- vor 10 Stunden
On 19 October 2004, Corporate Airlines Flight 5966, operating for AmericanConnection, crashes short of the runway while on approach to Kirksville Regional Airport in Missouri, killing 13 of the 15 people on board. The pilots had descended below the minimum safe altitude under the effects of fatigue.
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00:00when I woke up we were suspended up in trees corporate Airlines flight 59 66 crashes on
00:13final approach to Kirksville Missouri I just thought I need to get out of this
00:19plane before it blows up only two people survive if you went to the accident site
00:24you wouldn't recognize it as an airplane the wreckage provides no clues instruments
00:30all checked out it was fit to fly and the cockpit voice recorder reveals a team
00:35working well together no flags except for the vertical keep it slow until the
00:40flight's final seconds no trees things went bad real fast so the question
00:49became what happened
01:19if we have to go miss to a set max power flaps 10 positive rate you're up the
01:27pilots of corporate Airlines flight 59 66 complete their approach briefing into
01:33Kirksville Missouri Regional Airport then we'll climb 3,000 feet then direct
01:37Kirksville VOR captain Kim sassy has been a pilot since the late 1980s but only
01:44started flying professionally in the last five years
01:47I'll ask you to walk me through that if we do that I will categorize Kim as a
01:56a bon vivant with a colorful language he was very calm when he was flying and his
02:01knowledge was excellent first officer Jonathan Palmer has three years
02:06professional flying experience with regional airlines the pilots viewed your
02:12time with the regionals as somewhat of the dues you pay to get to the
02:17airlines or the high-end corporate jobs this is where you built your time it's
02:21where you've got your experience there are 13 passengers on tonight's flight that
02:29flight was actually a pretty smooth flight I don't remember any turbulence or
02:33bouncing or anything it was a nice way Wendy Bonham is with a group of doctors
02:39traveling to a medical conference
02:42do you have another copy I left mine at home
02:48the topic of the conference was compassion in medicine which was a great
02:59topic so I was kind of excited to go I'm really looking forward to some of these panels I had
03:08only started at Kirksville College a few months before that so I wasn't
03:12familiar with all the people who are on board but they all knew each other really
03:16well and they were all chatting with each other so it was kind of fun to watch
03:20tonight's flight is a short 50-minute trip from st. Louis to Kirksville Missouri where visibility is
03:30reduced the workload on short flights is intense because as soon as you get the airplane squared
03:39away from the takeoff you've immediately got to start preparing it for the landing
03:43we're going into the crap look at so you're even creepy these pilots have flown multiple times
03:55together over the last week and encountered a lot of bad weather I got a suffocating feeling
04:00every time I see that the office in which pilots work is is quite small it's got a wonderful view but
04:12it is actually a quite tight working environment and you're in that environment for six eight ten hours
04:18during a day you have to find ways to get along the pilots are flying a jet stream 32 a twin engine
04:27high-performance turboprop aircraft built for short-range flights the jet stream was designed
04:34for this type of work it was an economical airplane it was reasonably comfortable for the passengers but
04:39it was capable of going in and out of smaller airports and still being able to make a profit for the airline
04:46the jet stream is fuel efficient and reliable but this particular model has no autopilot
04:55the jet stream not having any autopilot made our days very long you had to constantly fly the
05:04airplane and autopilot would be nice on those long sequence so we were doing but on a positive part
05:11the jet stream made you a very good pilot flight 5966 is being monitored by a central controller in Kansas
05:20city as there is no controller at Kirksville Airport or bex 5966 turn right heading 330 maintain 3,000 till
05:31established on localizer 3,000 till established cleared for the approach clear for the approach 16 miles south of
05:43the airport the pilots begin to configure the aircraft for landing course alive cross-check no flags except for the
05:52vertical keep it slow all the time we need let's go flaps 10 and we're going to figure early to give ourselves as
06:02as much time as we can all right flaps 10 the crew is flying a non-precision approach they don't have vertical
06:10landing guidance configuring early reduces the workload as they near the airport one of the things that in any
06:22approach but particularly in a non-precision approach you want to minimize the number of variables and one of
06:28the ways you do that is you get the airplane in a position to land earlier than normal let's make
06:36sure the lights are up please the lights at Kirksville are pilot activated the airports without a lot of
06:46traffic that goes in and out of them one of the ways that they reduce the cost of running the airport is
06:52they don't have the lights on all the time the pilots have the ability to control those lights with
06:58a series of microphone clicks on a specific radio frequency evil slides are not on particularly when
07:07you fly with a low visibility and at night you won't see the runway so if you don't see the runway you can
07:13land seven times I clicked it I did they're still too far out to see the lights captain sassy wants to
07:24avoid surprises all we can do is we can call Kirksville ops and ask them to confirm they're up the pilots
07:32confirm with airline operations on the ground Kirksville ops Corfex 5966 yeah could you tell me of the
07:41the approach lights are up I would do that when I didn't see the airport say hey did you see the
07:48lights coming on for the approach it's a good technique cool thanks there was one doctor up in the front who
08:02didn't put her seat belt on and I wanted to call out to her and say put your seat belt on but I it I
08:13didn't I wasn't afraid but I just I'm a rule keeper and thought she should have her seat belt on
08:20two and a half miles from the airport the pilots search for the runway 400 it's very critical to
08:33maintain that altitude because if you don't see the runway you gotta go missed because you cannot land
08:37without seeing the runway flight 5966 emerges from the clouds 350 here we are two miles from the runway the
08:52pilots are still looking for the approach lights you are flying 336 feet above the ground so there's not a
09:01a lot of room for error what do you think I could see ground there I don't see anything oh yeah there it
09:13is a protest inside but just as the pilots appear to have the runway lights in sight flaps 35 something
09:21goes wrong no no trees what's going on I just remember thinking I can't believe this is happening
09:33no stop oh my god
09:36corporate airlines flight 5966 has crashed into a wooded area 1.2 miles south of the airport at
09:53Kirksville Missouri
09:54when I woke up it was dark and it was quiet
10:05and the only sound that I could hear then was just the sound of fire we were suspended up in trees
10:15Wendy Bonham and her colleague Dr. Krogh struggled to escape
10:19I just felt like I needed to move I have always had a fear of blowing up and there was a fire in the
10:30back of the plane and I just thought I need to get out of this plane before it blows up
10:34I don't remember walking from my seat to the side of the plane
10:44it was a ways down and there was fire down there there is no other way out of the plane
10:55I don't remember falling from the plane down to the ground
10:59I remember before and after and I stood up and I could see Dr. Krogh pretty close to the plane and he was laying down
11:09the other 11 passengers and both pilots are dead
11:15they were all really incredible people that did incredible things for their communities
11:22for the pilot community this is something that is touching us because that could be us that could be me we want to know why what happened
11:40it's up to the National Transportation Safety Board to investigate but there's not much left of the plane for them to examine
11:50most of the aircraft itself was consumed by the fire there wasn't a lot left I mean there's engines propellers and other things but
12:00um if you went to the action site you wouldn't recognize it as an airplane
12:13what a mess
12:16this is what we have from structures
12:19although the plane was almost completely destroyed an on-site team is able to analyze the debris
12:29I'm amazed that we were able to get this much data from that heat
12:33investigators turn to the wreckage analysis to determine if the plane had any mechanical problems that could have caused the accident
12:40we've gone through that wreckage with the fine-tooth comb engines controls instruments all checked out
12:48looking at all the data we had from the accident site it appeared that the airplane was fully functional the time it hit the ground
12:55the planes working fine
12:58they might still have lost control
13:01they examine the direction of the plane's trail of debris
13:06they first hit the trees here just over 1.3 miles short of the runway
13:15they fly another 775 feet
13:18they hit another set of trees here
13:22the plane was headed straight for the runway the entire time
13:27we had enough information that looking at all the pieces
13:30this accident started to look like it was a human performance issue and not an airplane issue
13:36what kind of an approach were they flying that night?
13:43non-precision to runway 36
13:45unfortunately the accident rate for non-precision approaches is dramatically higher than on those approaches with an instrument landing system
13:55what do we know about the weather that night?
14:02wind was nominal no turbulence or rain to speak of
14:06hold on a sec
14:10cloud ceiling was low 300 feet
14:16the cloud ceiling is the distance between the base of the clouds and the ground
14:23visibility was three to five miles
14:33they're flying blind through the clouds
14:40it's misty visibility is poor
14:43those are bad conditions for a non-precision approach
14:46question is are they bad enough to cause this accident?
14:50well, let's find out
14:54in low visibility conditions
14:57a non-precision approach is very challenging to fly
15:01because you come down to the lowest altitude
15:04you have to level off there
15:06and you fly along looking for the runway environment
15:12investigators speak to a pilot who landed in Kirksville ahead of flight 5966
15:18how bad was the weather that night?
15:21flying was smooth
15:23the visibility was right on the cusp
15:25maybe two to five miles
15:28half the state had been soupy for a couple days
15:30how was the visibility for landing?
15:33no issues
15:35if it had been worse we would have gone around
15:40why did flight 5966 crash when other aircraft flew the same approach safely that night?
15:47so the question became what went wrong that day?
15:50and that takes time to put together
15:52we've got the performance data ready to go
15:57let's see how they handled the approach
15:59using a combination of data from the flight recorder and radar
16:05investigators analyze the flight's descent profile
16:08it was important for the team to take a look at the descent profile
16:12how did it wind up where it did?
16:14so we start backing up during the whole approach where it was during these segments
16:19so they come in like this and continue straight to the ground
16:27can we see their MDA?
16:29so the plane was supposed to level off at the minimum descent altitude
16:41before continuing to descend to the runway
16:45why would they blow right past the MDA like that?
16:48if they didn't level off at the minimum descent altitude
16:53why not?
16:54what didn't they see or what didn't they do?
16:59how fast were they descending?
17:011,200 feet per minute
17:08what should they have been doing?
17:10below 300 feet of altitude the max is 900 feet per minute
17:18once you get to minimum descent altitude
17:21you should stop your descent altogether
17:23and continue on
17:25why did flight 5966 descend so low and so fast?
17:31they continued that descent speed right up until they crashed
17:35why didn't they slow down before striking the trees?
17:40investigators listen to the cockpit voice recorder
17:46to understand why the pilots of corporate airlines 5966 crashed short of the runway in Missouri
17:53ready?
17:55ok let's take it back to 5 minutes before the accident
17:59when they're lined up for the runway
18:01the cockpit voice recorder is one of the most critical elements in the investigation
18:09it's your most direct evidence on how the crew is interacting
18:12on how they're following procedures
18:14on exactly what happens on the human side
18:21course alive
18:22cross check
18:23no flags except for the vertical
18:26keep it slow
18:28all the time we need
18:31let's go flaps 10 and we'll configure early too
18:34give ourselves as much time as we can
18:36alright, flaps 10
18:38they're configuring the plane to land early
18:45the team hears evidence of a cautious and prepared crew
18:50smart move and low visibility
18:52the crew on this flight knew that the weather was going to be challenging
18:57and one of the ways that they tried to mitigate that or to improve their chances of a successful landing was to get the airplane configured early
19:07let's make sure the lights are up please
19:13alright
19:14there are cases where the captain does an exemplary job where he goes beyond the requirements
19:22he asked the first officer to call ahead to make sure from the ground that the lights are working and that they're turned up fully
19:28it's not required it's an excellent idea especially in these conditions
19:33I'm hearing an organized crew here
19:35take it to when they near the MDA
19:37if there's a big mistake it'll likely be then
19:41the minimum descent altitude is the lowest altitude you're permitted to fly at until you see the runway environment
19:47400
19:53350
19:57here we are
19:58okay, they're at the MDA
20:00it's decision time
20:02so?
20:03what do you think?
20:05I could see a ground there
20:07minimums, minimums, minimums
20:09I-I-I don't see anything
20:11oh yeah, there it is
20:12approach that's in sight
20:14hold it there
20:16they're two miles out
20:19300 feet up
20:20they've just come out of the clouds
20:22with the mist that night
20:23they probably couldn't see the runway lights
20:25there's only farmland from here to the airport
20:28I can't see anything the captain could have mistaken for runway
20:32why is the captain even looking for the approach lights
20:37so the captain's the first one to say I see something outside the airplane
20:41he sees the ground
20:42he sees the lights
20:43he shouldn't be doing that
20:45he should be totally focused inside the airplane
20:48the first officer is supposed to see the approach lights and call out approach lights in sight continue
20:54but the CVR recording tells a different story
20:58instead they're both looking for the runway
21:00and nobody is paying attention to the plane's descent speed and altitude
21:10the flying pilot should have been monitoring exclusively instruments
21:14and what sadly occurred
21:17was that the normal flight path continued below the minimum descent altitude
21:23and neither one of them caught it
21:25no
21:26trees
21:27and that is very apparent
21:29when you hear this
21:31trees
21:32and that-and it shocked both of them
21:34they did not expect to see that
21:36they spent four and a half minutes following procedure
21:43they configure the plane early for landing
21:47here they make sure the runway lights are on early
21:51first officer calls out minimum descent altitude
21:55and from this point
21:5823 seconds from impact
22:01it all goes wrong
22:02captain's looking outside when he shouldn't
22:04the first officer
22:05doesn't challenge him
22:06next thing they're crashing
22:08it's surprising
22:15how much
22:16the captain's performance suddenly fell apart
22:19at the end
22:20that even listening to it
22:22he sounded like he was much better than that
22:24it's a surprise for me professionally
22:26that this can happen
22:27investigators need to find out how a crew that seemed to be flying so well
22:32flaps 35
22:33no
22:34no
22:35trees
22:36made such crucial mistakes in the last seconds of the flight
22:40no
22:41holy crap
22:49take it back 30 minutes before impact
22:54investigators return to the cockpit conversation
22:57for clues to explain why the crew ignored established procedures
23:01in the final 23 seconds of their flight
23:04and there
23:07my hair was down in my breast pocket
23:09are you serious?
23:11right here you can hold my hair like this
23:13I cannot see you with long hair like that
23:16I used to wear a black derby with the rim turned down
23:21it was my concert hat
23:23at a Fu Manchu
23:25at a Fu Manchu
23:29yeah it was fun
23:30yeah it was fun
23:32I cannot imagine you like that
23:34corp x 5966 climb and maintain one two thousander
23:41twelve thousander
23:43twelve thousander
23:44one two thousand corporate x 5966
23:49twelve er thousander
23:53I detect a bit of an attitude there
23:55I might have to call him a jerk
23:57does that seem a bit casual to you?
24:02yeah but they're above ten thousand
24:06so cockpit doesn't have to be sterile at this point
24:10the philosophy of the sterile cockpit rule is below ten thousand feet
24:16the flight crew is engaged in only what's required to basically fly the airplane
24:23no non-pertinent conversations
24:25keep going
24:27I have a good time flying with you
24:33yeah me too
24:35just letting you know that
24:36you gotta have fun
24:39that's truth man you gotta have fun
24:41too many of these jerks take themselves way too seriously in this job
24:44I've flown with them and it sucks
24:46a month of freaking agony
24:48all you want to do is strangle the jerk when you get to the ground
24:51oh
24:52the conversation raises a major concern for investigators
24:56sure they're joking but the captain is essentially telling him how he wants the first officer to behave
25:08that's disturbing and it sets a disturbing atmosphere
25:11it's a bad setting for the captain in terms of priorities
25:15okay what's next
25:19cruise check power check you push his foot away
25:34yes
25:36it's a relatively compact airplane and the passengers in the front of the airplane can sometimes put their foot into the cockpit area
25:46cruise power check
25:49cruise power check
25:51all you gotta do is you open the curtain a little bit it's like
25:54man
25:55some people I invite their feet up to make them more comfortable but
25:58damn
26:00I dropped my book on him purposely one time
26:04right on top of the arch of the foot
26:06oh
26:07okay stop it
26:10the captain
26:12starts his cruise power checks
26:15but then interrupts himself to tell
26:17a story about hurting a passenger
26:19mm-hmm
26:20it's really inappropriate
26:22uh
26:23the lack of respect for passengers is striking in his conversation
26:28your power levers
26:29right on top of his foot
26:31the power spiked up a bit
26:33the first officer has to tell the captain twice to adjust his power levers but he insists on telling this irrelevant story
26:43all right well let's see if the first officer can get him back on track
26:50all I'm thinking about is a Philly frickin cheesesteak and an iced tea
26:56sounds good
26:58uh
26:59cruise power is set
27:02centimeters
27:04centimeters 2-9-9-0
27:05set
27:06and
27:07cross-checked
27:08now the captain interrupts their checklist to discuss his dinner plans
27:17how'd he get 2-9-9-0
27:19cause you're an idiot
27:22it should be 2-9-9-2
27:25you never said it when they cleared to the runway
27:28investigators hear the captain mocking the first officer while confirming their altimeter setting
27:35and I've been sitting here living alive for the last 20 minutes
27:38yeah you lying scum bucket
27:40okay
27:42damn boost pumps are off
27:44pressurization is set
27:46and external light
27:48you blustering scabby pustule
27:50are externalized
27:52your damn cruise checklist is
27:54frickin done
27:56the captain's jokes have totally eroded procedure even the first officer has given in and turned his checklist into a joke
28:07there would be pressure on the first officer
28:10uh he does go along with the joking
28:13but the captain is still the pilot in command and he has to set the tone
28:17there's a danger that the first officer will not focus to the extent that's required
28:21did a breakdown in the cockpit command structure affect the first officer's actions at a critical moment
28:28350 here we are
28:41what do you think
28:43I could see ground there
28:45minimos
28:46minimos
28:47minimos
28:48I don't see anything
28:49oh yeah
28:50there it is
28:51approach that's inside
28:56you gotta have fun
29:00too many of these jerks take themselves way too seriously in this job
29:06flaps 35
29:07the kind of atmosphere he set up earlier
29:10in making fun of other pilots and making fun of the passengers
29:13sets up the wrong tone
29:15it doesn't encourage the first officer to object
29:18when things were falling apart
29:20he he could have stepped in and done something
29:27it looks like a complete breakdown
29:30in command structure led to this accident
29:32the question is
29:34why
29:47got their personnel files
29:48investigators study the pilots training and previous flights
29:53to determine if the crew of flight 5966 had a history of deviating from airline procedures
29:59it's very important to get a broad sense of what the pilots like from previous flights
30:06what is their reputation
30:08have any of the problems that show up in this accident shown up before
30:13is this a recurring problem
30:16captain left a well-paying job to become a pilot
30:20plenty of hours
30:22passed all the checks
30:24he had an interview lined up with a major airline
30:28you have a capable pilot
30:32who's devoted to aviation
30:34who gave up a computer industry job that paid several times as much money
30:38because he wanted to be a pilot
30:40first officer checks out too
30:42ten years experience squeaky clean record no incidents
30:45they were joking a fair bit almost punch drunk
30:55do you think they may have been overtired
30:58fatigue can greatly impact performance you get more tired and all of a sudden your level of precision can go downhill
31:10the team turns to other corporate airlines pilots for more insight into the crew
31:17hi
31:23did you see any unusual behavior from these pilots that would suggest they were tired
31:29actually uh captain sass did try to take a nap here in the pilot's lounge before the flight
31:35they noted that he's six foot four very tall and the couch was actually quite small he didn't quite fit on it
31:42so it couldn't have been ideal for sleeping
31:45any idea how long he was asleep
31:49maybe an hour
31:51thank you
31:55fatigue is insidious
31:57and that
31:59and that
32:00you get
32:01an increasing performance degradation
32:03once you are at a higher level of fatigue
32:06and performance impairment
32:08it can be somewhat like alcohol
32:11these are the classic signs of fatigue
32:16this is what we're looking for
32:18when I have a case
32:20that involves fatigue
32:22I go back to the cockpit voice recording again
32:24to see
32:25do they sound tired
32:27here's something
32:29visibility for
32:34mist
32:35sky condition
32:36overcast
32:37300
32:38an automated weather update notifies the pilots of the poor visibility in Kirksville
32:43we're not getting in
32:48crap
32:50go all this damn way
32:55let's try it
32:56yeah we're gonna try it
32:57I don't want to come all the way out here for nothing tonight
33:00they haven't even gotten into the bad weather yet
33:03and the captain's determined to land in it
33:05yeah
33:06he's fixated on landing
33:08it had not been an easy duty day
33:18and so
33:19they're probably
33:21getting towards the end of like
33:23we would like to get this flight over
33:25but there's more than just fixation going on here
33:30the pilots discussion provides more evidence of fatigue
33:34when they find out the weather's bad the captain should be talking about options other than landing
33:41well he has the opportunity to discuss options now
33:44what does he do
33:49I'll be so happy when we have an ILS
33:51the next job everywhere we go we'll have an ILS
33:54yep
33:55the captain complains about not having automated landing assistance
33:59an ILS at the airport
34:01the only options he's talking about are future job prospects
34:06instead of discussing options if they can't land
34:09the captain is talking about his ambitions of flying for a bigger company
34:16we're going into the crap
34:18look it's all you're even creepy
34:22mmm
34:25ten minutes earlier they're upset about the bad weather but when they're actually in it they're cracking jokes
34:32the crew isn't responding fast enough to the changing situation
34:37that can be a sign of fatigue
34:41people start to become giddy and are not critical enough or or enough careful of their behavior
34:48after this they don't discuss the weather again for
34:54three minutes
34:56how's crooksville looking weatherwise
34:59visibility three miles
35:01sky condition overcast
35:03300
35:05still overcast 300 feet
35:08and when they do check again the visibility is still bad and they don't discuss options besides landing
35:21they discover that the crew ignored multiple warnings about conditions on the approach
35:27in fatigue you don't respond to warnings that there are warnings that this is not working but that you're slow to respond to it
35:34just missing one piece
35:39you already have it
35:41the risky decision is to try to land when they can't decide if they can see the runway
35:46I could see you ground there
35:49I don't see anything
35:52oh yeah there it is
35:54approach ice inside
35:55it's a decision the pilots regret almost immediately
35:59flaps 35
36:02no
36:03no
36:04no
36:05trees
36:06investigators conclude that fatigue played a major role in the crash of flight 5966
36:12they can see the runway
36:13so they've fixated on landing
36:15uh huh
36:16right
36:17they don't consider any of the other options
36:19and they make the risky decision to land anyways
36:22mm-hmm
36:23all the signs are there
36:24I personally feel that fatigue is the largest human performance area that we can address as an industry to prevent accidents from happening
36:35it's not always obvious when someone is tired and it's not obvious to them
36:39that scientific evidence is that people typically under report how tired they are
36:45they have to do
36:47they have to do
36:48they have to do
36:49they have to do
36:50how much did these guys work before the accident flight
36:54investigators analyze the pilots duty hours leading up to the flight
36:58to study fatigue we look at the person is getting the amount of sleep that they normally get
37:05we look at how long they've been awake
37:07uh we look at the time of day
37:09uh those are scientifically worked out and we can get an idea from that
37:14the night of the flight they had worked three days straight
37:18that'll tire you out
37:19yeah well they had seven and a half hours of available rest time the night before the flight
37:24that day they flew six flights an hour each
37:27and they were on duty for 14 hours straight starting at 5 45 a.m.
37:33the team discovers that the crew of flight 5966 worked an extremely long day before the accident flight
37:41the day of the accident was very busy
37:44they had to get up about four in the morning their first flight was around five in the morning
37:48they were originally scheduled for eight flights and they would have been on duty for about 14 hours
37:53it's it's it's quite a long day
37:56so it was an extremely long day not enough rest at that plane with no autopilot
38:02the FAA regulations have to say about working in those conditions
38:08were the pilots made to work too many hours without sufficient rest
38:17check this out
38:18pilots can't fly more than eight flight hours in a day but that's it
38:23I flew in those days and you had a maximum number of flight hours in a day
38:28but the number of duty hours and the time of day was not even taken into consideration
38:33isn't there data out there that says it isn't safe to fly if you've been up that long
38:45a 2003 study of data from 55 accidents concluded that pilots who worked 13 or more duty hours
38:53had an accident rate several times higher than those working shorter days
38:57why isn't this information reflected in the regulations
39:03this might have something to do with it
39:06investigators discover the reason why the FAA's rest and duty regulations don't reflect the latest research
39:14last time these regulations were updated
39:191964
39:21you had a dedicated and very capable crew
39:26you had a company that was trying to do a good job
39:29really the regulations needed to be updated according to scientific principles
39:35to improve the safety for everyone
39:38the team now has a comprehensive picture of the accident of corporate airlines flight 5966
39:47at the end of a 14 hour day
39:51two tired pilots attempt one final landing in challenging conditions
39:56I got a suffocating feeling every time I see that
39:59the captain's joking and casual tone in the cockpit undermines the command structure between him and the first officer
40:11you gotta have fun
40:13that's truth man you gotta have fun
40:15too many of these jerks take themselves way too seriously in this job
40:18the pilots roles break down so much that in the critical 23 seconds before crashing
40:24neither of them is doing his job
40:27so what do you think
40:29the captain ignores protocol and takes his eyes off his instruments
40:33I can see ground there
40:35I don't see anything
40:37and the first officer doesn't challenge him
40:40flaps 35
40:43the pilots fatigue likely contributed to poor decision-making and fatal preoccupation with landing
40:49no
40:51no
40:52no
40:53trees
40:55no stop
40:57oh my god
40:58holy crap
41:00oh
41:01oh
41:02oh
41:03oh
41:04oh
41:05oh
41:06oh
41:07oh
41:08oh
41:09oh
41:10oh
41:11oh
41:12oh
41:13oh
41:14oh
41:15oh
41:16oh
41:17oh
41:18to consider elements like length of duty day, start time, workload,
41:24and other factors that can affect pilots' alertness.
41:27The NTSB had been advising changes in the regulations,
41:32in the flight and duty time regulations, for decades before this happened.
41:36But I think with this accident, it really focused to a point that industry realized that this was necessary.
41:42This was a push from the major airlines first that then trickled down into other operations
41:49that were smaller, like the regional airlines and corporate operators.
41:53For Wendy Bonham, the change came at too high a cost.
41:58I'm comforted to hear that there were changes made in that length of time that pilots can fly because of this crash.
42:12I suppose it's something good that came out of something that wasn't good at all.