- vor 21 Stunden
On 2 October 1996, shortly after take off, the crew of Aeroperú Flight 603 are confused by false speed and altitude readings and contradictory warnings from the aircraft's air data system. In preparation for an emergency landing, the crew descend the aircraft, but unknowingly descend too far by relying on the false readings. The aircraft crashes into the Pacific Ocean, killing all 70 people on board. The false readings and contradictory warnings were caused by duct tape over the static ports, which was used to protect the ports during maintenance, but was not removed afterwards.
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LernenTranskript
00:02just minutes after taking off from Lima we declare an emergency the pilots of
00:08Aero Peru flight 603 get mixed messages from their plane I cut the engines but
00:13the speed is increasing having erroneous airspeed indications now puts into your
00:19brain am I climbing am I not climbing they seek assistance from the ground
00:23can you tell us our altitude please you're a 9700 but nothing makes sense all 70
00:35people on board are killed investigators compare the cockpit voice recording with
00:45the flight data recorder captain doesn't realize how close they are to the water
00:48and suspect a single faulty sensor prevented the crew from averting disaster
00:53it violates the laws of physics airplanes just don't do that
01:22it's nearing 1 a.m. at Jorge Chavez International Airport in Lima Peru
01:31thick clouds blanket the sky as Aero Peru 603 taxis to the runway
01:39the weather in Lima Peru is very very stable environment especially this time of the year
01:45the captain is 58 year old Eric Schreiber he's highly experienced having logged almost 22,000 flight hours
01:54Aero Peru 603 authorized to Santiago initial level 29,000 feet and afterwards on course transponder
02:065603 42 year old first officer David Fernandez has flown nearly 8,000 hours
02:12correct he will be the pilot flying the aircraft tonight
02:17Roger
02:20he's doing double duty by also operating the radio
02:26Lima Tower Aero Peru 603 runway 15
02:30ready for takeoff
02:33Aero Peru 603 wind calm clear for takeoff runway 15
02:40there are 61 passengers and seven flight attendants on board
02:54takeoff at 41 minutes past midnight on the dots what precision like the Suez let's go
03:12the crew is extremely professional they accomplished their checklists and procedures as what would be expected
03:17and they were basically an on-time machine
03:36flight 603 will fly out to the Pacific Ocean before heading south to Santiago
03:43the aircraft is a four-year-old Boeing 757 200 the Boeing 757 is a long narrow-bodied aircraft twin
03:53engine it's simple in its design simple instrumentation and just an overall comfortable airplane to fly
04:02the passengers settle in for the three-and-a-half-hour flight
04:08the passengers settle in for the three-and-a-half-hour flight
04:10in the cockpit
04:12the first officer spots a potential problem
04:16the ultimators are stuck
04:25the pilots also get a wind shear warning
04:30this is you the wind shear is an alert that we're entering into an environment of undesirable winds
04:36they could be highly critical in the safety of the aircraft
04:40those type of winds are just very uncommon in that area and we're not forecast that night at all
04:48flight 603 climbs into the thick clouds above Lima the pilots lose sight of the ground
04:55the speed
04:57they now discover another instrument isn't working
05:02yeah right
05:04flying in the clouds at night without knowing how fast they're going or their height above the ground the pilots
05:11face a potentially dangerous situation
05:15am i climbing am i not climbing am i near mountainous terrain which is very close to the coastal line
05:21of Peru
05:23tower aero peru 603
05:25flight 603 updates the tower controller
05:28aero peru 603 tower
05:30go ahead
05:31we have no altimeter and no airspeed
05:34declaring an emergency
05:39when a pilot declares an emergency with air traffic control the controller is going to give that aircraft priority handling
05:47roger change frequency to 119.7 for further instruction from radar control
05:58before contacting radar control the captain takes over from the first officer
06:04okay i have control
06:06the captain may decide to take over the flying role and tell the first officer to talk on the radio
06:12and work procedures
06:18the pilots request directions for a return to the airport
06:22roger we suggest a right turn heading 330
06:26it was a good call to ask air traffic control give us vectors
06:29we're so busy up here dealing with everything else
06:32you can certainly help us out if you tell us which direction to turn and guide us back towards the
06:36airport
06:37turn right heading 330
06:41a heading of 330 will take the plane north to a position where it can then make the turn back
06:47to lima
06:49but two and a half minutes later
06:52aero peru 603 you're showing level 9200
06:56what is your heading now
06:58the radar controller notices that flight 603 hasn't turned back towards the airport
07:07heading 205
07:17the captain decides to fly further out to sea before returning to lima
07:23they go out over the ocean which is one of the best decisions to possibly do
07:27they don't now have to worry about other aircraft in the andes mountains
07:33in the cabin passengers are unaware of what's happening in the cockpit
07:42safely away from shore
07:44according to the radar you're crossing radial 230 from lima distance west southwest is 37 miles
07:53flight 603 finally starts turning north to begin the approach to lima and needs to begin its descent to the
08:01airport
08:01i'll try to descend with the power cut
08:11he was going to descend at idle thrust which is a good way to descend it's nice and steady in
08:16a 757 and keeps the airspeed under good control
08:26i cut the engines but the speed is increasing
08:30even with power to the engines cut the airspeed indicators show that the plane is accelerating
08:37can you tell us the speed please
08:39can you tell us the speed please
08:40i have 320
08:42we have 350
08:45they'll need to use a different strategy to descend
08:51getting to the lower altitude hopefully getting into some clearer areas to see the coastal line
08:56could give them more comfort for a safe landing
08:59take the speed brakes out
09:03that is another great way of slowing the aircraft and getting better control of the airspeed
09:12but deploying the speed brakes has the opposite effect
09:19over speed
09:19a new warning tells them they're flying far too fast
09:25the airplane's above its maximum allowable airspeed
09:27it's in danger of breaking apart if they don't do something right now
09:36but i have the speed brakes out and all the power is cut
09:39this can be right
09:42what more possibly can be confusing and going wrong right now
09:48seconds later they get a contradictory warning that the plane's flying far too slow
09:56the stick shaker indicates to pilots that if the airplane gets any slower it's going to be in a stall
10:02condition
10:04are they going too fast or too slow the pilots must decide which alarm to react to
10:18the captain decides to increase the speed by pitching the nose down silencing the stall warning
10:28but they're not out of danger yet
10:33with conflicting warnings and no reliable airspeed or altitude readings the pilots of flight 603 urgently need help
10:43is there any plane that can take off to rescue us
10:49at this point it was a totally out of the box thought by the first officer to ask for
10:56for this type of assistance which would have given them a visual reference right next to them with altitude airspeed
11:04also communications and we have somebody alongside of us holding our hand to the airport
11:11the plane is now 50 miles from lima's airport
11:16aero peru 603
11:18you are heading 270
11:2010,000 feet
11:21while they wait for a rescue plane
11:24the captain attempts to join the approach path to the runway
11:27i'll try to intercept the ils
11:29and then descent
11:31lima aero peru 603
11:33we will try to intercept the ils
11:35roger aero peru 603
11:37they think they're flying at a nice safe altitude
11:40and they think that they pretty much have airspeed under control
11:43they probably thought they were in a pretty darn good position
11:49soon after the radar controller provides an update on the escort flight
11:54aero peru 603
11:56there is a 707 about to take off
11:59starting to move now
12:04it seems to be flying well
12:08can you tell us our altitude please
12:10you're at 9700 feet according to my radar
12:14terrain
12:15too low
12:16terrain
12:19too low
12:20terrain
12:20terrain
12:219700 feet
12:22but we're getting a terrain warning
12:25pull up
12:26pull up if he's telling you to pull up
12:28terrain
12:29we're hitting the water
12:30pull up
12:38we're running over
12:4929 minutes after taking off
12:52flight 603 crashes into the pacific ocean
12:5548 miles from lima peru
13:04within hours
13:05a navy aircraft
13:07discovers debris
13:08from flight 603
13:12the accident occurred at night
13:14and the wave conditions were very high
13:16so the first few ships
13:18that went out to look for the wreckage
13:19really struggled to find it
13:22heavy fog also hampers recovery efforts
13:40by the end of the first day the bodies of only 13 of the 70 people on board are recovered
13:47there are no signs of survivors
13:52those who haven't been found are believed to be inside the fuselage on the seabed
14:10it's up to air crash investigators from peru's accident investigation board to find out why a plane
14:17last observed flying nearly 10,000 feet above the sea
14:21suddenly crashed into it
14:28we have the military radar
14:30with the underwater wreckage still beyond reach
14:33investigators get their first lead from the peruvian military
14:39any coastal nation will have military radar that's constantly scanning for any approaching
14:44aircraft so by querying the peruvian military radar we were able to get some data about the altitude and position
14:53of the accident flight
14:54so after taking off they follow the approved flight plan over the ocean and then they start heading north
15:01yeah they're headed back towards lima
15:06the flight climbs to 13,000 feet and then it starts to descend
15:11and now
15:14in the last seven minutes
15:15the flight has a series of erratic climbs and descents before it crashes
15:21it appears they lost control
15:27it becomes just a roller coaster ride of altitudes because they don't have control
15:38what could have caused the pilots to lose control
15:42when you start putting an investigation together you start putting the what-ifs on the table
15:48what if this failed what if that failed what if this went wrong what if the crew made a mistake
15:53pre-takeoff seems okay
15:56investigators scrutinize the communications between air traffic control and the pilots
16:01look at this the crew reported problems with airspeed and altitude readings only two and a half minutes into the
16:06flight
16:07tower aero peru 603
16:09aero peru 603 tower go ahead
16:12we have no altimeters and no airspeed
16:20faulty air data
16:22sounds like an issue with the pitostatic system
16:27the pitostatic system uses tubes and sensors mounted on the plane which measure air pressure to calculate airspeed and altitude
16:37but wasn't there a recent crash involving the pitostatic system
16:40but wasn't there a recent crash involving the pitostatic system
16:43virgen air flight 301
16:47only eight months earlier another boeing 757 crashed soon after taking off from puerto plata
16:53in the dominican republic the cause was a blocked pitot tube
16:59some investigators were wondering if we had a similar situation to what we had in bergen air
17:04it wasn't entirely the same but it still involved blockage or covering parts of the pitostatic system
17:12maybe that's what happened here
17:23nearly two weeks since aero peru flight 603 crashed into the ocean
17:28a u.s navy ship helps the peruvian navy to track the pings from the boeing 757's
17:34two black boxes the wreckage is finally located at a depth of 680 feet
17:44using remotely operated vehicles investigators finally get their first view of the wreckage site
17:53the wreckage was very concentrated the plane was intact when it hit the water
18:05the fact that all the major pieces of the airplane are in one concentrated area really gives the
18:10investigators a much clearer picture of how the airplane came down so they either came down in a flat
18:16spin or came down nose first which is a very unusual accident
18:24there the black boxes are also located
18:29they're very very critical to get both recorders first you want to know how the airplane was behaving
18:35and then secondly what was going on in the cockpit between the crew members of the airplane
18:42they are packed in seawater and sent to washington where the ntsb the national transportation safety
18:49board will process their invaluable data
18:58that's it keep moving that way
19:01the team also searches for evidence of some kind of blockage of the pitot tubes and static ports
19:08there keep going they focus on a section of the left fuselage where the static ports are located
19:16okay now moving
19:21that's it the static ports were blocked
19:27they can see that the ports are covered
19:34when we saw that those static ports were covered it was case closed drop the curtains we knew exactly
19:41what happened in this accident how did such a critical device which determines airspeed and altitude get covered up and
19:50blocked
19:50it make sure you tag everything investigators survey the recovered wreckage of aero peru flight 603
19:59to find out what is covering the static ports
20:06look at that
20:09looks like silver tape same color as a fuselage
20:19that's it
20:37players
20:38why were the ports covered with tape
20:41and by whom it wasn't our job to assign blame or liability but we wanted to
20:51understand the procedure to make sure that important step of removing the
20:56tape would never get overlooked again
21:01so let's check the last block entry okay investigators check maintenance
21:06records to understand why the ports were taped over interesting hey
21:14birth strike during the plane's last landing before the accident the right
21:24engine was struck by birds they replaced the turbine blades the hydraulic pump was
21:30repaired and they polished the lower front of the 757 exactly what the static
21:36ports are located did maintenance personnel follow the correct procedures
21:41for polishing the 757 when you're performing work on the airplane such as
21:46polishing and washing it it's important not to get any debris into the ports
21:51because when you take off temperatures go down they may freeze in place which
21:57could cause severe instrument problems the airplane according to the maintenance
22:02manual they're supposed to cover the static ports whoever polished the plane
22:05cover the static ports with tape and didn't remove it so why wasn't the
22:13tape removed after the area was polished if you look at the maintenance process on an
22:20airplane and cleaning and polishing an airplane is maintenance there's multiple
22:24steps multiple people and multiple looks the whole purpose of that is to make sure
22:30that nothing is missed were the static ports inspected as part of flight 603 the line check it was a
22:41crazy night investigators interview the line mechanic to determine if the static ports were inspected after the work was done
22:48the line chief usually does it but he was sick so I did it
23:05so I guess you didn't see the tape then
23:12aluminum tape is pretty common and
23:15if you take it and just spread it over those ports
23:17it blends in perfectly
23:19and it makes it very easy for somebody to miss it
23:24was he adequately trained
23:26I would say the answer to that is no
23:31did you see either pilot do a pre-flight check
23:34yes
23:35the captain
23:39you know if he checked them
23:43couldn't tell you
23:46if I had a new person on my crew
23:48I would tell them to watch the captain
23:50see what he's doing
23:52and it becomes routine for mechanics
23:54to watch what the flight crew does
23:57okay thank you for your time
24:00there's at least one if not two line checks that are done by
24:04supervisors of the line maintenance
24:06and then one of the crew members would do a walk around as they are obligated to do always
24:12so there are several levels where things should have been detected but weren't in this flight
24:22so both the line mechanic and the pilot missed
24:27investigators now know
24:29that despite all the safety checks that were meant to be performed
24:32no one spotted the silver tape covering the static ports
24:36so we know what caused the faultier speeds and altitudes
24:39but faultier data alone
24:41doesn't cause a plane to crash
24:43so
24:44what did
24:52investigators turn to the cockpit voice recorder from aero peru flight 603
24:57there you go thank you
24:59to determine how the pilots dealt with faulty airspeed and altitude data
25:03pick it up from the takeoff
25:25the plane is barely off the ground when the pilots identify the first problem
25:30the altimeters are stuck
25:32the captain's altimeter
25:34the first officer's altimeter
25:36the standby altimeter
25:38all three sources were different and they were all wrong
25:44keep V2 plus 10
25:46V2 plus 10
25:47it's quickly followed by a second issue
25:50the speed
25:52the airspeed is also stuck
25:54yeah right
25:56hold on
26:01they were only at 200 feet above the ground and they already knew that there are problems
26:05with altitude and airspeed
26:07in three different places in the cockpit they're seeing unreliable airspeed and altitude
26:14according to the FDR they're still climbing let's see how they handle that faulty data
26:22what's going on
26:23we're not climbing
26:24I'm climbing
26:27investigators hear the captain continue to rely on the faulty data on his altimeter
26:31climb, climb, climb
26:33I am climbing
26:35despite what the first officer tells him
26:38the captain is looking at his altimeter and saying what he sees right in front of him
26:44it's very hard to ignore this false data
26:47the airspeed and altitude readings are like a magnet drawing your eye and attention again and again
26:52climb, climb
26:53I am climbing
26:54so in this initial moments of the climb
26:57it seems like the first officer was more in touch with what the airplane was really doing
27:02what else do the pilots do to handle the situation?
27:05keep playing
27:07let's go to basic instruments
27:10but within a minute the captain stops focusing on the faulty instruments
27:15he decides to use the pitch and power procedure
27:17that's good
27:19very quickly on the captain says basic instruments
27:22I believe he means the pitch and power procedure
27:29the pitch and power procedure requires reducing the pitch angle of the aircraft to two degrees nose up
27:36and the throttles to 55 percent
27:38this should result in level flight
27:41by flying with set pitch and power
27:44and ignoring the unreliable airspeed and altitude
27:47gives the crew time to sort out what's going on
27:51and think through what might be causing the unreliable indications
27:56then they declare the emergency
27:58pick it up after that
27:59let's see if they did the procedure properly
28:06switching to
28:071, 19.7
28:09auto throttle has disconnected
28:11auto throttle has disconnected
28:13but instead of checking his attitude indicator and engine gauges
28:18let's see read that
28:20the captain focuses on the crew alerting screen
28:23which is displaying more alerts
28:26rudder ratio and max speed trim
28:29the rudder ratio and max speed trim warnings
28:32were just the result of the unreliable airspeed and altitude indications in the cockpit
28:37they shouldn't have been the primary focus of the crew
28:41they're getting distracted by false alerts
28:43they ignore the pitch and power procedure
28:48we're flying without speed
28:49soon after
28:50speed is zero
28:53all airspeed indicators at zero
28:59investigators hear the pilots turning their attention back
29:02to the erroneous airspeed and altitude readings
29:06the tape on the static ports
29:09meant that the airspeed and altitude were always wrong
29:12and they were always changing as the airplane climbed and descended
29:18we will maintain 10,000 feet
29:20set it
29:2110,000 feet
29:22but at no point did they disregard the unreliable airspeed and altitude
29:27they looked at them constantly
29:2912,000 feet
29:31the crew never switched their mindset to just using pitch and power
29:37they climbed for seven more minutes
29:40but if they were climbing
29:42how did the crew end up hitting the ocean
29:45they can't keep climbing forever
29:48we have problems reading our instruments
29:50investigators continue listening to the cockpit voice recorder of aero peru flight 603
29:56to determine how the crew carried out the return to lima with faulty instrument data
30:01set the approach please
30:02i did
30:03i did
30:03then let's go
30:07the captain
30:08he knew he had to
30:09to get down to lima airport
30:11i'll try to descend with the power cut
30:14and the way to do that was to reduce the power
30:18no sooner do the pilots cut the power
30:21than they face another problem
30:23the speed is increasing
30:26why is the speed so high
30:28is it the real speed
30:29that's what worries me
30:30i don't think so
30:34they think they're speeding up
30:36but they can only be slowing down
30:42the pilots don't know whether to believe the faulty airspeed indicator
30:47that's showing they're going too fast
30:49after having pulled their thrust levers back to idle
30:53that'd be totally confusing for the captain
30:55he'd be saying this can't be happening
30:58it's impossible
30:59it violates the laws of physics of aircraft
31:02but the captain's thought process is overtaken by what happens next
31:07overspeed
31:10the faulty airspeed data is now triggering the overspeed warning
31:15an overspeed warning gets your attention very quickly
31:20and you want to react to it
31:22but this is the time when he should have been questioning
31:25whether that was correct
31:29the first officer makes a split second decision
31:32take the speed brakes out
31:36and now
31:39with the power cut and the speed brakes out
31:43slows the plane down to the point of stalling
31:46the erroneous overspeed data leads the pilots to reduce their speed
31:51which puts their plane into a stall
32:04the crew instinctively lowered the nose
32:07and increased their actual airspeed
32:09those are the steps that will keep you from stalling the airplane
32:15responding to the stall warning was the right move
32:19but after that
32:23they head further out to sea
32:24instead of towards lima
32:27why would they do that
32:33shortly after the stall warning ends
32:37a new warning tells them they are dangerously close to terrain
32:42the captain doesn't realize how close they are to the water
32:46on the 757
32:48a radio altimeter measures the plane's altitude when below 2,500 feet
32:52and sounds the ground proximity warning
32:55when the plane drops too close to the terrain
32:57the ground proximity warning system is separate from the pedostatic system
33:02it was telling them the truth
33:03too low terrain
33:06too low terrain
33:07and now we've induced a terrifying alert of
33:11I'm about to hit a mountain
33:14the pilots thought they were near a mountain
33:16when they were actually approaching the surface of the ocean
33:19too low terrain
33:23let's go left
33:24too low terrain
33:32radar shows you're turning left
33:35you're heading to the west
33:37we're heading 250
33:39we're heading out to sea
33:40because we have a low terrain warning
33:43too low terrain
33:46he knew that the water
33:48the ocean
33:49is to the left
33:50and that's going to be my safe environment
33:52sink rate
33:54sink rate
33:56no sooner do they deal with the terrain warning
33:58than the pilots are confronted by an alert
34:01telling them they are descending too rapidly
34:03sink rate
34:05sink rate
34:06let's climb
34:06let's go up
34:08too low terrain
34:12now going up
34:13was the right call
34:14they were descending at 3,000 feet per minute
34:16they climbed to 4,000 feet
34:18and they stay there for
34:21approximately one minute
34:27so what led to the final plunge into the sea
34:31let's go back to Lima
34:32I'll try to intercept the ILS
34:34and then the set
34:36after 25 harrowing minutes
34:38the captain initiates a turn back to Lima
34:41Lima
34:42Ero Peru 603
34:44we will try to intercept the ILS
34:47can you tell us our altitude?
34:49is our altitude
34:499700 feet
34:52roger
34:52Ero Peru 603
34:54you're showing level at 9700
34:59but when the terrain warning activates
35:01investigators know the plane was below 2500 feet
35:06they both had the wrong altitude
35:10investigators discover the controller
35:13was also providing flight 603
35:15with incorrect altitude information
35:19the assumption was
35:20the controllers can tell us our altitude
35:22but the flaw in that is
35:24is that that altitude
35:25is actually being sent to the controller
35:26from the aircraft itself
35:28terrain
35:28if the information on board the aircraft is incorrect
35:31then the information that's being sent to the radar
35:34is also going to be incorrect
35:38investigators speak to the controller
35:40to understand why he relayed the faulty readings
35:43back to flight 603
35:45so it looks like you were providing the crew
35:47with altitude data
35:49yes
35:49they said they didn't have any altimeters
35:51so I told them what I was seeing
35:53on my radar screen
35:55were you using SSR in mode C?
35:58yes that's right
35:59your radar's altitude is coming
36:00from the plane's transponder
36:06when the controller
36:08confirmed the altitudes for the pilots
36:10I think it gave them a false sense of hope
36:12that at least one of our problems
36:14has been solved
36:14the altitude problem
36:16when in fact
36:17that was tragically incorrect
36:23but even with the faulty altitude readings
36:26could the pilots still have landed their planes safely?
36:37pick it up during their final descent
36:39to determine if the pilots had any other options
36:42to save their plane
36:43investigators listen to the final moments of Aero Peru flight 603
36:49it seems to be flying well
36:52can you tell us our altitude?
36:54you're at 9700 feet according to my radar
37:009700 feet?
37:01but we're getting a terrain warning
37:04the crew can't understand the conflicting information
37:09but there was a way for the pilots to determine their actual altitude
37:13and save the plane
37:15if they checked the radio altimeter
37:16they would have realized how close they are to crushing
37:22when the ground proximity warning system activated in the cockpit
37:25the crew could have referred to the radio altimeter
37:28and that would have given them the truth data
37:30about how high they were above the ground
37:33too low terrain
37:35but they never check their radio altimeter
37:38pull up
37:40too low terrain
37:42pull up
37:43pull up
37:44we're just telling you to pull up
37:46terrain
37:49we're hitting the water
37:52when an aircraft
37:53has its wing touch the water
37:56in a bank attitude
37:58the situation is hopeless
38:09the pilots try to get the plane back in the air
38:15but the plane banks left
38:16and falls back towards the sea
38:18we're running out
38:33they really had no idea how low they were
38:35and all those alarms fall so real just
38:37made matters worse
38:49the situation in the cockpit was so confusing
38:55it was hard for either crew member to understand
38:57which cautions and warnings were true and important
39:01and there didn't seem to be a good balance
39:03between the two crew members in sorting that out
39:07for investigators there's one final unanswered question
39:12were the pilots properly prepared to handle an emergency like this
39:17they examine the quick reference handbook
39:20which provides guidance in emergency situations
39:22as well as aero peruse training procedures
39:28well there's nothing here
39:31anything in the training procedures
39:33not one single word on how to handle erroneous air data
39:39the lack of training worked against them
39:44a big takeaway from this accident
39:46was that flight crews need to be better trained
39:48to get to pitch and power
39:50in the event of unreliable airspeed and altitude
39:57investigators needed only two months to solve the mystery of flight 603
40:02they now know that blocked static ports
40:08created faulty air data readings
40:13and those faulty readings created so much confusion in the cockpit
40:17but i have the speed brakes out
40:19another power is cut
40:21that can be right
40:22that the overwhelmed crew was unable to separate
40:25the false alarms from the true ones
40:30they really needed to develop a laser focus
40:33on just flying the airplane
40:34but they never got there
40:37the captain's failure to react
40:39to the ground proximity warnings in time
40:43he's telling you to pull up
40:45we're hitting the water
40:46we're hitting the water
40:46we're hitting the water
40:47we're hitting the water
40:47we're hitting the water
40:47we're hitting the water
40:49contributed to the death of 70 people
41:07there's nothing highly technical about tape
41:10but boy did it start a chain of events
41:16the investigations report outlines a number of recommendations
41:20but chief among them is for more training
41:23to ensure crews know how to deal with inaccurate air data
41:28and implementing the use of eye-catching static port covers
41:32while a plane is being maintained
41:35remember it's the simple things
41:38that cause problems
41:41and we need to keep that in everybody's mind
41:44attention to detail
41:46if you perform that detail
41:48whatever it is
41:49you're not going to get problems
41:55this accident was one of the pillars
41:58of safety procedures
42:03our training changed
42:05our pre-flight procedures changed
42:07our attention to details changed
42:09and it still lives to this day
42:12and it was time for the primary computers