1
00:00:02,716 --> 00:00:04,426
(alarm sounding)

2
00:00:04,468 --> 00:00:05,928
- We just lost 1 and 2.

3
00:00:05,970 --> 00:00:10,933
(narrator): All four engines
shut down on a jet headed
straight for a U.S. suburb.

4
00:00:11,433 --> 00:00:14,687
- It takes a few things
to make an engine run,
and one of them is fuel.

5
00:00:14,687 --> 00:00:18,816
- Everyone, we're about
to evacuate the plane.
Remain calm.

6
00:00:19,191 --> 00:00:21,569
(narrator): In Japan,
a plane catches fire

7
00:00:21,569 --> 00:00:25,739
with all 165 passengers and crew
still on board.

8
00:00:26,157 --> 00:00:29,618
- The only time you have
too much fuel on board
the aircraft

9
00:00:29,660 --> 00:00:31,328
is when you're on fire.

10
00:00:31,370 --> 00:00:33,289
- We just lost an engine!

11
00:00:33,289 --> 00:00:35,082
- Hang on.

12
00:00:35,583 --> 00:00:37,793
(narrator): And the crew
of a 737 are forced

13
00:00:37,835 --> 00:00:40,713
to make a crash landing
in the Amazon jungle.

14
00:00:41,088 --> 00:00:43,924
- Something is very, very,
very wrong here.

15
00:00:44,717 --> 00:00:50,431
(narrator): Three mysterious
accidents send investigators
hunting for clues.

16
00:00:53,100 --> 00:00:57,730
Is it possible these tragedies
all share the same cause?

17
00:01:00,107 --> 00:01:02,067
- Mayday, mayday!

18
00:01:04,486 --> 00:01:06,322
- It's going up!

19
00:01:07,114 --> 00:01:09,617
(indistinct radio chatter)

20
00:01:23,172 --> 00:01:25,424
(narrator):
United Airlines Flight 173

21
00:01:25,466 --> 00:01:29,303
is 22 miles away from Portland
International Airport.

22
00:01:29,929 --> 00:01:35,935
The 189 passengers on board
are returning home
after the holidays.

23
00:01:36,644 --> 00:01:43,150
- United 173 would like
clearance for an approach
into 28 left now.

24
00:01:44,026 --> 00:01:47,613
(narrator):
Captain Malburn McBroom,
a Second World War veteran,

25
00:01:47,655 --> 00:01:50,574
is one of United's
most experienced pilots.

26
00:01:51,116 --> 00:01:56,872
First Officer Rod Beebe
has more than 5,000 hours'
flying experience.

27
00:01:58,874 --> 00:02:03,587
Flight Engineer
Forrest Mendenhall
is the third crew member.

28
00:02:04,630 --> 00:02:05,714
- Okay.

29
00:02:05,714 --> 00:02:08,801
(narrator): He's tasked
with monitoring
the DC-8's engines.

30
00:02:09,343 --> 00:02:14,473
The flight began
in New York City
with a stopover in Denver.

31
00:02:15,516 --> 00:02:17,101
- United 173 heavy.

32
00:02:17,101 --> 00:02:19,353
Okay, roll out, heading...

33
00:02:19,395 --> 00:02:22,273
010 to runway 28 left.

34
00:02:23,607 --> 00:02:26,193
(narrator): Air-traffic
controller Ed Kingrey

35
00:02:26,235 --> 00:02:28,779
clears flight 173 to land.

36
00:02:32,408 --> 00:02:35,828
Suddenly, an alarm sounds
in the cockpit.

37
00:02:36,328 --> 00:02:39,581
- We're losing an engine.
(beeping)

38
00:02:41,083 --> 00:02:42,751
It's flamed out.

39
00:02:42,751 --> 00:02:45,879
- You're gonna lose
in a minute, too.

40
00:02:47,673 --> 00:02:52,386
(narrator):
Two of the plane's four engines
have just shut down.

41
00:02:53,262 --> 00:02:55,556
- You gotta keep 'em running,
Frosty.
- Yes, sir.

42
00:02:55,556 --> 00:03:00,519
(narrator):
The engineer struggles to keep
the last two engines running.

43
00:03:01,895 --> 00:03:04,690
- How far do you show us
from the field?

44
00:03:05,107 --> 00:03:08,694
- I'd call it, uh...
I told him it's 18 flying miles,

45
00:03:08,694 --> 00:03:12,072
which would include
the base leg to the final,

46
00:03:12,072 --> 00:03:15,326
and then the turn to final
to the end of the runway.

47
00:03:15,367 --> 00:03:18,579
(alarm sounding)
(automation): Airspeed low.

48
00:03:18,620 --> 00:03:21,332
- We just lost 1 and 2.

49
00:03:25,961 --> 00:03:31,342
(narrator): Flight 173
has now lost all four engines.

50
00:03:34,887 --> 00:03:39,308
With the aircraft dropping
by more than 3,000 feet
a minute,

51
00:03:39,350 --> 00:03:42,895
Captain McBroom makes
a horrifying calculation.

52
00:03:43,562 --> 00:03:45,731
- We can't make it.

53
00:03:46,899 --> 00:03:48,901
- We can't make anything.

54
00:03:49,234 --> 00:03:50,611
- Okay, declare a mayday.

55
00:03:50,861 --> 00:03:55,949
- Portland Tower,
United 173 heavy. Mayday.
The engines are flaming out.

56
00:03:58,994 --> 00:04:02,915
(narrator): McBroom needs
to find a safe place
to put the aircraft down

57
00:04:02,956 --> 00:04:06,001
and try to save the lives
of all on board.

58
00:04:10,839 --> 00:04:13,217
- I could see him coming in
from the south,

59
00:04:13,258 --> 00:04:15,469
his navigational lights
flashing.

60
00:04:15,469 --> 00:04:18,263
You could tell he was quite low.

61
00:04:20,057 --> 00:04:23,185
(passengers screaming)

62
00:04:26,271 --> 00:04:27,815
(screaming)

63
00:04:27,856 --> 00:04:30,567
I saw the bright flash
out there,

64
00:04:30,609 --> 00:04:34,446
and, uh,
and knew he had gone down.

65
00:04:38,992 --> 00:04:44,581
(narrator): The DC-8 has
crash-landed in a wooded suburb
in Portland, Oregon.

66
00:04:46,458 --> 00:04:51,839
(dog barking)
Eight passengers and two members
of the crew are dead.

67
00:04:54,425 --> 00:04:58,554
Incredibly, 179 people survive.

68
00:05:01,557 --> 00:05:06,979
(news): A United Airlines plane
crashed five miles
southeast of Portland Airport,

69
00:05:07,020 --> 00:05:08,689
in a residential area.

70
00:05:08,689 --> 00:05:11,942
Two homes were hit,
one disintegrated.

71
00:05:16,613 --> 00:05:18,073
(narrator): The next morning,

72
00:05:18,115 --> 00:05:21,743
investigators from the National
Transportation Safety Board
are on the scene.

73
00:05:21,785 --> 00:05:26,457
One of the team members
is Human Factors Specialist
Alan Diehl.

74
00:05:29,460 --> 00:05:32,504
- When I saw how close he'd come
to apartment complexes,

75
00:05:32,546 --> 00:05:37,217
I realized this could've been
one of the worst accidents
in history.

76
00:05:42,931 --> 00:05:46,810
(narrator): Investigators hope
survivors can provide
some insight

77
00:05:46,810 --> 00:05:49,146
into what brought this jet down.

78
00:05:49,271 --> 00:05:52,399
- When did you first notice
something out of the ordinary?

79
00:05:53,692 --> 00:05:58,280
(narrator):
They learn from the passengers
that an hour before the crash,

80
00:05:58,280 --> 00:06:00,699
the captain
made an announcement.

81
00:06:01,366 --> 00:06:03,994
- Ladies and gentlemen,
this is your captain speaking.

82
00:06:04,036 --> 00:06:07,498
(narrator):
The crew were having trouble
with the landing gear.

83
00:06:08,040 --> 00:06:11,168
(Captain): We're not sure
whether or not it's working
correctly.

84
00:06:11,210 --> 00:06:13,420
We'll be running
a few routine checks.

85
00:06:13,795 --> 00:06:17,090
(narrator): But something
isn't making sense to Diehl.

86
00:06:17,966 --> 00:06:21,303
- How does a landing-gear
problem bring down a plane?

87
00:06:27,017 --> 00:06:31,939
(narrator): At the crash site,
the plane's flight recorders
are recovered.

88
00:06:32,731 --> 00:06:37,611
They're sent for analysis
at the National Transportation
Safety Board headquarters

89
00:06:37,653 --> 00:06:39,571
in Washington.

90
00:06:44,618 --> 00:06:46,495
While they wait
for the flight data,

91
00:06:46,537 --> 00:06:49,706
investigators continue
to speak to witnesses,

92
00:06:49,748 --> 00:06:51,166
including Ed Kingrey,

93
00:06:51,208 --> 00:06:54,253
the controller who handled
Flight 173's approach.

94
00:06:54,253 --> 00:06:57,047
- I cleared 'em for an approach
to runway 28.

95
00:06:57,381 --> 00:07:00,634
I was about to hand 'em off
to the tower controller.

96
00:07:00,926 --> 00:07:03,178
- Uh, negative.
We'll stay with you.

97
00:07:03,220 --> 00:07:05,597
We've got a gear problem.
We'll let you know.

98
00:07:05,597 --> 00:07:08,600
- He basically said
he'd stay with me, that...

99
00:07:08,642 --> 00:07:12,563
he was having some kind of, uh,
unsafe-gear indication.

100
00:07:12,938 --> 00:07:16,567
(narrator): Captain McBroom
wanted time to troubleshoot
the gear problem.

101
00:07:16,608 --> 00:07:22,656
So Kingrey cleared Flight 173
to fly a holding pattern
south of the airport,

102
00:07:22,698 --> 00:07:25,075
over the Portland suburbs.

103
00:07:25,784 --> 00:07:28,412
- A holding pattern
would basically give him...

104
00:07:28,412 --> 00:07:34,209
his own airspace there
to do whatever he had to do.

105
00:07:35,335 --> 00:07:40,674
(narrator):
But Flight 173 circled Portland
for an unusually long time.

106
00:07:41,967 --> 00:07:44,928
- They continued circling
for about an hour.

107
00:07:45,762 --> 00:07:50,225
(narrator): The pilots then made
a shocking call
to the Portland Tower.

108
00:07:50,601 --> 00:07:52,227
- I recall hearing...

109
00:07:52,227 --> 00:07:56,523
the captain tell the tower
they're losing engines.

110
00:07:57,441 --> 00:07:59,234
There was no indication
to me,

111
00:07:59,276 --> 00:08:02,696
uh... the gravity
of the situation.

112
00:08:04,031 --> 00:08:06,908
(narrator): What happened
during that hour of circling

113
00:08:06,908 --> 00:08:09,494
that turned
a landing-gear malfunction...

114
00:08:09,536 --> 00:08:11,872
- We've got a gear problem.
We'll let you know.

115
00:08:11,872 --> 00:08:15,167
(narrator):
...into a catastrophic
engine failure?

116
00:08:15,167 --> 00:08:17,669
- The engines are flaming out.
We're going down.

117
00:08:17,669 --> 00:08:20,380
We're not gonna be able
to make it to the airport.

118
00:08:20,380 --> 00:08:22,007
- I was clearly very interested
in, you know,

119
00:08:22,049 --> 00:08:26,637
how a highly experienced captain
could, uh, fly around
for over an hour,

120
00:08:26,678 --> 00:08:28,805
in sight of the airport,
in good weather,

121
00:08:28,805 --> 00:08:32,059
and not put this airplane
on the ground safely.

122
00:08:35,062 --> 00:08:41,318
(narrator): NTSB investigator
Dennis Grossi joins the effort
to find out what went wrong.

123
00:08:41,318 --> 00:08:43,153
- I was assigned to be the...

124
00:08:43,195 --> 00:08:46,865
aircraft performance engineer
for this accident.

125
00:08:50,118 --> 00:08:51,495
Okay, let's go.

126
00:08:51,536 --> 00:08:53,497
(narrator):
If there was a malfunction,

127
00:08:53,497 --> 00:08:56,458
he hopes the cockpit
voice recorder picked up
the pilots discussing it.

128
00:08:56,500 --> 00:08:59,127
- Ladies and gentlemen,
this is your captain speaking.

129
00:08:59,628 --> 00:09:03,048
(narrator): The recording begins
30 minutes before the crash

130
00:09:03,048 --> 00:09:05,175
as the pilots circle
over Portland.

131
00:09:05,175 --> 00:09:07,386
- ...because I only got this
thing to shine down there.

132
00:09:07,386 --> 00:09:10,472
(narrator):
They hear the flight engineer
leave the cockpit

133
00:09:10,472 --> 00:09:14,601
to troubleshoot
the landing-gear problem.
(alarm sounding)

134
00:09:18,355 --> 00:09:20,691
When the landing gear
is lowered,

135
00:09:20,691 --> 00:09:22,651
a small rod pops up in the wing,

136
00:09:22,693 --> 00:09:26,363
providing visual confirmation
that the gear is in place.

137
00:09:26,947 --> 00:09:29,908
- The flight engineer
would be asked by the captain
to go back and check

138
00:09:29,908 --> 00:09:33,203
the mechanical indicators
for the position
of the landing gear.

139
00:09:33,245 --> 00:09:35,372
- Excuse me.
Can I look out the window here?

140
00:09:35,372 --> 00:09:39,084
- And he could look over,
and there are tabs that actually
come up and go down,

141
00:09:39,084 --> 00:09:44,381
and he could see if the gear
was extended and locked.

142
00:09:44,798 --> 00:09:46,675
- How's that main gear
back there?

143
00:09:46,717 --> 00:09:49,386
- Uh, both appear to be down
and locked.

144
00:09:50,095 --> 00:09:52,222
(narrator):
Despite his engineer's report,

145
00:09:52,222 --> 00:09:56,143
Captain McBroom
still sounds concerned.
(alarm sounding)

146
00:09:57,352 --> 00:09:59,730
- There's one check we missed.

147
00:10:00,021 --> 00:10:02,482
Checking the gear warning horn.

148
00:10:03,108 --> 00:10:05,402
- Uh-huh. Right.

149
00:10:05,444 --> 00:10:07,154
- Right.
- Right.

150
00:10:07,654 --> 00:10:10,657
- Normally, when we see
these problems of a gear light
not coming on,

151
00:10:10,699 --> 00:10:13,869
it's a light bulb or some
minor piece of circuitry.

152
00:10:14,786 --> 00:10:17,247
(narrator): It appears
that a minor electrical problem

153
00:10:17,247 --> 00:10:20,375
became a major distraction
for Captain McBroom.

154
00:10:20,959 --> 00:10:25,589
But it still doesn't explain
why all four engines were out.

155
00:10:28,091 --> 00:10:31,178
Then investigators make
a shocking discovery.

156
00:10:32,012 --> 00:10:34,181
- Losing an engine.
It's flamed out.

157
00:10:34,181 --> 00:10:36,266
- Why?

158
00:10:36,641 --> 00:10:39,436
- Fuel.
(captain sighing)

159
00:10:45,901 --> 00:10:49,696
(narrator):
The cockpit voice recorder
from United Flight 173 reveals

160
00:10:49,696 --> 00:10:54,284
that the captain is unaware
that his plane
is running out of fuel.

161
00:10:56,495 --> 00:10:58,413
- He was asking
what was causing that,

162
00:10:58,455 --> 00:11:01,458
and he got a very adamant answer
saying: fuel.

163
00:11:01,500 --> 00:11:03,668
- Fuel.
- As if to say:

164
00:11:03,710 --> 00:11:06,797
We've been trying to tell you
about this all along.

165
00:11:06,838 --> 00:11:08,799
- Number 2 is empty.

166
00:11:09,591 --> 00:11:12,302
- You're gonna lose 3
in a minute, too.

167
00:11:13,261 --> 00:11:17,933
(narrator): One by one,
fuel starvation shuts down
all the engines,

168
00:11:17,974 --> 00:11:20,936
leaving the DC-8
without any power.

169
00:11:23,688 --> 00:11:25,357
- Okay, declare a mayday.

170
00:11:25,941 --> 00:11:31,696
- How could an experienced crew
lose track of how much fuel
they had on board,

171
00:11:31,738 --> 00:11:34,032
and in fact run out of fuel

172
00:11:34,032 --> 00:11:37,661
when they were in view
of the airport?

173
00:11:38,662 --> 00:11:43,583
(narrator): Captain McBroom
may be the only one
who can provide answers.

174
00:11:44,334 --> 00:11:47,379
He's in hospital
recovering from injury,

175
00:11:47,420 --> 00:11:50,257
but well enough
to speak to investigators.

176
00:11:50,257 --> 00:11:51,967
(alarm sounding)

177
00:11:51,967 --> 00:11:53,635
- I recall...

178
00:11:53,635 --> 00:11:57,597
seeing
come on,

179
00:11:57,597 --> 00:11:59,724
but I...

180
00:11:59,766 --> 00:12:01,685
I knew we had fuel.

181
00:12:02,102 --> 00:12:04,771
- He was still convinced
that somehow,

182
00:12:04,813 --> 00:12:07,232
the fuel had either leaked out
of the tanks,

183
00:12:07,232 --> 00:12:11,027
or the fuel burn was too high,
or the gauges were wrong.

184
00:12:13,405 --> 00:12:17,325
(narrator): Investigators wonder
if the fuel gauges
were malfunctioning

185
00:12:17,367 --> 00:12:19,369
and confusing the pilots.

186
00:12:20,161 --> 00:12:24,374
To find out, investigators
study the transcript
of the cockpit voice recorder,

187
00:12:24,416 --> 00:12:27,919
focusing on the pilots'
discussion of fuel levels.

188
00:12:28,128 --> 00:12:31,882
- The crew discussed
how much fuel do we have.
We have 5,000 pounds.

189
00:12:31,882 --> 00:12:34,593
You take the data
and apply the time factor to it,

190
00:12:34,593 --> 00:12:38,889
and you can figure out
how much fuel
they should've had remaining.

191
00:12:40,515 --> 00:12:42,934
- Five thousand.
That's exactly right.

192
00:12:43,435 --> 00:12:47,063
(narrator): The team discovers
there's nothing wrong
with the gauges.

193
00:12:47,397 --> 00:12:52,485
Flight 173's fuel system
was working exactly
as it should.

194
00:12:54,279 --> 00:12:56,448
With mechanical failure
ruled out,

195
00:12:56,489 --> 00:12:59,659
the team now explores
the human factors,

196
00:12:59,701 --> 00:13:03,830
specifically Captain McBroom's
behaviour.

197
00:13:05,040 --> 00:13:07,876
- How much fuel you got now?
- Four. Four.

198
00:13:07,876 --> 00:13:11,087
(narrator):
Investigators play back
the cockpit voice recorder

199
00:13:11,129 --> 00:13:13,214
to study his performance.

200
00:13:15,800 --> 00:13:17,469
- How much fuel you got now?

201
00:13:17,510 --> 00:13:22,390
(narrator): They hear something
alarming in the conversation.
(alarm sounding)

202
00:13:23,266 --> 00:13:29,606
- How much fuel we got now?
- Four. Four, uh, thousand,
in each, pounds.

203
00:13:31,733 --> 00:13:34,819
- Both the first officer
and the second officer...

204
00:13:35,278 --> 00:13:36,947
...were acutely aware
of the fuel status.

205
00:13:36,988 --> 00:13:42,160
(narrator): His crewmates tried
more than once to alert him
to the fuel situation.

206
00:13:42,369 --> 00:13:45,830
But McBroom is focused
on the broken landing gear.

207
00:13:45,830 --> 00:13:48,124
- There's one check we missed.

208
00:13:48,541 --> 00:13:51,002
Checking the gear warning horn.

209
00:13:51,753 --> 00:13:54,297
- Uh-huh. Right.

210
00:13:54,339 --> 00:13:56,424
- Right.
- Right.

211
00:13:56,424 --> 00:13:58,426
So how do we do that?

212
00:13:58,843 --> 00:14:00,512
- Flying with a very senior
captain,

213
00:14:00,553 --> 00:14:06,017
it would be very difficult
to challenge that captain
in those days, uh,

214
00:14:06,017 --> 00:14:08,103
about something like fuel.

215
00:14:10,563 --> 00:14:15,568
- The captain was so focused
on the gear collapsing
that he lost the big picture.

216
00:14:15,568 --> 00:14:20,740
- They lost sight
of the real emergency,
which was the lack of fuel.

217
00:14:22,409 --> 00:14:25,370
(narrator):
Captain McBroom's obsession
with the landing gear,

218
00:14:25,370 --> 00:14:28,206
along with his crewmates'
failure to speak up,

219
00:14:28,206 --> 00:14:33,086
caused the plane to run out
of fuel and crash
in the Portland suburb.

220
00:14:33,628 --> 00:14:37,465
- After this accident,
the National Transportation
Safety Board

221
00:14:37,507 --> 00:14:41,845
said flight crew members
need to be better trained
to communicate

222
00:14:41,886 --> 00:14:45,098
when they have
safety-of-flight issues.

223
00:14:47,976 --> 00:14:51,271
(narrator): In a move
that has a lasting impact
on airline safety,

224
00:14:51,312 --> 00:14:55,066
the Federal Aviation Authority
adopts a training system
developed by NASA,

225
00:14:55,066 --> 00:14:59,946
known as Cockpit Resource
Management, or CRM.

226
00:15:00,864 --> 00:15:02,699
- It teaches captains
to listen better,

227
00:15:02,699 --> 00:15:07,787
and it teaches the other members
on the flight deck
to be respectfully assertive.

228
00:15:08,371 --> 00:15:13,043
(narrator):
If the crew of Flight 173
had received CRM training,

229
00:15:13,043 --> 00:15:16,880
they might have insisted
that Captain McBroom
land immediately.

230
00:15:17,338 --> 00:15:21,885
- Not enough.
Fifteen minutes is really gonna
run us low on fuel here.

231
00:15:22,260 --> 00:15:26,806
(narrator): Instead,
they expected their captain
to make the right decision.

232
00:15:27,223 --> 00:15:29,142
- Had it not been
for this investigation,

233
00:15:29,142 --> 00:15:34,147
I'm pretty sure
that Crew Resource Management
would have taken place,

234
00:15:34,147 --> 00:15:35,523
but at some point in the future,

235
00:15:35,565 --> 00:15:39,694
and very likely other aircraft
would've crashed in the interim.

236
00:15:41,488 --> 00:15:42,989
(narrator): In 2007,

237
00:15:43,031 --> 00:15:45,283
a terrifying explosion
reminds investigators

238
00:15:45,283 --> 00:15:50,038
that catastrophic fuel failures
don't just happen in the air.

239
00:15:59,506 --> 00:16:04,302
(narrator):
China Airlines Flight 120
is on final approach for landing

240
00:16:04,344 --> 00:16:06,221
in Okinawa, Japan.

241
00:16:06,221 --> 00:16:08,431
(chiming)
(captain): Ladies and gentlemen,

242
00:16:08,431 --> 00:16:12,268
we're about to begin our descent
into Okinawa Naha Airport.

243
00:16:12,811 --> 00:16:15,146
Please give the flight
attendants your full cooperation

244
00:16:15,188 --> 00:16:17,357
as they prepare the cabin
for landing.

245
00:16:17,941 --> 00:16:21,736
(narrator): The captain
is 47-year-old Yu Chien-Kou.

246
00:16:22,695 --> 00:16:24,322
- What's the weather
for approach?

247
00:16:24,364 --> 00:16:27,784
- Cloud ceiling is 8,000 feet.
Winds at eight knots.

248
00:16:28,118 --> 00:16:32,038
(narrator): The first officer
is 26-year-old Tseng Ta-wei.

249
00:16:32,747 --> 00:16:38,461
The pilots have more
than 8,500 hours of flight
experience between them.

250
00:16:41,589 --> 00:16:46,469
This morning,
there are 157 passengers
and eight crew on board.

251
00:16:47,220 --> 00:16:50,390
- Please put your tray up
and fasten your seatbelt.

252
00:16:56,396 --> 00:16:58,648
(narrator): The pilots
reconfigure their plane

253
00:16:58,690 --> 00:17:02,235
as they slow down
and descend for landing.

254
00:17:03,111 --> 00:17:05,238
- Let's go to flaps 25.

255
00:17:06,114 --> 00:17:07,115
- Flaps 25.

256
00:17:07,157 --> 00:17:10,577
(narrator): They deploy flaps
from the wings' back edge,

257
00:17:10,577 --> 00:17:13,037
along with slats
from the front edge.

258
00:17:13,538 --> 00:17:18,209
These devices keep the plane
airborne at lower speeds.

259
00:17:25,758 --> 00:17:29,137
(automation): 30, 20, 10.

260
00:17:31,806 --> 00:17:34,142
(narrator):
It's a textbook landing.

261
00:17:37,687 --> 00:17:39,272
- Flaps in.

262
00:17:40,982 --> 00:17:46,070
(narrator): All that's left
for the China Airlines pilots
is to park the plane.

263
00:17:49,616 --> 00:17:51,743
- Engine start levers.

264
00:17:51,743 --> 00:17:54,412
- Engine start levers cut off.

265
00:17:55,788 --> 00:17:58,708
- Seatbelts.
- Seatbelts off.

266
00:18:03,171 --> 00:18:08,051
(narrator):
Then one passenger notices
that something's not right.

267
00:18:11,429 --> 00:18:13,681
(Speaking Japanese)

268
00:18:14,307 --> 00:18:17,352
(alarm sounding)
- Hey, what is this?

269
00:18:19,270 --> 00:18:20,521
- What's happening?

270
00:18:20,521 --> 00:18:23,399
(narrator):
Just when they thought
they were safely parked...

271
00:18:23,441 --> 00:18:25,693
- Cockpit, ground.
Number 2 engine fire.

272
00:18:25,735 --> 00:18:28,613
(narrator):
...a radio call alerts them
to a fire in the right engine.

273
00:18:28,655 --> 00:18:33,868
- Dynasty 120,
we are calling a fire truck.
Remain... Stand by.

274
00:18:35,119 --> 00:18:36,829
(shouting in Japanese)

275
00:18:36,871 --> 00:18:39,123
- Cabin crew,
prepare for evacuation.

276
00:18:39,165 --> 00:18:41,459
Prepare for evacuation.

277
00:18:44,295 --> 00:18:48,216
(narrator): Within minutes,
the fire engulfs both wings.

278
00:18:51,094 --> 00:18:52,595
- No pushing, no pushing.

279
00:18:52,595 --> 00:18:57,475
(narrator): Flight attendants
work to evacuate the passengers
as quickly as possible.

280
00:18:57,517 --> 00:19:00,478
The plane could explode
at any moment.

281
00:19:04,774 --> 00:19:08,528
- Captain, all passengers
are evacuated.
You're the last ones.

282
00:19:09,821 --> 00:19:11,739
(coughing)

283
00:19:12,323 --> 00:19:15,285
(narrator):
But it may be too late
for the pilots.

284
00:19:15,326 --> 00:19:17,662
Thick smoke is consuming
the cabin,

285
00:19:17,704 --> 00:19:21,374
so they will have to escape
through a small cockpit window.

286
00:19:21,416 --> 00:19:23,459
- You first.
- Yes, sir.

287
00:19:27,005 --> 00:19:30,341
(people screaming)
(man): Oh! Whoa!

288
00:19:37,807 --> 00:19:42,353
(narrator): Incredibly,
both pilots evacuate
just in time.

289
00:19:44,647 --> 00:19:49,193
All 165 people on board
escape unharmed.

290
00:19:52,196 --> 00:19:55,575
- I've never heard
of any evacuation
where somebody wasn't hurt.

291
00:19:56,075 --> 00:19:58,995
To get this many people off
in such a dire circumstance

292
00:19:58,995 --> 00:20:03,458
in a very short period of time
with no injuries is miraculous.

293
00:20:04,000 --> 00:20:09,339
- It's highly unusual
for an aircraft to catch fire
at that phase of flight,

294
00:20:09,380 --> 00:20:12,050
so, uh, that sparked
a great deal of interest.

295
00:20:12,050 --> 00:20:14,135
(indistinct radio chatter)

296
00:20:14,677 --> 00:20:18,014
(narrator):
A team of international
air-crash investigators

297
00:20:18,056 --> 00:20:20,058
are immediately called in.

298
00:20:20,391 --> 00:20:25,021
They need to find the cause
before there's another
deadly explosion.

299
00:20:27,648 --> 00:20:28,941
Across the globe,

300
00:20:28,983 --> 00:20:33,696
there are more than 5,000
Boeing 737s in service.

301
00:20:34,697 --> 00:20:37,075
- There's a 737 taking off
and landing

302
00:20:37,075 --> 00:20:39,577
every three or four seconds
in the world.

303
00:20:40,078 --> 00:20:43,581
(narrator):
Knowing countless passengers
could be at risk,

304
00:20:43,623 --> 00:20:48,753
investigators race
to figure out how an airliner
that landed safely

305
00:20:48,753 --> 00:20:50,838
suddenly burst into flames.

306
00:20:52,799 --> 00:20:55,760
- Okay, let's get to work!

307
00:20:56,052 --> 00:20:59,722
The challenge
for the investigator is...

308
00:20:59,722 --> 00:21:02,350
most of the evidence
will be destroyed by the fire.

309
00:21:02,850 --> 00:21:06,145
(narrator):
While recovery workers collect
the scorched wreckage,

310
00:21:06,187 --> 00:21:09,107
the team begins
interviewing eyewitnesses.

311
00:21:09,148 --> 00:21:10,566
- What did you see?

312
00:21:10,608 --> 00:21:15,196
(narrator): A ground worker
who saw the explosion
provides a critical detail.

313
00:21:15,696 --> 00:21:18,324
- The ramp worker
on the right side
of the aircraft

314
00:21:18,366 --> 00:21:21,411
said very distinctly
that he saw a liquid

315
00:21:21,452 --> 00:21:26,374
running down the leading edge
of the right wing
before the fire broke out.

316
00:21:26,499 --> 00:21:27,708
- Thanks.

317
00:21:27,750 --> 00:21:31,212
(narrator): Fluid leaking
from this part of the wing
of the aircraft

318
00:21:31,254 --> 00:21:33,464
can only be one thing:

319
00:21:34,465 --> 00:21:36,008
Jet fuel.

320
00:21:36,467 --> 00:21:41,514
The Boeing 737 holds
4,390 gallons of fuel,

321
00:21:41,514 --> 00:21:46,894
much of it in tanks
located inside the plane's
two massive wings.

322
00:21:47,645 --> 00:21:51,399
- When we figured out
that an actual fuel leak
had occurred,

323
00:21:51,441 --> 00:21:54,986
it was a breakthrough,
a true breakthrough
in the investigation.

324
00:21:55,903 --> 00:22:00,533
- We know the fuel was leaking,
but from where?

325
00:22:03,202 --> 00:22:08,541
(narrator): Investigators
examine what remains
of the 737's fuel tanks.

326
00:22:09,917 --> 00:22:15,173
The tanks are made
from aluminum alloy
and should never crack or leak.

327
00:22:17,758 --> 00:22:20,720
They use a small camera
called a borescope

328
00:22:20,720 --> 00:22:23,723
to see inside
the right fuel tank.

329
00:22:27,393 --> 00:22:32,190
What it reveals
changes the course
of the entire investigation.

330
00:22:34,942 --> 00:22:37,236
- Whoa. Would you look at that?

331
00:22:39,697 --> 00:22:44,368
(narrator): While examining
the right fuel tank
of China Airlines Flight 120,

332
00:22:44,368 --> 00:22:48,414
investigators find a bolt
lodged in the side of the tank.

333
00:22:48,456 --> 00:22:50,166
- All of a sudden,
clear as a bell,

334
00:22:50,208 --> 00:22:54,712
we saw this bolt sticking out
of the fuel tank itself.

335
00:22:55,713 --> 00:22:58,049
(narrator):
The bolt has ruptured the tank,

336
00:22:58,090 --> 00:23:02,136
right where the ground worker
spotted leaking fuel.

337
00:23:02,512 --> 00:23:04,972
- It's hard to describe
how significant this was.

338
00:23:04,972 --> 00:23:07,934
I mean, this was the core
of the investigation.

339
00:23:11,562 --> 00:23:14,232
(narrator): But where did
the bolt come from?

340
00:23:15,441 --> 00:23:17,944
- Okay. Got it.

341
00:23:23,574 --> 00:23:29,288
(narrator): Investigators
compare the piece to schematics
of the 737 wing structure

342
00:23:29,288 --> 00:23:31,958
to figure out
exactly what it is.

343
00:23:37,004 --> 00:23:39,257
They soon get their answer.

344
00:23:41,717 --> 00:23:43,844
- A downstop assembly.

345
00:23:44,971 --> 00:23:46,430
(narrator):
The downstop assembly

346
00:23:46,430 --> 00:23:49,725
is part of the slat mechanism
on the wing's leading edge.

347
00:23:49,767 --> 00:23:51,978
- Let's go to flaps 25.

348
00:23:52,228 --> 00:23:53,437
- Flaps 25.

349
00:23:53,479 --> 00:23:58,651
(narrator): Pilots extend flaps
and slats during every takeoff
and landing.

350
00:24:00,528 --> 00:24:05,491
The downstop is fixed
to the end of a track
that slides back and forth.

351
00:24:05,491 --> 00:24:09,745
The device prevents the slats
from moving too far forward.

352
00:24:11,080 --> 00:24:13,291
- We had the assembly.
We knew it punctured the tank.

353
00:24:13,291 --> 00:24:17,712
Our next step was trying
to figure out how this could
possibly have occurred.

354
00:24:19,964 --> 00:24:23,301
(narrator): When comparing
the downstop assembly
from Flight 120

355
00:24:23,342 --> 00:24:26,220
to Boeing schematics...

356
00:24:27,722 --> 00:24:31,100
...the team uncovers
a vital clue.

357
00:24:31,601 --> 00:24:33,269
- We decided to count parts,

358
00:24:33,311 --> 00:24:36,063
and lo and behold,
a washer was missing.

359
00:24:36,439 --> 00:24:39,859
(narrator):
There's supposed to be a washer
right behind the nut.

360
00:24:39,859 --> 00:24:41,694
- Where is it?

361
00:24:45,656 --> 00:24:50,620
(narrator): Could a single
missing washer have played
a role in the accident?

362
00:24:52,413 --> 00:24:55,583
- Alright. Now let's test it
without a washer.

363
00:24:56,542 --> 00:25:01,255
(narrator): The team experiment
with the suspicious bolt
from Flight 120

364
00:25:01,255 --> 00:25:04,592
to see how it performs
without the washer.

365
00:25:06,344 --> 00:25:08,763
They make a stunning discovery.

366
00:25:12,224 --> 00:25:15,478
The small washer
is the only thing preventing

367
00:25:15,519 --> 00:25:18,439
the unit from falling out
of its mount.

368
00:25:19,482 --> 00:25:23,110
- Without the washer...
it fails.

369
00:25:26,697 --> 00:25:32,036
(narrator): Investigators need
to find out how the part
could've disappeared.

370
00:25:32,495 --> 00:25:34,246
- We went to China Airlines

371
00:25:34,246 --> 00:25:40,086
to ask them to demonstrate
how they do...
the maintenance work.

372
00:25:40,836 --> 00:25:44,632
- Sometimes maintenance records
don't tell you the true story.

373
00:25:45,925 --> 00:25:51,806
(narrator): They learn a repair
was ordered on the downstop
a few weeks before the accident.

374
00:25:53,015 --> 00:25:56,769
A mechanic demonstrates
how he performed the repair.

375
00:25:58,896 --> 00:26:03,442
- After applying glue...
you put the bolt into place.

376
00:26:05,653 --> 00:26:09,782
(narrator): But reaching
the downstop's location
proves challenging.

377
00:26:10,157 --> 00:26:15,496
- You can imagine
that you're under the wing
and you cannot see it.

378
00:26:21,961 --> 00:26:24,088
- Sorry. I just dropped it.

379
00:26:24,630 --> 00:26:26,632
Don't worry.
It's easy to pick up again.

380
00:26:26,632 --> 00:26:29,635
(narrator): It's an eye-opening
demonstration.

381
00:26:32,388 --> 00:26:35,933
- It's not very easy for them
to confirm

382
00:26:35,975 --> 00:26:40,438
they finished their job
and everything is in order
there.

383
00:26:42,148 --> 00:26:45,568
(narrator):
Investigators believe the washer
must've fallen off

384
00:26:45,568 --> 00:26:48,779
during the maintenance procedure
in Taiwan.

385
00:26:55,494 --> 00:27:00,458
The sequence of events that led
to the devastating fuel fire
in Okinawa

386
00:27:00,499 --> 00:27:02,668
is finally clear.

387
00:27:03,878 --> 00:27:07,089
Six weeks after the failed
repair of a downstop...

388
00:27:07,131 --> 00:27:09,633
- Please give the flight
attendants your full cooperation

389
00:27:09,675 --> 00:27:11,343
as they prepare the cabin
for landing.

390
00:27:11,385 --> 00:27:14,054
(narrator):
A descent into Okinawa
requires the pilots

391
00:27:14,096 --> 00:27:17,057
to deploy the flaps and slats
as usual.

392
00:27:21,562 --> 00:27:24,648
Inside one of the track
assemblies on the right wing,

393
00:27:24,690 --> 00:27:29,153
the loosened bolt
without a washer
is just barely holding on.

394
00:27:30,780 --> 00:27:35,993
Touchdown is enough of a jolt
to finally knock it
out of its track.

395
00:27:37,787 --> 00:27:38,996
- Flaps up.

396
00:27:38,996 --> 00:27:43,083
(narrator):
The unsuspecting crew soon
retracts the flaps and slats.

397
00:27:43,459 --> 00:27:48,214
The plane's powerful hydraulics
move the slat track
back into place.

398
00:27:48,839 --> 00:27:51,884
But now the downstop bolt
is in the way.

399
00:27:52,092 --> 00:27:53,969
The track pushes it to the back,

400
00:27:54,011 --> 00:27:56,138
puncturing
the right-wing fuel tank

401
00:27:56,180 --> 00:28:00,059
and causing thousands
of litres of fuel to leak.

402
00:28:04,772 --> 00:28:06,816
- After-landing checklist.

403
00:28:07,566 --> 00:28:11,445
(narrator): Once the pilots park
and shut down the engines...

404
00:28:12,905 --> 00:28:18,494
...the leaking fuel
starts dripping directly onto
the scorching-hot tail pipe,

405
00:28:18,494 --> 00:28:20,621
igniting on contact.

406
00:28:25,125 --> 00:28:27,920
In the wake
of the China Airlines explosion,

407
00:28:27,920 --> 00:28:30,047
aviation authorities
around the world

408
00:28:30,089 --> 00:28:34,218
order the inspection
of the entire fleet of 737s.

409
00:28:34,677 --> 00:28:36,679
In the U.S. alone,

410
00:28:36,679 --> 00:28:39,974
21 planes are found
to have the same defect,

411
00:28:40,015 --> 00:28:44,311
all of them at risk
of a catastrophic fuel leak
and fire.

412
00:28:45,062 --> 00:28:46,856
Boeing takes immediate action.

413
00:28:46,856 --> 00:28:49,567
It redesigns
the downstop mechanism

414
00:28:49,608 --> 00:28:53,279
and ensures
that the improved part
is installed

415
00:28:53,320 --> 00:28:54,780
on each and every plane.

416
00:28:54,822 --> 00:28:58,617
- In today's aviation,
the failure of any kind
of component part,

417
00:28:58,659 --> 00:29:02,705
especially as it relates
to a fuel system,
is a rare event.

418
00:29:03,539 --> 00:29:05,833
You stand a better chance
of survival

419
00:29:05,875 --> 00:29:08,502
if you have a catastrophic event
on the ground.

420
00:29:08,544 --> 00:29:12,172
But as the airplane goes up,
so does the risk level.

421
00:29:12,590 --> 00:29:15,509
(automation): Terrain. Terrain.
(narrator): In Brazil,

422
00:29:15,551 --> 00:29:17,761
investigators uncover
another fatal problem

423
00:29:17,761 --> 00:29:23,559
when a disastrous fuel failure
brings down a plane
in the Amazon jungle.

424
00:29:31,609 --> 00:29:35,571
(narrator):
Brazil in the late 1980s
is a country in transition.

425
00:29:36,030 --> 00:29:41,619
Developing cities
are scattered throughout
the dense Amazon rainforest.

426
00:29:43,621 --> 00:29:49,501
In Marabá,
the crew of Varig Flight 254
is preparing for takeoff.

427
00:29:50,628 --> 00:29:52,129
- Exterior check complete.

428
00:29:52,129 --> 00:29:55,799
(narrator):
There are 48 passengers
on board.

429
00:29:57,801 --> 00:30:02,389
Flight 254
is an hour-long flight
from the mining town of Marabá

430
00:30:02,389 --> 00:30:05,851
to Belém, near the mouth
of the Amazon River.

431
00:30:06,810 --> 00:30:12,107
The crew dials in
a compass heading to guide them
to their destination.

432
00:30:15,694 --> 00:30:17,780
- Here we go.

433
00:30:22,534 --> 00:30:26,205
(narrator): Captain Cézar Garcez
is flying the airplane
tonight,

434
00:30:26,205 --> 00:30:29,833
while First Officer Nilson Zille
monitors the instruments.

435
00:30:29,833 --> 00:30:31,710
- V1.

436
00:30:32,795 --> 00:30:34,797
Rotate.

437
00:30:38,258 --> 00:30:43,013
(narrator):
The Boeing 737 steadily climbs
to cruising altitude.

438
00:30:49,311 --> 00:30:53,190
After 23 minutes,
the flight computer
tells the captain

439
00:30:53,232 --> 00:30:55,734
that they're getting close
to Belém.

440
00:30:56,443 --> 00:30:59,029
- Looks like we're nearly there.
- Mm.

441
00:31:00,280 --> 00:31:04,743
Belém Tower, Varig 254,
requesting descent.

442
00:31:09,289 --> 00:31:11,917
Belém Tower, Varig 254.

443
00:31:13,752 --> 00:31:15,963
- Belém Tower, do you read?

444
00:31:16,755 --> 00:31:20,426
(narrator): Strangely,
they get no response
from the tower.

445
00:31:20,426 --> 00:31:24,763
- Let me try.
Belém Tower, Varig 254.

446
00:31:25,889 --> 00:31:27,975
- Hmm. That's funny.

447
00:31:28,559 --> 00:31:29,852
- What?

448
00:31:30,185 --> 00:31:32,730
- We're not picking up
the beacon either.

449
00:31:33,105 --> 00:31:34,606
(narrator):
Airports are equipped

450
00:31:34,648 --> 00:31:39,653
with Very High Frequency
Omnidirectional Range beacons,
or VOR beacons.

451
00:31:40,112 --> 00:31:43,824
Their signal guides
incoming aircraft
to the runway.

452
00:31:44,324 --> 00:31:45,868
- I'll call the tower on HF.

453
00:31:45,868 --> 00:31:51,874
(narrator): The captain switches
his radio to high frequency
and tries making contact again.

454
00:31:51,915 --> 00:31:55,127
- Belém Tower, Varig 254.

455
00:31:55,586 --> 00:31:58,338
(narrator): Thankfully,
his strategy works.

456
00:31:58,797 --> 00:32:01,175
- Varig 254, Belém Tower.
Go ahead.

457
00:32:01,175 --> 00:32:05,721
- Belém, we're on approach,
but we aren't seeing the VOR.
Is the beacon down?

458
00:32:05,721 --> 00:32:09,475
- Negative, 254.
Looks like it's on your end.

459
00:32:13,103 --> 00:32:14,563
- Understood.

460
00:32:15,606 --> 00:32:17,941
(narrator): The crew
will have to approach Belém

461
00:32:17,983 --> 00:32:19,860
without the help
of the VOR signal.

462
00:32:19,860 --> 00:32:24,323
The captain checks his system
and calculates
when they'll arrive.

463
00:32:24,656 --> 00:32:27,117
- Belém, we're 25 minutes out.

464
00:32:27,159 --> 00:32:29,703
Request descent
for final approach.

465
00:32:29,745 --> 00:32:32,539
- Roger, Varig 254.

466
00:32:32,539 --> 00:32:35,542
Cleared to flight level 2-0-0.

467
00:32:37,711 --> 00:32:39,880
(narrator): As the plane drops
below the clouds,

468
00:32:39,922 --> 00:32:42,966
the captain looks
for the lights of Belém.

469
00:32:44,009 --> 00:32:46,053
- Where are the lights?

470
00:32:46,845 --> 00:32:48,889
Where's the airport?

471
00:32:51,058 --> 00:32:53,477
(narrator):
But there's only darkness.

472
00:32:56,188 --> 00:32:58,816
- No visible lights, Captain.

473
00:33:00,692 --> 00:33:03,737
(narrator): In Belém,
the controller is concerned.

474
00:33:03,946 --> 00:33:06,865
Flight 254 should have landed
by now.

475
00:33:07,449 --> 00:33:12,246
But he doesn't have a radar,
so he has no way
of tracking the plane.

476
00:33:15,791 --> 00:33:20,003
- We need to land soon,
or else we're gonna run
out of fuel!

477
00:33:20,003 --> 00:33:21,964
- I think we're close.

478
00:33:22,589 --> 00:33:25,425
(narrator): The captain searches
for a local radio signal,

479
00:33:25,467 --> 00:33:28,262
hoping it will guide them
towards the city.

480
00:33:28,303 --> 00:33:31,348
- Now we can follow the signal
towards Belém.

481
00:33:32,182 --> 00:33:35,435
- Turning right, heading 1-6-5.

482
00:33:42,442 --> 00:33:44,444
(narrator):
After 2.5 hours in flight,

483
00:33:44,444 --> 00:33:48,198
the captain is confident
he's now on course.

484
00:33:49,032 --> 00:33:50,951
- There we go.

485
00:33:52,161 --> 00:33:53,745
We're over the Amazon now.

486
00:33:53,787 --> 00:33:56,957
(narrator): Belém is near
the mouth of the Amazon.

487
00:33:57,249 --> 00:34:01,044
Following the river
should lead the pilots
to the city.

488
00:34:03,797 --> 00:34:06,466
But seconds later...
(alarm sounding)

489
00:34:06,508 --> 00:34:08,135
- We've got a fuel warning!

490
00:34:08,177 --> 00:34:11,221
(narrator): ...Flight 254
is running out of fuel.

491
00:34:11,889 --> 00:34:15,601
The pilots suddenly realize
they can't make it to Belém.

492
00:34:15,976 --> 00:34:21,273
- Flaps to 2. We need to do
a controlled descent.

493
00:34:23,692 --> 00:34:28,322
(narrator): They'll have to make
a forced landing
in the dense Amazon rainforest.

494
00:34:31,283 --> 00:34:32,701
- We just lost an engine!

495
00:34:32,701 --> 00:34:37,331
- Hang on.
(alarm sounding)
I'm going to put her down.

496
00:34:41,251 --> 00:34:43,295
- There goes the other one!

497
00:34:47,216 --> 00:34:50,093
(narrator):
The inevitable impact
is just seconds away.

498
00:34:50,093 --> 00:34:53,055
(automation): Terrain. Pull up.
- Just... need... to...

499
00:34:53,055 --> 00:34:54,681
bring us down!

500
00:34:54,723 --> 00:34:58,393
Nice... and... slow!

501
00:35:09,279 --> 00:35:12,241
(alarm sounding)
(automation): Pull up.

502
00:35:25,963 --> 00:35:30,801
(narrator):
Of the 54 passengers and crew,
six die on impact.

503
00:35:33,553 --> 00:35:37,307
Many are badly hurt,
including First Officer Zille.

504
00:35:40,936 --> 00:35:41,937
(baby crying)

505
00:35:42,354 --> 00:35:45,983
The captain tends to the wounded
while they wait to be rescued.

506
00:35:45,983 --> 00:35:48,443
- Ah!
(clattering)
(man): Help.

507
00:35:48,819 --> 00:35:53,907
(narrator): But no one
in the outside world knows
where the plane has gone down.

508
00:35:57,536 --> 00:36:01,415
(narrator):
Investigators conduct
an aerial search around Belém

509
00:36:01,456 --> 00:36:03,625
for Varig Flight 254.

510
00:36:04,167 --> 00:36:07,087
But there's no sign
of the missing aircraft.

511
00:36:10,007 --> 00:36:12,884
(interpreter for Machado):
You get anxious to find
the plane quickly,

512
00:36:12,884 --> 00:36:17,139
because people have
a better chance of survival
during the first 48 hours.

513
00:36:17,139 --> 00:36:21,435
After that, survivors
are more likely to die.

514
00:36:24,938 --> 00:36:27,607
(narrator): After two nights
in the jungle,

515
00:36:27,649 --> 00:36:30,485
a small group sets off
to find help.

516
00:36:34,489 --> 00:36:37,534
Hours later,
they stumble on a farmhouse.

517
00:36:40,329 --> 00:36:42,039
- They found survivors!

518
00:36:42,622 --> 00:36:46,793
(interpreter):
It's sort of a relief to realize
the scenario is not as tragic,

519
00:36:46,835 --> 00:36:51,548
and there's an urgent desire
to get to the location
and start to work.

520
00:36:52,966 --> 00:36:55,218
- Where did you say they are?

521
00:36:55,802 --> 00:36:59,181
(narrator): The crash site
is nowhere near Belém.

522
00:36:59,181 --> 00:37:02,100
- It came down right... here.

523
00:37:02,893 --> 00:37:07,272
(narrator): The wreckage
of Flight 254 is lying
in the Amazon jungle,

524
00:37:07,314 --> 00:37:09,775
nearly 700 miles away.

525
00:37:10,108 --> 00:37:13,570
- How on earth did they get
way over there?

526
00:37:14,488 --> 00:37:16,823
No wonder we couldn't spot
the beacon.

527
00:37:17,616 --> 00:37:19,951
It's nowhere near
the destination.

528
00:37:20,994 --> 00:37:22,245
(narrator): Within hours,

529
00:37:22,287 --> 00:37:26,833
Brazilian military reach
the remote crash site
of Varig 254.

530
00:37:26,875 --> 00:37:29,127
They find 43 survivors.

531
00:37:30,003 --> 00:37:35,050
Five people have died
waiting for rescue,
and another dies soon after.

532
00:37:39,262 --> 00:37:42,599
Shortly after
the rescue efforts,
there's a major breakthrough:

533
00:37:42,599 --> 00:37:46,686
the discovery of the plane's
two flight recorders.

534
00:37:47,437 --> 00:37:53,026
Investigators hope
they will reveal why Flight 254
was so badly off course.

535
00:37:56,738 --> 00:37:59,574
(interpreter):
We were relying on the two
flight-data recorders.

536
00:37:59,616 --> 00:38:04,788
Both pilots were alive,
so we thought we were certain
to come to a conclusion.

537
00:38:09,376 --> 00:38:13,213
(narrator):
But when investigators review
the flight data,

538
00:38:13,255 --> 00:38:15,674
it paints a confusing picture.

539
00:38:17,300 --> 00:38:19,344
Instead of flying north
to Belém,

540
00:38:19,344 --> 00:38:25,475
the plane took off west
and flew in the wrong direction
the entire flight.

541
00:38:28,562 --> 00:38:32,983
(interpreter):
This became a central focus
of the investigation,

542
00:38:33,024 --> 00:38:36,945
to know why the aircraft
was so far off course.

543
00:38:39,906 --> 00:38:45,412
(narrator): Investigators wonder
if the crew were given
the wrong navigation details.

544
00:38:46,288 --> 00:38:49,624
Thankfully, Flight 254's
flight plan from the airline

545
00:38:49,624 --> 00:38:52,961
is among the documents
recovered from the cockpit.

546
00:38:53,295 --> 00:38:56,965
- Oh, thanks. Let's see
what this will tell us.

547
00:39:00,177 --> 00:39:02,804
I think I know
what they did wrong.

548
00:39:05,932 --> 00:39:09,436
(Fox): Their computer
flight-plan system
has four digits.

549
00:39:10,645 --> 00:39:16,359
This is very, very unusual,
as they almost always, uh,
have only three.

550
00:39:16,359 --> 00:39:18,945
The number 0270...

551
00:39:18,987 --> 00:39:21,281
was intended to mean...

552
00:39:21,281 --> 00:39:24,117
27.0 degrees.

553
00:39:26,328 --> 00:39:28,246
(interpreter):
When we noticed that,

554
00:39:28,246 --> 00:39:32,459
it gave us the idea
that instead of entering 027,

555
00:39:32,501 --> 00:39:37,172
which was the heading to Belém,
he had entered 270.

556
00:39:39,090 --> 00:39:42,677
- The captain read it
as 270 degrees,

557
00:39:42,719 --> 00:39:45,847
or due west,
so instead of flying
northeast...

558
00:39:45,889 --> 00:39:47,682
- They went west instead,

559
00:39:47,682 --> 00:39:49,559
going 270.

560
00:39:50,185 --> 00:39:52,479
He entered the wrong heading.

561
00:39:53,897 --> 00:39:57,901
(narrator):
Flying for more than three hours
in the wrong direction...

562
00:40:00,820 --> 00:40:03,740
...investigators suspect
the aircraft ran out of fuel,

563
00:40:03,782 --> 00:40:07,118
forcing the crew to make
a crash landing in the Amazon.

564
00:40:19,089 --> 00:40:20,465
To confirm their suspicions,

565
00:40:20,465 --> 00:40:25,554
they call in Captain Garcez
to tell his side of the story.

566
00:40:26,054 --> 00:40:28,098
- I'll try to help you.

567
00:40:28,431 --> 00:40:30,892
(narrator):
Under intense questioning,

568
00:40:30,892 --> 00:40:33,728
he admits he misread
the flight plan,

569
00:40:33,728 --> 00:40:37,732
causing the aircraft to fly
hundreds of miles off course.

570
00:40:39,317 --> 00:40:42,404
- Look,
it was an honest mistake.

571
00:40:45,198 --> 00:40:50,745
(narrator): Company records show
the airline began printing
their flight plans in a new way

572
00:40:50,787 --> 00:40:53,331
while the captain
was on vacation.

573
00:40:53,915 --> 00:40:56,418
- It's easy to see
how you'd get confused.

574
00:40:56,418 --> 00:40:58,211
(interpreter):
From that moment on,

575
00:40:58,211 --> 00:41:02,882
the cause or the basic framework
of the accident was determined.

576
00:41:04,593 --> 00:41:07,262
(narrator):
But the first officer
was also required

577
00:41:07,262 --> 00:41:09,764
to enter the heading
from the flight plan.

578
00:41:09,973 --> 00:41:13,226
Why didn't he catch
the captain's mistake?

579
00:41:15,604 --> 00:41:19,190
Aviation Psychologist
Kathy Mosier provides insight.

580
00:41:19,190 --> 00:41:22,944
- The co-pilot,
probably after many experiences
with captains

581
00:41:22,944 --> 00:41:25,572
who had always done it right
and never had to double-check,

582
00:41:25,614 --> 00:41:27,407
just entered
what the captain had put in,

583
00:41:27,407 --> 00:41:29,993
and assumed
that it was the right thing.
So in this case,

584
00:41:29,993 --> 00:41:35,206
your safeguard is gone,
because the co-pilot
is not crosschecking.

585
00:41:38,918 --> 00:41:40,337
- The original...

586
00:41:40,337 --> 00:41:44,382
navigation mistake, um,
was that of the captain.

587
00:41:44,758 --> 00:41:50,096
What is disheartening here
is that both pilots
went along with it.

588
00:41:52,557 --> 00:41:58,688
(narrator): Flight 254 was
flying in the wrong direction
from the moment it took off.

589
00:41:59,314 --> 00:42:00,940
Instead of asking for help,

590
00:42:00,940 --> 00:42:06,363
the captain tried
to get back on course
using a local radio signal.

591
00:42:06,613 --> 00:42:09,783
He thought he found a station
in Belém,

592
00:42:09,824 --> 00:42:13,787
but instead picked up a signal
in the opposite direction,

593
00:42:13,828 --> 00:42:17,207
taking them further away
from their destination.

594
00:42:19,751 --> 00:42:22,879
(interpreter):
His pride prevented him
from saying to his colleague:

595
00:42:22,879 --> 00:42:26,466
"Help me. I'm in trouble."
That would've been
a better approach.

596
00:42:26,675 --> 00:42:28,218
(narrator):
While scanning their radar,

597
00:42:28,259 --> 00:42:31,179
the crew thought they spotted
the Amazon River,

598
00:42:31,221 --> 00:42:33,515
which would take them
back to Belém.

599
00:42:33,556 --> 00:42:36,685
But the river they saw
was the Xingu,

600
00:42:36,726 --> 00:42:40,438
more than 600 miles
southwest of Belém.

601
00:42:41,398 --> 00:42:45,527
- How could they be so confused
for so long?

602
00:42:45,527 --> 00:42:47,278
- I think we're close.

603
00:42:47,862 --> 00:42:50,699
(narrator):
Investigators conclude the crew
was in the grip

604
00:42:50,740 --> 00:42:53,201
of what's known
as confirmation bias...

605
00:42:53,868 --> 00:42:59,040
...the tendency to favour
information that confirms
something we already believe.

606
00:42:59,416 --> 00:43:01,626
- When I saw the river,
I was sure.

607
00:43:01,626 --> 00:43:03,586
I was sure we were close
to Belém.

608
00:43:03,628 --> 00:43:05,922
- It just goes to show you
anybody can...

609
00:43:05,964 --> 00:43:08,049
fall into decision traps,

610
00:43:08,049 --> 00:43:11,219
and even experts
have to always be on guard.

611
00:43:11,886 --> 00:43:15,598
(narrator): The accident report
faults both pilots
for the actions

612
00:43:15,640 --> 00:43:18,601
that caused the plane
with 54 people on board

613
00:43:18,643 --> 00:43:22,021
to run out of fuel
and crash in the jungle.

614
00:43:24,441 --> 00:43:26,735
After the crash of Varig 254,

615
00:43:26,776 --> 00:43:28,737
the airline changes
their flight plans,

616
00:43:28,737 --> 00:43:31,614
so the decimal place
is clearly marked.

617
00:43:31,865 --> 00:43:33,742
They also improve
pilot training.

618
00:43:34,075 --> 00:43:40,248
Brazil's national radar system
is modernized and expanded
to cover the entire country,

619
00:43:40,290 --> 00:43:43,710
making it less likely
that a plane would go missing.

620
00:43:44,002 --> 00:43:47,380
- Fuel management in flight
is the responsibility

621
00:43:47,380 --> 00:43:49,340
of the pilots in the cockpit.

622
00:43:49,382 --> 00:43:53,219
But you can have
those same human errors
on the ground.

623
00:43:53,678 --> 00:43:59,142
The big common thread
between these three accidents

624
00:43:59,184 --> 00:44:00,435
is the human factor.

625
00:44:00,477 --> 00:44:04,439
It is the responsibility
to have not only a knowledge
of what you're doing,

626
00:44:04,481 --> 00:44:09,486
but a fundamental understanding
so that you can execute
properly.

627
00:44:37,347 --> 00:44:39,557
Subtitling: difuze