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Air Crash Investigation Series S21E09 Seconds from Touchdown

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00:00Looks like we lost hydraulics.
00:03Air crash investigators discover Propair Flight 420 faced an onslaught of problems.
00:10What's going on? He wants to roll left.
00:13As pilots attempt to return to the airport, their situation becomes critical.
00:18Fire. The left engine's on fire.
00:21Is that a passenger?
00:23If you can't get that airplane on the ground very quickly, it can kill you in as little as five minutes.
00:27Left gear hasn't dropped.
00:29No time to sort that out.
00:31Hold on, back there. It's going to be a rough landing.
00:35Freeze!
00:37They were within a few seconds of everybody being on the ground safe and going home.
00:41That must have been hell.
00:45BD, BD!
00:46I'm taking a full stop.
00:50For the line check, it's your leg out to Peterborough.
01:14I'll take the second.
01:16Roger.
01:16It's the first flight of the day for the crew of Propair Flight 420.
01:28Propair 420, we're holding in position, runway 24L, ready for takeoff.
01:36Propair 420, cleared for takeoff, 24L, frequency 12465.
01:42Roger, Propair 420, cleared for takeoff, 24L.
01:48Captain Jean Provencher is the airline's chief pilot.
01:56Landing light's on.
01:59Co-pilot Walter Stricker is an experienced first officer, but is newer to this type of aircraft.
02:05I have control, your control.
02:10Yes.
02:13The captain watches Stricker closely.
02:20More right rudder, more right rudder.
02:22OK, more right rudder.
02:23He's conducting a line check, a crucial testing stage for the first officer.
02:34A line check is required every time a pilot is new on an airplane.
02:39The check pilot wants to make sure that the new pilot knows his standard operation procedures very well,
02:45and his flying skills are good.
02:47As a check pilot, it's pretty busy, you're doing your duties, you're monitoring the other guy's duties.
03:14They get in the air just fine.
03:17Flight 420 ascends to its cruising altitude of 16,000 feet.
03:24The pilots are flying a 14-seat Fairchild Metroliner twin turboprop.
03:30The Metroliner was a fast airplane without burning too much fuel.
03:40Having a pressurized cabin, the Metroliner was able to fly at a higher altitude,
03:45so it made it more comfortable for the passengers.
03:48Although it's a modern plane, the Metroliner has no autopilot.
03:55The first officer is flying manually.
03:58For my dad being a pilot, it was his dream job, it was his main purpose in life, other than me and my mom, obviously,
04:10but he was always talking about it, and he was really, it made him really happy.
04:16Today's flight is a 90-minute hop from Dorval to Peterborough, Ontario.
04:23The nine passengers on board are engineers from General Electric, who are headed to Peterborough for project meetings.
04:31The plane has been in the air for 12 minutes.
04:35Everything has been normal since takeoff.
04:38All of a sudden...
04:43What?
04:44What is it?
04:46Looks like we lost hydraulics.
04:53Not only one light, but two, saying that his hydraulic pressure are failing on both sides,
05:03meaning that he will have problems if he keeps proceeding to Peterborough.
05:08Dorval approach, this is Prop A420.
05:11We've had dual hydraulic failure.
05:13Request clearance to return to Darbat.
05:18The Metroliner has two hydraulic systems.
05:21One controls the flaps.
05:23The other, the landing gear.
05:25You don't really need the hydraulic systems until you're coming in.
05:28It's not a, we're going to die at this very moment kind of situation.
05:31It's just, we have a problem, we need to turn back, and it's standard operating procedure at that point.
05:36Sorry folks, we have a technical problem.
05:39We have to head back to Darbat.
05:41And your seats with seat belts fastened.
05:49Looks like we're landing without flaps.
05:53With no flaps, the pilots can't reduce their speed without stalling.
05:58They'll have to come in fast.
06:00Not having any flaps, it was not really a problem.
06:06They had a 12,000 foot runway ahead of them.
06:10Time was of the essence.
06:12We had to land the airplane very quickly.
06:16Without hydraulics, the landing gear will have to be lowered manually.
06:20It's going to make everything longer and not much harder for you.
06:24It's going to delay where you're normally used to doing your configuration.
06:30Then, just 30 seconds after losing hydraulics, before they've started back to the airport.
06:35What's going on?
06:36What's to hold left?
06:37Really?
06:38I'm holding it right.
06:39Something's wrong with the controls.
06:40Need to trim half turn to the right.
06:41That should do it.
06:42If the plane is rolling in one direction, applying trim avoids the need for continuous pilot inputs.
06:56Trimming it right brings the left wing up and levels the plane.
07:15But as Stricker starts to turn towards Dorval...
07:18Still rolling left.
07:21The airplane wants to turn to the left, and the first officer has to apply more and more right ailerons, which is not normal.
07:30It's getting stiffer.
07:31I'm going to give it a few more ticks of aileron trim to the right.
07:34Roger.
07:39Remember, no autopilot, so that's putting a lot of pressure on this first officer.
07:45And any pilot who has this kind of problem has to ask himself, is it going to get worse?
07:51Still rolling left.
07:52Yes.
07:53Both engines are working.
07:54Why do we need so much trim?
07:56The captain has to be racking his brain.
08:11He had more than 5,000 hours on the metro.
08:14He was the chief pilot, a Czech pilot, and he can't seem to make sense of the situation.
08:18They are 12 minutes from Dorval Airport.
08:21As they descend through thick clouds, visibility is near zero, and they have to fly on instruments.
08:30Rolling to the left.
08:31Bang more to the right.
08:32Pulling the approach place for Dorval.
08:33Roger.
08:34As flight 420 gets halfway back to Dorval.
08:37Fire.
08:38Fire.
08:39The left engine is on fire.
08:40Fire.
08:41The left engine is on fire.
08:42An even bigger problem emerges.
08:44Fire in the left engine.
08:45Confirmed.
08:46Yes, I see smoke.
08:47The moment the anti-pilot hears fire, he has to take immediate action.
08:54It's a very serious situation.
08:55It can kill you in as little as five minutes.
08:59Left engine shut down procedure.
09:00The pilots attempt to extinguish the fire.
09:01It can kill you in as little as five minutes.
09:02Left engine shut down procedure.
09:06The pilot's attempt to extinguish the fire in the left engine.
09:13He's got a plan.
09:14action it's a very serious situation it can kill you in as little as five minutes
09:24left engine shutdown procedure the pilots attempt to extinguish the fire in the left engine
09:33he's got a plan what am i going to do and how much time do i have before i have to land this
09:40airplane left power lever confirmed left the captain executes the engine shutdown procedure
09:51back to idle confirmed left shutoff lever confirmed pulling left engine stop lever
09:58shutting down the engine also cuts off its fuel supply the rationale for shutting that engine
10:04down is you don't want the fire spreading that's the biggest concern at this point this isn't good
10:09keep the speed up let's get back to the island roger
10:18when you're shutting down an engine it's a bit of an alarming situation it's not a comfortable
10:22experience no matter what you're doing the airplanes have two engines for a reason and
10:26you've cut your redundancy down to one
10:27my controls your controls facing fire control problems and an engine shutdown the captain of
10:43prop air 420 assumes control the airplane was descending from 8 000 feet for its approach you had altitude that
10:52you could trade for airspeed so with captain's provincial experience shutting down the engine that was not a problem
11:00dorval approach prop air 420 left engine is on fire we've shut it down
11:05prop air 420 i see you are returning to dorval i can give you direct to mirabel
11:12affirmative direct to mirabel
11:14while flight 420 is only 11 minutes from dorval they reroute to montreal's other airport mirabel which
11:23is closer material approach prop air 420 requesting ils runway 24 please what is the frequency
11:32the long runway at mirabel will give the crew more room for a high speed landing
11:40irs 24 frequency is 111.7 inbound course is 240 degrees roger 111.7 thank you
11:51emergency crews are dispatched to runway 24
11:59firefighter michelle brisson remembers the moment the call came in
12:04we receive a crash call from the tower control so we take position mirabel airport being an international
12:12airport they got ready pretty quickly the airport is fully equipped to receive the crippled airplane
12:18with their level of experience with the firemen folks air traffic control has asked us to reroute to
12:25mirabel flight 420 is now seven minutes from touchdown at this point they know that behind them are nine
12:34people and uh they're going to do everything in their power to get that airplane on the ground as
12:38safely and quickly as possible i see flames now flames from the engine nozzle the situation goes from bad to
12:47dire the engine shutdown should have contained the fire instead it's growing
12:55when the passenger tells the crew that their engine is on fire they're puzzled let's get this
13:01plane on the ground landing checklist flaps zero speed lever high rpm their main focus is to fly the airplane
13:14fly the airplane and fly the airplane fire crews park alongside the runway at mirabel airport for the
13:21emergency landing of flight 420 michelle brisson is one of the first on the scene
13:29we were waiting for the aircraft the water was not too good we couldn't see far
13:34captain provenche is struggling to maintain control he's flying on one engine with no hydraulics and his
13:47plane is on fire now he has to lower the landing gear manually with no guarantee it will work you're down
13:56now you're down the nose and right wheels have dropped but one light stays off left gear hasn't
14:09dropped no time to sort that out provenche has no choice but to put the plane down on only two sets of
14:17gear if i'm in an airplane fighting fire an engine that i've shut down controllability issues we're not
14:24going around you're landing that airplane on that runway whether you land gear up uh or not
14:30flight 420 is one kilometer from the runway the clock is ticking you have to get down and get
14:37that airplane on the ground now 300 feet the moment it gets to about 280 feet he sees the threshold
14:50he sees the fire truck and he thinks that he's made it and saved 11 lives prop air 420 is 20 seconds from
14:59touchdown there was some smoke coming out of the aircraft and my heart tight a bit there and i said to
15:07myself uh we've got some business here this morning okay here we go 200 feet
15:17hold on back there it's gonna be a rough landing
15:27rolling left not now
15:29they're just five seconds from being able to touch down at this point the crew would be fighting
15:37for every breath they have
15:41prop air 420 is almost on the ground at montreal's mirabel airport when disaster strikes within a split
15:49second the aircraft started to go 90 degrees and that must have been hell captain provencher probably
15:58thought that he was going to die i saw the aircraft flip over 180 degrees
16:06that was it i'll never forget the sound that it made when it touched the ground
16:10the plane crashes into a watery ditch next to the runway
16:27my first concern was to go to the fuselage to try to save some lives
16:32sylvain carrière was the fire chief at mirabel airport at the time of the incident
16:36as soon as the aircraft crashed the firefighters were on the move
16:42they put out the fire with the foam and then they got close to the aircraft
16:46trying to get inside to rescue the victims
16:52it was very tough on the firefighters
16:56they had to deal with trying to manage water up to their waist
17:01they had to break the windows to get vital signs
17:03the aircraft being inside down and all the seats were dislodged from their footing
17:11so it was uh total chaos
17:18despite the best efforts of rescue crews no one makes it out of the plane alive
17:27we took three people out took their pulse and there was nothing
17:33we took three people out of the plane
17:37everybody was gone
17:46we're never prepared for that you know
17:47i was seven years old when my dad died
17:59we were really close
18:03i remember my mom crying
18:08she said something terrible happened to your dad and it's not coming back
18:12i thought i was in the dream
18:23this is why we do these investigations it's it's to make sure it doesn't happen again
18:30could you please tell me what you saw as the plane was coming in within hours of the accident
18:38investigators from the transportation safety board of canada get to work when it broke through the
18:43clouds there was smoke coming off the plane where was the smoke it was on the left side
18:52there was fire coming out of the left wing and near the mortar and then what
18:57it exploded it exploded yeah and then it flipped upside down
19:07not even 25 feet above the ground the wing folded and the airplane went to a roll
19:14he was just maybe five seconds from landing but it was just because of the breakup
19:20they could not do anything to really save the situation
19:29have a seat investigators need to determine what caused the left wing to fail just 25 feet from the
19:36ground they start by interviewing the dorval flight controller what was the first sign of trouble
19:4412 minutes into the flight and they reported hydraulic failure
19:51dorval approach this is club by 420 we've had dual hydraulic failure quest clearance to return to dorval
19:59anything else 30 seconds later they call in a flight control problem
20:09we're having control issues
20:14so they're headed back to dorval they're having hydraulic and control problems
20:27did they report a fire yes engine fire
20:36investigators realized that the crew was battling multiple system failures
20:41the mystery is how they're all connected dorval approach prop air 420
20:47left engine is on fire we've shut it down thank you very much
20:55the metro liner doesn't have a flight data recorder on board investigators must rely on old-fashioned methods
21:03we laid down the full aircraft with all the related components to their relative position
21:07the landing gear the hydraulic systems the brake systems the brake components flaps components
21:14i say we start here
21:23since the left wing failed in the middle near the engine investigators decide to tear it down for a full inspection
21:30we looked at the engine before sending it to the manufacturer for a deeper investigation
21:40go a little further in for me please
21:43they're looking for any evidence of fire the exterior has plenty of soot but inside
21:50it's clean it's clean i don't see any fire damage it's not what they expected
22:01we could see the engine had no evidence of any fire or fuel lines in the area of the engine
22:08the engine was running properly as far as we could tell
22:12why would the crew report an engine fire when there wasn't one
22:25what what is it looks like we lost hydraulics investigators now turned to the cockpit voice
22:34recorder of prop air 420 to determine why firefighters and the pilots both reported an engine fire stop
22:41for a second
22:44do they even mention fire
22:49nope not at all by now they're 12 minutes into the flight
23:00i've got the column halfway to the right i can't believe it's taken this much trip to hold it straight
23:05hang on
23:07control problems just 30 seconds after hydraulic failure
23:11the door valve is here now they're barely out of the gate before the hydraulics fail here
23:22they haven't even begun their turn and the controls start acting up here
23:27okay let's see what happens next
23:31left wing overheat light on over
23:35a wing overheat warning sounds when high temperatures are detected by a sensor in the wheel well
23:45the wing overheat light is indicating to you that there's smoke heat and potentially a fire
23:51what the
23:52but the warning mysteriously shuts off 30 seconds later overheat warning light off
24:02good
24:02we don't need the checklist
24:06before they have a chance to do anything about it the light goes out so they say ah the problem
24:10doesn't exist anymore we don't have to worry about that
24:17several more minutes pass before anyone mentions fire fire the left engine's on fire
24:25is that a passenger fire in the left engine confirm yes i see smoke sounds like it's coming from the cabin
24:33now now they're here and finished their turn back to door valve
24:43the passenger report of an engine fire confuses the crew
24:49the engine already warning is off
24:54left engine shutdown procedure
24:55the captain follows the checklist but it doesn't solve the problem
25:01i see flames now flames from the engine nozzle i don't have a fire light
25:07everything in the airplane is telling you the engine isn't on fire
25:10but you have a passenger in your back telling you the engine is on fire
25:14which road you go down it's hard to fault a pilot for going down either road at this point
25:18the cockpit voice recording provides investigators with their biggest lead yet
25:26the initial wing overheat warning could indicate that something in the wheel well was overheating
25:35maybe the fire started in the wheel well
25:39that's so close to the engine the crew could have made that mistake
25:43we start zeroing on the fact that this is probably where we should concentrate our efforts
25:51is there something within the wheel well that has the potential to catch fire
25:57check out the left landing gear the team discovers that pieces of the left landing gear
26:02are burned almost beyond recognition it's an important clue we know there has been an in-flight fire at this
26:11point because we have pieces of metal that tell us that we just don't know how it started what
26:17caused it and this is going to be the big part of this investigation what caused this fire
26:23they start by examining the brakes on the left landing gear
26:28at this point in the investigation we knew that we had to look at the brakes because
26:32we thought that the problem probably began in there but we weren't sure we had to find out
26:41it's everything a complete examination of the brake system was performed
26:48each of the components calipers discs we looked at every details of the brakes
26:54some severe damage here
26:59the team finds that several components of the left side brakes show significant heat damage
27:06piston housings are melted cylinders are blackened the damage of heat that were done to the components
27:13along the brake calipers and the tires and then the wheel well was really the smoking gun
27:20investigators can finally confirm that an in-flight fire aboard prop air 420 began in the left wheel well
27:28but they still don't know what started it this is the left brake disc correct
27:35one component is key thing got pretty hot somehow the grayish blue color stands out
27:43these brake discs would have to get to a temperature of about 1100 degrees fahrenheit or 600 degrees celsius
27:51for five or six minutes in order to get to that color could overheated brakes have started the fire that
27:58brought down prop air 420 the landing gear would need a fuel source to ignite but the wheel well is nowhere
28:07near the heavily reinforced tanks
28:15something in here must have caused the brakes to catch fire investigators focus on the tubing inside
28:22the left wheel well called the nacelle hydraulic line there in the design of the left wheel well
28:31nacelle you have the hydraulic lines that run through there to operate the landing gear also for the flaps
28:42doorbell approach this is probably 420 we've had dual hydraulic failure request clearance to return to
28:48doorbell
28:50the melted lines would cause the hydraulics to fail the first problem reported by the crew
28:56so the heat from the brakes melts the line hydraulic fluid pours out everywhere there's a fire
29:09right there it's a good theory but they need evidence to back it up
29:19investigators design a test to determine if hydraulic fluid could ignite when exposed to
29:24overheated brakes
29:33the same make of brake discs that was used in the metro liner
29:40they heat the disc to 1100 degrees fahrenheit the temperature that would have been needed to give
29:46the left brake discs their grayish blue color
29:49we sprayed a small quantity of hydraulic fluid at a rate of two tablespoon per minute
30:00oh
30:09investigators are able to prove that the left brake disc on board prop air 420 did get hot enough to
30:15ignite the hydraulic fluid and it started the ignition of a flame eight inches high
30:21but they still don't know why the brake discs overheated could there have been a malfunction with the brakes
30:30let's have a look investigators look through old metroliner incident reports
30:36i've got some for you in the united states about 10 years before a metroliner exactly had the same problem
30:491988 peninsula airways loss of hydraulic pressure left wing overheat left wheel well fire damage
30:56and that one in winnipeg and that one in winnipeg 1990 perimeter airline in fact same thing
31:02in both those cases the crews were able to land the plane safely
31:07the history of the metroliner revealed to us you know that the brake system had issues
31:13we combined something like 68 events you know that were involving the brake systems
31:19why does this keep happening the incident reports reveal a similar culprit in many of these incidents
31:29brake dragging the brake to have gotten that hot had to have been dragging
31:38brake drag is what happens when the calipers don't fully retract from the disc as the brakes are released
31:44the brake disc overheated because there was probably still some pressure on them and so the the wheels
31:52were not turning freely this dragging of the brakes got the temperature higher and higher
32:00investigators conclude the dragging must have occurred while taxiing at dorval airport nose wheel steering
32:07armed naturally there will be a lot of heat developed on that brake system if it's dragging as
32:13the airplane accelerates but for that kind of heat to develop the left brake had to be dragging for
32:19some period of taxi time to find out how long the left brake might have been dragging the team talks to
32:26the controller overseeing the flight's departure from dorval airport they taxied from the hangar there
32:34to the runway here did the crew report anything unusual on the taxi
32:38this isn't surprising if the brakes were only dragging on one side the way you taxi a metro liner you have
32:47a nose wheel steering
32:50but just one dragging brake you can turn the nose wheel steering gear and you won't be able to notice
32:55that the brake is dragging so this is possibly what happened
32:59well about 420 we're holding in position runway 24 left ready for takeoff
33:08what about the takeoff it took them a long time to get airborne really where did they lift off
33:15the plane lifted off between the a1 and a2 taxiways which are between 4100 and 5500 feet from the runway threshold
33:37so takeoff distance to rotation should be 1800 feet
33:47this plane took more than 4 000 the problem with the brakes began probably as the airplane
33:56departed the hangar it must have been the brake track
33:59they used 1400 feet to go to the threshold of 24 left so for about 5200 feet the brakes were dragging
34:12and creating a lot of overheating on the disc of the brakes the findings back up their suspicions
34:21the brakes must have been dragging which explains why it took the plane so long to reach takeoff speed
34:27and they went up in the wheel well very very hot 12 minutes in the air is plenty of time for
34:43the overheated brakes to raise the temperature in the wheel well when the landing gear comes up the
34:50doors closed and then if you have any heat in there that heat has nowhere to dissipate so the
34:57temperature inside goes up very very quickly but what could have caused the brake drag in the first
35:04place what about the parking brake
35:10just like in your car if you drove away with the parking brake on and you keep driving it's still going
35:15to create friction which there entail creates heat parking brake off roger investigators wonder if
35:24there was an issue when the captain released the parking brake if the parking brake had been on you
35:31would have had both motors overheat only one wheel overheated so somehow whenever the parking brake was
35:38released one of them let go the right side the other one didn't otherwise you would have had two fires
35:44they search the manufacturer's documentation for evidence of faulty parking brakes
35:58now here's something a five-year-old newsletter advises pilots to verify the parking brake is fully released
36:06some residual pressure can remain even with the knob in the off position
36:14i'm sad as a pilot to see that this information was through newsletters and not into the aircraft
36:21flight manual it was very deceiving to see this were the pilots unaware of a faulty parking brake
36:30without a flight data recorder and with the pilots deceased they'll never know for sure but it's a solid theory
36:40all right so the brake drag caused the wheel well fire right the team has finally determined how the fire
36:51started but there's one question remaining could the crew have done anything to prevent any of this from happening
37:09when you take the controls make sure to make smooth inputs on the nose wheel steering passengers can feel
37:15it we want to give them a nice ride investigators returned to earlier in the cockpit voice recording
37:22to see if the crew of prop air 420 realized their brakes were dragging that's the captain's voice so he's
37:29steering right the uh first officer takes over on the takeoff roll i have control your controls
37:37the first hint of trouble starts soon after more right rudder more right rudder so the captain's correcting the
37:49first officer plane must be drifting the left of center on the runway probably because the left brake is dragging
37:58it's going left more right rudder the captain starts telling the copilot more rudder more rudder that's when
38:12the problem of a brake dragging should have been evident but because he's checking the copilot he's not on
38:20the controls himself had he been on the controls himself with his experience he would have known
38:26the captain makes no mention of the plane taking longer than usual to lift off he's doing a line
38:33check he's busy he's got to make sure that the first officer is doing the jobs that he's supposed to do
38:37it's an honest mistake investigators finally understand what caused the crash of prop air flight 420
38:46a dragging left brake gets hot enough to melt the hydraulic lines when the wheel is retracted after takeoff
38:55door valve approach this is caught by 420 we've had dual hydraulic failure request clearance to return to
39:04door valve they're thinking that it's just a hydraulic failure we'll request back to uh
39:10the airport and we'll land there uh safely dripping hydraulic fluid ignites let's bring overheat light on
39:21they have no idea that they've got a brake fire that is starting to rage in the left nacelle
39:30overheat warning light off
39:31good we don't need the checklist what likely happened at that point is that the circuit probably
39:40was burnt through by the fire that is developing in that nacelle the intense heat begins to weaken
39:47the structure of the left wing causing it to lose lift what's going on it wants to roll left
39:54like any kind of metal as it super heats it's going to distort and change its shape
39:57so they're dealing with an aerodynamics of the wing you're never going to know if it moves two
40:02degrees but you're going to feel it on your control call fire the left engine's on fire the engine over
40:10here warning is off i don't have the fire light there's definitely fire
40:17so they're pulling left engine stop lever well i did the right thing i had to shut it down
40:30yeah they were really up against it and all that happened in just five minutes
40:40when we train on board simulators we rarely give more than two problems to a pilot because it's very
40:50unusual that you will have compounding problems like prop air 420 had despite the high level of
40:58experience of captain provanchi he probably never trained for all these emergencies at one time
41:04despite everything you're down now they almost made it
41:13left gear hasn't dropped as the situation continued to deteriorate from an investigator's standpoint he did
41:21the perfect job he was coming right at the center and he was coming at a good rate of descent
41:27one final problem is insurmountable the captain doesn't know it but
41:35the fire has weakened the wing structure
41:40if that wing hadn't failed upwards they were within a few seconds of everybody being on the
41:45ground safe and going home
41:49at this point if you're a pilot you're along for the ride in that airplane
41:57they did everything right
42:06they didn't have a chance
42:14i met with the widow of the captain
42:17i did mention to her the reason why that airplane crashed was beyond the cruise control is that they
42:23did not have enough information to be able to determine what the real problem was
42:30and i told her that
42:42you meet people like that and you never forget
42:46in its final report the transportation safety board noted that unlike many other planes the metro
42:57liner did not have a break over heat warning in the cockpit and the aircraft flight manual did not
43:03clearly warn pilots that brake dragging could lead to wheel well fires the first recommendation that the
43:09board issued was to make sure that the crew was aware that if an overheat light came on on that
43:15nacelle you probably had a good chance of having a fire starting or developing in that nacelle
43:25checklists were changed and we were able to make it a lot safer for people going forward
43:29even though my dad's been gone for 22 years he's still held
43:37so
43:41so
43:45so
43:47so
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