- vor 22 Stunden
On 6 April 1993, a crew member accidentally deploys the slats on China Eastern Airlines Flight 583 over the Pacific Ocean, causing severe oscillations. The aircraft later lands safely at Shemya Air Force Base in Alaska. Two passengers die from their injuries.
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00:00After declaring an emergency...
00:02Injured passengers due to severe turbulence.
00:05China Eastern Airlines Flight 583 seeks permission
00:09to land at a restricted U.S. military base in the Bering Sea.
00:13300 feet.
00:14The Pentagon would have to take a look at what's happening.
00:17Is this a ruse to take a look at our radar site?
00:21Once the plane is examined,
00:23officials discount the possibility of espionage.
00:28Never seen anything like it before.
00:31This accident was definitely a catastrophic event.
00:35Two passengers died.
00:38The flight data recorder shows an erratic flight path.
00:42Wow.
00:43Being on this airplane was like being on a roller coaster.
00:49Only the cause is not what the pilots reported.
00:53The weather was clear.
00:54It's unlikely there was any turbulence.
00:56That changes everything.
01:00Mayday, mayday.
01:04Oh, fuck.
01:06I think I want to open up.
01:08I think I'll come back to my client.
01:09I don't want to go.
01:10I don't want to go.
01:11I don't want to go.
01:12I don't want to go.
01:13I don't want to go.
01:14The crew of China Eastern Airlines Flight 583 is on an overnight flight from Beijing to Los Angeles.
01:29Approaching 39 degrees north, 172 degrees east.
01:33All good back there?
01:34In 1993, China Eastern Airlines was a fairly new company.
01:45It had only been around a couple of years.
01:48The entire China aviation market was rapidly changing.
01:58China Eastern Airlines began operation in 1988.
02:03It was an exciting time with people finding that they suddenly had the ability to start travelling overseas.
02:10235 passengers have just finished their meal service.
02:18Some rest, while others watch a movie.
02:25You press the switch, and the air conditioning pops up.
02:30The captain is a veteran pilot with more than 8,000 flying hours.
02:35You try.
02:37The captain was flying the airplane from the right seat because he was training the person who was in the left seat to be a new captain.
02:50His first officer is a seasoned pilot, but new to this plane, an MD-11.
03:00McDonnell Douglas developed the MD-11 as a fuel-efficient option for long-haul flights.
03:06In the early 1990s, approximately 100 of them were in service worldwide.
03:13The MD-11 was an upgraded version of the DC-10.
03:18It was more efficient flying at cruise speeds.
03:21Although it had an automated system for flying the aircraft,
03:25it was also changed in such a way that it was very responsive to pilot input, if they were flying it manually.
03:31This plane is one of five the airline bought to grow its international service.
03:42Field check numbers look good.
03:44Copy that.
03:46During the cruise portion of the flight, things are fairly routine.
03:54Flying at 33,000 feet, the autopilot's on.
03:58They've completed the first leg of the flight from Beijing to Shanghai,
04:05and are now flying over the North Pacific bound for Los Angeles.
04:14Ladies and gentlemen, the cabin crew is now passing out customs declaration cards,
04:19which must be completed before entering the United States.
04:22For many passengers, this is their first overseas flight. The process is unfamiliar.
04:35Do you postal code of the hotel we're staying?
04:38Yeah.
04:43Something's going on with the speed indicator.
04:45The crew has pre-programmed a cruising speed into the computer,
04:49which is now telling them to fly at a different speed.
04:52The flight control computer is making numerous checks of various systems,
04:57including air temperature, air speed, fuel burn, etc.
05:00And they sometimes give suggestions to the pilots of how they can fly more efficiently.
05:05In this case, fly more slowly.
05:10That didn't fix it.
05:12The captain tries to clear the computer's suggested speed.
05:18It's not a big concern. The airplane's flying fine.
05:21But it's just odd. And the captain tries to sort it out.
05:26I'm going to try this.
05:30What's that?
05:33While they're sorting out the speed issue,
05:37the plane seems to hit some turbulence.
05:40They start feeling this buffeting.
05:43And the airplane's shaking around.
05:46Definitely something that will get any pilot's attention.
05:49Suddenly, one of the worst things a pilot can hear.
05:54A stall warning alarm.
05:56I'm taking control.
05:57I'm taking control.
05:59The nose of the plane is pitching up,
06:01which shouldn't happen while cruising at altitude with the autopilot on.
06:06He needs to get the nose down because the airplane truly stalls.
06:10It no longer has enough lift to stay flying.
06:12It's going to start dropping from the sky.
06:14The captain pushes the yoke with enough force to override the autopilot.
06:19Autopilot off.
06:20Off.
06:23And to avoid a stall.
06:28But now the nose pitches too far down.
06:31Pull up.
06:35The effects of the dive are felt even more severely in the cabin.
06:38Trying to gain control of the airplane, trying to understand what's going on.
06:48The adrenal level goes dramatic real quick.
06:52The captain uses all of his strength to keep the plane from diving.
06:58But the aircraft pitches up steeper than expected, exerting massive G-forces on everyone and everything in the cabin.
07:05Timberlands!
07:07Seatbelts, everyone!
07:11What's going on?
07:13In essence, this airplane was pitching up, then pitching down.
07:18It's almost like being on a roller coaster.
07:23The captain attempts to level the plane, but it goes into an even more extreme dive.
07:29It happens so fast. The forces are so great.
07:39You wouldn't have time to even think of trying to get your seatbelt on.
07:44Eight degrees, no doubt.
07:47Nine.
07:49Ten.
07:50The captain halts the terrifying dive, with severe consequences for unbuckled passengers.
07:59You're being slammed back into your seat, and then thrown back onto whatever might be below you at the time.
08:08As the plane is tossed up and down, the crew avoids a stall by keeping the nose from pitching up too much.
08:15But the nose downs are a problem.
08:17The pitch downs were more extreme than the pitch ups.
08:21And the aircraft is losing altitude.
08:26On the next oscillation, the plane pitches down an astonishing 24 degrees.
08:31The captain battles to stop the plane from diving, while passengers struggle for their lives.
08:47A lot's going on. It's a dark night. He's used these instruments. Forces are nothing like he's ever seen before.
09:01And so it takes several of these cycles of this porpoicine until finally he is able to get the airplane back to level.
09:07Thirty seconds in, the oscillations lessen, and the plane begins to stabilize.
09:18Levels at zero degrees.
09:22To the crew, it probably felt like it lasted, you know, an hour.
09:26In reality, it lasted a little less than a minute.
09:35What just happened?
09:38No idea.
09:39Even with the autopilot on, there's no time to relax. There's no guarantee that what happened won't happen again.
09:49They're flying over the vast Pacific Ocean, nowhere near an airport. And several passengers are seriously wounded.
09:57We have many injuries.
10:02We need to get this plane on the ground.
10:09China Eastern Airlines Flight 583 is back at 33,000 feet. Now it needs a place to land.
10:17235 passengers on board. Unknown number injured.
10:21Call it in now.
10:22Flight 583, requesting the nearest airport. This is an emergency.
10:28Airspeed?
10:31298 knots.
10:33Angle of attack?
10:35Zero.
10:37For now, everything seems to be working.
10:40All they know at the moment is the airplane's flying, what appears to be fine, but then again, until we land and get out, look at it, we don't know.
10:48With injured passengers on board, the captain can't take the risk of flying 3,700 miles to their destination, Los Angeles.
10:59We're 39 degrees north, 176 east.
11:03Copy. Please stand by.
11:05The crew considers where they might land.
11:09Are we closer to Russia or to the US?
11:12This far out over the Pacific, mainland Russia is 2,200 miles to the northwest.
11:21Anchorage, Alaska is the same distance to the northeast.
11:24They're in one of the few places in the world where there's nothing really close by.
11:30Ladies and gentlemen, the plane encountered severe turbulence and the damage is being assessed.
11:36Please cooperate and be patient. We are planning for an emergency landing.
11:41Flight 583 is overseen by air traffic control in Honolulu, 2,000 miles away.
11:48What is your emergency?
11:52Injured passengers due to severe turbulence.
11:56Stand by, please.
11:58It's an unusual situation.
12:00A civilian Chinese airplane in international airspace in urgent need of an airport.
12:06Looks like it's either Anchorage or Shemya.
12:09Waiting for clearance.
12:10Shemya, a tiny island on the western tip of Alaska's Aleutian Island chain, is about 1,000 miles away.
12:21Anchorage is twice as far.
12:23Because it's an air force base, Shemya has medical staff and equipment to treat injured passengers.
12:29Shemya is basically an island in the middle of nowhere.
12:34Operated by the U.S. Air Force is strictly for military operation.
12:40There are no commercial flights.
12:42The decision to allow the China Eastern Airlines flight to land is taken to the highest levels.
12:49The Pentagon would have to take a look at what's happening here.
12:53Is this a real emergency or is this a ruse to take a look at our big radar site we have there?
13:02I imagine there was a lot of discussion going on from a security point of view.
13:07Clear to divert to Shemya.
13:10We're clear to divert to Shemya.
13:12The captain had a choice to make.
13:16Do I go to the closest available runway, which was Shemya, or do I go further on to Anchorage, which might be catastrophic had there been damage to the aircraft?
13:26Okay, we're going to Shemya.
13:30We have received permission to land at Shemya Air Force Base.
13:35Damage to our aircraft is unknown.
13:37Can we get a weather report?
13:41The crew prepares for a difficult night landing on an airstrip they've never seen before, with unknown damage to their airplane.
13:50Shemya has extreme weather. Heavy cloud cover, fog, and high winds is the norm.
13:57After a nerve-wracking two hours in the air, the plane is now only 40 miles from the airbase.
14:02Altimeters set.
14:05They really don't know what's going to happen when they slow up.
14:10Did the elevators get damaged? Will the landing gear come down?
14:15There's a lot of things they've got to be concerned about.
14:18As they get closer, the weather intensifies.
14:22Islas armed. Runway 28.
14:25Runway 28.
14:27The crew connects to an instrument landing system that uses radio signals to guide them in.
14:332,000 feet.
14:35The crew at this point is going to be under a good amount of stress and pressure to make sure that they do it right the first time.
14:42Wanting to get the people to help as quickly as possible.
14:45Autopilot off. Taking control.
14:53They're now only six miles from the runway.
14:57Gear down.
15:06Landing gears down.
15:07500 feet.
15:21400 feet.
15:25300 feet.
15:27The ILS gets the plane as far as 200 feet above the ground.
15:32Then the captain has to fly by sight.
15:34I have touched down.
16:00The emergency is over.
16:02The plane is safely on the ground.
16:09Medical teams immediately assess passengers.
16:16The findings are grim.
16:19149 people are injured.
16:22Dozens of passengers and crew are taken to hospital.
16:26One passenger is dead.
16:28Another is fatally wounded.
16:29This accident was definitely a catastrophic event.
16:35Many, many passengers and flight attendants were seriously injured.
16:43Passengers who are well enough to travel are flown to Anchorage International Airport and transferred to hospital for treatment there.
16:56At that time, I think I would die.
16:57At that time, I think I would die.
16:59Of course, surely I would die.
17:02A team of investigators from the National Transportation Safety Board, or NTSB, flies in from Washington.
17:11Greg Fythe leads the investigation.
17:13Greg Fythe leads the investigation.
17:14Greg Fythe leads the investigation.
17:15Greg Fyfe leads the investigation.
17:23Never know anything that was wrong with it from here.
17:27They did land on U.S. territory,
17:29and so we were going to conduct the investigation.
17:32And because it was an MD-11, it was a relatively new airplane.
17:36I'll go check inside.
17:38We needed to find out what really happened.
17:45As soon as investigators arrive at Shemya,
17:50they inspect the aircraft for signs of damage.
17:56I'll go check out the cockpit.
18:04We didn't have a lot of information.
18:06We knew that there had been an emergency landing,
18:08that the airplane had encountered severe turbulence.
18:11With that kind of information,
18:13you can build a lot of different storylines.
18:18The cockpit looked normal.
18:23But as soon as you looked down the aisle,
18:26it looked like a bomb had gone off.
18:34Never seen anything like it before.
18:38Row 15.
18:40Bend down on seats B and C.
18:41Seat 23B, signs of impact damage.
18:48The cabin gives them a glimpse into the tragedy
18:51that unfolded during the flight.
18:54There was a lot of baggage that had come out of the overheads.
18:58Broken glasses, broken dishes.
19:00They are basically lethal weapons
19:03if they are flying through the air.
19:06Hey, check out those marks.
19:08Likely scuff marks from shoes.
19:15That was really disturbing
19:17because passengers,
19:19they had to have been floating
19:20not only in space,
19:22but they had to have rotated
19:23so that their feet were above their head.
19:28Seems like there was a sudden pitch down.
19:30The damage is worse in the ass section.
19:45Someone got badly hurt here.
19:50People in the back are more likely to get injured.
19:52That tail of the airplane tends to get whipped about
19:56almost like a fishtail.
19:59Let's see if we can find some passengers
20:01that are well enough to talk to us.
20:02We really needed statements
20:07from passengers and flight attendants
20:09who had experienced the violence.
20:12They were going to give us a first-hand account
20:15of what really took place.
20:20Thanks for coming in today.
20:21The shaking could be the result of turbulence.
20:45How quickly did this happen?
20:47So fast.
20:48I think I'm lucky to be alive.
21:03When the plane started shaking,
21:05did the crew give a turbulence warning?
21:06One of the common causes of turbulence
21:15tends to be bad weather,
21:17such as rain or hailstorms.
21:20If the turbulence is unforeseen,
21:23passengers who don't have their seatbelts on
21:25are at much greater risk for injury.
21:28Did you see out a window?
21:36Was there any bad weather?
21:39Not that I could see.
21:47They described that the flight
21:49was actually relatively smooth.
21:50They didn't notice any kind of turbulence.
21:52There was nothing unusual about the flight
21:56leading up to the main event.
22:03Investigators turned to the weather reports
22:05from the day of the incident.
22:06This isn't what I expected.
22:09The weather was clear.
22:11It's unlikely there was any turbulence.
22:12That changes everything.
22:18What about the elevators?
22:24Definitely worth a look.
22:25A damaged elevator
22:29could have led to a loss of control.
22:32We had to determine
22:34whether or not there was a problem.
22:38Elevators are hinged flaps
22:40on the trailing edge
22:41of the horizontal stabilizer.
22:43When the pilot pushes
22:45or pulls on the control column,
22:46the elevators respond
22:48by rising or lowering,
22:50creating pitch.
22:51Investigators look for
22:55any exterior signs
22:57of elevator damage.
22:58Everything looks good
22:59on the outside.
23:01I'll check for internal damage.
23:04We use what's called
23:05the tap test.
23:07And it's a very simple test.
23:08And in fact,
23:09it's done with a quarter.
23:12It should sound solid.
23:16If you hear
23:17a hollow type of sound,
23:19that's a very good indication.
23:21that there is a delamination
23:23in one or multiple layers
23:25of that composite material.
23:27I'm hearing nothing
23:28out of the ordinary.
23:32After we cleared
23:33the elevators,
23:33we still had to understand
23:35what may have caused
23:36this airframe buffet.
23:37No substructure failures
23:39or anomalies were found.
23:43Nothing wrong
23:43with the elevators.
23:46Then what else?
23:51What did the captain
23:53have to say?
23:55To check the status
23:55of his interview.
24:02We wanted to know
24:03what he was doing
24:05as far as his duties
24:06and responsibilities
24:07leading up to the upset.
24:09I'm taking control.
24:22Hey,
24:23you're not going to believe this.
24:25Page 22.
24:26NTSB investigators
24:29turned to the captain's
24:31account of China
24:32Eastern Airlines
24:33Flight 583's
24:34high-altitude incident.
24:36He mentions turbulence
24:37before the onset
24:37of the incident.
24:39We knew there wasn't any.
24:40That's not all.
24:41Keep reading.
24:44He noticed
24:45the slats were extended?
24:47Yep.
24:48The MD-11
24:53has eight slats
24:55on the leading edge
24:56of each wing.
24:57When extended,
24:58they change
24:59the curvature
24:59of the wing,
25:00creating more surface area.
25:03Used in tandem
25:03with the flaps,
25:05they provide extra lift
25:06during take-off.
25:08That's weird.
25:09Why would the slats
25:09be extended during cruise?
25:10Investigators now
25:18have a very promising lead.
25:22There's no reason
25:23to deploy slats
25:24at 33,000 feet.
25:26As soon as you would see
25:27that the slats
25:28have extended
25:28at that altitude
25:29to cruise,
25:30that would be
25:31an alarm bell.
25:35If the slats
25:36were out,
25:38that would explain
25:38the pitch-up
25:39described by the passengers.
25:40They're controlled
25:42by this handle here.
25:46You should check
25:46the entire slats system.
25:50We had to determine
25:52whether one or more
25:53of the components
25:54in that slats system
25:55had either malfunctioned
25:57or failed.
26:06First look is clean.
26:08No obvious signs
26:09of damage.
26:10We had to access
26:12all the mechanical linkages.
26:14There's hydraulic valves,
26:16electrical mechanical systems.
26:18So we had to make
26:18the determination
26:19whether or not
26:20they were functioning
26:21as designed.
26:23Okay, let's test them.
26:25Extend the slats.
26:29There's one handle
26:30in the cockpit
26:31that controls both
26:32the slats and the flaps.
26:33typically the slats
26:38typically the slats
26:39are deployed first
26:40so when you pull it
26:41back to the first notch
26:42the slats get deployed.
26:44You pull it back further
26:45the flats get deployed.
26:49All seems to be
26:50working fine.
26:52I've not seen
26:52any mechanical issues
26:53at all.
26:55They examined
26:56the whole system
26:57and they extended
26:59normally
26:59and they retracted
27:00normally.
27:00there was no obvious
27:01damage to the aircraft.
27:05I still think the slats
27:07are part of the problem.
27:09Maybe it wasn't mechanical.
27:13Good thought.
27:15Maybe it wasn't.
27:16everything showed
27:20that the airplane
27:21was perfectly fine
27:23to fly.
27:24And so
27:24the investigation
27:25would focus to
27:26what the pilots
27:28did or did not do
27:29that caused the upset.
27:32Did the pilots
27:33somehow deploy
27:34the slats
27:35at high altitude?
27:38Now we had to determine
27:39whether or not
27:40those slats
27:40had been deployed
27:41inadvertently.
27:42have any pilots
27:50accidentally deployed
27:51the slat handle
27:52in an MD-11?
27:54They review
27:55old incident reports.
28:00We do what's called
28:01a look back.
28:02So we're looking at
28:03whether or not
28:04this is an isolated event
28:06or a systemic problem.
28:07Hey.
28:11Look at this.
28:12What have you got?
28:15Ten incidents
28:16in two years.
28:21Clipboard fell
28:22on the handle.
28:23First officer
28:24rested his arm
28:24on the handle.
28:26Slats extend
28:27in cruise flight.
28:31There had been
28:32other events
28:33with this particular system,
28:35either an uncommanded
28:36or inadvertent
28:37deployment
28:38of the slats.
28:3950% were due
28:41to some sort
28:42of pilot contact
28:43with the slat handle.
28:45If the pilot
28:46didn't know
28:47he knocked the handle,
28:48he probably
28:48didn't hit it that hard.
28:52So it could have moved
28:53to the slats-only position.
28:58Deploying the slats
28:59at high speed
28:59would trigger
29:00the buffeting,
29:01which was likely
29:02misconstrued
29:02as turbulence.
29:06What was happening
29:12in the cockpit
29:12right before
29:13the buffering started?
29:15The captain said
29:16he was using
29:17the control keypad.
29:19Here.
29:21They are really
29:22close together.
29:26Investigators
29:26have a new theory.
29:28A simple movement
29:29could have triggered
29:30the entire chain
29:32of events.
29:33We've got to see
29:34how easy it is
29:35to knock this handle
29:36out of place.
29:43Investigators test
29:44whether the crew
29:45of China Eastern Airlines
29:46Flight 583
29:47could have inadvertently
29:49knocked the slat handle
29:50out of position
29:51during flight.
29:52Ready?
29:53Ready.
29:56Hey, move.
29:58Now, the first officer
29:59was sitting in the left seat,
30:00so he could have knocked it.
30:01But the captain said
30:02he was playing
30:03with the keypad.
30:06They tried
30:07different techniques
30:08about, okay,
30:09if you hit the handle
30:11from the right side back,
30:12you hit the handle
30:13from the front side back,
30:14what would it take
30:15to jar the handle
30:17out of position?
30:19Hang on,
30:19let me try something.
30:24Bingo.
30:25That's what the captain
30:26was doing
30:26when the buffeting started.
30:28Didn't take much force either.
30:31It's a major breakthrough.
30:34Proof that the handle
30:35could have been
30:36accidentally moved
30:37while the captain
30:38reached for the keypad.
30:41It was real easy
30:42during normal movement
30:44using the keypad
30:45on the center pedestal
30:47to inadvertently
30:48strike the handle
30:49and cause an uncommanded
30:50slap deployment.
30:57Investigators have uncovered
30:58a dangerous design floor
31:00in the MD-11.
31:01So the handle
31:02probably moved
31:03in flight.
31:06And then the captain
31:07retracted the slats.
31:10The captain said
31:12that he saw
31:12that the slat handle
31:14had been out of position
31:15at about the same time
31:16the stall warning system
31:17triggered.
31:18He immediately
31:19moved the slat handle
31:21back into the retract position.
31:22The slats were fully extended
31:26for just seconds.
31:29Now,
31:30that explains
31:30the initial pitch-up.
31:32But
31:32there has to be
31:34more to it than that.
31:35I mean,
31:35the plane went up and down
31:36several times.
31:37The slats wouldn't have
31:38caused that.
31:38investigators still
31:48don't understand
31:49why flight 583
31:51experienced
31:51so many
31:52extreme oscillations.
31:54The cockpit voice recorder
31:56would record
31:57for 30 minutes
31:59and override itself.
32:00So we didn't have
32:01that information.
32:03However,
32:03with the flight data recorder,
32:04we could see
32:05control positions,
32:07we could gain
32:07other information.
32:08Okay,
32:11first up,
32:12let's look at pitch.
32:14So we have
32:14five big oscillations
32:16in roughly 20 seconds.
32:18Biggest pitch-up
32:18is here.
32:20Oscillation one,
32:219.5 degrees.
32:23Biggest pitch down
32:24happens here,
32:25minus 24 degrees,
32:27oscillation number four.
32:29For the first time,
32:30they can see
32:31the severity
32:32of the oscillations
32:33passengers describe.
32:35And it starts
32:35to stabilize
32:36here.
32:38the team launches
32:41into a second-by-second
32:43analysis
32:43of the first pitch-up.
32:49The slats were
32:50extended here
32:50during the beginning
32:51of the first pitch-up.
32:54It's gradual at first.
32:57Is the autopilot on?
32:59So it's on for the first
33:04few seconds.
33:06And it would have been
33:06fighting to bring
33:07the nose down.
33:09When the slats deploy,
33:10the airplane will have
33:11a natural nose
33:12or pitch-up tendency.
33:14With the autopilot
33:15engaged,
33:16it will actually
33:17correct for that pitch-up
33:18and return the airplane
33:19to a level attitude.
33:21But the autopilot's
33:25losing the battle.
33:27The pitch keeps increasing,
33:29and that would trigger
33:30the stall warning.
33:35Yep.
33:36The stall warning
33:37turns on here.
33:39A few seconds later,
33:40the autopilot disengages,
33:42and now the nose
33:43dives down sharply.
33:44I'm taking control.
33:49Autopilot.
33:51Off.
33:58So the captain's
33:59at the controls
33:59when the big drop happens.
34:03Show me the elevator data.
34:09Wow.
34:11So the captain
34:12made some elevator inputs.
34:13starting right here.
34:16That is a huge
34:17nose-down command.
34:22It's an overcorrection,
34:24and I think I know why.
34:28I'm taking control.
34:32Autopilots are designed
34:33so they won't just
34:34let go easily.
34:36You don't want somebody
34:37just accidentally
34:38bumping against the controls
34:39to suddenly knock
34:41the autopilot off.
34:44He felt the resistance
34:46and pushed against
34:48that resistance
34:48of the autopilot,
34:50disengaging it.
34:53Unfortunately,
34:54that led to
34:55an excessive amount
34:56of nose-down elevator command.
34:58he started a chain reaction
35:03of pushing and pulling
35:05too hard on the yoke.
35:08At high altitude,
35:10the pitch forces
35:10are very light
35:11on the yoke.
35:14So when he pulls back
35:15to get the nose up,
35:17he's putting in
35:19too much up force.
35:20It goes up too high.
35:28He pitches down,
35:29it goes down too low.
35:38And he puts in
35:39several cycles
35:40on the control yoke,
35:41trying to get back
35:42to normal.
35:43It's called
35:48a pilot-induced
35:49oscillation,
35:50or PIO.
35:52The pilot
35:52overcorrects
35:54and the plane
35:54responds,
35:55creating increasingly
35:56uncontrollable movements.
36:03Once you get into
36:03the oscillation,
36:04it's hard to stop.
36:08Everything's
36:09tapping fast.
36:13We were able
36:14to calculate
36:15that the occupants
36:16of the airplane
36:16experienced
36:171.24 negative G's
36:20and two positive G's.
36:23No wonder
36:24there were so many injuries,
36:26including two fatalities.
36:30He did get the plane
36:31back into control.
36:32It just took a while.
36:35Pilot-induced
36:36oscillations
36:37can cause
36:38extreme stresses
36:39on the aircraft.
36:41Usually,
36:41the best course
36:42of action
36:42is to put in
36:43less control force.
36:45Once that happens,
36:46you can have
36:46a nice,
36:47stable flight.
36:48So why would
36:49an experienced
36:50captain struggle
36:51so long
36:51to get a plane
36:52back under control?
37:02Long day ahead.
37:04Don't need this.
37:06I pulled
37:07the captain's files.
37:09Investigators
37:10turned their attention
37:11to the captain
37:12of Flight 583's
37:13training
37:13to determine
37:15why he repeatedly
37:16overcorrected
37:17with his control column.
37:19He had over 1,300 hours
37:21on the MD-11.
37:22That should be plenty.
37:25He flew other passenger jets, too.
37:26The captain had flown
37:31to Lucien's.
37:31He had flown Airbus 300s.
37:35He had experience
37:36with big aircraft.
37:37He had experience
37:38with high-altitude flight.
37:40Everything would indicate
37:41that he was well-qualified
37:43to fly the airplane.
37:45No complaints.
37:47No prior accidents.
37:50It's clean as a whistle.
37:51The captain passed
37:54all of his MD-11
37:55training without incident.
37:57He even took
37:57a refresher course
37:58a few weeks
37:59before the accident flight.
38:02Hmm.
38:03Let me see
38:04the training manual.
38:10Investigators
38:11take a closer look
38:12at the training
38:13the captain received.
38:14A critical aspect
38:17of accident investigation
38:18when you're looking
38:19at an event like this
38:20is pilot training.
38:23The captain
38:24did go through
38:25a very comprehensive
38:26textbook or classroom training.
38:29Find anything?
38:32Actually,
38:34it's what I didn't find
38:36that interests me.
38:38No simulator training.
38:40None?
38:41Nope.
38:42Not for an inadvertent
38:44slot deployment
38:45during cruise
38:45or an upset
38:47at high altitude.
38:50Hmm.
38:51Just giving them
38:52something to read
38:53is sort of like
38:54trying to learn
38:55to ride a bicycle
38:56if you've only
38:57read a manual.
38:59What's going on?
39:03With simulator training,
39:05you get some
39:05hands-on training
39:06and you have a good idea
39:07of what to expect.
39:09He did not
39:12have that training
39:13so in fact
39:14he was really
39:15a test pilot
39:16trying to get
39:17this airplane
39:18back under control
39:19after this
39:20uncommanded
39:21slot deployment.
39:25Was there
39:25something about
39:26the design
39:27of the aircraft
39:27that made it
39:28difficult
39:29to regain control?
39:32This is the
39:32Airbus A300
39:33here
39:34and the DC-10.
39:35Here
39:36is our MD-11.
39:37When compared
39:39to other
39:39large passenger jets,
39:41one design feature
39:42stands out.
39:44Look at the
39:44center of gravity.
39:46It's so far aft.
39:48Most planes
39:48have their
39:49center of gravity
39:50further forward
39:51in the midsection.
39:52That would make
39:54the MD-11
39:54less stable.
39:58The MD-11
39:59was designed
40:00to increase
40:01fuel efficiency
40:02and to do
40:03that
40:04you move
40:04the center
40:05of gravity
40:05back fairly
40:07far aft.
40:08The airplane
40:09becomes more
40:10pitch sensitive.
40:13I found
40:14the airplane
40:15to be very
40:16maneuverable
40:17but some people
40:18would get
40:18a little bit
40:19behind it
40:20and you could
40:21end up
40:21in cases
40:22where the airplane
40:23would overshoot
40:24what you were
40:25expecting.
40:29Investigators
40:29conclude that
40:30the captain
40:31could have
40:31stabilized
40:32the oscillations
40:33sooner
40:33with faster,
40:34less forceful
40:35control inputs.
40:39But the design
40:40of the aircraft
40:41made that
40:43difficult to do.
40:49In their final report,
40:52NTSB investigators
40:53found that
40:54an unintended
40:54movement of
40:55the slat handle
40:56likely caused
40:57the slats to extend
40:58and the airplane
40:59to pitch up.
41:00the probable
41:06cause is determined
41:07by the NTSB
41:08did not place
41:09any kind of
41:10blame
41:11or even talk
41:12about the flight
41:13crew actually
41:14causing this event.
41:16This was a strict
41:18design issue
41:20that unfortunately
41:21the crew
41:22became a victim of.
41:23The report
41:28also notes
41:29that many of the
41:30severely injured
41:31passengers
41:31either had
41:32their seatbelts
41:33unfastened
41:34or were standing
41:35in the aisle.
41:40The flight attendants
41:41had made an
41:42announcement
41:42about seatbelts
41:44but as is often
41:45the case,
41:46passengers may have
41:47ignored that
41:47announcement.
41:48And that
41:51left many
41:51passengers
41:52vulnerable.
41:55When you
41:56are in an
41:57airplane,
41:58not just for
41:59takeoff,
42:00not just for
42:00landing,
42:01it is critical
42:02that you keep
42:03your seatbelt
42:04on.
42:05You never know
42:07what can happen
42:08in flight.
42:09arms going
42:12from the
42:25程度
42:25.
42:25mammogram
42:27.
42:33.
42:34.
42:34.
42:35.
42:35.
42:37.
42:37.
42:38.