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Air Crash Investigation Series S24E03 Deadly Departure
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TVTranscript
00:00The pilots of Air Transport International Flight 782 prepare to depart from Kansas City with just three of their four working engines.
00:11A three-engine ferry. It's a difficult maneuver.
00:14A hundred knots.
00:16Okay.
00:17Their takeoff goes tragically wrong.
00:20We're off the runway.
00:21Go max power.
00:23You got it!
00:24This accident, of course, was very tragic, and they did not make it.
00:31Examination of the wreckage reveals very little.
00:34Stem to stern, wingtip to wingtip was airworthy.
00:37But when investigators visit the simulator used to train the pilots...
00:41This is not how their aircraft would have behaved.
00:44...they begin to understand the origins of this accident.
00:47The simulators are extremely accurate.
00:50We were shocked that this one was not.
00:53M.D., M.D., M.D.
00:55Oh, up.
01:01I need one .
01:03I need one .
01:04I need a .
01:10I need zero .
01:11Okay, first things first. Let's review our three-engine ferry procedure.
01:25Sure thing.
01:26Yep.
01:29Air Transport International Flight 782 has been cancelled. One of its four engines won't start.
01:37Maintain directional control using rudder and nose wheel steering.
01:43The replacement crew is taking the cargo plane for repairs to a maintenance facility in Massachusetts.
01:50The only crews that are permitted to do a three-engine ferry are the very experienced crews because it is very dangerous. It does not happen very often.
01:58Captain Walter Meager has worked his way up from flying the DC-6 and DC-7 and is now captain on the airline's DC-8 aircraft.
02:09The captain had about 4,000 hours in the DC-8. He'd been flying the DC-8 for years.
02:19Max Winford takeoff, crosswinds 10 knots, tailwinds 5 knots.
02:23Okay, let's check the weather on that.
02:26First officer Mark Alma is new to the company and the plane, but he's been flying for 14 years.
02:32He only had about 200 hours in the DC-8. However, he was commended for being enthusiastic, for trying to learn, and being an important part of the crew.
02:44There's a third crew member on board, flight engineer Kerry Hardy.
02:50Flight engineer had more than 4,000 hours of flight time and in large airplanes. He was a very experienced pilot.
02:58It's a two-hour flight from Kansas City to Chicopee, Massachusetts, where the engine is to be repaired.
03:07Here you go.
03:10The crew has concerns about their schedule.
03:17There is a curfew on the airport in Massachusetts.
03:20The airline had told the crew that they needed to land by 11 p.m. because that is when that airport would close.
03:28What we're going to need to do is get as much direct as we can.
03:33That'll allow us to fly a little bit better than the 280 knots indicated.
03:38Well, as pilots, we're always trying to hurry.
03:41The crew had decided that they wanted to fly a more direct route at a faster speed.
03:47So we'll be using 1-9 right.
03:49First officer Alma wants the longest runway for their takeoff.
03:54I'm going to request right because we'll get an extra 1,300 feet.
03:56I'm going to get an extra 1,300 feet.
03:57Okay.
04:00In order to take off, the DC-8 needs power from at least three of its four engines.
04:08You always want the longest runway that you can get with a takeoff like this so that you have more room to get the airplane up to the proper speeds.
04:17Kansas City, this is Air Transport 782, ready to taxi.
04:23We're going to be a three-engine departure.
04:24Flight 782 checks with air traffic control about their runway assignment.
04:33Air Transport 782, south on Bravo, taxi runway one left.
04:37Okay, south on Bravo, taxi one left.
04:42Air Transport 782.
04:44What's the winds?
04:45Winds 2-4-0 at 4.
04:48Roger.
04:49That's a tailwind, right?
04:50Yep.
04:52You don't want a tailwind with a three-engine takeoff because it's going to take more runway.
04:582-4-0 and we're running into what?
05:004.
05:024 knots.
05:06The tailwind was acceptable.
05:07The maximum tailwind allowed was 5 knots and they had 4 knots.
05:12Flight 782 taxis to the longer runway.
05:17Takeoff data?
05:18Okay, this is a max power takeoff.
05:23The pilots review the required speeds for the three-engine takeoff.
05:27Okay, I got VMCG of 107, 123 for VR, 140 for V2 and 210 for the cleanup.
05:35Set.
05:35This takeoff requires raising both inboard engines, engine 2 and engine 3, to max power.
05:44Only when the plane reaches a certain speed can the third working engine, engine 4, be increased to max power.
05:51Controlling the airplane on the runway while you are adding the power from the third engine is vital.
05:57It must be done slowly and you must be able to keep control of the airplane at all times.
06:02And of course, we'll all be watching real close for loss of directional control.
06:10Two engines on the right side are going to cause the aircraft to veer to the left.
06:16It's only going to have one engine operating on the left side.
06:19So, directional control is the critical issue on a three-engine takeoff like this.
06:27Number one engine is inoperative.
06:29So, what we're going to do is set max power on number two and number three.
06:33Right.
06:33Right.
06:34As the crew nears the end of the taxi, they finalize the takeoff plan.
06:39Okay, then I'll ease in number four.
06:42And I'll call increments of point one.
06:43Yeah.
06:43Flight 782 is now ready for takeoff.
06:57Okay, coming up on two and three.
07:02The crew lets the inboard engine spool up before the plane starts moving.
07:08Set max power.
07:10Max power two and three.
07:13At 8.20 p.m., Air Transport International Flight 782 begins its takeoff.
07:271.3.
07:291.4.
07:30The flight engineer closely monitors engine power.
07:33Airspeed's alive.
07:341.6.
07:3580 knots.
07:3690 knots.
07:40But 20 seconds into the takeoff roll, the plane veers left of the center line.
07:461.8.
07:48100 knots.
07:50The captain uses his rudder to redirect the plane to the center of the runway.
07:55But it doesn't work.
07:58Abort.
07:59Spoilers.
08:06Air Transport 782 aborting takeoff.
08:10Flight 782 aborts its three-engine takeoff.
08:15Air Transport 782, roger.
08:18When able, turn right off the runway.
08:21Do you need any assistance?
08:23Negative assistance?
08:23No, negative.
08:25Negative assistance, Air Transport 782.
08:26The crew considers what went wrong.
08:34We were at 1.6, and then power went all the way up to 1.90 as you ran it up.
08:39So it went up real fast.
08:40And number four jerked up while I was trying to ease it in.
08:44You brought it up too fast, or it jerked up, or what?
08:47The power on it just came on too fast.
08:50That's what happened.
08:51Hardy proposes a solution.
08:59If you want to try it again, I could try adding the power if you like.
09:04Okay.
09:04Let's do it that way.
09:06It was decided that the flight engineer would help the captain,
09:10and he would add the power on the third engine for the second takeoff.
09:15Tell him we want to taxi back, and have another try at it.
09:19Kansas City Ground, Air Transport 782.
09:22We'd like to taxi back to depart one left again.
09:26Air Transport 782, roger.
09:28Taxi one left.
09:31Okay.
09:35While returning to the runway, the crew revisits the takeoff procedure.
09:39Okay, when do I have to have max power in on the outboard engine?
09:46107.
09:54Flight 782 is again ready for takeoff.
10:00Kansas City Control, Air Transport 782, ready to go at the end of one left.
10:04Three engine takeoff.
10:06Air Transport 782, heavy, control one left.
10:11Turn right, zero, three, zero.
10:13Clear for takeoff.
10:17I've lined up just to the right of the center line here.
10:20That's a good idea.
10:23The captain did line up on the right side of the runway
10:26because they veered off to the left on the first takeoff,
10:30and he wanted to give himself more runway width available
10:33in order to do the second takeoff.
10:36Okay, make sure the two and three are set.
10:39Max power?
10:40Yeah.
10:42At 8.26 in the evening,
10:44Flight 782 begins its second takeoff attempt.
10:47One, one, two, one, three, one, four,
10:59one, five, one, six.
11:05Air speed's alive.
11:14Ten seconds into the takeoff roll,
11:16the plane again starts veering to the left.
11:19One, seven.
11:22The captain tries to direct it back to the center line with the rudder.
11:30God bless you.
11:31Keep it going.
11:37Keep it going?
11:37Yeah.
11:4080 knots.
11:4290 knots.
11:43Okay.
11:43The captain attempts to get airborne.
11:52We're off the runway.
11:54But he doesn't have the speed.
11:56Go max power.
11:57He tries to salvage the takeoff.
12:03Flight 782 is barely in the air.
12:07Get the nose down!
12:09Go max power.
12:10You got it!
12:12Max power!
12:13Max power!
12:13Alert 3, runway 01, North End.
12:32DC 8 on takeoff.
12:36Air Transport International Flight 782 has crashed beside the runway at Kansas City Airport.
12:43Fire and rescue units are nearby on a night training exercise.
12:49They rush to the crash site.
12:52We heard a real loud boom like something hit the dock real hard.
12:55Take long for fire rescue crews to arrive on the scene, I'm assuming.
12:57No, no, just in a matter of 60 seconds.
13:02All three crew members are dead.
13:07The National Transportation Safety Board, or NTSB, is notified.
13:11And Bob Benzon is named lead investigator.
13:15The aircraft had broken apart, although it was in three large pieces.
13:19A fuselage behind the wings seemed to be reasonably intact.
13:23The wing assembly itself seemed to be in one piece.
13:26The question Benzon must answer, why was the crew unable to execute this takeoff, not once, but twice?
13:35We were aware that it was an attempted three-engine takeoff.
13:41And because that is an unusual maneuver, we wondered if that could have been part of the reason the aircraft crashed.
13:48Thanks for taking the time to meet.
13:51While the plane wreckage is collected, investigators speak to the controller to learn more about the crash.
13:57When did you realize there was an issue with Flight 782?
14:03I guess the first thing that caught my attention was that they aborted their first takeoff.
14:08Why?
14:09I was told the plane veered left on the runway.
14:13And then?
14:15They lined up for their next takeoff, and the same thing happened, only worse.
14:20The plane veered left, and this time they rotated awkwardly, nose high.
14:25There was a fire coming out of one of the engines, and then there was a loud bang.
14:35Then the plane stalled, rolled left, and crashed.
14:49A fire, what side?
14:51Left.
14:52That had to be engine number two.
15:01Plane engines are numbered from left to right.
15:04For Flight 782, the number one engine was inoperative.
15:09If engine two failed, the crew would be left with only the right engines.
15:14We knew because this was a three-engine takeoff attempt, and if we'd lost any more power on the left side of the aircraft, it may have caused an immediate crash.
15:24What have you got?
15:30Investigators examine engine number two after its recovery from the crash site.
15:34They discover that it was operative, and it didn't fail on takeoff.
15:50The compressor surge is a phenomenon that occurs when the tilt of the engine is high enough that it disturbs the airflow going into the intake and causes a big bang, flames coming out both ends, perhaps.
16:12But technically, the engine isn't damaged at all.
16:20No unusual wear.
16:22If all three remaining engines were working, could one of the brakes have locked, causing the plane to veer left?
16:31The treads look almost new.
16:33No flat spots.
16:35The tires show no sign of abnormal braking.
16:38We thought that because they had aborted the earlier takeoff, maybe they used the brakes very heavily and caused them to fail, frankly, or weaken, and then fail completely during the second takeoff.
17:00Brake sack assembly looks fine.
17:11No discoloration or pitting on the pads.
17:15Discs are clean.
17:16No signs of overheating.
17:21We looked at brakes very carefully.
17:23We found nothing really physically wrong.
17:26There was no overheating or melting together.
17:29So, in essence, the brake system did not become an issue.
17:34The NTSB is still unable to determine why the crew lost control.
17:40Let's check out the rudder.
17:43The rudder plays a massive role in a three-engine takeoff.
17:48It is the key to keeping the airplane going straight and being safe.
17:51Three-engine takeoffs require the two inboard engines to reach VMCG, or minimum control speed on the ground.
18:01Only then can the rudder counteract the directional force of the third working engine as it's powered up.
18:07The faster you are going, the more rudder control you have, and you need that rudder control to be able to keep the airplane on the runway.
18:19How does the rudder control cable look?
18:27Did the rudder malfunction, causing the crew to lose control of the plane?
18:32Cable severed in several different places, see?
18:35There's no corrosion or fraying.
18:38Probably severed in the crash.
18:40Agreed.
18:42Let's test the rudder.
18:45We looked very carefully at the cabling that we used in the rudder system,
18:49and the only thing we did note were simple breaks in the cables because of overload, instant overload, which occurred during the crash.
18:59Control cable ready?
19:01Good to go.
19:02If the rudder cables didn't fail, then could the rudder itself have malfunctioned?
19:09Okay, deflect left.
19:12Investigators test its movement.
19:15Turning to the left.
19:19But the rudder moves freely.
19:22We're good.
19:24On occasion, in previous accidents, rudders have locked up or become blocked by some broken part.
19:32And we found that this did not occur during this event.
19:37The mystery of Flight 782's crash deepens.
19:44In the end, we looked at the entire wreckage very, very carefully, from stem to stern, wingtip to wingtip,
19:51and determined that it was airworthy.
19:55We had to look into other areas to determine what happened.
19:58Okay, we found skid marks on the runway for the first take-off, starting here, all the way to here.
20:11Then they aborted.
20:13Investigators now turned to evidence left behind by Flight 782 to determine why it veered off the runway.
20:20In the second take-off, the skid starts even earlier, here.
20:25And the marks last till here.
20:33Skid marks were there, indicating that although the aircraft was rolling forward,
20:38it was skidding to the left side of the runway.
20:40The skid marks are a tell-tale sign.
20:45It looks like they had too much power to the right side of the plane.
20:48And it happened early on.
20:50Look, on both take-offs, they skidded to the left after only 500 feet.
20:57Correct.
21:01So maybe there was an issue with the power in that third-looking engine.
21:05Let's find out.
21:06We discovered that the engine operation would probably be some kind of an issue.
21:11And the only way we could determine that was to go to the flight data recorder.
21:17Did engine number four somehow cause the plane to veer too far to the left?
21:25There's the airspeed data there.
21:28Investigators examined the flight data recorder to learn how the crew managed their engines.
21:34Looks like we have a glitch here.
21:36To learn more about how the crew manipulated the throttles,
21:41we needed two parameters from the FDR.
21:43Airspeed and the engine pressure ratio, or the EPR.
21:48We had airspeed, but unfortunately this FDR did not record correctly the EPR.
21:55We need a workaround to get that engine data.
21:59What about a sound spectrum analysis?
22:03Sure, let's give it a shot.
22:04Okay, coming up on two and three.
22:14There's a microphone in the cockpit that records every sound.
22:21And they can record and hear the engines as they are increased or decreased.
22:26And they're very accurate.
22:38The team conducts a digital analysis of the engine's sounds.
22:44Done.
22:45Great work.
22:46Let's compare the third working engine, engine four, with the plane's overall airspeed data.
22:56In the end, we use both the FDR and the CVR to determine the airspeed throughout the entire flight
23:02and the power setting for all three of the operating engines.
23:07It looks like the third working engine, engine number four, almost reaches max power in ten seconds,
23:21when the airspeed is only about 65 knots.
23:23That seems awfully slow.
23:30Was the power to engine four increased too soon in the takeoff roll?
23:36Let's check the three-engine takeoff chart.
23:40Investigators examined the chart used by the crew to determine the speed they needed to reach
23:45before applying max power to engine number four.
23:50What was their weight?
23:52Their weight was 220,000 pounds.
23:55Temperature is zero degrees.
24:00They shouldn't have put the third working engine to max power until they reached 116 knots.
24:05That's the target speed.
24:08At 65 knots, it was way too much power too soon.
24:11One, three, one, four, one, five, one, six.
24:20Airspeed's alive.
24:22One, seven.
24:24Investigators conclude engine four was powered up too fast, pushing the plane to the left.
24:35They never reached the speed they needed for the rudder to counteract the power of both engines
24:39on the right side of the plane.
24:41That's why they veered off the runway.
24:47Why did the pilots increase power to the right outboard engines so quickly?
24:55We knew that the issue here was reaching VMCG at exactly the right time with the correct airspeed
25:02and everything.
25:03But the crew didn't do that, and that became the big question.
25:06Why?
25:06Why didn't they do that?
25:08Whenever you're ready.
25:16Benzen's team listens to the cockpit voice recorder, or CVR, to better understand how the
25:22pilots of Flight 782 perform the three-engine procedure.
25:26Okay, this is a max power takeoff, speeds.
25:30VR 123, 140, and 210.
25:34VMCG of 107.
25:36Okay, I got VMCG of 107, VR of 123, 140 for V2, and 210 on the cleanup.
25:47Both pilots think the VMCG is 107 knots.
25:54It should be 116.
25:55Yep.
25:56VMCG is 116 knots.
25:58So how did the flight engineer get that wrong?
26:07Wait a minute.
26:08Check this out.
26:09107 is the speed for a temperature of 30 degrees Celsius.
26:20Investigators discover the flight engineer used the speed for a temperature of 30 degrees Celsius.
26:26But on the night of the crash, it was 30 degrees Fahrenheit, approximately zero degrees Celsius.
26:36That C for Celsius is so small.
26:39He must have used 30 Celsius, thinking the chart is in Fahrenheit.
26:43They selected the wrong line to get their V speeds.
26:56Here you go.
26:57Thanks.
26:58They were nine knots off on what VMCG should have been.
27:07It's happened before, four years earlier.
27:13A flight engineer on another Air Transport DC-8 miscalculated the plane's weight, providing
27:19the captain with the wrong takeoff speeds.
27:21I was one of the first investigators from the NTSB to arrive on scene.
27:27And when I went into the cockpit, it didn't take any smarts at all to see the takeoff data
27:33was 100,000 pounds too low.
27:37And as a result, the company very seriously began to emphasize the need to check those calculations
27:44and make sure they're accurate.
27:45And so it's disturbing that in this accident, that did not happen.
27:49Is that the only thing the pilots missed?
27:53A question I consider, Captain.
28:06Once we get near VMCG, if we've used all the rudder control, you might want to consider abort.
28:10Because when we get higher, we're going to be in worse trouble, correct?
28:13Well, that's correct, absolutely.
28:20The CVR of Flight 782 reveals that the captain and first officer were uncertain about the impact
28:27of VMCG speed on rudder control.
28:31The first officer made the comment that you have, rudder control is less effective once
28:37you go beyond VMCG, when actually the opposite is true.
28:45Uh, no, actually.
28:47The flight engineer realizes their mistake.
28:50Above VMCG, rudder has more authority.
28:53It's helping you more.
28:55I understand.
28:57But the captain fails to acknowledge the correction.
29:01The flight engineer had the right answer, that the faster the airplane goes, the more
29:05effective the rudder becomes.
29:07And you need that effectiveness to keep the airplane on the runway.
29:14Why didn't the crew stop and discuss it until they reached a consensus?
29:18That's the advantage of having three people in the cockpit.
29:23The right answer generally exists somewhere in the cockpit.
29:26In this instance, the flight engineer had the right answer.
29:30Maybe their lack of understanding about the procedure caused them to abort their first
29:33take-off.
29:35It's possible.
29:40Here it is.
29:43Check that out.
29:48Power went all the way up to 190 as you ran it up.
29:51So it went up real fast.
29:53And number four jerked up while I was trying to ease it in.
29:57You brought it up too fast?
30:00Investigators learned that the captain struggled with engine four's thrust during the first take-off
30:05roll.
30:06Power on, it just came on too fast.
30:09It's what happened.
30:13If you want to try it again, I can try adding the power if you like.
30:16The flight engineer proposes an unorthodox change to the procedure.
30:21Okay.
30:22Let's do it that way.
30:26The flight engineer took over control of engine four.
30:29That's crazy.
30:31They couldn't have understood the difficulty of the procedure if they split the responsibility.
30:37The core problem is the captain could not tell how much rudder he was going to need because
30:42he wasn't the one adding the thrust to the airplane.
30:46It's like trying to have two people drive a stick shift car.
30:50One doing the steering, one doing the shifting.
30:53It just doesn't work.
30:54You need to have one person in control at one time.
30:59The flight engineer and the captain thought they could coordinate the take-off together.
31:07Let's figure out how they did.
31:11We worked with the Douglas Aircraft Company and they produced a graph of what an ideal
31:16three-engine take-off should look like with airspeed and engine speed.
31:22We compared that with what actually happened.
31:25So this is what the crew was supposed to fly.
31:28It seems like the power and speed rise steadily in unison until they reach VMCG.
31:33Very, very smooth and synchronized.
31:37But in the accident flight, the flight engineer brings up power to the engine number four really
31:43quickly.
31:47The plane begins to veer left off the runway.
31:50Then he brings down the power abruptly here, probably in reaction to the plane being out of control.
32:00Most probable thing we think happened was that the flight engineer saw the aircraft going off to the left of the runway and kind of panicked and tried to pull the engines back a little bit.
32:10God bless you.
32:17Keep it going.
32:18Keep it going?
32:19Yeah.
32:20Instead of aborting, the captain attempts to get airborne because they're about to veer off the runway.
32:25He was countermanded by the captain who said, no, no, keep going.
32:30So the engines went back up.
32:31We're off the runway.
32:32Go max power.
32:38Then the captain insists that he goes to max power a few seconds later.
32:42They don't have enough speed for takeoff.
32:45The captain never decided to abort, and it appeared to be that he thought he could get the airplane in the air.
32:52We will never know.
32:57The captain and the flight engineer can never coordinate their actions.
33:03One, two, one, three.
33:10Why did the crew fail to execute a takeoff procedure that they were specifically sent to Kansas City to perform?
33:20You got it!
33:29Find anything?
33:30Investigators review the work history of Flight 782's crew to determine their experience with three-engine takeoffs.
33:39Our flight engineer and our first officer were new hires.
33:43They were still on probation.
33:45It's almost certain that neither had performed a three-engine takeoff.
33:49And the captain?
33:56He'd done it three times, but only his first officer.
33:59He'd never actually flown as a captain.
34:04They were all greed.
34:06The closest the captain came to flying this type of takeoff was in a simulator.
34:12He only trained on it twice.
34:19Investigators traveled to Colorado to assess the simulator the airline used to train its pilots to perform three-engine takeoffs.
34:26Okay.
34:29This is a three-engine takeoff and we're watching for directional control.
34:36Did the pilots have sufficient training to perform this difficult procedure?
34:40I'll call it engine power until you get to max.
34:44Part of the examination was to see if the simulator accurately portrayed what a three-engine takeoff should entail.
34:50Okay.
34:51Let me give this a try.
34:53Engines two and three are spooled up.
34:58Engine four is set.
35:00Here we go.
35:04Slowly bringing up four.
35:05One five.
35:06One six.
35:07One seven.
35:08I am barely using my rudder.
35:09There is no force pushing me off the runway.
35:10One eight.
35:11We have VMCG.
35:12Max powered engine four.
35:13And rotate.
35:14In the simulator, the three-engine takeoff is no different from a regular takeoff.
35:27Okay.
35:28Cut.
35:29The simulator was not calibrated properly and then did not require the normal amount of rudder that would be required with a three-engine takeoff.
35:42This is not how their aircraft would have behaved.
35:43Not a chance.
35:44Simulators are for the most part extremely accurate.
35:45And in this particular case, we were frankly shocked that this one was not.
35:50It also happened to be the one that had to be the one that had to be one of the two-engine takeoff to be one of the two-engine.
35:54This is not how their aircraft would have behaved.
35:58Not a chance.
36:02Simulators are, for the most part, extremely accurate.
36:05And in this particular case, we were frankly shocked that this one was not.
36:11It also happened to be the one the crew trained on.
36:15And this would really give them, I think, a false sense of security when it came to the difficulty of making a three-engine takeoff.
36:23I'm calling from the NTSB.
36:26How did Air Transport International, or ATI, compare to other cargo operators on three-engine takeoffs?
36:34I'd like to talk to your chief pilot.
36:38We checked with the other cargo operators who were operating the DC-8. There were nine of them.
36:44So only your most qualified pilots do it, huh?
36:46The vast majority of them used their most experienced crews and limited the operation to daytime and good weather.
36:58Now, this led us to believe that the industry as a whole understood the danger and the difficulty of a three-engine takeoff better than ATI did.
37:08Why did the airline choose such an inexperienced crew for such a difficult flight?
37:14I think it's time we asked them that.
37:18Our team went to Little Rock, which is the headquarters of the ATI operation, and we met with all of the key people there.
37:26Thanks for meeting with me.
37:30So I've been told that you didn't use your most experienced crew. Why not?
37:35I needed my experienced crew for a revenue flight.
37:39The Flight 782 crew is only legal for a non-revenue flight.
37:44How so?
37:46They'd only had enough rest for a non-revenue flight.
37:49You don't say.
37:50They discover that the crew was selected because of a critical regulation governing non-revenue flights and rest times.
38:00Normal flights where the company makes revenue are covered by flight and duty time regulations.
38:06For safety reasons, they have to provide a crew that has been properly rested.
38:10But there is a loophole that if the flight is not revenue, then there are no flight and duty time regulations.
38:20In theory, a crew could fly in non-revenue flights indefinitely.
38:26Abort.
38:29Investigators now wonder how rested the crew was when Flight 782 prepared for takeoff.
38:39So, take us through this.
38:44Investigators closely examine the crew of Flight 782's recent flight assignments.
38:49Okay, the morning before the accident, our crew lands in Germany after a seven-hour flight.
38:57From Delaware.
39:01And how many time zones did they cross?
39:05Six.
39:07Later that same day, they return, landing first in Gander, Newfoundland.
39:12And another flight to Delaware.
39:19So, they cross another six time zones heading back.
39:24We were aware that the circadian rhythm had to be pretty much out of sync.
39:31It's simply not a good thing.
39:32Fatigue is not easy to recognize, but it degrades all aspects of thinking, decision-making, and performance.
39:44They got into their hotel in Delaware at 2.40 a.m. on the day of the crash.
39:51How much uninterrupted rest did the captain get?
39:56Less than five hours.
39:58So, they didn't have enough rest to fly anything except this flight.
40:01And they were sent, despite lacking the training and experience they needed.
40:14The NTSB concludes its investigation, outlining the fateful steps that caused the crash of Flight 782.
40:22It begins with the poorly rested crew.
40:24One of the consistent findings of fatigue research is that people tend to underestimate how tired they are.
40:34Much of the time, you can conduct a safe flight doing that.
40:39But if something unexpected happens, you're at a real disadvantage.
40:44In this case, the takeoff procedure was much more complicated than the crew had been trained to expect.
40:52Here you go.
40:53Thanks.
40:55The flight engineer makes an error in a calculation that the other pilots don't catch.
41:01Once we get near VMCG, if we've used all the rudder control, you might want to consider abort.
41:06Because when we get higher, we're going to be in worse trouble, correct?
41:09That's correct. Absolutely.
41:12The pilots are confused about the takeoff procedure.
41:16No, actually.
41:18Above VMCG, your rudder has more authority.
41:21It's helping you more.
41:22This was a very delicate procedure, and they seemed to think otherwise.
41:28If you want to try it again, I can try adding the power if you like.
41:32Okay, let's do it that way.
41:35A decision to improvise a difficult takeoff leads to the plane veering out of control.
41:42It was a very bad decision to improvise on this procedure because only the person operating
41:49the rudder can tell how effective that is when advancing the throttle.
41:53The captain decides not to abort a second time.
42:02The plane lacks enough speed to safely get airborne.
42:06It's hard to say what was going through his mind, but I think he believed he could get the aircraft airborne.
42:23In their report, the NTSB makes several key recommendations.
42:29One is to revise the training procedures for three-engine takeoffs.
42:34The crew not only was not trained well, it was inexperienced in the particular maneuver they were talking about, and they were tired.
42:43Closing the loopholes that allow flight crews to perform non-revenue flights without adequate rest is another recommendation.
42:53The reason this is relevant is because the company elected to have this tired crew fly the three-engine ferry,
43:02rather than the rested crew that was already present in Kansas City.
43:06It was legal, but it was not a good idea.
43:10The NTSB also recommends that three-engine ferry flights be assigned to specially designated experienced crews.
43:20Training instructors advised pilots of the simulator's shortcomings for three-engine takeoffs.
43:26The company exceeded the board's requests.
43:29They really took it very seriously and did change their whole procedure to prevent this.
43:35The airline industry as a whole does not follow suit.
43:38Non-revenue flights remain exempt from flight and duty time regulations.
43:44There should be no difference with safety whether there are people on the airplane, freight on the airplane, or the airplane is empty.
43:51One rest rule requirement should apply to everybody, every time, everywhere.
43:56One rest rule requirement should apply to everybody, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time, every time
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