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00:00:09,576 --> 00:00:11,411
On a cold day
in Northern Ontario,
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00:00:11,478 --> 00:00:14,714
a passenger jet is unable
to climb above the trees.
3
00:00:11,478 --> 00:00:14,714
a passenger jet is unable
to climb above the trees.
4
00:00:14,781 --> 00:00:15,782
I thought, oh, my God.
5
00:00:15,849 --> 00:00:16,750
We're going to crash.
6
00:00:19,619 --> 00:00:22,155
Would have been nice of
them to clear the snow.
7
00:00:22,222 --> 00:00:23,790
During a
snowstorm in Sweden,
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00:00:23,857 --> 00:00:29,329
a routine takeoff leads to a
mysterious engine malfunction.
9
00:00:23,857 --> 00:00:29,329
a routine takeoff leads to a
mysterious engine malfunction.
10
00:00:29,396 --> 00:00:32,432
There was a really big
roar in the aircraft,
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00:00:29,396 --> 00:00:32,432
There was a really big
roar in the aircraft,
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00:00:32,499 --> 00:00:34,601
almost like an explosion.
13
00:00:34,667 --> 00:00:37,036
Boom.
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00:00:34,667 --> 00:00:37,036
Boom.
15
00:00:39,105 --> 00:00:40,273
Go around!
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00:00:40,340 --> 00:00:41,574
Go around, thrust.
17
00:00:41,641 --> 00:00:43,743
And when a jet
crashes into a hillside
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00:00:41,641 --> 00:00:43,743
And when a jet
crashes into a hillside
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00:00:43,810 --> 00:00:46,379
above Canada's Arctic Circle...
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00:00:46,446 --> 00:00:49,215
A 737 has just gone
down at Resolute Bay.
21
00:00:46,446 --> 00:00:49,215
A 737 has just gone
down at Resolute Bay.
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00:00:49,282 --> 00:00:52,218
...investigators
wonder if a magnetic phenomenon
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00:00:52,285 --> 00:00:53,620
is at play.
24
00:00:53,686 --> 00:00:55,355
His compass is drifting.
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00:00:53,686 --> 00:00:55,355
His compass is drifting.
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00:00:55,422 --> 00:00:58,458
He's off by about 17 degrees.
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00:00:58,525 --> 00:01:00,260
Three airline disasters
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00:00:58,525 --> 00:01:00,260
Three airline disasters
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00:01:00,326 --> 00:01:03,797
in harsh Northern locations.
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00:01:03,863 --> 00:01:06,099
Investigators struggle to uncover
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00:01:03,863 --> 00:01:06,099
Investigators struggle to uncover
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00:01:06,166 --> 00:01:08,234
how distinct
challenges in the North
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00:01:08,301 --> 00:01:11,304
overwhelmed all three flights.
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00:01:12,705 --> 00:01:13,673
Ladies and gentlemen,
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00:01:13,740 --> 00:01:15,074
we are starting our approach.
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00:01:15,141 --> 00:01:16,810
We lost both engines.
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00:01:16,876 --> 00:01:18,344
Emergency response.
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00:01:16,876 --> 00:01:18,344
Emergency response.
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00:01:18,411 --> 00:01:19,245
May-day, may-day!
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00:01:19,312 --> 00:01:19,679
Brace for impact!
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00:01:38,231 --> 00:01:40,467
A midday snow
falls in the airport
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00:01:40,533 --> 00:01:46,272
at Dryden, a remote community
in Northern Ontario, Canada.
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00:01:40,533 --> 00:01:46,272
at Dryden, a remote community
in Northern Ontario, Canada.
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00:01:46,339 --> 00:01:50,810
Air Ontario Flight 1363
to Winnipeg is refueling.
45
00:01:46,339 --> 00:01:50,810
Air Ontario Flight 1363
to Winnipeg is refueling.
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00:01:50,877 --> 00:01:54,113
Kenora Dryden, it's Ontario 363.
47
00:01:50,877 --> 00:01:54,113
Kenora Dryden, it's Ontario 363.
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00:01:54,180 --> 00:01:55,648
Ontario 363.
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00:01:55,715 --> 00:01:57,717
As first officer
Keith Mills checks the weather
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00:01:57,784 --> 00:02:01,287
conditions, Captain
George Morwood returns
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00:01:57,784 --> 00:02:01,287
conditions, Captain
George Morwood returns
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00:02:01,354 --> 00:02:03,356
after making a phone call.
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00:02:03,423 --> 00:02:04,657
Looking at accumulation...
54
00:02:04,724 --> 00:02:05,592
It's getting worse.
55
00:02:05,658 --> 00:02:07,293
What's the latest?
56
00:02:05,658 --> 00:02:07,293
What's the latest?
57
00:02:07,360 --> 00:02:08,661
...and won't
clear till late afternoon.
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00:02:08,728 --> 00:02:09,796
Check that.
59
00:02:09,863 --> 00:02:11,531
Quite heavy snow,
looks like it's
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00:02:11,598 --> 00:02:15,168
going to be a bad one, but
still within our takeoff limit.
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00:02:11,598 --> 00:02:15,168
going to be a bad one, but
still within our takeoff limit.
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00:02:15,235 --> 00:02:17,303
Captain Morwood
has been a commercial pilot
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00:02:17,370 --> 00:02:19,439
for 34 years.
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00:02:17,370 --> 00:02:19,439
for 34 years.
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00:02:19,506 --> 00:02:20,406
Cross check.
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00:02:22,575 --> 00:02:23,843
First officer Mills has
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00:02:23,910 --> 00:02:26,279
14 years of flight experience.
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00:02:23,910 --> 00:02:26,279
14 years of flight experience.
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00:02:28,248 --> 00:02:33,419
The Fokker F28 began the day in
Winnipeg, flew to Thunder Bay,
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00:02:28,248 --> 00:02:33,419
The Fokker F28 began the day in
Winnipeg, flew to Thunder Bay,
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00:02:33,486 --> 00:02:35,421
and is now stopping
over in Dryden
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00:02:35,488 --> 00:02:36,823
before returning to Winnipeg.
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00:02:35,488 --> 00:02:36,823
before returning to Winnipeg.
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00:02:39,626 --> 00:02:41,528
But the weather
is deteriorating.
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00:02:43,997 --> 00:02:46,833
A blanket of snow is
falling and I couldn't
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00:02:46,900 --> 00:02:48,334
see the tree line anymore.
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00:02:46,900 --> 00:02:48,334
see the tree line anymore.
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00:02:48,401 --> 00:02:50,303
It was like looking
through a sheer.
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00:02:56,242 --> 00:02:56,910
B1.
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00:02:59,646 --> 00:03:00,513
Rotate.
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00:02:59,646 --> 00:03:00,513
Rotate.
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00:03:04,751 --> 00:03:09,956
The F28 gets off the
ground but it isn't climbing.
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00:03:04,751 --> 00:03:09,956
The F28 gets off the
ground but it isn't climbing.
84
00:03:10,023 --> 00:03:13,826
Our takeoff
was very slow and sluggish.
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00:03:10,023 --> 00:03:13,826
Our takeoff
was very slow and sluggish.
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00:03:13,893 --> 00:03:17,630
There's this dip to the left,
and then dip to the right.
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00:03:17,697 --> 00:03:19,332
I thought, oh my God.
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00:03:17,697 --> 00:03:19,332
I thought, oh my God.
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00:03:19,399 --> 00:03:20,266
We're going to crash.
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00:03:22,936 --> 00:03:29,709
49 seconds
after lifting off,
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00:03:22,936 --> 00:03:29,709
49 seconds
after lifting off,
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00:03:29,776 --> 00:03:33,513
Flight 1363 crashes a
half mile from the runway.
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00:03:29,776 --> 00:03:33,513
Flight 1363 crashes a
half mile from the runway.
94
00:03:44,424 --> 00:03:46,459
I didn't know where I was.
95
00:03:46,526 --> 00:03:47,860
And at that point, I
thought, oh my gosh.
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00:03:47,927 --> 00:03:49,562
I'm alive.
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00:03:47,927 --> 00:03:49,562
I'm alive.
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00:03:49,629 --> 00:03:53,366
I'm still alive, that this
is all happening so quickly.
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00:03:53,433 --> 00:03:56,803
45 people
survived the accident.
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00:03:53,433 --> 00:03:56,803
45 people
survived the accident.
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00:03:56,869 --> 00:03:59,973
24, including Captain Morwood
and first officer Mills,
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00:04:00,039 --> 00:04:00,907
do not.
103
00:04:02,809 --> 00:04:04,844
This way, come on!
104
00:04:04,911 --> 00:04:07,347
Why did the
plane fall out of the sky
105
00:04:04,911 --> 00:04:07,347
Why did the
plane fall out of the sky
106
00:04:07,413 --> 00:04:08,548
just after takeoff?
107
00:04:11,985 --> 00:04:15,421
A team of investigators from the
Canadian Aviation Safety Board
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00:04:11,985 --> 00:04:15,421
A team of investigators from the
Canadian Aviation Safety Board
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00:04:15,488 --> 00:04:17,423
arrives at the scene
the following day.
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00:04:23,696 --> 00:04:26,566
You're going there hopefully
with the idea that you can find
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00:04:23,696 --> 00:04:26,566
You're going there hopefully
with the idea that you can find
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00:04:26,633 --> 00:04:28,267
out what happened,
why it happened,
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00:04:28,334 --> 00:04:31,304
and how do you prevent it
from happening in the future.
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00:04:28,334 --> 00:04:31,304
and how do you prevent it
from happening in the future.
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00:04:31,371 --> 00:04:33,606
We walked the entire path
of the airplane right
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00:04:33,673 --> 00:04:34,807
to the crash site.
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00:04:34,874 --> 00:04:37,944
That was the first
thing that I did.
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00:04:34,874 --> 00:04:37,944
That was the first
thing that I did.
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00:04:38,011 --> 00:04:41,748
I wanted to document what I
was seeing by photographing.
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00:04:43,383 --> 00:04:44,884
The path of
destruction through the forest
121
00:04:44,951 --> 00:04:47,353
provides investigators
with their first clue.
122
00:04:52,959 --> 00:04:55,094
Look at how these tree
tops have been clipped off.
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00:04:52,959 --> 00:04:55,094
Look at how these tree
tops have been clipped off.
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00:04:57,730 --> 00:04:59,666
It didn't ever fly.
125
00:04:59,732 --> 00:05:02,935
What happened was the airplane
went off the end of the runway
126
00:04:59,732 --> 00:05:02,935
What happened was the airplane
went off the end of the runway
127
00:05:03,002 --> 00:05:04,804
in what we would
call ground effect,
128
00:05:04,871 --> 00:05:06,472
and just stayed at that height.
129
00:05:04,871 --> 00:05:06,472
and just stayed at that height.
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00:05:15,481 --> 00:05:17,550
The team
recovers the F28's two
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00:05:17,617 --> 00:05:20,353
black boxes from the wreckage.
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00:05:17,617 --> 00:05:20,353
black boxes from the wreckage.
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00:05:20,420 --> 00:05:23,022
But they suffered extreme
heat damage and the data
134
00:05:23,089 --> 00:05:24,624
is unrecoverable.
135
00:05:23,089 --> 00:05:24,624
is unrecoverable.
136
00:05:29,629 --> 00:05:32,065
Investigators will have to
rely on survivor's accounts
137
00:05:29,629 --> 00:05:32,065
Investigators will have to
rely on survivor's accounts
138
00:05:32,131 --> 00:05:32,999
for clues.
139
00:05:36,135 --> 00:05:38,071
They said in their
witness statements
140
00:05:38,137 --> 00:05:40,873
there was snow and ice on
the wings when the airplane
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00:05:40,940 --> 00:05:44,043
attempted to take off.
142
00:05:40,940 --> 00:05:44,043
attempted to take off.
143
00:05:44,110 --> 00:05:46,546
Was the storm
a factor in the accident?
144
00:05:49,082 --> 00:05:51,417
Weather charts show that
during the half hour
145
00:05:51,484 --> 00:05:54,554
the F28 was on the
ground at Dryden Airport,
146
00:05:51,484 --> 00:05:54,554
the F28 was on the
ground at Dryden Airport,
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00:05:54,620 --> 00:05:56,889
snowfall grew
significantly worse.
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00:05:59,659 --> 00:06:02,095
Investigators now have a theory.
149
00:05:59,659 --> 00:06:02,095
Investigators now have a theory.
150
00:06:02,161 --> 00:06:04,731
And though we may
find other reasons,
151
00:06:04,797 --> 00:06:06,999
for sure, snow and
ice on the wings
152
00:06:04,797 --> 00:06:06,999
for sure, snow and
ice on the wings
153
00:06:07,066 --> 00:06:08,701
was a factor in this accident.
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00:06:10,536 --> 00:06:12,638
Flight attendant
Sonia Hartwick's account
155
00:06:10,536 --> 00:06:12,638
Flight attendant
Sonia Hartwick's account
156
00:06:12,705 --> 00:06:13,940
offers a crucial detail.
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00:06:15,775 --> 00:06:18,778
As we took off, I
noticed that the wings just
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00:06:15,775 --> 00:06:18,778
As we took off, I
noticed that the wings just
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00:06:18,845 --> 00:06:22,682
became a solid sheen
of gray, shiny ice.
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00:06:24,984 --> 00:06:26,986
The team
consults the F28's
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00:06:27,053 --> 00:06:32,625
manual to find out the extent
of its anti-icing system.
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00:06:27,053 --> 00:06:32,625
manual to find out the extent
of its anti-icing system.
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00:06:32,692 --> 00:06:35,595
They discover that only the
wing's leading edges are
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00:06:35,661 --> 00:06:39,732
protected, so it
wouldn't have cleared
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00:06:35,661 --> 00:06:39,732
protected, so it
wouldn't have cleared
166
00:06:39,799 --> 00:06:42,835
the ice Hartwick noticed forming
on the surface of the wings.
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00:06:39,799 --> 00:06:42,835
the ice Hartwick noticed forming
on the surface of the wings.
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00:06:48,007 --> 00:06:51,144
Investigators now suspect
that the buildup, what
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00:06:51,210 --> 00:06:53,780
experts call wing
contamination, played
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00:06:53,846 --> 00:06:55,181
a major role in the accident.
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00:06:53,846 --> 00:06:55,181
a major role in the accident.
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00:06:57,917 --> 00:07:01,721
To verify their theory, they
call in engineers from Fokker
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00:06:57,917 --> 00:07:01,721
To verify their theory, they
call in engineers from Fokker
174
00:07:01,788 --> 00:07:05,691
to run computer
simulations of the crash.
175
00:07:05,758 --> 00:07:09,662
They were able to get some
very good data simulating
176
00:07:05,758 --> 00:07:09,662
They were able to get some
very good data simulating
177
00:07:09,729 --> 00:07:11,964
the type of loads,
temperatures, et
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00:07:12,031 --> 00:07:15,935
cetera, that the Dryden aircraft
would have been exposed to.
179
00:07:16,002 --> 00:07:18,805
The simulations
reveal that due to the angle
180
00:07:16,002 --> 00:07:18,805
The simulations
reveal that due to the angle
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00:07:18,871 --> 00:07:23,442
of the F28's wings, even a
small accumulation of ice
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00:07:23,509 --> 00:07:25,611
will make the aircraft
vulnerable to stalling.
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00:07:23,509 --> 00:07:25,611
will make the aircraft
vulnerable to stalling.
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00:07:28,247 --> 00:07:31,083
The finding supports
what witnesses saw.
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00:07:28,247 --> 00:07:31,083
The finding supports
what witnesses saw.
186
00:07:31,150 --> 00:07:36,489
It just barely got airborne,
dropping wings, losing lift,
187
00:07:31,150 --> 00:07:36,489
It just barely got airborne,
dropping wings, losing lift,
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00:07:36,556 --> 00:07:39,859
and then hitting trees and
decelerating to the point
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00:07:39,926 --> 00:07:40,793
where it broke up.
190
00:07:44,564 --> 00:07:45,731
The team
is now certain
191
00:07:45,798 --> 00:07:47,800
that ice contamination
on the wings
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00:07:47,867 --> 00:07:51,003
was the main cause of the crash.
193
00:07:47,867 --> 00:07:51,003
was the main cause of the crash.
194
00:07:51,070 --> 00:07:53,773
The conclusion raises a
more intriguing question.
195
00:07:56,542 --> 00:08:00,012
Virtually all cold climate
airports, including Dryden,
196
00:07:56,542 --> 00:08:00,012
Virtually all cold climate
airports, including Dryden,
197
00:08:00,079 --> 00:08:03,583
are equipped with the technology
to remove ice from a plane.
198
00:08:07,720 --> 00:08:11,190
Yet, Captain Morwood
never requested de-icing.
199
00:08:11,257 --> 00:08:12,124
Why?
200
00:08:11,257 --> 00:08:12,124
Why?
201
00:08:15,728 --> 00:08:18,264
Investigators scrutinize
his employment records
202
00:08:15,728 --> 00:08:18,264
Investigators scrutinize
his employment records
203
00:08:18,331 --> 00:08:19,665
searching for an answer.
204
00:08:22,134 --> 00:08:24,537
They portray a
conscientious pilot
205
00:08:22,134 --> 00:08:24,537
They portray a
conscientious pilot
206
00:08:24,604 --> 00:08:27,707
who had delayed and even
canceled flights in the past
207
00:08:27,773 --> 00:08:30,910
because of icing concerns.
208
00:08:27,773 --> 00:08:30,910
because of icing concerns.
209
00:08:30,977 --> 00:08:33,913
Why did he fail to do so
on the day of the accident?
210
00:08:36,949 --> 00:08:39,619
Another pilot who has had
Dryden airport that morning
211
00:08:39,685 --> 00:08:40,853
provides some of the answer.
212
00:08:43,222 --> 00:08:47,260
He heard an angry Morwood
on the phone to Air Ontario.
213
00:08:47,326 --> 00:08:51,697
That is what I have
been trying to tell you.
214
00:08:47,326 --> 00:08:51,697
That is what I have
been trying to tell you.
215
00:08:51,764 --> 00:08:54,700
Right, so now what
am I supposed to do?
216
00:08:51,764 --> 00:08:54,700
Right, so now what
am I supposed to do?
217
00:08:54,767 --> 00:08:58,037
No, you figure it out.
218
00:08:58,104 --> 00:09:00,172
It's an
important new lead.
219
00:08:58,104 --> 00:09:00,172
It's an
important new lead.
220
00:09:00,239 --> 00:09:03,709
The team now wants to know
the reason behind the argument
221
00:09:03,776 --> 00:09:06,245
and if it might explain
why Captain Morwood
222
00:09:03,776 --> 00:09:06,245
and if it might explain
why Captain Morwood
223
00:09:06,312 --> 00:09:08,114
didn't de-ice the wings.
224
00:09:11,918 --> 00:09:14,020
They delve into the
plane's flight log
225
00:09:11,918 --> 00:09:14,020
They delve into the
plane's flight log
226
00:09:14,086 --> 00:09:16,756
and discover that on
the day of the crash,
227
00:09:16,822 --> 00:09:20,126
the plane's auxiliary power
unit wasn't functioning.
228
00:09:16,822 --> 00:09:20,126
the plane's auxiliary power
unit wasn't functioning.
229
00:09:24,630 --> 00:09:27,667
The APU is a generator
that provides the power
230
00:09:27,733 --> 00:09:29,001
needed to start the engines.
231
00:09:31,904 --> 00:09:34,640
Normally, the captain
would rely on the APU
232
00:09:34,707 --> 00:09:36,609
to restart his
engines after shutting
233
00:09:34,707 --> 00:09:36,609
to restart his
engines after shutting
234
00:09:36,676 --> 00:09:38,878
them both down for refueling.
235
00:09:38,945 --> 00:09:40,680
But if he couldn't
use his APU,
236
00:09:40,746 --> 00:09:42,815
he couldn't shut
his engines down.
237
00:09:40,746 --> 00:09:42,815
he couldn't shut
his engines down.
238
00:09:42,882 --> 00:09:46,085
That meant Flight
1363 had to be refueled
239
00:09:46,152 --> 00:09:49,755
with one engine running.
240
00:09:46,152 --> 00:09:49,755
with one engine running.
241
00:09:49,822 --> 00:09:52,792
But Air Ontario policy
prohibited de-icing
242
00:09:52,858 --> 00:09:55,928
with an engine running.
243
00:09:52,858 --> 00:09:55,928
with an engine running.
244
00:09:55,995 --> 00:09:58,297
The fluid can be
ingested in the engines
245
00:09:58,364 --> 00:10:00,866
and then find its way from
there to the air conditioning
246
00:09:58,364 --> 00:10:00,866
and then find its way from
there to the air conditioning
247
00:10:00,933 --> 00:10:05,004
on the airplane and make it
extremely noxious in the cabin
248
00:10:05,071 --> 00:10:06,005
portion of the airplane.
249
00:10:05,071 --> 00:10:06,005
portion of the airplane.
250
00:10:08,841 --> 00:10:11,210
If Morwood had
shut down both engines,
251
00:10:11,277 --> 00:10:15,348
he wouldn't have been
able to restart the plane.
252
00:10:11,277 --> 00:10:15,348
he wouldn't have been
able to restart the plane.
253
00:10:15,414 --> 00:10:20,086
He would ground the aircraft
there, effectively, requiring
254
00:10:15,414 --> 00:10:20,086
He would ground the aircraft
there, effectively, requiring
255
00:10:20,152 --> 00:10:23,622
the billeting of
passengers and hotels
256
00:10:23,689 --> 00:10:26,092
and added expense to
the airline for which
257
00:10:23,689 --> 00:10:26,092
and added expense to
the airline for which
258
00:10:26,158 --> 00:10:27,626
- he would be answerable.
- Right.
259
00:10:27,693 --> 00:10:28,894
So now what...
260
00:10:28,961 --> 00:10:30,096
So he was under a
great deal of pressure.
261
00:10:28,961 --> 00:10:30,096
So he was under a
great deal of pressure.
262
00:10:30,162 --> 00:10:33,899
No, you figure it out.
263
00:10:33,966 --> 00:10:36,902
And I believe that the
conversation on the phone
264
00:10:33,966 --> 00:10:36,902
And I believe that the
conversation on the phone
265
00:10:36,969 --> 00:10:39,939
would have been about that
scenario and his displeasure
266
00:10:40,006 --> 00:10:43,642
with it, but he didn't
have any other chance.
267
00:10:40,006 --> 00:10:43,642
with it, but he didn't
have any other chance.
268
00:10:43,709 --> 00:10:44,377
It's getting worse.
269
00:10:44,443 --> 00:10:45,244
What's the latest?
270
00:10:45,311 --> 00:10:46,779
Quite heavy snow.
271
00:10:46,846 --> 00:10:48,714
Looks like it's going to
be a bad one, but still
272
00:10:46,846 --> 00:10:48,714
Looks like it's going to
be a bad one, but still
273
00:10:48,781 --> 00:10:50,182
within our takeoff limits.
274
00:10:50,249 --> 00:10:52,818
Investigators discover
that although the amount
275
00:10:52,885 --> 00:10:55,221
of snow on the wings
was still within limits,
276
00:10:52,885 --> 00:10:55,221
of snow on the wings
was still within limits,
277
00:10:55,287 --> 00:10:58,424
it's what was hidden beneath
the snow that doomed the flight.
278
00:11:01,060 --> 00:11:06,198
The fuel in a plane's wings
can get as cold as -40 degrees.
279
00:11:01,060 --> 00:11:06,198
The fuel in a plane's wings
can get as cold as -40 degrees.
280
00:11:06,265 --> 00:11:10,136
The frigid fuel cools the
metal surface of the wing.
281
00:11:10,202 --> 00:11:13,139
When snow hits this
super cooled surface,
282
00:11:10,202 --> 00:11:13,139
When snow hits this
super cooled surface,
283
00:11:13,205 --> 00:11:17,076
it freezes instantly into a
barely visible layer of ice.
284
00:11:19,378 --> 00:11:21,213
And this, of course,
is what's disrupting
285
00:11:21,280 --> 00:11:23,249
the airflow on the
wing and destroying
286
00:11:23,315 --> 00:11:24,917
the lifting capabilities.
287
00:11:23,315 --> 00:11:24,917
the lifting capabilities.
288
00:11:24,984 --> 00:11:27,386
Advise, Kenora,
we're ready to proceed.
289
00:11:27,453 --> 00:11:29,155
And Kenora Dryden Ontario...
290
00:11:29,221 --> 00:11:31,157
Perhaps not wanting
to face the consequences
291
00:11:29,221 --> 00:11:31,157
Perhaps not wanting
to face the consequences
292
00:11:31,223 --> 00:11:34,060
of shutting down
his engines, Morwood
293
00:11:34,126 --> 00:11:37,430
opted to take off for Winnipeg
without de-icing the plane.
294
00:11:34,126 --> 00:11:37,430
opted to take off for Winnipeg
without de-icing the plane.
295
00:11:39,331 --> 00:11:41,067
He must have
concluded that the ice
296
00:11:41,133 --> 00:11:44,270
would blow off on takeoff.
297
00:11:41,133 --> 00:11:44,270
would blow off on takeoff.
298
00:11:44,336 --> 00:11:48,140
That is where he made a
mistake, a tragic mistake.
299
00:11:44,336 --> 00:11:48,140
That is where he made a
mistake, a tragic mistake.
300
00:11:51,977 --> 00:11:54,747
In the
wake of Flight 1363,
301
00:11:51,977 --> 00:11:54,747
In the
wake of Flight 1363,
302
00:11:54,814 --> 00:11:58,350
Canada upgrades airports'
de-icing capabilities.
303
00:11:58,417 --> 00:12:01,420
We now have
runway end de-icing
304
00:11:58,417 --> 00:12:01,420
We now have
runway end de-icing
305
00:12:01,487 --> 00:12:05,991
pads so they can get a final
de-icing before they take off.
306
00:12:06,058 --> 00:12:09,795
This was something directly the
result of the Dryden Commission
307
00:12:09,862 --> 00:12:11,497
inquiry.
308
00:12:11,564 --> 00:12:14,467
But frigid conditions
have more than one way
309
00:12:11,564 --> 00:12:14,467
But frigid conditions
have more than one way
310
00:12:14,533 --> 00:12:16,402
of endangering an aircraft...
311
00:12:16,469 --> 00:12:18,237
On-ground emergency!
312
00:12:16,469 --> 00:12:18,237
On-ground emergency!
313
00:12:18,304 --> 00:12:20,005
Bend down, bend down!
314
00:12:20,072 --> 00:12:22,308
...as the crew
of one Swedish airliner
315
00:12:22,374 --> 00:12:23,809
suddenly discovers.
316
00:12:28,214 --> 00:12:30,282
It's two
days after Christmas.
317
00:12:30,349 --> 00:12:32,918
Stockholm-Arlanda
Airport is blanketed in
318
00:12:30,349 --> 00:12:32,918
Stockholm-Arlanda
Airport is blanketed in
319
00:12:32,985 --> 00:12:36,822
snow, slush, and ice.
320
00:12:36,889 --> 00:12:39,492
Passengers are boarding
Scandinavian Airlines Flight
321
00:12:36,889 --> 00:12:39,492
Passengers are boarding
Scandinavian Airlines Flight
322
00:12:39,558 --> 00:12:43,929
751 to Copenhagen.
Among them is Per
323
00:12:39,558 --> 00:12:43,929
751 to Copenhagen.
Among them is Per
324
00:12:43,996 --> 00:12:48,267
Holmberg, an off-duty captain
who flies for the airline.
325
00:12:48,334 --> 00:12:50,569
He is scheduled to command
another flight later
326
00:12:48,334 --> 00:12:50,569
He is scheduled to command
another flight later
327
00:12:50,636 --> 00:12:52,104
in the day.
328
00:12:52,171 --> 00:12:55,341
In the cockpit is
34-year-old Ulf Cedermark,
329
00:12:55,407 --> 00:12:57,943
who's been with the
airline for four years.
330
00:12:55,407 --> 00:12:57,943
who's been with the
airline for four years.
331
00:12:58,010 --> 00:13:02,014
He is the first officer
on today's flight.
332
00:12:58,010 --> 00:13:02,014
He is the first officer
on today's flight.
333
00:13:02,081 --> 00:13:04,950
Temperature was just below
freezing and light winds.
334
00:13:05,017 --> 00:13:08,087
We were going to fly Stockholm
to Copenhagen, and then
335
00:13:05,017 --> 00:13:08,087
We were going to fly Stockholm
to Copenhagen, and then
336
00:13:08,154 --> 00:13:12,591
to Warsaw, back to Copenhagen,
and down to Barcelona that day.
337
00:13:14,326 --> 00:13:16,896
The captain
in command of the MD81
338
00:13:16,962 --> 00:13:19,198
is Danish pilot
Stefan Rasmussen.
339
00:13:23,068 --> 00:13:24,603
Where are we now
with the de-icing?
340
00:13:24,670 --> 00:13:26,172
The wings aren't quite done.
341
00:13:24,670 --> 00:13:26,172
The wings aren't quite done.
342
00:13:26,238 --> 00:13:27,306
They've done the underside.
343
00:13:27,373 --> 00:13:29,308
Now they're doing the top.
344
00:13:29,375 --> 00:13:30,943
The ground
crew is conducting
345
00:13:31,010 --> 00:13:32,344
a second round of de-icing.
346
00:13:31,010 --> 00:13:32,344
a second round of de-icing.
347
00:13:34,947 --> 00:13:36,482
And it took a while,
348
00:13:36,549 --> 00:13:40,119
but they had trouble getting rid
of the snow on top of the wing.
349
00:13:36,549 --> 00:13:40,119
but they had trouble getting rid
of the snow on top of the wing.
350
00:13:40,186 --> 00:13:44,156
So we were slightly late for
our push back out to our runway.
351
00:13:40,186 --> 00:13:44,156
So we were slightly late for
our push back out to our runway.
352
00:13:44,223 --> 00:13:47,927
Shortly after 8:30
AM, the process is complete.
353
00:13:50,529 --> 00:13:52,932
Scandinavian 751, you are cleared
354
00:13:52,998 --> 00:13:55,968
for takeoff from runway 08.
355
00:13:52,998 --> 00:13:55,968
for takeoff from runway 08.
356
00:13:59,271 --> 00:14:00,606
Gear up.
357
00:14:00,673 --> 00:14:01,607
Gear up selected.
358
00:14:00,673 --> 00:14:01,607
Gear up selected.
359
00:14:07,179 --> 00:14:09,281
When Ulf reached
out for the gear,
360
00:14:07,179 --> 00:14:09,281
When Ulf reached
out for the gear,
361
00:14:09,348 --> 00:14:12,618
I heard things which
were different.
362
00:14:18,624 --> 00:14:22,194
There was a really big
roar in the aircraft,
363
00:14:18,624 --> 00:14:22,194
There was a really big
roar in the aircraft,
364
00:14:22,261 --> 00:14:24,263
almost like an explosion.
365
00:14:24,330 --> 00:14:26,098
Boom.
366
00:14:24,330 --> 00:14:26,098
Boom.
367
00:14:29,368 --> 00:14:32,938
There was another
banging noise,
368
00:14:29,368 --> 00:14:32,938
There was another
banging noise,
369
00:14:33,005 --> 00:14:34,506
but I just thought,
what is that?
370
00:14:34,573 --> 00:14:36,575
I had never heard that before.
371
00:14:39,378 --> 00:14:41,213
That sounds serious.
372
00:14:41,280 --> 00:14:45,117
I believe it's a
compressor stall.
373
00:14:41,280 --> 00:14:45,117
I believe it's a
compressor stall.
374
00:14:45,184 --> 00:14:49,688
I took the right throttle
and moved a little back,
375
00:14:45,184 --> 00:14:49,688
I took the right throttle
and moved a little back,
376
00:14:49,755 --> 00:14:52,424
but there, it really
became strange
377
00:14:52,491 --> 00:14:56,328
because the engine
performance increased
378
00:14:52,491 --> 00:14:56,328
because the engine
performance increased
379
00:14:56,395 --> 00:14:59,064
when I reduced the turbo.
380
00:14:59,131 --> 00:15:01,267
3,200 feet
above the ground,
381
00:15:01,333 --> 00:15:03,302
the emergency escalates.
382
00:15:01,333 --> 00:15:03,302
the emergency escalates.
383
00:15:05,738 --> 00:15:09,441
When we have flown a
little over one minute,
384
00:15:05,738 --> 00:15:09,441
When we have flown a
little over one minute,
385
00:15:09,508 --> 00:15:11,977
the right engine just went down.
386
00:15:14,313 --> 00:15:19,118
Two seconds later,
the left engine also quits.
387
00:15:19,184 --> 00:15:20,986
The plane loses all thrust.
388
00:15:19,184 --> 00:15:20,986
The plane loses all thrust.
389
00:15:23,455 --> 00:15:26,091
Less than a minute and
a half after takeoff,
390
00:15:23,455 --> 00:15:26,091
Less than a minute and
a half after takeoff,
391
00:15:26,158 --> 00:15:29,128
the MD81 begins
falling from the sky.
392
00:15:33,532 --> 00:15:35,301
And after that, it
was complete silence.
393
00:15:38,203 --> 00:15:43,208
And I think that was
the worst moment for me.
394
00:15:43,275 --> 00:15:44,443
Engine relay.
395
00:15:43,275 --> 00:15:44,443
Engine relay.
396
00:15:44,510 --> 00:15:46,211
The pilots
try to restart
397
00:15:46,278 --> 00:15:52,751
their engines, only to see the
left engine erupt in flames.
398
00:15:46,278 --> 00:15:52,751
their engines, only to see the
left engine erupt in flames.
399
00:15:55,654 --> 00:15:58,357
The fire could spread to
the rest of the plane.
400
00:15:58,424 --> 00:15:59,658
Should I pull?
401
00:15:59,725 --> 00:16:01,527
But if the
pilots activate the fire
402
00:15:59,725 --> 00:16:01,527
But if the
pilots activate the fire
403
00:16:01,593 --> 00:16:04,129
extinguisher in the
left engine, they
404
00:16:04,196 --> 00:16:05,631
won't be able to restart it.
405
00:16:09,068 --> 00:16:10,636
They decide to
extinguish the fire.
406
00:16:15,808 --> 00:16:22,781
Flight 751 is now falling at a
rate of 1,200 feet per minute.
407
00:16:15,808 --> 00:16:22,781
Flight 751 is now falling at a
rate of 1,200 feet per minute.
408
00:16:22,848 --> 00:16:25,284
We have problems
with our engines, please.
409
00:16:25,351 --> 00:16:27,019
We need to go back to...
410
00:16:25,351 --> 00:16:27,019
We need to go back to...
411
00:16:27,086 --> 00:16:28,420
to go back to Arlanda.
412
00:16:30,656 --> 00:16:31,657
751, Roger.
413
00:16:30,656 --> 00:16:31,657
751, Roger.
414
00:16:31,724 --> 00:16:33,092
Turn right heading to...
415
00:16:34,526 --> 00:16:36,662
Suddenly, the radio goes dead,
416
00:16:36,729 --> 00:16:38,430
a result of the engine failure.
417
00:16:36,729 --> 00:16:38,430
a result of the engine failure.
418
00:16:53,612 --> 00:16:55,180
How can I help?
419
00:16:55,247 --> 00:16:57,249
Captain Per
Holmberg steps in to assist.
420
00:16:55,247 --> 00:16:57,249
Captain Per
Holmberg steps in to assist.
421
00:16:59,551 --> 00:17:01,153
Like, he came
out in the cockpit
422
00:17:01,220 --> 00:17:03,389
and he said, is there
anything I can help you with?
423
00:17:01,220 --> 00:17:03,389
and he said, is there
anything I can help you with?
424
00:17:03,455 --> 00:17:07,426
I don't think I even said yes,
I said just said start the APU.
425
00:17:03,455 --> 00:17:07,426
I don't think I even said yes,
I said just said start the APU.
426
00:17:07,493 --> 00:17:09,628
He managed to start
the auxiliary power
427
00:17:09,695 --> 00:17:14,166
unit so my flight instruments
were supplied from that.
428
00:17:09,695 --> 00:17:14,166
unit so my flight instruments
were supplied from that.
429
00:17:14,233 --> 00:17:16,835
But for some reason,
Captain Rasmussen's instruments
430
00:17:16,902 --> 00:17:19,371
don't come back online.
431
00:17:19,438 --> 00:17:22,641
He managed to fly the
plane basically by feel.
432
00:17:22,708 --> 00:17:26,612
However, the APU
is powering the radio again.
433
00:17:22,708 --> 00:17:26,612
However, the APU
is powering the radio again.
434
00:17:26,678 --> 00:17:29,415
Stockholm air traffic
control instructs the pilots
435
00:17:29,481 --> 00:17:30,616
to return to the airport.
436
00:17:35,187 --> 00:17:40,159
But the plane is now just
1,600 feet from the ground.
437
00:17:35,187 --> 00:17:40,159
But the plane is now just
1,600 feet from the ground.
438
00:17:40,225 --> 00:17:43,195
Holmberg wants Rasmussen
to focus on finding a place
439
00:17:43,262 --> 00:17:46,098
to make an emergency landing.
440
00:17:43,262 --> 00:17:46,098
to make an emergency landing.
441
00:17:46,165 --> 00:17:47,466
Look straight ahead.
442
00:17:50,436 --> 00:17:52,638
Prepare for
on-ground emergency.
443
00:17:52,704 --> 00:17:54,239
On-ground emergency!
444
00:17:55,808 --> 00:17:57,409
Bend down.
445
00:17:57,476 --> 00:17:58,877
Bend down!
446
00:17:58,944 --> 00:18:00,212
Bend down!
447
00:18:00,279 --> 00:18:01,613
Captain Rasmussen finds
448
00:18:00,279 --> 00:18:01,613
Captain Rasmussen finds
449
00:18:01,680 --> 00:18:04,316
himself gliding without
power over a dense forest.
450
00:18:07,419 --> 00:18:11,723
I could use the trees
as almost like a pillow.
451
00:18:11,790 --> 00:18:13,625
Should I lower
the landing gear?
452
00:18:11,790 --> 00:18:13,625
Should I lower
the landing gear?
453
00:18:13,692 --> 00:18:15,394
Yes, gear down.
454
00:18:34,813 --> 00:18:38,717
Scandinavian Airlines
Flight 751 crashes nine miles
455
00:18:34,813 --> 00:18:38,717
Scandinavian Airlines
Flight 751 crashes nine miles
456
00:18:38,784 --> 00:18:40,819
Northeast of
Stockholm-Arlanada Airport.
457
00:18:45,691 --> 00:18:49,595
The fuselage is broken
into three pieces.
458
00:18:45,691 --> 00:18:49,595
The fuselage is broken
into three pieces.
459
00:18:49,661 --> 00:18:51,330
Rescuers arrive within minutes.
460
00:18:54,833 --> 00:18:56,835
92 of the passengers
are injured.
461
00:19:00,405 --> 00:19:03,275
But when a head
count is conducted,
462
00:19:03,342 --> 00:19:05,511
the crew learns that
not a single person
463
00:19:05,577 --> 00:19:06,678
was killed in the crash.
464
00:19:05,577 --> 00:19:06,678
was killed in the crash.
465
00:19:12,451 --> 00:19:15,487
Just honored to have
this captain in the world.
466
00:19:15,554 --> 00:19:18,257
We were all alive.
467
00:19:15,554 --> 00:19:18,257
We were all alive.
468
00:19:18,323 --> 00:19:20,225
It was a great moment.
469
00:19:20,292 --> 00:19:21,793
Sweden's
Accident Investigation
470
00:19:21,860 --> 00:19:23,595
Board takes charge of the case.
471
00:19:26,365 --> 00:19:28,400
They're joined by a
team of investigators
472
00:19:28,467 --> 00:19:32,237
from Scandinavian Airlines,
led by Tore Hultgren.
473
00:19:28,467 --> 00:19:32,237
from Scandinavian Airlines,
led by Tore Hultgren.
474
00:19:32,304 --> 00:19:37,943
It's most unusual that the
plane crashes in a wooded area
475
00:19:32,304 --> 00:19:37,943
It's most unusual that the
plane crashes in a wooded area
476
00:19:38,010 --> 00:19:39,444
and everybody survives.
477
00:19:39,511 --> 00:19:40,846
I've never heard of it before.
478
00:19:43,549 --> 00:19:47,286
We had a complete aircraft,
nothing had burnt.
479
00:19:47,352 --> 00:19:48,987
I mean, we had
lots of good data.
480
00:19:47,352 --> 00:19:48,987
I mean, we had
lots of good data.
481
00:19:50,355 --> 00:19:51,456
The plane's cockpit voice
482
00:19:51,523 --> 00:19:52,925
recorder and flight
data recorder
483
00:19:52,991 --> 00:19:57,329
are recovered for analysis.
484
00:19:52,991 --> 00:19:57,329
are recovered for analysis.
485
00:19:57,396 --> 00:19:59,631
In the meantime,
investigators interview
486
00:19:59,698 --> 00:20:00,899
the passengers and crew.
487
00:19:59,698 --> 00:20:00,899
the passengers and crew.
488
00:20:02,467 --> 00:20:05,604
Would you mind telling
me what you saw and heard?
489
00:20:05,671 --> 00:20:08,807
They recall hearing
repeated booming noises before
490
00:20:05,671 --> 00:20:08,807
They recall hearing
repeated booming noises before
491
00:20:08,874 --> 00:20:11,476
the left engine caught fire.
492
00:20:11,543 --> 00:20:15,013
The cockpit voice recorder
picked up those sounds.
493
00:20:11,543 --> 00:20:15,013
The cockpit voice recorder
picked up those sounds.
494
00:20:15,080 --> 00:20:18,817
We could correlate that
with when the damage occurred.
495
00:20:15,080 --> 00:20:18,817
We could correlate that
with when the damage occurred.
496
00:20:18,884 --> 00:20:21,954
You can see that on the
flight data recorder.
497
00:20:22,020 --> 00:20:24,423
For investigators,
the booming sounds
498
00:20:22,020 --> 00:20:24,423
For investigators,
the booming sounds
499
00:20:24,489 --> 00:20:28,327
are evidence that the
MD81's engines were surging.
500
00:20:28,393 --> 00:20:32,564
Jet engines rely on a steady
stream of air for combustion.
501
00:20:28,393 --> 00:20:32,564
Jet engines rely on a steady
stream of air for combustion.
502
00:20:32,631 --> 00:20:36,268
A series of fans moves incoming
air through various stages
503
00:20:32,631 --> 00:20:36,268
A series of fans moves incoming
air through various stages
504
00:20:36,335 --> 00:20:37,869
of compression.
505
00:20:37,936 --> 00:20:41,773
But when that flow is disrupted,
fuel at the rear of the engines
506
00:20:41,840 --> 00:20:45,377
ignites and shoots forward
in what's called a surge.
507
00:20:46,878 --> 00:20:49,848
This surge process
was very violent.
508
00:20:46,878 --> 00:20:49,848
This surge process
was very violent.
509
00:20:49,915 --> 00:20:52,951
So after a very short
time, we had an aircraft
510
00:20:53,018 --> 00:20:55,854
with two engines that
could not be restarted,
511
00:20:53,018 --> 00:20:55,854
with two engines that
could not be restarted,
512
00:20:55,921 --> 00:20:58,423
that didn't generate any thrust.
513
00:20:58,490 --> 00:21:02,628
Basically, you had a giant
glider at that point.
514
00:20:58,490 --> 00:21:02,628
Basically, you had a giant
glider at that point.
515
00:21:04,463 --> 00:21:06,565
What caused
the engines to surge?
516
00:21:04,463 --> 00:21:06,565
What caused
the engines to surge?
517
00:21:10,502 --> 00:21:13,071
A close look at the fan blades
from the front of the engines
518
00:21:10,502 --> 00:21:13,071
A close look at the fan blades
from the front of the engines
519
00:21:13,138 --> 00:21:14,906
provides an explanation.
520
00:21:19,378 --> 00:21:20,912
They're badly dented.
521
00:21:20,979 --> 00:21:23,949
The damage would have prevented
them from smoothly directing
522
00:21:20,979 --> 00:21:23,949
The damage would have prevented
them from smoothly directing
523
00:21:24,016 --> 00:21:25,550
air to the rear of the engines.
524
00:21:26,985 --> 00:21:29,087
This damage, the
twist of the fan blade,
525
00:21:29,154 --> 00:21:30,756
started this process.
526
00:21:29,154 --> 00:21:30,756
started this process.
527
00:21:30,822 --> 00:21:33,725
You got this disturbed
air in the fan.
528
00:21:33,792 --> 00:21:37,362
You got this rotating fan
stall that then triggered
529
00:21:33,792 --> 00:21:37,362
You got this rotating fan
stall that then triggered
530
00:21:37,429 --> 00:21:39,931
this whole breakdown,
the compressor surge,
531
00:21:39,998 --> 00:21:41,667
and then the whole
process that led
532
00:21:41,733 --> 00:21:43,802
up to the dual engine failures.
533
00:21:41,733 --> 00:21:43,802
up to the dual engine failures.
534
00:21:43,869 --> 00:21:46,772
But what
damaged the blades?
535
00:21:46,838 --> 00:21:49,341
There are ways to find out.
536
00:21:46,838 --> 00:21:49,341
There are ways to find out.
537
00:21:49,408 --> 00:21:52,644
If it comes from a stone,
rubber, ice, and so on,
538
00:21:52,711 --> 00:21:55,981
you can see it on the
shape of the damage.
539
00:21:52,711 --> 00:21:55,981
you can see it on the
shape of the damage.
540
00:21:56,048 --> 00:21:58,517
Analysis of dent
patterns on the fan blades
541
00:21:58,583 --> 00:21:59,685
is conclusive.
542
00:21:59,751 --> 00:22:01,720
They were struck by ice.
543
00:21:59,751 --> 00:22:01,720
They were struck by ice.
544
00:22:01,787 --> 00:22:04,656
The ice
causes very specific damages.
545
00:22:04,723 --> 00:22:06,458
It's sort of like a soft dent.
546
00:22:04,723 --> 00:22:06,458
It's sort of like a soft dent.
547
00:22:11,697 --> 00:22:13,598
Investigators need to discover
548
00:22:11,697 --> 00:22:13,598
Investigators need to discover
549
00:22:13,665 --> 00:22:16,501
where the ice came from.
550
00:22:16,568 --> 00:22:19,571
They learn that the
MD81 arrived from Zurich
551
00:22:16,568 --> 00:22:19,571
They learn that the
MD81 arrived from Zurich
552
00:22:19,638 --> 00:22:22,641
the night before with its fuel
tanks more than half full.
553
00:22:24,476 --> 00:22:27,012
The fuel in the
wing tanks were
554
00:22:27,079 --> 00:22:29,114
close to -20 degrees Celsius.
555
00:22:32,184 --> 00:22:33,852
The frigid
conditions were
556
00:22:33,919 --> 00:22:37,389
ideal for the formation of
clear ice on the wing surface.
557
00:22:33,919 --> 00:22:37,389
ideal for the formation of
clear ice on the wing surface.
558
00:22:37,456 --> 00:22:41,560
And here, you had very, very
cold fuel on the top wing skin.
559
00:22:41,626 --> 00:22:43,862
And as the temperature
dropped during the night,
560
00:22:41,626 --> 00:22:43,862
And as the temperature
dropped during the night,
561
00:22:43,929 --> 00:22:48,533
it went to snow and
rain, and finally snow.
562
00:22:43,929 --> 00:22:48,533
it went to snow and
rain, and finally snow.
563
00:22:48,600 --> 00:22:52,938
Got 10 inches total on top
of the wings in the morning.
564
00:22:53,004 --> 00:22:54,906
Investigators wonder if the pilot
565
00:22:53,004 --> 00:22:54,906
Investigators wonder if the pilot
566
00:22:54,973 --> 00:22:57,109
did all he could
to ensure his plane
567
00:22:57,175 --> 00:22:59,911
was completely free of ice.
568
00:22:57,175 --> 00:22:59,911
was completely free of ice.
569
00:22:59,978 --> 00:23:02,814
Rasmussen claims he
instructed technicians
570
00:23:02,881 --> 00:23:05,851
to de-ice the plane thoroughly.
571
00:23:02,881 --> 00:23:05,851
to de-ice the plane thoroughly.
572
00:23:05,917 --> 00:23:08,420
Noticing there was still
frost on the wings,
573
00:23:08,487 --> 00:23:11,990
the head technician also
ordered a second round.
574
00:23:08,487 --> 00:23:11,990
the head technician also
ordered a second round.
575
00:23:12,057 --> 00:23:14,493
Where are
we now with the de-icing?
576
00:23:14,559 --> 00:23:15,861
The wings aren't quite done.
577
00:23:15,927 --> 00:23:17,429
They've done the underside.
Now they're...
578
00:23:17,496 --> 00:23:18,597
The cockpit
voice recorder
579
00:23:17,496 --> 00:23:18,597
The cockpit
voice recorder
580
00:23:18,663 --> 00:23:20,565
backs up Rasmussen's testimony.
581
00:23:20,632 --> 00:23:22,634
You've got it
good and clean under the wings?
582
00:23:22,701 --> 00:23:24,069
Yes, yes.
583
00:23:22,701 --> 00:23:24,069
Yes, yes.
584
00:23:24,136 --> 00:23:25,670
The ground crew insists
585
00:23:25,737 --> 00:23:27,239
that after they
sprayed the wings,
586
00:23:27,305 --> 00:23:29,841
they appeared to be clean.
587
00:23:27,305 --> 00:23:29,841
they appeared to be clean.
588
00:23:29,908 --> 00:23:33,512
But that appearance
was deceptive.
589
00:23:33,578 --> 00:23:35,714
It looked perfect
because the clear
590
00:23:35,781 --> 00:23:40,786
ice on top of the fuel tanks,
you cannot see the clear ice.
591
00:23:40,852 --> 00:23:42,788
A technician
inspected the front of the wing
592
00:23:40,852 --> 00:23:42,788
A technician
inspected the front of the wing
593
00:23:42,854 --> 00:23:44,990
and found no ice.
594
00:23:45,056 --> 00:23:47,626
But further back
beyond his reach,
595
00:23:47,692 --> 00:23:50,061
the situation was different.
596
00:23:47,692 --> 00:23:50,061
the situation was different.
597
00:23:50,128 --> 00:23:54,766
But still, there was maybe an
inch of ice on top of the wing
598
00:23:50,128 --> 00:23:54,766
But still, there was maybe an
inch of ice on top of the wing
599
00:23:54,833 --> 00:23:56,802
when the aircraft took off.
600
00:23:56,868 --> 00:24:00,906
As soon as the plane
took off, ice became a problem.
601
00:23:56,868 --> 00:24:00,906
As soon as the plane
took off, ice became a problem.
602
00:24:00,972 --> 00:24:03,575
On this aircraft,
the engines are
603
00:24:03,642 --> 00:24:06,711
positioned behind the wings.
604
00:24:03,642 --> 00:24:06,711
positioned behind the wings.
605
00:24:06,778 --> 00:24:10,882
And as the aircraft rotated
and the wings bent in order
606
00:24:10,949 --> 00:24:13,084
to take the weight
of the aircraft,
607
00:24:10,949 --> 00:24:13,084
to take the weight
of the aircraft,
608
00:24:13,151 --> 00:24:16,955
this ice in the wing
roots loosened and it
609
00:24:17,022 --> 00:24:19,057
sucked right into the engine.
610
00:24:17,022 --> 00:24:19,057
sucked right into the engine.
611
00:24:19,124 --> 00:24:20,792
The ice
damaged the fan
612
00:24:20,859 --> 00:24:23,295
blades at the front of the
engine, causing them to surge.
613
00:24:27,265 --> 00:24:32,137
Nobody really expected this
would happen or could happen,
614
00:24:27,265 --> 00:24:32,137
Nobody really expected this
would happen or could happen,
615
00:24:32,204 --> 00:24:33,104
but it did.
616
00:24:35,207 --> 00:24:37,075
Now investigators wonder,
617
00:24:35,207 --> 00:24:37,075
Now investigators wonder,
618
00:24:37,142 --> 00:24:40,278
did the pilots respond
correctly to the search,
619
00:24:40,345 --> 00:24:42,681
or did they make
the situation worse?
620
00:24:40,345 --> 00:24:42,681
or did they make
the situation worse?
621
00:24:45,383 --> 00:24:47,018
They combed through
the flight data
622
00:24:47,085 --> 00:24:50,655
to track what the pilots did
when the emergency struck.
623
00:24:47,085 --> 00:24:50,655
to track what the pilots did
when the emergency struck.
624
00:24:50,722 --> 00:24:53,625
The first thing you do
when you have a search,
625
00:24:53,692 --> 00:24:56,595
if you recognize
this at the search,
626
00:24:53,692 --> 00:24:56,595
if you recognize
this at the search,
627
00:24:56,661 --> 00:24:57,963
is that you reduce power.
628
00:25:00,298 --> 00:25:02,667
Of course, you just
pull the throttle back.
629
00:25:02,734 --> 00:25:06,137
And that was
actually what I did.
630
00:25:02,734 --> 00:25:06,137
And that was
actually what I did.
631
00:25:06,204 --> 00:25:07,772
But the
flight data recorder
632
00:25:07,839 --> 00:25:09,708
tells a different story.
633
00:25:09,774 --> 00:25:11,910
Why is the engine
power increasing?
634
00:25:09,774 --> 00:25:11,910
Why is the engine
power increasing?
635
00:25:11,977 --> 00:25:15,247
It clearly shows that
in the moments after the surge,
636
00:25:15,313 --> 00:25:20,051
thrust was reduced, but seconds
later increased to full power.
637
00:25:15,313 --> 00:25:20,051
thrust was reduced, but seconds
later increased to full power.
638
00:25:22,654 --> 00:25:26,258
And the throttle position was
moving, and it shouldn't be.
639
00:25:22,654 --> 00:25:26,258
And the throttle position was
moving, and it shouldn't be.
640
00:25:26,324 --> 00:25:28,793
The only thing that could
move the throttle up
641
00:25:28,860 --> 00:25:29,895
was the pilot's hand.
642
00:25:28,860 --> 00:25:29,895
was the pilot's hand.
643
00:25:32,330 --> 00:25:34,733
But if Rasmussen
didn't push the throttles
644
00:25:34,799 --> 00:25:36,935
forward himself, what did?
645
00:25:34,799 --> 00:25:36,935
forward himself, what did?
646
00:25:40,272 --> 00:25:44,309
Investigators consult with the
MD81's manufacturer to find out
647
00:25:40,272 --> 00:25:44,309
Investigators consult with the
MD81's manufacturer to find out
648
00:25:44,376 --> 00:25:47,345
what could have caused Flight
751's throttles to increase
649
00:25:47,412 --> 00:25:51,850
power shortly before the crash.
650
00:25:47,412 --> 00:25:51,850
power shortly before the crash.
651
00:25:51,917 --> 00:25:55,654
The answer is something called
automatic thrust restoration,
652
00:25:51,917 --> 00:25:55,654
The answer is something called
automatic thrust restoration,
653
00:25:55,720 --> 00:25:57,389
or ATR.
654
00:25:57,455 --> 00:25:59,090
It's brand new.
655
00:25:59,157 --> 00:26:02,260
It automatically increases
the thrust during the climb.
656
00:25:59,157 --> 00:26:02,260
It automatically increases
the thrust during the climb.
657
00:26:02,327 --> 00:26:04,296
ATR was
recently introduced
658
00:26:04,362 --> 00:26:08,633
as a safety feature on
Scandinavian Airlines planes.
659
00:26:04,362 --> 00:26:08,633
as a safety feature on
Scandinavian Airlines planes.
660
00:26:08,700 --> 00:26:11,670
It was designed to stop
pilots from throttling back
661
00:26:11,736 --> 00:26:13,772
to dangerous levels
in an effort to reduce
662
00:26:11,736 --> 00:26:13,772
to dangerous levels
in an effort to reduce
663
00:26:13,838 --> 00:26:15,307
noise over residential areas.
664
00:26:18,710 --> 00:26:22,881
So as soon as he powered
back, the system kicked in.
665
00:26:22,948 --> 00:26:25,884
Investigators learned
that when Rasmussen reduced
666
00:26:22,948 --> 00:26:25,884
Investigators learned
that when Rasmussen reduced
667
00:26:25,951 --> 00:26:30,689
power to clear his engine surge,
the ATR system recognized this
668
00:26:25,951 --> 00:26:30,689
power to clear his engine surge,
the ATR system recognized this
669
00:26:30,755 --> 00:26:32,857
as a dangerously
low power setting
670
00:26:32,924 --> 00:26:35,827
and automatically pushed
the throttles forward.
671
00:26:32,924 --> 00:26:35,827
and automatically pushed
the throttles forward.
672
00:26:35,894 --> 00:26:39,130
The increased thrust
made the surging worse.
673
00:26:39,197 --> 00:26:41,266
And it went on to
self-destruct both engines.
674
00:26:41,333 --> 00:26:45,737
In a few seconds, they were
both totally destroyed.
675
00:26:41,333 --> 00:26:45,737
In a few seconds, they were
both totally destroyed.
676
00:26:56,848 --> 00:27:00,051
The system was so
new that no one at Scandinavian
677
00:26:56,848 --> 00:27:00,051
The system was so
new that no one at Scandinavian
678
00:27:00,118 --> 00:27:01,853
Airlines was aware
that it had been
679
00:27:01,920 --> 00:27:03,989
installed on their airplanes.
680
00:27:04,055 --> 00:27:05,857
We hadn't bought
that modification
681
00:27:04,055 --> 00:27:05,857
We hadn't bought
that modification
682
00:27:05,924 --> 00:27:09,961
and it was sneaked in
via another system.
683
00:27:14,366 --> 00:27:17,102
The investigation
concludes that the pilots
684
00:27:17,168 --> 00:27:19,371
followed the right
procedures to clear the surge
685
00:27:17,168 --> 00:27:19,371
followed the right
procedures to clear the surge
686
00:27:19,437 --> 00:27:22,407
and prevent the catastrophe.
687
00:27:22,474 --> 00:27:24,976
But the ATR undermined
their efforts.
688
00:27:22,474 --> 00:27:24,976
But the ATR undermined
their efforts.
689
00:27:29,814 --> 00:27:32,851
In the wake of the crash,
Scandinavian Airlines
690
00:27:32,917 --> 00:27:37,122
began training pilots in
how to use the ATR system.
691
00:27:32,917 --> 00:27:37,122
began training pilots in
how to use the ATR system.
692
00:27:37,188 --> 00:27:40,392
They also implemented procedures
to ensure their airplanes
693
00:27:40,458 --> 00:27:44,362
don't take off with
clear ice on the wings.
694
00:27:40,458 --> 00:27:44,362
don't take off with
clear ice on the wings.
695
00:27:44,429 --> 00:27:46,364
We changed all the procedures.
696
00:27:46,431 --> 00:27:49,434
It provided stairs
for the mechanic,
697
00:27:46,431 --> 00:27:49,434
It provided stairs
for the mechanic,
698
00:27:49,501 --> 00:27:52,837
and we made it a requirement
to go up on top of the wing
699
00:27:52,904 --> 00:27:58,009
and touch it with your hand
to verify after de-icing.
700
00:27:52,904 --> 00:27:58,009
and touch it with your hand
to verify after de-icing.
701
00:27:58,076 --> 00:28:00,278
As planes
travel further North,
702
00:27:58,076 --> 00:28:00,278
As planes
travel further North,
703
00:28:00,345 --> 00:28:03,815
they have to contend with
more than just snow and ice.
704
00:28:03,882 --> 00:28:05,517
Go around!
705
00:28:05,583 --> 00:28:07,352
Flying in the high Arctic
706
00:28:05,583 --> 00:28:07,352
Flying in the high Arctic
707
00:28:07,419 --> 00:28:09,187
presents another unseen danger.
708
00:28:12,857 --> 00:28:17,395
26,000ft over Canada's
Nunavut territory.
709
00:28:20,331 --> 00:28:23,468
CYRB military, this
is First Air 6560.
710
00:28:23,535 --> 00:28:25,970
CYRB Military, ETA at resolute.
711
00:28:23,535 --> 00:28:25,970
CYRB Military, ETA at resolute.
712
00:28:26,037 --> 00:28:27,806
16:43.
713
00:28:27,872 --> 00:28:33,545
First Air Flight 6560
is approaching Resolute Bay.
714
00:28:27,872 --> 00:28:33,545
First Air Flight 6560
is approaching Resolute Bay.
715
00:28:33,611 --> 00:28:36,981
The remote community is
home to about 200 residents.
716
00:28:33,611 --> 00:28:36,981
The remote community is
home to about 200 residents.
717
00:28:39,250 --> 00:28:42,353
The land is well
above the tree line.
718
00:28:39,250 --> 00:28:42,353
The land is well
above the tree line.
719
00:28:42,420 --> 00:28:43,788
It's very barren.
720
00:28:43,855 --> 00:28:45,090
There's nothing on it.
721
00:28:45,156 --> 00:28:47,859
There's no tundra, no plants.
722
00:28:45,156 --> 00:28:47,859
There's no tundra, no plants.
723
00:28:47,926 --> 00:28:51,129
It's just sand and rock.
724
00:28:51,196 --> 00:28:54,065
The 737 charter
is carrying cargo along
725
00:28:51,196 --> 00:28:54,065
The 737 charter
is carrying cargo along
726
00:28:54,132 --> 00:28:56,034
with 11 passengers and 4 crew.
727
00:28:59,537 --> 00:29:04,309
Flight 6560 left Yellowknife
an hour and a half earlier.
728
00:28:59,537 --> 00:29:04,309
Flight 6560 left Yellowknife
an hour and a half earlier.
729
00:29:04,375 --> 00:29:08,446
It's due to land in
approximately 30 minutes.
730
00:29:04,375 --> 00:29:08,446
It's due to land in
approximately 30 minutes.
731
00:29:08,513 --> 00:29:10,882
Wind 180 degrees at 8 knots.
732
00:29:12,650 --> 00:29:14,819
First Officer
David Hare joined
733
00:29:14,886 --> 00:29:16,254
First Air four years ago.
734
00:29:20,258 --> 00:29:21,860
Ah, there we go.
735
00:29:21,926 --> 00:29:23,294
The captain,
Blair Rutherford,
736
00:29:23,361 --> 00:29:27,132
has been with the airline
for more than 15 years.
737
00:29:23,361 --> 00:29:27,132
has been with the airline
for more than 15 years.
738
00:29:27,198 --> 00:29:29,167
OK, let's go
over the approach.
739
00:29:29,234 --> 00:29:30,902
OK,
740
00:29:29,234 --> 00:29:30,902
OK,
741
00:29:30,969 --> 00:29:33,438
Today, Resolute Bay
is blanketed in heavy fog,
742
00:29:33,505 --> 00:29:35,974
so the crew will be
relying on their autopilot
743
00:29:33,505 --> 00:29:35,974
so the crew will be
relying on their autopilot
744
00:29:36,040 --> 00:29:37,175
during the approach.
745
00:29:37,242 --> 00:29:39,177
Checklist complete.
746
00:29:39,244 --> 00:29:42,147
Autopilot set.
747
00:29:39,244 --> 00:29:42,147
Autopilot set.
748
00:29:43,648 --> 00:29:45,316
This way, they don't
have to worry about lining
749
00:29:45,383 --> 00:29:47,585
up with the runway visually.
750
00:29:47,652 --> 00:29:50,021
The plane's computer
will maintain control
751
00:29:47,652 --> 00:29:50,021
The plane's computer
will maintain control
752
00:29:50,088 --> 00:29:51,289
until they're ready to land.
753
00:29:57,529 --> 00:30:01,366
At 11:40 AM, Flight 6560
begins its final approach
754
00:29:57,529 --> 00:30:01,366
At 11:40 AM, Flight 6560
begins its final approach
755
00:30:01,432 --> 00:30:02,300
to the runway.
756
00:30:04,602 --> 00:30:07,472
First Air 6560, we're
three miles out on final.
757
00:30:04,602 --> 00:30:07,472
First Air 6560, we're
three miles out on final.
758
00:30:11,276 --> 00:30:14,479
Uh, we're over
the shoreline now.
759
00:30:11,276 --> 00:30:14,479
Uh, we're over
the shoreline now.
760
00:30:14,546 --> 00:30:15,413
All right.
761
00:30:22,387 --> 00:30:24,022
Oh.
762
00:30:22,387 --> 00:30:24,022
Oh.
763
00:30:24,088 --> 00:30:26,958
Suddenly, the low
altitude warning goes off.
764
00:30:27,025 --> 00:30:27,625
Go around.
765
00:30:27,692 --> 00:30:28,560
Go for it.
766
00:30:34,732 --> 00:30:36,067
Go around.
767
00:30:34,732 --> 00:30:36,067
Go around.
768
00:30:36,134 --> 00:30:37,202
Go around thrust.
769
00:30:46,277 --> 00:30:47,979
Ahh!
770
00:30:48,046 --> 00:30:51,649
Flight 6560 is too
low and slams into the ground
771
00:30:48,046 --> 00:30:51,649
Flight 6560 is too
low and slams into the ground
772
00:30:51,716 --> 00:30:53,918
at 180 miles an hour.
773
00:31:00,258 --> 00:31:03,261
The plane skids across
the crest of the hill...
774
00:31:00,258 --> 00:31:03,261
The plane skids across
the crest of the hill...
775
00:31:05,296 --> 00:31:06,464
...and bursts into flames.
776
00:31:11,302 --> 00:31:13,972
A 737 has just gone
down at Resolute Bay.
777
00:31:14,038 --> 00:31:15,440
No duff.
778
00:31:14,038 --> 00:31:15,440
No duff.
779
00:31:15,506 --> 00:31:18,276
By coincidence,
a military flight heading
780
00:31:18,343 --> 00:31:20,578
to Resolute Bay is
carrying air crash
781
00:31:20,645 --> 00:31:25,283
investigators from Canada's
Transportation Safety Board.
782
00:31:20,645 --> 00:31:25,283
investigators from Canada's
Transportation Safety Board.
783
00:31:25,350 --> 00:31:27,352
They're participating
in an armed forces
784
00:31:25,350 --> 00:31:27,352
They're participating
in an armed forces
785
00:31:27,418 --> 00:31:32,257
exercise simulating an
air accident in the North.
786
00:31:32,323 --> 00:31:35,460
But suddenly, they're
dealing with the real thing.
787
00:31:32,323 --> 00:31:35,460
But suddenly, they're
dealing with the real thing.
788
00:31:35,526 --> 00:31:37,128
We need to hit
the ground running.
789
00:31:48,106 --> 00:31:50,275
Rescuers arrive at the crash site
790
00:31:50,341 --> 00:31:53,411
and discover three
passengers have survived.
791
00:31:50,341 --> 00:31:53,411
and discover three
passengers have survived.
792
00:31:58,049 --> 00:32:01,052
The other 12 people on
board, including both pilots,
793
00:32:01,119 --> 00:32:01,786
are dead.
794
00:32:06,291 --> 00:32:07,525
Are you guys with the TSB?
795
00:32:07,592 --> 00:32:09,127
Show me what you got.
796
00:32:07,592 --> 00:32:09,127
Show me what you got.
797
00:32:09,193 --> 00:32:10,628
It's up
to investigator
798
00:32:10,695 --> 00:32:14,465
Brian MacDonald and his team
to find out what happened.
799
00:32:14,532 --> 00:32:16,000
We're here.
800
00:32:14,532 --> 00:32:16,000
We're here.
801
00:32:16,067 --> 00:32:18,236
They came down here,
two clicks East.
802
00:32:20,405 --> 00:32:21,706
They got pretty
close to the runway.
803
00:32:20,405 --> 00:32:21,706
They got pretty
close to the runway.
804
00:32:23,574 --> 00:32:24,742
The plane's cockpit voice
805
00:32:24,809 --> 00:32:26,444
recorder and flight
data recorder are
806
00:32:26,511 --> 00:32:29,080
recovered from the wreckage.
807
00:32:26,511 --> 00:32:29,080
recovered from the wreckage.
808
00:32:29,147 --> 00:32:31,716
We were able to get
them on an aircraft
809
00:32:31,783 --> 00:32:36,321
and down to our laboratory in
Ottawa on the following day.
810
00:32:31,783 --> 00:32:36,321
and down to our laboratory in
Ottawa on the following day.
811
00:32:36,387 --> 00:32:38,156
While they
wait for the data,
812
00:32:38,222 --> 00:32:40,525
the team tracks the
flight's final moments
813
00:32:38,222 --> 00:32:40,525
the team tracks the
flight's final moments
814
00:32:40,591 --> 00:32:42,593
using records from
a temporary radar
815
00:32:42,660 --> 00:32:46,064
system set up by the military.
816
00:32:42,660 --> 00:32:46,064
system set up by the military.
817
00:32:46,130 --> 00:32:48,700
They immediately discover
something unusual.
818
00:32:48,766 --> 00:32:49,834
Where the hell are they going?
819
00:32:52,670 --> 00:32:56,507
The radar shows
Flight 6560 was flying parallel
820
00:32:56,574 --> 00:32:58,343
to the runway when it crashed.
821
00:32:56,574 --> 00:32:58,343
to the runway when it crashed.
822
00:33:00,511 --> 00:33:01,746
Why?
823
00:33:01,813 --> 00:33:06,184
Why did the aircraft
track in that direction?
824
00:33:01,813 --> 00:33:06,184
Why did the aircraft
track in that direction?
825
00:33:06,250 --> 00:33:08,486
The 737's
autopilot should have
826
00:33:08,553 --> 00:33:10,755
guided the plane to the runway.
827
00:33:08,553 --> 00:33:10,755
guided the plane to the runway.
828
00:33:10,822 --> 00:33:14,325
Why did it crash into a hill
more than a mile away instead?
829
00:33:21,833 --> 00:33:24,769
All right, let's see what
these guys were thinking.
830
00:33:24,836 --> 00:33:28,239
The TSB's John
Stewart needs to find out why
831
00:33:24,836 --> 00:33:28,239
The TSB's John
Stewart needs to find out why
832
00:33:28,306 --> 00:33:31,809
Flight 6560 drifted off course.
833
00:33:31,876 --> 00:33:36,314
He listens to the cockpit
voice recorder for clues.
834
00:33:31,876 --> 00:33:36,314
He listens to the cockpit
voice recorder for clues.
835
00:33:36,381 --> 00:33:38,182
GPS has
us going off to the right.
836
00:33:43,755 --> 00:33:45,723
The first officer knew
they were off course.
837
00:33:43,755 --> 00:33:45,723
The first officer knew
they were off course.
838
00:33:49,394 --> 00:33:52,663
So, uh, are we too
far to the right?
839
00:33:49,394 --> 00:33:52,663
So, uh, are we too
far to the right?
840
00:33:54,632 --> 00:33:55,533
We'll get there.
841
00:33:58,736 --> 00:34:02,607
If we're going right, Resolute
Hill is right of the runway.
842
00:34:02,673 --> 00:34:05,309
Not only did the
first officer realize they were
843
00:34:02,673 --> 00:34:05,309
Not only did the
first officer realize they were
844
00:34:05,376 --> 00:34:07,745
off course, he knew
they were headed
845
00:34:07,812 --> 00:34:09,380
toward a hill near the runway.
846
00:34:07,812 --> 00:34:09,380
toward a hill near the runway.
847
00:34:12,683 --> 00:34:14,585
But the plane's
autopilot system should
848
00:34:14,652 --> 00:34:17,288
have been locked onto
Resolute Airport's instrument
849
00:34:14,652 --> 00:34:17,288
have been locked onto
Resolute Airport's instrument
850
00:34:17,355 --> 00:34:19,290
landing system, the ILS.
851
00:34:25,496 --> 00:34:29,200
The ILS emits a signal
known as a localizer beam.
852
00:34:25,496 --> 00:34:29,200
The ILS emits a signal
known as a localizer beam.
853
00:34:29,267 --> 00:34:32,303
It can be picked up by the
plane's autopilot to navigate
854
00:34:32,370 --> 00:34:33,771
the plane safely to the runway.
855
00:34:32,370 --> 00:34:33,771
the plane safely to the runway.
856
00:34:36,240 --> 00:34:37,675
We're not on the localizer.
857
00:34:37,742 --> 00:34:38,876
Ah, we're fine.
858
00:34:37,742 --> 00:34:38,876
Ah, we're fine.
859
00:34:38,943 --> 00:34:41,712
The autopilot is
tracking the localizer.
860
00:34:41,779 --> 00:34:43,347
I think we should
abandon the approach,
861
00:34:43,414 --> 00:34:44,749
go around, and sort this out.
862
00:34:44,816 --> 00:34:46,150
No, we're good.
863
00:34:44,816 --> 00:34:46,150
No, we're good.
864
00:34:46,217 --> 00:34:48,352
We'll continue the approach.
865
00:34:48,419 --> 00:34:49,287
OK.
866
00:34:51,622 --> 00:34:52,523
Continuing approach.
867
00:34:53,925 --> 00:34:56,194
The captain is
confident the autopilot will
868
00:34:56,260 --> 00:34:58,763
adjust their course
for the runway.
869
00:34:56,260 --> 00:34:58,763
adjust their course
for the runway.
870
00:34:58,830 --> 00:35:00,498
But then...
871
00:35:00,565 --> 00:35:01,332
Go around.
872
00:35:01,399 --> 00:35:02,266
Go for it!
873
00:35:04,902 --> 00:35:05,837
Go around.
874
00:35:05,903 --> 00:35:06,804
Go around thrust!
875
00:35:13,277 --> 00:35:15,680
The ILS beacon
should have guided the plane
876
00:35:13,277 --> 00:35:15,680
The ILS beacon
should have guided the plane
877
00:35:15,746 --> 00:35:16,914
all the way to the runway.
878
00:35:20,751 --> 00:35:23,721
Investigators need to find
out why that didn't happen.
879
00:35:20,751 --> 00:35:23,721
Investigators need to find
out why that didn't happen.
880
00:35:26,557 --> 00:35:28,493
We had the, uh,
download information
881
00:35:26,557 --> 00:35:28,493
We had the, uh,
download information
882
00:35:28,559 --> 00:35:31,596
from the flight data recorders.
883
00:35:31,662 --> 00:35:34,432
OK, pitch up two degrees.
884
00:35:31,662 --> 00:35:34,432
OK, pitch up two degrees.
885
00:35:34,499 --> 00:35:36,634
Using the
flight recorder data...
886
00:35:36,701 --> 00:35:39,971
Speed to 168 knots.
887
00:35:36,701 --> 00:35:39,971
Speed to 168 knots.
888
00:35:40,037 --> 00:35:42,373
...the team
retraces the plane's approach
889
00:35:42,440 --> 00:35:44,375
to Resolute Bay.
890
00:35:44,442 --> 00:35:45,576
Turn left two degrees.
891
00:35:44,442 --> 00:35:45,576
Turn left two degrees.
892
00:35:50,581 --> 00:35:52,984
But on the final
turn toward the runway,
893
00:35:50,581 --> 00:35:52,984
But on the final
turn toward the runway,
894
00:35:53,050 --> 00:35:55,019
they identify the
critical moment.
895
00:35:57,922 --> 00:36:00,324
That's where it
started to go wrong.
896
00:36:00,391 --> 00:36:04,595
They turned too wide and
never got back on the beam.
897
00:36:00,391 --> 00:36:04,595
They turned too wide and
never got back on the beam.
898
00:36:04,662 --> 00:36:06,531
What happened
during the turn
899
00:36:06,597 --> 00:36:08,900
that sent the plane off course?
900
00:36:06,597 --> 00:36:08,900
that sent the plane off course?
901
00:36:08,966 --> 00:36:12,336
To carry out the ILS landing...
902
00:36:12,403 --> 00:36:14,872
Autopilot set.
903
00:36:12,403 --> 00:36:14,872
Autopilot set.
904
00:36:18,042 --> 00:36:21,546
...the crew needed to
set their autopilot to a mode...
905
00:36:18,042 --> 00:36:21,546
...the crew needed to
set their autopilot to a mode...
906
00:36:21,612 --> 00:36:22,880
Localizer alive.
907
00:36:22,947 --> 00:36:25,416
...which locks
it onto the ILS signal.
908
00:36:28,319 --> 00:36:31,656
Let me just see the
control wheel inputs.
909
00:36:31,722 --> 00:36:36,627
So the turn started out OK,
nice and smooth through here.
910
00:36:31,722 --> 00:36:36,627
So the turn started out OK,
nice and smooth through here.
911
00:36:36,694 --> 00:36:39,964
Definitely the
autopilot in control.
912
00:36:36,694 --> 00:36:39,964
Definitely the
autopilot in control.
913
00:36:40,031 --> 00:36:45,269
But during the
final turn, the data changes.
914
00:36:40,031 --> 00:36:45,269
But during the
final turn, the data changes.
915
00:36:45,336 --> 00:36:48,839
These jagged corrections
have got to be human.
916
00:36:48,906 --> 00:36:51,809
They must have been
flying on manual.
917
00:36:48,906 --> 00:36:51,809
They must have been
flying on manual.
918
00:36:51,876 --> 00:36:53,744
Sometime during the turn,
919
00:36:53,811 --> 00:36:56,781
control of the plane
switched to manual.
920
00:36:56,847 --> 00:37:00,451
The autopilot wasn't locked
in any longer to the localizer
921
00:37:00,518 --> 00:37:02,553
beam.
922
00:37:02,620 --> 00:37:04,655
Without ILS, the pilots
923
00:37:02,620 --> 00:37:04,655
Without ILS, the pilots
924
00:37:04,722 --> 00:37:06,357
would have to
depend on their eyes
925
00:37:06,424 --> 00:37:08,492
to line up with the
runway in heavy fog.
926
00:37:10,995 --> 00:37:14,966
Who or what changed the
control mode, and why?
927
00:37:10,995 --> 00:37:14,966
Who or what changed the
control mode, and why?
928
00:37:15,032 --> 00:37:17,969
Investigators hear nothing
on the cockpit voice recorder
929
00:37:18,035 --> 00:37:19,904
to indicate the
captain switched off
930
00:37:19,971 --> 00:37:22,573
the autopilot intentionally.
931
00:37:19,971 --> 00:37:22,573
the autopilot intentionally.
932
00:37:22,640 --> 00:37:25,977
But there's another possibility.
933
00:37:26,043 --> 00:37:29,046
Autopilot systems have
built-in capability for pilots
934
00:37:26,043 --> 00:37:29,046
Autopilot systems have
built-in capability for pilots
935
00:37:29,113 --> 00:37:31,515
to override it,
the aircraft is not
936
00:37:31,582 --> 00:37:35,052
reacting quick enough or it's
doing something too quickly.
937
00:37:31,582 --> 00:37:35,052
reacting quick enough or it's
doing something too quickly.
938
00:37:35,119 --> 00:37:38,022
Flight data reveals
a slight pressure was applied
939
00:37:38,089 --> 00:37:41,692
to the captain's control
column, just enough to trigger
940
00:37:38,089 --> 00:37:41,692
to the captain's control
column, just enough to trigger
941
00:37:41,759 --> 00:37:44,495
the switch to manual.
942
00:37:44,562 --> 00:37:47,031
We believe it was likely
an inadvertent pressure
943
00:37:44,562 --> 00:37:47,031
We believe it was likely
an inadvertent pressure
944
00:37:47,098 --> 00:37:48,666
on the wheel.
945
00:37:48,733 --> 00:37:53,037
Perhaps someone was leaning
over to check something.
946
00:37:48,733 --> 00:37:53,037
Perhaps someone was leaning
over to check something.
947
00:37:53,104 --> 00:37:55,673
With neither
the autopilot nor the crew
948
00:37:55,740 --> 00:37:57,642
steering the plane
toward the runway,
949
00:37:55,740 --> 00:37:57,642
steering the plane
toward the runway,
950
00:37:57,708 --> 00:38:01,345
the wind began
pushing it off course.
951
00:38:04,915 --> 00:38:08,586
So, um, aren't we
too far to the right?
952
00:38:08,653 --> 00:38:10,821
The first officer
noticed the problem.
953
00:38:08,653 --> 00:38:10,821
The first officer
noticed the problem.
954
00:38:10,888 --> 00:38:14,358
Investigators now want to
know, why didn't the captain
955
00:38:14,425 --> 00:38:15,693
do something about it?
956
00:38:14,425 --> 00:38:15,693
do something about it?
957
00:38:21,699 --> 00:38:22,767
Let's see what
this flight looked
958
00:38:22,833 --> 00:38:25,603
like from inside the cockpit.
959
00:38:22,833 --> 00:38:25,603
like from inside the cockpit.
960
00:38:25,670 --> 00:38:28,439
Investigators want
to know what the captain was
961
00:38:28,506 --> 00:38:30,374
seeing and hearing
in the moments
962
00:38:30,441 --> 00:38:34,078
leading up to the
crash of Flight 6560.
963
00:38:30,441 --> 00:38:34,078
leading up to the
crash of Flight 6560.
964
00:38:34,145 --> 00:38:37,515
They combine information from
both the flight data recorder
965
00:38:34,145 --> 00:38:37,515
They combine information from
both the flight data recorder
966
00:38:37,581 --> 00:38:41,552
and cockpit voice recorder
to recreate the journey
967
00:38:41,619 --> 00:38:43,821
on a dashboard simulation.
968
00:38:41,619 --> 00:38:43,821
on a dashboard simulation.
969
00:38:43,888 --> 00:38:45,623
The key thing
that we try to do
970
00:38:45,690 --> 00:38:49,660
is to understand why events made
sense from their point of view.
971
00:38:45,690 --> 00:38:49,660
is to understand why events made
sense from their point of view.
972
00:38:49,727 --> 00:38:53,898
I wanted to see what could each
pilot see in their positions.
973
00:38:53,964 --> 00:38:55,433
What could they hear?
974
00:38:53,964 --> 00:38:55,433
What could they hear?
975
00:38:55,499 --> 00:38:57,702
What lead them to make
the decisions they did?
976
00:38:57,768 --> 00:39:01,405
First Air 6560, we're 10
miles from runway 35, true.
977
00:38:57,768 --> 00:39:01,405
First Air 6560, we're 10
miles from runway 35, true.
978
00:39:01,472 --> 00:39:02,740
Gear down.
979
00:39:02,807 --> 00:39:05,109
The recreation
reveals that both pilots
980
00:39:05,176 --> 00:39:07,611
were busy preparing to land.
981
00:39:05,176 --> 00:39:07,611
were busy preparing to land.
982
00:39:12,149 --> 00:39:13,684
There.
983
00:39:12,149 --> 00:39:13,684
There.
984
00:39:13,751 --> 00:39:16,420
So busy, it seems,
that neither noticed the
985
00:39:16,487 --> 00:39:19,590
critical control mode change.
986
00:39:16,487 --> 00:39:19,590
critical control mode change.
987
00:39:19,657 --> 00:39:21,826
That's where the
autopilot mode switched.
988
00:39:21,892 --> 00:39:23,561
There's a lot going
on in the cockpit
989
00:39:23,627 --> 00:39:26,030
also in the turn at this time,
so they're not necessarily
990
00:39:23,627 --> 00:39:26,030
also in the turn at this time,
so they're not necessarily
991
00:39:26,097 --> 00:39:29,200
looking to see if there's
one light in a sea
992
00:39:29,266 --> 00:39:32,470
of lights that's no longer lit.
993
00:39:29,266 --> 00:39:32,470
of lights that's no longer lit.
994
00:39:32,536 --> 00:39:35,039
We're not on track here.
995
00:39:35,106 --> 00:39:37,842
We're off to the right a bit.
996
00:39:35,106 --> 00:39:37,842
We're off to the right a bit.
997
00:39:37,908 --> 00:39:40,678
GPS has us going
off to the right.
998
00:39:40,745 --> 00:39:43,581
Both the GPS and
the horizontal indicator
999
00:39:40,745 --> 00:39:43,581
Both the GPS and
the horizontal indicator
1000
00:39:43,647 --> 00:39:45,516
were clearly showing
the plane was drifting
1001
00:39:45,583 --> 00:39:46,584
further from the runway.
1002
00:39:50,054 --> 00:39:51,789
We'll get there.
1003
00:39:51,856 --> 00:39:54,024
Yet, the captain did
nothing to correct the problem.
1004
00:39:58,095 --> 00:40:00,264
OK, what's he thinking?
1005
00:40:03,868 --> 00:40:05,970
Investigators find a possible answer
1006
00:40:06,036 --> 00:40:08,672
in the flight data.
1007
00:40:06,036 --> 00:40:08,672
in the flight data.
1008
00:40:08,739 --> 00:40:11,575
His compass is drifting.
1009
00:40:11,642 --> 00:40:15,112
He's off by about 17 degrees.
1010
00:40:11,642 --> 00:40:15,112
He's off by about 17 degrees.
1011
00:40:15,179 --> 00:40:16,814
The captain's compass was
1012
00:40:16,881 --> 00:40:20,684
reacting to an invisible
natural phenomenon.
1013
00:40:16,881 --> 00:40:20,684
reacting to an invisible
natural phenomenon.
1014
00:40:20,751 --> 00:40:23,220
This far North, a
compass will always
1015
00:40:23,287 --> 00:40:25,523
point to the
magnetic North Pole,
1016
00:40:23,287 --> 00:40:25,523
point to the
magnetic North Pole,
1017
00:40:25,589 --> 00:40:28,192
not to the geographic
North Pole, two
1018
00:40:28,259 --> 00:40:31,762
different points on the globe.
1019
00:40:28,259 --> 00:40:31,762
different points on the globe.
1020
00:40:31,829 --> 00:40:34,765
Pilots have to regularly
recalibrate their compasses
1021
00:40:34,832 --> 00:40:38,969
using GPS to establish
their true heading.
1022
00:40:34,832 --> 00:40:38,969
using GPS to establish
their true heading.
1023
00:40:39,036 --> 00:40:40,704
Oh, there we go.
1024
00:40:40,771 --> 00:40:43,574
You might as well do yours too.
1025
00:40:40,771 --> 00:40:43,574
You might as well do yours too.
1026
00:40:43,641 --> 00:40:46,110
Heading 029 degrees.
1027
00:40:46,177 --> 00:40:47,912
Investigators determine
1028
00:40:47,978 --> 00:40:52,183
the pilots only made one compass
adjustment during the flight.
1029
00:40:47,978 --> 00:40:52,183
the pilots only made one compass
adjustment during the flight.
1030
00:40:52,249 --> 00:40:54,218
And that was before
they made the turn
1031
00:40:54,285 --> 00:40:57,955
to begin their final approach.
1032
00:40:54,285 --> 00:40:57,955
to begin their final approach.
1033
00:40:58,022 --> 00:41:00,991
As the plane descended
toward Resolute Bay,
1034
00:41:01,058 --> 00:41:03,994
their compasses were
drifting at different rates.
1035
00:41:01,058 --> 00:41:03,994
their compasses were
drifting at different rates.
1036
00:41:08,999 --> 00:41:11,836
Each pilot had a completely
different understanding
1037
00:41:11,902 --> 00:41:14,071
of what was happening.
1038
00:41:11,902 --> 00:41:14,071
of what was happening.
1039
00:41:14,138 --> 00:41:15,306
We're not on the localizer.
1040
00:41:15,372 --> 00:41:16,674
Ah, we're fine.
1041
00:41:16,740 --> 00:41:18,809
The autopilot is
tracking the localizer.
1042
00:41:21,745 --> 00:41:24,715
The captain had a
perception that they
1043
00:41:24,782 --> 00:41:26,317
were on a correction course.
1044
00:41:24,782 --> 00:41:26,317
were on a correction course.
1045
00:41:30,321 --> 00:41:33,791
Rutherford's compass was
telling him that he was flying
1046
00:41:30,321 --> 00:41:33,791
Rutherford's compass was
telling him that he was flying
1047
00:41:33,858 --> 00:41:39,163
331 degrees straight
back towards the center
1048
00:41:33,858 --> 00:41:39,163
331 degrees straight
back towards the center
1049
00:41:39,230 --> 00:41:41,732
line of the runway.
1050
00:41:45,002 --> 00:41:53,244
But he was actually
flying 348 degrees
1051
00:41:45,002 --> 00:41:53,244
But he was actually
flying 348 degrees
1052
00:41:53,310 --> 00:41:54,979
straight towards the hill.
1053
00:41:57,681 --> 00:42:01,585
Having two pilots that
have different perceptions of
1054
00:41:57,681 --> 00:42:01,585
Having two pilots that
have different perceptions of
1055
00:42:01,652 --> 00:42:03,320
the situation is problematic.
1056
00:42:10,327 --> 00:42:11,862
Continuing approach.
1057
00:42:11,929 --> 00:42:13,998
As the less
experienced pilot,
1058
00:42:11,929 --> 00:42:13,998
As the less
experienced pilot,
1059
00:42:14,064 --> 00:42:16,834
First Officer Hare may have
felt reluctant to voice
1060
00:42:16,901 --> 00:42:20,838
his concerns more forcefully.
1061
00:42:16,901 --> 00:42:20,838
his concerns more forcefully.
1062
00:42:20,905 --> 00:42:24,308
Moments later, the captain
was caught by surprise.
1063
00:42:24,375 --> 00:42:25,142
Go around.
1064
00:42:25,209 --> 00:42:26,944
Go for it!
1065
00:42:25,209 --> 00:42:26,944
Go for it!
1066
00:42:27,011 --> 00:42:28,679
By the time the crew
decided to abort the landing...
1067
00:42:28,746 --> 00:42:29,947
Go around!
1068
00:42:30,014 --> 00:42:31,649
Go around, thrust.
1069
00:42:30,014 --> 00:42:31,649
Go around, thrust.
1070
00:42:31,715 --> 00:42:33,751
...it was too
late to get the power they
1071
00:42:33,817 --> 00:42:36,887
needed to climb out of trouble.
1072
00:42:36,954 --> 00:42:43,260
Two seconds later, he slammed
into the hill near the runway.
1073
00:42:36,954 --> 00:42:43,260
Two seconds later, he slammed
into the hill near the runway.
1074
00:42:49,733 --> 00:42:52,836
There were so many things
that had to have happened
1075
00:42:52,903 --> 00:42:57,141
for this outcome, that if need
one of those didn't happen,
1076
00:42:52,903 --> 00:42:57,141
for this outcome, that if need
one of those didn't happen,
1077
00:42:57,207 --> 00:42:59,944
you wouldn't have
had the accident.
1078
00:43:00,010 --> 00:43:01,712
Following the investigation,
1079
00:43:00,010 --> 00:43:01,712
Following the investigation,
1080
00:43:01,779 --> 00:43:05,149
the Safety Board urges First
Air to review how pilots
1081
00:43:05,215 --> 00:43:07,751
calibrate their compasses.
1082
00:43:05,215 --> 00:43:07,751
calibrate their compasses.
1083
00:43:07,818 --> 00:43:09,186
I think we should
abandon the approach,
1084
00:43:09,253 --> 00:43:10,788
go around, and sort this out.
1085
00:43:10,854 --> 00:43:12,056
No, we're good.
1086
00:43:12,122 --> 00:43:13,991
We'll continue the approach.
1087
00:43:12,122 --> 00:43:13,991
We'll continue the approach.
1088
00:43:14,058 --> 00:43:16,694
It also recommends
that the company institute
1089
00:43:16,760 --> 00:43:19,997
clear policies on how first
officers should take control
1090
00:43:16,760 --> 00:43:19,997
clear policies on how first
officers should take control
1091
00:43:20,064 --> 00:43:22,700
in dangerous situations.
1092
00:43:22,766 --> 00:43:25,135
As the flight progresses,
you can see in the conversation
1093
00:43:25,202 --> 00:43:26,870
between the two of
them, that the two
1094
00:43:25,202 --> 00:43:26,870
between the two of
them, that the two
1095
00:43:26,937 --> 00:43:32,242
pilots have differing views
as to what needs to be done.
1096
00:43:26,937 --> 00:43:32,242
pilots have differing views
as to what needs to be done.
1097
00:43:32,309 --> 00:43:35,446
Three planes fall
prey to the hidden dangers
1098
00:43:35,512 --> 00:43:38,382
of flying in the North.
1099
00:43:35,512 --> 00:43:38,382
of flying in the North.
1100
00:43:38,449 --> 00:43:41,719
With each investigation,
the cause is revealed.
1101
00:43:44,321 --> 00:43:46,890
And Northern skies
become a safer place.
1102
00:43:50,060 --> 00:43:53,130
Our job is to illuminate
where the deficiencies are,
1103
00:43:53,197 --> 00:43:55,866
and the industry
and the regulator
1104
00:43:53,197 --> 00:43:55,866
and the industry
and the regulator
1105
00:43:55,933 --> 00:43:59,436
will take action to
mitigate those risks.
85573
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