Original subtitles

On approach during a thunderstorm.

Both runways are wet. Severe turbulence.

American Airlines Flight 1572 loses a valuable lifeline.

Be advised, the tower is closed.

There's a leaky window in the tower.

The tower had actually been abandoned. This is a very unusual situation.

NTSB investigators learn that a supervisor went to the deserted tower.

I told them they could land.

Landing is at your discretion.

The runway does appear to be clear. Moments before touchdown, disaster

strikes, and both of the plane's engines fail.

What role did an out-of-service tower play in jeopardizing the lives of the 78

people on board?

Tell them we're going down.

On a stormy November night, American Airlines Flight 1572 cruises 35

,000 feet above Pennsylvania.

Smoother right up here than at 33,000.

Captain Kenneth Lee, a former military pilot, has been flying with American

Airlines for 10 years.

That's for sure.

First Officer John Richards also flew with the military.

and has seven years of commercial aviation experience.

This was a very experienced flight crew that was very comfortable with the

aircraft they were flying.

They're flying the MD-83, a twin-engine narrow-body jet.

It has two turbofan engines mounted in the tail. It has a T-tail and a swept

main wing. It was one of the last aircraft that actually had direct

connection between...

the controls in the cockpit and the services on the airplane.

Better get the cabin ready for our descent.

Hi. We're starting our descent now, so you can lock the cabin up and prepare

for landing.

Will do.

Please fasten your seatbelt.

It's a short two-hour flight from Chicago's O'Hare Airport to Bradley

International Airport at Windsor Locks, Connecticut.

There are five crew and 73 passengers on board, many of them returning home.

Please put your seat in the upright position.

The flight started out rather routinely. It was the second day of a three-day leg

trip for these guys.

American 1572, descend at pilot's discretion.

Maintain flight level 190.

Discussion to 190.

American 1572.

Let's go down.

The flight is 25 minutes from landing.

I'm going to get the ATIS real quick.

Bradley Airport information, Victor 03.

ATIS, or Automatic Terminal Information Service, provides pilots with important

airport data like weather and approaches.

Both runways are wet. Severe turbulence.

All right.

Sounds like it's going to be a bumpy ride.

Tell the passengers.

They'll encounter some rough weather along the way, but nothing this

experienced crew can't manage.

Many times I have experienced the same kind of winds and weather that this crew

has had, and the winds will have a drastic effect on the airplane and

pushing it around.

The crew was very familiar with the weather, and they were highly

experienced enough to handle anything.

We've started our descent, and right now they've reported some moderate

turbulence on the descent, so it might get a little choppy.

Just watch me the whole way.

Yeah, man, you got it.

The pilots prepare for the landing.

Any comments? Just scream out.

You're going to get a lot of turbulence.

You know how to land it.

They support each other, they back each other up.

If anything goes wrong or somebody does something wrong, the other one catches

it and corrects it.

50 miles from the airport, the weather worsens.

It's a lot of rain. I can see that.

The en route controllers had told them the weather was going to be bad due to

thunderstorms and wind shear.

Wind shear is a sudden change of wind speed or direction that can be dangerous

close to the ground.

American 1572, descend and maintain 4000.

Descending 4000.

Flight 1572 is the last plane flying into Bradley Airport tonight.

Approaching 4000.

The crew is making a difficult non-precision approach.

A non-precision approach means that you don't have a navigation aid.

There's more reliance on the crew to figure out the altitude and descend

those altitudes correctly and avoid all the terrain that's below there.

We're established on the inbound track for the VOR approach.

Flaps 5.

Check.

Flaps 5.

This type of approach creates extra work for the pilots.

The non-precision approach is the hardest of all the approaches to fly

because it takes so much attention.

to fly the approach. It has to be set up correctly.

American 1572, be advised, the tower is closed at this time due to a problem

with one of the windows.

The non-precision approach and rough weather aren't the only challenges

facing the crew.

Copy.

There's a leaky window in the tower.

At larger airports, the control tower has two areas for managing incoming and

outgoing flights.

Approach control, typically located on one of the lower floors, and tower

control at the top.

Mark Guio was the air traffic manager at Bradley Airport for 12 years.

Once they're within five miles of the airport, the approach controller turns

them over to the tower to bring them in for landing and taxiing to the gate.

But a leaky window has shut down the tower, forcing the air traffic

controller to leave her post.

The tower controllers are the pilot's eyes on the ground. They're the ones

that ensure that the runway is sterile and clear for them to land on, that

there are no obstructions, no other traffic. They also provide critical

information in the late stages of the flight.

Flaps 11, please.

You got it?

The pilots must now rely on their own observations to land safely.

The pilots were expecting someone to be able to be in the tower, the controller,

to see the condition of the runway and to give them the information needed to

see if anything during the thunderstorm had blown onto the runway so they could

make a safe landing.

The approach controller is closely monitoring the flight.

He notices the plane is veering off course.

American 1572, looks like you're a bit to the left of final.

Yeah, looks like we're left of it.

Copy.

Seven miles from the airport, Captain Lee gets the plane back on course.

Let's have gear down.

Gear down.

I'm going up to the tower.

The supervisor in approach control volunteers to give the crew of Flight

1572 some guidance.

American 1572, there is someone in the tower. It's not officially open, but you

can change the tower frequency.

It would have been a big relief to the crew to have someone in the tower, the

controller up there, to give them the information they need for the approach.

Hey, tower.

American 1572, we are six miles from runway 15.

Landing is at your discretion.

The runway does appear to be clear.

Copy.

Any landing is really at the pilot's discretion.

But in this particular case, they need to be extra vigilant because they did

not have any official tower assistance.

Flaps 40.

The pilots configure the aircraft for landing.

Flaps and slats to 40-40.

You are clear to land.

There's a thousand feet.

Okay.

Flight 1572 is just 60 seconds from touchdown.

Bells and whistles were going off, lights were flashing, and something had

to be done.

Two and a half miles from Bradley Airport in Connecticut, American

Airlines Flight 1572 has struck something while descending to the

runway. The pilots must act quickly to avoid crashing.

Go. Go around.

Go around.

They pull the nose up in an attempt to recover.

Flaps 15.

Positive rate. Gear up.

Gear up.

The crew immediately.

began a go-around procedure.

They raised the gear, raised the flaps, crammed the engines forward, and

immediately after that, things went downhill very quickly.

Left motor's failed.

Seconds after the pilots commenced the go-around, the plane's left engine loses

power.

That's the last thing you need to have happen is a power failure on one of the

engines.

There's a runway straight ahead.

Okay.

Tell them we're going down. Tell them emergency.

Okay, tower.

Call for emergency equipment. We are going down on the runway.

Looks like we got an emergency on 1572.

Send the trucks.

Emergency vehicles have been dispatched.

As the pilots prepare for an emergency landing, the situation worsens.

The right engine also fails, turning the MD-83 into a 60-ton glider.

They realized they had the second power failure, which made double trouble.

Without its engines, the plane has drifted further off course.

Captain Lee tries to line it back up with the runway.

You've got it, dude. You're going to make it.

But they may not have enough lift to reach it.

A stall is an aerodynamic effect. It's when the wings lose lift.

and the airplane loses directional control.

The only way to fly out of a stall is max power, which they did not have.

Hold on, guy.

Hold it down, buddy.

Hold it down.

Hold it down.

Hold it down.

Hold it down.

Hold it.

God bless you.

You made it.

It was a miracle that the first officer saw the runway and the crew reacted so

quickly. It was a very good reaction and certainly saved a lot of people's lives.

Flight 1572 has landed safely after a treacherous final approach.

Everyone has survived.

And remarkably, only one person has suffered a minor injury.

The pilots are hailed as heroes for saving their plane and everyone on

board.

One of the key things about something like this is that you never stop flying

the airplane.

And those who do, don't live to tell about it.

The events that nearly brought down Flight 1572 are a complete mystery.

What have we got so far?

It will be up to investigators from the National Transportation Safety Board, or

NTSB, to find the answers.

Bob Benson heads up the team.

I was the investigator in charge with about a dozen NTSB people underneath me,

plus many people from the industry.

The aircraft hit the ground hard approaching the runway threshold.

Maybe the engines had something to do with it.

Did a loss of engine power cause flight 1572 to crash land in front of the

runway threshold?

When we first arrived at the accident site, our first order of business really

was to kind of do a reconnaissance look at the aircraft.

This thing looks like it flew through a war zone.

During our initial examination...

The aircraft was very, very damaged. It reminded me of something like a B-17

that had gone through a raid on Schweinfurt in World War II. It was beat

to heck.

Branches sticking out of the landing gear, engine blades missing, battered

flaps.

The aircraft was unflyable.

They definitely hit some trees.

Oh, they sure did.

And the engines definitely had power.

and they shredded those branches.

Mangled branches in the plane's engines indicate that they were working

normally.

The discovery raises another question.

If the engines had power, why'd they hit the trees?

The main question became why the aircraft was low enough to hit trees and

still make it to the runway.

If you're going to analyze an accident like this, which is to be categorized as

a controlled flight into terrain, you have to understand where the airplane

went and when it went there and why it went there.

Where exactly did they hit the trees?

To understand why Flight 1572 struck trees, investigators try to identify the

first point of impact.

The trees they hit are on top of a ridge about two and a half miles northwest of

the runway.

We have a team out there now.

Let's see if the trees or the ridge were marked on the chart.

The approach chart itself, when you look at it, had the ridge marked with a small

dot with the altitude.

The chart has the top of the ridge at 819 feet.

Once we began to look at the approach chart itself that the crew was using, we

noted that the ridge line was just a mere dot with the number 819 next to it

in altitude.

That dot could have been anything. It could have been a building, a giant

tree. Other airlines use a slightly different chart that shows topographical

features, including this ridge line.

Did Flight 1572 come in too low because there was a lack of detail on their

approach chart?

Do we have an altitude for the tree strike?

I need an altitude for the first impact mark.

771 feet.

They shouldn't have been anywhere near those trees.

The team is surprised to discover that when Flight 1572 hit trees, it was 48

feet below the altitude listed for the ridgeline.

They weren't just below the ridge.

They dropped 309 feet below the minimum descent altitude.

The minimum descent altitude, or MDA, is the lowest altitude a crew can descend

to until they are able to see the runway.

It's designed to keep planes above terrain or obstructions.

Those altitudes are hard altitudes.

When the FAA builds those altitudes in there, they have to take in

consideration of all the clearances, the trees, the elevation, to keep the

airplane at a safe altitude.

Why would they drop so low?

Maybe there was something wrong with their altimeters.

Investigators see the airplane descended too low, so the question is, did the

crew have the correct indication?

Let's see if the static system is working.

The static system was quite important.

Because that system controls altitude, altimeters, it controls air speed

indicators, and it also controls the vertical velocity indications.

Did sensors provide incorrect data to the plane's altimeters?

The MD-83 has three sets of sensors on the exterior fuselage.

They measure air pressure.

to determine air speed, altitude, and vertical speed.

If one of the static sensors is leaking or obstructed, it can give pilots

inaccurate information, making them think they are above or below their

actual altitude.

If the pitot tube is clogged, you lose those vital instruments.

And that can happen from a variety of reasons.

You know, static systems have caused problems before.

Problems severe enough to cause crashes.

You ready?

Yep.

The test forces air into the sensor to determine if the air pressure is being

measured accurately.

But it proves to be a dead end.

The static system is working.

Well then.

Let's see what the controllers can tell us.

It's always valuable to be able to speak to the air traffic controllers after an

accident. Often the air traffic controller is the last person to speak

to the crew prior to an accident.

Did the crew report anything unusual on their descent into Windsor Locks? No.

No, it was a standard approach.

But the weather conditions weren't great at the time.

Were there any downdrafts?

Did strong winds push Flight 1572 into the trees?

If an airplane encounters severe downdrafts, it could push the airplane

down several hundred feet.

Wind shear poses a danger to aircraft.

In 1985, a severe downdraft slammed Delta Airlines Flight 191 into the

ground, more than a mile short of the runway in Dallas, Texas.

137 people lost their lives.

In 1994, a year before Flight 1572's close call in Connecticut, U.S. Air

Flight 1016 crashed into trees while attempting to land in a powerful

thunderstorm in North Carolina.

It plowed into a residential neighborhood, killing 37 people.

Thunderstorms have incredible wind shear. They can have updrafts 200 miles

an hour.

Half a second later, after you pass through that, you get a downdraft at 200

miles an hour.

There was a lot of wind around the airport all night.

What about when this flight was coming through?

There was some wind shear.

Investigators learned that airport sensors registered some downdrafts. We

made sure to give them updates.

Like I said, it was rough.

So they knew what they were flying into?

Yes.

Given the weather conditions at the time and the unstable air, investigators were

able to determine that there may have been downdrafts up to 300 or 400 feet

per minute occurring at the time of this event.

So if there was a downdraft, these guys would have been prepared for it?

Oh, yes.

It was possible that Windshear could have pulled the aircraft down into the

trees, but a careful look at the weather at the time, after that, we determined

that simply wasn't true.

Was there anything else out of the ordinary that night, besides the

weather?

Well, the tower was shut down for repairs at the time.

A leaky window.

One of our supervisors went out to make sure they landed okay.

You mean the tower was down during their approach?

Yes.

I'd like to speak to the supervisor who was in the tower.

Sure, of course.

Did Flight 1572 slam into trees due to a lack of guidance from the tower?

Air traffic control work is demanding, and it's a precise job.

If there are any major disruptions, either in the tower or on a radar scope,

it could affect aircraft traffic greatly.

Were there any signs the crew was having trouble during approach?

Not really.

It was all normal until they called in the emergency.

Take me through what happened.

They were already six miles out, lined up at the runway.

The runway looked clear, so I told them they could land.

We are six miles from runway 15.

Landing is at your discretion.

The runway does appear to be clear.

Copy.

Did you give them an actual clearance for landing?

The tower was closed.

I can only give advisories.

It's up to them to decide after that if they want to land.

Advisories are just information provided to the pilot for their own use.

They can listen to it, they can not listen to it, it's up to them.

In this case, the tower was not open, so therefore he didn't have authority to

issue a landing clearance.

Investigators still don't know if poor weather and a closed control tower

caused the pilots to drop below the minimum descent altitude and into the

trees.

Let's start it at 12.53 when the crew contacts the tower.

Investigators turn to the cockpit voice recording of Flight 1572's final

approach to determine why the plane dropped too low and flew into trees.

Landing is at your discretion.

The runway does appear to be clear.

And what are you showing right now for winds?

170 at 24.

Copy.

He's checking the runway, giving them weather updates.

Solid job so far.

The team listens to the supervisor giving the crew guidance to help them

land.

It was a good initiative for him to do that. It was something some people would

not have done based on the fact that the tower itself was a bit of a precarious

area.

Flaps 40.

Flaps and slats to 40-40.

You are clear to land.

Okay. Give me 1,000 down.

1,000 down.

You got it.

Stop that.

1,000 feet a minute?

No way.

As they neared the ground, the crew decided to make their final descent at 1

,000 feet per minute, nearly double what is normal.

That, in my mind, is quite excessive. You didn't have to descend that steeply.

Especially on a non-precision approach, where you have a minimum descent

altitude that you should not be going below, the faster you're descending, the

earlier you have to start leveling off, or else you end up going below the

target altitude by the time you correct and come back up again.

According to the descent profile, they're five miles from the airport at 1

,900 feet.

Using the radar beacon data from air traffic control,

Investigators track Flight 1572's cockpit conversation throughout the

descent.

At 1,000 feet per minute, they're below their MDA in less than a minute.

Sure, that's fast, but the first officer should be calling out the altitudes.

While the aircraft is descending, the pilot is supposed to monitor the

airplane's MDA, minimum descent altitude.

The first officer should call 1,000 above the MDA to the captain, and then

100 foot.

to the mda and then the mda altitude okay let's listen to the first officer's

call outs there's a thousand feet

good he made a thousand foot call out but they don't hear any more call outs

after that the first officer called out the thousand foot above the mda he did

not call out the hundred foot above the mda

Investigators then hear something unusual.

The 1080 is your... Right.

You're going below your... Hang

on.

Was that the minimum descent altitude callout? I think it was supposed to be.

The team discovers that the first officer mishandled the remaining call

-outs.

The first officer started to call out for the MDA but never finished his

sentence.

So he makes half a call at their minimums. And then doesn't say anything

else until they're below it.

And by then they've hit the trees.

Why did the pilots make such a critical error so close to landing?

Let's talk to the pilots.

In this particular case, we were very fortunate to have a live crew to

interview. We wanted to determine exactly what they were thinking about

during the accident.

Walk me through your actions. Four miles from the airport as you approached

minimum descent altitude.

Look, the weather was rough. We were two hours late departing.

I was monitoring the instruments.

1,080 is your right.

Okay. And then what?

As we got closer to the minimum descent altitude, I looked outside for the

airport.

And when I looked back, we were below minimums.

You're going below your... During that time, he was looking out.

He was not monitoring the flight gauges as closely as he should have been. In

this case, the appropriate procedure would have had the first officer glued

to the altimeter and the compass and other instruments in the cockpit until

the captain said, I see the runway.

Why didn't you call for a go-around?

Well, there was no time. We immediately hit the trees.

It was a stressful night.

There could be a bit of task saturation in there. This went from an easy, kind

of relaxed flight with a little bit of weather difficulty to, oh my gosh,

everything's going wrong really, really fast.

Something doesn't add up.

The first officer couldn't have been at his minimum seconds before hitting the

trees.

Maybe there was an issue with the altimeter settings.

Pilots must calibrate the altimeters based on outside air pressure, which can

change dramatically in extreme weather conditions.

Pilots frequently recalibrate the altimeters to maintain an accurate

altitude reading.

Altimeter settings are very important. You can't do an approach in bad weather

unless you know what the altitude of your airplane is.

Let's see what settings they used.

It's a lot of rain.

I can see that.

In this case, because of the storm that was going through that area, the

pressure was falling rapidly. And when that happens, your altimeter setting

goes down quickly.

It means if you don't reset your altitude, then your airplane is flying

lower than you think it is.

Here.

The dispatcher updated them with an altimeter setting of 29.23.

NTSB investigators check whether the pilots of American Airlines Flight 1572

properly set the altimeter during the stormy approach into Bradley Airport.

What time was that?

12.30 a.m.

That was 25 minutes before they hit the trees.

And with changing weather conditions, they must have received an update from

Bradley ATC.

Well, one thing is the crew...

considers and expects from the tower our air traffic is the update of the weather

as quick as possible so they can also amend what they need to do.

Okay, they first contacted approach control at 1243.

Bradley Approach, American 1572.

We are at 11,000 feet.

Investigators expect the approach controller to give the crew a weather

update, including the altimeter pressure setting.

The approach control issue the altimeter setting on initial contact when an

arriving aircraft enters their airspace.

The altimeter is displayed as a digital display in the control tower as well.

American 1572, Bradley approach Roger.

Expect VOR runway 15 approach.

But the update is never provided.

Approach did not update their altimeter setting even though the pressure was

dropping rapidly.

There's nothing at all from Approach right up until he passes them off to the

tower.

Why wouldn't the Approach controller give them a weather update?

Good question. Let's ask him.

One thing that puzzled investigators was why the air traffic controllers in the

Bradley Tower didn't keep the pilots updated with the current altimeter

setting. You mentioned before that the weather was quite active that night.

Yes, it was changing quickly all night.

What was the airport's altimeter setting at the time of the accident?

Let me see.

29.15.

Investigators learned that the altimeter pressure setting at the time of the

accident was not the setting the pilots were originally given.

Why didn't the crew receive an updated setting?

Um...

29.15.

I didn't think to give it to them.

Sometimes things that you do over and over and over again become too routine,

and late at night when there's not a whole lot going on, sometimes those are

the things that drop through the cracks.

We warned him about that excuse a little bit, but it's what he said.

So in essence, the pilots did not have the current altimeter setting when they

flew the approach.

We got the altimeter setting from the time of the accident.

Comparing the two altimeter settings will reveal how much lower the plane was

flying than it should have been.

0.08.

The difference in the altimeter setting from what they had put on their

instruments to what was reality was about 0.08 inches of mercury, which

equates to 76 feet.

Because of the pilot's outdated setting, they thought they were 76 feet higher

than they actually were.

The discovery is eye-opening.

Once you get close to the ground, 76 feet is a big deal.

Once you're coming across the minimum descent altitude and you're keeping the

airplane level at the minimum descent altitude, 76 feet is critical.

The question is, would they have hit anything had they been 76 feet higher?

Well, we know they struck the trees at an altitude of 771 feet.

Add 76 feet to that.

They wouldn't have hit anything.

No impact.

If they had the correct altimeter setting, even though they went below the

MDA, they still would have been 76 feet higher.

And we probably wouldn't be talking about this right now.

because they would have missed the trees.

But that doesn't explain why there were 309 feet below their minimum descent

altitude.

76 feet of that are on ATC. The other 233 feet are pilot error.

This was out of the control of the pilots to a certain extent, but going

below the MDA should have been caught by both the first officer and the captain.

This is what created the accident.

In the end, it came down to the crew's decision.

Investigators now understand what happened to Flight 1572.

The outdated altimeter setting and the rough weather meant that the crew had

almost no room for error on the approach.

And when they were descending too fast and past their minimum descent altitude,

there was no way they could recover before hitting the trees.

Only one question remains unanswered.

In spite of hitting the trees, how did they make that landing?

Here's the FDR readout.

NTSB investigators turn to Flight 1572's flight data recorder to learn how the

crew managed to recover their jet after they struck the trees.

So, they hit the trees, and they immediately pull the flaps back to 15

and go to max thrust.

The data shows that the crew quickly configured the plane for a go-around.

Go go around going around

Flaps

15 positive rate gear up You're up Then

just as they begin their go-around they lose their left engine The

aircraft actually ingested

Trees the tops of the trees into the engines left motors failed followed

by their right engine Here you have a

scenario where Something devastated just happened. We just plowed through some

trees on the top of a ridge two and a half miles away from the runway and

losing Capabilities on this aircraft by the second they've got the nose way up.

They're losing speed and both their engines are gone That's a recipe for a

stall if I've ever seen one.

All of a sudden, they were starting to lose airspeed.

They were in a nose-high attitude, and that's the worst time that could happen.

Airspeed is what makes the airplane fly.

If there isn't enough air moving over the wings, the wings stop flying.

And that is what's referred to as a stall.

There's a runway straight ahead.

Fortunately, the first officer saw the runway. They had to get the airplane on

the ground in a hurry.

because they would not be able to keep on flying with the ancient power they

had. Okay.

Tell them we're going down. Tell them emergency.

So now he's got to reconfigure the aircraft again. And remember, this is

all happening in seconds.

He's got to focus on trying to save whatever altitude and airspeed he has

left to make it across the fence and to the runway environment.

This is a critical stage of flight now because he doesn't have power.

All he can do is trade altitude for airspeed. Now we know they're flaps.

We're all the way down at 40.

Flaps 40, all the way down.

They're all the way down.

He's going to generate something else that's going to get him across the

fence, and that's when he drops 40 degrees flaps.

The drag from the flaps slows them down, but for the first few seconds, it

balloons them up.

40 degrees of flaps change the curve of the wing, which increases the lift of

the wing, and gives him that extra little bounce to get a little bit

further.

If he had not have done that, or if he would have delayed it a little bit, the

accident could have been totally catastrophic.

You got it, dude. You're going to make it.

They glide down to the runway.

Unfortunately, they didn't have quite enough airspeed and altitude, so they

landed early, kind of scooted and flopped onto the pavement of the runway.

They made mistakes going into the tree strike, if you will, and yet did a

brilliant job landing the aircraft.

That's an incredible show of airmanship.

The crew's actually excellent cockpit resource management in the very

difficult situation that occurred after they hit the ridgeline.

They cooperated.

They didn't panic.

The way these two pilots worked together was remarkable.

And one of the last things that's on the tape that kind of really gives you a

chill is after they make the runway, the first officer says, God bless you. You

made it.

This is an accident that probably is not well known to a lot of people. And

that's because the aircraft was able to end up on a runway and nobody was

killed.

The captain's impressive recovery doesn't make up for the crew's errors.

The NTSB's final report concludes that the probable cause of this accident was

the crew flying below the minimum descent altitude before they could see

the runway.

We think in essence the main factor involved in the accident was the fact

that the pilots did not monitor the altitudes they were flying through

correctly.

They should have leveled off at a point, and they simply did not do so.

Following the accident, American Airlines increased the MDA requirement

by 100 feet and visibility requirement by half a mile for non-precision

approaches to Bradley Airport.

That's a lot of rain.

The NTSB also recommends that in conditions where pressure is falling

rapidly, controllers should issue altimeter setting updates as frequently

as possible.

The approach controller issues the current altimeter setting.

That didn't happen either.

What's important to understand, though, in terms of responsibility, is that the

captain is the final authority on the flight. It's ultimately the captain's

responsibility to ensure the safety of the flight.

In this case, he did not ensure that he had the most current altimeter setting.

This accident was important to me because it was one of the few where

nobody was killed, nobody was hurt.

And yet the Safety Board came up with some pretty good recommendations to

mitigate some of the factors that existed.