bombardier regional jet,

a CRJ, took off
moments before the Beech.

That CRJ sure is
a good looking plane, isn't it?

Yeah. I wish I was flying it.

The wake turbulence
is generated from the wing tips
of any airplane

as soon as it starts
to lift off the ground.

It makes what people sometimes
call horizontal tornadoes.

Vortexes of air that can create
hazardous turbulence.

Runway 18 right.

Taxi into position...

Air traffic controllers
do have standard procedures

for spacing out airplanes

so that they have a chance
to avoid the wake turbulence

or let the wake dissipate.

One year earlier,
an American Airlines jet

taking off from New York
encountered wake turbulence.

The plane crashed into
a residential neighborhood.

Two hundred and sixty people
on the plane

and five people on the ground
were killed.

They're gonna blast us
with his jet blast.

Air Midwest 5481
cleared for takeoff.

Oh!

Air Traffic
Investigator Bill English

must now determine
if wake turbulence from the CRJ

caused Flight 5481 to crash.

Bill English studies
the flight path
of Captain Leslie's plane

and finds it consistent
with a plane
flying into wake turbulence.

A pitch up is not unheard of
in a wake-turbulence encounter

where the... the airplane
will suddenly go nose up

and the crew has trouble
to, uh...

Uh, to counter that
and get the nose back
where it belongs.

English needs to know
how close the Air Midwest
flight got to the larger jet.

The Charlotte Tower
has a sophisticated
computer system

that tracks the movement
of planes while they're still
on the ground.

The system gave
Bill English his answer.

That system had
a very rapid update

so we could see exactly
where on the runway

and at what time
the regional jet lifted off,

compared to when
the accident airplane
started its roll.

When Bill English
plots the precise position

of the planes at liftoff,
he makes a telling discovery.

Even though both planes
used the same runway,
their paths never crossed.

The RJ started lifting off
much farther down the runway

than the accident airplane did.

And the climb-out angle
of the regional jet

and the climb-out angle
of the accident airplane

never intersected.

The angle of the accident
airplane was very steep.

It really had no possibility
of, uh, intersecting

the wake turbulence
from the regional jet.

So, if our airplane lifted off

and climbed above the angle
of the previous airplane

we knew then that it...
it couldn't possibly
be a factor.

The wake vortex theory
is ruled out,
and Bill English's work is done.

Now it's up to Ward
and her crew to find clues

in the burnt out
wreckage of the plane.

Within two days,
her investigation will reveal

a string of errors
and faulty assumptions

that has been putting
tens of thousands
of passengers at risk for years.

Within hours of the crash,
investigators find

the cockpit voice recorder
and flight data recorder
from Air Midwest Flight 5481.

The recorders are designed
to withstand temperatures
of up to 1,100 degrees Celsius.

In this crash,
parts of the voice recorder
had actually melted.

The devices are photographed
and sent for analysis.

Then, amongst the tons of debris
on the ground,

investigators discover
the shredded remains
of the elevator control cables.

Vital to flight control,

these cables link
the pilot's control columns
to the flight elevator.

An aerodynamic panel
that helps pilots
climb and descend.

Turnbuckles keep the cables taut.

To climb,
pilots pull on the column.

The cables pull the elevator up,
forcing the nose to rise.

To descend, pilots push
on the control column.

The cables tilt
the elevator down
and the nose falls.

But as investigators examine
the burnt out cables
and turnbuckles

on Captain Leslie's plane,
already something looks wrong.

They looked unusual.

They weren't in, like,
the normal position
that you would find them.

In this case, we had one
adjusted all the way out,

and then one
adjusted all the way in.

Um, so those were set aside
for us to look at later.

While the lab work continues,

NTSB Investigator
Stephen Carbone
travels to Huntington, Virginia.

He interviews mechanics
who worked on the plane
the day before the crash.

It's all there.

At the time, we had known that

it had just come out of an...
of a detailed check,

which is a... a routine check.

And knowing that, we were
looking into the possibility

that something had been done
during the check
that needed to be looked at

from an investigation
point of view.

The cables needed servicing.

My guy wrote up a service order
and I put him on it.

Don't forget the manual.

Got it.

Every 1,200 flight hours,

Air Midwest planes go in
for routine maintenance work.

This includes adjusting
the cables that control
the plane's elevator.

In the process
of doing this check,

he found that...
The mechanic had found

that the cables
were out of limits,

so he had written up that
he was going to check
the cable tensions

and then adjust them
as per the manual.

Everything's all right?

The mechanics
tell Carbone that
the work was checked

and stamped
for quality assurance.

They believe that the aircraft
was properly rigged
as per the manual.

At first glance,
that belief appears to be right.

After maintenance,
this Beech aircraft took off

and landed nine times
without incident

before Captain Leslie
took the helm.

Investigators turn
to the flight data recorder

to learn what happened
on those flights.

The flight
data recorder stores data
from numerous flights,

both before and after
the plane's cables
were adjusted.

No one on any of those flights

had encountered any problems
with the plane's elevator.

So, at the time, we didn't know
how that affected the airplane

because it had flown
nine times successfully

before the accident flight.

Ward also discovers
that the crew tested
their elevator controls

before Flight 5481 took off.

Flight controls
free and correct.

Air Midwest 5481.

Ward and her team dig deeper,
looking to discover

if the unusual configuration
of the elevator cables

could have played a role
in this crash.

What they find
strikes at the very heart
of what went wrong.

Normally, both turnbuckles
are almost exactly
the same length.

But on Captain Leslie's plane,

one turnbuckle is noticeably
longer than the other.

To establish
the correct cable tension,

mechanics tighten
the turnbuckles,

but too much tightening
of a turnbuckle
shortens the cables

and cuts the range of motion
of the elevator control.

The elevator should be able
to tilt to a nose down
position of 14 degrees.

But their downward range
has actually been cut in half
to only seven degrees.

The result is deadly.

As the flight got underway,
the nose pitched up
as expected during takeoff.

What?

Push the nose down. Oh, my God!

But the reduced range
in the elevator

made it impossible
for the pilots
to bring the nose down again.

Due to the adjustment
that had been done

in the maintenance
a few nights earlier,

there was nothing that the crew
could have done at that time.

Unable to bring the nose down,

the pitch of the wings
became too pronounced.

With no air flowing
over the top of the wings,
the plane lost its lift

and began falling from the sky.

The pilots' struggle
with the elevator

helps explain why
Flight 5481 crashed that day.

Somehow, the elevator cables
were improperly adjusted.

The pilots simply
could not control
the pitch of their airplane.

Stephen Carbone wants to know
how mechanics had made
such a critical mistake.

Yeah, I see that here.

He goes back to the hangar

to question the mechanics
on duty that night.

And this time they tell him
a different story.

Most of the guys
were just learning the ropes.

The mechanics working
on the airline

were subcontractors
to the contract company.

And the mechanics
working on the aircraft
that night

had limited experience
on the Beech 1900D.

And the person
performing the rig

was receiving
training that night
on that specific task.

Once you have the rig pin set,
adjust the turnbuckle barrels
for more tension in the cable.

Yeah, I see that here.

Adjusting the elevator cables
is not a simple process.

It's a time consuming procedure
that involves
25 different steps.

Got it.

Uh, well, what about
the other steps?

Yeah. Uh,
don't worry about those.

Just check the cable tension
when you're done
and we're good, that's it.

The quality
assurance inspector

and the mechanic
took it upon themselves

to decide which steps to perform
because they felt that

the steps they were performing
were the only ones necessary
to get the task done.

The mechanic
skipped nine steps that night,

one of those involved
manipulating the elevator

through its full range
of motion.

Had the mechanic
tried to do that,

he would have noticed
that the elevator's motion

was restricted by cables
that had been improperly rigged.

If they had followed the steps
as described in the manual,

they would have found
the problems that had come up.

But there was an inspector
supervising the work.

Carbone discovers
that the inspector
was actually the person

teaching the mechanics
how to do the work.

The problem was that
the quality assurance inspector

was actually acting
as an instructor.

So, he was taking the mechanic

through the process
of the job task

and teaching him
how to do the rig.

Well, when you put yourself
in that position,

you're actually doing the task
because even as an...

as... as a teacher,
you're performing the task.

And then he came in
behind himself

and then signed off
as an inspector
what he had done.

When I found out that, uh,
that this mechanic

had skipped procedures,
uh, I was upset.

Uh... The procedures that...
that affected our lives,

that affected the lives
of 21 people,

21 families were...
were destroyed.

You never get over
something like this.

The Shepherds sue the airline.

They also demand something
unheard of in US aviation,
an apology.

They wanted more than just
to achieve a just settlement
in monetary terms.

They had a need
to press the issues

that humanize and put a face

on the people
who are the victims
of these tragedies.

The Shepherds
believe that their best chance
of getting an apology

is by putting a face
to Christiana's name.

So, we decided
to take this picture
and to send it to those people

that were involved in the...
in the... in the accident
and the investigation

so that...
so that Christiana would...
would not be just a number.

Or a seat number.
Or a ticket number.
Or a settlement amount.

So that they could actually see
that she was a person.

The legal journey
began when we determined

that we wanted the apology,
that we wanted someone to say
"We really blew this."

We assumed
the airline would apologize.

We had no idea
that airlines don't apologize.

They did something wrong.

Obviously, you should
stand up and say,

"We are so sorry
that we messed up in this,
and we're fixing this."

In this case,
the mechanics thought

they were doing something
that was perfectly reasonable.

They thought this was,
uh, you know,
another day at the job.

And then they come to find out
that now 21 people have been,

you know, killed
due to their inadvertent act.

For Lorinda Ward
and her team,

it looks like
they've found the problem.

But something
still doesn't add up.

Why didn't the problem
with the plane's faulty rigging

surface on any
of its previous flights?

We kept scratching our head,
wondering,

okay, this airplane flew
nine times previously,
and we had no problems.

So, we're trying to decide,
well, what was unusual
about this flight.

Ward has to figure out
what happened in the hours
and minutes before the crash.

And did you
notice anything unusual
before takeoff?

Well, it was sitting low
when it taxied out.

It looked heavy.

We had a couple of witnesses
that were implying that

we had a very
heavily loaded airplane.

The baggage people
said that it was hard
to shut the door

'cause they thought
bags were gonna come out.

Each plane
has a maximum weight
it can handle

before the engines
can't get it off the ground.

Before takeoff,
it's the pilot's job
to calculate the onboard weight.

We got a full house back there?

How many we got to take off?

We're figuring it out.

The crew of Flight 5481
did perform that calculation.

Cool. Seventeen thousand
and eighteen.

We hear them on the CVR
going through the numbers

to make sure that they'd have
their center of gravity

within the range
for them to take off.

Seventeen thousand
one hundred twenty
is our weight, huh?

Yeah, as our max.

On any plane,
large or small,

the weight of cargo
and passengers
has to be distributed evenly.

The balancing point
of an airplane
is called its center of gravity.

For a plane to fly safely,

it can neither be
too far forward
nor too far back or aft.

So, we're cool.

So, yeah.

We don't think
we're gonna have
to take anything off.

Air Midwest pilots
are instructed

how to make weight
and center of gravity,
or CG calculations.

They use average weights
to make that calculation.

One hundred and seventy five
pounds per passenger
and 20 pounds per bag.

They knew that
they had a very aft CG.

But due to using
the average weights

and average calculations,
the paperwork showed them

being within the range
that they needed to take off.

But Ward needs to know
if the plane really was

within the proper
range of weight
and balance to take off.

What we did was
we looked at the weight

of the actual baggage itself
that was on board,

and then the weight
of the passengers and the crew.

Technicians weigh
the remains of the burnt luggage
from the wreckage site.

Doctor? Yes.
Could you tell me, please,

what the last recorded weight
of your patient was, please?

And obtain
the real weight of passengers
on board that day.

Two hundred and twelve.
Thank you.

When all the numbers are in,

Ward discovers the real weight
of Flight 5481 is 17,700 pounds.

Some 580 pounds over
its maximum takeoff weight.

They would not have been able
to take off if they had
used actual weights.

They would have had to pull
either passengers or bags off.

Because of the higher
than expected weight

of the passengers
and baggage on the flight

and the large number of bags
stowed in the rear,

the airplane was tail heavy.

Its center of gravity
ever so slightly
too far to the rear,

which wasn't a problem
until the landing gear
was raised.

Gear up.

When the gears weight
moved backwards from the nose,

it tipped
the balance of weight...

What?
...too far back.

The pilots' efforts
to regain control
of the aircraft were futile,

crippled by the airplane's
defective elevator controls.

When the nose gear
moved aft, they lost the ability

to control the aircraft because
all the weight went back

and they had
no elevator movement enough
to bring the nose back down.

And at the height
that they were at,
they had no recovery.

The passengers
and crew of Flight 5481

were doomed the moment
the plane left the ground.

They had no way of knowing
that two unrelated problems

would combine
to bring down their plane.

This was just a normal
routine flight for them.

And they did
all the pre-flight checks,

they did their weight
and balance,

they did the correct calls,
they were on the right runway.

They... It was just
another day at the job

and they didn't know
that they had

these two
hidden latent failures
that were waiting for them.

But faulty maintenance
and above average weights

weren't the only issues
uncovered by
Lorinda Ward's investigation.

Hey, you got a sec?
I have an idea.

Lorinda Ward suspects
she's uncovered problems

that didn't just affect
this one flight,

but that also affected
every commuter plane in the air.

NTSB investigators
say that every plane crash
makes flying safer.

Flight 5481 was no exception.

Fourteen months
after the accident,
lead investigator Lorinda Ward

and her team
file a comprehensive report

to ensure the mistakes
that killed those aboard
Flight 5481 are never repeated.

Among Ward's recommendations
that the FAA review

its average passenger
and baggage weights,

an average that had not
been revised since 1936.

And since studies suggest
that Americans and other adults

were getting heavier
from year to year,

Ward suspected that
the averages were off.

We made a recommendation
to the FAA
to have the operators go out

and survey their operations
both summer and winter time

to see how accurate
these average weights reflected
the actual flying public

that was getting
onto their airplanes.

After conducting
a survey of passengers, the FAA
comes to a shocking conclusion.

The average weight of adult
American passengers
was 195 pounds, not 175.

The FAA also discovered
that the average weight
of carry-on luggage

was being underestimated
by 5 pounds per bag.

We had a average weight
that were being used
that needed to be updated.

Had these higher average weights
been in effect

on January 8th 2003, Flight 5481
would not have been legal
for takeoff.

Captain Leslie
would have had to remove bags
and passengers.

48107. Cool. 17018.

Air Midwest pilots
now use an average weight
of 200 pounds per passenger,

which means
that their Beechcraft planes

can only carry 17 passengers,
not 19.

But Ward's report
goes on to say that even

with updated industry averages,
there's still room for error.

Her report states
that flying small aircraft

will be safest
only when airlines

stop using average weight
assumptions altogether

and calculate the real weight
on board before takeoff.

New technologies
are being developed
to allow air carriers

to measure actual weight
and control balance in real time
as the plane is loaded.

Knowing the actual weight
of passengers
and baggage is vital.

More and more people are flying
on small commuter jets.

As the cost of jet fuel soars,
the smaller,
fuel efficient planes

become more attractive
to airlines.

In the United States alone,
more than 10 million
people a year

board planes
with fewer than 30 seats.

Smaller aircraft
are more sensitive
to the weight,

weight and balance issue,
than say a larger airplane.

In spite
of Ward's recommendations
and the available technology,

almost 70% of small planes
on scheduled flights

still use average
instead of actual weights.

For Doug
and Tereasa Shepherd,
there is still another danger

that threatens to strike again.

If the FAA took a very active
role in their regulation,

then subcontracting
could actually be a plus.
The way it's handled today,

the mistakes
will just continue.

Uh, what about the other steps?

Yeah. Uh,
don't worry about those.

Just check the cable tension
when you're done
and we're good.

In her report,
Ward states that
all air carriers

need to provide direct oversight

to make sure
that even subcontracted work
is completed correctly.

This investigation
was unique to me personally

because it was my first launch
as an investigator in charge.

This was, in my mind,
a significant investigation

in the fact that we had
the 22 safety recommendations

that came out from a small
accident investigation.

For the Shepherds,

the NTSB recommendations
come too late.

But after a lengthy
legal battle,
Air Midwest does deliver

a rare and formal apology
for the mistakes that cost

18-year-old
Christiana Shepherd her life.

My name is Ron Goldman
and, um, my role here today

is that I will be introducing
the public apology and then
I'll have a few words...

The public apology
is in aviation cases
unprecedented.

We are here today

to remember the victims

of Flight 5481,
and to offer our apologies,

our condolences
and sincere sympathy

to the surviving family members,
of the passengers
and crew who perished

in the January 8th 2003 crash
of Air Midwest
flight number 5481.

The acceptance
of accountability suggests
that the recommendations

made by the safety investigators

are not to be taken as a book
to throw in a drawer
and forget about

but are to be taken seriously
because if you don't take them
seriously,

there's going to be
public accountability as well as
private accountability.

What people should never forget

is that as we're going about
and doing our job day to day,

we need to remember
the importance of doing our job.

Doesn't matter
where we're at on the ladder,
or the corporate ladder,

whether we're at the bottom rung
or the top rung,
we have responsibilities.

It took a complicated string
of errors and miscalculations

to bring down Flight 5481.

But some believe
there was one person

who performed admirably
that day.

Captain Katie Leslie.
With an unbalanced plane

and faulty controls,
Captain Leslie
could not have saved the flight.

But her final actions
may have saved some lives.

You know,
she's an unsung hero to me

because I don't think
many people
know about what she did

and how she was fighting it
and trying to pull the plane
away from the hangar

and she actually did.

She kept it
from really more of a head-on
hit into the hangar.

Which probably saved
countless other people

from perishing that day.

It was firefighter
Cindy Overcash

who found the body
of captain Katie Leslie
among the wreckage.

To this day,
Overcash still feels
a special connection

to the young pilot.

I don't know.
I just felt a kinship.

I don't know why. I don't know.

You know, it could be as simple
as I found her,

and I was there
when she left this world.

I don't know,
but I thought about her a lot.

Lorinda Ward's investigation
could have ended

when she uncovered the errors
that caused the crash
of Flight 5481.

By digging a bit deeper,
she made flying safer
for millions of people.