All language subtitles for Air.Disasters.S20E05.1080p.PMTP.WEB-DL.DDP5.1.H.264-BLOOM_track3_[eng]

We just lost 1 and 2.

All four engines
shut down on a jet headed

straight for a US suburb.

straight for a US suburb.

Takes a few things to make
an engine run, and one of them

is fuel.

Everyone, we're about
to evacuate the plane.

Everyone, we're about
to evacuate the plane.

Remain calm.

In Japan,
a plane catches fire

with all 165 passengers
and crew still onboard.

with all 165 passengers
and crew still onboard.

The only time you
have too much fuel

onboard the aircraft
is when you're on fire.

onboard the aircraft
is when you're on fire.

We just lost an engine!

Hang on.

Hang on.

And the crew of a
737 is forced to make a crash

landing in the Amazon Jungle.

landing in the Amazon Jungle.

Something is very,
very, very wrong here.

Three mysterious
accidents send investigators

Three mysterious
accidents send investigators

hunting for clues.

Is it possible these tragedies
all share the same cause?

Ladies and gentlemen,

Ladies and gentlemen,

we are starting our approach.

We lost both engines.

...emergency liftoff.

Mayday, mayday.

Mayday, mayday.

Brace for impact!

I think I lost one.

Investigation starting...

He's gonna crash!

He's gonna crash!

United Airlines Flight 173

is 22 miles away from Portland
International Airport.

is 22 miles away from Portland
International Airport.

The 189 passengers
onboard are returning

home after the holidays. .

home after the holidays. .

United 173 would like
clearance for an approach

United 173 would like
clearance for an approach

into 28 left now.

Captain Malburn McBroom,

Captain Malburn McBroom,

a Second World War
veteran, is one of United's

most experienced pilots.

First Officer Rod Bibby
has more than 5,000 hours

First Officer Rod Bibby
has more than 5,000 hours

flying experience.

Flight engineer
Forrest Mendenhall

is the third crew member.

OK.

OK.

He's tasked with
monitoring the DC-8's engines.

He's tasked with
monitoring the DC-8's engines.

The flight began in New York
City with a stopover in Denver.

United 173 heavy.

United 173 heavy.

OK, rollout heading
010 to runway 28 left.

OK, rollout heading
010 to runway 28 left.

Air traffic
controller Ed Kingrey

clears Flight 173 to land.

clears Flight 173 to land.

Suddenly, an alarm
sounds in the cockpit.

Suddenly, an alarm
sounds in the cockpit.

We're losing an engine.

It's flamed out.

You're going to lose
number 3 in a minute, too.

Two of the
plane's four engines

have just shut down.

have just shut down.

You've got to keep
them running, Frosty.

Yes sir.

The engineer
struggles to keep

the last two engines running.

the last two engines running.

How far do you
show us in the field?

How far do you
show us in the field?

I'd call it, uh...

I told him it's 18 flying
miles, which would include

the base leg to the
final, and then the turn

the base leg to the
final, and then the turn

to final to the
end of the runway.

We just lost 1 and 2.

Flight 173 has
now lost all four engines.

Flight 173 has
now lost all four engines.

With the aircraft dropping by
more than 3,000 feet a minute,

Captain McBroom makes a
horrifying calculation.

Captain McBroom makes a
horrifying calculation.

I can't make it.

I can't make it.

I can't make anything.

OK, declare mayday.

Portland tower, United 173.

Portland tower, United 173.

Heavy mayday.

The engines are flaming out.

McBroom needs
to find a safe place

to put the aircraft
down and try to save

the lives of all onboard.

the lives of all onboard.

I could see

him coming in from the south,
his navigational lights

flashing.

You could tell he was quite low.

You could tell he was quite low.

I saw the bright
flash out there and...

I saw the bright
flash out there and...

and knew he had gone down.

and knew he had gone down.

The DC-8 has
crash-landed in a wooded suburb

The DC-8 has
crash-landed in a wooded suburb

in Portland, Oregon.

Eight passengers and two
members of the crew are dead.

Incredibly, 179 people survive.

A United Airlines plane

A United Airlines plane

crashed 5 miles southeast
of Portland Airport

in a residential area.

Two homes were hit.

One disintegrated.

One disintegrated.

Next morning, investigators

from the National Transportation
Safety Board are on the scene.

One of the team members is human
factor specialist Alan Diehl.

One of the team members is human
factor specialist Alan Diehl.

When I saw how close he'd
come to apartment complexes,

I realized this could
have been one of the worst

I realized this could
have been one of the worst

accidents in history.

Investigators hope survivors

Investigators hope survivors

can provide some insight into
what brought this jet down.

When did you first notice
something out of the ordinary

When did you first notice
something out of the ordinary

Um...

They learned
from the passengers

that an hour before
the crash, the captain

that an hour before
the crash, the captain

made an announcement.

Ladies and gentlemen,

Ladies and gentlemen,

this is your captain speaking.

The crew were having
trouble with the landing gear.

We're
not sure whether or not

We're
not sure whether or not

it's working correctly.

We'll be running a
few routine checks.

But something
isn't making sense to Diehl.

But something
isn't making sense to Diehl.

How does a landing gear
problem bring down a plane?

How does a landing gear
problem bring down a plane?

At the crash
site, the plane's

flight recorders are recovered.

flight recorders are recovered.

They're sent for
analysis to the National

Transportation Safety Board
headquarters in Washington.

Transportation Safety Board
headquarters in Washington.

While they wait for
the flight data,

investigators continue
to speak to witnesses,

including Ed Kingrey,
the controller who

including Ed Kingrey,
the controller who

handled Flight 173's approach.

I cleared them for an
approach to runway 28.

I cleared them for an
approach to runway 28.

I was about to hand them
off to the tower controller.

Negative.

We'll stay with you.

We'll stay with you.

We've got a gear problem.

We'll let you know.

He basically

said he'd stay with me.

said he'd stay with me.

That he was having some kind
of unsafe gear indication.

Captain McBroom wanted
time to troubleshoot the gear

Captain McBroom wanted
time to troubleshoot the gear

problem, so Kingrey
cleared Flight 173 to fly

problem, so Kingrey
cleared Flight 173 to fly

a holding pattern
south of the airport

over the Portland suburbs.

A holding pattern
would basically

A holding pattern
would basically

give him his own airspace there
to do whatever he had to do.

give him his own airspace there
to do whatever he had to do.

But Flight
173 circled Portland

for an unusually long time.

And they continued
circling for about an hour.

And they continued
circling for about an hour.

The pilots
then made a shocking call

to the Portland tower.

to the Portland tower.

I recall hearing the
captain tell the tower...

them losing engines.

There was no indication to me
the gravity of the situation.

What happened
during that hour

of circling that turned a
landing gear malfunction...

of circling that turned a
landing gear malfunction...

We've got a gear problem.

We'll let you know

...into a
catastrophic engine failure?

...into a
catastrophic engine failure?

The engines are flaming out.

We're going down.

We're not going to be able
to make it to the airport.

I was clearly very
interested in, you know,

I was clearly very
interested in, you know,

how a highly experienced
captain could fly around

for over an hour inside of
the airport, in good weather,

for over an hour inside of
the airport, in good weather,

and not put this airplane
on the ground safely.

and not put this airplane
on the ground safely.

NTSB investigator
Dennis Grossi joins the effort

NTSB investigator
Dennis Grossi joins the effort

to find out what went wrong.

I was assigned to be
the aircraft performance

I was assigned to be
the aircraft performance

engineer for this accident.

OK.

OK.

Let's go.

If there
was a malfunction,

he hopes the cockpit
voice recorder picked

up the pilots discussing it.

up the pilots discussing it.

Ladies and gentlemen,

this is your captain speaking.

The recording begins
30 minutes before the crash,

The recording begins
30 minutes before the crash,

as the pilots circle
over Portland.

...correctly.

Because I've only got this
thing to shine down there.

They hear
the flight engineer

They hear
the flight engineer

leave the cockpit
to troubleshoot

the landing gear problem.

When the landing
gear is lowered,

When the landing
gear is lowered,

a small rod pops up in the wing,
providing visual confirmation

that the gear is in place.

that the gear is in place.

The flight engineer would
be asked by the captain

to go back and check the
mechanical indicators for the

to go back and check the
mechanical indicators for the

position of the landing gear.

Excuse me.

Can I look out the window here?

And he could look over,

and there are tabs that
actually come up and go down.

and there are tabs that
actually come up and go down.

And he could see if the gear
was extended and locked.

And he could see if the gear
was extended and locked.

How's that main
gear back there?

Both appear to
be down and locked.

Despite his
engineer's report,

Despite his
engineer's report,

Captain McBroom still
sounds concerned.

There's one check we missed.

Checking the gear warning horn.

Checking the gear warning horn.

Uh... right.

Right.

Right.

Normally, when we see these
problems of a gear light

Normally, when we see these
problems of a gear light

not coming on, it's a light
bulb or some minor piece

of circuitry.

It appears that
a minor electrical problem

became a major distraction
for Captain McBroom.

became a major distraction
for Captain McBroom.

But it still doesn't explain
why all four engines were out.

Then investigators make
a shocking discovery.

Losing an engine.

Losing an engine.

It's flamed out.

Why?

Fuel.

The cockpit voice
recorder from United Flight 173

The cockpit voice
recorder from United Flight 173

reveals that the captain is
unaware that his plane is

running out of fuel.

running out of fuel.

He was asking what
was causing that,

and he got a very adamant
answer saying "Fuel."

and he got a very adamant
answer saying "Fuel."

Fuel.

As if to say, we've
been trying to tell

you about this all along.

Number 2 is empty.

Number 2 is empty.

You're going to lose
number 3 in a minute, too.

You're going to lose
number 3 in a minute, too.

One by
one, fuel starvation

shuts down all the
engines, leaving

the DC-8 without any power.

the DC-8 without any power.

OK, declare mayday.

OK, declare mayday.

How could an experienced
crew lose track

of how much fuel
they had onboard,

of how much fuel
they had onboard,

and in fact, run out
of fuel when they

were in view of the airport?

were in view of the airport?

Captain McBroom
may be the only one

who can provide answers.

who can provide answers.

He's in the hospital
recovering from injury,

but well enough to
speak to investigators.

but well enough to
speak to investigators.

I recall
seeing the number 1 and number

I recall
seeing the number 1 and number

2 warning lights come on.

But I... I knew we had fuel.

But I... I knew we had fuel.

He was still convinced that
somehow the fuel had either

leaked out of the tanks, or
the fuel burn was too high,

leaked out of the tanks, or
the fuel burn was too high,

or the gauges were wrong.

Investigators wonder if the fuel

gauges were malfunctioning
and confusing the pilots.

gauges were malfunctioning
and confusing the pilots.

To find out, investigators study
the transcript of the cockpit

voice recorder,
focusing on the pilots'

voice recorder,
focusing on the pilots'

discussion of fuel levels.

The crew discussed
how much fuel they had.

We had 5,000 pounds.

We had 5,000 pounds.

You take the data and apply
the time factor to it,

and you can figure
out how much fuel

and you can figure
out how much fuel

they should have had remaining.

5,000.

That's exactly right.

That's exactly right.

The team
discovers there's

nothing wrong with the gauges.

Flight 173's fuel system was
working exactly as it should.

Flight 173's fuel system was
working exactly as it should.

With mechanical
failure ruled out,

With mechanical
failure ruled out,

the team now explores
the human factors.

Specifically, Captain
McBroom's behavior.

Specifically, Captain
McBroom's behavior.

How much fuel do you got now?

How much fuel do you got now?

4,000.
4,000.

Any...

Investigators played
back the cockpit voice recorder

to study his performance.

to study his performance.

How much fuel you got now?

They hear something
alarming in the conversation.

They hear something
alarming in the conversation.

How much fuel we got now?

How much fuel we got now?

4,000.

4,000 in each.

Pounds.

Both the first officer
and the second officer

were acutely aware
of the fuel status.

were acutely aware
of the fuel status.

His crewmates tried
more than once to alert him

to the fuel situation,
but McBroom is focused

to the fuel situation,
but McBroom is focused

on the broken landing gear.

There's one check we missed,
checking the gear warning horn.

There's one check we missed,
checking the gear warning horn.

Uh... right.

Right.

Right.

So how do we do that?

Flying with a
very senior captain,

Flying with a
very senior captain,

it would be very
difficult to challenge

that captain in those days
about something like fuel.

that captain in those days
about something like fuel.

The captain was so focused
on the gear collapsing

The captain was so focused
on the gear collapsing

that he lost the big picture.

They lost sight of
the real emergency,

They lost sight of
the real emergency,

which was the lack of fuel.

Captain McBroom's
obsession with the landing

Captain McBroom's
obsession with the landing

gear, along with his
crewmates' failure to speak up,

caused the plane to run
out of fuel and crash

caused the plane to run
out of fuel and crash

in the Portland suburb.

After this accident, the
National Transportation Safety

After this accident, the
National Transportation Safety

Board said flight crew
members need to be

better-trained to
communicate when they

better-trained to
communicate when they

have safety of flight issues.

In a move that has
a lasting impact on airline

In a move that has
a lasting impact on airline

safety, the Federal
Aviation Administration

adopts a training
system developed

adopts a training
system developed

by NASA known as Cockpit
Resource Management, or CRM.

It teaches captains
to listen better,

It teaches captains
to listen better,

and it teaches the other
members of the flight deck

to be respectfully assertive.

to be respectfully assertive.

If the crew of Flight
173 had received CRM training,

If the crew of Flight
173 had received CRM training,

they might have
insisted that Captain

McBroom land immediately.

Not enough.

Not enough.

15 minutes is really going
to run us low on fuel here.

Instead, they
expected their captain

Instead, they
expected their captain

to make the right decision.

Had it not been for
this investigation,

I'm pretty sure
that Crew Resource

I'm pretty sure
that Crew Resource

Management would have taken
place, but at some point

in the future.

And very likely
other aircraft would

And very likely
other aircraft would

have crashed in the interim.

In 2007, a terrifying
explosion reminds investigators

that catastrophic fuel failures
don't just happen in the air.

that catastrophic fuel failures
don't just happen in the air.

China Airlines Flight
120 is on final approach

China Airlines Flight
120 is on final approach

for landing in Okinawa, Japan.

Ladies and gentlemen,

we're about to begin our descent
into Okinawa Naha Airport.

we're about to begin our descent
into Okinawa Naha Airport.

Please give the
flight attendants

your full cooperation
as they prepare

the cabin for a landing.

The captain is
47-year-old You Chien-kou.

The captain is
47-year-old You Chien-kou.

What's the weather
for approach?

Cloud ceiling says 1,000 feet.

Wind's at 8 knots.

The first officer
is 26-year-old Tseng Ta-wei.

The first officer
is 26-year-old Tseng Ta-wei.

The pilots have more than
8,500 hours of flight

experience between them.

experience between them.

This morning, there are 157
passengers and 8 crew onboard.

This morning, there are 157
passengers and 8 crew onboard.

Please put your tray up
and fasten your seatbelt.

Please put your tray up
and fasten your seatbelt.

The pilots reconfigure
their plane as they slow down

and descend for landing.

and descend for landing.

Let's go to flaps 25.

Flaps 25.

Flaps 25.

They deploy flaps
from the wing's back edge,

along with slats
from the front edge.

along with slats
from the front edge.

These devices keep the plane
airborne at lower speeds.

30, 20, 10.

It's a
textbook landing.

Flaps up.

All that's left
for the China Airline

All that's left
for the China Airline

pilots is to park the plane.

Engine start levers

Engine start levers cut off.

Engine start levers cut off.

Seatbelts.

Seatbelts off.

Then one
passenger notices

that something's not right.

that something's not right.

Hey, what is this?

What's happening?

Just when they thought
they were safely parked...

Cockpit, ground, number 2 engine fire.

Cockpit, ground, number 2 engine fire.

...a radio
call alerts them

to a fire in the right engine.

DYNASTY 120,
we are calling a fire truck.

DYNASTY 120,
we are calling a fire truck.

Remain.

Standby.

Cabin crew, prepare
for evacuation.

Cabin crew, prepare
for evacuation.

Prepare for evacuation.

Within minutes,
the fire engulfs both wings.

No pushing.

No pushing.

Please keep moving forward.

Please keep moving forward.

Flight attendants
work to evacuate the passengers

as quickly as possible.

The plane could
explode at any moment.

The plane could
explode at any moment.

Captain, all
passengers are evacuated.

Captain, all
passengers are evacuated.

You're the last one.

But it may be
too late for the pilots.

But it may be
too late for the pilots.

Thick smoke is
consuming the cabin,

so they will have to escape
through a small cockpit window.

so they will have to escape
through a small cockpit window.

You first.

Sir...

Oh.

Whoa!

Incredibly, both
pilots evacuate just in time.

All 165 people onboard
escape unharmed.

All 165 people onboard
escape unharmed.

I've never heard
of any evacuation

where somebody wasn't hurt.

where somebody wasn't hurt.

To get this many people off
in such a dire circumstance,

in a very short period of
time, with no injuries,

in a very short period of
time, with no injuries,

is miraculous.

It's highly
unusual for an aircraft

to catch fire at that
phase of the flight.

to catch fire at that
phase of the flight.

So that sparked a
great deal of interest.

A team of
international air crash

investigators are
immediately called in.

investigators are
immediately called in.

They need to find the
cause before there's

another deadly explosion.

another deadly explosion.

Across the globe, there
are more than 5,000

Across the globe, there
are more than 5,000

Boeing 737's in service.

There's a 737 taking
off and landing every 3

There's a 737 taking
off and landing every 3

or 4 seconds in the world.

Knowing countless
passengers could be at-risk,

Knowing countless
passengers could be at-risk,

investigators raced to figure out

how an airliner that
landed safely suddenly

how an airliner that
landed safely suddenly

burst into flames.

OK, let's get to work!

OK, let's get to work!

The challenge
for investigators

is most of the evidence would
be destroyed by the fire.

is most of the evidence would
be destroyed by the fire.

While recovery workers
collect the scorched wreckage,

the team begins
interviewing eyewitnesses.

the team begins
interviewing eyewitnesses.

What did you see?

A ground worker
who saw the explosion

A ground worker
who saw the explosion

provides a critical detail.

So the ramp worker on the
right side of the aircraft

So the ramp worker on the
right side of the aircraft

said very distinctly that
he saw a liquid running

down the leading edge
of the right wing

before the fire broke out.

before the fire broke out.

Thanks.

The fluid
leaking from this part

of the wing of the aircraft
can only be one thing.

of the wing of the aircraft
can only be one thing.

Jet fuel.

Jet fuel.

The Boeing 737 holds 4,390
gallons of fuel, much of it

The Boeing 737 holds 4,390
gallons of fuel, much of it

in tanks located inside the
plane's two massive wings.

When we figured out that the
actual fuel leak had occurred,

When we figured out that the
actual fuel leak had occurred,

it was a breakthrough.

A true breakthrough
in the investigation.

A true breakthrough
in the investigation.

We know the fuel was leaking.

But from where?

Investigators examine what remains

of the 737's fuel tanks.

of the 737's fuel tanks.

The tanks are made
from aluminum alloy

and should never crack or leak.

and should never crack or leak.

They use a small camera
called a borescope to see

They use a small camera
called a borescope to see

inside the right fuel tank.

What it reveals
changes the course

of the entire investigation.

of the entire investigation.

Whoa.

Would you look at that?

While examining
the right fuel tank of China

Airlines Flight 120,
investigators find a bolt

Airlines Flight 120,
investigators find a bolt

lodged in the side of the tank.

All of a sudden,
it clears a bell.

All of a sudden,
it clears a bell.

We saw this bolt sticking
out of the fuel tank itself.

The bolt has ruptured
the tank right where the ground

The bolt has ruptured
the tank right where the ground

worker spotted leaking fuel.

It's
hard to describe

It's
hard to describe

how significant this
was I mean, this was

the core of the investigation.

But where
did the bolt come from?

OK.

Got it.

Investigators compare the piece

to schematics of the
737 wing structure

to schematics of the
737 wing structure

to figure out
exactly what it is.

They soon get their answer.

They soon get their answer.

A downstop assembly.

A downstop assembly.

The downstop assembly
is part of the slot mechanism

on the wing, s leading edge.

Let's go to flaps 25.

Let's go to flaps 25.

Flaps 25.

Pilots extend flaps
and slats during every takeoff

Pilots extend flaps
and slats during every takeoff

and landing.

The downstop is fixed
to the end of a track

The downstop is fixed
to the end of a track

that slides back and forth.

The device prevents the slats
from moving too far forward.

The device prevents the slats
from moving too far forward.

We had the assembly.

We knew it punched
through the tank.

Our next step was trying
to figure out how this

Our next step was trying
to figure out how this

could possibly have occurred.

When comparing the
downstop assembly from Flight

When comparing the
downstop assembly from Flight

120 to Boeing's schematics...

...the team uncovers
a vital clue.

We decided
to count parts.

We decided
to count parts.

And lo and behold, a
washer was missing.

There's supposed to be
a washer right behind the nut.

There's supposed to be
a washer right behind the nut.

Where is it?

Could a single
missing washer have

played a role in the accident?

All right.

Now let's test it
without a washer.

The team experiments
with the suspicious bolt

from Flight 120 to see how it
performs without the washer.

from Flight 120 to see how it
performs without the washer.

They make a stunning discovery.

The small washer is the only
thing preventing the unit

The small washer is the only
thing preventing the unit

from falling out of its mount.

Without the washer it fails.

Without the washer it fails.

Investigators need
to find out how the part

could have disappeared.

We went to China Airlines
to ask them to demonstrate how

they do the maintenance work.

they do the maintenance work.

Sometimes, maintenance records
don't tell you the true story.

They learn a repair
was ordered on the downstop

a few weeks before the accident.

a few weeks before the accident.

A mechanic demonstrates how
he performed the repair.

After applying glue, you
put the bolt into place.

After applying glue, you
put the bolt into place.

But reaching
the downstop's location

proves challenging.

proves challenging.

You can imagine that
you are under the wing,

and you cannot see it.

and you cannot see it.

Sorry.

I just dropped it.

Don't worry.

It's... it's easy
to pick up again.

It's an
eye-opening demonstration.

It's an
eye-opening demonstration.

It's not very easy
for them to confirm

It's not very easy
for them to confirm

they finished their job and
everything is in order there.

they finished their job and
everything is in order there.

Investigators believe the washer

must have fallen off
during the maintenance

must have fallen off
during the maintenance

procedure in Taiwan.

The sequence of events that led
to the devastating fuel fire

The sequence of events that led
to the devastating fuel fire

in Okinawa is finally clear.

in Okinawa is finally clear.

Six weeks after the field
repair of a downstop...

Please give the
flight attendants

Please give the
flight attendants

your full cooperation as they
prepare the cabin for landing.

...a
descent into Okinawa

requires the pilots to deploy
the flaps and slats as usual.

requires the pilots to deploy
the flaps and slats as usual.

Inside one of the track
assemblies on the right wing,

the loosened bolt
without a washer

is just barely holding on.

is just barely holding on.

Touchdown is enough
of a jolt to finally

Touchdown is enough
of a jolt to finally

knock it out of its track.

Flaps up.

Flaps up.

The unsuspecting crew soon

retracts the flaps and slats.

The plane's powerful
hydraulics move

The plane's powerful
hydraulics move

the slat track back into place.

But now the downstop
bolt is in the way.

But now the downstop
bolt is in the way.

The track pushes it to
the back, puncturing

the right wing fuel tank
and causing thousands

the right wing fuel tank
and causing thousands

of gallons of fuel to leak.

After-landing checklist.

Once the pilots park
and shut down the engines,

Once the pilots park
and shut down the engines,

the leaking fuel starts
dripping directly

the leaking fuel starts
dripping directly

onto the scorching-hot
tailpipe, igniting on contact.

In the wake of the China
Airlines explosion,

In the wake of the China
Airlines explosion,

aviation authorities around the
world ordered the inspection

of entire fleets of 737's.

of entire fleets of 737's.

In the US alone,
21 planes are found

to have the same
defect, all of them

to have the same
defect, all of them

at risk of a catastrophic
fuel leak and fire.

at risk of a catastrophic
fuel leak and fire.

Boeing takes immediate action.

It redesigns the
downstop mechanism

and ensures that the
improved part is installed

and ensures that the
improved part is installed

on each and every plane.

In today's aviation,
the failure of any kind

In today's aviation,
the failure of any kind

of component part, especially
as it relates to a fuel system,

is a rare event.

is a rare event.

You stand a better
chance of survival

if you have a catastrophic
event on the ground.

But as the airplane goes
up, so does the risk level.

But as the airplane goes
up, so does the risk level.

In Brazil, investigators

In Brazil, investigators

uncover another
fatal problem when

a disastrous fuel
failure brings down

a plane in the Amazon Jungle.

a plane in the Amazon Jungle.

Brazil in the late 1980s
is a country in transition.

Developing cities are scattered
throughout the dense Amazon

Developing cities are scattered
throughout the dense Amazon

Rainforest.

In Marabá, the crew
of Varig Flight 254

is preparing for takeoff.

There are
48 passengers onboard.

Pulling right now.

Pulling right now.

Flight 254
is an hour-long flight

from the mining town of
Marabá to Belém near the mouth

from the mining town of
Marabá to Belém near the mouth

of the Amazon River.

The crew dials in a
compass heading to guide

The crew dials in a
compass heading to guide

them to their destination.

Here we go.

Captain Cézar
Garcez is flying the airplane

tonight while first
officer Nilson

tonight while first
officer Nilson

Zille monitors the instruments.

B1.

Rotate.

The Boeing 737 steadily

climbs to cruising altitude.

After 23 minutes,
the flight computer

tells the captain that they're
getting close to Belém.

tells the captain that they're
getting close to Belém.

Looks like we're nearly there.

Mm.

Belém tower, Varig 254
requesting descent.

Belém tower, Varig 254
requesting descent.

Belém tower, Varig 254.

Belém tower, do you read?

Belém tower, do you read?

Strangely, they get
no response from the tower.

Strangely, they get
no response from the tower.

Let me try.

Belém tower, Varig 254.

Hm.

Hm.

That's funny.

What?

We're not picking up
their beacon either.

We're not picking up
their beacon either.

Airports are equipped with very

high-frequency omnidirectional
range beacons, or VOR beacons.

high-frequency omnidirectional
range beacons, or VOR beacons.

Their signal guides incoming
aircraft to the runway.

I'll call the tower on HF.

I'll call the tower on HF.

The captain switches
his radio to High Frequency

and tries making contact again.

and tries making contact again.

Belém tower, Varig 254.

Thankfully, his strategy works.

Thankfully, his strategy works.

Varig 254, Belém tower.

Go ahead.

Go ahead.

Belém, we're on approach,
but we aren't seeing the VOR.

Is the beacon down?

Negative, 254.

Looks like it's on your end.

Looks like it's on your end.

Understood.

The crew will have to
approach Belém without the help

of the VOR signal.

of the VOR signal.

The captain checks his
system and calculates

when they'll arrive.

Belém, we're 25 minutes out.

Belém, we're 25 minutes out.

Request to send
for final approach.

Varig 254, clear
to flight level 200.

Varig 254, clear
to flight level 200.

As the plane
drops below the clouds,

As the plane
drops below the clouds,

the captain looks for
the lights of Belém.

Where are the lights?

Where are the lights?

Where is the airport?

Where is the airport?

But there's
only darkness.

No visible lights, Captain.

In Belém, the
controller's concerned.

In Belém, the
controller's concerned.

Flight 254 should
have landed by now.

But he doesn't have
a radar, so he has

But he doesn't have
a radar, so he has

no way of tracking the plane.

We need to land soon or else
we're going to run out of fuel.

I think we're close.

I think we're close.

The captain searches
for a local radio signal,

hoping it will guide
them toward the city.

hoping it will guide
them toward the city.

Now we can follow the
signal towards Belém.

Now we can follow the
signal towards Belém.

Turning right, heading 165.

After 2 and
1/2 hours in flight,

After 2 and
1/2 hours in flight,

the captain is confident
he's now on-course.

There we go.

There we go.

We're over the Amazon now.

Belém is near
the mouth of the Amazon.

Belém is near
the mouth of the Amazon.

Following the river should
lead the pilots to the city.

But seconds later...

We've got a fuel warning!

We've got a fuel warning!

...Flight 254
is running out of fuel.

The pilots suddenly realized
they can't make it to Belém.

The pilots suddenly realized
they can't make it to Belém.

Flaps to 2.

We need to do a
controlled descent.

We need to do a
controlled descent.

They'll have
to make a forced landing

in the dense Amazon Rainforest.

in the dense Amazon Rainforest.

We just lost an engine!

We just lost an engine!

Hang on.

I'm going to put her down.

But there goes the other one!

The inevitable
impact is just seconds away.

Pull up.

Pull up.

Just need to bring
us down nice and slow.

Just need to bring
us down nice and slow.

Of the 54 passengers
and crew, six die on impact.

Many are badly hurt,
including First Officer Zille.

The captain tends to the wounded
while they wait to be rescued.

The captain tends to the wounded
while they wait to be rescued.

Hello?

But no one
in the outside world

But no one
in the outside world

knows where the
plane has gone down.

Investigators conduct
an aerial search

around Belém for
Varig Flight 254,

around Belém for
Varig Flight 254,

but there's no sign of
the missing aircraft.

You get anxious to find the plane

quickly, because people have
a better chance of survival

quickly, because people have
a better chance of survival

during the first 48 hours.

After that, survivors
are more likely to die.

After that, survivors
are more likely to die.

After two
nights in the jungle,

After two
nights in the jungle,

a small group sets
off to find help.

Hours later, they
stumble on a farmhouse.

They found survivors.

It's sort of a relief
to realize the scenario

It's sort of a relief
to realize the scenario

is not as tragic.

And there's an urgent desire
to get to the location

and start to work.

and start to work.

Where did you say they are?

The crash site
is nowhere near Belém.

The crash site
is nowhere near Belém.

It came down right here.

The wreckage of Flight 254

The wreckage of Flight 254

is lying in the Amazon
Jungle, nearly 700 miles away.

is lying in the Amazon
Jungle, nearly 700 miles away.

How on Earth did they
get way over there?

No wonder we couldn't
spot the beacon.

No wonder we couldn't
spot the beacon.

It's nowhere near
the destination.

Within hours,
Brazilian military

Within hours,
Brazilian military

reached the remote
crash site of Varig 254.

reached the remote
crash site of Varig 254.

They find 43 survivors.

Five people have died
waiting for rescue,

Five people have died
waiting for rescue,

and another dies soon after.

Shortly after the
rescue efforts,

there's a major breakthrough.

The discovery of the plane's
two flight recorders.

The discovery of the plane's
two flight recorders.

Investigators hope they
will reveal why Flight

254 was so badly off-course.

254 was so badly off-course.

We were
relying on the two flight data

recorders.

Both pilots were alive, so we
thought we were certain to come

Both pilots were alive, so we
thought we were certain to come

to a conclusion.

But when investigators
review the flight data,

it paints a confusing picture.

Instead of flying
north to Belém,

the plane took off west and
flew in the wrong direction

the plane took off west and
flew in the wrong direction

the entire flight.

This became a central focus

of the investigation, to
know why the aircraft was

of the investigation, to
know why the aircraft was

so far off-course.

Investigators wonder if the crew were given

the wrong navigation details.

the wrong navigation details.

Thankfully, Flight 254's
flight plan from the airline

is among the documents
recovered from the cockpit.

is among the documents
recovered from the cockpit.

oh, thanks.

Let's see what
this will tell us.

I think I know what
they did wrong.

Their computer flight

plan system has four digits.

plan system has four digits.

This is very, very
unusual, as they

almost always have only three.

almost always have only three.

The numbers "0270" was
intended to mean 27.0 degrees.

The numbers "0270" was
intended to mean 27.0 degrees.

When we noticed that,

it gave us the idea that
instead of entering "027,"

which was the heading to
Belém, he had entered "270."

which was the heading to
Belém, he had entered "270."

The captain read it as
270 degrees, or due west.

So instead of flying northeast...

So instead of flying northeast...

They went west
instead, going 270.

He entered the wrong heading.

He entered the wrong heading.

Flying for more than
3 hours in the wrong direction...

Flying for more than
3 hours in the wrong direction...

...investigators suspect
the aircraft ran out

...investigators suspect
the aircraft ran out

of fuel, forcing
the crew to make

a crash-landing in the Amazon.

To confirm their suspicions,
they call in Captain Garcez

To confirm their suspicions,
they call in Captain Garcez

to tell his side of the story.

I'll try to help you.

I'll try to help you.

Under intense questioning,

he admits he misread
the flight plan,

he admits he misread
the flight plan,

causing the aircraft to fly
hundreds of miles off-course.

Look, it
was an honest mistake.

Company records show
the airline began printing

their flight plans in a new
way while the captain was

their flight plans in a new
way while the captain was

on vacation.

It's easy to see how
you'd get confused.

From that moment on,

the cause, or the basic
framework of the accident,

was determined.

was determined.

But the
First Officer was

also required to enter the
heading from their flight plan.

Why didn't he
catch the captain's mistake?

Aviation psychologist Kathy
Mosier provides insight.

The co-pilot, probably after
many experiences with captains

The co-pilot, probably after
many experiences with captains

who had always done it right
and never had to double-check,

just entered what the captain
had put in and assumed

just entered what the captain
had put in and assumed

that it was the right thing.

So in this case, your safeguard
is gone, because the co-pilot

So in this case, your safeguard
is gone, because the co-pilot

is not cross-checking.

The original
navigation mistake

The original
navigation mistake

was that of the captain.

was that of the captain.

What is disheartening
here is that both pilots

went along with it.

went along with it.

Flight 254 was
flying in the wrong direction

from the moment it took off.

from the moment it took off.

Instead of asking
for help, the captain

tried to get back on-course
using a local radio signal.

tried to get back on-course
using a local radio signal.

He thought he found
a station in Belém,

He thought he found
a station in Belém,

but instead picked up a signal
in the opposite direction,

taking them further away
from their destination.

taking them further away
from their destination.

His pride prevented him from saying

His pride prevented him from saying

to his colleague, help me.

I'm in trouble.

That would have been
a better approach.

While scanning their radar,

While scanning their radar,

the crew thought they spotted
the Amazon River, which

would take them back to Belém.

would take them back to Belém.

But the river they saw was
the Xingu, more than 600 miles

southwest of Belém.

southwest of Belém.

How can they be so
confused for so long?

How can they be so
confused for so long?

I think we're close.

Investigators conclude
the crew was in the grip

Investigators conclude
the crew was in the grip

of what's known as "confirmation
bias," the tendency

to favor information
that confirms

something we already believe.

something we already believe.

When I saw the
river, I was sure.

I was sure we were
close to Belém.

I was sure we were
close to Belém.

Just goes to show you anybody
can fall into decision traps.

And even experts have
to always be on-guard.

And even experts have
to always be on-guard.

The accident report faults

both pilots for the actions
that caused the plane

both pilots for the actions
that caused the plane

with 54 people onboard to
run out of fuel and crash

in the jungle.

After the crash of
Varig 254, the airline

After the crash of
Varig 254, the airline

changes their flight
plans so the decimal place

is clearly marked.

They also improve
pilot training.

They also improve
pilot training.

Brazil's national radar system
is modernized and expanded

to cover the entire country,
making it less likely

to cover the entire country,
making it less likely

that a plane would go missing.

Fuel management in-flight
is the responsibility

Fuel management in-flight
is the responsibility

of the pilots in the cockpit.

But you can have those same
human errors on the ground.

But you can have those same
human errors on the ground.

The big common thread
between these three accidents

The big common thread
between these three accidents

is the human factor.

It is the responsibility to have
not only a knowledge of what

It is the responsibility to have
not only a knowledge of what

you're doing, but a
fundamental understanding,

so that you can
execute properly.

so that you can
execute properly.