- 2 days ago
Air Crash Investigation Series S24E02 Disaster at Dutch Harbor
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00:01While landing at Dutch Harbor, Alaska.
00:05Hang on, I'm sliding.
00:07The pilots of Penn Air Flight 3296 run out of runway.
00:12All I could see is water.
00:14Everyone race!
00:17We're gonna go in.
00:24Not everyone makes it out alive.
00:27You never want to lose a passenger. For any reason.
00:30You're pretty beat up.
00:32NTSB investigators must piece together the evidence.
00:35We've got a dark 170 foot long skid mark.
00:39So the tire blew.
00:41We needed to do a deeper dive.
00:43They soon discover a critical oversight.
00:46There's no numbering on these wires.
00:48That was really the aha moment.
00:57Point is on the left.
01:00What is the target?
01:03107 yards.
01:04I've checked my size.
01:05We have to show you that.
01:061010бу.
01:071010.
01:08910.
01:091010.
01:101010.
01:111210.
01:121010.
01:151010.
01:161010.
01:171110.
01:181010.
01:191110.
01:201010.
01:211210.
01:2210010.
01:231010.
01:241010.
01:25islands. We should be getting directions here to descend soon. I'm going to see if I can't
01:32get the weather. Yeah, it's changed. Well, it's been updated. It's 310 at 11 knots.
01:4056-year-old captain Paul Wells is a new hire to Penn Air, but has 25 years of experience
01:47with other airlines. Okay. Paul is an amazing guy. I flew with him several times. He was
01:56a true decision maker as a captain. Peninsula 3296, descend pilot's discretion. Maintain
02:03flight level 290. Pilot's discretion 290, Peninsula 3296. 39-year-old first officer
02:13Justin Lunn, has been with Penn Air for five months. I couldn't have been with a better
02:19co-pilot. He was a very thorough individual, ex-military. There are 39 passengers on today's
02:26flight, including a high school swim team and their chaperones. Commercial pilot Steve Rainey
02:33is escorting his son, Jacob. We were on the flight to go to a swim meet. We'd worked really
02:41hard raising the money for the trip. It was a big deal. It's a two-hour flight from Anchorage
02:48to Unalaska Airport, also known as Dutch Harbor. The journey crosses some of the most rugged
02:55and isolated terrain in the world. The flight is over a spectacular part of Alaska. The entire
03:03Alaska Peninsula is in view. It's a great view. You can go grab a window seat further back.
03:12My son did move to a couple rows back so that he could get that view too. The pilots are flying
03:21a Swedish-made Saab 2000. Saab 2000 is a twin-engine turbojet aircraft. It seats approximately 50
03:31people. It's a good aircraft for reaching remote communities in Alaska. Dutch Ops 3296.
03:4030 minutes before landing, the first officer contacts the weather observer at Unalaska Airport
03:46for the latest conditions. Hello 3296. Right now winds 210 at 6 knots, gusting to 14. Temperature
03:568, dew point 1. Altimeter 29050. All right. Copy the weather. The airport at Dutch Harbor has
04:06a short runway, vulnerable to severe and unpredictable weather. Pilots need special training to land
04:13here. The terrain around the area in Dutch Harbor is mountainous. The wind conditions can change in
04:21seconds. Turbulence can be bad. Icing can be bad. So we have dedicated weather observers. That is
04:30invaluable. What did she say the wind was? Wind was 210. Pretty much a direct crosswind.
04:37Hmm. I guess we can go ahead and start heading down. All right.
04:53Peninsula 3296, are you planning on RNAV runway 31? 20 minutes before landing, Anchorage Air Traffic
05:01Control asks the pilots about their runway preference. Affirmative. Negative. We want the RNAV 13,
05:09Peninsula 3296. An Alaska airport is on an island, tucked behind a 1600-foot mountain. Planes can land in
05:20either direction, runway 13 from the west or runway 31 from the east. Most pilots would prefer to use runway 13,
05:30basically because they have more room to maneuver, more room to escape if you got to punch out or you got to go around.
05:37And just like the other day, if there's any major changes in the wind, we'll just, we'll switch.
05:45We always prepare for the worst and hope for the best. Minimize risk. That's what we do.
05:50Ladies and gentlemen, in order to... 12 miles from the airport, passengers prepare for landing.
05:58All right. Flaps 20, flight attendant is secure. Flaps set 20, indicating 20. Gear down.
06:15Four minutes from the airport, the crew begins the landing procedure.
06:22Down three green.
06:27At less than a thousand feet,
06:29The plane is rocked by turbulence.
06:35Ah. Bump. There's a bit of a bump there too.
06:39Yeah. Yeah, there you go.
06:42It's gonna be ugly in here, isn't it?
06:45Hmm. Paul was fighting the winds as they were coming in.
06:50Seconds from touchdown, Captain Wells notices he's too high for a safe landing.
06:59An updraft main calls you to balloon, so that causes you to go high.
07:04What do you think?
07:04Go around.
07:06At Dutch Harbor, I don't take chances. If we're high, we're going around.
07:13Max power.
07:14I would not have been able to safely get back down without putting people at horrible risk.
07:34The pilot pulled up and went around. I was assuming it was because of visibility issues.
07:41Dutch Harbor traffic, Peninsula 3296 going around. We're going to come back around for a visual.
07:49We were continuing with terrain, a lower layer of clouds, and maintaining a safe airspeed.
07:55They're very busy scanning inside and outside of the airplane.
08:02It only takes three minutes before the pilots of Penn Air Flight 3296 are ready to attempt another landing.
08:09If we couldn't main on this attempt, then we would go to our alternate airport.
08:13Two hundred.
08:14Plus ten, you got it?
08:15Got it.
08:17The pilots are seconds from touching down.
08:26Think rate.
08:27Yeah, I know.
08:31Seemed like we floated down the runway quite a bit, which didn't alarm me too much.
08:38Down.
08:44Okay, you got the yoke.
08:46I got it.
08:46Yeah, we're down there, 80 knots.
08:48As the captain begins slowing the plane, something isn't right.
08:54I was pushing on the brakes harder and noticing that I'm not getting any more effect from the brakes.
09:03When I saw the wind suck, the wind was definitely strong.
09:06And at that point, all alarm bells went off in me.
09:12Brakes.
09:14I got them all the way down.
09:17The pilots cannot reduce their plane's speed.
09:20I had to make a decision on whether to continue the landing or abort.
09:25In an instant, I realized that, no, there's not enough room to get the aircraft airborne again.
09:30In the cabin, Steve Rainey notices too.
09:33Brace.
09:35Everyone brace.
09:36I actually went in the brace position and I told the passengers around me to brace.
09:45Hang on, I'm sliding.
09:46The plane is swerving back and forth.
09:53I thought I was going to be able to turn off into the taxi area, but I was going too fast.
09:59The pilots are running out of runway.
10:02All I could see is water.
10:03The pilots of Penn Air flight 3296 are unable to stop their airplane.
10:13I saw the perimeter road and I told Paul, go right, go right.
10:18The only option was the road.
10:21The plane crashes through a fence, strikes a boulder and is propelled towards the water.
10:29That destroyed our exit plan.
10:30They have only a few seconds to stop.
10:35Now, all I could think of was we're going to go in.
10:37The left engine strikes a signal post and road sign, shattering the propellers into deadly fragments.
10:47Holy crap.
10:49We need to evacuate.
10:52Evacuate, right hand side. Get out and get away.
10:56In the cabin, it's eerily quiet.
10:58I could feel blood running down my face and my shoulder was sore and my head hurt.
11:08It was very, very surreal.
11:11A propeller blade has pierced the cabin and struck Steve Rainey.
11:15There was a propeller blade stuck up in the ceiling right up against me.
11:21Jacob, get off the plane. Don't wait for me.
11:26Steve's son Jacob is lucky to walk away from the accident unharmed.
11:31He would not have survived in the seat next to me because the blade was literally right there.
11:37But a passenger near him is severely injured.
11:43I had had a fair amount of training because of my job and so it was more or less an automatic reflex to go over and, you know, check for his pulse, see if he's still breathing.
11:54Within minutes, emergency responders arrive and transport 10 injured passengers to hospital.
12:0338-year-old passenger David Altman later succumbs to his injuries.
12:09In 10 years, he's one of only two people to be killed on a domestic flight in the United States.
12:14I was met in the hospital by a doctor and they told me he hadn't made it and that was a crushing blow.
12:24Investigators from the NTSB, the National Transportation Safety Board, are dispatched to the area as the plane is hoisted onto a barge and taken to a secure location.
12:35We weren't able to offload it the next day because of the weather, so it took a day to get the airplane secured.
12:41We're on record at 5.46 p.m.
12:48Investigators are eager to interview the pilot.
12:51Memories tend to fade and they tend to change, so we want to get to the information as soon as possible.
12:58I didn't even have you sleep before I showed up for that interview.
13:01And so, you're not, you know, you're not 100% clear.
13:04Okay.
13:06Take us through the events leading up to the accident.
13:09Everything was normal, just a nice flight.
13:18Everything was going fine until it wasn't.
13:20And this is pretty common when we talk to pilots after accidents.
13:26When I went to turn off the anti-ice, I got out of position on final.
13:30Captain Wells explains that the plane was hit by an updraft just as he took his eyes off the gauges.
13:37What do you think?
13:43Go around.
13:46Max power.
13:51We were too high.
13:53And instead of doing this stabilized approach and continue to the runway, we elected to go around.
14:00So, you're now set up for a second landing.
14:05Do you remember your speed at touchdown?
14:08One twenty-six.
14:09And where did you touch down?
14:16I planted it pretty much on the thousand.
14:19Right on the touchdown zone.
14:21Put it in reverse, and then I noticed it had stopped accelerating.
14:25I pushed down as hard as I could.
14:29But there's no response from the brakes.
14:31Brakes!
14:32I got him all the way down!
14:37No response.
14:39Exactly.
14:39Zero braking.
14:41But like on ice.
14:44That was puzzling.
14:46We knew we had to look at the braking system to understand what was occurring there.
14:51Did you get an update from the weather observer?
14:54Yes.
14:54They said anywhere from ten to twenty knots.
14:59The winds were changing.
14:59Any concerns at all on the second approach?
15:05The winds were dying down on the water.
15:08It looked like a direct crosswind.
15:11I had no doubt that this was going to be a fine approach.
15:17The captain said that he believed that they were flying into a crosswind and was confident in that approach.
15:25Your FO did the pre-flight on the aircraft?
15:28He did.
15:28Did he bring anything to your attention at all that was out of the ordinary?
15:34He did, actually.
15:36He noticed something with one of the tires.
15:39Pre-flight inspection complete.
15:50Any issues?
15:52Bald spot on the left outboard?
15:56Investigators learned that a pre-flight inspection of Flight 3296 revealed a worn tire on the left outboard wheel.
16:03It's not showing any cord.
16:05It was not down past the red line on the tire and didn't, to me, appear to be of any concern.
16:14I've had maintenance come to look at tires that are in very similar conditions to this tire.
16:20Have you reached any conclusion just in your own head about what you think went wrong or may have happened?
16:34If I had to make my best guess, I don't think it was brake failure.
16:40I think more than likely, it was one of those showers that put down some sleet or hail on the runway and I just couldn't see it.
16:51That's the only thing I can think of.
17:00Anything else you would like to add?
17:02I can't be more proud.
17:13I'm sorry.
17:15Take your time.
17:22I couldn't be more proud of my crew.
17:24The captain did get rather emotional, given his involvement in the accident.
17:39So they came in on runway 13 and the pilot said his airspeed was 126 knots and they touched down at the 1000 foot mark.
17:49Why did Flight 3296 come off the runway?
17:54At that speed, they should have been able to stop well before the end of the runway.
17:59Specifically for runway overruns, we're looking at how the airplane was configured, what those runway lengths were, as well as what it takes operationally to fly that airplane into the airport.
18:12What were the runway conditions?
18:16Was there rain, ice, snow?
18:19Anything on that runway that would have prevented the airplane from stopping on its surface?
18:26No rain, seven degrees.
18:29So hydroplaning is out of the question.
18:32Too warm for ice to form.
18:35Investigators eliminate the captain's theory.
18:38Weather conditions did not make the runway slippery.
18:41In this case, the runway wasn't contaminated, but there was plenty of information that the runway can tell us.
18:49What about debris, skid marks? Where are we at with the runway survey?
18:53Got it here.
18:55The team looks for any evidence left behind on the runway.
18:59The runway evidence was critical.
19:03We walked the runway numerous times.
19:05We documented the heck out of the runway.
19:09Starting at 1,835 feet past the threshold, we've got a dark 170-foot-long skid mark.
19:15Then there's further skidding down the runway.
19:17Skid marks on the tarmac are made when the wheels lock.
19:21Then the plane crosses the center line to the right and then straightens out.
19:27Which tire skidded?
19:30Based on the position of the skid mark?
19:34So-four tire.
19:35Left side.
19:37The Saab 2000 has four main wheels that brake.
19:41Why would only one of them skid?
19:48Wasn't that the one with the bald spot?
19:51Yep.
19:52The tire mark was a continuous black mark.
19:55It didn't have any tread marks on it.
19:57So we knew right off the bat that the tire was skidding on the bald spot and not on the tread.
20:07We also found tire fragments.
20:11Here.
20:13So the tire blew?
20:15Yeah.
20:20Hold on.
20:21That's one heck of a long skid.
20:24Even a brand new tire would have blown.
20:26The fact that the airplane was skidding on the bald spot may have caused it to burst a fraction of a second earlier.
20:34But in the end, it wasn't a contributing factor.
20:37This shouldn't happen.
20:39The plane has an anti-skid system.
20:40The anti-skid system is activated when one of the sensors on the four main wheels detects a skid.
20:49The brake pressure is released either on both inboard wheels or both outboard wheels, ensuring the plane remains stable while allowing the other two wheels to slow the plane.
20:59After we first noticed that there was a flat spot and a hole in the tire, we were immediately drawn to the anti-skid system because that's the purpose of the anti-skid system, to stop skids.
21:12Did the system fail, causing flight 3296 to run off the runway?
21:19Any news?
21:23It's going to take some time for the technicians to break down and test those brakes.
21:28Like you said, that is a long skid.
21:32Why would they need to brake so hard for so long?
21:34In the meantime, investigators consider other theories about the long skid marks.
21:42Overweight?
21:44Could the plane have exceeded its maximum allowable landing weight, requiring the pilot to brake harder than usual?
21:51A heavier airplane essentially has more inertia.
21:55So when a heavier airplane comes in to land, it would take longer to stop.
22:00According to the manifest, the captain calculated their landing weight at 45,213 pounds.
22:11And the maximum allowable?
22:1546,114.
22:23900 pounds under. Close, but within the limits.
22:27The airplane was not overloaded, and we could rule out an overweight airplane as a contributing factor for this event.
22:38What else might cause a pilot to brake so hard?
22:42The captain said that they had a crosswind, but maybe the direction changed to a tailwind.
22:48A tailwind during landing essentially means that you were moving faster over the ground than you normally would.
22:55So you would take up more space on the runway to safely stop.
23:00The automated weather system only gives hourly reports.
23:03Real-time updates come from a weather observer at the airport.
23:07I'll deal with that.
23:09I'll go help with the anti-skid system.
23:10Could flight 3296 have been hit by an unexpected gust of wind, causing it to land too fast and overshoot the runway?
23:27Thanks for coming in.
23:29You bet.
23:29Investigators question the on-site weather observer at Unalaska Airport about the wind conditions when Penn Air flight 3296 landed.
23:41So first, how early do you start providing crews with weather data?
23:46About 20 to 30 minutes out.
23:48And up until when?
23:49Two to three miles out.
23:51Dutch Harbor is a very unique airport.
23:53The topography around the runway actually lends to very rapidly changing weather conditions.
24:00And so a weather observer on the ground provides the ability to get updated information to pilots as it's happening.
24:10And what was the weather like at the airport when Penn Air was on approach?
24:14There was a storm coming in, but at the time it was clear.
24:18And what about the wind on the first attempt?
24:23Two, seven, zero degrees at 10 knots.
24:29Looks like a crosswind.
24:31Second attempt?
24:32About three minutes out, the wind shifted around to 290 at 16 knots gusting to 30 knots.
24:4230 knot tailwind?
24:43Mm-hmm.
24:44That would be an excessive tailwind.
24:47If a pilot decides to land with that tailwind, you essentially become a test pilot.
24:53What about when they landed?
24:54What was the tailwind then?
24:57The winds were 15 knots.
25:02Investigators confirm their suspicions about a tailwind on landing.
25:06Thank you for your time.
25:08My pleasure.
25:08One danger associated with landing in a tailwind is excessive ground speed, which potentially puts you in a situation where you run out of runway to safely stop the airplane.
25:23What's the SAAB 2000 max tailwind for landing?
25:36Was a 15 knot tailwind too much for the SAAB to manage?
25:4115 knots.
25:43Right at the limit.
25:45Why would they risk it?
25:46Down.
25:55Okay, you got the yoke.
25:56I got it.
25:57Yeah, we're down there.
25:58Investigators now know the pilots of Penn Air 3296 approached a difficult airport in tricky conditions, touching down with a tailwind nearing the plane's limits.
26:10Brakes.
26:10I got them all the way down.
26:20Okay.
26:21Weight roughly 45,000 pounds.
26:24Speed at touchdown 126 knots.
26:26Investigators calculate how a 15 knot tailwind affects the pilot's ability to stop.
26:32Our aircraft performance group developed several scenarios to understand whether an aircraft would be able to stop given those circumstances.
26:42Tailwind, 15 knots, flaps, 20.
26:46And let's do a loss of half of the braking power because of the skid.
26:49When the left outboard tire began to skid, the SAAB's anti-skid system would have released brake pressure to both outboard wheels, drastically reducing braking power.
27:09They had room to spare.
27:10With the tailwind of 15 knots and two working brakes, the plane could have stopped.
27:18What are we missing?
27:22Let's look at the FDR data.
27:32Hold on a sec.
27:33Just after touchdown, there's an anti-skid fault caution.
27:40This supports investigators' earlier suspicions that an anti-skid failure played a part in the accident.
27:49Hang on.
27:49I'm sliding.
27:50We've got to get to the bottom of that warning.
28:04In this case, we did have a fault on the flight data recorder related to this system that we couldn't explain.
28:12And so with that information, we needed to do a deeper dive in a lab.
28:20No issues with the control unit.
28:26Wheel sensors.
28:30Same with the control valves.
28:33We tested all the components of the anti-skid system.
28:36There were no significant faults, so it was a mystery.
28:42There's still the cables that connect the components.
28:46Investigators focus on the wires that carry signals from the wheels.
28:50Right here.
28:53Let's take a look at the wiring.
28:55They request that the cables be removed from the left landing gear, as that was the side that locked.
29:00Hey there.
29:02Can we get those wire harnesses sent up to the lab?
29:03When the airplane departed the runway, it hit a ditch and some larger boulders, and it collapsed the left main gear, which caused the wiring to fracture.
29:15These are pretty beat up.
29:23Investigators examine where the cables were connected to the wheels.
29:26These are identical.
29:34Can't tell the left one from the right.
29:36The team discovers a potential design flaw within the anti-skid system.
29:41The connectors at the wheels didn't have any distinguishing features, so this created potential for miswiring.
29:48Could the brake cables have been connected to the wrong wheels?
29:52Investigators examine the wires inside the cables.
29:55Normally, we're able to open up a wiring bundle and look at the wire numbers on the wires and compare it to an electrical diagram and determine if it's connected properly.
30:08There's no numbering on these wires.
30:09We found the wires were so small, the manufacturer didn't put wire numbers on them, so we're concerned about not being able to determine if they're correctly connected.
30:23There should be three wires inside the anti-skid cables.
30:27So we got three here.
30:29Then investigators notice something out of the ordinary.
30:32There's four wires here.
30:35There's an extra wire on the top half of this cable.
30:37The wiring inside the top and bottom half of the outboard cable doesn't match.
30:47There's four in each of these.
30:49The top outboard cable and the bottom inboard cable each had an extra wire, which means only one thing.
30:58They're crossed.
31:01No wonder the anti-skid system failed.
31:03When the left outboard wheel began to skid, the anti-skid system mistakenly released pressure to the inboard brakes.
31:14As a result, the skid continued and the left outboard tire burst.
31:19That was really the aha moment.
31:20When you have crossed wires, the airplane is then dumping the brake pressure to the two perfectly good wheels and allowing the other tire to skid.
31:35Brakes!
31:37I got them all the way down!
31:39Without braking power to the two inboard wheels and a blown left outboard tire, the pilots had a massively reduced ability to brake.
31:49You're reducing the effect of braking capacity by 75 percent, and now only the right outboard tire is providing braking.
31:57The cables have to go through the entire landing gear.
32:15How did maintenance workers mistakenly cross the wires of the braking system, leaving the pilots of Penn Air Flight 3296 with only one of four main landing gear brakes to stop their plane?
32:26See? It's not a straight line.
32:28And the wheel attachments are identical.
32:31So imagine trying to feed two wires through a small hole at the base of the landing gear.
32:36How do you know which one went to the left and which one went to the right?
32:39It would just be so easy to confuse the two.
32:42How long could these have been crossed?
32:45According to the records, there was a full overhaul of the left main landing gear.
32:50The wires were crossed two and a half years prior to the accident.
33:01We found out that the aircraft had been sitting for a couple of years in overhaul, and there wasn't any sort of procedure to check to see if there was any cross wiring.
33:17So how many flights did it make once it was back in service?
33:23About 500.
33:24They learned that the misrouted anti-skid wiring went undetected for nearly four months.
33:33So why did 500 flights manage to stop, but not these guys?
33:39Maybe the malfunction was happening just on a smaller scale.
33:43The balding tire.
33:44Was the worn left outboard tire an indication of the malfunctioning anti-skid system?
33:53We suspected that there were events of skidding, but the difficult thing is it would have to skid more than a second and a half for the airplane to display a fault that the system was malfunctioning.
34:07So this could have been happening gradually, with repeated small skids creating the bald spot on the tire.
34:12Yeah, but when they landed at that speed with that tailwind, they brake longer and harder than in previous flights.
34:22Brakes!
34:24I got them all the way down!
34:27That's really the insidious nature of this fault.
34:31You're not going to find out about this cross wiring until you really need it when you're slamming on the brakes.
34:37Hang on, I'm sliding.
34:38With the hidden anti-skid fault, investigators conclude the pilots of Penn Air Flight 3296 could not have stopped their plane on runway 1-3.
34:55There's one thing I'm curious about.
34:56Could they have stopped if they landed into the wind on runway 3-1 instead?
35:10It's possible.
35:12Their landing speeds would have been slower, and the drag caused by the extra wind would have stopped it in time.
35:19Then why did they choose runway 1-3 in the tailwind?
35:26Did the pilots of Penn Air Flight 3296 ignore crucial information about the wind and execute a risky landing?
35:34The decision to land on runway 1-3 with the reported tailwind was an inappropriate decision.
35:41This was an experienced crew, and they weren't sure what exactly had happened.
35:45Investigators turned to the cockpit voice recorder for answers.
35:51Pull up from the go-around onward.
35:56What do you think?
35:58Go-around.
36:00Max power.
36:04Dutch Harbor traffic, Peninsula 3296, going around.
36:08We're going to come back around for a visual.
36:09Now we're just going to get out of here, do a 180, and come back in.
36:15Roger.
36:16All right, you're at 1,000 feet.
36:18Pause for a second.
36:20So the captain says that he's doing a 180, which would line him up with 3-1.
36:26But that's not what he does.
36:28He takes a sweeping 360-degree turn around the mountain to 1-3.
36:33Why?
36:43We're at 1,200, coming back around for a 1, uh, for a visual 1-3.
36:493-1.
36:513-1.
36:523-1, I thought we were doing 1-3.
36:54Uh, okay.
36:56Sure.
36:58I'll try it again.
37:00Stop the tape?
37:00Stop the tape.
37:03So the captain wants to go to 3-1, but the first officer questions it.
37:09There was a back and forth between the captain and first officer in terms of which runway to use.
37:15I would categorize the captain's leadership as poor.
37:19Okay, get a wind check from her again.
37:21As the crew finalizes the second approach, the captain stays on top of the wind reports.
37:26Dutch weather 3296, another wind check.
37:28Right now, midfield winds at 3-0-0 at 24-0.
37:36Oh, God.
37:37Oh, crap.
37:39Stop the tape.
37:41Sounds like they're not happy with that tailwind.
37:44And yet they kept going.
37:45They were surprised of the wind direction and speed.
37:55But the interesting thing is, is that they were aware of the tailwind limitation for that particular aircraft.
38:05But they continued on with the decision to land.
38:12Try it again.
38:13Keep talking the weather.
38:14Why would the pilots of Penn Air Flight 3296 decide to land with a tailwind on a short runway in Dutch Harbor, Alaska?
38:25All right, we'll try it again.
38:27All right.
38:28Last try, Raj.
38:30It's like the captain's just going along with what his first officer is saying.
38:37He needs to take on more leadership.
38:39The captain suspected 3-1 was the better option, but he never stated his preference.
38:45The captain's capitulation to land on 1-3 does show ineffective leadership and that he did not fully evaluate the circumstances at hand in order to make an objective decision.
39:03Maybe he was fixated on landing.
39:05Instead of communicating their options, they continue their approach.
39:19Give me speed.
39:20Plus 15.
39:22Investigators conclude the pilot's decision to land on runway 1-3 was intentional and inappropriate.
39:29By making that decision, they put themselves at risk, but they also put the passengers at risk.
39:38Crossed wires, tailwind, some poor leadership.
39:42It all added up.
39:45And very little margin for error at such a tricky airport.
39:52The pilots of Penn Air Flight 3296 defend their decision to land on runway 1-3.
39:59We're at 1,200, coming back around for the visual 1-3.
40:063-1.
40:073-1.
40:083-1, I thought we were doing 1-3.
40:11Uh, okay, sure.
40:13We'll try again.
40:14After the first landing attempt, the captain claims his first officer saw no change in wind conditions on the runway.
40:23He called my attention to it, so I looked again to evaluate the situation.
40:27He was correct, it was a crosswind.
40:29If the conditions hadn't changed, I didn't see a reason to change the plan.
40:34Dutch weather 3296, another wind check.
40:37Right now, midfield winds at 3-0-0 at 24 knots.
40:43Oh, God.
40:45Oh, crap.
40:46What we were seeing was not what she was reporting at that point in time.
40:53Those winds were clearly a crosswind.
40:56We could see the white caps, and then the windsock itself was showing a crosswind.
41:02Commercial pilot and passenger Steve Rainey saw something different.
41:06I saw a direct tailwind, 20 to 30 knots.
41:11As a commercial pilot, that is something that I would not have attempted.
41:16When you get conflicting information from what you're seeing, that is a tough call for a pilot.
41:21Down.
41:29Okay, you got the yoke.
41:30I got it.
41:31Yeah, we're down there, 80 knots.
41:32When the brakes malfunction, the captain is unable to slow the plane.
41:38Brakes!
41:39I got them all the way down.
41:41We had no braking power at all.
41:43If we had one operational brake still, it would have locked up and blown as well.
41:46This particular aircraft didn't have an emergency brake.
41:50So, in the event that the main system failed, there's no way to bring this aircraft to a brake stop.
41:57Ah, hang on.
41:58I'm sliding.
42:00Quick thinking in turning the plane towards a road avoids a full plunge into Dutch Harbor.
42:06Go right, go right.
42:09The key to not going into the water was our decision to land on 1-3.
42:12We had the perimeter road.
42:14There was a lot more room on the 1-3 side.
42:22Tragically, fragments of the left propeller ripped through the fuselage, killing a passenger.
42:30You never want to lose a passenger for any reason.
42:36That's been very hard for me.
42:40Investigators conclude the probable cause of the accident
42:43is incorrect wiring of the anti-skid system.
42:47Contributing to the accident is the pilot's inappropriate decision
42:50to land on a runway with a powerful reported tailwind.
42:53That troubles me, because are we supposed to just blindly rely on our weather observers,
43:05or are we supposed to make a decision as the pilots on what the best course of action is,
43:09based on what we see?
43:11Saab released a service bulletin advising operators to inspect the anti-skid system for crossed wiring.
43:18You know, you can't afford for human error to be allowed in connecting wires.
43:25That's a very basic thing, especially on a critical safety system, such as the brakes.
43:32For Steve Rainey, the ordeal changed his attitude about flying.
43:37It took quite a while for myself to be comfortable again,
43:41but we live in a place where we have to fly.
43:45There's no choices about it.
43:47I would hope that there are lessons here as far as weather and maintenance
43:52that can keep accidents like this from happening again.
43:56Subtitling byanco Teryn
43:58Subtitling byesk
44:04So let's see.
44:05Subtitled by rock
44:08We'll see.
44:10Subtitled by rock
44:14Subtitle by sociale
44:22Subtitle by rock
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