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On 2 July 2021, Transair Flight 810 ditches in Māmala Bay about 11 minutes into a flight from Honolulu, Hawaii, to Kahului, Maui. However, both crew members survive. It was determined that the pilots inadvertently reduced power to the wrong engine during a failure.
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LernenTranskript
00:00Hey, Matt, we're going down.
00:03We can't keep going down.
00:06A Pacific Ocean, the pilots of Transair Flight 810
00:09can't get their cargo plane to climb.
00:11Just hitting the water is going to tear the airplane apart.
00:15We're in the water! We're in the water!
00:19Remarkably, they survive the crash
00:21and are rescued by the Coast Guard.
00:24They're covered in gasoline and hydraulic fluid,
00:26so it wasn't pretty.
00:28Investigators are eager to interview the crew.
00:30Did both engines fail at the same time?
00:33Most likely. That's my conclusion.
00:36The evidence does not support the pilot's assessment.
00:40It looks fine. No internal damage.
00:44So it was critical for us to get more information
00:47to better understand what had happened there.
00:52Mayday, mayday!
00:53It's the middle of the night
01:15at Daniel K. Inui International Airport
01:18in Honolulu, Hawaii.
01:22Okay.
01:23Let's see.
01:25Crews have just finished loading cargo
01:27for Transair Flight 810.
01:30Okay, thank you.
01:31See ya.
01:32The captain of tonight's flight is Henry Okai.
01:35He has almost 16,000 flying hours.
01:38So this captain is highly experienced in the aircraft
01:41and doing it for a while?
01:42Engine start checklist.
01:46Engine start checklist.
01:48Tail stand.
01:49Removed.
01:50Cargo.
01:51First officer Gregory Ryan
01:53is a lawyer who recently returned
01:55to flying part-time for Transair.
01:58It's not necessarily the best pilot career straight up,
02:01but you do get to be in Hawaii.
02:03You get to fly an airplane.
02:05Engine start checklist complete.
02:07And...
02:08Clear right.
02:11Clear right.
02:13Transair flights use Rhodes Express as a call sign.
02:18Tower, Rhodes Express 810.
02:20Taxi key loan.
02:22Rhodes Express 810, Honolulu Tower.
02:25Runway 8 right.
02:26Taxi via Charlie, Romeo, Tango, Romeo, Alpha.
02:29Transair is owned and operated by Rhodes Aviation,
02:40which transports cargo between the Hawaiian islands.
02:43They had the postal contract, which was quite lucrative.
02:46Their focus was on keeping their costs down
02:48to maintain their advantage
02:50over more and well-established competitors.
02:52The plane is a Boeing 737-200,
02:58built in the 1960s and 70s for passenger travel.
03:03Today, they're workhorses for transporting cargo.
03:06Twin engines, small aircraft.
03:08It was designed for short-haul operations.
03:10Wasn't very sophisticated, no automation.
03:12I love flying that airplane.
03:14The pilots prepare for takeoff.
03:18Runway 8 right confirmed
03:20before takeoff checklist complete.
03:23Road 810 cleared for takeoff.
03:27Runway 8 right,
03:28cleared for takeoff.
03:29Road 810.
03:36Tonight's flight is a short hop to Kahului,
03:39on the neighboring island of Maui,
03:41only 100 miles away.
03:44Okay, you have control.
03:46Okay, I have control.
03:50At 1.33 a.m.,
03:52Captain Okai hands over the plane
03:54to First Officer Ryan.
04:01Engine stable.
04:0580 knots.
04:07Check.
04:09V1.
04:11Rotate.
04:14V2.
04:16Positive rate.
04:16Gear up.
04:21Within seconds of lifting off.
04:28Damn.
04:29Lost an engine.
04:31You got it?
04:32Yeah, I got it.
04:34The pilots have lost thrust
04:36in one of their engines,
04:37only 390 feet off the ground.
04:40Losing an engine after takeoff
04:41is one of the most critical events
04:43that can happen in a flight.
04:44You're close to the ground,
04:45you're slow.
04:46However, we also know from our training
04:48that the aircraft will fly perfectly well
04:50on one engine.
04:51The first officer levels the plane
04:54and continues to climb away from the airport.
04:57Flaps.
04:59Turn 220 heading.
05:01I'll give you the flaps.
05:02Okay.
05:05Rhodes, A-10.
05:06We have an emergency.
05:08Stand by.
05:09We're on 220 heading.
05:11You can inch up to 2,000.
05:13The captain wants to put more distance
05:16between the plane and the ocean,
05:17so they have space to address the problem.
05:20Anytime you have an emergency situation,
05:22maintain aircraft control.
05:23You fail to do that,
05:24nothing else you do matters.
05:27Okay, Rhodes, A-10.
05:28We've lost an engine.
05:29We're on a 220 heading,
05:30maintaining 2,000.
05:31Declaring an emergency.
05:32How do you read?
05:34Rhodes Express, A-10.
05:36You are cleared visual approach.
05:38Runway four, right.
05:39You can turn in towards the airport.
05:42The controller clears flight A-10
05:44to return to the airport.
05:46Okay, Rhodes, A-10.
05:48We're going to run a checklist.
05:49I'll let you know when we're ready
05:50to come to the airport.
05:52Captain Okai wants to assess the situation further
05:56before returning to the airport.
05:59Flight A-10 has been in the air
06:00less than three minutes,
06:02flying over the Pacific Ocean
06:04on a very dark night.
06:06Okay, I have control.
06:08Roger.
06:09Okay, let's see what's the problem.
06:12What's going on with the gauges?
06:14The pilots troubleshoot the situation.
06:17So it looks like the number one.
06:20Number one's gone?
06:21Gone, yeah.
06:22We still have the number two.
06:24So we have number two.
06:25Okay.
06:25Okay.
06:25They confirm they've lost their number one,
06:31or left, engine.
06:32They now must rely on their right engine
06:34to return to the airport.
06:36Let's do the engine failure shutdown checklist,
06:38and I have the radios now.
06:40Okay.
06:42There's a number of things this checklist
06:43is going to do for you.
06:44It's going to confirm the failed engine,
06:46and you're going to want to secure that engine.
06:48Okay, engine failure or shutdown
06:52when one of these occurs.
06:53An engine failure,
06:54an engine flame out,
06:55another checklist directs an engine shutdown.
06:58As the pilots zero in on the problem engine,
07:01the situation intensifies.
07:04Hey, we're redline here.
07:05The right engine is now overheating,
07:08and they're losing altitude.
07:10We should pull back on the right one a little bit.
07:13Okay.
07:15We should head back to the airport.
07:17Yeah, we should.
07:18Yeah.
07:19The pilots now face the possibility
07:22of losing both engines.
07:24Problems on your second engine
07:26is going to significantly change your outlook
07:28because you've got the dark water below you,
07:30and you know you're running out of options.
07:32Okay, Rhodes A-10.
07:34We'd like to come to the airport now.
07:36We might lose the other engine.
07:38Rhodes Express A-10, Roger.
07:40Roger. Confirm you still have the airport in sight?
07:44All right. Negative.
07:47The pilots have descended too low to see the airport.
07:50Only the lights on the shoreline are visible.
07:54Hey, man, we're going down.
07:56We can't keep going down.
07:57We're descending.
07:59The captain has no other option
08:01but to increase power to the overheating engine,
08:04risking a double engine failure.
08:07How's the EGT?
08:08No, that's max. It's beyond max.
08:12The temperature of the right engine
08:14is now dangerously high,
08:15and the pilots suspect it could fail at any moment.
08:19Here we go, flops. Flops one.
08:21Fearing the worst,
08:22the first officer suggests configuring the plane
08:25for a water landing.
08:27No, no, not yet.
08:30Okay, we're very slow, though.
08:31The captain's efforts to reduce the loss in altitude
08:35aren't working.
08:37Shoot.
08:37Okay, flaps one.
08:41Just hitting the water is going to tear the airplane apart,
08:43so you want to be at the lowest possible airspeed.
08:46The flaps will facilitate that.
08:52Rose Express A-10, low altitude alert.
08:55As Transair Flight A-10 descends below 400 feet,
09:00the controller is automatically alerted
09:02to the aircraft's dangerously low altitude.
09:05Are you able to climb at all?
09:07Uh, negative.
09:08Can you let the Coast Guard know?
09:10We will.
09:15Watchdesk, please call the Coast Guard.
09:17Flight 810-737 is probably going to be in the water.
09:21How's the EGT?
09:22If the engine temperature has improved,
09:26they might be able to climb.
09:27Hot, way over.
09:29Corrine, corrine, pull, up.
09:32The chances of reaching the airport six miles away
09:35deteriorate as the plane descends even further.
09:39The controller has an idea.
09:42Express 810, do you want Kalailoa?
09:45There's a closer airport.
09:47It might be the pilot's last hope.
09:49We want the closest runway available, please.
09:52Anything we can land on.
09:56If they can't make it to the closer airport,
09:59there might be no other option
10:00than to ditch the 737 into the Pacific Ocean
10:03and hope for rescue.
10:07Too low.
10:08Here.
10:08Okay, give me a heading.
10:10Corrine, corrine.
10:11Pull, up.
10:12The pilots of Transair Flight 810
10:14have one last chance to reach land.
10:16Roads Express 810.
10:19The airport is about a 3-1-0 heading from you.
10:23But it's too late.
10:26Pull, up.
10:27Pull, up.
10:28Pull, up.
10:29Pull, up.
10:30Corrine, corrine.
10:31We're in the water.
10:32Pull, up.
10:32We're in the water.
10:33We're in the water.
10:3412 minutes after takeoff,
10:38Transair Flight 810 hits the ocean
10:40just two miles from the Kala'iloa airport.
10:49Watch desk.
10:49810's in the water.
10:50Two miles southeast of Kala'iloa.
10:52Coast Guard Air Rescue is immediately dispatched.
10:59Hearing that there's a 737 that crashed,
11:01I didn't believe it.
11:02But if there is,
11:04and there's 200 people in the water,
11:05what am I going to do?
11:07They told me two souls on board.
11:09We're like, all right,
11:10two is a lot more manageable than, like, 200.
11:1345 minutes later,
11:14there's still no sign of the plane or the pilots.
11:18Rescuers fear the worst until...
11:20There were a bunch of boxes now floating by us.
11:24I figured, all right,
11:25this might be the start of a debris field.
11:27So we started our second pass,
11:29and grabbing onto the vertical fin of the tail
11:31was one of our pilots.
11:35It's Captain Okai.
11:37I was like, all right,
11:39he is still okay, great.
11:41Still want to find the second pilot.
11:43They soon spot the first officer on a cargo pallet,
11:47bleeding from the head.
11:48Right before we started to make the moves
11:51to put me in the water,
11:52to go up to him,
11:53the plane moved.
11:55The tail section the captain had been clinging to
11:58sinks beneath the waves.
12:00The captain's drowning right now.
12:05They race back and deploy the rescue swimmer.
12:08As soon as I grabbed his hand,
12:12it's like his eyes rolled back and he went limp.
12:16They're dripping wet,
12:17covered in gasoline and hydraulic fluid,
12:19so it wasn't pretty.
12:21The first officer is soon rescued
12:24by a fire department vessel
12:25as the captain is rushed to a local hospital.
12:29Both pilots survive.
12:30Good planning, good crew,
12:32good decision-making,
12:34and then implementing those decisions
12:37is how we came out on top.
12:39While the pilots recover from their injuries,
12:42investigators from the National Transportation Safety Board,
12:45or NTSB,
12:46arrive on the scene.
12:48Right now we're in the fact-gathering phase.
12:51Once we finish the fact-gathering,
12:52we'll switch into the analytical side,
12:54and then that's when we'll go in
12:56to determine the probable cause
12:57and contributing factors.
13:02What can you tell me about last night?
13:04It was a normal night, slow.
13:07There was another Transair flight
13:09inbound around the same time.
13:12And when did Flight 810 alert you
13:14that there was a problem?
13:17Investigators turned to the controller
13:18to determine what might have caused
13:20Transair Flight 810 to ditch into the Pacific.
13:23It was about two minutes into the flight.
13:27They reported they'd lost an engine.
13:29Okay, Rhodes 810, we've lost an engine.
13:31We're on a 220 heading, maintaining 2,000,
13:33declaring an emergency.
13:34How do you read?
13:36They wanted to work on the problem
13:38before turning back.
13:39Did they say which engine?
13:42No, but not long after they said
13:44that they might lose the other engine as well.
13:47Really?
13:49Okay, Rhodes 810.
13:51We'd like to come to the airport now.
13:53We might lose the other engine.
13:55Could Transair 810 have really lost both engines?
13:59The only information we had to go on initially
14:01was the communications between the airplane
14:03and the controller,
14:05but the airplane and its recorders
14:06were at the bottom of the ocean.
14:12Another NTSB team is tasked with recovering
14:15the airplane and its engines
14:16lying 350 feet deep on the ocean floor.
14:20At the depth that the airplane was at,
14:23it's difficult to get divers down there.
14:25So in order to actually hook all of our equipment
14:29up to the aircraft and pull it up,
14:31we needed to use ROVs.
14:33It will take time for the investigation
14:35to secure the necessary equipment
14:37from a salvage company on the mainland.
14:39Good morning.
14:45Good morning.
14:46I'm glad to see you here.
14:47So am I.
14:48Very glad.
14:49Yeah.
14:51Investigators meet with Captain Okai
14:53to determine if Transair Flight 810
14:56did lose both engines.
14:59The purpose of this investigation
15:01is to determine probable cause
15:03and prevent recurrence.
15:04Our role is not to assign fault.
15:06I understand.
15:07It's critical to speak to pilots
15:10as soon as we can
15:11because we want to get those fresh memories.
15:14Walk me through what happened.
15:16Everything was normal up to about 400 feet.
15:22Gear up.
15:23There was a whoosh sort of a sound.
15:35Not a pow.
15:36It was a whoosh.
15:38Then it wasn't a roll.
15:40My first officer was able to counteract that.
15:44Lost an engine.
15:45You got it?
15:47Yeah, I got it.
15:51Eventually we leveled off at 2,000 feet
15:53and I go,
15:55Greg, what do we have?
15:57So it looks like the number one.
15:59Number one's gone?
16:00Gone, yeah.
16:02We still have the number two.
16:03So we have number two.
16:04Okay.
16:05Okay.
16:05I'm looking at number one EPR.
16:11There's no power.
16:12I'm looking at number two
16:14and EPR.
16:15It's coming down.
16:18The captain explains
16:20he first lost power in the left engine
16:22and was losing power in the right.
16:26How's the EGT?
16:29It's max.
16:30It's beyond max.
16:31Did both engines fail at the same time?
16:35Most likely.
16:36That's my conclusion.
16:41Thanks.
16:42We'll be in touch.
16:43What could have caused both engines to fail
16:46so soon after takeoff?
16:48The purpose of this investigation...
16:50A dual engine failure seemed improbable,
16:53but both the crew seemed to agree
16:56that that is what had occurred.
16:57And we couldn't confirm or deny it
16:59unless we could actually look at the wreckage
17:02and get the recorders.
17:04But those vital clues remain out of reach,
17:08deep on the bottom of the sea.
17:13Could contaminated fuel
17:14have brought down Transair Flight 810?
17:18You're looking for an item
17:19that's common to both engines
17:21would cause them both to shut down
17:22at the same time.
17:23For that would be most likely the fuel.
17:27So one thing that we did do
17:32at the airport
17:33was take samples from the fuel truck
17:35that had been used to fuel the airplane
17:37before it departed.
17:40The U.S. Navy conducts the testing.
17:43If you have water in your fuel,
17:45that was most likely
17:47to be the cause of fuel contamination.
17:51When the fuel samples are analysed,
17:53the results are conclusive.
17:55We actually found that the fuel
17:58that was in the aircraft
18:00conformed to standards
18:01as we would expect.
18:04So according to the pilots,
18:07they lose the left engine first
18:09and then the right.
18:10All the samples from the fuel truck
18:21tested clean.
18:26What was the weather like on that night?
18:28Any volcanic activity?
18:31Hawaii is in an active volcano zone.
18:34Could volcanic ash
18:36have caused the engines to fail?
18:37Volcanic ash is very bad for jet engines.
18:41It's like throwing sand in the gears.
18:43Jet engines will shut down.
18:46In 1982,
18:47a British Airways 747
18:49travelling from England to New Zealand
18:51flew through an ash cloud over Indonesia.
18:54All four engines failed.
18:57The plane was high enough
18:58for pilots to be able to restart the engines,
19:01find an airport,
19:02and land safely.
19:03Nothing here.
19:08Clear night.
19:16So that leaves maintenance.
19:18There are no reports
19:19of volcanic ash on that night.
19:21The only information
19:21that we have to work on
19:22is what the crew's telling us
19:23is that they had
19:24a dual engine failure,
19:25so we're going to look
19:26at the maintenance on the engines.
19:27In the meantime,
19:29recovery crews pinpoint
19:31the exact location of the plane.
19:33It has settled on the ocean floor
19:34in two large pieces.
19:37Often with water recoveries,
19:39we have an airplane
19:40that's in multiple different pieces.
19:42They're usually smaller pieces,
19:44and they're less heavy.
19:45So to bring them up intact
19:48was a bigger engineering problem.
19:51It means another delay
19:53for investigators.
19:54The plane is, what,
19:57like 40-something years old?
20:00The team digs into the engine history
20:03of the accident aircraft
20:05to determine why both engines
20:07might have failed.
20:0946.
20:11Flown over 69,000 cycles.
20:15The engines have been around, too.
20:17Left engine, 32,000 flying hours.
20:20And the right, over 70,000.
20:22Engines that old
20:25are going to need upkeep.
20:28Jet engines are very solid machines
20:30with proper inspection and maintenance.
20:32They can fly on forever.
20:34Anything in the FAA database?
20:39Investigators look into service reports
20:41filed by Transair
20:42with the Federal Aviation Administration,
20:44or FAA,
20:45to see if the aircraft
20:47had any history of engine troubles.
20:49I've got three reports
20:51on this aircraft.
20:53The most recent
20:54was two and a half years ago
20:57left engine failure
20:58at 2,000 feet.
21:01That's something.
21:04Did an aging aircraft
21:06put the lives
21:07of two pilots in jeopardy?
21:09The team researches
21:11the repair work
21:11that's been performed
21:12on the engines
21:13over the years.
21:14Both engines
21:17were serviced
21:17two years ago
21:18and underwent
21:19a daily check
21:21the day before
21:21the accident flight.
21:23Did they report anything?
21:28No discrepancies.
21:29It's possible that
21:37maintenance
21:39could have missed something.
21:41Call your contacts
21:42at the FAA.
21:44Maybe they can
21:45shed some light
21:46on Transair.
21:47And I'll speak
21:48to maintenance personally.
21:50Because of the possibility
21:51that there had been
21:53a dual engine failure,
21:54we did a deep dive
21:55on the maintenance organization
21:57at the airline
21:57trying to find
21:58potential theories
22:00for something
22:01that could have
22:02gone wrong.
22:04Bit of a mess
22:05over there
22:06at Transair Maintenance.
22:07What did you find out?
22:09Chief Maintenance Inspector
22:11quit six weeks
22:12ahead of the accident
22:13citing chronic
22:14maintenance issues
22:15and being understaffed.
22:17Also found
22:18multiple reports
22:19from different pilots
22:21about engines overheating.
22:24Investigators uncover
22:25internal Transair reports
22:27revealing issues
22:28with the engines.
22:29We noticed so many
22:30of these reported issues
22:32with temperature
22:34that we were starting
22:35to think that
22:36this might really involve
22:37a maintenance issue.
22:39There was just so much smoke
22:40we thought
22:40there had to be some fire.
22:44Anything specific
22:45to the accident aircraft?
22:47No, they involved
22:48other airplanes.
22:50Not exactly a smoking gun.
22:54Anything from the FAA?
22:55Most of the current
22:56inquiries into the company
22:58are policy and procedure related.
23:00Nothing to do
23:01with engine maintenance.
23:04Investigators don't find
23:06any maintenance issues
23:07that would have brought down
23:08Flight 810.
23:12We need those engines.
23:15So even though
23:16we were discovering
23:16these issues
23:17with pilot reports
23:18and maintenance records,
23:19there wasn't anything
23:20clearly indicating
23:21a specific problem
23:22that would have led
23:23to this reported
23:24dual-engine failure.
23:26With a salvage company
23:28in place
23:28and the weather clearing,
23:30the NTSB is finally able
23:32to attempt the recovery
23:34of Flight 810
23:35from 350 feet of water.
23:38This is one of the largest
23:39water recovery efforts
23:40we have done
23:41in a couple decades.
23:42The wreckage
23:43is successfully raised
23:44in two large pieces.
23:46The black boxes
23:47are recovered
23:48from the rear fuselage
23:49and sent to Washington
23:50for analysis.
23:52The engines
23:52are retrieved separately
23:53and brought to a warehouse
23:55for inspection.
23:57To be able to see
23:58that wreckage come up
23:59just creates immense satisfaction
24:01because you're like,
24:01OK, now,
24:02now we can start this
24:04in earnest.
24:10Let's start with this one.
24:13Investigators begin
24:14with an examination
24:15of the right engine,
24:17the one the pilots say
24:18was overheating.
24:19It's in better shape
24:20than I expected.
24:23They were in pretty good shape.
24:25There was damage
24:26due to the water impact.
24:29Let's take a look inside.
24:32They perform a bore scope
24:33inspection of the right engine.
24:36It enables them
24:36to examine the engine interior
24:38without the need
24:39for disassembly.
24:41There.
24:43Take a look.
24:44Broken fan blades.
24:45See if there's any damage
24:48downstream.
24:55Multiple puncture marks
24:57on the turbine.
24:58With that type of damage,
25:00the engine could have
25:01easily overheated.
25:04Investigators discover
25:05two fractured turbine blades,
25:07which caused shrapnel damage
25:09inside the right engine.
25:10The pilots were correct.
25:13The right engine
25:14was giving them trouble.
25:16So from the examination
25:17on the right engine,
25:19they were able to see
25:20that there were blades
25:21that had fractured
25:22in the high-pressure turbine.
25:24But it was only those two.
25:26And they knew that
25:28it would still be able
25:29to produce power.
25:30So it wasn't like
25:31a complete failure.
25:32Looks like rust
25:34and corrosion
25:35inside of the blades
25:36caused them to rupture.
25:38The routine maintenance
25:42inspection procedures
25:44contained in the
25:45maintenance manual
25:45would not necessarily
25:47have revealed
25:48the presence of cracks
25:49or one fractured blade.
25:51So this is the engine
25:53the pilot said
25:53failed first.
25:57Investigators turn
25:58their attention
25:58to the left engine.
26:04Let's see what we got.
26:08It looks fine.
26:17No internal damage.
26:19The pilot said
26:21the left engine failed,
26:23followed by the right.
26:24But investigators
26:25can't find anything wrong
26:26with the left engine.
26:28When we found out
26:29that the left engine
26:30was undamaged prior to impact,
26:32it really changed
26:33the course of our investigation
26:35in terms of focusing
26:37more on the crew actions.
26:40We pulled the flight path
26:41from the radar data.
26:44We've got the CVR data.
26:48And here's
26:50a copy of the transcript.
26:55Investigators turn
26:56to the cockpit voice recorder,
26:57or CVR,
26:58of Flight 810
26:59to determine why
27:01the pilots thought
27:02the left engine failed,
27:03as the evidence suggests
27:05it did not.
27:07Let's hear it
27:07from takeoff.
27:1180 knots.
27:13Check.
27:15V1.
27:16Rotate.
27:18V2.
27:20Positive rate.
27:24Gear up.
27:24Definitely sounds like
27:50an engine surge.
27:51They discover
27:53that Flight 810
27:54suffered engine trouble
27:5517 seconds
27:57after takeoff.
27:59Most likely
28:00the blades
28:01breaking apart
28:02in the right engine.
28:03Keep playing.
28:05Lost an engine.
28:07You got it?
28:08Yeah, I got it.
28:10Yep, looks like
28:11you lost number...
28:12Number two.
28:13Number two.
28:14Right.
28:16Hold it right there?
28:17They both said
28:18number two.
28:19The right engine.
28:20They were correct.
28:26The pilot's
28:27original assessment
28:28matches what
28:29investigators have
28:29discovered.
28:30The initial problem
28:31was with the right
28:33engine.
28:33So,
28:34why did they think
28:35that the left
28:36engine had failed?
28:38We were able
28:39to hear the crew
28:40discuss they had
28:40correctly identified
28:41the right engine.
28:43So at some point,
28:44you know,
28:44in their mindset,
28:45it had flipped
28:46to the wrong engine.
28:46Let's hear what
28:49happens next.
28:51Flaps.
28:52Turn 220 heading.
28:54I'll give you
28:55the flaps.
29:00Rhodes,
29:01A-10.
29:01We have an emergency.
29:03Stand by.
29:04We're on 220 heading.
29:06You can inch up
29:07to 2,000.
29:10Captain calls in
29:11the emergency.
29:13Tells the first
29:13officer to climb
29:14to a safe altitude.
29:15All sounds good.
29:18And we're on 220 heading.
29:21Say again.
29:22Heading 2, 4, 0.
29:242, 4, 0 heading.
29:26Rhodes, A-10.
29:27No,
29:28Rhodes,
29:288, 0, 9.
29:29Rhodes,
29:298, 0, 9.
29:30Left,
29:312, 4, 0.
29:34Sounds like
29:35there's some overlap
29:36with another
29:37trans air flight.
29:40According to
29:41these transcripts,
29:42the captain spends
29:43the next minute
29:45and 40 seconds
29:46communicating with
29:47the controller.
29:48That's a long time
29:49and a critical moment.
29:53Investigators learn
29:55that instead of
29:55monitoring the engines...
29:58Rhodes Express,
29:598, 10.
29:59You are cleared
30:00visual approach
30:01runway 4, right.
30:03The captain
30:04is distracted
30:04by a conversation
30:06with the controller.
30:07Okay, Rhodes,
30:088, 10.
30:09We're going to run
30:09a checklist.
30:10I'll let you know
30:11when we're ready
30:11to come to the airport.
30:13When you have
30:13an emergency situation,
30:15it is important
30:15to aviate,
30:16navigate,
30:17and communicate.
30:18Your third priority
30:19is communicating
30:20your emergency.
30:22What happens next?
30:24The captain starts
30:35flying the plane
30:36and turns
30:36his attention
30:37to the engines.
30:39So it looks like
30:39the number 1.
30:41Number 1's gone?
30:42Gone, yeah.
30:43We still have
30:44the number 2.
30:45So we have
30:46number 2.
30:46Okay.
30:48Stop.
30:50The FO changes
30:51his diagnosis.
30:52Investigators confirm
30:54that the first officer
30:56correctly assesses
30:57that the right engine
30:58lost power
30:59on takeoff.
31:00Yep, looks like
31:01you lost number...
31:03Number 2.
31:04But less than
31:054 minutes later,
31:06he tells Captain Okai
31:08it's the left engine
31:09that's failed.
31:10So it looks like
31:10the number 1.
31:12Number 1's gone?
31:13Gone, yeah.
31:15Why?
31:18It wasn't clear
31:19why they had
31:21changed their minds
31:21about it.
31:22The captain
31:25then instructs
31:26the FO
31:27to do the
31:27engine shutdown
31:28checklist
31:29but he only
31:29gets through
31:30the first step.
31:33Hey, we're
31:34redline here.
31:35We should pull
31:35back on the
31:36right one a little bit.
31:37Okay.
31:39The right engine
31:40overheats
31:41because of
31:42the internal damage
31:43leading the pilots
31:44to believe
31:44they're losing
31:45both engines.
31:46Once the crew
31:47had convinced
31:48themselves
31:48that they had
31:49a dual engine
31:49failure,
31:50they were focused
31:52almost exclusively
31:52on altitude
31:53and airspeed
31:54and eventually
31:56they ran out
31:56of options
31:57and had to ditch.
31:59It's clear
32:00that the right engine,
32:01the one with the issue,
32:03is overheating
32:04and not producing
32:05full thrust.
32:06what led them to think
32:08the left engine
32:09wasn't working.
32:10Let's see what the
32:11flight data recorder
32:12can tell us.
32:13Okay, let's see what
32:19the engines were doing.
32:21Investigators examined
32:22the engine power data
32:23of flight A-10
32:24to determine
32:25what actions
32:26the pilots took
32:27that led them
32:28to believe
32:29their perfectly working engine,
32:30the left one,
32:31had failed.
32:34After the right engine
32:36failed,
32:36both engines
32:37are brought back
32:38to flight idle
32:39once they level off
32:40at 2,000 feet.
32:41That's proper procedure
32:49to get the speed down.
32:51But the first officer
32:52never told the captain
32:53he brought the engines
32:54back to idle.
32:58They discover
32:59a key step missing
33:00in the pilot's actions.
33:04It was procedure
33:05for a crew member
33:06to verbalize
33:07when they moved
33:08the engine controls.
33:09In this case,
33:10the first officer
33:11actually did not do that
33:12and that could have
33:13affected the captain's
33:15situational awareness
33:16of where those
33:16engine throttles were.
33:19Why did the first officer
33:21fail to inform
33:22the captain
33:22of his action?
33:25Send someone
33:26to interview
33:26the first officer again
33:27about bringing
33:28the throttles back.
33:29So, it was critical
33:33for us to get
33:34more information
33:35to better understand
33:36what had happened there.
33:38Did anyone
33:39actually ever
33:40test the throttles?
33:42After they leveled off,
33:44the pilots
33:45could have increased
33:46power to the left engine
33:47to confirm
33:48which engine
33:49had failed.
33:52No.
33:53The left engine
33:53throttle
33:54stayed at idle
33:55for the rest
33:56of the flight.
33:59If you're going
34:00into the water
34:01and you have
34:02no other option left,
34:03you're going to
34:03firewall both throttles
34:04just in case
34:06it might help.
34:08Why didn't the captain
34:10check the first officer's
34:11misdiagnosis?
34:14Let's ask him.
34:17When the first officer
34:18subsequently said
34:19it was the number one,
34:20the captain
34:20had just accepted it.
34:21He didn't
34:22effectively
34:22cross-check
34:23that erroneous
34:24assertion.
34:26So,
34:27we wanted
34:28to ask him
34:29why.
34:30Why did he
34:31accept that?
34:35Captain Okai,
34:36thanks for meeting
34:37with me again.
34:40You're muted.
34:43Investigators
34:43speak to
34:44Captain Okai
34:45one more time
34:46to find out
34:47why he thought
34:47the left engine
34:48had failed.
34:49Sorry about that.
34:51Glad I can help.
34:52When Greg told you
34:53the left engine
34:54had failed,
34:55do you recall
34:56initially thinking
34:57the right one
34:57had failed?
35:00No.
35:01The thing with Greg
35:02is I've flown
35:02with him so many times.
35:04He's never
35:04made a mistake.
35:05If Greg says
35:06the left is gone,
35:07the left engine
35:07is gone.
35:10Investigators
35:11learn the captain
35:12put his faith
35:13in his first
35:14officer's diagnosis.
35:16While trust
35:17is very important
35:17when it comes
35:18to crew resource
35:19management,
35:19you also
35:21want to verify.
35:22The captain
35:23did not verify
35:24the information
35:25that the first
35:25officer was giving
35:26him.
35:28Okay.
35:30Sure, thank you.
35:32It's really critical
35:33when you do have
35:34an engine failure
35:34to look at
35:36all the available
35:37information
35:37and cross-check
35:39and agree
35:40that you have
35:41identified the
35:42correct engine.
35:43In this case,
35:44that didn't occur.
35:45What were the
35:47power readings
35:48when the engines
35:49were at idle?
35:51Even if the
35:52captain trusted
35:53the first officer,
35:54wouldn't there
35:54be other indicators
35:56showing which
35:56engine had failed?
36:01The left
36:02engine was
36:031.05,
36:06and the right
36:071.12.
36:09The team
36:11discovers the
36:11power was a
36:12little bit lower
36:13on the left
36:14engine,
36:15even though both
36:16engines were set
36:17to idle.
36:18Okay, let's see
36:19what's the problem.
36:20What's going on
36:21with the gauges?
36:21They did have
36:24slightly different
36:25power outputs,
36:26and that is
36:26something you
36:27would see
36:27with two
36:28different engines.
36:29That could have
36:30really affected
36:31the captain's
36:31decision-making.
36:34If the captain
36:35had checked
36:36the gauges,
36:37the readings
36:38would have
36:38supported his
36:39first officer's
36:40report that
36:41the left
36:41engine had
36:42failed.
36:43So it looks
36:44like the
36:44number 1.
36:45Number 1's
36:46gone?
36:46Gone, yeah.
36:47So we have
36:48number 2.
36:48Okay.
36:51But this
36:53doesn't explain
36:54why the first
36:54officer never
36:55told the
36:56captain that
36:56he brought
36:57both throttles
36:58back in the
36:58first place.
37:05If the first
37:05officer had
37:06said, hey,
37:07I pulled the
37:07thrust back
37:07on both
37:08engines,
37:08then that
37:09might have
37:09caused the
37:10captain to
37:11engage in a
37:12different thought
37:12process about
37:13what might be
37:14going on.
37:21first officer
37:22follow-up
37:23interview.
37:25Why didn't
37:26the first
37:26officer of
37:27Transair
37:27Flight 810
37:28tell the
37:29captain he
37:29brought the
37:30power levers
37:31back after
37:31the right
37:32engine failed?
37:33He has no
37:34recollection of
37:35bringing either
37:36thrust lever
37:37back to
37:38idle.
37:40We believe
37:41that the
37:42first officer
37:43forgot because
37:44he was
37:44busy.
37:44that leads
37:47to stress,
37:48stress leads
37:49to tunneling
37:49of attention,
37:51that can lead
37:51to fixation
37:52on a small
37:53number of
37:53parameters.
37:56But even
37:57if the first
37:58officer didn't
37:59tell the
37:59captain about
37:59the thrust
38:00levers,
38:01there must
38:01have been
38:01other signs
38:02which engine
38:03failed.
38:06Check out
38:07the rudder
38:07data.
38:09Immediately
38:10after the
38:10right engine
38:11failed on
38:12takeoff,
38:135.5 degrees
38:14of left
38:15rudder is
38:15applied.
38:20You got
38:21it?
38:22Yeah,
38:22I got it.
38:26After the
38:27right engine
38:28lost power
38:28on takeoff,
38:30the plane
38:30pulled to
38:31the right.
38:32When the
38:32first officer
38:33applied the
38:34left rudder,
38:35the plane
38:36straightened
38:36out.
38:37The foot
38:38that isn't
38:38pressing on
38:39the rudder
38:39paddle is
38:40the side
38:40with the
38:40bad engine,
38:41so it's
38:42usually a
38:42pretty clear
38:43indication of
38:43which engine
38:44has failed.
38:46He held
38:47that left
38:47rudder for
38:49three minutes.
38:50He had a
38:51clear indicator,
38:52but it never
38:53registered.
38:54The fact that
38:55the first officer
38:56was applying
38:57left rudder
38:57was an indication
38:58that the right
38:59engine had
39:00lost power.
39:01It's very
39:01possible that
39:02under those
39:02stressful conditions
39:03in the middle
39:03of the night
39:04over the water,
39:04you could make
39:05that mistake.
39:06they made
39:09the right
39:09assessment
39:10initially,
39:11but in
39:11the end,
39:13the stress
39:13of the
39:14situation
39:14degraded
39:15their ability
39:16to fly
39:16the plane.
39:20Investigators
39:21now know
39:21the series
39:22of events
39:23that led
39:23to the
39:23ditching
39:24of Transair
39:25Flight 810.
39:28When the
39:29right engine
39:29loses power
39:30after takeoff,
39:36both pilots
39:38make the
39:38proper assessment.
39:41Yep,
39:41looks like
39:41we lost
39:42number...
39:43Number two.
39:44Number two.
39:46But while
39:47the captain
39:47communicates
39:48with air
39:49traffic control...
39:51Okay,
39:51Rhodes,
39:52810.
39:53We're gonna
39:53run a checklist.
39:54The first
39:55officer reduces
39:56engine power.
39:58Okay,
39:58let's see
39:59what's the
40:00problem.
40:01In a moment
40:02of stress,
40:03he forgets
40:03to tell
40:04the captain.
40:05What's going
40:06on with
40:06the gauges?
40:07The slightly
40:08different readings
40:09on the gauges
40:10lead the pilots
40:11to believe
40:11the fully
40:12functioning
40:12left engine
40:13has failed.
40:14So it looks
40:15like the
40:15number one.
40:16Number one's
40:17gone?
40:17The captain
40:18relies on the
40:19first officer's
40:20assessment
40:20without doing
40:21his own
40:22analysis
40:22of the
40:22situation.
40:23Gone,
40:24yeah.
40:25We still
40:25have the
40:26number two.
40:27So we have
40:27number two.
40:28Okay.
40:28Instead of
40:30confirming
40:31which engine
40:32had actually
40:32lost power
40:33and forgetting
40:34their original
40:35assessment,
40:36the pilots
40:36end up flying
40:37on a damaged
40:38engine.
40:39How's the
40:40EGT?
40:42It's maxed.
40:43It's beyond maxed.
40:45Setting them
40:45up for an
40:46inevitable
40:47ditching.
40:48We're in the
40:49water!
40:49We're in the
40:50water!
40:50The pilots
41:06misidentification
41:07of the damaged
41:08engine and
41:09their use of
41:09the only...
41:10Before the
41:11NTSB's final
41:12report is
41:12published,
41:13Rhodes Aviation
41:14is shut down
41:15by the Federal
41:16Aviation
41:16Administration
41:17for numerous
41:18safety and
41:19maintenance
41:20violations.
41:23While it may
41:24be disappointing
41:25that the crew
41:25never actually
41:26touched their
41:27left engine
41:28that was
41:28working properly,
41:30it is a
41:30testament to
41:31the human
41:32limitations that
41:32actually arise
41:33when you have
41:34stressful,
41:35high workload
41:36situations,
41:37and that's
41:37what we need
41:38to account
41:38for.
41:39With only
41:4050 737-200s
41:42remaining in
41:43service,
41:44it's deemed
41:44impractical to
41:45fit them with
41:46engine sensors
41:47that would
41:47alert pilots
41:48to a failed
41:49engine.
41:50But it's
41:51now standard
41:51in most
41:52passenger airliners.
41:55Engine
41:55monitoring
41:56technology has
41:57improved
41:57considerably
41:58since this
41:59aircraft was
41:59manufactured.
42:01Newer
42:01airplanes actually
42:02give very
42:03clear indications
42:04to the pilot
42:05regarding which
42:06engine is bad
42:07and reduces
42:09the risk of
42:10the crew
42:10misidentifying it.