- vor 8 Minuten
On 6 September 1985, the right engine of Midwest Express Airlines Flight 105 explodes shortly after takeoff from General Mitchell International Airport. The aircraft banks to the right and crashes into an open field in Oak Creek. All 31 people on board are killed.
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00:00I remember being amazed how quickly the accident took place.
00:09They were flying, and the next thing you know, the airplane's lost.
00:15Midwest Express Flight 105 crashes.
00:18Seconds after taking off from Milwaukee, Wisconsin, all 31 people on board are killed.
00:24And what do you say to the public about the crashes that we've been having?
00:281985 becomes one of the deadliest years in civil aviation.
00:32It's up to investigators to put the public at ease.
00:36This is how the plane hit the ground.
00:38When they examine the engines, they find a component prone to failure.
00:43Well, when we heard that this part had failed 45 times before, it's a big deal.
00:49But the flight data turns the investigation on its head.
00:53The ruptured red engine didn't bring down this plane.
00:56It did not.
00:57There are 27 passengers boarding Midwest Express Airlines Flight 105,
01:24a cross-country commuter flight from Milwaukee to Atlanta.
01:28Many are employees of the manufacturer Kimberly Clark.
01:33Midwest Express Airlines used the slogan, best care in the air,
01:37and they really meant it, because they had as close to an all-business aircraft as you could have.
01:45Treats for when we're airborne.
01:46And they also baked fresh cookies on board and made the place smell amazing when you walked on.
01:55Mid-X 105 requesting IFR clearance to Atlanta.
02:03Both pilots on this flight are captains with the airline.
02:07They've already flown two flights together today.
02:09Mid-X 105, clear to Atlanta.
02:15Climb and maintain 5,000.
02:18Climb and maintain 5,000.
02:20Mid-X 105.
02:21For this leg of the flight, Danny Martin will be the acting captain and Bill Weiss, the first officer.
02:27We had two captains, and they literally could switch seats because of that.
02:33And they did do that over the course of two days,
02:36flipping out who was the pilot flying and who was the pilot not flying.
02:39Our alternate will be DCA if we can't make Atlanta.
02:45There are thunderstorms in Atlanta, so the crew has taken on additional fuel
02:49in case they have to divert to another airport.
02:54Takeoff weight is 771, 22 pounds.
02:56Set stab trim to 2.2.
03:02Just past 3 in the afternoon, the pilots start the engines.
03:09Starting number one.
03:13The DC-9 used for today's flight is powered by two Pratt & Whitney engines
03:18mounted on the fuselage at the rear of the plane.
03:23Because the engines were in the back, they were close together,
03:28which made for a little bit easier flying in emergency situations.
03:32Second of all, for the passengers, it's quieter.
03:37Can I put that up here for you?
03:43The plane is loaded and ready to depart on schedule.
03:51Airspeed bug, 133 sets, and 1.9 on the EPR.
03:56Okay.
03:56Ladies and gentlemen, we are number one for departure,
04:07so we should be airborne within one minute.
04:10Flight attendants, please be seated.
04:16Mid-X.05, clear for takeoff.
04:20Mid-X 105.
04:21Here we go.
04:27It's pulling up.
04:32This was a very normal morning for a very normal flight.
04:36It was a gorgeous blue sky, September day.
04:40There was a little bit of gusty winds,
04:43but it was nothing for Milwaukee.
04:47Power normal.
04:50100.
04:51The pilots need to reach a speed of 127 knots for takeoff.
04:57V1.
04:59Rotate.
05:00At 3.21 in the afternoon,
05:07flight 105 begins its journey.
05:12The flight plan calls for the plane to climb to an altitude of 33,000 feet
05:17for the two-hour trip to Atlanta.
05:25Gear up.
05:26Just 450 feet above the ground.
05:35What the hell was that?
05:37The pilots lose power in one of the engines.
05:41It's a critical situation,
05:43because if you don't do something about it immediately,
05:46you won't have time to do anything about it.
05:49Altitude is your friend.
05:51Mid-X 105.
05:57Turn left, heading 175.
06:01What do we got here, Bill?
06:04Here.
06:06Mid-X 105, Roger.
06:09We got an emergency here.
06:13Mid-X 105, Roger.
06:14The plane begins rolling to the right and dropping.
06:23Oh, crap.
06:25The DC-9 is stalling.
06:30Get your heads down.
06:38Heads down!
06:39Heads down!
06:40Heads down!
06:40Less than a minute after takeoff,
06:45flight 105 is diving towards the ground
06:48at more than 170 miles an hour.
07:01The plane hits the ground,
07:03less than 1,700 feet from the runway.
07:05A DC-9 has crashed southwest of runway 19 right.
07:20All 31 people on board have been killed.
07:28The crash of Midwest Express Flight 105
07:31is the third major accident in the United States this year.
07:35And the eighth accident worldwide.
07:38With more than 1,200 people killed,
07:41this is becoming one of the deadliest years
07:43in the history of civil aviation.
07:45Passengers are unnerved.
07:48Everyone says, my God, another one.
07:50What do you say to the public
07:51about the crashes that we've been having?
07:53Well, insofar as the National Transportation Safety Board
07:55is concerned, we are sparing no effort
07:56to determine the cause of each one of them.
07:58And we will make the necessary recommendations
08:00to keep any repeat of any one of them from happening.
08:02Ed, what do you tell them about?
08:07Can you show me where it started to bank?
08:10Investigators from the NTSB
08:12begin by interviewing witnesses
08:13of Midwest Express Flight 105's fatal dive.
08:18They either came forward or we tracked them down.
08:20We ended up making out a questionnaire
08:22with 40 or 50 questions on it
08:24to kind of cover all the bases.
08:28Okay, got it.
08:34While the witness accounts differ in detail,
08:36they all describe more or less the same thing.
08:40I saw a couple puffs of black smoke come out,
08:42and I just figured that they had gunned the engines a little bit.
08:46Instant later, the left wing rose up,
08:48and it tipped over and went nose first
08:50and through the trees here.
08:55Most of the witnesses agree
08:57that takeoff appeared normal
08:59until the airplane was about 300 feet off the ground.
09:03Almost all report smoke and fire
09:05coming from the right engine.
09:07Several remember hearing loud bangs.
09:10Most said that the plane then rolled abruptly
09:12into a steep right bank,
09:14went into a nose-low spin,
09:16and crashed.
09:18The value of having
09:22so many witness statements to look at,
09:24they gave us a picture
09:25of what happened right at the end.
09:27A loss of control,
09:29fire,
09:30and, of course, the impact itself.
09:33Investigators must now determine
09:35what could have caused
09:36such a catastrophic loss of control
09:38so soon after takeoff.
09:44I'm guessing this was made by the right wing.
09:47Yep, agreed.
09:48Let's see what we can figure out.
09:55After securing the crash site
09:57of Midwest Express Flight 105,
09:59investigators begin mapping the wreckage field.
10:02I think the whole length of the impact site
10:05was about 295 feet,
10:07not much more than two times
10:09the length of the airplane.
10:10So the airplane hit pretty steeply
10:13and didn't go very far.
10:15Right wing tip here,
10:17and the horizontal stabilizer here.
10:23This is how the plane hit the ground.
10:26A 90-degree right roll
10:27and a right yaw.
10:29Can you grab a picture?
10:35Got it.
10:37The wreckage path
10:38confirms eyewitness reports.
10:40Right.
10:40It very definitely indicates
10:43right up front
10:43that you've got a lost control.
10:45It doesn't suggest
10:46why you had the lost control.
10:48It kind of opens the door
10:49to a lot of different
10:50investigative avenues.
10:54Yeah, it's fire damage for sure,
10:56but it looks like
10:57all the pieces are here.
11:00Investigators study
11:01the plane's control surfaces,
11:03starting with the ailerons.
11:05The ailerons on each wing
11:07direct the plane's roll.
11:10If an aileron malfunctions
11:12and gets stuck in one position,
11:14it could cause
11:15a devastating lack of control.
11:19Control tabs are in place.
11:21They seem to be intact.
11:24We didn't find a problem
11:26with other components
11:27that are part of that system.
11:28With the ailerons ruled out,
11:32investigators turn their attention
11:34to the rudder system.
11:37Dampers are still working.
11:39Hinges are intact.
11:42The fractures look like overload,
11:44not stress.
11:47I don't think the rudder
11:48is our culprit.
11:51We didn't find anything wrong
11:53with any of the control systems
11:54based on that preliminary look-see.
11:58Could the engines provide insight
12:00into the crash
12:01of Midwest Express Flight 105?
12:05If the engines were,
12:06well, obviously banged up,
12:07they were fire damaged,
12:09and they were along
12:10the wreckage path,
12:11which is always good,
12:13that means they didn't fall off
12:14somewhere earlier.
12:19There's a spacer missing here.
12:21Most of the blades
12:27from this stage are gone.
12:29The team finds damage
12:31inside the right engine
12:33that could not have been
12:34caused on impact.
12:36The missing engine pieces
12:37include a spacer
12:39and the compressor blades
12:41from the 9th and 10th
12:43compressor stages.
12:45They're found more than half a mile
12:47from the main wreckage site.
12:49Finding any part
12:50of the airplane
12:51short of where
12:53the airplane had crashed
12:54was a suggestion
12:55of a malfunction
12:56or failure
12:57that had occurred
12:58in flight
12:58and required
12:59further investigation.
13:02The engine
13:03and the pieces
13:03are moved
13:04to a nearby warehouse
13:05where they can be
13:06more closely examined.
13:08In the end,
13:09we ended up finding
13:10about 90% by weight
13:11of the spacer,
13:13so that was a big boon
13:14to the investigation.
13:15Investigators study
13:18the recovered spacer
13:19to determine
13:20why it failed
13:21on Midwest Express
13:22flight 105.
13:25All on the pedestal here,
13:28it's definitely
13:30not overstressed.
13:32They discover
13:33a telltale crack
13:35on the spacer
13:35that appears
13:36to have spread
13:37over time,
13:38what's called
13:39progressive cracking.
13:40There may be
13:42stress marks,
13:42there may be
13:43cracks,
13:45there may be
13:45things that
13:46suggest a direction
13:47of failure
13:48and a time frame
13:49where the fracture
13:50would have occurred.
13:51It doesn't occur
13:52all at one time.
13:54Can we determine
13:55how long that crack
13:56has been spreading for?
13:57I'll see what I can do.
14:00We became
14:01interested,
14:02not just in
14:03detailing that,
14:04but trying to find
14:05whether this was
14:06a fracture
14:06that could have
14:07been detected
14:08previously.
14:08A closer look
14:10at the crack
14:11on the steel spacer
14:12reveals it's
14:13filled with nickel.
14:15A lightweight
14:16nickel coating
14:17is applied
14:17to certain
14:18vital engine pieces
14:19like the compressor
14:20spacers and blades
14:21to prevent corrosion.
14:25The compressor
14:26was brought in
14:27to be refurbished
14:27in 1981.
14:30Coating stripped,
14:31spacer examined,
14:32and, oh,
14:33here we go.
14:35Replated.
14:36That was four years
14:38ago.
14:39The maintenance
14:40records tell
14:41investigators that
14:42work had been done
14:43on the spacer
14:44that failed
14:45on Midwest Express
14:46Flight 105.
14:48Nickel-cadmium
14:49plating
14:50is the last step
14:51of the refurbishment
14:53process
14:53that would have
14:54been done
14:55by the maintenance
14:56facility
14:56that was involved
14:57with essentially
14:58the overhaul
14:59of that part.
14:59Four years
15:01before the accident,
15:02the spacer
15:03was removed
15:04from the engine,
15:05stripped of its coating,
15:06and examined
15:06for cracks.
15:08The inspector
15:09reported no cracks
15:10and sent the part
15:11to be replated
15:12with nickel.
15:13Since nickel
15:14was found
15:15inside the crack,
15:16it must have been
15:17present when the nickel
15:18was applied.
15:19The DC-9 flew
15:24about 2,500 flights
15:26over the next
15:27four years
15:28with the damaged
15:28spacer
15:29until it finally
15:30ruptured
15:31on Flight 105.
15:35It should have been
15:36caught during
15:37an overhaul,
15:38but it wasn't,
15:39and so the crack
15:40kept growing and growing
15:41until it finally
15:42hit its failure point.
15:45Investigators wonder
15:46what caused the crack
15:48to form on the spacer
15:49in the first place.
15:51These spacers
15:52have been used
15:52inside the JT-8D
15:54for more than 20 years.
15:55This can't be
15:56the first one to break.
16:00There are identical
16:01spacers
16:02in more than
16:0214,000 JT-8D engines
16:05used on airplanes
16:06around the world.
16:08Is there any history
16:09of similar failures?
16:12It turns out
16:12that Pratt and Plady
16:13were well aware
16:14of spacer failures
16:15that occurred before,
16:16so we started
16:17to wonder
16:18what have they
16:18done about it.
16:24Seems to happen a lot.
16:27While researching
16:28spacer issues
16:29in other aircraft,
16:30investigators uncover
16:3245 similar failures
16:34prior to
16:34Midwest Express
16:35Flight 105's accident.
16:38Well, when we heard
16:38that this part
16:39had failed
16:4045 times before,
16:42we kind of looked
16:42askance a bit
16:44at the manufacturer.
16:45That's a big deal.
16:47But of all the failures
16:49uncovered by the NTSB...
16:51Not a single loss
16:53of aircraft
16:53or even a single injury.
16:56Well, that says something.
16:58In every previous incident,
17:00the plane landed safely.
17:02So why did the rupture
17:04of a spacer
17:04on Flight 105
17:05cause the plane
17:07to become uncontrollable
17:08and crash?
17:11Well, we knew
17:12that none of the
17:12previous failures
17:13had led to an accident,
17:14so one of the questions
17:16was what made
17:17this one different.
17:19Let's see what got hit.
17:22Investigators consider
17:23the possibility
17:24that pieces of the
17:25ruptured spacer
17:26on Flight 105
17:27punctured the plane's
17:29fuselage
17:29and damaged
17:30vital control systems,
17:32such as cables
17:33or hydraulic lines.
17:35When a part
17:36like a spacer
17:37or a fan disc
17:39breaks
17:40under a lot of stress,
17:43it's almost like
17:44a small explosion
17:45going off.
17:46You have fragments
17:48of metal flying
17:48at very, very high speeds.
17:52Okay, let's see
17:53894.
17:56They study
17:57the location
17:58and pattern
17:59of all the
17:59puncture marks
18:00found on the skin
18:01of the plane
18:02to see if any
18:03were near
18:03vital control links.
18:06No control cables,
18:07no hydraulics.
18:1110-12.
18:17No control cables,
18:18no hydraulics.
18:21What about
18:22the pieces of the plane
18:23that we haven't
18:24been able to find?
18:25There are many
18:26critical pieces
18:27of the plane
18:28that have not
18:29been recovered
18:29or are too badly
18:31damaged to study.
18:33Is it possible
18:34to figure out
18:35if they could have
18:36been hit
18:36by the engine pieces?
18:38We have what we need
18:40to run a trajectory
18:40analysis.
18:43All right.
18:45We were looking at
18:46could these parts
18:47that have left
18:47the engine
18:48strike a control surface
18:51or the hydraulic system
18:53or anything else
18:55where they could have
18:55done secondary damage
18:57that would have
18:57compounded the situation
18:59the pilots were facing.
19:01Knowing the plane's
19:02velocity,
19:03angle of ascent
19:04and the wind speed
19:05at the time
19:06the engine failed,
19:07the team calculates
19:08the path of debris
19:10ejected from the engine.
19:11The smallest piece
19:13we found was about
19:14half an ounce.
19:16The largest piece
19:17was just over a pound.
19:18So everything
19:19moves away from the plane,
19:21nothing hits it.
19:22The trajectory analysis
19:24tells investigators
19:25that none of the
19:26ejected engine pieces
19:27would have struck
19:28the airplane
19:29with enough force
19:30to cause substantial
19:31damage to the control
19:32systems.
19:33The analysis
19:35indicated that
19:36it was so unlikely
19:38that we considered
19:40it an impossibility
19:41that those parts
19:42leaving the engine
19:43in the direction
19:44they went
19:44and the size
19:45that they had
19:46could have
19:47caused secondary damage
19:49that would cause
19:49lost control.
19:51If spacer fragments
19:53didn't hit vital components
19:55and cause the loss
19:56of control,
19:57perhaps the initial
19:58explosive force
19:59opened the cowling
20:01or engine cover
20:02affecting the
20:03plane's aerodynamics.
20:05If the cowling
20:06had been blown open,
20:08it would cause
20:09a lot of drag,
20:10it might cause
20:11the airplane to roll,
20:13it might cause
20:13the airplane
20:14to become uncontrollable.
20:16There's a hole
20:17in the cowling,
20:18looks to be about
20:19two square inches.
20:20The team finds evidence
20:22that the cowling
20:23was pierced
20:24by fragments
20:25ejected from the engine.
20:27But all four latches,
20:30one, two, three, four,
20:32they're all latched.
20:33Can't have opened
20:34in flight.
20:36They found them all
20:38either latched
20:38or fully intact
20:40with no damage
20:41at all.
20:41So that scenario
20:43kind of went out
20:43the window.
20:46So the ruptured
20:47red engine
20:47didn't bring down
20:48this plane?
20:49It did not.
20:53Well, reasonably early
20:54in the investigation,
20:56the team figured out
20:57that a spacer
20:57had failed
20:58and the engine
20:58had failed.
20:58and now we had
21:01the rest of the accident
21:02to figure out.
21:03Why would that
21:04cause a crash?
21:09Investigators examine
21:10Midwest Express
21:11Flight 105's
21:12flight data recorder
21:13in hopes of understanding
21:15how the loss
21:16of the right engine
21:17caused the death
21:18of 31 people.
21:20Doesn't give us much,
21:22but it's all
21:22we've got to work with.
21:23It was only recording
21:25four flight parameters.
21:27It had airspeed,
21:27altitude,
21:29heading,
21:30and vertical acceleration.
21:32Right here,
21:34a sudden deceleration
21:35at 450 feet.
21:36This must be
21:37where the right
21:37engine failed.
21:38Well, that's consistent
21:39with what the witnesses
21:40told us.
21:43The engine failure
21:44we know
21:45occurred
21:46above the airport,
21:47so the airplane
21:48had only been airborne
21:49for a few seconds.
21:52But,
21:53the heading doesn't change
21:54when the engine fails.
21:55They must be
21:56applying left rudder
21:57to compensate.
21:59Oh,
21:59dead right engine,
22:00left rudder.
22:01That's the right move.
22:04When the right engine fails,
22:06the remaining engine
22:08should force the plane
22:09to the right.
22:10To counteract that,
22:11a pilot would apply
22:12left rudder
22:13to keep the plane
22:14flying straight.
22:21What the hell was that?
22:23The data shows
22:24that's precisely
22:25what Captain Martin did
22:26in response
22:27to Flight 105's
22:29engine failure.
22:30After a few seconds,
22:32they start this yacht
22:32to the right.
22:33So,
22:34right rudder?
22:36Four seconds
22:38after the failure
22:39of the right engine,
22:41the FDR data
22:42indicates that the pilot
22:43moved the rudder
22:44from left
22:45to right.
22:46That forced the plane
22:47into a sudden yaw
22:48to the right.
22:52He's in a side slip.
22:54He's deviating
22:55further and further
22:56to the right.
22:58Then he starts
22:59to lose altitude.
23:02Huh,
23:02148 knots.
23:03He's in a high-speed stall.
23:08How'd they let
23:09that happen?
23:11You went
23:12into a right skid
23:14and then
23:14followed by
23:16an abrupt
23:16right turn and dive.
23:17That would
23:18be consistent
23:19with a stall,
23:20but the air speeds
23:21indicated
23:22were high enough
23:23that you wouldn't
23:24normally have
23:25a stall
23:26at those speeds.
23:27clearly lost
23:29control of the plane.
23:30Five seconds later,
23:31they hit the ground.
23:34The flight data
23:35tells investigators
23:36that it took
23:37only 10 seconds
23:38for the pilots
23:39to lose control
23:40of the plane
23:41after the failure
23:42of the right engine.
23:43I have never
23:46seen an accident
23:47sequence
23:48that brief
23:49before or since.
23:55So,
23:56he responds
23:56correctly at first
23:57with left rudder
23:58and nose-down pitch,
24:00then he inexplicably
24:02switches to right rudder?
24:03And that's what
24:04leads to the yaw,
24:05the right roll,
24:05and the eventual stall.
24:07Right rudder,
24:08it makes no sense.
24:09It was clear
24:11from all the data
24:12that the pilot
24:14didn't understand
24:14what happened.
24:15He responded
24:16inappropriately,
24:17and within seconds
24:18the airplane was lost
24:19and everybody on board
24:20was killed
24:21in the accident.
24:23Was there something
24:24about the DC-9's
24:25handling characteristics
24:26that led the pilot
24:28to input
24:28the right rudder?
24:30So,
24:31it was relatively
24:32easy to control,
24:32then?
24:35Just with the
24:36control wheel?
24:37Huh?
24:39Investigators
24:40interviewed
24:40DC-9 pilots
24:42to determine
24:42how the plane
24:43handles
24:44with only one engine.
24:45The DC-9 pilots
24:46that we talked to,
24:47it was overwhelmingly
24:48described as a very
24:49easy,
24:50docile aircraft
24:51to handle
24:51in those situations.
24:53Oh,
24:53this has been
24:54extremely helpful.
24:55Thanks.
24:55Okay.
24:56Bye.
24:58They all say
24:59the same thing.
25:00It's no big deal
25:01with one engine.
25:05Because the DC-9's
25:06engines are mounted
25:07on the fuselage
25:08instead of the wings.
25:10When one engine fails,
25:11it does not force
25:12the plane into
25:13a severe turn.
25:14DC-9 is almost
25:16a centerline thrust
25:17aircraft,
25:18so if you lose
25:19one engine
25:19on either side,
25:22there's not that much
25:23excess yawing
25:25or controllability
25:26problems at all.
25:29How easy is it
25:30to handle a DC-9
25:31in the situation
25:32the pilots
25:33of Flight 105
25:34found themselves
25:35in?
25:37It was valuable
25:38to do a simulation
25:40or test flight
25:41to get a better
25:42idea of exactly
25:43how the airplane
25:44performed under
25:46the circumstances
25:47of the accident,
25:48but at a higher
25:49altitude.
25:53Okay.
25:53When we get
25:54to 10,000 feet,
25:55I'm going to cut
25:55power to the right,
25:56leaving the left
25:57at takeoff power.
25:58Keep the flaps
25:59at 20.
25:59Target speed
26:00is 170 knots.
26:03They tried to
26:04match the parameters
26:04of the airplane
26:05in terms of the flaps,
26:06gear,
26:07and airspeed,
26:10and then
26:10proceeded to
26:12cut the engine power.
26:14Okay.
26:16Cutting power.
26:25Okay.
26:27Let's go around
26:28for another.
26:30Flight demonstrations
26:31showed that
26:32the pilot
26:33didn't have to
26:33input rotor at all.
26:35If he had only
26:36used the ailerons,
26:37he could have
26:38safely fallen out of it.
26:40Okay.
26:41This time,
26:41no reaction.
26:42Let's see what
26:43the plane does.
26:45With no input
26:46from the pilot
26:47after the loss
26:48of the right engine,
26:49the plane rolls right
26:51and the nose drops.
26:52Okay.
26:57You can recover?
27:00Even with no
27:01immediate action,
27:02the pilot is easily
27:03able to recover
27:04the plane.
27:07Okay.
27:09I think we have
27:10what we need.
27:11That may have
27:12actually been
27:12the best thing to do
27:13was to do nothing,
27:16watch the airplane's
27:17response,
27:17understand the airplane's
27:18response,
27:19and respond appropriately
27:20to the nature
27:20of the emergency.
27:21How was that?
27:27If the DC-9
27:29is so easy to control,
27:31why were two
27:32experienced pilots
27:33unable to recover
27:34from the loss
27:35of their right engine?
27:40Okay.
27:41We know they were
27:42both captains
27:42with the airline,
27:43but how much experience
27:44did they actually have?
27:46Investigators look
27:47into the backgrounds
27:48of the pilots
27:49of Midwest Express
27:50Flight 105.
27:51to understand
27:52why they didn't
27:53recover from
27:54a single-engine failure.
27:55Neither had a lot
27:56of turbojet experience.
27:58One was upgraded
27:59to Captain
28:00with 600 hours
28:01on the DC-9,
28:02the other
28:02with only 500.
28:04Doesn't seem
28:05like a whole lot.
28:07Advancement
28:07to Captain
28:08happened within
28:09a year
28:09for both of these
28:10pilots
28:11at Midwest Express
28:12airlines
28:13airlines
28:13at that time.
28:15And the reason
28:16why
28:16was it was
28:17a small airline,
28:18it was growing
28:19quickly,
28:20they were adding
28:21airplanes.
28:23They consult
28:24large US airlines
28:25to determine
28:26their qualifications
28:27for an upgrade.
28:28Okay, thanks.
28:33That's the same
28:33for both airlines.
28:35Ten years
28:35seniority
28:36and 7,500 hours
28:37as DC-9
28:38first officer
28:39to be considered
28:39for an upgrade.
28:40Yeah, these guys
28:42weren't anywhere
28:42near that.
28:44While the pilots
28:45may have been
28:46experienced,
28:47neither had spent
28:48much time
28:48piloting the DC-9
28:50before they were
28:51promoted to captain.
28:52The more
28:53experienced
28:54someone has
28:54exercising command,
28:55the more likely
28:56they are
28:57to exercise
28:58that command
28:59in situations
28:59that call
29:00for calm thinking,
29:01for rational response,
29:02and so on.
29:05So how much
29:06training did these
29:07guys get
29:07on engine failures?
29:08To understand
29:10why the pilots
29:11of Flight 105
29:12were not able
29:13to control
29:14their plane
29:15following an engine
29:15failure,
29:16investigators look
29:17at their training
29:18records.
29:19What was their
29:19experience?
29:21What kind of pilots
29:22were they?
29:22How did they respond
29:23to unusual events?
29:25Did they seem
29:26self-confident?
29:27How well did
29:28they work together?
29:30Okay.
29:32So,
29:33the captains
29:34practiced 12
29:36engine failures
29:37on takeoff
29:38in the simulator,
29:39first officer,
29:4115 sessions.
29:43They discover
29:44that both pilots
29:45had been extensively
29:46trained to cope
29:47with engine failure
29:48on takeoff.
29:50Precisely the type
29:51of emergency
29:52they faced
29:53on Flight 105.
29:54But what exactly
29:56were they taught?
29:58We looked very closely
30:00at the training
30:01these pilots received
30:02and interviewed
30:03the flight instructor
30:04who oversaw
30:05their training
30:06in the DC-9
30:06from Inter-West Express.
30:09Tell me what
30:10you can remember
30:11about Captains
30:12Martin and Weiss.
30:16They were both
30:16excellent pilots.
30:18Trained to proficiency.
30:21Lots of simulator
30:22training on engine failure.
30:24You bet.
30:25We ran them
30:26through all sorts
30:27scenarios.
30:30Let's focus
30:31on takeoff
30:32with simulated
30:33engine failure.
30:34What were they
30:35taught?
30:40Pay attention
30:41to your yachts,
30:42your best cue.
30:45You're on
30:46right.
30:46I'm right.
30:47Line left
30:48rudder.
30:49Control wheel
30:50as needed.
30:51Keep the plane
30:51level.
30:53Nice and easy.
30:55It's a good job.
30:56Got it.
30:58Captain Martin
30:59was trained
30:59to pay close
31:00attention to the
31:01plane's yawing motion
31:02when identifying
31:03and correcting
31:04an engine failure.
31:06Looks like
31:07they had
31:07excellent training.
31:09Thanks for the insight.
31:10We found
31:14the instructor
31:14to be very capable
31:16and very dedicated
31:18and we found
31:18the simulators
31:19to be okay
31:20for that time.
31:24If Captain Martin
31:25was extensively
31:26trained to cope
31:27with engine failure
31:28on takeoff,
31:29why didn't he do
31:30what he was trained
31:31to do?
31:35Most of their
31:36training was for
31:37an engine failure
31:38at takeoff.
31:39Pretty easy
31:40to identify
31:40which way
31:41you're yawing.
31:43Investigators
31:43consider the timing
31:44of the engine failure.
31:46If you're closer
31:47to the ground,
31:48there are much more
31:48visual cues available
31:49from the ground
31:50to see what
31:51the airplane
31:52is encountering.
31:54Not so easy
31:55when you're already
31:56in a steep climb.
31:57Right.
32:00As Flight 105
32:01was climbing,
32:02only blue sky
32:04would have been
32:04visible to the pilots,
32:05making it more
32:06difficult to identify
32:07the direction
32:08of the yaw.
32:09What the hell
32:13was that?
32:14With no outside
32:16visual cues,
32:17investigators believe
32:18Captain Martin's
32:19initial response
32:20was a spontaneous
32:21reaction to the
32:22plane's changing
32:23motion,
32:24and not the result
32:25of an analysis
32:26of the situation.
32:27But what triggered
32:28the incorrect rudder
32:29application a few
32:30seconds later
32:31that resulted in
32:32a total loss
32:33of control?
32:33response to the
32:44plane.
32:44All right,
32:44let's see what these guys
32:45were doing.
32:45mid-x 105 here we go
32:52investigators pin their hopes on the CVR to explain captain Martin's actions
32:59spilling out power normal
33:05100
33:08B1 rotate
33:16you're up
33:22Stacy it's 105 turn left heading 175
33:27what do we got here Bill here mid-x 105 roger uh we got an emergency here
33:34I've never heard an accident unfold so quickly
33:52holy smokes and I remember just being amazed how quickly the accident took place it was like
34:00they're fine you hear the engine fail and the next thing you know the airplane is lost
34:09okay so what did we hear sure happened fast yep 15 seconds from the sound of the engine
34:16exploding to the end of the recording astonishing
34:19what else what was that what have we got the captain seemed uncertain agreed
34:38what we got here Bill well it was clear from the cockpit voice recorder that the pilot didn't recognize what
34:46had happened he articulates that what was that what do we got here Bill
34:53how was that the sound of the engine the sensation of the right yaw and the instruments should have
35:00told captain Martin that he was dealing with a failure of his right engine
35:04anything else on that tape not a lot of troubleshooting or communication between
35:13them really actually none
35:23what do we got here Bill here mid-x 105 roger uh we got an emergency here
35:32investigators hear captain Martin asking his first officer for assistance in assessing the situation
35:39but first officer weiss never replies that was troubling to me because i would have expected that
35:47in an emergency situation and especially when asked for help that the other crew member would have
35:54helped if he could so it prompted some further investigation okay let's start with that
36:04why was the captain confused about what had happened it should have been obvious
36:114600 flight hours but he's never experienced an actual engine failure
36:16ntsb investigators looking into the crash of midwest express flight 105 have learned that captain
36:22martin martin's only experience with a single engine failure was in a simulator
36:27yeah and deceleration don't feel the same plus all the sounds are different
36:31it's not the same as a real thing it was a catastrophic engine failure where they had thrust
36:35and then they didn't it was immediate uh i don't think they were trained in that kind of scenario
36:43what do we got here bill the limitations of the simulator may explain captain martin's initial
36:49confusion but it does not explain the first officer's unusual silence let's have another listen
36:59they returned to the cockpit voice recording to better understand how first officer weiss reacted to
37:05the emergency
37:10how was that that's one of five turn left heading 175 what do we got here bill that's two here that's three
37:23he asked for help three times but the fo says absolutely nothing to him the entire time
37:27not even i'm not sure or i don't know not a word in this situation seconds were critical had he said right away i don't know
37:39then the captain would immediately have tried to rely on his own understanding of the situation
37:44rather than expect the first officer to come up with an explanation of what he had
37:47what could have caused the first officer's silence hang on what altitude were they at when the engine failed
38:02450 feet this could be it then pilots say they were taught not to make call outs or even verbalize the
38:09the nature of an emergency after 100 knots before reaching 800 feet let me see
38:24not even to identify a failed engine no communication at all until 800 feet
38:31i couldn't imagine a management team at midwest express thinking this silent cockpit business
38:38made any sense it just flies in the face of communication which is kind of the fabric that
38:45holds a safe flight together so it just blew my mind frankly
38:55how was that investigators think first officer weiss may have been following a midwest express
39:02unwritten rule of not discussing emergencies until the plane reaches 800 feet
39:07it's important during an emergency is for people to talk to each other because they both may not be
39:13looking at the same instrument they both may not be looking at the same thing outside you have to talk you
39:18have to talk one last thing troubles investigators in spite of his first officer's silence captain martin
39:27could have easily identified which engine had failed simply by looking at his instruments both pilots had
39:33visual information from the engine fight instruments the bank turn indicator and so on that would have
39:39told them um what was going on in terms of the loss of thrust i don't think either of them were scanning
39:46the instruments agreed they never saw which engine had failed the direction of the or the severity of
39:52the roll the ntsb concludes that the pilots failure to monitor their instruments contributed to captain
40:00martin martin's incorrect rudder application with the lack of visual cues the only sure way they would
40:05have had to recognize which engine failed would be to look at the instruments the pilots lack of
40:12awareness ultimately led to the stall that brought down flight 105
40:23up until here he should be fine but then there's no communication and no instrument scanning
40:30and this this is what dooms them he puts in a right rudder which sends them into a side slip
40:36an extreme right roll and a stall if they had talked to each other scan their instruments you don't get
40:44this accident the reality of the situation is the mismanagement inside the cockpit caused the accident
40:54not the engine failure the ntsb's final report makes several key recommendations to prevent this type of
41:01accident from happening again they recommend a directive requiring airlines to replace the existing spacers
41:08with a new type of spacer which is less likely to fail they also recommend that airlines are advised to
41:14teach their pilots to communicate during onboard emergencies it should never be overstated the importance
41:22of crew coordination every crew member has something valuable to add anything that is an abnormality
41:28it needs to be discussed at the proper time they also suggest that airlines review their simulator training
41:38to ensure pilots are taught to use their instruments to assess the nature of engine failures
41:44i think this accident still has an impact today because it's such a clear illustration
41:53of what happens when you don't do what you should do in an emergency anytime there's an emergency should have
42:01the exact same procedures and you should run right to them midwest express airlines continued to operate
42:10until 2009 it merged with frontier airlines in 2010