- 5 tháng trước
Chuyến bay Transair 810 là chuyến bay được vận hành bởi một máy bay chở hàng được cải tạo từ Boeing 737-200 , do Rhoades Aviation sở hữu và vận hành dưới tên thương mại Transair , trên một chuyến bay chở hàng ngắn trên đường từ Sân bay quốc tế Honolulu đến Sân bay Kahului trên đảo Maui lân cận của Hawaii vào ngày 2 tháng 7 năm 2021. Ngay sau khi cất cánh vào sáng sớm, một trong hai động cơ phản lực cánh quạt Pratt & Whitney JT8D của máy bay bị trục trặc và cơ phó đã giảm công suất cho cả hai động cơ. Hai phi công - những người duy nhất trên máy bay - đã bận tâm đến việc nói chuyện với kiểm soát không lưu và thực hiện các nhiệm vụ bay khác, và không tuân theo các quy trình thích hợp để xác định chính xác vấn đề. Cơ trưởng đã xác định nhầm động cơ bị hỏng, tăng công suất cho động cơ đó và không tăng công suất cho động cơ còn lại đang hoạt động bình thường. Tin chắc rằng không có động cơ nào hoạt động bình thường và không thể duy trì độ cao với một động cơ bị trục trặc và động cơ còn lại chạy không tải, các phi công đã hạ cánh ngoài khơi bờ biển Oahu sau khoảng 11 phút bay. Cặp đôi này đã được giải cứu khoảng một giờ sau vụ tai nạn trong một phản ứng liên ngành phối hợp với sự tham gia của nhiều máy bay và thuyền. Cả hai phi công đã được đưa vào bệnh viện và sau đó được xuất viện. Xác máy bay được tìm thấy vào tuần sau ở độ sâu lên tới 420 feet (130 m) cách Bãi biển Ewa 2 dặm (3 km) và sau đó đã được trục vớt.
Danh mục
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TiviPhụ đề
00:00Hey man, we're going down. We can't keep going down.
00:04Above the Pacific Ocean, the pilots of Transair Flight 810 can't get their cargo plane to climb.
00:10Just hitting the water is going to tear the airplane apart.
00:14We're in the water! We're in the water!
00:18Remarkably, they survive the crash and are rescued by the Coast Guard.
00:23They're covered in gasoline and hydraulic fluid, so it wasn't pretty.
00:27Investigators are eager to interview the crew.
00:30Did both engines fail at the same time?
00:33Most likely. That's my conclusion.
00:36The evidence does not support the pilot's assessment.
00:40It looks fine. No internal damage.
00:44So, it was critical for us to get more information to better understand what had happened there.
00:50It's the middle of the night at Daniel K. Inouye International Airport.
00:55It's the middle of the night at Daniel K. Inouye International Airport in Honolulu, Hawaii.
01:21The captain of tonight's flight is Henry Okai. He has almost 16,000 flying hours.
01:40So, this captain is highly experienced in the aircraft and doing it for a while.
01:46Engine start checklist.
01:48Engine start checklist.
01:51Tail stand.
01:52Removed.
01:53Cargo.
01:54First officer, Gregory Ryan, is a lawyer who recently returned to flying part-time for Transair.
02:01It's not necessarily the best pilot career straight up, but you do get to be in Hawaii.
02:06You get to fly an airplane.
02:09Engine start checklist complete.
02:12And...
02:13Clear right.
02:15Clear right.
02:16Transair flights use Rhodes Express as a call sign.
02:22Tower, Rhodes Express 810. Taxi, Kilo.
02:26Rhodes Express 810, Honolulu Tower. Runway 8, right. Taxi via Charlie, Romeo, Tango, Romeo, Alpha.
02:34Transair is owned and operated by Rhodes Aviation, which transports cargo between the Hawaiian islands.
02:48They had the postal contract, which was quite lucrative.
02:51Their focus was on keeping their costs down to maintain their advantage over more and well-established competitors.
02:58The plane is a Boeing 737-200, built in the 1960s and 70s for passenger travel.
03:09Today, they're workhorses for transporting cargo.
03:12Twin engines, small aircraft. It was designed for short-haul operations.
03:16Wasn't very sophisticated. No automation. I love flying that airplane.
03:21The pilots prepare for takeoff.
03:23Runway 8, right. Confirmed.
03:27Before takeoff checklist complete.
03:30Rhodes 810, cleared for takeoff.
03:34Runway 8, right.
03:35Cleared for takeoff.
03:36Rhodes 810.
03:43Tonight's flight is a short hop to Kahului, on the neighboring island of Maui, only 100 miles away.
03:50Okay, you have control.
03:54Okay, I have control.
03:57At 1.33 a.m., Captain Okai hands over the plane to First Officer Ryan.
04:09Engine stable.
04:1480 knots.
04:16Check.
04:18V1.
04:18Rotate.
04:23V2.
04:25Positive rate.
04:28Gear up.
04:30Within seconds of lifting off.
04:38Damn.
04:39Lost an engine.
04:41You got it?
04:42Yeah, I got it.
04:43The pilots have lost thrust in one of their engines, only 390 feet off the ground.
04:50Losing an engine after takeoff is one of the most critical events that can happen in a flight.
04:54You're close to the ground, you're slow.
04:56However, we also know from our training that the aircraft will fly perfectly well on one engine.
05:01The first officer levels the plane, and continues to climb away from the airport.
05:07Flaps.
05:09Turn 220 heading.
05:11I'll give you the flaps.
05:13Okay.
05:16Rhodes 810.
05:18We have an emergency.
05:19Stand by.
05:20We're on 220 heading.
05:21You can enter up to 2,000.
05:24The captain wants to put more distance between the plane and the ocean, so they have space to address the problem.
05:32Anytime you have an emergency situation, maintain aircraft control.
05:35You fail to do that, nothing else you do matters.
05:39Okay, Rhodes 810.
05:40We've lost an engine.
05:41We're on a 220 heading, maintaining 2,000.
05:43Declaring an emergency.
05:44How do you read?
05:46Rhodes Express 810.
05:48You are cleared visual approach.
05:50Runway 4, right.
05:52You can turn in towards the airport.
05:55The controller clears Flight 810 to return to the airport.
05:59Okay, Rhodes.
06:00810.
06:01We're going to run a checklist.
06:02I'll let you know when we're ready to come to the airport.
06:06Captain Okai wants to assess the situation further before returning to the airport.
06:10Flight 810 has been in the air less than three minutes, flying over the Pacific Ocean on a very dark night.
06:20Okay, I have control.
06:22Roger.
06:23Okay, let's see what's the problem.
06:26What's going on with the gauges?
06:28The pilots troubleshoot the situation.
06:32So it looks like the number one.
06:34Number one's gone?
06:35Gone, yeah.
06:37We still have the number two.
06:38So we have number two.
06:40Okay.
06:40They confirm they've lost their number one, or left, engine.
06:47They now must rely on their right engine to return to the airport.
06:51Let's do the engine failure shutdown checklist.
06:54And I have the radios now.
06:55Okay.
06:57There's a number of things this checklist is going to do for you.
06:59It's going to confirm the failed engine, and you're going to want to secure that engine.
07:03Okay, engine failure or shutdown when one of these occurs.
07:09An engine failure, an engine flame-out, another checklist directs an engine shutdown.
07:13As the pilots zero in on the problem engine, the situation intensifies.
07:19Hey, we're red line here.
07:21The right engine is now overheating, and they're losing altitude.
07:26We should pull back on the right one a little bit.
07:28Okay.
07:32We should head back to the airport.
07:34Yeah, we should.
07:35Yeah.
07:35The pilots now face the possibility of losing both engines.
07:41Problems on your second engine is going to significantly change your outlook,
07:45because you've got the dark water below you, and you know you're running out of options.
07:50Okay, Rhodes A-10.
07:52We'd like to come to the airport now.
07:54We might lose the other engine.
07:56Rhodes Express A-10, Roger.
07:59Confirm you still have the airport in sight?
08:03Negative.
08:05The pilots have descended too low to see the airport.
08:08Only the lights on the shoreline are visible.
08:11Hey, man, we're going down.
08:14We can't keep going down.
08:16We're descending.
08:17The captain has no other option but to increase power to the overheating engine,
08:23risking a double engine failure.
08:26How's the EGT?
08:28No, it's max. It's beyond max.
08:31The temperature of the right engine is now dangerously high,
08:34and the pilots suspect it could fail at any moment.
08:38Here we go, flops. Flops one.
08:40Fearing the worst, the first officer suggests configuring the plane for a water landing.
08:46No, no, not yet.
08:50Okay, we're very slow, though.
08:52The captain's efforts to reduce the loss in altitude aren't working.
08:57Shoot.
08:57Okay, flaps one.
09:01Just hitting the water is going to tear the airplane apart,
09:03so you want to be at the lowest possible airspeed.
09:06The flaps will facilitate that.
09:09As Transair flight A-10 descends below 400 feet,
09:21the controller is automatically alerted to the aircraft's dangerously low altitude.
09:26Are you able to climb at all?
09:29Uh, negative. Can you let the Coast Guard know?
09:32We will.
09:37Watch desk, please call the Coast Guard.
09:39Flight 810-737 is probably going to be in the water.
09:44How's the EGT?
09:45If the engine temperature has improved, they might be able to climb.
09:50Hot. Way over.
09:52Moraine. Moraine. Pull up.
09:54The chances of reaching the airport six miles away deteriorate
09:59as the plane descends even further.
10:01The controller has an idea.
10:03Express 810, do you want Kalailoa?
10:08There's a closer airport.
10:10It might be the pilot's last hope.
10:13We want the closest runway available, please.
10:16Anything we can land on.
10:19If they can't make it to the closer airport,
10:22there might be no other option
10:24than to ditch the 737 into the Pacific Ocean
10:27and hope for rescue.
10:31Hello. Here.
10:32Okay. Give me a heading.
10:34Hooray. Hooray. Pull up.
10:36The pilots of Transair Flight 810
10:38have one last chance to reach land.
10:42Rhodes Express 810.
10:44The airport is about a 3-1-0 heading from you.
10:48But it's too late.
10:51Pull up. Pull up. Pull up. Pull up. Pull up.
10:55Hooray. Hooray. We're in the water.
10:57Pull up. We're in the water.
10:5812 minutes after takeoff,
11:03Transair Flight 810 hits the ocean
11:05just two miles from the Kalailoa airport.
11:15Watchdesk. 810's in the water.
11:16Two miles south, east of Kalailoa.
11:20Coast Guard Air Rescue is immediately dispatched.
11:23Hearing that there's a 737 that crashed,
11:27I didn't believe it.
11:29But if there is,
11:30and there's 200 people in the water,
11:32what am I going to do?
11:34They told me two souls on board.
11:36We're like, all right,
11:36two is a lot more manageable than, like, 200.
11:3845 minutes later,
11:41there's still no sign of the plane or the pilots.
11:45Rescuers fear the worst.
11:47Until...
11:48There were a bunch of boxes now floating by us.
11:51I figured, all right,
11:52this might be the start of a debris field.
11:55So we started our second pass,
11:56and grabbing onto the vertical fin of the tail
11:59was one of our pilots.
12:02It's Captain Okai.
12:04I was like, all right,
12:07he is still okay, great.
12:09Still want to find the second pilot.
12:11They soon spot the first officer on a cargo pallet,
12:15bleeding from the head.
12:17Right before we started to make the moves
12:20to put me in the water to go up to him,
12:22the plane moved.
12:23The tail section the captain had been clinging to
12:26sinks beneath the waves.
12:29The captain is drowning right now.
12:30They race back
12:35and deploy the rescue swimmer.
12:39As soon as I grabbed his hand,
12:41it's like his eyes rolled back
12:43and he went limp.
12:45They're dripping wet,
12:47covered in gasoline and hydraulic fluid,
12:49so it wasn't pretty.
12:51The first officer is soon rescued
12:53by a fire department vessel
12:55as the captain is rushed to a local hospital.
12:59Both pilots survive.
13:00Good planning, good crew,
13:03good decision-making,
13:04and then implementing those decisions
13:07is how we came out on top.
13:09While the pilots recover from their injuries,
13:13investigators from the National Transportation Safety Board,
13:16or NTSB, arrive on the scene.
13:19Right now we're in the fact-gathering phase.
13:22Once we finish the fact-gathering,
13:24we'll switch into the analytical side,
13:26and then that's when we'll go into
13:27determining the probable cause
13:28and contributing factors.
13:29What can you tell me about last night?
13:36It was a normal night, slow.
13:39There was another Transair flight
13:41inbound around the same time.
13:44And when did Flight 810 alert you
13:47that there was a problem?
13:49Investigators turned to the controller
13:51to determine what might have caused
13:53Transair flight 810 to ditch into the Pacific.
13:57It was about two minutes into the flight.
13:59They reported they'd lost an engine.
14:02OK, roads 810, we've lost an engine.
14:04We're on a 220 heading, maintaining 2,000.
14:06Declaring an emergency.
14:07How do you read?
14:09They wanted to work on the problem
14:11before turning back.
14:13Did they say which engine?
14:14No, but not long after they said
14:17that they might lose the other engine as well.
14:21Really?
14:22OK, roads 810.
14:25We'd like to come to the airport now.
14:26We might lose the other engine.
14:29Could Transair 810 have really lost both engines?
14:33The only information we had to go on initially
14:35was the communications
14:37between the airplane and the controller,
14:39but the airplane and its recorders
14:41were at the bottom of the ocean.
14:43Thank you.
14:46Another NTSB team is tasked
14:49with recovering the airplane and its engines
14:51lying 350 feet deep on the ocean floor.
14:56At the depth that the airplane was at,
14:58it's difficult to get divers down there.
15:00So in order to actually hook all of our equipment
15:04up to the aircraft and pull it up,
15:06we needed to use ROVs.
15:09It will take time for the investigation
15:11to secure the necessary equipment
15:13from a salvage company on the mainland.
15:19Good morning.
15:21Good morning.
15:22I'm glad to see you here.
15:23So am I.
15:24Very glad.
15:25Yeah.
15:28Investigators meet with Captain Okai
15:30to determine if Transair Flight 810
15:32did lose both engines.
15:36The purpose of this investigation
15:37is to determine probable cause
15:39and prevent recurrence.
15:41Our role is not to assign fault.
15:43I understand.
15:46It's critical to speak to pilots
15:47as soon as we can
15:48because we want to get those fresh memories.
15:51Walk me through what happened.
15:54Everything was normal up to about 400 feet.
15:56gear up.
16:00Gear up.
16:09Damn.
16:11There was a whoosh sort of a sound.
16:13Not a pow.
16:14It was a whoosh.
16:16Then it wasn't a roll.
16:18My first officer was able to counteract that.
16:20lost an engine.
16:24You got it?
16:25Yeah, I got it.
16:30Eventually, we leveled off at 2,000 feet.
16:33And I go,
16:34Greg, what do we have?
16:36So it looks like the number one.
16:38Number one's gone?
16:39Gone, yeah.
16:41We still have the number two.
16:43So we have number two.
16:44Okay.
16:44I'm looking at number one EPR.
16:50There's no power.
16:52I'm looking at number two
16:53and EPR.
16:55It's coming down.
16:58The captain explains
17:00he first lost power in the left engine
17:02and was losing power in the right.
17:07How's the EGT?
17:10Oh, it's max.
17:10It's beyond max.
17:11Did both engines fail at the same time?
17:16Most likely.
17:17That's my conclusion.
17:20Thank you.
17:22Thanks.
17:23We'll be in touch.
17:24What could have caused both engines to fail
17:27so soon after takeoff?
17:29The purpose of this investigation...
17:31A dual-engine failure seemed improbable,
17:34but both the crew seemed to agree
17:37that that is what had occurred.
17:39and we couldn't confirm or deny it
17:41unless we could actually look at the wreckage
17:43and get the recorders.
17:46But those vital clues remain out of reach,
17:50deep on the bottom of the sea.
17:55Could contaminated fuel
17:57have brought down Transair Flight 810?
17:59You're looking for an item
18:02that's common to both engines
18:03would cause them both to shut down
18:05at the same time.
18:06For that would be most likely the fuel.
18:13So one thing that we did do
18:15at the airport
18:16was take samples from the fuel truck
18:18that had been used to fuel the airplane
18:21before it departed.
18:21The U.S. Navy conducts the testing.
18:27If you have water in your fuel,
18:29that was most likely
18:31to be the cause of fuel contamination.
18:35When the fuel samples are analyzed,
18:37the results are conclusive.
18:41We actually found that the fuel
18:43that was in the aircraft
18:44conformed to standards
18:45as we would expect.
18:46So according to the pilots,
18:51they lose the left engine first
18:53and then the right.
19:04All the samples from the fuel truck
19:06tested clean.
19:11What was the weather like on that night?
19:13Any volcanic activity?
19:16Hawaii is in an active volcano zone.
19:20Could volcanic ash
19:21have caused the engines to fail?
19:24Volcanic ash is very bad
19:26for jet engines.
19:27It's like throwing sand in the gears.
19:29Jet engines will shut down.
19:32In 1982,
19:34a British Airways 747
19:35traveling from England to New Zealand
19:38flew through an ash cloud
19:39over Indonesia.
19:41All four engines failed.
19:43The plane was high enough
19:44for pilots to be able
19:46to restart the engines,
19:47find an airport,
19:49and land safely.
19:53Nothing here.
19:55Clear night.
20:03So that leaves maintenance.
20:06There are no reports
20:07of volcanic ash on that night.
20:08The only information
20:09that we have to work on
20:10is what the crew's telling us
20:11is that they had
20:12a dual engine failure.
20:13So we're going to look
20:14at the maintenance on the engines.
20:16In the meantime,
20:17recovery crews pinpoint
20:19the exact location of the plane.
20:21It has settled on the ocean floor
20:23in two large pieces.
20:26Often with water recoveries,
20:28we have an airplane
20:29that's in multiple different pieces.
20:31They're usually smaller pieces
20:32and they're less heavy.
20:33So to bring them up intact
20:37was a bigger engineering problem.
20:40It means another delay
20:42for investigators.
20:45The plane is, what,
20:46like 40-something years old?
20:50The team digs into the engine history
20:53of the accident aircraft
20:54to determine why both engines
20:56might have failed.
20:57Uh, 46.
21:01Flown over 69,000 cycles.
21:05The engines have been around, too.
21:07Left engine 32,000 flying hours
21:10and the right over 70,000.
21:15Engines that old
21:16are going to need upkeep.
21:19Jet engines are very solid machines
21:21with proper inspection and maintenance.
21:23They can fly on forever.
21:25Anything in the FAA database?
21:27Investigators look into service reports
21:32filed by Transair
21:33with the Federal Aviation Administration,
21:35or FAA,
21:37to see if the aircraft
21:38had any history of engine troubles.
21:40I've got three reports
21:43on this aircraft.
21:45The most recent
21:46was two and a half years ago
21:48left engine failure
21:50at 2,000 feet.
21:53That's something.
21:54Did an aging aircraft
21:58put the lives
21:59of two pilots in jeopardy?
22:02The team researches
22:03the repair work
22:04that's been performed
22:05on the engines
22:06over the years.
22:08Both engines
22:09were serviced
22:10two years ago
22:11and underwent
22:12a daily check
22:13the day before
22:14the accident flight.
22:15did they report
22:17anything?
22:21No discrepancies.
22:29It's possible that
22:31maintenance could have
22:33missed something.
22:34call your contacts
22:36at the FAA.
22:38Maybe they can
22:39shed some light
22:40on Transair
22:40and I'll speak
22:42to maintenance
22:42personally.
22:44Because of the possibility
22:46that there had been
22:47a dual engine failure,
22:48we did a deep dive
22:50on the maintenance
22:50organization
22:51at the airline
22:52trying to find
22:53potential theories
22:54for something
22:56that could have
22:56gone wrong.
22:57Bit of a mess
23:00over there
23:01at Transair
23:01Maintenance.
23:02What did you find out?
23:04Chief Maintenance
23:05Inspector
23:06quit six weeks
23:07ahead of the accident
23:08citing chronic
23:09maintenance issues
23:10and being understaffed.
23:12Also found
23:13multiple reports
23:15from different pilots
23:16about engines
23:17overheating.
23:19Investigators uncover
23:20internal Transair
23:22reports
23:22revealing issues
23:24with the engines.
23:25We noticed
23:26so many of these
23:27reported issues
23:28with temperature
23:30that we were
23:31starting to think
23:31that this might
23:33really involve
23:33a maintenance issue.
23:35There was just
23:35so much smoke
23:36we thought
23:37there had to be
23:37some fire.
23:40Anything specific
23:41to the accident
23:42aircraft?
23:43No,
23:44they involved
23:45other airplanes,
23:47not exactly
23:47a smoking gun.
23:50Anything from
23:51the FAA?
23:52Most of the
23:53current inquiries
23:54into the company
23:55are policy
23:56and procedure
23:56related.
23:57Nothing to do
23:58with engine
23:59maintenance.
24:01Investigators
24:02don't find
24:03any maintenance
24:03issues that
24:04would have brought
24:05down Flight 810.
24:09We need those
24:10engines.
24:12So even though
24:13we were discovering
24:14these issues
24:15with pilot reports
24:16and maintenance
24:16records,
24:17there wasn't
24:17anything clearly
24:18indicating a
24:19specific problem
24:20that would have
24:21led to this
24:21reported dual
24:23engine failure.
24:24With a salvage
24:26company in place
24:27and the weather
24:28clearing,
24:29the NTSB is
24:30finally able
24:31to attempt
24:31the recovery
24:32of Flight 810
24:33from 350 feet
24:35of water.
24:37This is one
24:38of the largest
24:38water recovery
24:39efforts we have
24:39done in a couple
24:40of decades.
24:41The wreckage
24:42is successfully
24:42raised in two
24:43large pieces.
24:45The black boxes
24:46are recovered
24:47from the rear fuselage
24:48and sent to
24:49Washington for analysis.
24:51The engines
24:52are retrieved
24:52separately
24:53and brought
24:54to a warehouse
24:54for inspection.
24:56To be able
24:57to see that
24:58wreckage come up
24:59just creates
24:59immense satisfaction
25:00because you're like,
25:01okay, now,
25:02now we can start
25:03this in earnest.
25:10Let's start
25:11with this one.
25:13Investigators
25:14begin with an
25:15examination
25:15of the right
25:16engine,
25:17the one the pilots
25:18say was overheating.
25:19It's in better
25:20shape than I expected.
25:24They were
25:25in pretty good shape.
25:26There was damage
25:27due to the water
25:27impact.
25:30Let's take
25:31a look inside.
25:32They perform
25:34a borescope
25:34inspection
25:35of the right
25:36engine.
25:37It enables
25:37them to examine
25:38the engine
25:39interior
25:39without the need
25:40for disassembly.
25:43There.
25:44Take a look.
25:45Broken fan blades.
25:48See if there's
25:49any damage
25:50downstream.
25:57Multiple
25:58puncture marks
25:59on the turbine.
26:01With that
26:01type of damage,
26:02the engine
26:02could have
26:03easily overheated.
26:06Investigators
26:07discover two
26:08fractured turbine
26:09blades,
26:10which caused
26:10shrapnel damage
26:11inside the
26:12right engine.
26:13The pilots
26:14were correct.
26:16The right
26:16engine was
26:17giving them
26:17trouble.
26:19So from
26:19the examination
26:20on the right
26:22engine,
26:22they were able
26:23to see that
26:23there were blades
26:24that had fractured
26:25in the high-pressure
26:26turbine.
26:27But it was
26:27only those two.
26:29and they knew
26:31that it would
26:31still be able
26:32to produce
26:33power.
26:33So it wasn't
26:34like a complete
26:35failure.
26:36Looks like rust
26:38and corrosion
26:38inside of the
26:40blades
26:40caused them
26:41to rupture.
26:46The routine
26:46maintenance
26:46inspection
26:47procedures
26:48contained in the
26:49maintenance manual
26:49would not
26:50necessarily have
26:51revealed the
26:52presence of cracks
26:54or one fractured
26:55blade.
26:56So this is the
26:57engine the pilot
26:57said failed
26:58first.
27:01Investigators
27:02turned their
27:03attention to
27:03the left
27:04engine.
27:09Let's see
27:10what we got.
27:11It looks
27:19fine.
27:22No internal
27:23damage.
27:25The pilot
27:26said the
27:27left engine
27:27failed,
27:28followed by
27:29the right.
27:30But investigators
27:31can't find
27:31anything wrong
27:32with the
27:33left engine.
27:34When we
27:34found out
27:35that the
27:35left engine
27:36was undamaged
27:37prior to impact,
27:38it really
27:39changed the
27:39course of our
27:40investigation in
27:42terms of
27:42focusing more
27:44on the
27:44crew actions.
27:46We pulled
27:47the flight
27:47path from
27:48the radar
27:48data.
27:50Got the
27:51CVR data.
27:55And here's
27:57a copy
27:59of the
27:59transcript.
28:02Investigators
28:02turned to the
28:03cockpit voice
28:04recorder, or
28:05CVR, of
28:06Flight 810
28:07to determine
28:08why the
28:08pilots thought
28:09the left
28:10engine failed
28:10as the
28:11evidence
28:12suggests it
28:12did not.
28:14Let's hear
28:15it from
28:15takeoff.
28:1980 knots.
28:21Check.
28:23V1.
28:24Rotate.
28:26V2.
28:28Positive rate.
28:32Gear up.
28:33definitely sounds
29:00like an engine
29:00surge.
29:01They discover
29:02that Flight 810
29:04suffered engine
29:05trouble 17
29:06seconds after
29:07takeoff.
29:08Most likely
29:09the blades
29:11breaking apart
29:11in the right
29:12engine.
29:13Keep playing.
29:15Lost an engine.
29:17You got it?
29:19Yeah, I got it.
29:20Yep, looks like
29:21you lost number...
29:23Number two.
29:24Number two.
29:25Right.
29:26Hold it right there?
29:27They both said
29:28number two, the right
29:30engine.
29:34They were correct.
29:36The pilot's
29:38original assessment
29:39matches what
29:40investigators have
29:41discovered.
29:41The initial problem
29:43was with the right
29:44engine.
29:45So why did they think
29:46that the left engine
29:47had failed?
29:49We were able to hear
29:51the crew discuss.
29:52They had correctly
29:53identified the right
29:53engine.
29:54so at some point
29:55in their mindset
29:57it had flipped
29:57to the wrong
29:58engine.
30:00Let's hear what
30:01happens next.
30:03Flaps.
30:04Turn 220 heading.
30:07I'll give you
30:07the flaps.
30:08Roads, A-10.
30:14We have an emergency.
30:15Stand by.
30:16We're on 220 heading.
30:19You can inch up
30:19to 2,000.
30:23Captain calls in
30:24the emergency.
30:25Tells the first
30:26officer to climb
30:27to a safe altitude.
30:29All sounds good.
30:31And we're on 220
30:32heading.
30:34Say again.
30:36Heading 240.
30:38240 heading.
30:39Roads, A-10.
30:41No, roads,
30:42809.
30:43Roads, 809.
30:44Left, 240.
30:48Sounds like
30:49there's some overlap
30:50with another
30:51transair flight.
30:54According to
30:55these transcripts,
30:56the captain spends
30:57the next minute
30:59and 40 seconds
31:00communicating with
31:01the controller.
31:02That's a long time
31:04and a critical moment.
31:08investigators learn
31:09that instead of
31:10monitoring the engines...
31:12Roads, express,
31:13A-10.
31:14You are cleared
31:15visual approach
31:16runway 4 right.
31:18The captain
31:19is distracted
31:20by a conversation
31:21with the controller.
31:23Okay, roads, A-10.
31:24We're going to run
31:25a checklist.
31:26I'll let you know
31:26when we're ready
31:27to come to the airport.
31:28When you have
31:29an emergency situation,
31:30it is important
31:31to aviate,
31:32navigate,
31:32and communicate.
31:34Your third priority
31:34is communicating
31:36your emergency.
31:38What happens next?
31:41Okay, I have control.
31:43Roger.
31:45Okay, let's see
31:46what's the problem.
31:47What's going on
31:48with the gauges?
31:50The captain starts
31:51flying the plane
31:52and turns his attention
31:53to the engines.
31:55So it looks like
31:56the number one.
31:57Number one's gone?
31:58Gone, yeah.
32:00We still have
32:01the number two.
32:02So we have number two.
32:03Okay.
32:05Stop.
32:07The FO changes
32:08his diagnosis.
32:11Investigators confirm
32:12that the first officer
32:13correctly assesses
32:14that the right engine
32:15lost power on takeoff.
32:18Yep, looks like
32:19you lost number...
32:20Number two.
32:22But less than
32:23four minutes later,
32:24he tells Captain Okai
32:25it's the left engine
32:27that's failed.
32:28So it looks like
32:28the number one.
32:30Number one's gone?
32:31Gone, yeah.
32:31Why?
32:36It wasn't clear
32:37why they had
32:39changed their minds
32:40about it.
32:43The captain
32:44then instructs
32:45the FO
32:45to do the engine
32:46shutdown checklist,
32:48but he only gets
32:48through the first step.
32:52Hey, we're redline here.
32:54We should pull back
32:55on the right one
32:55a little bit.
32:55Okay.
32:58The right engine
33:00overheats
33:00because of the
33:01internal damage,
33:02leading the pilots
33:03to believe
33:04they're losing
33:04both engines.
33:06Once the crew
33:07had convinced themselves
33:08that they had
33:08a dual engine failure,
33:10they were focused
33:11almost exclusively
33:12on altitude
33:13and airspeed,
33:14and eventually
33:16they ran out
33:16of options
33:17and had to ditch.
33:19It's clear
33:20that the right engine,
33:22the one with the issue,
33:23is overheating
33:24and not producing
33:25full thrust.
33:27But what led them
33:28to think
33:29the left engine
33:30wasn't working?
33:30Let's see what
33:32the flight data
33:33recorder can tell us.
33:38Okay, let's see
33:39what the engines
33:40were doing.
33:42Investigators examined
33:43the engine power data
33:44of Flight A-10
33:45to determine
33:46what actions
33:47the pilots took
33:48that led them
33:49to believe
33:50their perfectly
33:51working engine,
33:52the left one,
33:53had failed.
33:55After the right
33:57engine failed,
33:58both engines
33:59are brought back
33:59to flight idle
34:00once they level off
34:02at 2,000 feet.
34:09That's proper procedure
34:11to get the speed down.
34:14But the first officer
34:15never told the captain
34:16he brought the engines
34:17back to idle.
34:20They discover
34:21a key step missing
34:23in the pilot's actions.
34:26It was procedure
34:28for a crew member
34:29to verbalize
34:30when they moved
34:31the engine controls.
34:32In this case,
34:33the first officer
34:34actually did not do that
34:35and that could have
34:36affected the captain's
34:38situational awareness
34:39of where those
34:40engine throttles were.
34:43Why did the first officer
34:44fail to inform
34:45the captain
34:46of his action?
34:49Send someone
34:49to interview
34:50the first officer again
34:51about bringing
34:52the throttles back.
34:53So it was critical
34:57for us to get
34:58more information
34:59to better understand
35:00what had happened there.
35:03Did anyone actually
35:04ever test
35:05the throttles?
35:07After they leveled off,
35:09the pilots could
35:10have increased power
35:11to the left engine
35:12to confirm
35:13which engine
35:13had failed.
35:16No.
35:18The left engine
35:18throttle stayed
35:20at idle
35:20for the rest
35:21of the flight.
35:24If you're going
35:25into the water
35:26and you have
35:27no other option left,
35:28you're going to
35:28firewall both throttles
35:30just in case
35:32it might help.
35:34Why didn't the captain
35:35check the first officer's
35:37misdiagnosis?
35:39Let's ask him.
35:43When the first officer
35:44subsequently said
35:45it was the number one,
35:46the captain
35:46had just accepted it.
35:47He didn't effectively
35:48cross-check
35:49that erroneous
35:50assertion.
35:52So we wanted
35:54to ask him
35:55why.
35:57Why did he
35:57accept that?
36:01Captain Okai,
36:03thanks for meeting
36:04with me again.
36:07You're muted.
36:10Investigators speak
36:11to Captain Okai
36:12one more time
36:13to find out
36:14why he thought
36:15the left engine
36:16had failed.
36:16Sorry about that.
36:18Glad I can help.
36:20When Greg told you
36:21the left engine
36:22had failed,
36:23do you recall
36:23initially thinking
36:24the right one
36:25had failed?
36:28No.
36:29The thing with Greg
36:30is I've flown with him
36:30so many times.
36:32He's never made a mistake.
36:33If Greg says
36:34the left is gone,
36:35the left engine
36:36is gone.
36:39Investigators learn
36:40the captain
36:40put his faith
36:41in his first officer's
36:43diagnosis.
36:43While trust
36:45is very important
36:46when it comes
36:47to crew resource
36:48management,
36:48you also want
36:50to verify.
36:51The captain
36:52did not verify
36:53the information
36:54that the first officer
36:55was giving him.
36:57Okay.
36:58Thank you.
36:59Sure thing.
37:01It's really critical
37:02when you do
37:03have an engine failure
37:04to look at
37:06all the available
37:06information
37:07and cross-check
37:08and agree
37:09that you have
37:10identified the
37:11correct engine.
37:13In this case,
37:14that didn't occur.
37:16What were the
37:17power readings
37:18when the engines
37:18were at idle?
37:21Even if the captain
37:22trusted the first officer,
37:24wouldn't there be
37:25other indicators
37:26showing which engine
37:27had failed?
37:31The left engine
37:33was 1.05
37:35and the right
37:371.12.
37:41The team
37:41discovers
37:42the power
37:43was a little bit
37:44lower on the left
37:45engine,
37:46even though both
37:47engines were set
37:48to idle.
37:49Okay, let's see
37:50what's the problem.
37:51What's going on
37:52with the gauges?
37:54They did have
37:55slightly different
37:56power outputs
37:57and that is something
37:58you would see
37:59with two different
38:00engines.
38:01That could have
38:02really affected
38:02the captain's
38:03decision-making.
38:06If the captain
38:07had checked
38:08the gauges,
38:09the readings
38:10would have supported
38:11his first officer's
38:12report that the
38:13left engine
38:13had failed.
38:15So it looks like
38:16the number one.
38:17Number one's gone?
38:18Gone, yeah.
38:20So we have
38:20number two.
38:21Okay.
38:25But this doesn't
38:26explain why
38:27the first officer
38:27never told the captain
38:29that he brought
38:29both throttles back
38:31in the first place.
38:32If the first officer
38:39had said,
38:40hey, I pulled
38:40the thrust back
38:41on both engines,
38:42then that might have
38:42caused the captain
38:44to engage in a
38:45different thought
38:46process about
38:46what might be going
38:47on.
38:47First officer follow-up
38:57interview.
38:59Why didn't the
39:00first officer of
39:01Transair Flight 810
39:02tell the captain
39:03he brought the
39:04power levers back
39:05after the right
39:06engine failed?
39:08He has no
39:09recollection of
39:10bringing either
39:11thrust lever back
39:12to idle.
39:15We believe that the
39:16first officer forgot
39:18because he was busy.
39:21That leads to stress.
39:23Stress leads to
39:24tunneling of attention.
39:26That can lead to
39:27fixation on a small
39:28number of parameters.
39:29But even if the
39:33first officer didn't
39:34tell the captain
39:35about the thrust
39:35levers,
39:36there must have
39:37been other signs
39:38which engine
39:39failed.
39:42Check out the
39:43rudder data.
39:45Immediately after
39:46the right engine
39:47failed on takeoff,
39:495.5 degrees of
39:50left rudder is
39:51applied.
39:56You got it?
39:58Yeah, I got it.
40:03After the right
40:04engine lost power
40:05on takeoff,
40:06the plane pulled
40:07to the right.
40:09When the first
40:10officer applied the
40:11left rudder,
40:12the plane
40:13straightened out.
40:14The foot that
40:15isn't pressing on
40:16the rudder paddle
40:17is the side with
40:17the bad engine.
40:18so it's usually a
40:19pretty clear indication
40:20of which engine
40:21has failed.
40:23He held that
40:24left rudder
40:25for three minutes.
40:28He had a clear
40:29indicator,
40:30but it never
40:30registered.
40:32The fact that
40:33the first officer
40:34was applying left
40:35rudder was an
40:36indication that
40:37the right engine
40:38had lost power.
40:39It's very possible
40:40that under those
40:40stressful conditions
40:41in the middle of
40:42the night over the
40:42water, you could
40:43make that mistake.
40:47They made the
40:47right assessment
40:48initially, but in
40:50the end, the
40:52stress of the
40:52situation degraded
40:54their ability to
40:55fly the plane.
40:59Investigators now
41:00know the series of
41:01events that led to
41:02the ditching of
41:03Transair Flight 810.
41:07When the right
41:08engine loses power
41:10after takeoff,
41:15both pilots make
41:17the proper
41:18assessment.
41:20Yep, looks like
41:21lost number...
41:23Number two.
41:24Number two.
41:26But while the
41:27captain communicates
41:28with air traffic
41:29control...
41:31Okay, Rhodes,
41:32810.
41:33We're going to run a
41:33checklist.
41:34The first officer
41:36reduces engine
41:37power.
41:38Okay, let's see
41:39what's the problem.
41:42In a moment of
41:43stress, he forgets
41:44to tell the
41:45captain.
41:46What's going on
41:47with the gauges?
41:48The slightly
41:49different readings
41:50on the gauges
41:51lead the pilots
41:52to believe the
41:53fully functioning
41:53left engine has
41:55failed.
41:56So it looks like
41:56the number one.
41:58Number one's gone?
41:58The captain relies
42:00on the first officer's
42:01assessment without
42:02doing his own
42:03analysis of the
42:04situation.
42:05Gone, yeah.
42:07We still have
42:07the number two.
42:08So we have
42:09number two.
42:10Okay.
42:12Instead of
42:12confirming which
42:13engine had
42:14actually lost power
42:15and forgetting
42:16their original
42:17assessment, the
42:18pilots end up
42:19flying on a
42:20damaged engine.
42:21How's the EGT?
42:24Ah, it's max.
42:25It's beyond max.
42:27Setting them up
42:28for an inevitable
42:29ditching.
42:30We're in the water.
42:32We're in the water.
42:48The pilots'
42:50misidentification
42:50of the damaged
42:51engine and their
42:52use of the only...
42:53Before the NTSB's
42:55final report is
42:56published, Rhodes
42:57Aviation is shut
42:59down by the Federal
43:00Aviation Administration
43:01for numerous safety
43:03and maintenance
43:04violations.
43:07While it may be
43:08disappointing that the
43:09crew never actually
43:11touched their left
43:12engine that was
43:13working properly,
43:14it is a testament to
43:16the human limitations
43:17that actually arise
43:18when you have
43:19stressful, high-workload
43:20situations, and that's
43:22what we need to
43:22account for.
43:23With only 50
43:25737-200s remaining
43:28in service, it's
43:29deemed impractical
43:30to fit them with
43:31engine sensors that
43:32would alert pilots
43:33to a failed engine.
43:35But it's now standard
43:37in most passenger
43:38airliners.
43:40Engine monitoring
43:41technology has improved
43:43considerably since this
43:44aircraft was
43:45manufactured.
43:47Newer airplanes
43:47actually give very
43:49clear indications to
43:50the pilot regarding
43:51which engine is bad
43:53and reduces the risk
43:55of the crew
43:56misidentifying it.
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