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00:00A turboprop plane slams into a desert in central Argentina.
00:1222 fatalities. My God.
00:21The aircraft was completely destroyed, burned, and the debris was dispersed approximately 200 meters.
00:30Investigators are mystified by what they uncover.
00:34Pull back harder.
00:35Stop the playback.
00:38And then they drop like a rock.
00:40But exploring all possible causes.
00:43Take a look. No failures.
00:45Turns up nothing.
00:48There's not a single red flag in his record.
00:51Until a single microscopic filament provides the first clue to solving the case.
00:57What's wrong?
00:59I don't know.
01:01May the 18th, 2011.
01:11No Ken, Argentina.
01:13Okay, gentlemen. So here's what we're looking at for tonight.
01:23Seoul Airlines flight dispatcher is briefing the pilots on tonight's flight to the port city of Commodoro Rivadavia.
01:39So what have we got? Any problems along the way?
01:43Wind five knots, visibility eight kilometers, light icing, nothing unusual.
01:51I've filed a standard cruising altitude of 19,000 feet.
01:57Okay. Have a good flight, gentlemen.
02:01You will.
02:03You will.
02:04I will.
02:05I will.
02:06I will.
02:07I will.
02:08I will.
02:09I will.
02:10I will.
02:11I will.
02:12I will.
02:13I will.
02:14I will.
02:15I will.
02:16I will.
02:17I will.
02:18I will.
02:19I will.
02:20I will.
02:21You have plans for Commodoro?
02:22I do.
02:23So I'm glad Carlos let me take a shift.
02:26Tonight, Bolatti has swapped shifts with another sole pilot, Carlos Piscinato.
02:34I had been scheduled to work on that flight, but the co-pilot had requested to work that flight instead.
02:40The co-pilot and I got along very well.
02:43He was very well versed in the aircraft systems, maintenance, and mechanics.
02:52Welcome back.
02:53It's been three weeks already.
02:57There is one flight attendant and 19 passengers on tonight's flight.
03:02The typical passengers are people who work in the oil wells, people who we came to know that traveled with us often, from Nukin to Commodoro.
03:12Prop RPM.
03:15Fire.
03:16Trim position?
03:17Check.
03:18Anti-ice.
03:19As needed.
03:20Sol flight 5428, you are clear for takeoff.
03:23Roger.
03:24Sol flight 5428, clear for takeoff.
03:27Roger.
03:28Sol flight 5428, clear for takeoff.
03:31V1.
03:32Rotate.
03:33At 8.05 PM, Sol flight 5428 lifts off from the airport in Nukin.
03:50The plane will fly directly south from Nukin to Commodoro Rivadavia on the Patagonian coast.
04:07The route that we flew in the south was a regular route.
04:11We usually flew it twice a week.
04:13The landscapes are beautiful.
04:15Tonight, the pilots are flying a Swedish-made Saab 340 turboprop.
04:24The Saab 340 is a twin-engine turboprop typically used for shorter flights that are connecting to larger hubs.
04:34It lends itself to flying easily.
04:37It is a wonderful aircraft to fly.
04:40Airspeed.
04:41Airspeed.
04:42140 knots.
04:43Check.
04:44Gear up.
04:45Gear up.
04:46Flaps up.
04:47Flaps up.
04:48Gauge autopilot.
04:49The passengers settle in for the 90-minute flight.
05:04Buenos Aires, Sol flight 5428, reporting waypoint Ecopa.
05:09We are climbing through flight level 50 for 190.
05:13ATC Buenos Aires, received.
05:17First Officer Bolatti relays the aircraft's position to air traffic control.
05:22Hope we don't get in too late.
05:24The guys are waiting for us.
05:26Tonight, dinner's on them.
05:29We'll get there for 10.
05:31Don't worry.
05:33As per their flight plan, the Saab 340 will climb to a cruising altitude of 19,000 feet.
05:42When flying propeller aircraft, they do fly lower.
05:45They're not going to get up, generally, much above 25,000 feet.
05:48Although, occasionally, they're certified for higher than that.
06:00It's like we're picking up some ice.
06:03Oftentimes, particularly in mountainous terrain, turboprops will encounter icing conditions.
06:10It's very common, so it's generally not an issue.
06:13Nothing to worry about.
06:14We're expecting some light icing.
06:16It should be better when we get to 19,000.
06:20When in icing conditions, your first objective is to climb above it.
06:25At 19,000 feet, water droplets freeze solid, which keeps them from clinging to the aircraft.
06:37The challenge of flying turboprop airplanes is to evaluate the weather ahead of time
06:43and really look at the paths of least risk as it pertains to things like icing, turbulence.
07:02Building up some ice on my wing.
07:06With the icing conditions getting worse, the captain changes the plan.
07:11Okay, let's get it down to where it's warmer to melt it off.
07:14Ask to descend to a lower altitude, 14,000.
07:16Roger.
07:18Seoul Flight 5428 requesting descent to flight level 140.
07:22Seoul 5428, you are clear to 140.
07:30As Seoul 5428 gets to the lower altitude...
07:35All finished?
07:38...it's proving to be an uneventful flight.
07:41Then, in the cockpit...
07:46Feel that?
07:48...the situation suddenly changes.
07:50The propellers vibrating.
07:52The pilots feel some vibrations.
07:54It could be a sign of ice building up on the propellers.
07:58Put them on, Max.
07:59Roger.
08:00Oh, hell!
08:03What's wrong? I don't know!
08:07Oh, hell!
08:16What's wrong? I don't know!
08:17Let's go.
08:25The turboprop is suddenly pitching down and banking.
08:32Pull back, pull back, pull back.
08:35The pilots struggle to get the plane under control.
08:42Come on.
08:43Come on.
08:44We got a claw, come on, come on.
08:49Come on.
08:54But they can't escape the dive.
08:56Come on, come on, come on.
08:58We need it.
08:59Meet it, meet it, meet it.
09:01Fight, fight.
09:02Meet it, meet it, meet it.
09:06Now, now, now, pull up.
09:08Pull up, pull up, pull up, pull up, pull up.
09:14The turboprop crashes and explodes in a remote region of Patagonia.
09:28News of the accident hits Carlos Piscinato especially hard.
09:32He knew both the captain and first officer.
09:35It was night time.
09:39I received a call from a crew member.
09:41I realized something was wrong.
09:43To get a call at 3 a.m. was not normal.
09:47There was just great sorrow for our colleagues.
09:50Argentina's civil defense agency sends emergency crews to the crash site.
10:02But because of its remote location, on a desert plateau in Rio Negro province, it takes hours for them to arrive.
10:10The accident took place in a very complex area of the Argentinian Patagonia.
10:22The cold weather and the mountainous range made it very difficult for us to have safe land access.
10:31When the crews do arrive, they find that there are no survivors.
10:40Argentinian investigators examine the crash site of Sol Flight 5428.
10:45They need clues that might explain what brought the plane down.
10:4922 fatalities.
10:52My God.
10:55It's always a shock to have an accident of this magnitude.
10:59One has to set their emotions aside and be professional and serious about the job one has to perform.
11:04Augusto DeSantis is coordinating the technical teams from Argentina's Civil Aviation Accident Investigation Board, or JIAAC.
11:16All right, let's start here, work our way out.
11:22It's DeSantis' job to determine what brought down Sol Flight 5428.
11:27The aircraft was completely destroyed, burned, and the debris was dispersed approximately 200 meters from the first point of impact.
11:45It doesn't look good.
11:52Two key components, the flight data recorder and cockpit voice recorder, are found intact, but they are severely damaged.
12:02Okay, let's ship these out and see what we get.
12:06The first thing we did was send the data recorders and the cockpit recordings to the NTSB in the United States.
12:18Next, investigators look for signs that indicate how the plane hit the ground.
12:25It was very complex.
12:27Every accident, every case is absolutely unique.
12:31Most of the debris is in front of the impact point.
12:38The aircraft's initial impact left a four to five meter crater.
12:42That indicates a very hard initial impact.
12:45It must have crashed at a pretty steep angle.
12:50This pattern showed that the aircraft was out of control when it crashed, with a great dive angle, which is what caused the crater.
12:59The debris field was relatively small.
13:06Catalog every piece, no matter how small.
13:12Wreckage is brought to a temporary facility near the accident site.
13:19Because the crash was so catastrophic, many of the pieces are almost unrecognizable.
13:28Identifying each and every one is a painstaking process.
13:35The first priority for investigators is to determine if certain parts of the plane are missing.
13:41A key component like an aileron detaching from the plane mid-flight could have caused the crash.
13:48So it's all here?
13:49Okay then.
13:50Engines!
13:51With no evidence of a break-up before the crash, the investigators focus on the engines.
14:07We initially tried to evaluate the engine damage to determine if they were providing power to the aircraft at the moment of impact.
14:14The remains of the turboprop's two engines are sent for analysis.
14:22Technicians examined their turbines looking for the type of damage that would indicate they were not working when the crash occurred.
14:32Both engines presented a similar damage pattern.
14:35The visible damages, the torsion damage, led us to think that both engines were powering the aircraft at the moment of impact.
14:44Investigators rule out engine failure.
14:49But did some other key component break down in flight?
14:53Okay, thanks.
14:57JIAAC investigator Horatio La Rosa joins the investigation.
15:02Okay.
15:03Let's dig into maintenance.
15:06Since the plane hit the ground nose first, the team wonders if a propeller malfunction could have brought the plane down.
15:14They dig into the maintenance records.
15:17As an aeronautical engineer and manager of the technical research, the main role was to review the technical documentation.
15:30It says the prop maintenance was incomplete.
15:34Investigators have discovered an airworthiness directive that wasn't carried out.
15:39The order required the base of the propeller blades to be inspected for cracks.
15:44Hey, I got something.
15:47They missed an inspection.
15:52Could a missed crack at the base of the propeller be the culprit?
15:59Investigators inspect what's left of the propellers to see if they were working at the time of impact.
16:05The prop leads are pretty charred.
16:08Some markings here.
16:11It's tough to say for sure if they were spinning at impact.
16:17Let's see where the propellers ended up.
16:20Based on the position the components were found, and on their condition, we could check if they had been working or not at the moment of impact.
16:29If an engine's propeller blades are working at impact, they are projected away from the crash site.
16:38If they aren't working, they stay near.
16:41Left engine prop is here.
16:46Investigators discover that the broken propellers were some distance from the rest of the wreckage.
16:52The prop blades are some of the furthest pieces from the point of impact.
16:59They were spinning.
17:01The great distance in which the fragments landed gives the impression that the propellers were functioning at impact.
17:12Back to square one.
17:19Investigators are no closer to explaining why Seoul Flight 5428 plummeted violently to the ground, killing everyone on board.
17:31Okay, let's add the flight path.
17:43Investigators now turn their attention to the weather conditions on the night Seoul 5428 crashed.
17:50This is the flight path from Neuquen to Comodoro.
17:56Look what's waiting for them here.
17:59They flew right into this cold front.
18:03The information showed that there was severe icing.
18:08Ice on a plane can lead to disaster.
18:12In 1997, Comair Flight 3272 was on approach to Detroit Metropolitan Airport in near freezing weather.
18:23When the Embraer turboprop stalled and crashed.
18:30All 29 people on board were killed.
18:35After months of investigation, the cause was finally revealed.
18:40A thin layer of ice had formed on the plane's wings, causing it to lose lift.
18:53Did the pilots know what they were in for?
18:57Investigators wonder if the pilots were aware of the icing conditions and took proper steps to protect the plane.
19:05It's something only one person can answer.
19:12You were the flight's dispatcher that night.
19:15The airline's flight dispatcher provided the crew with crucial information.
19:20The dispatcher tells you about the passengers you will have on board, the amount of fuel you will need to go from one destination to another, and they provide you with weather conditions for the entire route.
19:33You didn't know there was severe icy weather?
19:40I told the pilots to expect only light icing.
19:43So what have we got? Any problems along the way?
19:47Wind five knots, disability eight kilometers, light icing, nothing unusual.
19:52Can I take a look at the meteorological report you gave them?
20:05There you go. Thank you.
20:10Investigators discover the report the flight dispatcher provided did not indicate the potential for severe icing.
20:17The report you gave them suggested icing would be mild, but it was actually severe.
20:29They had been dispatched with information that did not indicate this weather condition, and were told that if there was a possibility of encountering icing, it would not be severe.
20:42The information in the meteorological report showed a possible icing situation, but not as critical as they found it to be.
20:51Where did you get your report?
20:54Investigators need to find out why the dispatcher didn't have the right information.
21:03The team learns that because the airport's meteorological office closed at 4 p.m., the weather report the dispatcher provided was more than five hours old and no longer accurate.
21:16The departure airport did not have a 24-hour meteorological service, so they departed with a weather forecast that did not anticipate severe icing.
21:39Looks like we're picking up some ice.
21:41Nothing to worry about. We were expecting some light icing.
21:45I believe the crew was surprised by the severe icing conditions. They were not expecting to find such conditions during their flight.
22:00But establishing that the pilots encountered more severe weather than they expected is not enough to prove that ice brought down their plane.
22:10In icing conditions, pilots use the plane's anti-ice protection.
22:17On the Saab 340A, that consists mostly of pneumatic boots made of rubber.
22:22The boots inflate and break up the ice on the wing's leading edge.
22:27To determine if the anti-icing system was activated on the night of the crash, investigators examine a key component recovered from the wreckage, the Saab's central warning panel.
22:41It's a panel located at the center of the cockpit that both pilots can see.
22:48It's composed of a series of light indicators that warn if there's an abnormality in any of the plane's systems.
22:55Or components that aren't functioning.
22:59Investigators analyze tiny filaments attached to each of the indicators.
23:05When they are lit, electricity is sent through the filaments.
23:10If they were on during impact, the hot filaments would stretch, not break.
23:15The team discovers a filament is stretched.
23:29Ice protection was on.
23:31It's a tantalizing lead for investigators.
23:34But did a malfunction of the ice protection bring down Seoul Flight 5428?
23:43What's going on for me?
23:45What are you doing?
23:47What are you doing?
23:52Investigators of Seoul Flight 5428 scour the wreckage for confirmation that a failure in the ice protection system brought the plane down.
24:01All that survived are the valves.
24:10Okay. Let's get them checked out.
24:13Yep.
24:20The primary function of the valves is to control the flow of pressurized air that inflates the ice protection boots.
24:27Was there a problem with the valves?
24:33We isolated the anti-ice valve and we analyzed what was left of it.
24:38When they test the valve components, it's discovered that enough pressurized air was passing through the valves to inflate the boots.
24:48Take a look.
24:55No failures.
24:57So there was no doubt that the systems were being operated and that they were working.
25:04If the pilots knew they were flying in ice and the ice protection system was working, then ice alone doesn't explain the accident.
25:17The team has finally received the flight data recordings from Washington.
25:27This information is crucial for uncovering the true cause of the crash.
25:31The information from the recorders was vital to figuring out a lot of the things that the naked eye, or the elements picked up and analyzed at the crash site, could not reveal.
25:49Could not reveal.
25:51Okay, look here.
25:53Their airspeed dropped to 129 knots, then 126 knots.
25:58They're in ice.
26:00They should be speeding up, not slowing down.
26:02The cruising altitude is supposed to be 19,000 feet.
26:15Instead, they level out just under 18,000 feet and slow down to less than 130.
26:32The aircraft flight manual says that when climbing in icing conditions, the minimum speed is 160 knots.
26:45They're 30 knots below that.
26:48Then, they descend to 14,000 feet and slow again to 138 knots.
26:56And then they drop like a rock.
26:58It's immediately obvious to investigators why the plane crashed.
27:05They lost so much speed, they stalled.
27:09The speed was progressively decreasing, which harmed the aircraft aerodynamically.
27:19Oh hell!
27:21And took it to a final stall and loss of control.
27:23You pick up ice, you should increase your speed.
27:29Pretty basic.
27:33Why didn't these guys do that?
27:36If the speed decreases, the pilot must increase all power to try and get out of the situation to maintain the speed of flight.
27:44Let's see their power settings.
27:47The investigators need to find out how the pilots could have let the plane slow to the point of stalling.
27:5215,000 feet.
28:03This is where they should start increasing power for the climb.
28:07But engine power barely budges.
28:10They don't even have enough power to finish the climb.
28:14Nothing to worry about.
28:16We were expecting some light icing.
28:18It should be better when we get to 19,000.
28:20Once they stabilized on the 170 level, which was not the cruising level that had been planned for this flight, they did not increase the power.
28:33Instead, they let the aircraft reach that level and remain there.
28:36Let's check their autopilot settings.
28:41The investigators now wonder if the pilots used the correct setting for the weather conditions they were in.
28:51The autopilot selects what the crew needs.
28:55For instance, the route, the speed, different parameters.
29:12It was set to vertical speed after they leveled off.
29:16Vertical speed is one of the autopilot modes used to gain altitude during flight.
29:22Vertical speed mode is going to allow you to climb or descend at a predetermined foot per minute.
29:30So if you select 700 foot per minute, it'll climb at 700 foot per minute.
29:37The purpose is to make climbs and descents faster.
29:41But to do this, the autopilot will maintain a steep climb angle at the expense of speed.
29:50Vertical speed?
29:52Does that make sense?
29:55In this flight, we found that the vertical mode was selected.
29:59And we compared this information to the aircraft's manual on how to fly under these conditions.
30:07When investigators dig into the flight manual, they discover that the autopilot setting the pilots chose was wrong.
30:16That's their mistake.
30:17The pilots should have selected a different autopilot mode that maintains airspeed, not rate of climb.
30:28In vertical speed mode, the autopilot put the aircraft in a higher pitch in order to maintain the desired rate of ascent.
30:35In icing conditions, that's a problem.
30:42It's going to expose the whole underside of the wing and you're just going to pack on ice even faster.
30:48The situation is made worse by the lack of anti-ice protection on the belly of the aircraft.
30:53This ice buildup adds weight on different parts of the aircraft, which makes it less controllable.
31:02It becomes a major effort for the crew or the autopilot to control the aircraft.
31:07The performance is not the same.
31:09Investigators conclude a heavy buildup of ice caused the plane to lose speed.
31:19The captain had almost 7,000 flight hours, more than 2,000 on the Sob 340.
31:27And he flew this route often.
31:32He should have had the experience to handle the situation.
31:35Only 1,300 hours for the first officer, but there's not a single red flag in his record.
31:40Looks like they both check out.
31:44This raises a perplexing question.
31:49They were a very qualified cabin crew.
31:52Juan had flown similar aircraft.
31:55The first officer had many hours of experience in flying under those conditions.
32:00It should be better when we get to 19,000.
32:03Investigators can't figure out why two experienced pilots used the wrong autopilot setting
32:08to fly through the icing conditions.
32:12I can put it on vertical.
32:14Okay, the sooner the better.
32:16Roger.
32:18Why did the pilots make such a big mistake?
32:27Okay, from the top, right after takeoff.
32:30Airspeed 140 knots. Check.
32:32Check.
32:34Investigators hope the cockpit voice recorder of Sol Flight 5428 will shed light on why the pilots chose the wrong autopilot setting for the icing conditions.
32:47Clubs up.
32:49Engage autopilot.
32:51The team wants to know, were the pilots aware of ice early enough to prevent a dangerous level of build-up?
32:57It was crucial for us to obtain that information.
33:01It was one of the most essential elements for us to understand what was happening,
33:06and also in providing us with information to analyze.
33:09Hope we don't get them too late.
33:11The guys are waiting for us.
33:13Tonight dinner's on them.
33:15We'll get there for dinner.
33:17Initially, what we heard could be said to be a normal operation.
33:20They had a personal conversation that had nothing to do with the operation.
33:27So when did they hit the ice?
33:29Investigators listen for confirmation that the pilots were aware of the icy conditions.
33:45Looks like we're picking up some ice.
33:47There it is.
33:50Nothing to worry about.
33:52We were expecting some light icing.
33:55I don't know if one might be more than we thought.
33:58This ice makes me a bit nervous.
34:01He's definitely worried.
34:03They were aware that there was ice build-up, and that it was progressing.
34:09Should be better when we get to 19,000.
34:12They're going to try and get above the ice.
34:16If they're so worried about the ice, they should focus on the airspeed.
34:22Keep going.
34:25Now investigators listen for indications that the pilots knew their airspeed was a problem.
34:30Want it to gain speed?
34:32I can put it on vertical.
34:34Okay. The sooner the better.
34:36Roger.
34:38They're covered in ice, losing speed, and not climbing.
34:44And what do they do? Switch to vertical speed mode.
34:46Big mistake.
34:48Vertical speed mode actually does the opposite of what the pilots needed.
34:59It prevents the plane from picking up the speed they need to stop ice build-up.
35:03This shocked us a lot because a person won't make a mistake because they want to.
35:10This indicates that there was a root problem that led them to make an inadequate decision
35:16in something as crucial as losing speed under icing conditions.
35:20They're just focused on getting above the bad weather.
35:25They can't. They're carrying too much ice to climb any higher.
35:39Keep going.
35:43Building up some ice on my wing.
35:46That's when the crew began to observe the ice build-up on both wings.
35:51Okay, let's get it down to where it's warmer to melt it off.
35:56Ask to descend to a lower altitude.
35:5814,000. Roger.
36:00Solar flight 5428 requesting descent to flight level 140.
36:04Go to 14, melt the ice. Not a bad idea.
36:08Once it became apparent that they were picking up ice quickly and they were unable to climb,
36:13they make a decision to descend and reduce the amount of ice accumulation on the airframe
36:18and find an altitude where the temperature is such that that ice would melt.
36:27I don't think that helped very much.
36:31The CVR reveals that conditions are no less treacherous when the pilots get to 14,000 feet.
36:41Ice is hitting everywhere.
36:42Can you imagine how the aircraft's belly is looking?
36:46It's okay. We're gonna stay at this altitude for now.
36:49We'll keep de-icing until we get there.
36:54But the pilots can't rely entirely on de-icing.
36:58They also need to push the throttles forward to increase power.
37:01It was noted that while they were aware of the ice buildup and how things were progressing,
37:10they were not taking strong measures to change the situation.
37:16The turboprop is on the verge of an aerodynamic stall.
37:17The turboprop is on the verge of an aerodynamic stall.
37:19It's because there's too much ice on the propellers.
37:20What about Max?
37:23Roger.
37:24Propellers?
37:25They're misreading the signals from the plane.
37:27They believe that the cause of the vibrations was that the propellers had too much pressure.
37:30The turboprop is on the verge of an aerodynamic stall.
37:35It's because there's too much ice on the propellers.
37:38What about Max? Roger.
37:40Propellers? They're misreading the signals from the plane.
37:45They believe that the cause of the vibrations was that the propellers had too much ice buildup.
37:50When an aircraft's propeller accumulates too much ice, the plane can begin to shake or buff it.
38:00Increasing the propeller's speed can be effective in dislodging it.
38:08What was actually happening was a structural vibration of the entire aircraft.
38:15The aircraft was virtually dying.
38:17It was at a speed threshold where the next thing was the loss of control due to the loss of lift.
38:30What's wrong? I don't know.
38:33That's the stick shaker. How did they not realize that they're stolen?
38:38The stick shaker is a device that actually will shake the control yoke in order to very viscerally communicate to the pilot
38:47that you have a low-speed event and prompt the pilot to action.
38:51But what the investigators hear next is most troubling of all.
38:57Pull back! Pull back!
39:01Pull back! Pull back!
39:06Investigators are surprised by how the pilots respond when the plane begins to stall.
39:11It's a shocking revelation.
39:23The pilots are doing the exact opposite of what they should be doing.
39:27When they encountered that stall event, what they should have done is push forward enough to break that stall
39:33and not being so worried about losing altitude, but rather regaining their airspeed.
39:41Investigators suspect the pilot's last-minute attempt to climb slowed them even more,
39:46making the stall unavoidable.
39:51Come on! Come on! Come on!
39:52Come on! Come on!
39:54Come on!
39:56Mayday! Mayday! Mayday!
39:57Slow flight 5-4-2-8! Mayday! Mayday! Mayday!
39:59As soon as they fight the stick shaker, they're too far gone.
40:05They can't recover.
40:07Investigators now know why Sol 54-28 crashed into a desert plateau in Patagonia.
40:15A wrong autopilot setting here.
40:18A misread of the plane's vibrations here.
40:21And when they finally stall, try to pull the nose up to level off instead of trying to gain speed.
40:27What kind of training did these guys get?
40:32We realized that we had to dig deeper in terms of training.
40:38How the company prepared two people who faced a situation they could not adequately manage.
40:48Investigators pour through the pilot's training records.
40:51Yeah.
40:54So, this is a regular route where bad weather is common, right?
40:59Right.
41:00Guess what's left out of the training program?
41:03Training on the anti-ice system.
41:08The flight simulator they used couldn't even simulate flying in icy conditions.
41:12There was only training done on how to turn on the different systems,
41:24to manage the formation of ice, and how to de-ice the plane.
41:29But no training is done on what to do once the ice buildup has advanced,
41:34and how to get out of that situation by increasing speed.
41:38The revelation that the pilots were not adequately trained to fly in icing conditions
41:46is the last piece of the puzzle in this horrifying crash.
41:50It should be better when we get to 19,000.
41:53Investigators conclude the airline's lack of proper training
41:56led directly to the pilots selecting the wrong autopilot setting.
42:00I can put it on vertical.
42:02Okay.
42:03The sooner the better.
42:04Roger.
42:05And to their failure to increase speed in icing conditions.
42:18Oh, hell.
42:19What's wrong?
42:20I don't know.
42:21The result was a stall, which they mishandled.
42:25Pull back!
42:26Pull back!
42:26By fighting the plane's stick pusher safety feature.
42:29They understood the situation they were in,
42:34because they were aware of the ice at all times.
42:37Pull back harder!
42:39The problem was that the actions they took
42:41were not effective enough in order to mitigate the situation.
42:43Pull back!
42:44Pull back!
42:45Pull back!
42:46Pull back!
42:48In the final report, investigators recommend sweeping changes to training
43:15at all levels of commercial aviation in Argentina.
43:27The most important recommendation that this accident generated
43:31is about the pilot's training process in emergency situations
43:35and how to handle the aircraft in icing conditions.
43:38There's a lot of work being done to prevent this from happening again.
43:46We can't say we'll avoid all accidents,
43:49but our goal is to have the least number of accidents
43:51and the least number of casualties.
43:54That is the most important thing.
43:56That is the most important thing.
43:57If not, please don't try to do the same thing.
43:58That is the most important thing.
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