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I documentari di mistero e indagini esplorano casi irrisolti, fenomeni inspiegabili e indagini su crimini reali o eventi paranormali. Dai grandi classici del true crime alle teorie su UFO, alieni, civiltà perdute e misteri storici, fino alle inchieste giornalistiche più moderne, questi documentari affascinano chi ama scoprire verità nascoste e segreti mai chiariti.
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00:57Se il personaggio di controllo è così attraverso,
01:00quindi perché sono queste tragedie?
01:27Pilots are trained to handle all sorts of external threats and hazards
01:36But sometimes it's the personal problems, impatience, arrogance, incompetence
01:42That lead to tragedy
01:44In 1972, the Hawker Sidley Trident is the pride of British aviation
01:53Be line 548 requesting start
01:55The crew of British European Airways Flight 548
01:59Is completing final preparations for an afternoon flight
02:03From London's Heathrow Airport to Brussels
02:06Looks like the weather's going to give us a bumpy ride today
02:10Be line 548 cleared for start
02:15Captain Stanley Key was called in to work on his day off
02:19Key is a former RAF pilot
02:22And one of the airline's most qualified captains
02:25Start the master
02:28On
02:30Captain Key had been on the aircraft for a long time
02:33So he's very experienced
02:34And if you expected to fly with him
02:36You expected to fly to the book
02:38And to do it accurately with no arguing
02:40Today, Captain Key has had to wait for another crew catching a lift to Brussels
02:46Have a seat, Captain
02:49Be line 548 ready for takeoff
02:52Be line 548 clear for takeoff
02:55548
02:56Maximum thrust
03:00Stopwatch on
03:08Rotate
03:13Once the Trident has gained enough altitude
03:21The crew will have to throttle back slightly
03:23They'll be flying over the small town of Staines
03:28Which lies very close to the airport
03:30It's a very noisy engine
03:32With a particularly nasty crackle to it
03:34So noise abatement would be an issue
03:36Crews are required to minimise aircraft noise over populated areas
03:41And the carriage up
03:44First officer Jeremy Keeley prepares to throttle back the engines
03:56If he does it too soon
03:59The plane won't have enough power to climb
04:0275 seconds
04:0490 seconds
04:09If he's late
04:10The crew will violate noise restrictions
04:12Right on time
04:14Keeley throttles back
04:16Passing 1500 feet
04:20The tower clears them to a higher altitude
04:24Up to 6-0
04:30Suddenly
04:32What was that?
04:35The plane begins to lose altitude
04:38And plummets like a rock
04:40Look at the speed!
04:43Look at the speed!
04:45The airspeed dropped quite rapidly
04:47There was then a very high rate of descent
04:49The pilots were just passengers
04:52In their own aircraft
04:53All 118 people on board are killed
05:11The plane missed the town of Staines by a few feet
05:15And this accident was pretty horrifying
05:18Because it was the worst airline accident
05:20That Britain had ever experienced
05:22And BEA was reckoned in those days
05:26To be the kind of airline that just didn't have crashes
05:29And this time they did
05:32Flight BE548 on route to Belgium
05:35Crashes in a field not far from Heathrow
05:37And only a few feet from houses in the main road
05:40A team from Britain's accidents investigation branch reaches the crash site
05:45Investigators are struck by something unusual
05:48In most accidents
05:51Momentum carries the wreckage forward after it hits the ground
05:54The crash at Staines is different
05:57After impact, the tail barely slid forward
06:01The rest of the aircraft
06:03Probably hadn't moved forward more than about 50 yards
06:08You know, which for such a heavy aeroplane
06:10Is very, very little distance
06:12It's a sure sign that the plane stalled
06:16An aircraft stalls when it's flying too slowly
06:20To generate sufficient wind over the wings
06:23To give it lift
06:24When that aircraft hit the ground
06:27It was actually slightly nose up
06:29It was falling through the sky like that
06:32An airplane can stall for many different reasons
06:36From engine failure to pilot error
06:39To determine the cause of the crash
06:42Investigators face a huge hurdle
06:44In 1972, planes in the United Kingdom
06:48Are not required to carry cockpit voice recorders
06:51Investigators will have to rely on information
06:56Gleaned from the Trident's flight recorders
06:58And the vast jigsaw puzzle of debris salvaged from the wreckage
07:02Following an impact of this sort
07:04Everything is comprehensively wrecked and jumbled up
07:08And most of the components on the aircraft
07:11Particularly the electronic components
07:13All look very similar
07:14Early in the investigation
07:16Something doesn't make sense
07:18That can't be right
07:19The lever controls the Trident's slats
07:23Or droops
07:24Droops increase lift during take-off
07:28To help the plane climb
07:29They should remain extended
07:32Until the plane has reached the necessary speed
07:34To maintain lift
07:36But according to the lever's position
07:39At the time of the crash
07:40The droops had already been retracted into the wing
07:43This would have been too soon
07:45And would have instantly put the plane into a dangerous stall
07:49How on earth did somebody manage to retract the droop lever
07:53And nobody noticed that that had happened
07:56And it didn't make a lot of sense
08:00There's no way to tell
08:01Just by looking at the droop lever
08:03Whether the crew retracted it before the crash
08:06Or if it was jostled out of place by the crash itself
08:09It might even have been moved during recovery operations
08:15Hang on, will you?
08:20We had the whole of the droop system
08:22Laid out on tables in front of the wing
08:25Retracted
08:41They determined by an examination of the wreckage
08:44That the droops had been retracted
08:47There's no longer any doubt
08:49Someone in the cockpit retracted the droop lever much too soon
08:54This prompts urgent questions about the crew's performance
08:59Investigators focus in on the highly experienced Captain Key
09:04They study the captain's previous flights
09:08He has an impeccable reputation
09:10At least with management
09:12Put up the photo of Key
09:15Now the tray table from the wreckage
09:17There's a piece of wreckage
09:19That raises questions about the captain's reputation with his colleagues
09:23And there was some graffiti scribbled
09:26Which gave a few rather facetious comments
09:30Obviously from a pilot who'd been sitting in that position
09:33Bloody force
09:37They said Key must go
09:38And then a few other derogatory comments added as well
09:41There was over 30 years difference between Captain Key
09:44And the two other members of his crew
09:46And this produces the natural differences you have between the generation
09:49One who regards the others as old and stuffy
09:52And one who regard the youngsters as being young and irresponsible
09:55This produced a generational gap
09:58Did some kind of generational friction erupt in the cockpit
10:01And bring this airplane down?
10:03Investigators looking at the crash of BEA Flight 548
10:14Want to know what other pilots thought about Captain Stanley Key
10:17I hear you're someone we should talk to
10:23Yeah
10:25I'll need to tell you what happened
10:27Pilots at British European Airways are on the verge of a strike
10:32Captain Stanley Key is seen by many as a company man
10:36There was work to rule going on
10:39Most of the co-pilots, which included me, were working to rule
10:42And he thoroughly disapproved of this as not being a professional way to behave
10:46And was leading a campaign against it
10:48According to witnesses, things came to a head 90 minutes before the flight to Brussels
10:54Captain Key
10:56May the battle start and go our way
11:00What did you say?
11:03I just meant that
11:04You know that during the war we flew in real battles?
11:07Selfish, pampered, immature crybaby's making a lot of ridiculous demands
11:12Look here, just because your lot flew in the war
11:14You ungrateful bastard
11:16If you're flying that plane for money, then you're in the wrong profession
11:20I think we better agree to disagree
11:22Bunch of fools
11:24The argument is so severe that investigators face a new possibility
11:30Did the captain's agitation interfere with his ability to fly the plane safely?
11:37Bloody fools
11:38548, climb to flight level 60
11:40Squawk 6615
11:42Possibly still angry and distracted
11:45Up to 60
11:48He might have retracted the droop handle too early without being aware of it
11:53Stalling the plane, triggering alarms
11:57If you go from what is apparently an all-flight into something which is seriously dangerous
12:03It will produce a shock response
12:05And that means your ability to think clearly and to act decisively is very difficult
12:11The Trident is not equipped with a cockpit voice recorder
12:14So investigators can't know for sure what happened in the cockpit
12:19D-line 548, ready for takeoff
12:21But the captain's conversations with air traffic control are recorded
12:26D-line 548, clear for takeoff, 28 right
12:29548
12:30These recordings do not reveal if the captain retracted the droop lever too soon
12:36But investigators notice something unusual
12:38The captain seems awfully quiet
12:42Up to 60
12:43The captain's radio calls are so infrequent and so brief
12:47They don't meet aviation standards
12:49But these recordings provide no clue about why the captain sounded so restrained
12:57What was going on in that cockpit?
13:02Then a startling discovery
13:03It turns out Captain Key had a serious heart condition
13:07That had not shown up in his regular medical exams
13:10Key had, without even knowing it, a clogging of the coronary arteries
13:16And unworthy of the wings on your unip
13:18Just because you're a lot through in the war, doesn't it?
13:20You ungrateful bastard!
13:23And the autopsy reveals something else
13:25Pathologists believe that Captain Key suffered heart failure
13:29Sometime within a two-hour window before the crash
13:32Up to 6-0
13:35If his blood pressure was particularly high because he was agitated
13:39It might affect his reasoning
13:43His level of pain would have increased over the period
13:47Up to a point where he would have become partly or totally incapacitated
13:52The former RAF pilot was old school
13:55If he was in severe physical distress
13:57He likely carried on and did his duty
13:59Never asking his crew for any help
14:02And this raises a parallel question
14:05There were other qualified pilots in the cockpit that day
14:08What was that?
14:10Why didn't one of them do something to save the plane?
14:13Neither Captain Key nor the other pilots realized that it was the retraction of the droop
14:19Which had caused the stall
14:21Because nobody attempted to put it back down again
14:23If they had done, they could have unstalled the airplane
14:27Investigators keep turning back to that argument before takeoff
14:32Investigators learned that an hour and a half before takeoff
14:38Co-pilot Jeremy Keeley witnessed Key's outburst
14:41If you're flying that plane for money, you're in the wrong
14:44They suspect it made a big impact on the young pilot
14:47Having witnessed an outburst like that
14:49One can only surmise that if you are new to the fleet
14:52You don't know the captain
14:53You're slightly unconfident of yourself
14:56You may be nervous if you're in performance
14:58Shaken by his captain's temper
15:01Bunch of fools
15:02Keeley may have been far less likely to correct his captain's errors
15:07It would certainly reinforce the concept that the captain was authoritarian
15:14And not somebody that you should challenge lightly
15:17Especially on that day
15:19The crash of BEA Flight 548
15:23Was the result of a tragic combination of human factors
15:26Centred around the captain
15:27Heart failure
15:30A lever moved too soon
15:32And co-pilots too junior or too intimidated to step in when things started to go wrong
15:38Lessons learned from Britain's deadliest air disaster helped to change the industry
15:45Cockpit voice recorders are now standard equipment in almost all commercial passenger planes
15:51The modern airline is operated very, very differently
15:55The way that crews handle things has improved
15:58It's a much better and safer world
16:01The regret is we've had to build it on the death of 118 people
16:05In northern Minnesota
16:10A commuter crash kills everyone on board
16:13Investigators think the problem lies in the cockpit
16:16You have the responsibility as a captain of creating an interactive team
16:21To where no one on that team would hesitate to speak up
16:24If you saw, heard, felt, or even intuited that something was wrong
16:27You didn't check the damn exterior lights
16:30Northwest Air Link Flight 5719 cruises across the skies of Minnesota
16:42First officer Chad Erickson is two months into his first airline job
16:48I'm sure that Chad was excited
16:52That was the first step in getting the job
16:54That would lead you to the big job
16:56To fly the big iron at big airlines
16:58This is the first time he's flown a route with an overnight stay
17:02Do we get our own room?
17:04No, you're gonna have to room with me
17:09And it's only a single bed
17:10So you'll have to curl up at my feet
17:13Of course you get your own room
17:17You're under contract now
17:19Erickson's captain is Marvin Follett's
17:23The captain grew up in New York City
17:25He was described as having a personality
17:28That was somewhat at odds with a Midwestern personality
17:31Breaking coffee tastes like piss
17:35He had an issue with dealing with other people
17:40Captain Follett's and first officer Erickson
17:43Are flying a Jetstream BA-3100
17:46A small twin-engine turboprop
17:48The Jetstream was a handful to fly
17:51And we had to fly it by hand all the time
17:53Craig Railsback is a former Northwest Air Link pilot
17:57Who also flew the BA-3100
17:59It was fairly unstable
18:02It was like balancing a beach ball on top of a Coke bottle
18:04The upside of flying an airplane like that
18:08Was you were incredibly proficient
18:09I mean, we got to be really good at instrument flying
18:12And we flew in some really, really difficult
18:15Challenging conditions
18:16Which, you know, for a young guy was great fun
18:18Flight 5719 left Minneapolis just before 7pm for Hibbing, Minnesota
18:25About an hour away
18:27There are 16 passengers on board
18:30After that, it's scheduled to continue onto a final stop in International Falls
18:35Twin City 719, Hibbing weather
18:46Sky partially obscured, freezing drizzle
18:49Hibbing's a small airport that does not have a control tower
18:52At about the 20 miles from the airport
18:56They'll clear you for the instrument approach
18:58If the weather is below visual limits
19:00And at that point, once you're cleared for the approach
19:03You're pretty much on your own
19:04You can't take the ILS 3-1
19:08Because of the snow on the runway?
19:11What?
19:13Because of the snow on the runway?
19:15I don't like to land with a tailwind anyway
19:17Tell them we'll take the localizer back course to 1-3
19:21Hibbing airport has two approaches
19:24The captain decides to approach from what's called the back course
19:29This approach is not equipped with the instruments needed to fully guide the pilots to the runway
19:34It is known as a non-precision approach
19:37Would we like the back course up to 1-3?
19:40Roger, proceed
19:41But you're on your own
19:42Non-precision approaches are in fact more demanding than the precision ones
19:50For the reason that you have to monitor the descent rate, the descent altitude
19:54The navigation where you are laterally across the ground
19:58So there's actually quite a bit more going on
20:01Just before 7.50pm
20:10Flight 5719 starts descending into the blowing snow of a cold Minnesota night
20:15Gear down
20:18Gear down
20:20Did you click the airport lights?
20:28In an airport like Hibbing that does not have a lot of traffic
20:32In an effort to save money, because the light bulbs are very expensive
20:36They are what's called pilot-controlled lighting
20:40You click it?
20:41Uh, I, um
20:43The pilots with a series of clicks from their radios can turn the lights up and down
20:48Clicked it seven times
20:50Got it now
20:52I, um, I, um
21:08It takes one hour for emergency responders
21:30to locate the crash site
21:31two miles northwest of the airport
21:34There are no survivors
21:36The National Transportation Safety Board
21:43sends out investigator John DeLisi
21:45The wreckage was up on a hill
21:48so it was in a precarious position
21:51and some of the bodies had been ejected
21:54many were still inside the fuselage
21:56It was the holiday season
22:01so many folks that were traveling
22:03had brought Christmas presents
22:05they were scattered in the debris
22:07There was blood in the snow
22:12It really was one of the most difficult accident sites
22:16I'd ever been to
22:17DeLisi knows that a plane this size
22:22will likely be equipped with only one of the black boxes
22:25the cockpit voice recorder
22:28Here's the CVR
22:29At the time, commuter airplane with 19 or less seats
22:34only a requirement for a cockpit voice recorder
22:37not a flight data recorder
22:38All right, let's go
22:45With no FDR, the difficult job of explaining the crash just got harder
22:52When there's no flight data recorder
22:57it puts us in a bit of an old school type of investigation
23:00where the analysis of the physical evidence
23:04becomes so much more critical
23:06DeLisi turns to radar data from approach control
23:11to track the plane's descent path
23:12It's very steep
23:14and comes late
23:15Investigators can't make sense of it
23:18The rate of descent was double what we'd normally see
23:22It should be about a thousand feet per minute
23:24Now in this case it was over 2,000
23:27Some more times up to 2,200
23:30Why did they start their descent so late?
23:35Me as a pilot
23:36it does make you wonder
23:39because the later you start the descent
23:42the faster you're going to have to descend to get down
23:45and the faster you descend
23:47the harder it is to break that rate of descent
23:49Investigators wonder
23:55if ice on the wings
23:56caused the steep descent and crash
23:59Buildup of ice
24:00particularly on the wings of an airplane
24:02can kill the lift that the wings are capable of generating
24:06So sometimes an airplane with a rapid rate of descent
24:11might be indicative of an out of control motion
24:14caused by a buildup of ice
24:17I'm just wondering if you have a couple of minutes
24:20Investigators determine icing conditions were moderate
24:24and could not have caused the crash
24:26If ice didn't bring the plane down
24:29what did?
24:31In talking to other pilots at Northwest
24:33we began to learn about what they referred to as a slam dunk approach
24:39A slam dunk approach was described as one in which
24:43while you have to pass through an area of icing
24:46crews want to minimize the time they spend there
24:49so they may hold their altitude
24:52close into the airport
24:53and then very rapidly do a steep descent
24:56to get through the altitudes in which there was icing as quickly as possible
25:02That's not a standard technique
25:04but as we began to hear about it
25:06it matched what we were seeing on the air traffic control radar
25:09It's something professional pilots deal with a lot
25:13and it requires a lot of skill in aircraft handling
25:17to get the airplane down quickly
25:20without having the speed go up
25:23to an unacceptably high level
25:25Marvin Follets was an experienced captain
25:29He should have been more than capable of safely performing a slam dunk approach
25:34So what went wrong on flight 5719?
25:45Investigators examine how the pilots on Northwest Air Link flight 5719
25:50performed a so-called slam dunk approach
25:53They hope the cockpit voice recording will shed some light
25:57Before final checklist complete
25:59It's what is not said that alarms them the most
26:03Why isn't the first officer making his altitude call-outs?
26:13We didn't hear the regular call-outs
26:15about 2,000, 1,000 feet
26:18distance from the airport
26:20It seemed as if the first officer
26:22didn't really know what was going on in the approach
26:25You're down?
26:28Blast 20
26:28He never told the captain
26:32how close they were getting to the ground
26:331.93
26:36Investigators need to know what was going on with the novice first officer
26:40Was this tragedy his fault?
26:44There are no red flags in his official record
26:47In fact, it's quite the opposite
26:50This guy graduated number one in his class
26:57The first officer had prepared index cards
27:01with aviation data for every airport that the airline flew to
27:06This was above and beyond what was normally required
27:09He was doing special studying so he could be prepared
27:11and be a better pilot
27:13Why would he not make those call-outs?
27:19What would cause him not to make those?
27:21So, what do we know about the captain?
27:24Captain Follett's was an experienced senior pilot
27:26But a deeper look reveals a man with a troubling record
27:30Soon after he joined the company, he failed his oral exam
27:39He failed two more proficiency exams in his career
27:42That's unusual for a professional pilot to fail that many times
27:46Are all these formal complaints against Captain Follett?
27:52Marvin was the first captain I flew with after my IOE
27:57My initial operating experience
27:59And he tended to be a little bit domineering
28:02And would berate you
28:03And was intolerant of mistakes
28:05And really not a particularly great instructor pilot
28:10Hmm, wow
28:12Perhaps the most disturbing complaint against Captain Follett's
28:18Is that he once struck a colleague in anger
28:20Is there a link between the captain's belligerence
28:27And the first officer's reticence?
28:32Hello?
28:34Investigators receive a phone call
28:35From a ramped service agent at Minneapolis Airport
28:38Okay
28:40Why isn't the exterior pre-flight done?
28:43I was...
28:44You didn't check the damn exterior lights
28:46The service agent witnessed Captain Follett's
28:49Berating First Officer Erickson over a pre-flight check
28:52Uh, I was gonna check the lights from inside the cockpit
28:55That's not how you do it
28:57You have to go outside and see it
28:59With your own stupid eyes
29:02Does Northwest even screen you guys anymore?
29:05You know what?
29:05Screw it
29:06I'll do it myself
29:07I mean, I...
29:08The captain was being very, very critical
29:12Of the first officer
29:14And the first officer was a relatively new pilot
29:17So, you know, you're gonna make mistakes
29:19So, there was a better way to handle it
29:21And the captain did not take the better way
29:23If we're late for departure
29:25It's on you!
29:29This happened immediately before the flight
29:31So it set the tone
29:32For the two of them working together
29:35Which was a bad way to do things
29:39Okay, thanks
29:40Let's get that CVR back in here
29:44We need to find out what was going on
29:46Between those two pilots
29:47Call company and tell them we need to fuel up
29:53In listening to the CVR
29:57The captain makes a lot of corrections
30:00Or directions to the first officer
30:02Of very simple things
30:04Uh, 719...
30:06Say Hibbing
30:07Hibbing, go ahead
30:08Uh, uh, Hibbing
30:11It was intimidating and not constructive
30:13Positive fuel? See you in a bit
30:15You can't just say ops
30:17You have to specify
30:18You're supposed to answer
30:19Hibbing, Sioux City, Duluth
30:21Before I was an airline pilot
30:24I was a flight instructor
30:25And one guaranteed way to have that guy shut down
30:28And not be able to perform
30:29Was to berate them
30:31Humiliate them
30:32Embarrass them
30:33He was paralyzed with fear
30:36That's why I didn't make his call-outs to the captain
30:40He was...
30:41He was terrified of him
30:43Investigators finally understand
30:46Why Northwest Air Link Flight 5719
30:48Ended in tragedy
30:50You have to go outside
30:51And see it
30:52With your own stupid eyes
30:54Well, this accident in many ways
30:56Has become a case study
30:57In just how valuable it is
30:59To empower either crew member
31:01To be assertive
31:02And to speak up
31:03When something isn't going right
31:05Even when the captain isn't a bully
31:18He can suffer from other flaws
31:21Hidden from view
31:22Hey, everybody seated?
31:23Yep
31:23Everybody's in
31:24Folks, this is your captain speaking
31:27We'll soon be landing in Durango
31:29And eventually those flaws can lead to tragedy
31:33We had so many examples of people
31:40Who could not or would not speak up
31:42But it all came down to the shoulders of the captain
31:44Trans-Colorado 2286
31:47You are cleared for takeoff
31:48Trans-Colorado is a small regional carrier
31:53That operates flights for Continental Airlines
31:552286, cleared for takeoff
31:58Thank you
31:59Captain Stephen Silver is in command
32:03Steve was a very happy
32:06Jovial, energetic pilot
32:09I enjoyed flying with Steve
32:11You're handling a fly in this leg, right?
32:14You bet
32:15First officer Ralph Harvey
32:18Will operate the controls for this flight
32:20Leaving the captain free to handle radio calls
32:23Takeoff power
32:26Airline pilots routinely trade the flying duties
32:31Part of it is for the reduction of fatigue
32:35So that one person's not doing all the work
32:37But it also divides the jobs up
32:40So that first officers that will be captains
32:43Are gaining experience
32:45100
32:47The captain keeps an eye on the airspeed
32:51As they accelerate for takeoff
32:52B1
32:54And rotate
32:56The cruise day began in Denver
33:09After two short hops to Riverton and Casper, Wyoming
33:13They circled back to Denver
33:15Now they're headed to Durango
33:18A route that takes them over the southern Rocky Mountains
33:22Control, we'll plan on a DME to runway 20
33:25That's approved
33:27Trans-Colorado 2286
33:29Cleared for runway 20 approach at Durango Airport
33:32Like many small airports in America
33:35Durango does not have its own air traffic control
33:39The controller is in Denver
33:41More than 200 miles away
33:43Once they cleared you for that approach
33:46They basically gave you the responsibility
33:49To get that airplane down on the ground
33:52Radar coverage terminated
33:55Please report landing by radio
33:56Have a good night
33:58Geared out
34:04Geared out
34:06Three green
34:09Do you have the runway?
34:20Something's wrong
34:21The pilots can't see the runway
34:23Damn, we're weren't too low
34:29Hold on
34:30No, no, no, no, no
34:32Hold on
34:33There was this just big boom
34:41I thought we just had a rough landing
34:44And the plane began to do a flip
34:49That's when I thought it's happening
34:52We're crashing
34:52They usually say, stay where you are
35:04Someone will come and get you
35:05But we were out in the middle of nowhere
35:08We didn't know if anybody knew anything
35:10It was a remote area
35:15And so it made it difficult
35:17For the emergency responders to get there
35:19It took us a long time to figure out exactly where the crash was
35:24Of the 17 people on board
35:27The crash has killed nine
35:29Including both pilots
35:31Tom Houter of the National Transportation Safety Board
35:39Now faces a huge task
35:41Yeah, left wingtip right here
35:43Yeah, thanks guys
35:45We were having a hard time understanding
35:50How the crew impacted so far short of the airport
35:53That was going to be the big mystery here to try to understand
35:56Investigators wonder whether the approach into the airport
36:01Was too risky for the conditions that night
36:04The air traffic recording reveals that the controller gave the crew two options
36:09The first was to fly an easy path around the airport
36:14To a runway equipped with an instrument landing system
36:17Or ILS
36:18That guides the pilots down
36:20In the second, more challenging option
36:25Pilots must descend in steep steps
36:28To avoid mountains north of Durango
36:30Uh, we'll plan on using the 2-0, thank you
36:37We have hills here
36:43Here
36:44And here
36:46Why didn't they take the easy way down?
36:51It's the crew's fourth flight of the day
36:53And they're running late
36:54Captain Silver decides to fly the steeper, more difficult approach
36:58Listen, when we get to Durango
37:00I'd like to get in the air again as quickly as possible
37:02Shouldn't be a problem
37:03We won't need to refuel
37:05Let's see what else we can do to get these folks back on time
37:08Estimates show that the straight-in approach to runway 2-0
37:12Saves about ten minutes of flight time
37:15To me, it seems almost instinctive
37:17That he thought this is his way to catch up
37:20And get in faster
37:21Folks, this is your captain speaking
37:24We'll soon be landing in Durango
37:25The information explains why Captain Silver chose such a challenging approach on a snowy night
37:32But it doesn't explain the crash
37:34Tricky approach
37:36Lots of pilots say they did it all the time
37:40Investigators compare the flight path pilots are supposed to follow for runway 2-0
37:46To the actual descent of flight 2286
37:48It's quite clear that the crew descended below the published approach
37:54Why exactly, we don't know
37:56In Denver, Malcolm Brenner digs into the qualifications of the two pilots on Trans-Colorado flight 2286
38:04The file of First Officer Ralph Harvey, the pilot who was flying, is cause for real concern
38:10Tested for captain
38:14Failed
38:15Proficiency test, failed
38:18Instrument flying
38:21Below average
38:22Brenner might 2-0, sounds good
38:27Nothing we can't handle
38:29Brenner suspects that flying the challenging approach to Durango
38:33In limited visibility was more than the first officer could manage
38:36I think as long as the weather is good, he would probably be a very adequate pilot
38:42His trouble is when things start to happen very fast, it seems like
38:46For some reason, the captain didn't take over and save the plane
38:50I need to know why
38:51If the first officer wasn't up to the job
38:54Then why didn't Captain Silver step in and take over?
38:58Damn!
38:59Pull down!
38:59The captain and the first officer's performance on Trans-Colorado flight 2286 baffles investigators
39:09They contact friends and family, trying to piece together what the pilots were doing in the hours leading up to their last flight
39:17They're looking for any sign of stress or fatigue
39:22But as far as anyone can tell, Captain Silver spent a quiet evening with his family
39:28Then went home to sleep
39:30What a day
39:32What are we missing here?
39:36The case seems to have hit a dead end
39:38Hello?
39:40Until a phone call changes everything
39:43What?
39:46What a day
39:47Investigators learn that on the eve of the crash, Captain Silver may not have spent a quiet night alone after all
39:55Time to have a bit of fun
39:57Now you're speaking my language
39:59They hear a story about drug use and a woman who is alleged to have made a stunning admission
40:05I'm sure glad to be buried in right after the accident
40:12The night before, we'd done a bag of cocaine
40:15We did a bag of cocaine
40:18Would you like to go first?
40:25Yeah
40:25The best way I could describe the investigators was astounded
40:33Call the lab
40:34Technicians conduct toxicology tests on samples from the deceased captain of flight 2286
40:41The results leave no room for doubt
40:47He wasn't asleep
40:52He was up
40:53Using cocaine
40:55He was in withdrawal by the time of the accident
40:57I always thought
40:59Pilots were squeaky clean
41:01I mean, they are
41:02Carrying people's lives
41:04They have people's lives in their hands
41:06A captain suffering withdrawal is also under the gun to get back on schedule
41:15Listen, when we get to Durango, I'd like to get in the air again as quickly as possible
41:20Because of his actions, his deliberate actions, he presented himself for duty, not qualified
41:28And that goes against everything that professional pilots are taught
41:33What a horrible decision
41:37In withdrawal, he's not half the pilot he is when he's alert
41:43Trans-Colorado 2286 for your approach to Durango
41:48Would you rather shoot the ILS or will the approach to runway 20 be sufficient?
41:53Control, we'll plan on a DME to runway 20
41:56Already behind schedule
41:58The captain's habit of rushing leads him to choose a challenging approach
42:02When an easier option is available
42:03The struggling first officer is soon overwhelmed
42:08But the captain doesn't notice
42:10Do you have the runway?
42:15Until it's far too late
42:17Damn, we're too low!
42:20Pull that!
42:23No, no, no, no, no!
42:26Once they lost track of their altitude
42:34They didn't have a chance
42:36The NTSB's final report cites the first officer's poor flying
42:41And the captain's use of cocaine as contributing causes to the Trans-Colorado crash
42:46The FAA soon implements important changes
42:52Including more frequent drug testing for pilots
42:55To my knowledge, there has not been any other case of drugs involved in an airline accident
43:01Ego
43:04You ungrateful bastard!
43:07Intimidation
43:08That's not how you do it
43:09You have to go outside and see it with your own stupid eyes!
43:13Dereliction of duty
43:15Time to have a bit of fun
43:16These are the human flaws that have brought down airplanes and taken lives
43:22These tragedies have instigated a revolution in the relationship between the captain and the flight crew
43:28The godlike figure is gone and now the plane is flown by a true team
43:34It's all because we finally understood us
43:37Our failure modes as humans
43:40What we can do correctly 100% of the time and what we can't
43:44And how to use teamwork, even just a team of two
43:47To reduce by just an incredible amount the potential for human error metastasizing into an accident
43:54LISTEN
43:58wish
43:59It's all these kinds of things
44:00before you leave
44:01Trust your self
44:02You
44:02Don't
44:03You
44:04Don't
44:06Don't
44:06You
44:07Don't
44:09Don't
44:11You
44:13Don't
44:15And
44:19Don't
44:20Don't
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