All language subtitles for Air.Disasters.S09E06.Carnage.In.Sao.Paolo.1080p.PMTP.WEB-DL.AAC2.0.H.264-maldini_track3_[eng]

NARRATOR: A deadly
air crash in Brazil

leaves a neighborhood
in flames.

INTERPRETER: It looked
like a bomb had gone off.

NARRATOR: The Black
box data is baffling.

Look at engine number 2.

The power is all
over the place.

I was amazed because that's
just not supposed to happen.

NARRATOR: To solve
the crash of TAM 402,

investigators will need to
try something different.

Let's see what we got.

NARRATOR: Something that's
never been done before.

And it proved to
be very revealing.

Oh, no.

Don't tell me.

ANNOUNCER: Ladies
and gentlemen,

we are starting our approach.

We lost both engines.

Keep your mask up your nose.

Emergency descend.
- Mayday!

Mayday!

Brace for impact!

He's the last one.

Investigation
started in 2004.

He's going to crash.

NARRATOR: Sao Paulo,
Brazil, is the largest

city in South America.

With 16 million residents,
morning rush hour

is always a crawl.

The traffic overhead
is busy too.

Residential
neighborhoods are packed

tied around Congonhas Airport,
one of Brazil's busiest hubs.

Jorge da Silva and
his family lived

just a stone's throw away
from the airport terminal.

INTERPRETER: My
family has always

lived in this
neighborhood, all of us,

even after we grew
up and got married.

When we left our
parents' homes,

we bought houses in
the surrounding area.

NARRATOR: Every day,
more than 500 flights

come and go from this airport.

INTERPRETER: When we were
kids, watching a plane go by

would give us a feeling of
freedom, a desire to fly.

Seeing those machines in
flight is a fantastic thing.

NARRATOR: Today,
89 passengers are

getting ready for a
short hop from Sao Paulo

to Rio de Janeiro.

They're flying on TAM airlines.

The Brazilian
company has just won

an award for best
regional carrier

and wants everyone to know it.

INTERPRETER: The number
one painted on the plane

was part of an ad campaign
TAM had underway at the time,

promoting its business
and its aircraft.

No problem, but I should go.

I'm on board right now.

NARRATOR: Regina Lemos is
a Brazilian journalist.

She's on her way to Rio
to cover a fashion show.

INTERPRETER: My sister was
a standout in her field.

She'd been an editor at
Marie Claire Magazine

and was working on the
launch of a new magazine.

She traveled a lot,
covering stories,

reporting, interviewing.

Good morning.
How are you doing?

Great.

NARRATOR: One of TAM's
most experienced pilots

is in command.

José Antonio Moreno has
almost 6,500 flight hours.

Before we start, checklist?

Yes, captain.

Already done.

Good.

Go ahead and call
the tower so we

can get these engines started.

You got it.

NARRATOR: First
officer Ricardo Luis

Gomes is less experienced.

The 27-year-old has only
been qualified to fly

the Fokker 100 for one week.

Sao Paulo TAM 402,
we're ready to go

and requesting engine start.

AIR TRAFFIC CONTROLLER: TAM
402, you're clear to start.

Fire them up.

Starting number one,
starting engine two.

NARRATOR: The short-haul
jet is powered

by twin Rolls-Royce engines.

Yeah.

All right, I'll
put it away now.

NARRATOR: Ronaldo Jenkins is
not only Regina's brother.

He's also an aviation expert.

INTERPRETER: It's a short
flight, 35 minutes normally

from Sao Paulo to Rio,
and you have approximately

five flights every hour.

So it's a very busy route.

AIR TRAFFIC CONTROLLER:
TAM 402, you're cleared

for takeoff runway 17, right.

OK.

Here we go.

Take off the rust.

NARRATOR: It's 8:26 AM,
flight 402 is underway.

Well, as you roll
down the runway,

we typically will accelerate
the aircraft to a point

that we call V1, that is
a decision speed at which

the flight crew makes the
decision to either reject

the takeoff, that is
to abort the takeoff

or continue it with the
amount of runway remaining.

NARRATOR: As they
accelerate down the runway,

the crew gets a warning.

Hey, this is what?

It's out.

See, the autothrottle is up.

A single chime warning
is really of no consequence

during the takeoff roll.

At that point, it wasn't
something that they would

have rejected the takeoff for.

NARRATOR: Two more beeps tell
them the problem is affecting

their other engine as well.

The autothrottle is out.

Manual thrust.

NARRATOR: They'll have to
adjust engine power by hand.

They could certainly
continue to take

off in the manual mode.

Nothing to be alarmed
with at that point.

V1 rotate.

NARRATOR: It seems
like a routine takeoff.

At that moment, the
aircraft's climbing.

The nose attitude of
the aircraft is raising.

The aircraft is accelerating,
and the altitude

is increasing.

Those are all good
positive parameters.

No, no, no, no.

NARRATOR: Then, less
than 50 feet in the air,

the plane rolls
dangerously right.

The captain needs to
level the plane fast.

The timing of this
could not have been worse.

The aircraft is dissipating
energy, airspeed at a rate

of about two knots per second.

Speed is life.

So the resolution
of this malfunction

is super critical
in terms of time.

NARRATOR: The captain's
efforts start to pay off.

The wings move
back towards level.

What was that?

NARRATOR: It's a
brief reprieve.

The airspeed is dropping
dangerously low.

Worse, the captain can't
keep the plane level.

DEVICE: Terrain.

Terrain.

It has to be an absolutely
sick feeling for that flight

crew at that point.

DEVICE: Terrain.

Terrain

NARRATOR: Just 25 seconds
after takeoff, flight 402

hits the ground.

In an instant, the Jabaquara
neighborhood is in ruins.

A passenger jet has
fallen from the sky.

Houses are crushed,
streets are in flames.

Emergency crews
respond quickly,

but there's little hope any
of the 95 people on board

have survived.

There are also expected to be
many casualties on the ground.

News of the horrific
crash spreads quickly.

INTERPRETER: My brother
phoned me and said

a plane fell in your house.

Come quickly.

NARRATOR: Jorge da Silva races
home, unsure what to expect.

INTERPRETER: My brother
is a bit of a joker.

I didn't believe him
at first, but I could

hear the fear in his voice.

NARRATOR: Jorge's
parents are trapped

at the center of the disaster.

The elderly couple finds
their way is blocked,

their escape route
engulfed in fire.

INTERPRETER: My father
looked back and saw

the room being destroyed.

So they rushed downstairs
to the ground floor,

and he saw flames
in front of them.

NARRATOR: If they don't get
out soon, it could be too late.

Jorge da Silva arrives home
to a scene of devastation.

His neighborhood is
in flames, and he

has no idea if his
parents are alive or dead.

My parents, have
you seen them?

INTERPRETER: It looked
like a bomb had gone off.

There was fire burning
throughout the whole street,

tall flames, lots of
smoke, and twisted metal.

It was terrible,
like something I'd

only ever seen in war movies.

NARRATOR: The plane's jet
fuel has ignited an inferno.

INTERPRETER: There
was a river of fire,

a line of flames down
the middle of the street

burning all the parked cars.

It was hard to believe
it was real that it

was actually happening.

NARRATOR: That as Silvas
make a narrow escape out

of the back of their house.

They are later reunited
with their family.

INTERPRETER: It was a
very emotional moment

that's difficult to describe.

In a short time, I
went from a sensation

of having lost them that
they were dead to having

found them again.

That was a rebirth.

It was fantastic.

NARRATOR: Others
are not so lucky.

Many of Jorge's neighbors are
injured, four of them fatally.

The crash has also killed all
95 people who were on board

the plane.

INTERPRETER: I got
a call from my son

saying that he'd seen on
TV that Regina, my sister,

was on the plane.

I knew there were no survivors.

That's when I
realized she was dead.

NARRATOR: Shortly
after the disaster,

Jenkins is asked to
investigate the TAM crash

for an insurance company.

The death of his sister
makes that impossible.

INTERPRETER: I had to
contact the insurance company

to say that I just
couldn't do the job

since I was now emotionally
involved in the case.

NARRATOR: Across Brazil,
the enormity of the disaster

sinks in.

It's the worst air crash
in Sao Paulo's history.

INTERPRETER: This tragedy was
a critical event in the history

of Brazil because
it was in a city,

especially the biggest
city in the country,

it affected everyone.

NARRATOR: Air
crash investigators

from the Brazilian Air Force
arrive at the crash site.

Major Carlos da
Conceicao leads the team.

INTERPRETER: When I got
there, it was really

a scene of total devastation.

The plane took down
everything in its path,

houses, cars, everything.

It was like a war zone.

NARRATOR: He
immediately realizes

the accident could have
been even more devastating.

At least the kids
were already in school.

NARRATOR: Flight 402 has
crashed less than 60 feet

from an elementary school
where 800 students were

attending morning classes.

INTERPRETER: It was
truly surprising

that the streets were empty
and there were so few victims.

For some strange
reason, at that moment,

there weren't many
people on the street.

Take your time.

We don't want to miss anything.

NARRATOR: Recovering
all the wreckage

will be a lengthy process.

But for investigators,
it's a crucial step.

INTERPRETER: First of
all, you have to find

the pieces of the aircraft.

The engines, landing gear,
the right wing, the left wing,

the tail section.

Is the airplane all
there, or did a part

come off before the crash?

And you start to put
together this puzzle.

NARRATOR: At the home of
Jorge da Silva's parents,

the recovery team makes
an incredible find.

The plane's landing gear
has smashed through the roof

and crushed the da Silva's bed.

INTERPRETER: It was a
miracle that they survived.

The landing gear of the
plane, I learned later,

weighs about two tons.

If my parents had been there,
they would have been killed.

NARRATOR: Piece by piece,
all the major components

of the plane are found
at the crash site.

OK, looks like we have
the whole plane here.

NARRATOR: It's
important confirmation

that the plane didn't lose
any pieces while in the air.

We know that the aircraft
departed control flight

at a very, very low altitude.

The first culprit in
that type of instance

would be loss of thrust.

NARRATOR: Da Conceicao
examines the Rolls-Royce

engines at the crash site
looking for signs of failure.

But damage deep
inside both engines

tells him they were
spinning at high speed

when the plane hit the ground.

Burning and turning.

These engines were fine.

NARRATOR: Ruling out
a potential cause

is a step in the
right direction.

But investigators
will need more

evidence before they
can zero in on what

brought down flight 402.

We're going to head
maybe just over there.

Can you keep those
people back, please?

NARRATOR: Onlookers crowd the
Sao Paulo crash site where

99 people lost their lives.

The city has declared
three days of mourning.

Brazil's president
pledges a safety

review of all city airports.

The pressure for
answers is intense.

INTERPRETER: It was the
first time I had ever

investigated a crash
like this, and it

was really very difficult.

OK, so it was definitely
rolling right like like this.

NARRATOR: Witnesses
tell investigators

the plane was banking
steeply to the right

just before the crash.

Any time you have witness
statements that describe

the aircraft
rolling or pitching

or observation of any moving
flight control surface,

it perks the interest
of the investigator.

NARRATOR: Shattered wreckage
at the Jabaquara crash site

confirms the
witness statements.

INTERPRETER: The right wing
was found stuck in a building.

The aircraft sliced into it
at an angle like a knife.

NARRATOR: A steep
right roll would

have caused the
wings to lose lift

and put the plane into a dive.

But why was the plane
rolling so steeply?

Investigators wonder if there
is a problem with the plane's

control surfaces, the flaps,
and slats that pilots extend

from the wings during takeoff.

If the crew didn't set
the flaps properly,

it might explain flight
402's fatal trajectory.

We do know that failure
to deploy the flaps

or configure the aircraft
properly for takeoff

has been involved with
many, many mishaps.

NARRATOR: They focus
on the mechanism that

moves the flaps in and out.

Precise measurements
should tell them if the TAM

crew made a deadly error.

What they find rules
out that possibility.

8 degrees, right
where it should be.

NARRATOR: The plane
was configured

properly for takeoff.

OK, mark it down.

8 degrees.

This is not-- this
is not helping us.

Investigators will
need to look elsewhere.

Yeah.

Check the records.

I want to know
everything the pilots

did in the last 24 hours.

How well was a pilot trained?

Was he rested?

Had he eaten within
the last several hours?

Everything that makes the
man-machine interaction work,

we want to find out what
went into that machine

prior to the mishap.

The records look fine.

NARRATOR: A comprehensive
review of the cruise records

turns up no red flags.

The crew was
well-rested and fully

qualified to fly the plane.

A good investigator will
take every bit of evidence

he can put together
and make a puzzle

and fit the piece
of the puzzle,

so it fits the scenario
rather than the scenario

trying to fit the malfunction.

NARRATOR: Investigators
hope the black boxes will

fill in some missing pieces.

This one's in good shape.

NARRATOR: The cockpit voice
recorder looks promising,

but the flight data
recorder, which

tracks the operation
of aircraft systems,

is badly burned.

Let's hope this isn't
as bad as it looks.

INTERPRETER: It was no longer
that orange color, which is

characteristic of black boxes.

It was completely gray from
all of the fire damage.

I was really anxious to know if
the data had survived or not.

OK, come on.

I need to get these
to the states.

NARRATOR: Brazil doesn't have
a lab equipped to analyze

the damaged recorder.

So they need to be sent
somewhere that does.

It was a US-manufactured
flight recorder,

so it was obvious to bring
the recorder to the United

States for analysis.

NARRATOR: Dennis Grossi is
quickly recruited to the team.

He's an investigator
with the National

Transportation Safety Board.

Thanks for helping us.

Of course.

Sure.

Happy to help.

NARRATOR: He's also one of
the world's leading experts

on flight recorders.

Let's see if this will
work like it's supposed to.

NARRATOR: But with
this recorder,

he faces a new challenge.

It's a digital device.

And at 1996, digital
technology is not very common.

We had a long experience
with tape recorders,

but we had no experience
with solid-state recorders.

And it was heavily
fire-damaged.

So we thought it was prudent
to take it to the manufacturer

to use their expertise in
opening it and accessing

the solid-state memory.

OK.

Here we go.

NARRATOR: The data inside
could be a huge windfall

for the investigation.

Nice and easy.

NARRATOR: But getting to
it is a delicate matter.

There's always
that anticipation.

Is it going to be destroyed,
or is it pristine?

What condition
is the memory in?

Are we going to come
up empty-handed,

or are we going to have a
viable piece of evidence here?

It looks promising.

Fingers crossed.

The vulnerabilities
was the chips breaking.

If you crack a chip, it's done.

Or if the chips
come off the board,

and then you have to do
a chip-level recovery,

which is very, very difficult.

NARRATOR: They hook the
card up to a computer

and attempt to download.

Does it always
take this long?

NARRATOR: The
data has survived.

Never had a moment's doubt.

The fire protection and
the crash impact

protection worked.

We were very happy
at that point.

NARRATOR: All of
Brazil wants to know

why flight 402 crashed.

Somewhere in the download
data, investigators

may now have the answer.

It's been three days since TAM
flight 402 crashed on takeoff.

Now with the help
of black box data,

investigators may
soon know why.

The flight recorder
has captured

dozens of parameters about
the Fokker 100 short flight.

INTERPRETER: This
specific recorder

has 106 parameters, 106
sensors on the aircraft,

which give us information.

So it's important,
very important, to have

this initial
information in our job.

No, no, no, no.

NARRATOR: But will
it be enough to tell

them why the plane rolled
so suddenly out of control?

As they study the data,
investigators immediately

noticed something unusual.

Look at Engine number two.

The power's all over the place.

The fact that the thrust was
was increasing and decreasing,

increasing, decreasing, and
then finally full thrust

was very confusing.

Why would this happen?

NARRATOR: After
fluctuating several times,

the engine finally
reaches full power,

the usual setting for takeoff.

It wasn't clear exactly
what was causing this.

Could it be a
automated system that

was malfunctioning and
causing this to happen,

or was it some crew activity?

Can you bring up all the
data on the thrust reversers?

NARRATOR: There's another
parameter investigators

are eager to see.

OK, so you saw
something moving

at the back of the engine?

NARRATOR: A witness
told investigators

he saw one of the
plane's thrust reversers

operating just
before the crash.

Thrust reversers
are buckets deployed

on landing to redirect the
flow of engine exhaust,

pushing it forward to
help the plane slow down.

Pilots never used
them in the air.

Witnesses saw
that the buckets

opening and closing,
opening and closing,

and then finally opening.

INTERPRETER: This was a
real surprise to everyone

because the reverser is
an aerodynamic brake,

which is used on landing.

Why would it open
during takeoff?

NARRATOR: If a thrust reversers
did somehow deploy in flight,

it could easily cause
the type of steep right

roll that doomed flight 402.

For investigators, witness
accounts aren't enough.

They need hard evidence.

They soon find it
in the flight data.

There.

NARRATOR: Just after
takeoff, the right thrust

reversers moves
back and forth twice

and then stays in the
dangerous deployed position.

This shouldn't
even be possible.

I was amazed because
that's just not supposed

to happen, especially
in a critical phase

of flight like takeoff.

NARRATOR: The thrust
reversers system

includes a safety
feature designed

to prevent accidental
deployment in the air.

The plane's wheels must
be firmly on the ground

before the buckets will open.

There's a switch called
a weight and wheel switch

that, once it was compressed,
once the aircraft touched

down, would allow the
pilots to manually

open the thrust reversers.

That was by design.

NARRATOR: Airlines all over
the world fly Fokker airplanes.

If there's a design flaw
in the reversers system,

the lives of thousands of
passengers could be in danger.

It's extremely important
that the operators know

of any malfunctions
so they may apply

that knowledge to
how they're operating

their particular fleet.

American Airlines,
US Airways were

big operators of the F-100.

It was critical
that information

was disseminated worldwide
to all the operators.

NARRATOR: Investigators
test the actuators that

move the reversers,
looking for a failure

that might explain why one
of them opened during flight.

But there's no sign
of any malfunction.

The movement of
the thrust reversers

it was a big mystery at first.

NARRATOR: They also
test the electronics

that detect when
the plane's wheels

are safely on the ground.

They need to check
every circuit.

The exhaustive effort pays
off with the discovery

of a faulty sensor.

It was failing intermittently,
signaling the reverse

here to open and close.

The result was chaos
in the cockpit.

The sensor failure
was intermittent.

So the buckets opened and
closed and opened again.

Every time those buckets
would open and close,

a different yaw moment would
be applied to the aircraft.

Every one of those yaw
moments would have to be

countered by the captain.

It was very, very involved
and very dynamic situation

at a very low altitude and
very low airspeed environment.

NARRATOR: But there's
one big problem with what

investigators have uncovered.

The Fokker 100 has an
additional safety net

that should have
kept the plane safe

even after the sensor failed.

If a faulty thrust reversers
deploys on takeoff,

power to the affected
engine is supposed

to drop to idle automatically
to prevent the reversal

from acting as a brake.

No alarm sounds in the
cockpit, but the safety

system kicks in immediately.

The pilots don't
have to do a thing.

If there is an uncommanded
trust reversal deployment,

the system would
automatically retard

the thrust level back to idle
without any crew involvement.

The Fokker 100 has more
than enough power to climb

safely on just one engine.

So the question remains,
why didn't flight 402 make

it safely away from Congonhas?

OK.

Go ahead, please.

The cockpit voice recording
may be investigators only hope

of finding the answer.

OK, here we go.

Takeoff thrust.

Clearing for takeoff.

NARRATOR: Investigators
listen intently

to the sounds captured in
the cockpit of flight 402.

INTERPRETER: When we started
listening to the tape,

everything seemed normal during
the beginning of the takeoff.

The equipment, the
pilots, everything

was as it should be.

Hey, this is what?

NARRATOR: Then,
four seconds later,

the crew gets a warning.

PILOT ANTONIO MORENO
(ON RECORDER): It's out.

See, the autothrottle is out.

It's a minor issue.

It shouldn't matter.

INTERPRETER: Captain
Moreno speaks

calmly to the co-pilot,
who he realized

was new to this plane.

He calmly tells him that the
autothrottle is out and keeps

going with the takeoff.

Why is he so calm and
not doing anything?

Because the disconnection
of the autothrottle

does not impede takeoff.

NARRATOR: As the plane
accelerates down the runway,

the pilots seem
perfectly in control.

Rotate.

NARRATOR: But not
long after liftoff,

the mood in the cockpit
changes dramatically.

PILOT ANTONIO MORENO (ON
RECORDER): No, no, no, no.

He sounds like he's
fumbling with something.

It's locked.

What's locked?

PILOT ANTONIO MORENO
(ON RECORDER):

Turn it off up
there, autothrottle.

Pull here.

FIRST OFFICER GOMES (ON
RECORDER): It's off.

It sounds like the
crew thought the problem

was the autothrottle.

NARRATOR: The pilots don't
mention the reverser at all.

They're focused on
the autothrottle

and seem to be struggling
with cockpit controls.

Turn it off up there.

Here too.

It's off!

It's off!

NARRATOR: There was
no alarm to tell

them a reverser had deployed.

DEVICE: Terrain.

Terrain.

Those guys had no
idea what was going on.

NARRATOR: It's clear
to investigators

that the crew was
confused, but they still

don't know what
the crew was doing

in those crucial last seconds.

You want to get clear
what, in fact, happened so

that this won't happen again.

NARRATOR: To build a
more detailed picture,

Dennis Grossi tries
something new.

He combines the flight
data with the cockpit

voice recording to create
a real-time animation

of the flight.

OK.

Take up speed was 127 knots.

It's something that, at that
point, the NTSB had never done

and it proved to
be very revealing.

Let's see what we got.

INTERPRETER: You can evaluate
second by second what happened

during the accident,
which helps us a lot

in recreating the events.

NARRATOR: The new animation
reveals an astounding

detail about how
the crew reacted

when the reverse are deployed.

PILOT ANTONIO MORENO (ON
RECORDER): No, no, no, no.

It's locked.

Hold it.

He must be reacting to the
movement of the thrust lever.

No, no, no, no.

The automation
just moved it to idle

just like it's supposed to.

NARRATOR: The sudden loss of
thrust in the right engine

indicates that the safety
system responded correctly

when the reverser deployed.

Turn it off up
there, autothrottle.

Pull here.

It's off.

But the pilots misinterpret
the lever's movement.

Oh, no.

Don't tell me.

NARRATOR: They think
it's a malfunction

that a faulty autothrottle
is cutting engine power.

Tragically, they tried
to override the system.

I think the first officer
is deliberately putting

the engine back to full power.

They, in fact, had ended up
with the thrust reverse fully

open and with full thrust on
that engine where the thrust

reversers were open.

Turn it off up there.
Here too.

It's off.

It off.

NARRATOR: With one engine
at full forward power

and the other in full
reverse, the plane

quickly rolls uncontrollably
into a fatal dive.

DEVICE: Terrain.

Terrain.

Once you put the engine
back to full power,

they didn't stand a chance.

NARRATOR: The
animation helps reveal

that the crew's actions
played a tragic part

in the crash of TAM 402.

But it raises new
questions as well.

Why was the crew so confused
about an automated system

designed to help
save their plane?

There's still a missing
piece to this puzzle.

The thought came, why?

How did this happen?

How did the crew not understand
what was happening to them?

Let's see how much time these
guys spent training for this.

NARRATOR: da Conceicao wants
to know how the airline

trains its pilots to deal
with accidental

reversal deployments.

INTERPRETER: We found out that
TAM had consulted with Fokker

to find out whether
there was any need

to train for a reverser
deployment during takeoff.

NARRATOR: Fokker's response
is a key piece of this puzzle.

A failure so rare they
decided not to train for it.

INTERPRETER: Fokker
formally responded,

saying the training
was not necessary

that the probability that
the reversers would open

during takeoff was very
small, and this training

was not necessary.

NARRATOR: Fokker estimated
the chance of such a failure

was less than 1 per
billion flight hours.

Turn it off up
there, autothrottle.

Pull here.

It's off.

NARRATOR: The pilot's
confusion starts to make sense.

For the crew not to know
that the thrust of reverser

deployment would, in fact,
pull the throttle back,

in this case, that
lack of training

really put the flight
crew in a bad situation.

Turn it off up there.

Here too.
- It's off.

It's off.

NARRATOR: Confused
and untrained,

the first officer
restores the full power he

thinks they need for takeoff.

Unfortunately,
they didn't have

enough information to
make the right decisions

at the right time.

NARRATOR: There's another
troubling mystery to solve.

What went wrong with
this safety system?

NARRATOR: That safety
system should be foolproof.

The first officer should not
have been able to overpower

the automation and push the
thrust lever to full power,

yet somehow he
did exactly that.

The question is how.

The levers are here.

NARRATOR: Investigators trace
the components of the safety

system, including
the cable that

pulls the thrust
lever back during

an accidental deployment.

It runs from the thrust lever
all the way to the reverser.

It was very important to,
in fact, examine the cable.

What condition was it in?

And the seeing why
their throttles

behaved the way they did and
the thrust behaved the way

it did.

This connects to
the faulty reverser?

NARRATOR: The cable
is in good condition,

except for one problem.

It has come apart at
a connection point.

It's a baffling discovery.

The cable is designed to
withstand an overwhelming 632

pounds of force.

I don't see how a pilot
could pull that hard.

Let's set up a test.

There's something
I want to try.

NARRATOR: Investigators decide
to put an identical cable

to the test.

They pull against the
cable from both ends.

Not only where it connects
to the thrust levers

but also from the opposite
end where it attaches

to the thrust reversers.

They'll soon know
exactly how strong

the cable system really is.

The safety cable system from
the Fokker 100 strains as it's

pulled apart with
more and more force.

Then at over 900 pounds of
force, it can take no more.

The cable actually failed
at a quick disconnect that

was supplied to allow for
maintenance so you could

disconnect and
reconnect fairly fast,

and that actually
turned out to be

the weak point in the system.

NARRATOR: But even
with the weak link,

the cable withstood more
force than the first officer

alone could have applied.

Then, in terms
of design limits,

one of the first
questions I would have

is how were they exceeded?

How did this component
actually fail?

NARRATOR: Investigators propose
an astonishing new hypothesis

to explain what happened.

It began with the
electrical failure.

NARRATOR: A failed
sensor disables

the lock on the right-side
thrust reverser.

The autothrottle disconnects
so that the safety

system can assume
control of engine power.

After takeoff, the
reverser deploys.

No, no, no, no.

NARRATOR: The safety system
pulls back the engine power,

but the crew doesn't
know what's happening,

and there's no cockpit alarm.

PILOT ANTONIO MORENO
(ON RECORDER):

Turn it off up there.
Here too.

FIRST OFFICER GOMES (ON
RECORDER): It's off.

It off.

PILOT ANTONIO MORENO
(ON RECORDER): Oh, God.

Three times, the safety
system pulls back the power,

and three times the first
officer puts the engines back

to full power.

NARRATOR: Investigators
conclude that when the thrust

lever snaps to idle
for the last time,

the first officer holds it
forward with all his might.

It's a natural response.

The object is to get
the airplane as high

and fast as you possibly can.

Given the information
that this flight crew had,

I would venture to say that
99% of all flight crews

would have reacted
exactly the same way.

NARRATOR: With the throttle
held forward, the next time

the reverse cycles
open, the first officer

is pushing while the
automation is pulling.

The combined force is stronger
than the designers

ever anticipated.

It pulls the cable apart.

You had the thrust
reversal buckets

fully deployed and
full thrust on one

engine in reverse and full
thrust on the other engine

in forward.

NARRATOR: The plane rolls
violently to the right.

The captain fights
to level the plane,

but his years of
experience aren't enough.

INTERPRETER: Once
the cable breaks,

the accident is inevitable.

At that point,
they had no options.

They did everything
they humanly could.

NARRATOR:
Investigators conclude

the crash was caused by a
rare combination of failures.

All of them contributing
to an accident that

should have been impossible.

INTERPRETER: The first thing to
learn from this investigation

is that nothing is fail-safe.

We need to have guidelines,
information, and training

to help pilots respond to
an emergency situation,

no matter how unlikely
that emergency might be.

NARRATOR: After the crash, TAM
airlines added new training

to teach its pilots how
to respond if a reversal

deploys during takeoff.

Fokker improved its
thrust reversal system.

They also modified
the cockpit alarm

so that pilots will now get
a warning if a reverse air

deploys on takeoff.

INTERPRETER: An investigation
from which nothing is learned

has no value.

The importance is in learning
and improving what we do.

INTERPRETER: Whenever we
investigate accidents,

we are always searching
to understand why.

We want to try and make
sure such accidents never

happen again.