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February the 12th, 2009.
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Just outside Buffalo, New York.
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Gear down.
4
00:00:17,740 --> 00:00:18,869
Looks alive.
5
00:00:18,870 --> 00:00:19,863
Gear's down.
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00:00:24,915 --> 00:00:26,032
Jesus Christ!
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The airplane entered
an aerodynamic stall.
8
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It did not recover.
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00:00:42,323 --> 00:00:44,949
It was one of the
grizzliest, nastiest scenes
10
00:00:44,950 --> 00:00:46,100
that I think I've seen.
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00:00:46,960 --> 00:00:48,699
The crash
of Continental Connection
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00:00:48,700 --> 00:00:52,009
Flight 3407 would be one of the NTSB's
13
00:00:52,010 --> 00:00:54,109
most important in decades,
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00:00:54,110 --> 00:00:55,769
and would see a grieving father
15
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fight for changes to the laws
governing small airlines.
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I'm focused and determined
to change what exists,
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and not have another dad sitting here.
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Mayday, mayday.
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Continental
Connection Flight 3407
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operated by Colgan Air, is en route
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from Newark, New Jersey
to Buffalo, New York.
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It's been a busy flight
for Captain Marvin Renslow.
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He's providing guidance
to a new first officer,
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Rebecca Shaw, a former flight
instructor from Seattle.
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Bless you.
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Shaw's only
been with the airline
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00:02:01,350 --> 00:02:03,639
for just over a year.
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She must decide if she now
wants to become a captain.
29
00:02:07,590 --> 00:02:10,609
I don't know what I want
to do with the upgrade.
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It depends where I'm based.
31
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Well, think of it this way.
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If you stayed on the
queue, obviously you're not
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making the captain rank.
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Right.
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But you may have a
better quality of life
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with regards to buying a
house, having a schedule--
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Shaw trained
to be a first officer
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on the plane they're flying now,
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a Canadian-made Bombardier Q400.
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It's a twin engine turboprop,
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popular with regional airlines.
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The 45 passengers have had a long night.
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00:02:43,364 --> 00:02:46,559
Their plane was held up
for two hours at Newark,
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a delay considerably
longer than their journey.
45
00:02:51,410 --> 00:02:55,613
Flight 3407 is heading
northwest over upstate New York.
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00:02:57,220 --> 00:02:59,153
The trip is only 53 minutes.
47
00:03:02,540 --> 00:03:05,859
Visibility is poor, and
there's a forecast of snow
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and moderate winds in Buffalo.
49
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Just some water, please.
50
00:03:14,721 --> 00:03:17,439
Ellyce Kausner is
a student at Florida Coastal
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School of Law in Jacksonville.
52
00:03:22,760 --> 00:03:26,109
She's on her way to visit
her family in Buffalo.
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00:03:26,110 --> 00:03:28,169
She had five nieces
and nephew at the time,
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and they had a love luncheon
at the kids' school,
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a couple of the nephews, and
they both wanted Aunt Elly
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to be their guest.
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Any excuse to come
home, and she came home.
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She talked to all of us from Newark.
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Hey.
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She called us from the lounge.
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00:03:42,980 --> 00:03:44,829
Yeah, it's been over two hours.
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She was p.o.'d
because of the delay.
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00:03:50,720 --> 00:03:54,089
Folks from the flight deck,
your first officer speaking.
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00:03:54,090 --> 00:03:57,729
It looks like at this time
we're about 10, maybe 15
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minutes outside of Buffalo.
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Weather in Buffalo is pretty foggy.
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00:04:02,750 --> 00:04:04,925
Snowing a little bit there.
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00:04:04,926 --> 00:04:05,989
I'd like to make sure everyone remains
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in their seats so the flight attendants
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can prepare the cabin for arrival.
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00:04:09,310 --> 00:04:10,143
Thank you.
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Colgan 3407, descend and maintain, 2300.
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Okay, down to 2300.
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Colgan 3407.
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Let's do a descend checklist, please.
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We can do the approach
checklist along with it.
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Sure.
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Bug set.
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Set.
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00:04:33,370 --> 00:04:37,489
GPWS landing flap selected, 15 degrees.
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The pilots go
through a list of settings
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for the plane to continue
its landing approach.
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Lights are off.
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Yup.
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Passengers can
already glimpse the lights
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00:04:47,570 --> 00:04:48,620
of Buffalo's suburbs.
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Clarence Center is on the approach path
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for aircraft landing at Buffalo's airport.
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00:05:08,640 --> 00:05:09,473
Gear down.
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00:05:11,310 --> 00:05:13,403
Looks alive.
- Gear's down.
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00:05:14,873 --> 00:05:15,705
All right.
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Flaps 15?
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Extending the
flaps provides more lift,
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00:05:19,420 --> 00:05:22,170
allowing the plane to slow
to its final approach scene.
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00:05:24,734 --> 00:05:25,567
Uh ...
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Jesus Christ!
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Suddenly, the
control column start to shake.
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00:05:35,870 --> 00:05:38,193
The Q400 is slipping out of control.
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Captain Renslow struggles
to keep his plane flying.
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00:05:50,330 --> 00:05:52,280
But it seems to have a mind of its own.
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The gear!
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Should the gear be up?
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00:06:17,157 --> 00:06:17,990
Gear up!
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Oh, damn!
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Oh, we're down.
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The plane
crashes into a house
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at 6038, Long Street.
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At air traffic control in Buffalo,
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Flight 3407 disappears from radar.
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Check Colgan Air.
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See if he's on yet.
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What's his call sign?
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Colgan, 3407.
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Nope, I don't have him.
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00:07:02,810 --> 00:07:04,628
Do you see anything out there?
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00:07:04,629 --> 00:07:05,962
Nothing.
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00:07:08,110 --> 00:07:08,943
All right.
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Call the fire department.
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I will never forget
the dispatcher's words.
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Plane crash, house on fire.
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I immediately got my
shoes on and my coat on.
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Got in my truck, and started
heading down the driveway.
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Firefighters
don't have far to go.
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6038 Long Street, home
of the Wielinski family,
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is less than a block from
the Clarence Center station.
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As I turned towards the village,
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the whole village was aglow.
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00:07:39,740 --> 00:07:42,333
You could see the smoke,
you could see the flame.
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00:07:43,630 --> 00:07:45,409
Karen
Wielinski and her daughter
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00:07:45,410 --> 00:07:47,699
make it out of their house alive,
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00:07:47,700 --> 00:07:49,583
but her husband, Douglas, is killed.
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00:07:51,970 --> 00:07:55,569
My initial reaction was there was no way
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that somebody made it out,
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00:07:57,460 --> 00:08:01,506
but the EMS division reported
that they had two people,
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00:08:01,507 --> 00:08:03,309
and they were taking them to the hospital.
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00:08:03,310 --> 00:08:05,509
And I said well, which
firefighters are they?
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00:08:05,510 --> 00:08:07,109
And they said they're
not firefighters, chief.
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00:08:07,110 --> 00:08:09,079
They're survivors from the house.
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00:08:09,080 --> 00:08:11,079
I actually physically had
to go to the ambulance
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00:08:11,080 --> 00:08:14,409
and look inside for myself to believe.
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00:08:14,410 --> 00:08:17,410
Firefighters have
never seen a blaze like this.
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00:08:18,990 --> 00:08:23,209
If you've ever gone to a
bonfire and stood five feet
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00:08:23,210 --> 00:08:26,089
from it and you couldn't take it anymore,
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00:08:26,090 --> 00:08:28,290
that's what it felt
like from 100 feet away.
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00:08:30,350 --> 00:08:33,109
The height of it was just unbelievable,
146
00:08:33,110 --> 00:08:35,277
obviously because of the fuel
that was probably added to it
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and the debris area was very large.
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It was a very, very horrific sight.
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We live in town, when
the plane went down
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00:08:45,590 --> 00:08:47,779
right down the road,
my son was driving home
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00:08:47,780 --> 00:08:52,089
from a soccer game, and went
right by the plane crash
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and called me up, and said
there's a plane down on Clarence.
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00:08:54,720 --> 00:08:58,439
Never really entered our brain
that it was Elly's plane.
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00:08:58,440 --> 00:09:02,129
Flight 3407 has
crashed eight kilometers short
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00:09:02,130 --> 00:09:04,179
of Buffalo airport.
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All 49 passengers and crew are dead,
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00:09:07,570 --> 00:09:10,049
including Captain Marvin Renslow,
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and first officer Rebecca Shaw.
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00:09:15,170 --> 00:09:18,069
But many more people could
easily have been killed.
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00:09:18,070 --> 00:09:21,299
When you picture a
house, and to see a plane
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00:09:21,300 --> 00:09:24,839
on top of this house, no more
house left, no more plane,
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only the tail section,
you're asking yourself
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how in god's creation did this happen,
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00:09:31,650 --> 00:09:34,953
and not wipe the whole block out?
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The next call was again from my son,
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said in fact it was Elly's plane.
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And he said Dad, there's no survivors.
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At which point, my wife shrieked,
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and just hit the ground.
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Chris said he had never heard his mother
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00:09:50,410 --> 00:09:53,399
make a sound like that, and
I hope he never does again.
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So that's when I knew that she was gone,
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and that was probably within
45 minutes of the accident.
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The scene in the morning
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is one of utter devastation.
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00:10:17,280 --> 00:10:19,449
Clint Crookshanks from the NTSB.
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Can I start poking around?
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00:10:20,730 --> 00:10:22,102
Clint Crookshanks
is one of the first
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00:10:22,103 --> 00:10:24,113
investigators on the case.
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00:10:25,200 --> 00:10:28,019
When we arrived on scene,
there was a fire still burning.
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00:10:28,020 --> 00:10:29,899
Turns out it was from a gas line
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that had been broken in the house,
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00:10:31,660 --> 00:10:33,539
that the firemen would put the fire out,
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00:10:33,540 --> 00:10:35,840
and it would reignite
every couple of minutes.
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It was one of the
grizzliest, nastiest scenes
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that I think I've seen.
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00:10:44,160 --> 00:10:47,849
Flight 3407
may have been a small plane,
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00:10:47,850 --> 00:10:52,029
but it's the worst crash in the
US in more than seven years.
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00:10:52,030 --> 00:10:53,919
It will become one of the NTSB's
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most important investigations.
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00:11:04,860 --> 00:11:08,069
The fire at the crash site of Flight 3407
192
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continues to burn,
preventing investigators
193
00:11:10,740 --> 00:11:12,223
from examining the wreckage.
194
00:11:22,820 --> 00:11:24,739
The airplane had crashed into a house,
195
00:11:24,740 --> 00:11:26,169
and then it had burned all night long,
196
00:11:26,170 --> 00:11:29,439
so all the debris was
basically in the house.
197
00:11:29,440 --> 00:11:31,689
Our concern was that
we're losing evidence.
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00:11:31,690 --> 00:11:34,089
It's perishable, and if
we can't get in there
199
00:11:34,090 --> 00:11:35,949
and get the fire out, then we're not able
200
00:11:35,950 --> 00:11:39,829
to maybe get a hold of
evidence that might help us
201
00:11:39,830 --> 00:11:41,299
during the investigation.
202
00:11:41,300 --> 00:11:43,159
Clint
Crookshanks urgently needs
203
00:11:43,160 --> 00:11:45,709
to recover the black
box flight recordings,
204
00:11:45,710 --> 00:11:49,269
which could contain valuable
clues about the accident.
205
00:11:49,270 --> 00:11:51,759
We knew that the recorders
were in the tail part
206
00:11:51,760 --> 00:11:53,119
of the airplane.
207
00:11:53,120 --> 00:11:55,169
Ordinarily,
investigators don't go near
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00:11:55,170 --> 00:11:56,943
a crash site that's still burning,
209
00:11:58,270 --> 00:12:00,889
but if the black boxes can't be rescued,
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00:12:00,890 --> 00:12:04,733
they may never find out what
brought down Flight 3407.
211
00:12:05,690 --> 00:12:08,379
We started looking
around, and poking around
212
00:12:08,380 --> 00:12:11,280
into the wreckage, and actually
found out where they were.
213
00:12:13,349 --> 00:12:14,181
Okay, whoa.
214
00:12:14,182 --> 00:12:16,319
It's probably in here, okay?
215
00:12:16,320 --> 00:12:18,009
The access panel is on the other side
216
00:12:18,010 --> 00:12:20,569
so we're gonna have to
cut a hole right there.
217
00:12:20,570 --> 00:12:21,402
Okay?
218
00:12:21,403 --> 00:12:23,599
The fire department produced a chop saw.
219
00:12:23,600 --> 00:12:26,350
We were able to cut a hole
in the side of the fuselage,
220
00:12:27,620 --> 00:12:30,170
and go in and grab the
recorders and pull them out.
221
00:12:32,492 --> 00:12:34,227
All right, that should do it.
222
00:12:36,050 --> 00:12:37,989
To the immense relief of all,
223
00:12:37,990 --> 00:12:39,813
the recorders are undamaged.
224
00:12:41,570 --> 00:12:43,739
Once we took the recorders
out of the airplane,
225
00:12:43,740 --> 00:12:45,369
we put them on the jet,
and they were flown
226
00:12:45,370 --> 00:12:47,470
back to Washington DC to our headquarters.
227
00:12:51,260 --> 00:12:54,210
Now investigators
are faced with a new hurdle.
228
00:12:55,300 --> 00:12:56,989
What little is left of the aircraft
229
00:12:56,990 --> 00:13:00,119
is hopelessly jumbled
together with human remains,
230
00:13:00,120 --> 00:13:02,409
and debris from the house.
231
00:13:02,410 --> 00:13:04,379
It all burned and
settled into the basement,
232
00:13:04,380 --> 00:13:06,859
so we had probably ten feet of debris
233
00:13:06,860 --> 00:13:09,209
that we had to dig through
in order to recover
234
00:13:09,210 --> 00:13:10,693
all of the airplane.
235
00:13:12,710 --> 00:13:14,649
Authorities
wonder how they can salvage
236
00:13:14,650 --> 00:13:16,993
any useful evidence from this chaos.
237
00:13:20,520 --> 00:13:23,713
They get invaluable assistance
from an unusual source.
238
00:13:24,710 --> 00:13:27,739
A group of students learning
to process crime scenes
239
00:13:27,740 --> 00:13:29,929
is enlisted to separate human remains
240
00:13:29,930 --> 00:13:31,333
from the rest of the debris.
241
00:13:34,080 --> 00:13:36,389
They were graduate
students from a local college,
242
00:13:36,390 --> 00:13:38,299
forensic anthropology students,
243
00:13:38,300 --> 00:13:40,359
and this was good experience
for them to come dig through
244
00:13:40,360 --> 00:13:43,298
wreckage like this, and
look for human remains.
245
00:13:43,299 --> 00:13:44,949
The landing gear over there, please.
246
00:13:44,950 --> 00:13:47,249
It's dirty, painstaking work,
247
00:13:47,250 --> 00:13:49,439
but it frees up
investigators to concentrate
248
00:13:49,440 --> 00:13:50,963
on the aircraft ruins.
249
00:13:52,120 --> 00:13:53,679
We were all on our hands and knees
250
00:13:53,680 --> 00:13:55,619
with brooms, with little shovels,
251
00:13:55,620 --> 00:13:59,759
scooping out debris, identifying
it as to house debris,
252
00:13:59,760 --> 00:14:02,710
or airplane debris, and then
putting it in different piles.
253
00:14:05,760 --> 00:14:08,599
The first question for me
as a structures engineer
254
00:14:08,600 --> 00:14:10,109
is to figure out if the whole airplane
255
00:14:10,110 --> 00:14:11,810
made it to the scene of the crash.
256
00:14:12,800 --> 00:14:15,319
The wreckage
is carefully studied.
257
00:14:15,320 --> 00:14:17,789
To determine if the plane's four corners,
258
00:14:17,790 --> 00:14:21,523
nose, tail, and both
wingtips, are present.
259
00:14:25,970 --> 00:14:28,009
If we find all four
corners of the airplane,
260
00:14:28,010 --> 00:14:30,839
then we know that there's
no inflight breakup,
261
00:14:30,840 --> 00:14:32,499
there was nothing that
departed the airplane
262
00:14:32,500 --> 00:14:35,869
during the flight that may
have caused the accident.
263
00:14:35,870 --> 00:14:38,909
One wing has
been consumed by fire.
264
00:14:38,910 --> 00:14:40,789
The other is shattered into pieces.
265
00:14:40,790 --> 00:14:42,516
Hey, have a look at this.
266
00:14:42,517 --> 00:14:44,639
But investigators
are gradually finding
267
00:14:44,640 --> 00:14:46,518
what they'd been searching for.
268
00:14:46,519 --> 00:14:47,351
Oh yeah.
269
00:14:47,352 --> 00:14:48,185
It's the last piece.
270
00:14:49,249 --> 00:14:51,629
It wasn't until several
days into the investigation
271
00:14:51,630 --> 00:14:53,769
as we were scraping
away some of the debris
272
00:14:53,770 --> 00:14:55,399
that we actually found evidence
273
00:14:55,400 --> 00:14:57,043
of the left wing and the nose.
274
00:14:58,200 --> 00:15:00,209
Investigators
now have all the pieces
275
00:15:00,210 --> 00:15:02,699
they need to conclude
that the entire plane
276
00:15:02,700 --> 00:15:04,123
is at the crash site.
277
00:15:05,200 --> 00:15:07,749
Whatever caused the
disaster was not the result
278
00:15:07,750 --> 00:15:09,595
of a breakup inflight.
279
00:15:17,000 --> 00:15:21,079
The tragedy of Flight 3407
is under intense scrutiny
280
00:15:21,080 --> 00:15:23,719
at the NTSB offices in Washington.
281
00:15:23,720 --> 00:15:25,419
Officials there try to determine
282
00:15:25,420 --> 00:15:27,923
if some kind of malfunction
caused the crash.
283
00:15:29,240 --> 00:15:30,869
On this particular
accident, we knew it was
284
00:15:30,870 --> 00:15:33,369
a landing accident, so
if we wanted to check
285
00:15:33,370 --> 00:15:36,239
the aircraft's performance,
and then also we check
286
00:15:36,240 --> 00:15:38,169
for flight control continuity.
287
00:15:38,170 --> 00:15:40,029
Much of
this responsibility falls
288
00:15:40,030 --> 00:15:41,203
to Scott Warren.
289
00:15:42,140 --> 00:15:44,059
My role in the investigation was to be
290
00:15:44,060 --> 00:15:46,769
the systems group chairman
for the safety board,
291
00:15:46,770 --> 00:15:48,299
so I was in charge of looking
292
00:15:48,300 --> 00:15:51,719
at all of the aircraft systems.
293
00:15:51,720 --> 00:15:53,429
Warren
analyzes the aircraft's
294
00:15:53,430 --> 00:15:56,659
cockpit voice recorder,
or CVR, to determine
295
00:15:56,660 --> 00:16:00,293
if there were any indications
of a problem in the cockpit.
296
00:16:00,294 --> 00:16:01,799
Prepare the cabin for arrival.
297
00:16:01,800 --> 00:16:02,633
Thank you.
298
00:16:04,600 --> 00:16:05,973
Is that ice on the windshield?
299
00:16:06,920 --> 00:16:10,029
He discovers that
six minutes before the crash,
300
00:16:10,030 --> 00:16:13,819
the crew of Flight 3407 had
noticed a buildup of ice
301
00:16:13,820 --> 00:16:14,809
on the aircraft.
302
00:16:14,810 --> 00:16:16,589
Got it on my side.
303
00:16:16,590 --> 00:16:17,463
Don't have yours?
304
00:16:19,320 --> 00:16:20,243
Oh, yeah.
305
00:16:21,450 --> 00:16:22,909
Oh, it's lots of ice.
306
00:16:22,910 --> 00:16:25,710
Ice can be a
deadly threat to any airplane.
307
00:16:27,720 --> 00:16:30,189
If an aircraft has ice on it,
it will have more drag on it
308
00:16:30,190 --> 00:16:33,673
so it will require more power
to maintain a given airspeed.
309
00:16:37,093 --> 00:16:38,279
Oh man.
310
00:16:38,280 --> 00:16:40,819
Most I've seen on the
leading edges in a long time.
311
00:16:40,820 --> 00:16:42,699
Until a
year ago, Rebecca Shaw
312
00:16:42,700 --> 00:16:45,383
had no experience with ice on an aircraft.
313
00:16:46,440 --> 00:16:48,140
I'd never seen icing conditions.
314
00:16:49,319 --> 00:16:50,489
I've never deiced.
315
00:16:50,490 --> 00:16:51,990
Never experienced any of that.
316
00:16:53,080 --> 00:16:55,559
When ice creates on a wing,
317
00:16:55,560 --> 00:16:56,989
it adds weight to the airplane,
318
00:16:56,990 --> 00:17:00,299
but most importantly, it
changes the shape of the wing,
319
00:17:00,300 --> 00:17:02,439
and of course, it's the
shape, the curved shape
320
00:17:02,440 --> 00:17:04,659
of the wing that actually
creates the lift.
321
00:17:04,660 --> 00:17:08,319
So by changing the lift
characteristics of the airplane
322
00:17:08,320 --> 00:17:11,131
it makes it less able to fly.
323
00:17:11,132 --> 00:17:12,772
You know, I would have freaked out.
324
00:17:12,773 --> 00:17:14,809
If I'd have seen this much ice and thought
325
00:17:14,810 --> 00:17:18,183
oh my gosh, we were gonna crash.
326
00:17:20,230 --> 00:17:22,769
Observing that there
was ice on the airplane
327
00:17:22,770 --> 00:17:25,859
was an important thing to
do, but then it would be
328
00:17:25,860 --> 00:17:27,399
important to turn around and verify
329
00:17:27,400 --> 00:17:30,529
that your ant-icing,
deicing equipment was on,
330
00:17:30,530 --> 00:17:32,859
and there was no indication
on the voice recorder
331
00:17:32,860 --> 00:17:34,483
that they actually re-checked.
332
00:17:35,554 --> 00:17:37,699
The CVR
reveals that only minutes
333
00:17:37,700 --> 00:17:39,819
after the crew detected ice,
334
00:17:39,820 --> 00:17:43,009
a device called the stick shaker went off.
335
00:17:43,010 --> 00:17:46,379
It was a warning that the
plane was about to stall,
336
00:17:46,380 --> 00:17:48,363
literally to fall out of the sky.
337
00:17:51,220 --> 00:17:54,613
Shortly afterwards, the
aircraft did precisely that.
338
00:18:00,400 --> 00:18:01,899
We know there were icing conditions.
339
00:18:01,900 --> 00:18:04,549
The only question was,
were they bad enough
340
00:18:04,550 --> 00:18:06,923
to induce this airplane to have a failure?
341
00:18:07,930 --> 00:18:09,779
Ice is now the chief suspect
342
00:18:09,780 --> 00:18:12,423
in the crash of Flight 3407.
343
00:18:13,413 --> 00:18:15,313
If it's ice, let's prove it.
344
00:18:16,180 --> 00:18:19,279
We were all convinced that
we had an icing accident.
345
00:18:19,280 --> 00:18:21,599
We said yeah, it's gonna
be an icing accident.
346
00:18:21,600 --> 00:18:22,609
We just gotta make sure we look
347
00:18:22,610 --> 00:18:26,529
for these few key aspects
of icing, verify that,
348
00:18:26,530 --> 00:18:28,049
and we're good.
349
00:18:28,050 --> 00:18:29,889
But some of
the victims' family members
350
00:18:29,890 --> 00:18:31,879
are less convinced.
351
00:18:31,880 --> 00:18:34,489
My initial thought was that
it was ice-related incident.
352
00:18:34,490 --> 00:18:37,609
It was a icy night that
brought the plane down.
353
00:18:37,610 --> 00:18:40,789
And as we began to talk to
people who knew airline travel
354
00:18:40,790 --> 00:18:43,349
who were pilots
themselves, they would look
355
00:18:43,350 --> 00:18:45,629
kind of askant and say I don't think so.
356
00:18:45,630 --> 00:18:46,830
That doesn't make sense.
357
00:18:48,100 --> 00:18:51,129
Some investigators
share that suspicion.
358
00:18:51,130 --> 00:18:53,826
Scott Warren knows a plane like the Q400
359
00:18:53,827 --> 00:18:56,313
has a sophisticated deicing system.
360
00:18:57,440 --> 00:18:59,539
It's designed to keep ice from building up
361
00:18:59,540 --> 00:19:02,240
on the wings and other
critical parts of the aircraft.
362
00:19:05,470 --> 00:19:08,649
To prevent ice accumulating,
the plane has rubber bladders
363
00:19:08,650 --> 00:19:11,803
along the front of the
wings called deicing boots.
364
00:19:12,730 --> 00:19:15,309
A series of valves uses
air from the engines
365
00:19:15,310 --> 00:19:18,373
to inflate the boots, and
crack the ice off the wing.
366
00:19:19,260 --> 00:19:22,769
Those boots are designed
to inflate periodically
367
00:19:22,770 --> 00:19:25,480
and that inflation breaks off the ice
368
00:19:26,720 --> 00:19:29,439
that's accumulated on those leading edges.
369
00:19:29,440 --> 00:19:32,839
Warren now wonders
if the crew of Flight 3407
370
00:19:32,840 --> 00:19:35,443
actually turned on
their deicing equipment.
371
00:19:37,100 --> 00:19:40,229
He studies data from the
plane's other black box,
372
00:19:40,230 --> 00:19:42,743
its flight data recorder, or FDR.
373
00:19:43,710 --> 00:19:46,839
It tracks the workings of
crucial aircraft systems,
374
00:19:46,840 --> 00:19:48,693
including the deicing mechanism.
375
00:19:50,950 --> 00:19:53,269
We know from the FDR data
that the deicing system
376
00:19:53,270 --> 00:19:55,479
had been selected on by the crew,
377
00:19:55,480 --> 00:19:59,169
and it was on during the
majority of the flight,
378
00:19:59,170 --> 00:20:00,759
and certainly at the end of the flight,
379
00:20:00,760 --> 00:20:04,019
it was recorded in the on position.
380
00:20:04,020 --> 00:20:05,859
But now
Warren needs to figure out
381
00:20:05,860 --> 00:20:08,169
if the device was actually working.
382
00:20:08,170 --> 00:20:10,829
Just because the data
records that the system is on,
383
00:20:10,830 --> 00:20:13,159
that's a start, but you can't necessarily
384
00:20:13,160 --> 00:20:15,799
believe that one piece of information.
385
00:20:15,800 --> 00:20:17,229
The only way to know
386
00:20:17,230 --> 00:20:20,469
is to find what remains of
the plane's deicing system
387
00:20:20,470 --> 00:20:23,623
and determine if it was active
when the aircraft went down.
388
00:20:25,700 --> 00:20:28,469
Clint Crookshanks' team
hunts for a crucial component
389
00:20:28,470 --> 00:20:30,559
of the system, the valves.
390
00:20:30,560 --> 00:20:31,393
Excuse me.
391
00:20:32,904 --> 00:20:33,736
Okay.
392
00:20:33,737 --> 00:20:37,039
For the deice valves, we
said here's what it looks like.
393
00:20:37,040 --> 00:20:38,649
Look for something like this.
394
00:20:38,650 --> 00:20:41,019
If we can find those valves,
then we can test them
395
00:20:41,020 --> 00:20:42,970
and see if they're operating correctly.
396
00:20:43,900 --> 00:20:45,579
The valves were very important to us,
397
00:20:45,580 --> 00:20:49,179
because they are the key
component that moves air
398
00:20:49,180 --> 00:20:51,849
from the engines where
the bleed air originates
399
00:20:51,850 --> 00:20:53,013
for the deicing system.
400
00:21:07,696 --> 00:21:08,819
Okay, good.
401
00:21:08,820 --> 00:21:09,663
Five more to go.
402
00:21:19,530 --> 00:21:22,019
Five of the
plane's six deicing valves
403
00:21:22,020 --> 00:21:23,403
are eventually recovered.
404
00:21:24,690 --> 00:21:25,819
Some were badly burned,
405
00:21:25,820 --> 00:21:27,499
some were in fairly good shape.
406
00:21:27,500 --> 00:21:30,239
And we took those valves, and we conducted
407
00:21:30,240 --> 00:21:31,439
as much testing on those valves
408
00:21:31,440 --> 00:21:34,479
as we thought was appropriate
for the level of damage.
409
00:21:34,480 --> 00:21:37,959
We looked at the level of
electrical conductivity,
410
00:21:37,960 --> 00:21:40,199
and we looked at the pressure testing.
411
00:21:40,200 --> 00:21:42,929
We looked at a wide variety of things
412
00:21:42,930 --> 00:21:45,280
depending on the condition
of the valve itself.
413
00:21:46,810 --> 00:21:48,619
And as far as we could
tell, all those valves
414
00:21:48,620 --> 00:21:49,720
were working properly.
415
00:21:51,037 --> 00:21:51,916
Is that ice on the windshield?
416
00:21:51,917 --> 00:21:53,519
Got it on my side.
417
00:21:53,520 --> 00:21:55,329
Now
investigators have to consider
418
00:21:55,330 --> 00:21:57,579
the possibility--
- Oh yeah.
419
00:21:57,580 --> 00:21:58,412
Oh, it's lots of ice.
420
00:21:58,413 --> 00:22:00,859
That there was
so much ice on the wings
421
00:22:00,860 --> 00:22:04,379
that the deicing system couldn't
get rid of it fast enough.
422
00:22:04,380 --> 00:22:05,212
Oh yeah.
423
00:22:05,213 --> 00:22:06,769
That's the most I've
seen on the leading edges
424
00:22:06,770 --> 00:22:07,633
in a long time.
425
00:22:09,970 --> 00:22:12,279
It has happened before.
426
00:22:12,280 --> 00:22:15,519
In Roselawn, Indiana, a
French-built commuter plane
427
00:22:15,520 --> 00:22:19,779
crashed in 1994 after suffering
a catastrophic buildup
428
00:22:19,780 --> 00:22:20,873
of ice on the wing.
429
00:22:29,230 --> 00:22:31,409
By analyzing how much power was needed
430
00:22:31,410 --> 00:22:33,749
for the plane to maintain its airspeed,
431
00:22:33,750 --> 00:22:36,343
investigators reach a
surprising conclusion.
432
00:22:37,200 --> 00:22:39,959
Basically, the aircraft
was flying as if it had
433
00:22:39,960 --> 00:22:42,299
a relatively small amount of ice on it,
434
00:22:42,300 --> 00:22:44,069
but a very manageable amount of ice.
435
00:22:44,070 --> 00:22:45,339
Looks normal.
436
00:22:45,340 --> 00:22:48,929
It was not overloaded,
it was not excessive.
437
00:22:48,930 --> 00:22:50,949
If ice didn't
bring down the plane,
438
00:22:50,950 --> 00:22:53,323
something else must
have caused it to stall.
439
00:22:55,970 --> 00:22:58,909
Warren studies the Q400's operating manual
440
00:22:58,910 --> 00:23:00,969
to learn the plane's stall speed,
441
00:23:00,970 --> 00:23:03,069
the velocity at which it
can no longer generate
442
00:23:03,070 --> 00:23:05,363
enough lift to stay in the air.
443
00:23:06,320 --> 00:23:09,509
He discovers that in the
conditions Flight 3407
444
00:23:09,510 --> 00:23:13,003
was flying through,
it's roughly 111 knots.
445
00:23:14,570 --> 00:23:16,499
He now compares the plane's stall speed
446
00:23:16,500 --> 00:23:18,649
with its actual airspeed just before
447
00:23:18,650 --> 00:23:20,123
the stall warning went off.
448
00:23:22,260 --> 00:23:26,273
131 knots, well above the danger zone.
449
00:23:28,420 --> 00:23:29,303
Flaps 15.
450
00:23:32,680 --> 00:23:34,882
When the stick shaker went off--
451
00:23:34,883 --> 00:23:37,557
- Uh--
- Jesus Christ!
452
00:23:39,430 --> 00:23:43,203
They were not necessarily
at the edge of a stall.
453
00:23:46,770 --> 00:23:50,749
They were still 20 knots
or so away from the stall.
454
00:23:50,750 --> 00:23:53,309
This new
revelation deepens the mystery
455
00:23:53,310 --> 00:23:55,569
of Flight 3407.
456
00:23:55,570 --> 00:23:59,330
If it wasn't stalling, why
did it fall out of the sky?
457
00:24:02,930 --> 00:24:05,859
Investigators turn their
attention to the critical seconds
458
00:24:05,860 --> 00:24:09,829
before Flight 3407 went out of control.
459
00:24:09,830 --> 00:24:11,489
They look for clues that could explain
460
00:24:11,490 --> 00:24:13,349
why the stall warning went off
461
00:24:13,350 --> 00:24:16,433
when the aircraft was flying
well within its safety margins.
462
00:24:19,720 --> 00:24:22,139
They discover that this
plane has a unique feature
463
00:24:22,140 --> 00:24:24,283
known as a reference speed switch.
464
00:24:25,310 --> 00:24:28,110
It governs the sensitivity
of the plane's stall warning.
465
00:24:29,100 --> 00:24:31,189
Very few airplanes in my experience
466
00:24:31,190 --> 00:24:32,669
have such a switch.
467
00:24:32,670 --> 00:24:33,952
This airplane is the only one I know of
468
00:24:33,953 --> 00:24:37,749
that has an actual switch
on the overhead panel.
469
00:24:37,750 --> 00:24:39,849
It was designed by the manufacturer
470
00:24:39,850 --> 00:24:41,899
to be an extra safety feature.
471
00:24:41,900 --> 00:24:44,189
So he had a variable ref speed?
472
00:24:44,190 --> 00:24:45,749
Pilots
are supposed to turn on
473
00:24:45,750 --> 00:24:47,759
the reference speed switch
when they're going to be
474
00:24:47,760 --> 00:24:50,139
flying through icing conditions.
475
00:24:50,140 --> 00:24:52,379
And we'll probably
be picking up some ice.
476
00:24:52,380 --> 00:24:54,099
When in
the increase position,
477
00:24:54,100 --> 00:24:56,409
it reminds pilots to fly faster
478
00:24:56,410 --> 00:24:58,959
to counteract any drag
effect ice will have
479
00:24:58,960 --> 00:24:59,793
on the aircraft.
480
00:25:01,970 --> 00:25:03,949
When you are in icing conditions,
481
00:25:03,950 --> 00:25:05,679
and ice does accrue on the wing,
482
00:25:05,680 --> 00:25:09,409
it can cause the stall speed to go up,
483
00:25:09,410 --> 00:25:12,299
and so this ref speed
switch correspondingly
484
00:25:12,300 --> 00:25:14,349
causes the warning to come on sooner,
485
00:25:14,350 --> 00:25:15,989
or at a higher speed.
486
00:25:15,990 --> 00:25:18,899
What that switch does is it basically
487
00:25:18,900 --> 00:25:21,479
changes the trigger settings
for the stick shaker.
488
00:25:21,480 --> 00:25:23,059
So we had to ask the manufacturer,
489
00:25:23,060 --> 00:25:24,969
how does this switch work?
490
00:25:24,970 --> 00:25:28,689
What we found was it was
part of a systems description
491
00:25:28,690 --> 00:25:31,149
that the crews got when
they went through training,
492
00:25:31,150 --> 00:25:32,499
but they didn't get a lot of training
493
00:25:32,500 --> 00:25:33,969
on how to handle that switch.
494
00:25:33,970 --> 00:25:36,493
It seemed like it was too
simple to worry about.
495
00:25:38,580 --> 00:25:40,149
Investigators need to know
496
00:25:40,150 --> 00:25:43,016
if the crew of Flight 3407 had turned on
497
00:25:43,017 --> 00:25:44,733
the reference speed switch,
498
00:25:45,810 --> 00:25:49,033
triggering the stick shaker
at a faster than normal speed.
499
00:25:51,490 --> 00:25:53,519
The flight data recorder doesn't show
500
00:25:53,520 --> 00:25:55,159
whether the switch was on.
501
00:25:55,160 --> 00:25:57,669
Investigators must find
another way of determining
502
00:25:57,670 --> 00:25:59,720
its position at the time of the accident.
503
00:26:08,440 --> 00:26:09,659
Clint here.
504
00:26:09,660 --> 00:26:12,175
Clint Crookshanks
is given a new priority.
505
00:26:12,176 --> 00:26:13,529
All right, I'll see if we have it.
506
00:26:13,530 --> 00:26:15,369
Recover
the ice protection panel
507
00:26:15,370 --> 00:26:17,559
from the Q400's cockpit,
508
00:26:17,560 --> 00:26:20,459
where the reference
speed switch is housed.
509
00:26:20,460 --> 00:26:22,069
Since the panel was in the cockpit,
510
00:26:22,070 --> 00:26:23,603
finding it is a challenge.
511
00:26:25,930 --> 00:26:27,239
Most of the front end of the airplane
512
00:26:27,240 --> 00:26:29,909
was consumed by fire, and
so we didn't find anything
513
00:26:29,910 --> 00:26:33,439
except for little balls
of molten aluminum,
514
00:26:33,440 --> 00:26:36,589
little wire bundles, and a lot of ash.
515
00:26:36,590 --> 00:26:38,699
But after
an extensive search,
516
00:26:38,700 --> 00:26:41,159
Crookshanks discovers that
the ice protection panel
517
00:26:41,160 --> 00:26:44,053
is one of the few pieces of
the cockpit that survived.
518
00:26:45,193 --> 00:26:46,719
Bingo.
519
00:26:46,720 --> 00:26:48,759
However,
the knobs and switches
520
00:26:48,760 --> 00:26:50,103
are barely recognizable.
521
00:26:51,180 --> 00:26:53,129
Crookshanks examines the charred panel
522
00:26:53,130 --> 00:26:55,730
to check the position of
the reference speed switch.
523
00:26:57,800 --> 00:27:00,099
It was set to activate stall warnings
524
00:27:00,100 --> 00:27:01,893
at higher than normal speeds.
525
00:27:04,160 --> 00:27:06,459
We did find the ref speed
switch in the wreckage,
526
00:27:06,460 --> 00:27:08,260
and it was in the increase position.
527
00:27:09,930 --> 00:27:13,023
This discovery
only raises more questions.
528
00:27:15,200 --> 00:27:16,589
We'll probably
be picking up some ice.
529
00:27:16,590 --> 00:27:18,479
The cockpit
voice recorder indicates
530
00:27:18,480 --> 00:27:22,089
that as Renslow was beginning
his descent into Buffalo,
531
00:27:22,090 --> 00:27:26,589
he commanded his plane to fly
at the normal approach speed.
532
00:27:26,590 --> 00:27:27,769
Left gear down.
533
00:27:27,770 --> 00:27:29,029
But what's strange
534
00:27:29,030 --> 00:27:32,159
is that with his
reference speed switch on,
535
00:27:32,160 --> 00:27:34,460
he actually should have
been flying faster.
536
00:27:36,063 --> 00:27:36,895
Bless you.
537
00:27:36,896 --> 00:27:37,728
As this is what the switch
538
00:27:37,729 --> 00:27:38,613
would remind him to do.
539
00:27:40,100 --> 00:27:42,129
So why wasn't he?
540
00:27:42,130 --> 00:27:45,569
The plane's computer warned
the crew to fly faster,
541
00:27:45,570 --> 00:27:48,069
according to the settings
they had configured,
542
00:27:48,070 --> 00:27:51,086
by displaying a set of red
bars on the airspeed indicator.
543
00:27:51,087 --> 00:27:52,599
But you may have a
better quality of life
544
00:27:52,600 --> 00:27:53,432
in regards to--
545
00:27:53,433 --> 00:27:55,249
These bars are
meant to warn the pilots
546
00:27:55,250 --> 00:27:57,400
that a stick shaker
activation is imminent.
547
00:27:58,260 --> 00:27:59,999
If you're looking at
the airspeed indicator,
548
00:28:00,000 --> 00:28:02,859
you should be aware that
you're getting slow,
549
00:28:02,860 --> 00:28:04,883
and the stall warning may come on.
550
00:28:06,750 --> 00:28:07,899
Jesus Christ!
551
00:28:07,900 --> 00:28:09,529
It seems Renslow and Shaw
552
00:28:09,530 --> 00:28:11,449
were caught off guard.
553
00:28:11,450 --> 00:28:14,293
Still, they could have easily
corrected the situation.
554
00:28:15,460 --> 00:28:18,999
Once the stick shaker have
activated, they could have
555
00:28:19,000 --> 00:28:20,609
turned the switch off,
556
00:28:20,610 --> 00:28:22,699
or they could have put the nose down
557
00:28:22,700 --> 00:28:24,289
and increased their airspeed.
558
00:28:24,290 --> 00:28:25,719
It's clear to investigators
559
00:28:25,720 --> 00:28:29,129
that Flight 3407 wasn't
in danger of stalling
560
00:28:29,130 --> 00:28:30,723
when the stick shaker went off.
561
00:28:31,600 --> 00:28:33,819
So now they need to know
exactly what happened
562
00:28:33,820 --> 00:28:35,813
after the stall warning was activated.
563
00:28:37,640 --> 00:28:40,370
An animated simulation of
the crash is constructed
564
00:28:41,330 --> 00:28:43,680
based on information from
the flight recorders.
565
00:28:44,730 --> 00:28:47,673
Watch what happens just after
the stick shaker goes off.
566
00:28:48,790 --> 00:28:51,099
It illustrates
that just after the stick shaker
567
00:28:51,100 --> 00:28:54,659
was triggered, the plane
suddenly pulled up.
568
00:28:54,660 --> 00:28:57,799
This action dramatically
slowed the aircraft,
569
00:28:57,800 --> 00:29:00,229
and at this point, it did stall.
570
00:29:00,230 --> 00:29:03,099
Essentially, the airplane
entered an aerodynamic stall
571
00:29:03,100 --> 00:29:05,049
from which it did not recover.
572
00:29:05,050 --> 00:29:06,629
It pitched over, and hit the ground.
573
00:29:06,630 --> 00:29:08,749
Investigators
are dumbfounded.
574
00:29:08,750 --> 00:29:13,689
Flight 3407 wasn't stalling
when the stick shaker went off,
575
00:29:13,690 --> 00:29:15,653
but a few seconds later, it was.
576
00:29:17,290 --> 00:29:19,919
The crew's every action
during that brief time
577
00:29:19,920 --> 00:29:21,773
now demands careful scrutiny.
578
00:29:23,060 --> 00:29:24,173
What did they do?
579
00:29:25,750 --> 00:29:27,169
It's a puzzle.
580
00:29:27,170 --> 00:29:29,569
How could a trained
flight crew take a plane
581
00:29:29,570 --> 00:29:32,969
that wasn't stalling, and in
the space of a few moments
582
00:29:32,970 --> 00:29:35,159
make it fall from the sky?
583
00:29:35,160 --> 00:29:37,289
Any time you have an apparent stall
584
00:29:37,290 --> 00:29:39,399
for no apparent reason, that's a mystery.
585
00:29:39,400 --> 00:29:44,400
We would expect that no flight
crew would stall an airliner.
586
00:29:44,820 --> 00:29:46,113
So the question is why.
587
00:29:47,430 --> 00:29:49,909
The focus of the
investigation now switches
588
00:29:49,910 --> 00:29:52,579
from the plane to the crew,
589
00:29:52,580 --> 00:29:54,769
specifically on the moves they made
590
00:29:54,770 --> 00:29:57,813
during the critical seconds
after the stall warning sounded.
591
00:29:58,980 --> 00:30:02,009
We wanted to see if the
way they flew the airplane
592
00:30:02,010 --> 00:30:03,839
was the way they were trained
593
00:30:03,840 --> 00:30:05,829
according to the standard
operating procedures
594
00:30:05,830 --> 00:30:08,163
that are portrayed in our flight manuals.
595
00:30:09,640 --> 00:30:12,059
The flight data
recorder retains information
596
00:30:12,060 --> 00:30:14,449
from more than 1000 different aspects
597
00:30:14,450 --> 00:30:16,653
of the Q400's flight operations.
598
00:30:18,650 --> 00:30:21,049
From the airspeed and altitude,
599
00:30:21,050 --> 00:30:23,600
to the position of the
rudder pedals and throttles.
600
00:30:24,660 --> 00:30:26,309
It also records the movements
601
00:30:26,310 --> 00:30:28,839
of the most critical flight control,
602
00:30:28,840 --> 00:30:30,063
the control column.
603
00:30:31,290 --> 00:30:34,019
Pilots use the control
column to change the position
604
00:30:34,020 --> 00:30:35,543
of the elevators and ailerons,
605
00:30:36,560 --> 00:30:38,560
which manage the direction of the plane.
606
00:30:40,140 --> 00:30:42,439
The flight data recorder
stores information
607
00:30:42,440 --> 00:30:45,469
not just about the
control column's position,
608
00:30:45,470 --> 00:30:47,713
but how much force is
applied to it as well.
609
00:30:49,353 --> 00:30:52,709
The FDR records what the
control positions were.
610
00:30:52,710 --> 00:30:54,759
It has sensors built
into the control column,
611
00:30:54,760 --> 00:30:57,499
it has sensors built
into the control wheel.
612
00:30:57,500 --> 00:30:59,009
What Scott Warren finds
613
00:30:59,010 --> 00:31:03,329
when analyzing the control
column's position is stunning.
614
00:31:03,330 --> 00:31:05,869
In response to the stick
shaker, Captain Renslow
615
00:31:05,870 --> 00:31:07,769
should have pushed the column forward
616
00:31:07,770 --> 00:31:10,013
to bring the nose down and gain speed.
617
00:31:10,970 --> 00:31:13,833
But for some reason, he
did the exact opposite.
618
00:31:14,760 --> 00:31:17,099
We found that the crew,
instead of pushing forward,
619
00:31:17,100 --> 00:31:20,569
which is the normal response
to a stick shaker triggering,
620
00:31:20,570 --> 00:31:23,969
the crew was actually
pulling back on the control.
621
00:31:23,970 --> 00:31:26,589
This had the
effect of pulling the nose up,
622
00:31:26,590 --> 00:31:29,799
causing the airspeed to drop,
and tipping the aircraft
623
00:31:29,800 --> 00:31:31,778
into an actual stall.
624
00:31:34,090 --> 00:31:36,359
Captain Renslow had apparently mishandled
625
00:31:36,360 --> 00:31:38,963
one of the most elemental
piloting maneuvers,
626
00:31:40,000 --> 00:31:41,593
how to recover from a stall.
627
00:31:42,850 --> 00:31:45,429
Above everything, it
requires gaining airspeed
628
00:31:45,430 --> 00:31:46,583
to get out of the red.
629
00:31:48,640 --> 00:31:50,139
The recovery procedure
630
00:31:50,140 --> 00:31:52,929
is fairly simple and straightforward.
631
00:31:52,930 --> 00:31:55,119
It requires pushing
forward on the controls,
632
00:31:55,120 --> 00:31:56,423
and adding full power.
633
00:31:57,730 --> 00:32:01,179
At any point in time, had
the captain pushed forward
634
00:32:01,180 --> 00:32:04,849
on those flight controls, he
had a reasonably good chance
635
00:32:04,850 --> 00:32:06,133
at recovering quickly.
636
00:32:08,270 --> 00:32:09,919
From everything we've gained,
637
00:32:09,920 --> 00:32:12,849
that stall was recoverable on
a repeated number of levels,
638
00:32:12,850 --> 00:32:13,682
and a repeated basis.
639
00:32:13,683 --> 00:32:15,709
There was no reason for
that plane to go down.
640
00:32:15,710 --> 00:32:17,119
Investigators also learn
641
00:32:17,120 --> 00:32:19,899
that first officer Shaw,
in trying to help Renslow
642
00:32:19,900 --> 00:32:23,203
deal with the crisis,
inadvertently made things worse.
643
00:32:24,703 --> 00:32:26,409
I put the flaps up!
644
00:32:26,410 --> 00:32:29,379
She retracted
the flaps, reducing the amount
645
00:32:29,380 --> 00:32:32,053
of lift as the plane
struggled to stay in the air.
646
00:32:33,460 --> 00:32:36,639
Had the first officer simply
called out you're stalled,
647
00:32:36,640 --> 00:32:39,319
advanced the power, pushed the nose over,
648
00:32:39,320 --> 00:32:41,769
the airplane would have
been able to recover.
649
00:32:41,770 --> 00:32:44,029
From a human point of
view, it's sad to recognize
650
00:32:44,030 --> 00:32:46,189
that those sorts of things happened,
651
00:32:46,190 --> 00:32:48,053
and the tragedy that came from that.
652
00:32:49,000 --> 00:32:51,499
It's concluded
that Captain Renslow's failure
653
00:32:51,500 --> 00:32:54,109
to properly respond to the stall warning
654
00:32:54,110 --> 00:32:58,399
was the primary cause of
the crash of Flight 3407.
655
00:32:58,400 --> 00:33:00,299
As the issue is now pilot error,
656
00:33:00,300 --> 00:33:02,669
rather than mechanical failure,
657
00:33:02,670 --> 00:33:04,359
human performance investigator
658
00:33:04,360 --> 00:33:06,213
Evan Byrne is brought onboard.
659
00:33:07,330 --> 00:33:11,079
His first question, why
hadn't either Renslow or Shaw
660
00:33:11,080 --> 00:33:13,219
noticed that their airspeed was too low
661
00:33:13,220 --> 00:33:14,603
for the icing conditions?
662
00:33:16,590 --> 00:33:20,149
In this case, we can
look back towards the fact
663
00:33:20,150 --> 00:33:22,249
that there were clear and conspicuous cues
664
00:33:22,250 --> 00:33:25,259
of the deteriorating
airspeed that were not heeded
665
00:33:25,260 --> 00:33:26,283
by the captain.
666
00:33:27,260 --> 00:33:29,549
Byrne listens to
the cockpit voice recording
667
00:33:29,550 --> 00:33:33,194
to try to understand what might
have led to that oversight.
668
00:33:33,195 --> 00:33:35,299
Where you could
be home with your husband,
669
00:33:35,300 --> 00:33:37,579
to take care of, and all that stuff.
670
00:33:37,580 --> 00:33:39,489
He learns that
the crew had been talking
671
00:33:39,490 --> 00:33:41,229
throughout the flight.
672
00:33:41,230 --> 00:33:44,769
The conversation continued
during the landing approach.
673
00:33:44,770 --> 00:33:48,143
It's a violation of a rule
known as the sterile cockpit,
674
00:33:48,990 --> 00:33:51,089
which bans nonessential conversation
675
00:33:51,090 --> 00:33:52,939
during critical phases of the flight.
676
00:33:52,940 --> 00:33:55,497
Yeah, you're gonna be
upgraded in six months.
677
00:33:55,498 --> 00:33:57,134
Blah, blah, blah.
678
00:33:58,040 --> 00:34:00,609
Quite simply, it prohibits conversations
679
00:34:00,610 --> 00:34:02,989
that aren't related to the
operation of the flight.
680
00:34:02,990 --> 00:34:05,049
Let's do a
descent checklist, please.
681
00:34:05,050 --> 00:34:07,646
We can do the approach
checklist along with it.
682
00:34:07,647 --> 00:34:08,730
Yeah, sure.
683
00:34:09,567 --> 00:34:10,399
Bug set.
684
00:34:10,400 --> 00:34:11,329
Byrne also discovers
685
00:34:11,330 --> 00:34:13,589
that because of the cockpit banter,
686
00:34:13,590 --> 00:34:16,823
the crew performed critical
checklists and briefings late.
687
00:34:18,880 --> 00:34:21,059
The hydraulic pressure and quantity--
688
00:34:21,060 --> 00:34:23,499
Distracted,
the crew probably didn't see
689
00:34:23,500 --> 00:34:26,419
the red bar indicating
they were flying too slowly
690
00:34:26,420 --> 00:34:29,070
for the conditions the plane
had been configured for.
691
00:34:30,450 --> 00:34:32,779
Approach checklist complete.
692
00:34:32,780 --> 00:34:33,612
Rock and roll.
693
00:34:33,613 --> 00:34:36,119
When crews deviate from
standard operating procedures,
694
00:34:36,120 --> 00:34:38,369
and perform checklists late, or don't make
695
00:34:38,370 --> 00:34:40,959
the required call outs,
they become more vulnerable
696
00:34:40,960 --> 00:34:44,829
to subtle mistakes that
they may make inadvertently
697
00:34:44,830 --> 00:34:48,149
that could lead to startle and surprise,
698
00:34:48,150 --> 00:34:51,239
or unanticipated events that
they have to respond to.
699
00:34:51,240 --> 00:34:53,389
The evidence is unequivocal.
700
00:34:53,390 --> 00:34:56,979
The crew of Flight 3407
was badly distracted
701
00:34:56,980 --> 00:34:58,509
throughout the approach.
702
00:34:58,510 --> 00:35:00,519
Even when we interviewed,
and he said yeah,
703
00:35:00,520 --> 00:35:02,609
you're gonna be upgraded in six months.
704
00:35:02,610 --> 00:35:04,369
They had
forgotten the key setting
705
00:35:04,370 --> 00:35:07,483
they had made that required
them to fly faster than normal.
706
00:35:08,990 --> 00:35:11,079
They had missed indications
that they were flying
707
00:35:11,080 --> 00:35:13,293
too slow for icing conditions.
708
00:35:14,360 --> 00:35:16,909
Then, Captain Renslow
had reacted incorrectly
709
00:35:16,910 --> 00:35:20,293
to a stall warning, sealing
the fate of the plane.
710
00:35:25,060 --> 00:35:27,749
Evan Byrne wonders what could have caused
711
00:35:27,750 --> 00:35:29,319
a trained airline flight crew
712
00:35:29,320 --> 00:35:31,293
to have made such missteps?
713
00:35:32,200 --> 00:35:35,243
He finds a clue on the
cockpit voice recording.
714
00:35:37,720 --> 00:35:38,770
Excuse me.
715
00:35:43,550 --> 00:35:46,149
The crew was
showing signs of fatigue.
716
00:35:46,150 --> 00:35:48,729
Could Renslow and Shaw have been too tired
717
00:35:48,730 --> 00:35:51,709
to function effectively
on the flight deck?
718
00:35:51,710 --> 00:35:53,309
It's a tough question.
719
00:35:53,310 --> 00:35:55,779
Answering it will require
tracking their movements
720
00:35:55,780 --> 00:35:58,889
during the 72 hours
leading up to the crash.
721
00:35:58,890 --> 00:36:00,739
It's basic gumshoe detective work
722
00:36:00,740 --> 00:36:03,249
in the investigation where
we're trying to collect
723
00:36:03,250 --> 00:36:04,859
as many facts as we can.
724
00:36:04,860 --> 00:36:07,169
Byrne interviews
the families of the pilots.
725
00:36:07,170 --> 00:36:09,070
Can I speak to Mrs. Renslow, please?
726
00:36:11,320 --> 00:36:13,689
He studies the
pilots' mobile phone bills,
727
00:36:13,690 --> 00:36:15,463
and records of text messages.
728
00:36:17,800 --> 00:36:20,409
He searches the airline's computer system
729
00:36:20,410 --> 00:36:22,669
to determine if and when the crew used it
730
00:36:22,670 --> 00:36:24,559
to check their schedules.
731
00:36:24,560 --> 00:36:26,673
He needs to track their every move.
732
00:36:27,883 --> 00:36:29,409
And what time did
Rebecca leave the house?
733
00:36:29,410 --> 00:36:32,529
We're talking to
colleagues or other pilots,
734
00:36:32,530 --> 00:36:37,219
check airmen, instructors,
and we ask all those people
735
00:36:37,220 --> 00:36:40,369
about the pilots, about
their recent activities.
736
00:36:40,370 --> 00:36:41,999
He learns that neither pilot
737
00:36:42,000 --> 00:36:43,983
actually lived anywhere near Newark,
738
00:36:45,280 --> 00:36:47,319
but could not afford to stay in hotels
739
00:36:47,320 --> 00:36:49,169
on their salaries.
740
00:36:49,170 --> 00:36:52,129
Captain Renslow was
earning $60,000 annually
741
00:36:52,130 --> 00:36:53,083
at Colgan Air.
742
00:36:54,440 --> 00:36:58,579
First officer Shaw was being
paid less than $16,000 a year,
743
00:36:58,580 --> 00:37:01,869
substantially less than
an average bus driver.
744
00:37:01,870 --> 00:37:04,019
As a result, both pilots had made
745
00:37:04,020 --> 00:37:06,649
long cross-country commutes to Newark,
746
00:37:06,650 --> 00:37:09,419
Captain Renslow from his home in Florida,
747
00:37:09,420 --> 00:37:11,713
and Rebecca Shaw from Seattle, Washington.
748
00:37:14,540 --> 00:37:17,249
In fact, Shaw had commuted
all night from Seattle
749
00:37:17,250 --> 00:37:20,093
on a cargo flight that
connected through Memphis.
750
00:37:23,480 --> 00:37:25,289
Captain Renslow had spent the night
751
00:37:25,290 --> 00:37:27,870
in the airline's crew
lounge at Newark airport
752
00:37:28,850 --> 00:37:31,253
after having already worked two days.
753
00:37:34,480 --> 00:37:37,033
He was seen sleeping on
a couch in the lounge.
754
00:37:39,090 --> 00:37:41,839
It was against company rules,
but pilots who couldn't
755
00:37:41,840 --> 00:37:44,393
afford housing near the
airport did it anyway.
756
00:37:45,820 --> 00:37:49,389
Records show that at 3:10 a.m.
on the morning of the crash,
757
00:37:49,390 --> 00:37:51,339
Renslow was awake.
758
00:37:51,340 --> 00:37:52,669
He checked his work schedule
759
00:37:52,670 --> 00:37:54,433
on the airline's computer network.
760
00:38:03,150 --> 00:38:04,223
Next stop, Buffalo.
761
00:38:06,320 --> 00:38:10,099
At 7:29 a.m.,
Rebecca Shaw sent a text message
762
00:38:10,100 --> 00:38:13,533
to her husband telling him
she'd arrived safely in Newark.
763
00:38:16,320 --> 00:38:17,999
Hi honey, it's me.
764
00:38:18,000 --> 00:38:19,189
Phone records indicate
765
00:38:19,190 --> 00:38:20,979
that later in the morning, Captain Renslow
766
00:38:20,980 --> 00:38:22,823
was on the phone several times.
767
00:38:24,830 --> 00:38:27,539
Rebecca Shaw was noticed having a nap
768
00:38:27,540 --> 00:38:29,979
catching up on the rest
she'd lost flying in
769
00:38:29,980 --> 00:38:31,053
the night before.
770
00:38:34,610 --> 00:38:36,010
That's not a lot of sleep.
771
00:38:38,810 --> 00:38:40,959
We ultimately concluded
that it was likely
772
00:38:40,960 --> 00:38:43,539
that both crew members were
experiencing some effects
773
00:38:43,540 --> 00:38:45,979
of fatigue at the time of the accident.
774
00:38:45,980 --> 00:38:47,730
Her job is to watch the airspeed.
775
00:38:48,830 --> 00:38:50,499
Her job was to watch the instrument panel,
776
00:38:50,500 --> 00:38:53,359
and in my view, if she
was fatigued to the point
777
00:38:53,360 --> 00:38:55,889
where it's like right
here, and you're so dull,
778
00:38:55,890 --> 00:38:56,722
I think that's where she was,
779
00:38:56,723 --> 00:38:58,429
and he just was not capable.
780
00:38:58,430 --> 00:39:01,653
He was just, he shouldn't
have been flying an airplane.
781
00:39:03,500 --> 00:39:05,729
The revelation
leads John Kausner
782
00:39:05,730 --> 00:39:08,893
to become a fierce advocate
for changes to the industry.
783
00:39:09,970 --> 00:39:13,649
He raises awareness among
both lawmakers and the public
784
00:39:13,650 --> 00:39:15,799
about the need to improve regulations
785
00:39:15,800 --> 00:39:18,053
governing pilots at regional airlines.
786
00:39:19,310 --> 00:39:21,619
This is just saying
we support 3407 families
787
00:39:21,620 --> 00:39:23,479
that are fighting for aviation safety,
788
00:39:23,480 --> 00:39:25,159
and these representatives
of congressmen and senators
789
00:39:25,160 --> 00:39:27,929
have done that for us, and
we're very appreciative.
790
00:39:27,930 --> 00:39:29,609
He takes
his fight all the way
791
00:39:29,610 --> 00:39:31,223
to Washington, DC.
792
00:39:32,130 --> 00:39:34,949
We needed to do something,
and so we began to advocate
793
00:39:34,950 --> 00:39:37,969
in Washington weekly, every other week,
794
00:39:37,970 --> 00:39:40,079
and we've innumerable trips down there.
795
00:39:40,080 --> 00:39:42,499
And immediately, the families just gelled.
796
00:39:42,500 --> 00:39:44,088
We all attended the hearings
797
00:39:44,089 --> 00:39:47,223
and began to say this is what we can do.
798
00:39:48,190 --> 00:39:50,759
The crash of Flight 3407
799
00:39:50,760 --> 00:39:53,833
focused the world's attention
on a growing safety problem.
800
00:39:55,610 --> 00:39:57,799
The relatives of those who were killed
801
00:39:57,800 --> 00:39:59,663
will help eliminate that threat.
802
00:40:04,250 --> 00:40:08,649
The crash of Flight 3407 exposed
wide-ranging shortcomings
803
00:40:08,650 --> 00:40:12,059
into regulations that
govern regional airlines.
804
00:40:12,060 --> 00:40:14,419
These smaller airlines now make up half
805
00:40:14,420 --> 00:40:17,679
of all daily passenger flights in the US.
806
00:40:17,680 --> 00:40:21,129
Their pilots are generally
younger, less experienced,
807
00:40:21,130 --> 00:40:23,283
earn less, and work long hours.
808
00:40:24,630 --> 00:40:27,339
Their levels of safety are way different
809
00:40:27,340 --> 00:40:28,172
from the majors.
810
00:40:28,173 --> 00:40:31,993
They have a much lower threshold,
in training, in ability.
811
00:40:33,870 --> 00:40:35,729
In pay, obviously, so they can't attract
812
00:40:35,730 --> 00:40:37,159
a higher qualified pilot.
813
00:40:37,160 --> 00:40:39,469
There are pretty low wages,
814
00:40:39,470 --> 00:40:41,270
pretty difficult working conditions.
815
00:40:42,470 --> 00:40:45,599
We don't seem to attract the same level
816
00:40:45,600 --> 00:40:48,309
of applicant that we used to.
817
00:40:48,310 --> 00:40:51,299
Some regional airlines get into a bind,
818
00:40:51,300 --> 00:40:53,619
and they have to hire the first people
819
00:40:53,620 --> 00:40:54,903
that meet the minimums.
820
00:40:56,360 --> 00:40:59,249
In the US, of
the seven fatal accidents
821
00:40:59,250 --> 00:41:02,049
involving passenger jets
over the past 10 years,
822
00:41:02,050 --> 00:41:04,683
five have involved regional airlines.
823
00:41:08,290 --> 00:41:11,909
Those include the crash of
Delta Connection Flight 5191
824
00:41:11,910 --> 00:41:15,579
in August 2006, which killed 49 people
825
00:41:15,580 --> 00:41:18,013
when the crew took off
from the wrong runway.
826
00:41:23,500 --> 00:41:26,759
John Kausner's campaign to
change laws governing pilots
827
00:41:26,760 --> 00:41:28,489
has paid off.
828
00:41:28,490 --> 00:41:31,059
We relied on your support,
we needed your support,
829
00:41:31,060 --> 00:41:32,159
you nurtured us.
830
00:41:32,160 --> 00:41:34,749
We wanna thank all of you, from all of us.
831
00:41:34,750 --> 00:41:37,399
A year and
a half after the crash,
832
00:41:37,400 --> 00:41:38,809
under pressure from Kausner
833
00:41:38,810 --> 00:41:41,499
and other victims' family members,
834
00:41:41,500 --> 00:41:43,149
the US Senate passed a bill
835
00:41:43,150 --> 00:41:45,699
which toughens training requirements,
836
00:41:45,700 --> 00:41:48,409
and forces the FAA to draw up new rules
837
00:41:48,410 --> 00:41:49,593
on pilot fatigue.
838
00:41:52,970 --> 00:41:55,529
Studies into the problem
of over-tired pilots
839
00:41:55,530 --> 00:41:56,853
are already underway.
840
00:42:00,320 --> 00:42:03,299
At the University of Iowa,
researchers are developing
841
00:42:03,300 --> 00:42:06,053
a system that could help
pilots resist fatigue,
842
00:42:07,440 --> 00:42:10,609
stay engaged with the
critical task of flying,
843
00:42:10,610 --> 00:42:14,583
and prevent future tragedies
like that of Flight 3407.
844
00:42:17,370 --> 00:42:20,363
Thomas Schnell is a
human factors engineer.
845
00:42:21,850 --> 00:42:26,069
We use a number of
neurocognitive and physiological
846
00:42:26,070 --> 00:42:30,819
sensors that we apply on
subjects, pilots that we invite
847
00:42:30,820 --> 00:42:31,653
for our studies.
848
00:42:36,185 --> 00:42:37,017
Well, just go ahead.
849
00:42:37,018 --> 00:42:39,029
He's studying
how pilots stay alert
850
00:42:39,030 --> 00:42:41,449
on the flight deck as
a test subject conducts
851
00:42:41,450 --> 00:42:43,979
a cross-country journey in a simulator.
852
00:42:43,980 --> 00:42:47,179
Using sensors, he can
determine how alert and engaged
853
00:42:47,180 --> 00:42:49,029
a pilot really is.
854
00:42:49,030 --> 00:42:50,899
The research could lead to the development
855
00:42:50,900 --> 00:42:52,953
of fatigue detectors on airplanes.
856
00:42:54,090 --> 00:42:57,469
We are trying to predict pilot state
857
00:42:57,470 --> 00:43:00,409
so that we can adjust
something on the flight deck
858
00:43:00,410 --> 00:43:03,149
to prevent the problem from getting worse,
859
00:43:03,150 --> 00:43:05,379
or starting in the first place.
860
00:43:05,380 --> 00:43:09,819
We monitor brain activity,
eye movement activity,
861
00:43:09,820 --> 00:43:14,399
heart, the EKG and respiration,
and other parameters,
862
00:43:14,400 --> 00:43:17,269
in an effort to figure out what the pilots
863
00:43:17,270 --> 00:43:19,119
or the crew's state is.
864
00:43:19,120 --> 00:43:21,599
Are they fatigued, overworked,
865
00:43:21,600 --> 00:43:23,763
are they disengaged or distracted?
866
00:43:27,320 --> 00:43:30,009
This section is where
they were really drowsy,
867
00:43:30,010 --> 00:43:33,323
and you can see that the gaze
has become kind of bored.
868
00:43:37,890 --> 00:43:39,829
Schnell
instructs the flight simulator
869
00:43:39,830 --> 00:43:42,996
to trigger a major systems
failure in the cockpit.
870
00:43:46,582 --> 00:43:47,414
It's no good.
871
00:43:47,415 --> 00:43:48,649
Everything's dead.
872
00:43:48,650 --> 00:43:50,200
Hydraulics systems have failed.
873
00:43:52,910 --> 00:43:54,869
Try and call that heat map so we can see
874
00:43:54,870 --> 00:43:56,563
what this brain activity was.
875
00:43:58,040 --> 00:43:59,488
Brace for effect.
876
00:44:01,220 --> 00:44:03,859
When a crew is fatigued,
what you might see
877
00:44:03,860 --> 00:44:06,659
is that their reaction to
events might slow down,
878
00:44:06,660 --> 00:44:10,323
so you'll see mistakes being
made on the flight deck.
879
00:44:11,760 --> 00:44:14,049
It's precisely
these kinds of mistakes
880
00:44:14,050 --> 00:44:15,860
on the part of Renslow and Shaw
881
00:44:17,690 --> 00:44:20,883
that ultimately crashed Flight 3407.
882
00:44:23,920 --> 00:44:25,653
And killed 50 people.
883
00:44:30,070 --> 00:44:32,239
It's a tragedy that
should not have happened.
884
00:44:32,240 --> 00:44:34,499
It was foreseeable, was preventable,
885
00:44:34,500 --> 00:44:37,199
and it's repeatable if we
don't do something about it.
886
00:44:37,200 --> 00:44:39,769
And I'm focused and determined
to change what exists
887
00:44:39,770 --> 00:44:41,623
and not have another dad sitting here.
68827
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