- vor 22 Stunden
On 17 October 2019, PenAir Flight 3296 overruns the runway on landing at Unalaska Airport in the Aleutian Chain of Alaska, killing one passenger. The accident was caused by incorrect wiring of the wheel speed transducer harnesses on the left main landing gear.
Kategorie
📚
LernenTranskript
00:00while landing at Dutch Harbor Alaska hang on I'm sliding the pilots of Penn
00:10Air flight 3296 run out of runway all I could see is water everyone brace we're
00:19gonna go in
00:22not everyone makes it out alive you never want to lose a passenger for any reason
00:30it's a pretty beat up NTSB investigators must piece together the evidence we've got a dark 170
00:38foot long skid mark so the tire blew we needed to do a deeper dive they soon discover a critical
00:45oversight there's no numbering on these wires that was really the aha moment
00:52pen air flight 3296 cruises
01:22over Alaska's Aleutian Islands now we should be getting directions here to descend soon I'm gonna
01:30see if I can't get the weather yeah it's changed well it's been updated it's 310 at 11 knots 56 year
01:39old captain Paul Wells is a new hire to Penn Air but has 25 years of experience with other airlines
01:46okay Paul is an amazing guy I flew with him several times he was a true decision maker as a captain
01:56peninsula 3296 to send pilots discretion to nine or zero peninsula 3296
02:0739 year old first officer Justin Lunn has been with Penn Air for five months I couldn't have been with a better
02:16pilot he's very thorough individual next military there are 39 passengers on today's flight including
02:24a high school swim team and their chaperones commercial pilot Steve Rainey is escorting his son Jacob we were
02:33on the flight to go to a swim meet we'd worked really hard raising the money for the trip it was a big deal
02:39it's a two-hour flight from Anchorage to unalaska airport also known as Dutch Harbor
02:46the journey crosses some of the most rugged and isolated terrain in the world the flight is over a
02:55spectacular part of Alaska the entire Alaska Peninsula is in view it's a great view go grab a window seat
03:03further back my son did move to a couple rows back so that he could get that view too the pilots are
03:15flying a Swedish made Saab 2000 Saab 2000 is a twin engine turbojet aircraft it seats approximately 50
03:24people it's a good aircraft for reaching remote communities in Alaska Dutch ops 3296 30 minutes
03:34before landing the first officer contacts the weather observer at unalaska airport for the latest
03:39conditions hello 3296 right now winds 210 at six knots gusting to 14 temperature eight dew point one
03:50all right copy the weather the airport at Dutch Harbor has a short runway vulnerable to severe and
04:01unpredictable weather pilots need special training to land here the terrain around the area in Dutch
04:09Harbor is mountainous the wind conditions can change in seconds turbulence can be bad icing can be bad so we
04:17have dedicated weather observers that is invaluable what did she say the wind was when was 210
04:26pretty much a direct crosswind hmm I guess we can go ahead and start heading down all right
04:3320 minutes before landing anchorage air traffic control asks the pilots about their runway preference
04:54affirmative negative we want the RNAV 13 peninsula 3296 on alaska airport is on an island tucked behind a 1600
05:06foot mountain planes can land in either direction runway 13 from the west or runway 31 from the east most pilots would
05:16prefer to use runway 13 basically because they have more room to maneuver more room to escape if you gotta punch out or you gotta go around
05:25and just like the other day if there's any major changes in the wind we'll just we'll switch
05:31we always prepare for the worst and hope for the best minimize risk that's what we do
05:38ladies and gentlemen in order 12 miles from the airport passengers prepare for landing
05:46items are stowed completely beneath the seat in front of you
05:50all right flaps 20 flight attendant is secure flaps set 20 indicating 20 gear down
06:02four minutes from the airport the crew begins the landing procedure down three green
06:09at less than a thousand feet the plane is rocked by turbulence
06:19ah bump there's a bit of a bump there too yeah yeah there you go it's gonna be ugly in here isn't it
06:30hmm Paul was fighting the winds as we were coming in
06:37seconds from touchdown captain wells notices he's too high for a safe landing
06:43an updraft main caused you to balloon so that causes you to go high
06:48what do you think go around at Dutch Harbor I don't take chances if we're high we're going around
06:56max power
07:08I would not have been able to safely get back down without putting people at horrible risk
07:15the pilot pulled up and went around I was assuming it was because of visibility issues
07:23Dutch Harbor traffic peninsula 3296 going around we're going to come back around for a visual
07:30we were continuing with terrain lower layer of clouds and maintaining a safe airspeed
07:37you're very busy scanning inside and outside of the airplane
07:40it only takes three minutes before the pilots of Penn Air flight 3296 are ready to attempt another landing
07:46if we couldn't man on this attempt then we would go to our alternate airport
07:53200 plus 10 you got it got it the pilots are seconds from touching down
08:01the plane
08:08hey great yeah I know
08:10seemed like we floated down the runway quite a bit which didn't alarm me too much
08:16down
08:23okay you got the yoke I got it yeah we're down there 80 knots
08:28as the captain begins slowing the plane
08:31something isn't right
08:34I was pushing on the brakes harder and noticing that I'm not getting any more effect from the brakes
08:41when I saw the wind suck the wind was definitely strong and at that point all alarm bells went off in me
08:50brakes
08:53I got them all the way down
08:56the pilots cannot reduce their plane speed
08:59I had to make a decision on whether to continue the landing or abort
09:03in an instant I realized that no there's not enough room to get the aircraft airborne again
09:08In the cabin Steve Rainey notices too
09:11Brace! Everyone braced!
09:15I actually went in the brace position and I told the passengers around me to brace
09:21Hang on I'm sliding
09:24The plane is swerving back and forth
09:29I thought I was going to be able to turn off into the taxi area but I was going too fast
09:35The pilots are running out of runway
09:38All I could see is water
09:42The pilots of Penn Air flight 3296 are unable to stop their airplane
09:49I saw the perimeter road and I told Paul go right go right
09:54The only option was the road
09:56The plane crashes through a fence strikes a boulder and is propelled towards the water
10:03That destroyed our exit plan
10:06They have only a few seconds to stop
10:10Now all I could think of was we're going to go in
10:12The left engine strikes a signal post and road sign shattering the propellers into deadly fragments
10:18Holy crap
10:25We need to evacuate
10:27Evacuate right hand side
10:29Get out and get away
10:31In the cabin it's eerily quiet
10:33I could feel blood running down my face and my shoulder was sore and my head hurt
10:41It was very very surreal
10:45A propeller blade has pierced the cabin and struck Steve Rainey
10:50There was a propeller blade stuck up in the ceiling right up against me
10:56Jacob get off the plane don't wait for me
10:59Steve's son Jacob is lucky to walk away from the accident unharmed
11:03He would not have survived in the seat next to me because the blade was literally right there
11:10But a passenger near him is severely injured
11:14I had had a fair amount of training because of my job
11:19And so it was more or less an automatic reflex to go over and you know check for his pulse see if he's still breathing
11:26Within minutes emergency responders arrive and transport 10 injured passengers to hospital
11:3338 year old passenger David Altman later succumbs to his injuries
11:39In 10 years he's one of only two people to be killed on a domestic flight in the United States
11:45I was met in the hospital by a doctor and they told me he hadn't made it and that was a crushing blow
11:53Investigators from the NTSB the National Transportation Safety Board are dispatched to the area as the plane is hoisted onto a barge and taken to a secure location
12:05We weren't able to offload it the next day because of the weather so it took a day to get the airplane secured
12:12We're on record at 5 46 p.m.
12:17Investigators are eager to interview the pilot
12:20Memories tend to fade and they tend to change so we want to get to the information as soon as possible
12:27I didn't even have you sleep before I showed up for that interview and so you're not you know you're not a hundred percent clear
12:33Okay
12:35Take us through the events leading up to the accident
12:39Um
12:41Everything was normal just a nice flight
12:46Everything was going fine until it wasn't and this is pretty common when we talk to pilots after accidents
12:54When I went to turn off the anti ice I got out of position on final
12:59Captain Wells explains that the plane was hit by an updraft just as he took his eyes off the gauges
13:06What do you think?
13:11Go around
13:13Max power
13:15We were too high
13:20And instead of doing the stabilized approach
13:23And continue to the runway
13:25We elected to go around
13:27So you're now set up for a second landing
13:31Do you remember your speed at touchdown?
13:34126
13:36And where did you touch down?
13:42I planted it pretty much on the thousand
13:45Right on the touchdown zone
13:46Put it in reverse and then I noticed it had stopped accelerating
13:51I pushed down as hard as I could
13:55But there's no response from the brakes
13:57Brakes!
14:00I got them all the way down
14:03No response
14:04Exactly
14:05Zero braking
14:06But like on ice
14:10That was puzzling
14:11We knew we had to look at the braking system to understand what was occurring there
14:16Did you get an update from the weather observer?
14:18Yes, they said anywhere from 10 to 20 knots
14:23The winds were changing
14:25Any concerns at all on the second approach?
14:27The winds were dying down on the water
14:32It looked like a direct crosswind
14:35I had no doubt that this was going to be a fine approach
14:40The captain said that he believed that they were flying into a crosswind
14:45And was confident in that approach
14:49Your FO did the preflight on the aircraft?
14:51He did
14:53Did he bring anything to your attention at all that was out of the ordinary?
14:58He did actually
15:00He noticed something with one of the tires
15:02Pre-flight inspection complete?
15:14Any issues?
15:16Bald spot on the left outboard?
15:19Investigators learned that a preflight inspection of Flight 3296 revealed a worn tire on the left outboard wheel
15:26It's not showing any cord
15:29I'm not worried about it
15:31It was not down past the red line on the tire
15:34And didn't to me appear to be of any concern
15:37I've had maintenance come to look at tires that are in very similar conditions to this tire
15:42They've basically said it's within serviceable limits and you can continue your flying
15:48Have you reached any conclusion, just in your own head, about what you think went wrong or may have happened?
15:56If I had to make my best guess
16:00I don't think it was brake failure
16:02I think more than likely
16:06It was one of those showers that put down some sleet or hail on the runway and
16:11I just couldn't see it
16:15That's the only thing I can think of
16:20Anything else you would like to add?
16:23I can't be more proud
16:33I'm sorry
16:35Take your time
16:42I couldn't be more proud of my crew
16:46The captain did get rather emotional given his involvement in the accident
16:53So they came in on runway 13
17:01And the pilot said his airspeed was 126 knots
17:05And they touched down at the 1000 foot mark
17:08Why did flight 3296 come off the runway?
17:12At that speed, they should have been able to stop well before the end of the runway
17:17Specifically for runway overruns, we're looking at how the airplane was configured
17:21But those runway lengths were
17:24As well as what it takes operationally to fly that airplane into the airport
17:29What were the runway conditions?
17:33Was there rain, ice, snow, anything on that runway that would have prevented the airplane from stopping on its surface?
17:41No rain, seven degrees
17:45So hydroplaning is out of the question
17:48Too warm for ice to form
17:50Investigators eliminate the captain's theory
17:54Weather conditions did not make the runway slippery
17:57In this case the runway wasn't contaminated, but there was plenty of information that the runway can tell us
18:00What about debris skid marks? Where are we at with the runway survey?
18:07Got it here
18:10The team looks for any evidence left behind on the runway
18:14The runway evidence was critical
18:18We walked the runway numerous times
18:21We documented the heck out of the runway
18:23Starting at 1835 feet past the threshold
18:27We've got a dark 170 foot long skid mark
18:30Then there's further skidding down the runway
18:32Skid marks on the tarmac are made when the wheels lock
18:35Then the plane crosses the center line to the right and then straightens out
18:41Which tire skidded?
18:44Based on the position of the skid mark
18:47Zopor tire, left side
18:50The Saab 2000 has four main wheels that brake
18:55Why would only one of them skid?
19:01Wasn't that the one with the bald spot?
19:03Yup
19:06The tire mark was a continuous black mark
19:08It didn't have any tread marks on it
19:10So we knew right off the bat that the tire was skidding on the bald spot
19:15And not on the tread
19:20We also found tire fragments
19:23Here
19:25So the tire blew?
19:27Yeah
19:28Hold on
19:30That's one heck of a long skid
19:32Even a brand new tire would have blown
19:34The fact that the airplane was skidding on the bald spot
19:38May have caused it to burst a fraction of a second earlier
19:41But in the end, it wasn't a contributing factor
19:42This shouldn't happen. The plane has an anti-skid system
19:44The anti-skid system is activated when one of the sensors on the four main wheels detects a skid
19:47The brake pressure is released either on both inboard wheels or both outboard wheels
19:50Ensuring the plane remains stable while allowing the other two wheels to slow the plane
19:53After we first noticed that there was a flat spot and a hole in the tire
19:59We were immediately drawn to the anti-skid system
20:01Because that's the purpose of the anti-skid system
20:02To stop skids
20:03Did the system fail causing flight 3296 to run off the runway?
20:04Any news?
20:06No
20:08No
20:09No
20:10No
20:11No
20:12No
20:13No
20:14No
20:15No
20:16No
20:17No
20:18No
20:19No
20:20No
20:21No
20:22No
20:23No
20:24No
20:25No
20:26No
20:27No
20:28No
20:29No
20:30No
20:31No
20:32No
20:33No
20:34It's gonna take some time for the technicians to break down and test those brakes
20:37Like you said?
20:38That is a long skid
20:40Why would they need to break so hard for so long?
20:43In the meantime, investigators consider other theories about the long skid marks
20:50Overweight?
20:52Could the plane have exceeded its maximum allowable landing weight
20:57Requiring the pilot to break harder than usual?
20:59a heavier airplane essentially has more inertia
21:03so when a heavier airplane comes in to land it would take longer to stop according to the manifest
21:11the captain calculated their landing weight at 45 213 pounds
21:19and the maximum allowable 46 114
21:24900 pounds under close but within the limits the airplane was not overloaded and we could rule
21:40out an overweight airplane as a contributing factor for this event what else might cause a
21:46pilot to break so hard the captain said that they had a crosswind but maybe the direction
21:53changed to a tailwind the tailwind during landing essentially means that you were moving faster
21:59over the ground than you normally would so you would take up more space on the runway to safely stop
22:05the automated weather system only gives hourly reports real-time updates come from a weather
22:10observer at the airport i'll deal with that i'll go help with the anti-skid system
22:18could flight 3296 have been hit by an unexpected gust of wind
22:23causing it to land too fast and overshoot the runway
22:33thanks for coming in you bet investigators question the on-site weather observer at unalaska airport
22:40about the wind conditions when penn air flight 3296 landed
22:44so first um how early do you start providing crews with weather data about 20 to 30 minutes out and up
22:52until when two to three miles out dutch harbor is a very unique airport the topography around the runway
22:59actually lends to very rapidly changing weather conditions and so a weather observer on the ground
23:06provides the ability to get updated information to pilots as it's happening and what was the weather
23:14like at the airport when panair was on approach no there was a storm coming in but at the time it was clear
23:19and what about the wind on the first attempt
23:27two seven zero degrees at 10 knots looks like a crosswind and second attempt about three minutes
23:36out the wind shifted around to two nine zero at 16 knots gusting to 30 knots
23:4430 knot tailwind that would be an excessive tailwind if a pilot decides to land with that tailwind
23:51they essentially become a test pilot what about when they landed what was the tailwind then
23:58the winds were 15 knots investigators confirm their suspicions about a tailwind on landing
24:06thank you for your time my pleasure
24:12one danger associated with landing in a tailwind is excessive ground speed which potentially puts
24:19you in a situation where you run out of runway to safely stop the airplane
24:23what's the sob 2000 max tailwind for landing was a 15 knot tailwind too much for the sob to manage
24:4115 knots right at the limit why would they risk it
24:45down okay you got the yoke i got it yeah we're down there investigators now know the pilots of pen air
24:593296 approached a difficult airport in tricky conditions touching down with a tailwind nearing
25:06the plane's limits brakes i cut them all the way down
25:18okay weight roughly 45 000 pounds speed at touchdown 126 knots investigators calculate how a 15 knot tailwind
25:27affects the pilot's ability to stop our aircraft performance group developed several scenarios
25:34to understand whether an aircraft would be able to stop given those circumstances tailwind 15 knots flaps 20
25:42and let's do a loss of half of the braking power because of the skid
25:47when the left outboard tire began to skid
25:50the saab's anti-skid system would have released brake pressure to both outboard wheels
25:55drastically reducing braking power
26:05they had room to spare with the tailwind of 15 knots and two working brakes the plane could have stopped
26:11what are we missing
26:18let's look at the fdr data
26:27hold on a sec just after touchdown there's an anti-skid fault caution
26:31this supports investigators earlier suspicions that an anti-skid failure played a part in the accident
26:43hang on i'm sliding
26:44we got to get to the bottom of that warning
26:58in this case we did have a fault on the flight data recorder related to this system that we couldn't
27:04explain and so with that information we needed to do a deeper dive in a lab
27:14we tested all the components of the anti-skid system there were no significant faults so it was a mystery
27:34there's still the cables that connect the components
27:37investigators focus on the wires that carry signals from the wheels
27:41right here let's take a look at the wiring they request that the cables be removed from the
27:48left landing gear as that was the side that locked hey there can we get those wire harnesses sent up to
27:54the lab when the airplane departed the runway it hit a ditch and some larger boulders and it collapsed
28:02the left main gear which caused the wiring to fracture
28:05these are pretty beat up
28:10investigators examine where the cables were connected to the wheels
28:22these are identical can't tell the left one from the right
28:26the team discovers a potential design flaw within the anti-skid system
28:30the connectors at the wheels didn't have any distinguishing features so this created potential
28:36for miswiring could the brake cables have been connected to the wrong wheels investigators examine
28:42the wires inside the cables normally we're able to open up a wiring bundle and look at the wire numbers
28:50on the wires and compare it to an electrical diagram and determine if it's connected properly
28:56there's no numbering on these wires
29:00we found the wires were so small the manufacturer didn't put wire numbers on them
29:04so we're concerned about not being able to determine if they're correctly connected
29:10there should be three wires inside the anti-skid cables
29:14so we got three here
29:16then investigators notice something out of the ordinary
29:19there's four wires here
29:22there's an extra wire on the top half of this cable
29:24the wiring inside the top and bottom half of the outboard cable doesn't match
29:34there's four in each of these
29:35the top outboard cable and the bottom inboard cable each had an extra wire
29:41which means only one thing
29:45they're crossed
29:47no wonder the anti-skid system failed
29:49when the left outboard wheel began to skid the anti-skid system mistakenly released pressure to
29:58the inboard brakes as a result the skid continued and the left outboard tire burst that was really
30:04the aha moment when you have crossed wires the airplane is then dumping the brake pressure to the two
30:13perfectly good wheels and allowing the other tire to skid
30:20brakes
30:21i cut them all the way down
30:24without braking power to the two inboard wheels and a blown left outboard tire the pilots had a
30:30massively reduced ability to brake
30:32you're reducing the effect of braking capacity by 75 percent and now only the right outboard tire is providing braking
30:41the cables have to go through the entire landing gear how did maintenance workers mistakenly
31:00cross the wires of the braking system leaving the pilots of penn air flight 3296 with only one of four
31:06main landing gear brakes to stop their plane see it's not a straight line and the wheel attachments are
31:12identical so imagine trying to feed two wires through a small hole at the base of the landing gear
31:18how do you know which one went to the left and which one went to the right it would just be so easy
31:23to confuse the two how long could these have been crossed according to the records there was a full
31:30overhaul of the left main landing gear when january 2017
31:38the wires were crossed two and a half years prior to the accident
31:44we found out that the aircraft had been sitting
31:48for a couple years in overhaul and there wasn't any sort of procedure to check to see if there was
31:55any cross wiring so how many flights did it make once it was back in service
32:04about 500. they learned that the misrouted anti-skid wiring went undetected for nearly four months
32:13so why did 500 flights manage to stop but not these guys
32:16maybe the malfunction was happening just on a smaller scale the balding tire
32:26was the worn left outboard tire an indication of the malfunctioning anti-skid system
32:32we suspected that there were events of skinning but the difficult thing is it would have to skid
32:39more than a second and a half for the airplane to display a fault that this system was malfunctioning
32:45so this could have been happening gradually with repeated small skids creating the bald spot on the
32:50tire yeah but when they landed at that speed with that tailwind they brake longer and harder than in
32:56previous flights
33:00brakes i cut them all the way down that's really the insidious nature of this fault you're not going
33:09to find out about this cross wiring until you really need it when you're slamming on the brakes
33:13hang on i'm sliding
33:18with the hidden anti-skid fault investigators conclude the pilots of pen air flight 3296
33:25could not have stopped their plane on runway 13
33:31there's one thing i'm curious about
33:37could they have stopped if they landed into the wind on runway 31 instead
33:41it's possible their landing speeds would have been slower and the drag caused by the
33:52extra wind would have stopped it in time
33:57then why did they choose runway 13 in the tailwind did the pilots of pen air flight 3296 ignore crucial
34:05information about the wind and execute a risky landing the decision to land on runway 13 with the
34:12reported tailwind was an inappropriate decision this was an experienced crew and you weren't sure what
34:19what exactly had happened investigators turned to the cockpit voice recorder for answers
34:25pull up from the go around onward
34:30what do you think go around max power
34:35dutch harbor traffic peninsula 3296 going around we're gonna come back around for a visual
34:44yeah we're just gonna get out of here do a 180 and come back in
34:49roger all right you're at a thousand feet pause for a second
34:54so the captain says that he's doing a 180 which would line him up with 3-1
34:59but that's not what he does he takes a sweeping 360 degree turn around the mountain to 1-3
35:11why
35:15we're at 1200 coming back around for a one uh for a visual one three three one
35:21three one three one i thought we're doing one three uh okay sure i'll try it again stop the tape
35:34so the captain wants to go to three one but the first officer questions it
35:40there was a back and forth between the captain and first officer in terms of
35:44which runway to use i would categorize the captain's leadership as poor
35:49okay get a wind check from her again as the crew finalizes the second approach the captain stays
35:55on top of the wind reports dutch weather 3296 another wind check right now midfield winds at
36:03300 at 24 knots oh god oh crap stop the tape sounds like they're not happy with that tailwind and yet
36:14they kept going the cvr raises questions about the captain's report of a crosswind
36:21they were surprised of the wind direction and speed but the interesting thing is is that
36:28they were aware of the tailwind limitation for that particular aircraft but they continued on with the
36:35decision to land
36:41try it again keep talking the weather why would the pilots of pen air flight 3296 decide to land with a
36:49tailwind on a short runway in dutch harbor alaska at 24 knots all right we'll try it again all right last
36:57try raj it's like the captain's just going along with what his first officer's saying
37:05he needs to take on more leadership the captain suspected 3-1 was the better option but he never
37:11stated his preference the captain's capitulation to land on 1-3 does show ineffective leadership
37:20and that he did not fully evaluate the circumstances at hand in order to make
37:27an objective decision maybe he was fixated on landing
37:39instead of communicating their options they continue their approach give me speed plus 15.
37:46investigators conclude the pilot's decision to land on runway 13 was intentional and inappropriate
37:56by making that decision they put themselves at risk but they also put the passengers at risk
38:03crossed wires tailwind some poor leadership it all added up and very little margin for error at such
38:11a tricky airport the pilots of penn air flight 3296 defend their decision to land on runway 13
38:25we're at 1200 coming back around for a one uh the visual 13 31 31 31 i thought we're doing 13
38:33uh okay sure we'll try again after the first landing attempt the captain claims his first officer saw no
38:42change in wind conditions on the runway he called my attention to it so i looked again to evaluate the
38:49situation he was correct it was a crosswind if the conditions hadn't changed i didn't see a reason to
38:55change the plan dutch weather 3296 another wind check right now midfield winds at 300 at 24 knots oh god oh crap
39:10what we were seeing was not what she was uh reporting at that point in time those winds were clearly
39:17crosswind we could see the white caps and then the windsock itself was showing a crosswind
39:22commercial pilot and passenger steve rainey saw something different
39:30i saw a direct tailwind 20 to 30 knots as a commercial pilot that is something that i would not have
39:36attempted when you get conflicting information from what you're seeing that is a tough call for a pilot
39:42down okay you got the yoke i got it yeah we're down there 80 knots when the brakes malfunction the
39:54captain is unable to slow the plane brakes i got them all the way down we had no braking power at all
40:03if we had one operational brake still it would have locked up and blown as well
40:06this particular aircraft didn't have an emergency brake so in the event that the main system failed
40:12there's no way to bring this aircraft to a brake stop ah hang on i'm sliding
40:19quick thinking in turning the plane towards a road avoids a full plunge into dutch harbor go right go right
40:28the key to not going into the water was our decision to land on one three
40:31we had the perimeter road there was a lot more room on the one three side
40:40tragically fragments of the left propeller ripped through the fuselage killing a passenger
40:48you never want to lose a passenger for any reason um that that's been very hard for me
40:55investigators conclude the probable cause of the accident is incorrect wiring of the anti-skid system
41:04contributing to the accident is the pilot's inappropriate decision to land on a runway
41:09with a powerful reported tailwind
41:16that troubles me because are we supposed to just blindly rely on our weather observers
41:21or are we supposed to make a decision as the pilots on what the best course of action is
41:25based on what we see saab released a service bulletin advising operators to inspect the anti-skid
41:32system for crossed wiring you know you can't afford for human era to be allowed in connecting wires
41:41that's a very basic thing especially on a critical safety system such as the brakes
41:46for steve rainey the ordeal changed his attitude about flying it took quite a while for myself to be
41:55comfortable again but we live in a place where we have to fly there's no choices about it i would hope
42:03that there are lessons here as far as uh weather and maintenance that can keep accidents like this from happening again
42:16so