Original subtitles

NARRATOR: February 12, 2009.

Just outside Buffalo, New York.

Gear down.

Looks alive.

Gear's down.

Jesus Christ!

The airplane entered an aerodynamic stall.

It did not recover.

CLINT CROOKSHANKS: It was one of the grisliest, nastiest scenes

that I think I've seen.

NARRATOR: The crash of Continental Connection flight

3407 would be one of the NTSB's most important in decades,

and would see a grieving father fight for changes

to the laws governing small airlines.

JOHN KAUSNER: I'm focused and determined

to change what exists, and not have another dad sitting here.

FLIGHT ATTENDANT: Ladies and gentlemen,

we are starting our approach.

PILOT: We lost both engines.

FLIGHT ATTENDANT: Pur your mask over your nose.

Emergency descent.

Brace for impact!

NARRATOR: Continental Connection flight

3407, operated by Colgan Air, is en route from Newark, New

Jersey, to Buffalo, New York.

It's been a busy flight for Captain Marvin Renslow.

He's providing guidance to a new first officer,

Rebecca Shaw, a former flight instructor from Seattle.

Bless you.

NARRATOR: Shaw's only been with the airline

for just over a year.

Yeah.

NARRATOR: She must decide if she now wants to become a captain.

I don't know what I want to do with the upgrade.

It depends where I'm based.

Well, think of it this way.

If you stayed on the queue, obviously,

you're not making the captain rate.

Right.

But you may have a better quality of life,

with regards to buying a house, having a scheduled--

NARRATOR: Shaw trained to be a first officer

on the plane they're flying now, a Canadian-made Bombardier

Q400.

It's a twin engine, popular with regional airlines.

The 45 passengers have had a long night.

Their plane was held up for two hours at Newark--

a delay considerably longer than their journey.

Flight 3407 is heading northwest,

over upstate New York.

The trip is only 53 minutes.

Visibility is poor, and there's a forecast of snow

and moderate winds in Buffalo.

Just some water, please.

NARRATOR: Ellyce Kausner is a student at Florida Coastal

School of Law in Jacksonville.

She's on her way to visit her family in Buffalo.

JOHN KAUSNER: She had five nieces and nephews at the time,

and they had a love luncheon at the kids' school

with a couple of the nephews.

And they both wanted Elly to be their guest.

Any excuse to come home, she came home.

She talked to all of us from Newark.

Hey.

JOHN KAUSNER: And she called us from the lounge.

Yeah, it's been over two hours.

JOHN KAUSNER: She was PO'd because of the delay.

Folks from the flight deck, your first officer speaking.

It looks like, at this time, we're about 10,

maybe 15 minutes outside of Buffalo.

Weather in Buffalo is pretty foggy.

It's snowing a little bit there.

I'd like to make sure everyone remains in their seats,

so the flight attendants can prepare the cabin for arrival.

Thank you.

FLIGHT DECK: Colgan 3407, descend and maintain, 2,300.

REBECCA SHAW: OK, down to 2,300.

Colgan 3407.

Let's do a descent checklist, please.

We can do the approach checklist along with it.

Sure.

Bug set.

Set.

GPWS, landing flaps selected, 15 degrees.

NARRATOR: The pilots go through a list

of settings for the plane to continue its landing approach.

Yup.

NARRATOR: Passengers can already glimpse the lights

of Buffalo's suburbs.

Clarence Center is on the approach path for aircraft

landing at Buffalo's airport.

Gear down.

Looks alive.

Gear's down.

All right.

Flaps 15.

NARRATOR: Extending the flaps provides

more lift, allowing the plane to slow

to its final approach speed.

Uh--

Jesus Christ!

NARRATOR: Suddenly, the control column starts to shake.

The Q400 is slipping out of control.

Captain Renslow struggles to keep his plane flying.

Mother-- ah!

NARRATOR: But it seems to have a mind of its own.

Mother bear.

Should the gear be up?

Gear up!

Agh, damn!

Ah, we're down!

Oh, my god!

NARRATOR: The plane crashes into a house at 6038 Long Street.

At air traffic control in Buffalo,

flight 3407 disappears from radar.

DAVID CASE: I'll never forget the dispatcher's words.

Plane crash, house on fire.

I immediately got my shoes on and my coat on.

Got in my truck and started heading down the driveway.

NARRATOR: Firefighters don't have far to go.

6038 Long Street, home of the Wielinski family,

is less than a block from the Clarence Center Station.

As I turned towards the village,

the whole village was aglow.

You could see the smoke.

You could see the flame.

NARRATOR: Karen Wielinski and her daughter

make it out of their house alive.

But her husband, Douglas, is killed.

My initial reaction was, there's no--

there was no way that somebody made it out.

But the EMS, the division reported

that they had two people, and they were

taking them to the hospital.

And I said, well, which firefighters are they?

And they said, they're not firefighters, Chief.

They are survivors from the house.

I actually physically had to go to the ambulance

and look inside for myself to to believe.

NARRATOR: Firefighters have never seen a blaze like this.

DAVID CASE: But if you've ever gone to a bonfire

and stood 5 feet from it, and you couldn't take it anymore,

that's what it felt like from 100 feet away.

MICHAEL ROGOWSKI: The height of it was

was just unbelievable, obviously, because of the fuel

that was probably added to it.

And the debris area was was very large.

It was a very, very horrific sight.

We live in the town where the plane

went down right down the road.

My son was driving home from a soccer game

and went right by the plane crash, and called me up

and said, there's a plane down in Clarence.

It never really entered our brain that it was Elly's plane.

NARRATOR: Flight 3407 has crashed 5

miles short of Buffalo Airport.

All 49 passengers and crew are dead,

including Captain Marvin Renslow And First officer Rebecca Shaw.

But many more people could easily have been killed.

You picture a house.

And to see a plane on top of this house--

no more house left, no more plane.

Only the tail section.

You're asking yourself, how in god's creation did this happen,

and not wipe the whole block out?

JOHN KAUSNER: The next call was again from my son,

and said, in fact, it was Elly's plane.

And he said, Dad, there's no survivors.

At which point, my wife shrieked and just hit the ground.

Chris said he'd never heard his mother make a sound like that,

and I hope he never does again.

So that's when I knew that she was gone.

And that was probably within 45 minutes of the accident.

NARRATOR: The scene in the morning

is one of utter devastation.

Clint Crookshanks from the NTSB.

Can I start poking around?

NARRATOR: Clint Crookshanks is one of the first Investigators

on the case.

CLINT CROOKSHANKS: When we arrived on scene,

there was a fire still burning.

It turns out it was from a gas line that

had been broken in the house.

The firemen would put the fire out,

and it would reignite every couple of minutes.

It was one of the grisliest, nastiest scenes

that I think I've seen.

NARRATOR: Flight 3407 may have been a small plane,

but it's the worst crash in the US in more than seven years.

It will become one of the NTSB's most important investigations.

preventing investigators from examining the wreckage.

Right in there.

That's where I think the--

the box--

The airplane had crashed into a house,

and then it had burned all night long.

So all the debris was basically in the house.

LORENDA WARD: Our concern is that we're losing evidence.

It's perishable.

And if we can't get in there and get the fire out,

then we're not able to maybe get a hold

of evidence that might help us during the investigation.

NARRATOR: Clint Crookshanks urgently

needs to recover the black box flight

recorders, which could contain valuable clues

about the accident.

We knew that the recorders were in the tail part

of the airplane.

NARRATOR: Ordinarily, investigators

don't go near a crash site that's still burning.

But if the black boxes can't be rescued,

they may never find out what brought down flight 3407.

We started looking around and poking around into the wreckage

and actually found out where they were.

OK, whoa, whoa.

It's probably in here, OK?

The access panel is on the other side,

so we're going to have to cut a hole right there.

OK?

The fire department produced a chop saw.

We were able to cut a hole in the side of the fuselage,

and go in and grab the recorders and pull them out.

All right.

That should do it.

NARRATOR: To the immense relief of all,

the recorders are undamaged.

Once we took the recorders out of the airplane,

we put them on the jet, and they were flown back to Washington,

DC, to our headquarters.

NARRATOR: Now, investigators are faced with a new hurdle.

What little is left of the aircraft

is hopelessly jumbled together with human remains and debris

from the house.

CLINT CROOKSHANKS: It all burned and settled into the basement.

So we had probably 10 feet of debris

that we had to dig through in order

to recover all of the airplane.

NARRATOR: Authorities wonder how they

can salvage any useful evidence from this chaos.

They get invaluable assistance from an unusual source.

A group of students learning to process crime scenes

is enlisted to separate human remains

from the rest of the debris.

CLINT CROOKSHANKS: They were graduate students

from a local college, forensic anthropology students.

And this was good experience for them

to come dig through wreckage like this

and look for human remains.

So landing gear over there, please.

NARRATOR: It's dirty painstaking work.

But it frees up investigators to concentrate

on the aircraft ruins.

We were on our hands and knees,

with brooms, with little shovels,

scooping out debris, identifying it

as to house debris or airplane debris,

and then putting it in different piles.

The first question for me, as a structures engineer,

is to figure out if the whole airplane made

it to the scene of the crash.

NARRATOR: The wreckage is carefully studied to determine

if the plane's four corners--

nose, tail, and both wingtips-- are present.

If we find all four corners of the airplane, then we know that

there was no in-flight breakup.

There was nothing that departed the airplane

during the flight that may have caused the accident.

NARRATOR: One wing has been consumed by fire.

The other is shattered into pieces.

Hey!

Have a look at this!

NARRATOR: But Investigators are gradually finding what

they've been searching for.

Oh, yeah, it's the last piece.

It's the left one.

CLINT CROOKSHANKS: It wasn't until several days

into the investigation, as we were scraping away some

of the debris, that we actually found evidence

of the left wing and the nose.

NARRATOR: Investigators now have all the pieces

they need to conclude that the entire plane is

at the crash site.

Whatever caused the disaster was not the result

of a breakup in flight.

The tragedy of flight 3407 is under intense scrutiny at

the NTSB offices in Washington.

Officials there try to determine if some kind of malfunction

caused the crash.

On this particular accident, we

knew it was a landing accident.

So we want to check the aircraft's performance,

and then also, we checked for flight control continuity.

NARRATOR: Much of this responsibility

falls to Scott Warren.

SCOTT WARREN: My role in the investigation

was to be the systems group chairman for the Safety Board,

so I was in charge of looking at all of the aircraft systems.

NARRATOR: Warren analyzes the aircraft's cockpit voice

recorder, or CVR, to determine if there were any indications

of a problem in the cockpit.

REBECCA SHAW (ON RECORDING): Flight attendants can

prepare the cabin for arrival.

Thank you.

Is that ice on the windshield?

NARRATOR: He discovers that six minutes before the crash,

the crew of Flight 3407 had noticed a buildup of ice

on the aircraft.

MARVIN RENSLOW (ON RECORDING): Got it on my side.

You don't have yours?

Oh, yeah.

Oh, it's lots of ice.

NARRATOR: Ice can be a deadly threat to any airplane.

SCOTT WARREN: If an aircraft has ice on it,

it will have more drag on it, so it'll require more power

to maintain a given airspeed.

MARVIN RENSLOW: Oh, yeah.

That's the most I've seen on the leading edges in a long time.

NARRATOR: Until a year ago, Rebecca Shaw had no experience

with ice on an aircraft.

I'd never seen icing conditions.

Never de-iced.

Never experienced any of that.

ROGER COX: When ice accretes on a wing,

it adds weight to the airplane, but most importantly, it

changes the shape of the wing.

And of course, it's the shape-- the curved shape of the wing--

that actually creates the lip.

So by changing the lift characteristics

of the airplane, it makes it less able to fly.

You know, I'd have freaked out.

Like, I'd have seen this much ice and thought, oh my gosh,

we were going to crash.

ROGER COX: Observing that there was ice on the airplane

was an important thing to do.

But then, it would be important to turn

around and verify that your anti-ice and de-ice equipment

was on.

And there was no indication on the voice recorder

that they actually rechecked.

NARRATOR: The CVR reveals that only minutes

after the crew detected ice, a device called

the stick shaker went off.

It was a warning that the plane was about to stall, literally,

to fall out of the sky.

Shortly afterwards, the aircraft did precisely that.

We know there were icing conditions.

The only question was, were they bad

enough to induce this airplane to have a failure?

NARRATOR: Ice is now the chief suspect

in the crash of Flight 3407.

If it's ice, let's prove it.

CLINT CROOKSHANKS: We were all convinced

that we had an icing accident.

We said, yeah, it's going to be an icing accident.

We just got to make sure we look for these few key aspects

of icing, verify that, and we're good.

NARRATOR: But some of the victim's family members

are less convinced.

Our initial thought was that it was an ice-related incident,

that it was the icy night that brought the plane down.

And as we began to talk to people who knew airline travel,

who were pilots themselves, they would look kind of askance

and say, I don't think so.

That doesn't make sense.

NARRATOR: Some investigators share that suspicion.

Scott Warren knows a plane like the Q400

has a sophisticated de-icing system.

It's designed to keep ice from building

up on the wings and other critical parts of the aircraft.

To prevent ice accumulating, the plane

has rubber bladders along the front of the wings,

called de-icing boots.

A series of valves uses air from the engines

to inflate the boots and crack the ice off the wing.

Those boots are designed to inflate periodically.

And that inflation breaks off the ice that's accumulated

on those leading edges.

NARRATOR: Warren now wonders if the crew of flight 3407

actually turned on their de-icing equipment.

He studies data from the plane's other black box, its flight

data recorder, or FDR.

It tracks the workings of crucial aircraft systems,

including the de-icing mechanism.

SCOTT WARREN: We know from the FDR data

that the deicing system had been selected on by the crew.

And it was on during the majority of the flight,

and certainly, at the end of the flight,

it was recorded in the on position.

NARRATOR: But now, Warren needs to figure out if the device was

actually working.

SCOTT WARREN: Just because the data records that the system is

on, that's a start, but you can't necessarily believe

that one piece of information.

NARRATOR: The only way to know is

to find what remains of the plane's de-icing system,

and determine if it was active when the aircraft went down.

Clint Crookshanks' team hunts for a crucial component

of the system--

the valves.

Excuse me.

OK.

Everyone, I just--

CLINT CROOKSHANKS: For the de-ice valves,

we said, here's what it looks like.

Look for something like this.

If we can find those valves, then we can test them and see

if they're operating correctly.

SCOTT WARREN: The valves were very important to us,

because they are the key component that moves air

from the engines where the bleed air originates

for the de-icing system.

OK, good.

Five more to go.

NARRATOR: Five of the plane's six de-icing valves

are eventually recovered.

SCOTT WARREN: Some were badly burned.

Some were in fairly good shape.

And we took those valves, and we conducted as much testing

on those valves as we thought was appropriate for the level

of damage.

We looked at the level of electrical conductivity,

and we looked at the pressure testing.

We looked at a wide variety of things,

depending on the condition of the valve itself.

And as far as we could tell, all those valves

were working properly.

Is that ice on the windshield?

I've got it on my side.

NARRATOR: Now, investigators have

to consider the possibility.

Oh, yeah.

Oh, it's lots of ice.

NARRATOR: But there is so much ice on the wings,

that the de-icing system couldn't get rid of it

fast enough.

Oh, yeah.

That's the most I've seen on the leading edges in a long time.

NARRATOR: It has happened before.

In Roselawn, Indiana, a French-built commuter plane

crashed in 1994 after suffering a catastrophic buildup of ice

on the wind.

By analyzing how much power was needed for the plane

to maintain its airspeed, investigators

reach a surprising conclusion.

Basically, the aircraft was flying as if it had

a relatively small amount of ice on it,

but a very manageable amount of ice.

Looks normal.

SCOTT WARREN: It was not overloaded.

It was not excessive.

NARRATOR: If ice didn't bring down the plane,

something else must have caused it to stall.

Warren studies the Q400 operating manual

to learn the plane's stall speed, the velocity

at which it can no longer generate

enough lift to stay in the air.

He discovers that in the conditions

flight 3407 was flying through, it's roughly 111 knots.

He now compares the plane's stall speed

with its actual airspeed just before the stall

warning went off.

131 knots, well above the danger zone.

Flaps 15.

When the stick shaker went off--

Uh, oh!

Jesus Christ!

--they were not necessarily at the edge of a stall.

They were still 20 knots or so away from the stall.

NARRATOR: This new revelation deepens

the mystery of flight 3407.

If it wasn't stalling, why did it fall out of the sky?

Investigators turn their attention

to the critical seconds before flight

3407 went out of control.

They look for clues that could explain why the stall warning

went off when the aircraft was flying

well within its safety margins.

They discover that this plane has a unique feature, known

as a reference speed switch.

It governs the sensitivity of the plane's stall warning.

ROGER COX: Very few airplanes, in my experience,

have such a switch.

This airplane is the only one I know

of that has an actual switch on the overhead panel.

It was designed by the manufacturer

to be an extra safety feature.

Some kind of variable ref speed?

NARRATOR: Pilots are supposed to turn on the reference speed

switch when they're going to be flying

through icing conditions.

And we'll probably be picking up some ice.

NARRATOR: When in the increased position,

it reminds pilots to fly faster to counteract any drag effect

ice will have on the aircraft.

ROGER COX: When you are in icing conditions

and ice does accrue on the wing, it can

cause the stall speed to go up.

And so this ref speed switch correspondingly

causes the warning to come on sooner or at a higher speed.

What that switch does is it basically changes the trigger

settings for the stick shaker.

So we had to ask the manufacturer,

how does this switch work?

ROGER COX: And what we found was,

it was part of the systems description

that the crews got when they went through training.

But they didn't get a lot of training

on how to handle that switch.

It seemed like it was too simple to worry about.

NARRATOR: Investigators need to know if the crew of flight 3407

had turned on the reference speed switch,

triggering the stick shaker at a faster-than-normal speed.

The flight data recorder doesn't show whether the switch was on.

Investigators must find another way of determining its position

at the time of the accident.

Clint here.

NARRATOR: Clint Crookshanks is given a new priority.

All right.

I'll see if we have it.

NARRATOR: Recover the ice protection panel

from the Q400 cockpit, where the reference

speed switch is housed.

Since the panel was in the cockpit, finding it

is a challenge.

CLINT CROOKSHANKS: Most of the front end of the airplane

was consumed by fire, and so we didn't find anything

except for little balls of molten aluminum, little wire

bundles, and a lot of ash.

NARRATOR: But after an extensive search,

Crookshanks discovers that the ice

protection panel is one of the few pieces

of the cockpit that survived.

Bingo.

NARRATOR: However, the knobs and switches

are barely recognizable.

Crookshanks examines the charred panel to check the position

of the reference speed switch.

It was set to activate stall warnings

at higher-than-normal speeds.

CLINT CROOKSHANKS: We did find the ref

speed switch in the wreckage, and it

was in the increased position.

NARRATOR: This discovery only raises more questions.

MARVIN RENSLOW (ON RECORDING): And we'll probably

be picking up some ice.

NARRATOR: The cockpit voice recorder

indicates that as Renslow was beginning his descent

into Buffalo, he commanded his plane to fly

at the normal approach speed.

MARVIN RENSLOW (ON RECORDING): Gear down.

NARRATOR: But what's strange is that with his reference

speed switch on, he actually should

have been flying faster--

--as this is what the switch would remind him to do.

So why wasn't he?

The plane's computer warned the crew to fly faster,

according to the settings they had configured,

by displaying a set of red bars in the airspeed indicator.

But you may have a better quality of life

with regards to--

NARRATOR: These bars are meant to warn the pilots that a stick

shaker activation is imminent.

If you're looking at the airspeed indicator,

you should be aware that you're getting slow,

and the stall warning may come on.

Jesus Christ!

NARRATOR: It seems Renslow and Shaw were caught off-guard.

Still, they could have easily corrected the situation.

Once the stick shaker had activated,

they could have turned the switch off,

or they could have put the nose down

and increased their airspeed.

NARRATOR: It's clear to investigators

that flight 3407 wasn't in danger of stalling

when the stick shaker went off.

So now, they need to know exactly

what happened after the stall warning was activated.

An animated simulation of the crash

is constructed, based on information

from the flight recorders.

Watch what happens just after the stick shaker goes off.

NARRATOR: It illustrates that just

after the stick shaker was triggered,

the plane suddenly pulled up.

This action dramatically slowed the aircraft,

and at this point, it did stall.

Essentially, the airplane entered an aerodynamic stall

from which it did not recover.

It pitched over and hit the ground.

NARRATOR: Investigators are dumbfounded.

Flight 3407 wasn't stalling when the stick shaker went off.

But a few seconds later, it was.

The crew's every action during that brief time

now demands careful scrutiny.

What did they do?

NARRATOR: It's a puzzle.

How could a trained flight crew take a plane

that wasn't stalling, and in the space of a view moments,

make it fall from the sky?

ROGER COX: Any time you have an apparent stall

for no apparent reason, that's a mystery.

We would expect that no flight crew would stall an airliner.

So the question is, why?

NARRATOR: The focus of the investigation

now switches from the plane to the crew.

Specifically, on the moves they made

during the critical seconds after the stall

warning sounded.

ROGER COX: We wanted to see if the way they flew the airplane

was the way they were trained, according

to the standard operating procedures that are portrayed

in their flight manuals.

NARRATOR: The flight data recorder retains information

from more than 1,000 different aspects of the Q400's flight

operations.

From the airspeed and altitude to the position of the rudder

pedals and throttles, it also records

the movements of the most critical flight control--

the control column.

Pilots use the control column to change the position

of the elevators and ailerons, which manage

the direction of the plane.

The flight data recorder stores information, not just

about the control columns position,

but how much force is applied to it as well.

The FDR records what the control positions were.

It has sensors built into the control column.

It has sensors built into the control wheel.

NARRATOR: What Scott Warren finds

when analyzing the control columns position is stunning.

In response to the stick shaker, Captain Renslow

should have pushed the column forward to bring

the nose down and gain speed.

But for some reason, he did the exact opposite.

SCOTT WARREN: We found that the crew, instead of pushing

forward, which is the normal response to a stick

shaker triggering, the crew was actually

pulling back on the controls.

NARRATOR: This had the effect of pulling the nose up, causing

the airspeed to drop and tipping the aircraft

into an actual stall.

Captain Renslow had apparently mishandled one of the most

elemental piloting maneuvers--

how to recover from a stall.

Above everything, it requires gaining air

speed to get out of the red.

ROGER COX: The recovery procedure is fairly

simple and straightforward.

It requires pushing forward on the controls

and adding full power.

At any point in time, had the captain pushed forward

on those flight controls, he had a reasonably good

chance of recovering quickly.

JOHN KAUSNER: From everything we've gained,

that stall was recoverable on a repeated number

of levels and a repeated basis.

There was no reason for their plane to go down.

NARRATOR: Investigators also learned that First Officer

Shaw, in trying to help Renslow deal with the crisis,

inadvertently made things worse.

I put the flaps up!

NARRATOR: She retracted the flaps,

reducing the amount of lift as the plane

struggled to stay in the air.

ROGER COX: Had the First Officer simply called out,

you're stalled, advanced the power, pushed the nose over,

the airplane would have been able to recover.

SCOTT WARREN: From a human point of view,

it's sad to recognize that those sorts of things happened

and the tragedy that came from that.

NARRATOR: It's concluded that Captain Renslow's failure

to properly respond to the stall warning

was the primary cause of the crash of Flight 3407.

As the issue is now pilot error rather than mechanical failure,

human performance investigator, Evan Byrne,

is brought on board.

His first question-- why hadn't either Renslow or Shaw

noticed that their airspeed was too low for the icy conditions?

Byrne listens to the cockpit voice recording

to try to understand what might have led to that oversight.

REBECCA SHAW (ON RECORDING): Exactly.

MARVIN RENSLOW (ON RECORDING): Where

you could be home with your husband to take

care of and all that stuff.

NARRATOR: He learns that the crew had been

talking throughout the flight.

The conversation continued during a landing approach.

It's a violation of a rule known as the sterile cockpit, which

bans nonessential conversation during critical phases

of a flight.

--be upgraded in six months.

Blah, blah, blah.

EVAN BYRNE: Quite simply, it prohibits conversations

that aren't related

to the operation of the flight.

MARVIN RENSLOW (ON RECORDING): Let's

do a descent checklist, please.

We can do the approach checklist along with it.

REBECCA SHAW (ON RECORDING): Yeah, sure.

Bug set.

NARRATOR: Byrne also discovers that because of the cockpit

banter, the crew performed critical checklists

and briefings late.

Off.

Hydraulic pressure and--

NARRATOR: Distracted, the crew probably didn't see the red bar

indicating they were flying too slowly

for the conditions the plane had been configured for.

--on.

Approach checklist complete.

Rock and roll.

When crews deviate from standard operating procedures

and perform checklists late or don't make the required

call-outs, they become more vulnerable

to subtle mistakes that they may make inadvertently.

That could lead to startle and surprise

or unanticipated events that they have to respond to.

NARRATOR: The evidence is unequivocal.

The crew of flight 3407 was badly distracted

throughout the approach.

He came in when we interviewed.

And he said, yeah, you're going to be upgraded in six months.

NARRATOR: They had forgotten a key setting

they had made that required them to fly faster than normal.

They had missed indications that they were flying

too slow for icing conditions.

Then, Captain Renslow had reacted incorrectly

to a stall warning--

Jesus Christ!

NARRATOR: --sealing the fate of the plane.

Evan Byrne wonders, what could have

caused a trained airline flight crew

to have made such missteps?

He finds a clue on the cockpit voice recording.

MARVIN RENSLOW (ON RECORDING): Excuse me.

NARRATOR: The crew was showing signs of fatigue.

Could Renslow and Shaw have been too tired to function

effectively on the flight deck?

It's a tough question.

Answering it will require tracking

their movements during the 72 hours leading up to the crash.

Byrne interviews the families of the pilots.

Can I speak to Mrs. Renslow, please?

NARRATOR: He studies the pilots mobile phone bills

and records of text messages.

He searches the airline's computer system

to determine if and when the crew used

it to check their schedules.

He needs to track their every move.

And what time did Rebecca leave the house?

EVAN BYRNE: We're talking to colleagues or other pilots,

check airmen, instructors.

And we ask all those people about the pilots,

about their recent activities.

NARRATOR: He learns that neither pilot actually lived anywhere

near Newark, but could not afford to stay

in hotels on their salaries.

Captain Renslow was earning $60,000 a year at Colgan Air.

First Officer Shaw was being paid less than $16,000 a year,

substantially less than an average bus driver.

As a result, both pilots had made long cross-country

commutes to Newark--

Captain Renslow, from his home in Florida,

and Rebecca Shaw, from Seattle, Washington.

In fact, Shaw had commuted all night

from Seattle on a cargo flight that connected through Memphis.

Captain Renslow had spent the night in the airline's crew

lounge at Newark Airport after having already worked two days.

He was seen sleeping on a couch in the lounge.

It was against company rules, but

pilots who couldn't afford housing near the airport

did it anyway.

Records show that at 3:10 AM, the morning of the crash,

Renslow was awake.

He checked his work schedule in the airline's computer network.

Next stop, Buffalo.

NARRATOR: At 7:29 AM, Rebecca Shaw

sent a text message to her husband,

telling him she'd arrived safely in Newark.

Hi, honey.

It's me.

NARRATOR: Phone records indicate that later in the morning,

Captain Renslow was on the phone several times.

Rebecca Shaw was noticed having a nap,

catching up on the rest she'd lost flying the night before.

It's not a lot of sleep.

EVAN BYRNE: We ultimately concluded that it was likely

that both crew members were experiencing

some effects of fatigue at the time of the accident.

JOHN KAUSNER: Her job is to watch the airspeed.

Her job was to watch the instrument panel.

And my view is, she was fatigued to the point

where it's, like, right here.

And you're so dull.

I think that's where she was, and he just was not capable.

He was just-- he shouldn't have been flying an airplane.

NARRATOR: The disturbing revelations about the crash

of flight 3407 leads John Kausner

to rally support and become a fierce advocate

for changes in the industry.

He raises awareness among both lawmakers and the public

about the need to improve regulations governing

pilots at regional airlines.

JOHN KAUSNER: This is just saying

we support 3407 families, their fight for aviation safety.

And these representatives and congressmen

and senators have done that for us,

and we're very appreciative.

NARRATOR: He takes his fight all the way to Washington, DC.

JOHN KAUSNER: We needed to do something.

And so we began to advocate in Washington weekly.

Every other week, I mean, we've made

innumerable trips down there.

And immediately, the families just gelled.

We all attended the hearings and began to say,

this is what we can do.

NARRATOR: The crash of Flight 3407

exposed wide-ranging shortcomings in the regulations

that govern regional airlines.

These smaller airlines now make up 1/2 of all daily passenger

flights in the US.

Their pilots are generally younger, less experienced,

earn less, and work long hours.

Their levels of safety are way different from the majors.

They have a much lower threshold in training, in ability--

so in pay, obviously, so they can't attract

a higher-qualified pilot.

There are pretty low wages, pretty

difficult working conditions.

And we don't seem to attract the same level of applicant

that we used to.

Some regional airlines get into a bind,

and they have to hire the first people that meet the minimums.

NARRATOR: In the US, of the seven fatal accidents involving

passenger jets over the past 10 years,

five have involved regional airlines.

Those include the crash of Delta Connection flight 5191

in August 2006, which killed 49 people when the crew

took off from the wrong runway.

John Kausner's campaign to change laws governing pilots

has paid off.

JOHN KAUSNER: We relied on your support.

We needed your support.

You nurture us.

We want to thank all of you from all of us.

NARRATOR: A year and a half after the crash,

under pressure from kosner and other victim's family members.

The US Senate passed a bill, which toughens training

requirements and forces the FAA to draw

up new rules on pilot fatigue.

Studies into the problem of overtired pilots

are already underway.

At the University of Iowa, researchers

are developing a system that could help pilots resist

fatigue, stay engaged with the critical task of flying,

and prevent future tragedies like that of flight 3407.

Thomas Schnell is a human factors engineer.

THOMAS SCHNELL: We use a number of neurocognitive and

physiological sensors that we apply on subjects, pilots,

that we invite for our studies.

--114 is going to be free floating.

OK.

Welcome.

Just go ahead.

NARRATOR: He's studying how pilots stay alert on the flight

deck as a test subject conducts a cross-country journey

in a simulator.

Using sensors, he can determine how alert

and engaged a pilot really is.

The research could lead to the development of

fatigue detectors on airplanes.

THOMAS SCHNELL: We are trying to predict pilot state, so that we

can adjust something on the flight deck

to prevent the problem from getting worse

or starting in the first place.

We monitor brain activity, eye movement activity, heart,

the EKG, and respiration, and other parameters,

in an effort to figure out what the pilots or the crew's

status.

Are they fatigued?

Overworked?

Are they disengaged or distracted?

This section is where they were really drowsy,

and you can see that gaze has become kind of bored.

NARRATOR: Schnell instructs the flight

simulator to trigger a major systems failure in the cockpit.

It's no good.

Everything's dead.

Hydraulic systems have failed.

Flaps not applicable.

THOMAS SCHNELL: Crank up that heat map,

so we can see what this brain activity was.

Brace for impact.

THOMAS SCHNELL: When a crew is fatigued, what you might see

is their reaction to events may slow down.

So you'll see mistakes being made on the flight deck.

NARRATOR: It's precisely these kinds of mistakes on the part

of Renslow and Shaw that ultimately crashed flight 3407

and killed 50 people.

It's a tragedy that should not have happened.

That was foreseeable, was preventable,

and it's repeatable, if we don't do something about it.

I'm focused and determined to change what exists, and not

have another dad sitting here.