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00:00Singapore 6, you are cleared for takeoff. Runway 05 left.
00:04During the takeoff, your heartbeat goes up a bit.
00:07Okay, cross-rack, hoga, hoga.
00:09Taking off is a complex task.
00:11Ignition set. Spoilers armed.
00:14Pilots need to carefully execute multiple steps to get their plane into the air.
00:19100 knots.
00:20But sometimes mistakes are made.
00:23They didn't follow procedures precisely.
00:26With tragic results.
00:27In Taiwan, a 747 fails to take off in a typhoon.
00:35I thought I was going to die.
00:37A departure from Detroit goes horribly wrong.
00:40Why didn't pilots perform the task?
00:43In a matter of seconds, an MD-82 is out of control in Madrid.
00:48Fly the plane. Fly it.
00:50On three different flights, small missteps ended in tragedy.
00:57Mayday, mayday.
01:05Mayday, mayday.
01:06Taipei, Taiwan.
01:23Singapore Airlines Flight 6 taxis to the runway through heavy wind and rain.
01:28Typhoon Jiangsen is closing in on Chiang Kai-shek Airport.
01:39Flight 6 needs to get airborne before the storm hits.
01:42Even a 747 can't take off in an actual typhoon.
01:47The closer this storm gets, the more likely it is that these guys are going to get stuck in Taipei.
01:52There are 179 people on board the overnight flight to Los Angeles, California.
02:01Singapore 6, for your information, surface wind 0-0 at 2-4.
02:04Coastal 4-3.
02:07Thank you, sir. Singapore 6.
02:09Let me know when it hits 30.
02:11If the crosswinds reach 30 knots, Captain Fong Chi Kong will have to abort the takeoff.
02:17As we were taxiing down the runway, it was very windy and the plane was moving left to right.
02:25Singapore 6, you are cleared for takeoff.
02:30Runway 0-5 left.
02:34Okay, thrust wrap toga toga.
02:40Okay, my control.
02:42The 747 accelerates to reach the takeoff speed of 180 miles an hour.
02:49V1.
02:50V1.
02:51As the plane was gaining speed to takeoff, at a certain time, the plane kind of lost it.
03:01What's happening?
03:03I felt the airplane spinning around.
03:06I thought I was going to die.
03:10After skidding down the runway,
03:12the 747 finally comes to a stop.
03:18Then I opened my eyes and I saw a fireball coming at me.
03:26Direct emergency vehicles to runway 0-5 left.
03:30Singapore 6.
03:31You read.
03:32Singapore 6.
03:34Let's go, go, go.
03:35The plane's tanks are fully loaded with tons of fuel.
03:46Fuel for a fire that rescuers battle in this violent storm.
03:51It takes about 15 minutes to control the fire and 45 minutes to extinguish all of them.
03:58So it's a difficult task for the firefighters.
04:0983 people have died.
04:14There are 96 survivors, including the pilots.
04:17One of Asia's busiest airports is immediately shut down.
04:29It's now up to the Aviation Safety Council of Taiwan to determine the cause of the disaster.
04:34When I went to the crash site, I can see all the wreckage spread the runway.
04:46Flight 6 was cleared for takeoff on runway 5 left.
04:52But much of the wreckage is spread over runway 5 right.
04:55Investigators wonder whether the typhoon blew the plane off its runway.
05:03When you're an investigator looking at a crash scene, you have to keep an open mind.
05:07You have to assume it could be any conceivable factor from the machinery,
05:11the human factors, to the weather, to who knows what.
05:15As investigators, we believe that we should interview pilots or operators as soon as possible
05:20because we believe that human memory will fade over time.
05:25Captain Fong Qigong is interviewed within hours of the crash.
05:31What happened?
05:34We collided with something on the runway.
05:38There's something there!
05:42There was something on that runway.
05:44Could you tell what it was?
05:46No.
05:48We could not see all the way down the runway.
05:50The focus shifts from the weather to the possibility that there was an obstacle on the runway.
06:00Investigators examined the wreckage for clues.
06:04It's difficult for us to collect all of the information, all of the wreckage,
06:09because it's blown to everywhere.
06:12Accidents during take-off can involve more than one aircraft.
06:17In 1991, a Sky West Metroliner preparing for take-off from Los Angeles
06:22was crushed by a U.S. Air 737, which was coming in to land on the same runway.
06:2834 people were killed.
06:32Is that what happened to Singapore Airlines Flight 6?
06:36Any signs of another plane?
06:39And no other flight's unaccounted for.
06:42At Chiang Kai-shek Airport, this theory is ruled out.
06:46All of the debris appears to be from just one plane, Flight 6.
06:52He didn't hit a plane.
06:55Investigators work through thousands of pieces of mangled wreckage.
07:01Part of the flap assembly.
07:03Right wing.
07:05They make an unexpected discovery.
07:08Some wreckage doesn't belong to the shattered 747.
07:12It looks more like construction equipment.
07:16Chiang Kai-shek Airport has three runways.
07:23Runway 5 left is the one Flight 6 was instructed to use.
07:28Parallel to that is Runway 5 right, a runway closed for construction.
07:34Investigators consider the possibility that Flight 6 hit material from the construction site.
07:41It wouldn't be hard to imagine some large object being blown into an engine
07:45or knocking out the windshield.
07:46There's lots of things that could have happened.
07:52There's something there.
07:56When investigators look at Runway 5 right, adjacent to Flight 6's designated take-off runway,
08:02they see something that doesn't make any sense.
08:05Fresh tire tracks on a runway that is supposed to be closed.
08:09We can actually see the tire mark of this aircraft starting from the take-off point all the way to the first impact point.
08:19The tire marks on Runway 5 right lead investigators to a startling conclusion.
08:27This is our point of impact.
08:28It seems Flight 6 was taking off from the wrong runway.
08:34But how could two experienced pilots make that mistake?
08:39The only way to determine what went wrong is with the data from the black boxes.
08:48When we get information out of the recorder, we read it, then we can know the exact position of the aircraft.
08:57Investigators compare positioning information from the flight data recorder to a satellite image of the airport.
09:03Well, he's lining up with the wrong runway.
09:09Somehow, the plane ended up on Runway 5 right instead of 5 left.
09:15He was supposed to be here.
09:20How did they end up here instead?
09:221,243 meters down the runway, he collides with the construction of Goodman.
09:28It seems like the kind of thing that shouldn't happen, ever, under any circumstances.
09:37Investigators need to know why Singapore Airlines Flight 6 tried to take off from the wrong runway at Taiwan Airport.
09:48Investigator Thomas Wang interviews Captain Fong again.
09:52Did you receive this notice?
09:56He has questions about a notice that Runway 5 right was closed.
10:01Of course I did.
10:03Everyone did.
10:05We discussed it during our briefing.
10:08Tell them we'll take 5 left.
10:11So why didn't air traffic controllers realise that the 747 had turned onto the wrong runway?
10:21I couldn't see them in that weather.
10:22When interviewed, the controllers said that night's storm limited visibility to around 2,000 feet.
10:32They confirmed Runway 5 left.
10:34That's the last I heard from them.
10:391,600 meters between the runway and the tower.
10:42There's no way he saw them.
10:43The crew assumed the tower was monitoring their progress.
10:52But the controller had lost sight of the plane.
10:58Investigators now try to determine how the pilots lost their way.
11:03We couldn't see very far, but we could see far enough.
11:06Cyrano studied the map while I followed the taxi lights.
11:09It led us directly to the runway.
11:12Okay, green lights are here.
11:14It appears that the crew had no trouble seeing their taxi route.
11:22Was this the map you were using?
11:25Yes.
11:26You didn't have any trouble reading it?
11:27I wasn't reading it.
11:30My first officer and the relief pilot were following the map.
11:34I only glanced at it when the route changed.
11:36They changed the route?
11:37Yes.
11:39Wang learns that the ground controller issued a last-minute change to their taxi route.
11:43Singapore 6, request taxi.
11:51Singapore 6, taxi to runway 06 via taxiway.
11:55Correction, runway 05 left via taxiway Sierra Sierra, West Cross, and November Papa.
12:02Pilots have to deal with last-minute changes all the time.
12:05The situation becomes complicated.
12:07It becomes hairy.
12:07Now you've got a typhoon bearing down on you.
12:09You've got gusts.
12:10So you're under pressure.
12:11Did additional workload in the cockpit cause the pilots to make a fatal mistake?
12:18Investigators turn to the cockpit voice recorder.
12:22It's coming in fast.
12:24The longer we delay, the worse it's going to get.
12:28The CVR reveals that the crew wanted to get off the ground before the weather closed in.
12:35Singapore 6, runway 05 left.
12:38Wind 020 at 28, gust 5-0.
12:41You're in for takeoff.
12:43Normally, a 747 taxi's about 25 knots.
12:46On this night, they're going 9 knots.
12:48They're doing exactly what they should have done, taking it nice and slow.
12:52The pilots pass signs that clearly identify the runways.
12:56I'm going to go very slow.
12:57I'm going to go very slow here.
12:59Otherwise, we'll skip.
13:02Indeed, he's crawling.
13:11020.
13:12From the left, 020.
13:14The winds consume the crew's attention.
13:1928.5.
13:20It's getting close to 30, sir.
13:23Okay.
13:23The captain was taxiing the aircraft in very slow speed.
13:28And the first officer is doing the before takeoff checklist.
13:34And the relief pilot is working on the crosswind component.
13:37So all pilots, they are occupied by something.
13:40They do not have enough attention to actually check which runway they are taxiing onto.
13:47They believe they are making a right turn onto the correct runway.
13:53Unfortunately, that's not the correct runway.
13:55That's 05 right.
13:56Captain Fong's extreme caution might have worked against him.
14:02Okay, nine knots.
14:06Because the turn took so long,
14:08Captain Fong may have believed that he'd gone further than he actually did.
14:12So much time had passed that he may have thought he had actually reached runway five left.
14:18The big irony of this crash is that they were taking off in very dangerous circumstances,
14:23near the limit of what their plane was capable of handling.
14:26But it wasn't the weather that did them in.
14:29But rather, the pressure of dealing with the storm distracted them from what turned out to be the real question.
14:35Were they in the right place?
14:39V1.
14:40V1.
14:47There's something there.
14:48One of the lessons of this accident is that you can have an exemplary crew
14:55performing their duties with utmost care
14:57and they still make a mistake with fatal consequences.
15:02Taiwan's Aviation Safety Council recommends immediate changes
15:05to pilots' procedures and training.
15:10Currently turning left on the taxiway November 1.
15:12New checklists are designed that include a visual step,
15:17obliging pilots to confirm that they're on the correct runway before takeoff.
15:23Singapore 006 reminded us again that if there's ambiguity in the cockpit
15:29and you're on the ground, you need to resolve and stop and get that resolved,
15:34particularly in very, very inclement weather.
15:37When visibility's reduced, you need to be sure where the airplane is.
15:40The crash of Singapore 6 isn't the first time
15:44a series of missteps during takeoff leads to disaster.
15:53Detroit Metropolitan Airport.
15:56More than 1,100 airplanes use one of its four runways every day.
16:02Northwest Airlines Flight 255, an MD-80,
16:06is bound for Phoenix, Arizona.
16:07There are 149 passengers on board.
16:15Captain John Maus is in command.
16:17A Las Vegas native, 57-year-old Maus is a veteran pilot.
16:23His first officer is 35-year-old David Dodds of Galena, Illinois.
16:30Look at this.
16:31Today, storms darken the flight path between Detroit and Phoenix.
16:39Several are moving quickly towards the airport.
16:42There's a line here.
16:45And another one here about 25 miles wide.
16:49If we get out of here pretty quick, we won't have a delay.
16:55Northwest 255.
16:57Clear to go.
16:57Already running a half hour late,
17:02Flight 255 is cleared to taxi to the runway.
17:05Let's do the checklist.
17:07Brakes.
17:08Set.
17:08Windshield heat.
17:11It's on.
17:12Loose the pumps.
17:14That's six.
17:16Pumps and pressure.
17:17On and checked.
17:18Damn.
17:20It's starting to rain.
17:22To beat the storms, they must leave immediately.
17:26They're all on.
17:27Fourth start checklist is...
17:29Flight 255 moves away from the gate and towards the runway.
17:34But the bad weather...
17:36Northwest 255.
17:38Now exit at Charlie runway, three center.
17:41...forces a last-minute runway change.
17:43Okay, uh, to Charlie for three center, Northwest 255.
17:50Charlie for three center right.
17:52Okay.
17:55Ladies and gentlemen, we're currently number one for departure.
17:59We should be rolling in a couple minutes.
18:03Blacker than hell out there.
18:05Where's Charlie at?
18:11By the time they get to the new runway, they are 45 minutes behind schedule.
18:19Northwest 255, runway three center.
18:21Clear for takeoff.
18:24Flight 255 hurdles down runway three C.
18:31Clamp.
18:32Hundred knots.
18:35V-1.
18:36Rotate.
18:39The pilots angle the plane's nose up for liftoff.
18:46But less than 50 feet off the ground,
18:50Flight 255 is in trouble.
18:55Moments after takeoff...
18:57Tower, lifeguard copter, one, zero, two.
19:00Northwest Airlines Flight 255 is out of control.
19:05The trail of debris is more than a mile long.
19:24Remarkably, a four-year-old girl has survived the crash.
19:27Rescuers spend hours searching the wreckage for other survivors.
19:37But the young girl is the only one.
19:39154 people on board, including Captain Mouse and First Officer Dodds, have been killed in the crash.
19:49On the ground, two people died in their cars when they were hit by the plane.
19:53Investigator Jack Drake and his team from the National Transportation Safety Board begin the search for clues.
20:04You know when you're at a crash site because you get this combination of burned plastic and kerosene and sometimes combined with a fire-retardant foam that has its own distinctive odor.
20:16The cockpit voice recorder is intact, but the flight data recorder has been damaged in the crash.
20:25Both recorders are sent to the NTSB lab in Washington, D.C.
20:32John Clarke is the team's flight performance engineer.
20:39He searches for ground scars and other impact marks and interviews witnesses to piece together where the plane fell and how.
20:48When I first started seeing the wreckage, your mind immediately starts turning to sorting out where it hit, how it hit, not where the wreckage ended up, but those first few inches where the airplane was coming down.
21:03According to witnesses, flight 255 lifted off in a nose-high position, but then couldn't climb.
21:11V1, rotate.
21:13That clue could indicate that the plane didn't have enough speed to get off the ground, or that high winds prevented it from lifting off.
21:27Until technicians can decode the damaged FDR, the team must rely on physical evidence from the crash site.
21:36One thing stands out.
21:39Is this the way it was found?
21:40The lever that extends and retracts the wing's flaps and slats.
21:47Flaps and slats are extensions that slide out of the back and front of the wing.
21:52They make the wings larger, increasing the amount of lift they can provide.
21:56They must always be extended for takeoff.
22:00But the way the flap handle is damaged suggests the plane's flaps were not extended when it crashed.
22:06The pin had left a mark.
22:10This happens because the aircraft comes to a very sudden stop and the handle jangles around.
22:16Metal-to-metal contact that's exaggerated by the impact.
22:21That indicator was that the flaps were zero or fully retracted and the slats were retracted as well.
22:27Even without data from the FDR, investigators can determine the flap position at takeoff.
22:35V1, rotate.
22:40Flaps and slats are moved by cables running through the wings.
22:44Each component of the slats system has its own drive system, and one of those was interrupted by the light pole that passed through the wing.
22:52When they examine the left wing, investigators see that the cable controlling the slats sliced in two when the wing hit the pole.
23:00By examining the cut cable, investigators can tell whether the slats and flaps were extended or retracted.
23:15It severed two cables.
23:17If you lined up those two severed ends, it corresponded with the slats being in the full retracted position.
23:24When data is finally extracted from the FDR, the report confirms what the cut cable suggested.
23:31The flaps were not extended on takeoff.
23:34It's a major breakthrough.
23:36Jack Drake now knows what brought down Flight 255.
23:40But the flight data recorder can't answer a more troubling question.
23:45So, why weren't the flaps deployed?
23:47For some reason, a seasoned crew allowed a critical misstep to occur while getting their plane off the ground.
23:59Why did the crew of Northwest Airlines Flight 255 fail to extend the flaps on takeoff?
24:10Investigators listen to the cockpit voice recorder again for answers.
24:13It indicates that a last-minute runway change led to confusion in the cockpit.
24:21Northwest 255, no exit at Charlie Runway, 3 Centre.
24:26Did he say 3 Centre?
24:283 Centre, yeah.
24:29That's why I was thinking we had to let it on.
24:32I was thinking 2-1.
24:34Well, they made a wrong turn, which might have been confusing, because they had to go a different route.
24:39Around Northwest 255, I guess we went by Charlie.
24:46We're going to 3 Centre, right.
24:48Northwest 255, affirmative.
24:50Make a left turn.
24:53They finally arrived at the runway 45 minutes late.
24:57We're okay for that centre runway, aren't we?
25:02Before they lost their way, the crew of Flight 255 carried out a number of checklists, but missed the taxi checklist.
25:10They apparently didn't consider the checklist, and key in the checklist is the configuration of the aircraft for departure.
25:16The first item on the taxi checklist is flaps, and because they didn't run the checklist, the crew neglected to set their flaps to take off position.
25:29I think Charlie was...
25:31No, it is Charlie.
25:33You sure?
25:36I think so.
25:37They hadn't done this checklist at the time they normally would, and as the activities piled up that were potential distractions,
25:47they were further and further away from the point at which they would normally perform that function.
25:52After the checklists, there is a last line of defence designed to prevent pilots from taking off without flaps set.
25:59An alarm should have sounded when the pilots started down the runway with their flaps retracted.
26:04Maybe it went off, but we just can't hear it.
26:08But no alarm is heard on the CVR.
26:12When investigators consult other MD-80 pilots, they're told the take-off configuration warning was a nuisance at times.
26:22Flaps. Flats. Flaps.
26:26If you're doing a single-engine taxi, you have to push your throttle up further to get a power to taxi,
26:31and you have to set off the take-off warning system.
26:33And if it's going off routinely all the time, it gets on their nerves.
26:38So apparently pilots were routinely silencing those take-off warnings.
26:44Investigators suspect that the crew of Flight 255 pulled a breaker to avoid the irritating take-off warning.
26:52It's determined that the downing of Flight 255 was caused by pilot error.
27:08The FAA orders a modification to the alarm system of all commercial jetliners to prevent nuisance alarms.
27:15I think a big lesson learned is that strict adherence to checklists is very important.
27:23Checklists, in my mind, is kind of the fabric that holds a flight together.
27:27It has to be religiously followed.
27:2921 years after Flight 255's deadly crash, another tragedy shows flight crews were still missing critical steps during take-off.
27:39At the last minute, Spanair Flight 5022 is delayed.
27:56There's a problem with a temperature probe.
27:58While it's checked out, the air conditioning is turned off.
28:04Passengers are sweltering in the heat.
28:10So, we're done?
28:13Yeah, I popped the breakers, so you're good to go.
28:15Okay, thanks.
28:17After a delay of more than an hour, Spanair Flight 5022 finally gets going.
28:26There are 166 passengers on board the flight bound for the Canary Islands.
28:33Today, Captain Antonio Luna is in command.
28:38A former Spanish Air Force pilot, he's been with Spanair for nine years.
28:43How's our time?
28:47About an hour and a quarter behind schedule.
28:51First officer Francisco Moulet joined the company just a year and a half ago.
28:57Spanair 5022, Jonexon line on runway 36L.
29:04Okay.
29:05Here we go.
29:11Preparing for take-off is an extremely busy time for the flight crew.
29:14They've got multiple checklists that they have to run.
29:17Ignition.
29:18Set.
29:19Exploilers.
29:20Armed.
29:21Make certain the aircraft is properly configured, the thrust is set right, the brakes, etc.
29:26Air conditioning.
29:28So, there are a plethora of factors that are all running through their minds simultaneously.
29:34Spanair 5022, you are cleared for take-off.
29:37Runway 36L.
29:39Cleared for take-off.
29:40Spanair 5022.
29:41Just after 2 p.m., the MD-82 aircraft starts speeding down the runway.
29:50100.
29:51The captain monitors their speed.
29:54They can't lift off until they reach 157 knots.
30:01V1.
30:02Rotate.
30:03Suddenly, an alarm sounds.
30:16Something is wrong.
30:18At Madrid Barajas Airport, an MD-82 is approaching disaster.
30:35The plane is less than 40 feet off the ground.
30:44Fly the plane.
30:46Fly it.
30:48Just seconds after take-off, flight 5022 slams into a riverbank alongside the runway.
31:08Airport fire crews race to the scene.
31:10The plane, with 172 people on board, is now shattered wreckage spread over half a mile.
31:22Only 18 people survived the crash of Spanair flight 5022.
31:29147 passengers are dead.
31:30So are both pilots.
31:33It was a tremendous tragedy. All the country was affected by that.
31:40Spain recruits an international team of experts to investigate the country's worst aviation disaster in 25 years.
31:47Okay, people. It looks like we have our work cut out for us.
31:54Marks on the ground paint a vivid picture.
31:58Here's our first impact.
32:00That reveals just how soon flight 5022 hit the ground.
32:04The first impact marks are just 200 feet from the runway.
32:10The plane then passed over a road and slid another 1,800 feet before crashing on the far side of the river.
32:17This airplane left a trail coming from the runway to the edge of the airport boundary.
32:24So it was quite clear for the investigation that the airplane had big problems just on liftoff.
32:32Investigators wonder if engine failure compromised the take-off.
32:35If we find mud, soil or grass throughout the engine,
32:41we can determine that the engine was fully operational at the time of the accident.
32:45Both engines are filled with debris ingested during the crash.
32:50The finding means the engines were running when the plane made impact.
32:57The engines were fine, but something stopped that plane from climbing.
33:03Controllers working the day of the crash present a potential lead.
33:10They had some kind of maintenance issue right before take-off.
33:15Madrid, Spanair 5022. We have a slight problem.
33:19We have to exit the runway.
33:21Investigators hear about the trouble with the temperature sensor.
33:25Oh, yeah. I took a look, but it wasn't serious.
33:28The sensor, called a Ram Air Temperature Probe,
33:31measures the outside air temperature
33:33and feeds the information to the plane's computer during flight.
33:42The sensor was sending out faulty readings.
33:45Check the ice protection meter selected.
33:48No, that didn't work either.
33:50Without it, the automation that adjusts engine power won't function properly.
33:55Look at that. It says 140 degrees now.
34:01Maintenance workers were unable to repair the faulty sensor.
34:05Right, got it.
34:06So they temporarily cut the power to the sensor, thereby disabling it.
34:11So, we're done?
34:13Yeah, pop the breaker, so you're good to go.
34:16Okay. Thanks.
34:19Investigators wonder if the disabled temperature probe is somehow linked to the crash.
34:23I don't see how this could cause a problem.
34:28But they quickly confirmed that the probe is not an essential piece of equipment.
34:32The crew can keep track of the outside temperature themselves,
34:35and then adjust engine power manually.
34:39Something else prevented the plane from climbing out.
34:43What kind of wreckage have we recovered from the wings?
34:45Get me everything you have.
34:47Investigators turned to the MD-82's control surfaces.
34:50They study the lever mechanism that pilots use to adjust the flaps.
34:59The flap lever was an essential part of the investigation.
35:04Well, well, what have we here?
35:12There's a deep scratch at the zero mark, the retracted position.
35:16It's a startling finding.
35:19One that suggests the flaps on flight 5022 were not extended on takeoff.
35:23It's disturbingly similar to the crash of Northwest Airlines flight 255 21 years before.
35:32Did the pilots in Madrid, like those in Detroit, fail to set the flaps properly before takeoff?
35:38V1.
35:39What happened to prevent them from being in the right position?
35:43Rotates.
35:44The answer to that question could explain why 154 people died.
35:52Investigators need to know if the pilots of Spanair flight 5022 took off without the flaps extended.
36:00They don't have a voice recording for the first takeoff attempt.
36:04It was erased when the MD-82 left the runway and powered down for maintenance.
36:08But they do have all the information from the flight data recorder.
36:15Flaps were set at 11 degrees on the first taxi, exactly where they should be.
36:20The flight data recorder reveals that the flaps were set correctly when the plane taxied onto the runway the first time.
36:28Then the pilots notice that there's a malfunctioning temperature probe.
36:32Madrid, Spanair 5022. We have a slight problem.
36:36We have to exit the runway.
36:37When the crew returned to the terminal for repairs, they retracted the flaps.
36:43Flaps and slats were retracted after coming off the runway as part of standard operating procedure.
36:49We're done.
36:49Yeah, I popped the break. I see you're good to go.
36:51Thanks.
36:53Taxiing back to the runway, the pilots should have extended the flaps for takeoff.
37:00The MD-82's pre-flight checklists direct the crew to check the flaps and slats three times.
37:07Ignition off.
37:10Air conditioning, set.
37:12On the after-start checklist, setting the flaps is the final step.
37:18Hydraulic pumps and valve.
37:21Set and check.
37:24Lights.
37:24On.
37:26Get permission from air traffic control to taxi, will you?
37:32Hold it, hold it, hold it.
37:34What is he doing?
37:35This is the worst possible time to interrupt him.
37:38The CVR reveals that just as the first officer is about to check the flaps and slats for the first time,
37:44the captain instructs him to make a radio call.
37:47Ground, spanner 5022, requesting taxi instructions.
37:52Spanner 5022.
37:54He didn't return to the checklist to finish that critical step.
37:58Humans are fallible, and we know that when we're multitasking,
38:01it's very easy to forget or miss a critical item.
38:07And they never set the flaps.
38:08The captain and first officer then fail to carry out this critical step on the final two checklists.
38:16Transponder.
38:17Set.
38:19Captain.
38:19Hang on.
38:20Stop.
38:22Where is the take-off briefing?
38:24Investigators now know what caused the crash of spanner 5022.
38:28V-1.
38:37Rotate.
38:38The pilots never extended their flaps before take-off, making it impossible for the plane to climb.
38:46And just as with Northwest Flight 255, investigators must answer a key question.
38:53Where's the warning?
38:54If the flaps were not set in the take-off position,
38:59there should be a very conspicuous sound saying that the aircraft is not ready for take-off.
39:05Once again, why didn't the alarm sound to warn the pilots that their flaps weren't set?
39:12These failures have to be connected somehow.
39:17Investigators look for a link between the failure of Flight 5022's take-off warning
39:22and the failed temperature sensor.
39:29Look at that.
39:30It says 104 degrees now.
39:32Investigators trace the complex pathways for the temperature sensor and the take-off warning.
39:38They make a critical discovery.
39:41The sensor and the take-off warning both pass through a single electronic relay,
39:46the R25 relay.
39:48It was very shocking to find out that two different systems,
39:52like the take-off warning system and the RAM air temperature probe heating,
39:56were controlled by the same device.
39:58Investigators suspect the R25 relay failed,
40:02disabling both the temperature sensor and the take-off warning.
40:08Technicians are not able to recreate that failure in the lab,
40:11but for Juan Carlos Lozano, the theory makes sense.
40:16That's it.
40:19That's the link.
40:20In my opinion, the relay R25 was the cause of the failure of the take-off warning system.
40:25Right, got it.
40:26With no take-off alarm, the pilots lost a critical line of defense.
40:38Just like the Northwest Airlines pilots in Detroit,
40:42the Madrid crew's failure to follow their checklists led to tragedy.
40:47The single biggest failure in this accident is the failure of the take-off warning system.
40:59This system was designed considering that the humans can make mistakes.
41:04And this is a clear example, that the last line of defense failed.
41:10After the crash of Spanair 5022, Boeing revised its checklists again
41:17to make extending flaps and slats even more prominent.
41:24Three disastrous take-offs lead to changes that have made a critical period of flight much safer.
41:31Technology is helping us with all three of these accidents.
41:36The take-off warning systems are better on the more modern airplanes
41:41so that if a crew attempts to take off, they get very definite warnings.
41:47Moving map displays that are now available for when you're taxiing on low visibility.
41:52It physically shows the airplane on an electronic map.
41:55That reduces the ambiguity about your position.
41:58So technology is helping us there,
42:00but that still comes back to good decisions, conservative decisions,
42:05and the adherence to standard operating practice.
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