- hace 2 meses
El vuelo 185 de Air Tahoma, un vuelo de carga nocturno procedente de Memphis, se encuentra en el tramo final a Cincinnati. Pero, a unos kilómetros del aeropuerto, y con la pista de aterrizaje a la vista, el turbohélice gemelo se precipita a tierra y cae en un campo de golf. Está claro que ambos motores colapsaron antes del impacto. Y el misterio sólo se profundiza cuando los investigadores descubren que aún había mucho combustible a bordo.
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TVTranscripción
00:00En aproximación a Cincinnati, Ohio,
00:07los pilotos de Air Tahoma, Flight 185, face desastre.
00:122,300 feet.
00:13Keep it steady.
00:14El aeropuente va a caer como un rock.
00:17My God.
00:19El aeropuente se desplazó en un golf course.
00:23Solo el aeropuente se desplazó.
00:26No se recuerda mucho de la aeropuente.
00:29Cuando un evento trágico ocurrió, los recuerdos no están ahí.
00:33Los aeropuentes de los aeropuentes nos ayudaron a los investigadores con la primera clube.
00:37No hay evidencia de burning o charring.
00:39Los aeropuentes se desplazaron antes de la acción.
00:41Pero según los gauges,
00:43había amplio fuel para el aeropuente.
00:46Si aún no había 5,600 lbs de fuel en el aeropuente,
00:49¿por qué no el aeropuente de los aeropuentes?
00:53Eso es algo que no había visto antes.
01:00¿Por qué no hay un aeropuente de la acción?
01:05¿Por qué no hay un aeropuente de la acción?
01:17¡Vamos!
01:19¡Dale, un aeropuente de la acción!
01:22¡Se acuerdan!
01:23a 15,000 feet.
01:25It's headed for Cincinnati,
01:26Northern Kentucky International Airport.
01:31Coffee's still hot, if you want some.
01:34No, thanks.
01:35I'm well rested.
01:37Captain Bruno Piccelli
01:38is an experienced pilot
01:40who has flown all over the world
01:42and also worked as a firefighter
01:44in British Columbia, Canada.
01:47Convair 580 pilot Bruno Saint-Jacques
01:50has flown alongside Captain Piccelli.
01:53He was a very good person,
01:55very easy to get along with.
01:57He flew well.
01:58Me and him was a very good joint venture.
02:04Michael Gelwix has logged nearly 2,500 hours
02:08as a pilot and flight engineer
02:10and is now a first officer for Air Tahoma.
02:15Tonight's flight from Memphis, Tennessee
02:17to Cincinnati, Ohio is 80 minutes.
02:21This was the first leg of a round trip
02:23and was done every weeknight by Air Tahoma.
02:28They're flying a Convair 580,
02:31a twin turboprop aircraft used for short-haul flights.
02:36The Convair 580 is about 50 years old,
02:40was used in passenger service for a long time
02:43and then transitioned to cargo service.
02:49It was always reputed to be
02:51a very stable, reliable airplane.
02:57So what was it like flying as a firefighter?
03:00Well, uh, long hours.
03:04Same plane as this.
03:05Different cargo, of course.
03:09There are five pallets
03:11containing mail and parcels
03:13from the courier DHL Express
03:15on board the aircraft.
03:26How's the paperwork?
03:29Almost done.
03:35The captain was focused on some paperwork
03:37that he needed to complete
03:38before he landed in Cincinnati,
03:40which he did.
03:54Captain Pacelli notices
03:56that one of his fuel tanks
03:57has more fuel than the other.
04:00The Convair 580 has two tanks
04:03and you can use one tank
04:05to feed both engines
04:06until both tanks are even.
04:12One hour into the flight,
04:14the crew receives a weather update.
04:16Tahoma 185?
04:17Winds are kind of weird today.
04:19Suggest 10 left to Cincinnati when able.
04:22Okay, 10 degrees left to Cincinnati
04:24when able.
04:25185, thank you.
04:27Already had it.
04:28Right on the money.
04:30Hey.
04:32As air Tahoma 185
04:34begins its descent,
04:35the first officer detects
04:37a change in the controls.
04:39Yoke feels funny.
04:42Say again?
04:44Feels like I need a lot of force.
04:50It's pushing to the right for some reason.
04:52I don't know why.
04:56The Convair doesn't use hydraulic
04:59to move the control surfaces.
05:01The pilot must use a lot of arm strength
05:05when the autopilot is not on.
05:09Four in the box.
05:1430 miles from the airport,
05:17the controller provides an update
05:18on the approach.
05:19Tahoma 185,
05:21fly heading 090,
05:22maintain 4,000.
05:24Maintain 4,000.
05:25185.
05:27They're packed tonight,
05:28so we're going to go bang,
05:29bang, bang, bang.
05:30Got it.
05:33There was pressure on it
05:34because if you get late
05:36in the sequence
05:37of the other aircraft
05:39landing in the airport,
05:41you're slowing down
05:42all the airplane behind you.
05:55As the crew receives clearance
05:58for a visual approach,
06:00the aircraft continues
06:01pulling to the right.
06:02What in the world
06:03is going on with this plane?
06:05This sucker's acting so funny.
06:08We'll do a full control check
06:10on the ground.
06:12Point it down at 3,000
06:14as quick as you can.
06:18Usually an airplane
06:19flies straight
06:21and wings level.
06:23It wouldn't give you
06:24a nice feeling
06:24to fly the plane
06:25which always want
06:27to turn on one side.
06:29185, runway 36R,
06:31clear to land.
06:32Clear to land,
06:3336R, 185.
06:36Runway's in sight.
06:38All right.
06:39I'll give you the in range.
06:42In range check.
06:44Cabin pressure.
06:46Set.
06:47Bypass is down.
06:49Hydraulic pressure.
06:50Quantity checks.
06:51As the crew
06:52runs the in range checklist...
06:54AC pump is on.
06:56Green light.
06:57Boost pump's on.
06:59The plane continues
07:00to handle poorly.
07:02Man, I'm telling you.
07:04What is wrong with this plane?
07:05It is really funny.
07:08Then,
07:09less than five miles
07:11from the airport
07:13and just 2,300 feet
07:15above the ground,
07:17both engines lose power.
07:29The airplane will fall
07:30like a rock
07:31because it needs
07:33at least
07:34one engine
07:35in good shape
07:36to bring them
07:37to the runway.
07:392,300 feet.
07:43My God.
07:45Assistant out of control.
07:47Tahoma 185.
07:49We're having
07:49engine problems.
07:50Tahoma 185,
07:52do you require
07:52emergency support?
07:58Negative.
08:03I think the reason
08:04he said no
08:05was he was still
08:06hoping
08:07that somehow
08:08he could get
08:09to the airport.
08:12Keep it steady.
08:14But they're dropping
08:15too fast
08:16to make it
08:16to the airport.
08:18Come on.
08:19They see
08:19an opening ahead.
08:21There's no time
08:22at all
08:22to raise the gear,
08:23raise the flap,
08:25restart the engine
08:25before you touch
08:26the ground.
08:27Their only option
08:28was to go straight
08:30to the safest place
08:32to put down
08:33the plane
08:34and hope
08:35for the best.
08:37Tahoma 185,
08:39please respond.
08:41They were
08:42at low altitude.
08:43Hold it up.
08:43They were short
08:44of the runway.
08:45It was dark outside.
08:46Tahoma 185,
08:47do you copy?
08:48The situation
08:49was very, very dire.
08:50Trees!
08:52Pull up.
08:53Pull up.
08:55Pull up.
08:58Pull up.
09:01They make it
09:02through the trees.
09:04Come on.
09:04Come on.
09:08But can't keep
09:10the plane
09:10on the ground.
09:11Come on.
09:13Come on.
09:30Come on.
09:39Emergency vehicles
09:41soon arrive
09:42at the crash site,
09:43just 1.2 miles
09:45south of Cincinnati's
09:46International Airport.
09:51The body
09:52of First Officer
09:53Gelwix
09:53is found
09:54in the wreckage.
09:59Incredibly,
10:00Captain Pacelli
10:01has survived.
10:07Investigators
10:07from the National
10:08Transportation Safety
10:09Board,
10:10or NTSB,
10:11rush to Cincinnati
10:12and begin looking
10:13into the crash
10:14of Air Tahoma
10:15Flight 185.
10:17So,
10:17what have we got
10:18so far?
10:19Both black boxes
10:20have been sent
10:20to Washington
10:21for analysis.
10:22Good.
10:23Structural failure?
10:24Take a look.
10:27When we first
10:28arrived,
10:29what we typically
10:29do is look
10:30for the four corners
10:31of the airplane
10:32to be able
10:33to rule out
10:34some sort
10:34of structural failure
10:36or a part
10:37or piece
10:38of the airplane
10:39departing prior
10:40to impact
10:40with the ground.
10:44We found
10:45all four corners
10:46of the plane.
10:47We found the tail
10:48here.
10:48We located
10:49both wingtips
10:50here and here
10:51and the nose
10:52was essentially
10:53split in half
10:53and fractured
10:54into small pieces.
10:55If it wasn't
10:56structural failure,
10:57then what?
10:58What did the
10:59captain have to say?
11:00He's still recovering
11:01in hospital.
11:01But I did speak
11:03with the air traffic
11:03controller.
11:04And?
11:05She says the crew
11:06reported having
11:06engine problems
11:07just before crashing.
11:18When we heard
11:18that the crew
11:19had reported
11:20engine problems,
11:21it made us think
11:22as investigators
11:23whether it was
11:24one engine
11:25or two engines.
11:26And that would be
11:27a big difference.
11:29With one engine,
11:30they would still
11:30be able to make
11:31the airfield.
11:33The Homa 185,
11:36we're having
11:36engine problems.
11:43If the engines
11:44were operating
11:45before the crash,
11:47investigators expect
11:48to find burnt debris
11:49inside the engine.
11:51There's no evidence
11:52of burning or charring.
11:55I don't think
11:56we had combustion
11:56on this engine.
11:58Ditto with engine two.
12:02So both engines
12:03flamed out
12:03before the crash?
12:06With a dual engine
12:07failure,
12:08that's not common.
12:10So we would think
12:11immediately about
12:12something with the fuel,
12:14either the loss of fuel
12:15or maybe even
12:16contamination
12:17within the fuel.
12:19Was the fuel
12:20on board flight 185
12:22contaminated?
12:24Fuel contamination
12:25is a danger
12:27to flight safety
12:28because it can affect
12:29both engines
12:30at the same time.
12:31Do we have the results
12:32of that fuel testing?
12:34Yeah, right here.
12:38Fuel checks out.
12:40Well, maybe they ran
12:41out of fuel?
12:43Well, it's possible.
12:46In 1978,
12:48pilots of United Airlines
12:49Flight 173
12:51ran out of fuel
12:52while troubleshooting
12:53a landing gear issue.
12:56The DC-8
12:58crashed into a neighborhood
12:59in Portland, Oregon.
13:04Ten of the 189 people
13:07on board
13:07were killed.
13:10To explore the possibility
13:11of whether the airplane
13:12ran out of fuel,
13:14we wanted to look initially
13:15at the fuel quantity
13:16indicators
13:17in the flight deck.
13:19Investigators recover
13:20Flight 185's
13:21instrument panel.
13:22They focus on the left
13:24and right
13:24fuel tank indicators.
13:26Zero
13:27and 5,600 pounds.
13:33That's odd.
13:35The expectation would be
13:36that both would be
13:37approximately
13:38the same value.
13:40That one was at zero
13:41wasn't surprising,
13:43I suppose,
13:44but the other one
13:44being so much different
13:45was certainly something
13:47that I had not seen before.
13:49Okay, so they didn't
13:50exactly run out of fuel,
13:51but why are the tanks
13:53so uneven?
13:55Maybe some kind of problem
13:56in the fuel system
13:57stopped fuel
13:57from flowing to the engines.
14:00See what you can salvage
14:01in terms of fuel pumps
14:02and piping from the wreckage?
14:03We'll have a look.
14:08While looking at
14:09all the different elements
14:10of the fuel system,
14:11the hope was that
14:12you would be able
14:13to document something
14:14going wrong,
14:15either loss of fuel
14:16or fuel starvation.
14:19Investigators slowly
14:20piece together
14:21elements of the plane's
14:22fuel system.
14:23So these are the
14:24cross-feed piping valves?
14:27Check it out.
14:32The cross-feed valves
14:34allow the pilot
14:35to provide both engines
14:37with fuel
14:37from only one tank
14:39when there's a fuel imbalance.
14:45Both valves are open.
14:47That means they were
14:48cross-feeding fuel
14:48before the crash.
14:50When we found that
14:52the cross-feed valves
14:53were open,
14:53that was a huge discovery.
14:55We wondered
14:56if that may have
14:58some sort of connection
14:59between the left tank
15:00having no fuel
15:02and the right tank
15:03having excessive fuel.
15:05But why would the crew
15:06be cross-feeding fuel
15:07so close to landing?
15:09Did they make a mistake?
15:11Only one person knows.
15:14Let's see if the captain
15:15can talk to us yet.
15:18The good thing
15:19in this accident
15:20was that the captain
15:20did survive.
15:21He was able to talk
15:22with us in the hospital
15:24because he only
15:24had minor injuries.
15:27How are you feeling?
15:30Okay, thanks.
15:35Can you tell me
15:37what you remember
15:37of the flight?
15:39Every detail counts.
15:44What is wrong
15:45with this plane?
15:45It is really funny.
15:48I remember...
15:50Visual approach,
15:5136 right.
15:52Keep the speed up.
15:53185.
15:54I remember talking
15:55on the radio.
15:56Dollar 185.
15:58Clear for visual approach.
16:00Keep your speed up.
16:01I saw the approach lights.
16:03Then we weren't
16:04getting power.
16:11Then the next thing
16:12I remember
16:12is the impact.
16:13Keep it steady.
16:14Keep it steady.
16:15Go, go, go.
16:17Go, go, go.
16:22Then...
16:25I was standing outside.
16:33One more thing.
16:35We found the crossfeed valves open.
16:40Do you remember crossfeeding fuel during the flight?
16:45I'm sorry, I don't.
16:51He did not remember much of the flight
16:54because when you have a tragic event happen,
16:57the memories are not there.
17:03Investigators searched the wreckage for clues
17:06that could explain why the two crossfeed valves were open.
17:11It's the weight and balance form for the flight.
17:14Hmm.
17:16The weight and balance form reflects
17:17where the cargo pallets are located,
17:19whether they're towards the front of the airplane
17:21or towards the back of the airplane,
17:22and that determines whether the airplane is nose-heavy
17:26or tail-heavy
17:27or right where it should be in the middle.
17:31That's strange.
17:32Looks like the captain was revising his calculations,
17:36possibly during the flight.
17:37Well, this is stranger.
17:39Here's a second one.
17:42This one has no corrections,
17:44and the captain signed it.
17:47Finding two weight and balance sheets for the same flight
17:49with different data on it at the accident site
17:52raised lots of questions for us.
17:55What was the captain doing during the flight?
17:58So it looks like the captain
18:00was revising his numbers on this first form.
18:02I was using it like a working copy.
18:04And this was his hard copy to hand in.
18:07Did the captain's weight and balance calculations
18:10play a role in the crash?
18:13Well, the center of gravity limits were within the envelope.
18:17All right, so I'm mistaken as weight and balance calculations
18:19didn't bring down the plan.
18:21Well, whatever his process,
18:22he was supposed to hand this in before departure.
18:27Check with the airline.
18:29See if the captain handed in his numbers before takeoff.
18:34Taking off without having computed
18:36the weight and balance limits
18:37is against procedures.
18:40It cuts the safety margin.
18:43You're sure?
18:44Okay, thanks.
18:46The airline just confirmed
18:48the plane departed without the captain
18:50leaving a weight and balance form behind in Memphis.
18:52So,
18:54why did our captain depart
18:56before completing his paperwork?
19:06Did you get coffee?
19:08Uh, fine, thanks.
19:10Investigators re-interview
19:11Captain Bruno Picelli
19:13to find out why he didn't follow
19:15proper procedure
19:16before Flight 185's departure.
19:18So,
19:20found some weight and balance forms
19:22in the wreckage.
19:23Why didn't you complete them
19:24before taking off?
19:28What can I say?
19:30I ran out of time.
19:34Normally,
19:34I fill out the form
19:35using their handheld computer.
19:37It had been acting up.
19:39Now,
19:40it was just dead.
19:42I'm not used to
19:43filling out that form manually.
19:45Frankly,
19:46I've never been trained to.
19:48So,
19:49I thought I'd finish it en route.
19:54Captain Picelli
19:55explains how he determined
19:57that Flight 185
19:58was safe to take off.
20:00I did my own assessment.
20:04I checked that the plane's
20:06maximum weight was acceptable.
20:08I saw that the position
20:10of the cargo pallets
20:11were evenly balanced.
20:14I also looked at
20:15the nose landing gear strut
20:18and the plane
20:20sat properly on it.
20:23If the nose wheel strut
20:24was compressed,
20:25that would be nose heavy.
20:26And if it were extended,
20:27it would be tail heavy.
20:28But it was in a normal position.
20:30So,
20:31on that basis,
20:32he decided
20:33that the airplane
20:33was actually
20:34within its weight
20:35and balance limits.
20:36From your corrections,
20:39it looks like
20:39your numbers
20:40weren't adding up.
20:43That's true.
20:44Yeah,
20:44at first,
20:46they didn't.
20:47So,
20:48I had to keep
20:48working on them.
20:51Yeah,
20:52it took me a while
20:52to get them right.
20:59How long did it take?
21:00I don't know.
21:02Did it interfere
21:03with your workflow?
21:04It was stressful.
21:06I mean,
21:06I was buried
21:07in paperwork.
21:09Right.
21:13So,
21:14even though
21:14the weight and balance
21:15was not an issue
21:16with the operation
21:17of the engines,
21:18it did raise questions
21:20with regard
21:20to the crew activity.
21:23Hey,
21:24any news?
21:25With no explanation
21:26for the cause
21:27of Flight 185's
21:29engine failure,
21:30the investigation
21:31finally gets a break.
21:32Great.
21:33Send it to us
21:34right away.
21:36The lab
21:37just finished
21:37transcribing the CVR.
21:39We've got good data.
21:41But,
21:42we don't have impact.
21:44The recording stops
21:45just before the crash.
21:47Well,
21:48if the recording stops,
21:48that means the plane
21:49must have lost power.
21:50Looks like it.
21:52And it supports
21:53a dual-engine flame-out.
22:01Having the CVR
22:03stop about two minutes
22:04prior to impact
22:05is another indication
22:06that we lost
22:07both engines
22:08because we likely
22:10had a rollback
22:11of both engines
22:11and therefore
22:12a change in
22:13electrical configuration.
22:15When you're ready.
22:18Investigators
22:18listen to the cockpit
22:19voice recording,
22:20or CVR,
22:22to determine
22:22why the engines
22:23flamed out,
22:24even though the plane
22:25still had plenty of fuel.
22:27How's the paperwork?
22:30Almost done.
22:36Okay.
22:40You know what?
22:43I'm just gonna balance
22:44out the fuel here.
22:53The captain wanted
22:54to balance his fuel tanks,
22:56but he didn't remember
22:57that at his interview.
22:59That must be
22:59when he opened
23:00the cross-feed valves
23:01at
23:0212.17 a.m.
23:07The question is,
23:09did he forget
23:10to close them?
23:11Let's find out.
23:16Okay,
23:1610 degrees left
23:17to Cincinnati
23:18when able.
23:20185,
23:21thank you.
23:22I already had it.
23:24Right on the money.
23:25The team
23:26pays close attention
23:27to any mention
23:28of the cross-feed valves
23:30being closed.
23:31The captain
23:32doesn't indicate
23:33that he's stopping
23:34the cross-feed
23:35or even mention it.
23:36It made me wonder
23:38if they had forgotten
23:39that the cross-feeding
23:40operation was going on.
23:43Then,
23:44just minutes
23:44before the flight's
23:45scheduled arrival...
23:47AC pump is on,
23:48green light.
23:50Boost pump's on.
23:53Man,
23:53I'm telling you,
23:55what is wrong
23:56with this plane?
23:56It is really funny.
24:03It's really funny.
24:08Yeah.
24:10Can you feel it?
24:11It feels like
24:12it's swinging
24:13back and forth.
24:18Yeah.
24:19We've got an imbalance
24:20on this darn cross-feed
24:22I left open.
24:24The captain
24:25finally realizes
24:27he forgot
24:27to stop cross-feeding
24:29fuel from the left tank.
24:30Is that what it is?
24:33Yeah.
24:35Oh, damn.
24:37I see.
24:42The cross-feed's
24:43been going on
24:43for almost half an hour.
24:46Looks like he never
24:47shut the cross-feed valves.
24:48He forgot to close it.
24:50That explains
24:51why the plane
24:51was so hard to handle.
24:57With the cross-feed valves
24:59open for 29 minutes,
25:01only the left fuel tank
25:03fed both engines.
25:05As the tank emptied,
25:06it created an imbalance
25:07which made it difficult
25:09to control the aircraft.
25:10That also explains
25:11why the left tank
25:12was empty.
25:14Yeah,
25:14but if there was still
25:155,600 pounds
25:16of fuel
25:16in the right tank,
25:18why didn't that fuel
25:19feed the engines?
25:25Do you have the list?
25:27Thanks.
25:31All right,
25:32let's figure this out.
25:34Did the pilots
25:35of Air Tahoma
25:36Flight 185
25:38follow the correct procedure
25:39for balancing their fuel?
25:42The question that I raise
25:43for me in the investigation
25:44is if there's ample fuel
25:47in the right tank,
25:48why did both engines fail?
25:50All right.
25:52To cross-feed fuel
25:53from the left tank
25:53to both engines,
25:54first the crew
25:55has to open
25:55the cross-feed valves
25:56here and here.
25:59Investigators consult
26:00the wreckage inventory.
26:02Now we know
26:03from the wreckage,
26:03the crew did the first step
26:04correctly,
26:05the valves are open.
26:07Second,
26:08they're supposed to close
26:09the right fuel pump here.
26:12Got it.
26:13It was turned off
26:14at the time of the crash.
26:16Step three,
26:18they were supposed
26:19to close the right fuel tank
26:20shutoff valve here.
26:23Looks like the right one
26:24was left open.
26:26They didn't shut the valve.
26:28So they did the procedure
26:29incorrectly.
26:32So the question we had
26:33was by leaving
26:34the right fuel tank valve open,
26:36did that somehow lead
26:37to the engine failure?
26:39I know they made a mistake,
26:40but I'm still confused.
26:42If they didn't close the valve,
26:44why wasn't fuel flowing
26:46from the right tank
26:47all the way to both engines?
26:50And why would
26:51the engines flame out?
26:55There's only one way
26:56to find out.
27:02As the investigation progressed,
27:04we decided to run a test
27:06to determine what occurred
27:08during the accident flight.
27:11Investigators build a replica
27:12of Flight 185's fuel system
27:15to better understand
27:16how both engines
27:18could have failed.
27:19Let's simulate
27:19what the captain did.
27:21Step one,
27:23open the crossfeed valves.
27:30Crossfeed valves open.
27:32All right, step two,
27:34turn off the right fuel pump.
27:36Right fuel pump off.
27:38Step three,
27:41he didn't close
27:42and there's the right fuel tank
27:43shut off valve.
27:44So we've got this
27:45in the open position.
27:49Let's see what happens.
27:58Okay.
28:01Looks like the left fuel pump
28:02is sending fuel
28:03from the left tank
28:04to both engines.
28:05So that part's working out
28:07just fine.
28:11Yeah, but fuel
28:13from the left fuel tank
28:14is also flowing
28:16to the right tank.
28:22With the right shutoff valve open,
28:25the left pump supplied fuel
28:27not only to both engines,
28:29but also to the right fuel tank.
28:37Look how quickly
28:38the left tank emptied.
28:41This was new to me.
28:43I had never seen
28:44a case where fuel
28:45was transferred
28:46to the point of
28:47the one tank being emptied.
28:50So the left tank ran dry
28:54and with that pump still running,
28:56that means that air
28:57was likely being pumped
28:58through the whole system.
29:02Investigators now understand
29:03why the plane's engines
29:05flamed out
29:06just before the crash.
29:11Once the left tank
29:13was empty,
29:14air was pumped
29:15into the fuel system,
29:16causing both engines
29:18to flame out.
29:20Turbine engines require
29:21a steady flow of fuel.
29:25When you start entering
29:26air into the system,
29:28the air bubbles
29:29then cause the interruption
29:30of the ignition of the fuel
29:32and that will cause
29:34the engines
29:35to roll back
29:35and stop.
29:38So if the captain
29:39had just followed procedure
29:40and shut off that valve?
29:43If he had,
29:44there would have been
29:45enough fuel in the left tank
29:46to power both engines
29:47to the airport.
29:50I'm just going to balance
29:51out the fuel here.
29:54The captain's failure
29:55to close the right fuel tank
29:57shutoff valve
29:58sealed their fate.
30:01So why didn't he follow
30:02the procedure?
30:09As the investigation
30:10progressed
30:11and new information
30:12came to light,
30:13it was helpful
30:14to go back
30:15to the captain
30:15to discuss his recall
30:17of what happened.
30:19In your airline's handbook,
30:21they instruct pilots
30:22to shut the right tank valve
30:24during the cross-feed procedure.
30:27You didn't shut the valve.
30:30I don't remember
30:32doing a cross-feed
30:34on the day.
30:36But typically,
30:37when I do the procedure,
30:40I leave the tank valve open.
30:47This was a surprise
30:48because that is
30:50totally contrary
30:51to the flight operating manual.
30:53I heard if you shut that valve,
30:55it might fail.
30:56Then you have no access
30:58to your fuel.
30:59So you've heard
31:00the valve is faulty?
31:02I sure have.
31:03And my old employer
31:04allowed me to do it this way.
31:10Previous employers
31:11had told him
31:12that it was
31:13the captain's discretion
31:14whether he closes
31:15the shut-off valve or not.
31:17And we confirmed
31:18that that was their position.
31:22Was there a history
31:23of fuel tank
31:24shut-off valves failing?
31:27I've gone through
31:28the FAA
31:29service difficulty reports
31:31database
31:31and I've found nothing.
31:32I can't find anything either.
31:35I don't think
31:36that valve has ever failed.
31:41There was no evidence
31:43of the valve getting stuck.
31:45This was a fiction
31:48that had somehow
31:49spread among
31:49the pilot community
31:51that simply did not
31:52have an accurate basis.
31:54This is the part
31:55I don't get.
31:57So what were they doing
31:58for 29 minutes?
32:0229 minutes
32:03is a long time
32:04to miss
32:05that there's
32:06that there's
32:06a cross-feed
32:07problem
32:08especially
32:09when the first officer
32:10reports that
32:11there are handling
32:12difficulties as well.
32:14And so it was
32:15very important
32:15to look into
32:16what might have
32:17caused this.
32:18Keep it steady.
32:25All right.
32:27Captain started
32:27the cross-feed
32:28at 12.17 a.m.
32:30He didn't notice
32:31the mistake
32:31until 29 minutes later.
32:34What happened
32:34in between?
32:36Investigators
32:37returned to
32:38flight 185
32:39CVR
32:40to determine
32:41why the pilots
32:42didn't notice
32:43that there was
32:43a growing fuel
32:44imbalance.
32:47looks like the
32:47captain finished
32:48his paperwork
32:48at 12.26 a.m.
32:51But he kept
32:51talking about it.
32:56All this time
32:56I couldn't figure out
32:57why on the landing
32:58I was out
32:59and I was
33:00okay on the takeoff
33:01and it was
33:02my chicken scratch.
33:03Ah.
33:04Yeah.
33:05Momentum is
33:061-6-6-7
33:07but I thought
33:09my chicken scratch
33:10I put 1-0-6-7
33:12couldn't work it out.
33:13Ah.
33:14It was my own doing.
33:15Ah, damn.
33:17I had it
33:18all along.
33:20We were
33:20okay
33:21all along.
33:23Is that right?
33:24Yeah.
33:25Oh, man.
33:28Okay, first
33:28he's distracted
33:29by his paperwork
33:30and then he
33:30keeps talking
33:31about it.
33:33Yeah.
33:33The captain's
33:34focus is on
33:34his paperwork
33:35for a while
33:37instead of
33:38monitoring the flight.
33:39What about
33:40after that?
33:40Any mention
33:41of the fuel gauges?
33:48What about
33:49the first officer?
33:49How come
33:50he didn't
33:50pick up on this?
33:5320 minutes
33:54after the crossfeed
33:54was open
33:55and the first officer
33:56knew something
33:57was wrong.
33:58Yoke feels funny.
34:00Say again?
34:01Feels like
34:02I need a lot
34:02of force.
34:06It's pushing
34:07to the right
34:07for some reason.
34:08I don't know
34:09why.
34:10I'm trying
34:11to...
34:12I'm not sure
34:13what's going on.
34:17All right,
34:17the first officer
34:18reports a problem
34:19with the flight controls
34:20but he doesn't
34:21check his fuel gauges
34:22for an imbalance.
34:23Why?
34:25Well,
34:26according to his work
34:26record,
34:27he was still pretty
34:27new at flying the plane.
34:30Plus,
34:30he'd only been
34:30with the airline
34:31three months.
34:35To his credit,
34:37he was assertive
34:39that he was having
34:39difficulty
34:40in the handling
34:41characteristics.
34:42So he was
34:43completely appropriate
34:44in asking for help
34:45and unfortunately,
34:46the captain
34:46did not respond
34:47as a pilot
34:48in command
34:49would be expected.
34:51Feels like
34:52I need a lot
34:53of force.
34:54Total 185,
34:55fly heading 090,
34:57maintain 4,000.
34:59090,
35:004,000,
35:02185.
35:02Thank you.
35:05090,
35:064,000.
35:10How many times
35:11did he alert
35:12the captain
35:12to the problem?
35:14He repeated
35:15his concerns
35:16at least
35:18seven times.
35:21Finally,
35:22the captain replied.
35:25We'll do a full
35:26control check
35:26on the ground then.
35:35He missed
35:35the cues
35:36from his co-pilot.
35:38How long
35:39has he been
35:39a captain?
35:40Here's the thing.
35:43He's been
35:43in a cockpit
35:44for over 20 years
35:45but only 100 hours
35:46or so as a captain.
35:50As captain,
35:51we would expect
35:52him to actually
35:53help the first
35:54officer troubleshoot
35:56why the aircraft
35:57was flying
35:59in a non-normal
36:00state.
36:01Still,
36:03wouldn't they
36:04have caught
36:04this mistake
36:05during the
36:05in-range checklist?
36:07That's a good
36:08point.
36:10The purpose
36:11of the in-range
36:11checklist is to
36:13prepare the airplane
36:13for landing
36:14and that includes
36:16a review of
36:16the cockpit instruments
36:17including
36:18the fuel gauges.
36:21So did they
36:21perform the
36:22in-range checklist?
36:24Yep.
36:25They started
36:26the checklist
36:26at 12.45 a.m.
36:28I'll give you
36:29the in-range.
36:32AC pump is on,
36:33green light,
36:34fuel panel,
36:36boost pump's on.
36:38Man, I'm telling
36:39you, what is wrong
36:41with this plane?
36:42It is really funny.
36:52Yeah, we have an
36:54imbalance on this
36:55darn cross-feet
36:56I left open.
36:59Is that what it is?
37:02Yeah.
37:04Oh, damn.
37:06I see.
37:07Yeah.
37:09We're going to
37:09flame out if we
37:10don't, aren't we?
37:19Ten seconds later,
37:20the engine's
37:20flamed out.
37:23Wow.
37:24The plane had
37:25become one gigantic
37:26glider about to
37:27hit the ground.
37:30They were too late
37:31to save it.
37:33They found out
37:34about the cross-feet
37:36issue at the same
37:37time they lost
37:38their engines.
37:43Did they start
37:44the checklist
37:45too late?
37:47They were at about
37:483,000 feet
37:48when they started.
37:56According to the
37:57airline's operating
37:58manual, they should
38:00have started the
38:01checklist at 12,000
38:02feet.
38:06They should have
38:07started at least
38:0710 minutes earlier.
38:09If they had, they
38:09would have caught
38:10their mistake with
38:10enough time to save
38:11the plane.
38:16If you're not
38:17monitoring the fuel
38:18gauges, when you run
38:19the in-range
38:19checklist, that'll
38:20remind you, but
38:22they waited until
38:23it was so late, they
38:24didn't have time to
38:25prevent the engines
38:26from flaming out.
38:31It still bugs me.
38:33Even with all the
38:34distractions and the
38:36inexperience, all
38:38professional pilots
38:39are trained to scan
38:40their instruments.
38:42Why didn't they?
38:46Maybe the fuel
38:46gauges are hard to
38:47see.
38:52Could the pilots
38:54actually see the fuel
38:55gauges from the
38:56seating positions that
38:58they were at?
39:03All right.
39:05So both our seats are
39:06fully forward.
39:08Investigators now
39:09visit a Convair 580
39:11cockpit to determine
39:13if its layout somehow
39:14prevented the pilots from
39:16monitoring their fuel gauges.
39:18So both fuel gauges are
39:19visible.
39:22But is that the case for
39:23every seat position?
39:26Let's make an adjustment.
39:38Wow.
39:39In this angle, the fuel gauges are
39:41much harder to see.
39:47The throttle control console is
39:48in the way.
39:55It depended on what position the
39:57seat was in.
39:58When the seat was aft, it was
39:59more difficult to see the fuel
40:01gauges.
40:02So the degree to which the fuel
40:04gauges are obscured changes
40:05depending on the seat position.
40:09It's hard to say if it played a role.
40:13Unfortunately, because of the
40:14destruction of the aircraft, the
40:16wreckage did not allow us to
40:19determine whether the captain's
40:20seat was forward or aft.
40:24What in the world is going on with
40:25this plane?
40:27Sucker's acting so funny.
40:30In this case, there was a concern
40:32about the fuel gauges and their
40:34location and whether they could be
40:36seen by the pilots.
40:41Yes, he would have to rise up just a
40:43little bit and look over at the
40:44thrust levers to be able to see the
40:45gauges.
40:46But it's your job to know what those
40:48instruments are saying at all times.
40:52I've been told some pilots put this
40:54sign up during a cross-feed as a
40:57reminder.
41:01Investigators have pieced together
41:03what led to the crash of Flight 185.
41:12You know what?
41:14I'm just going to balance out the
41:15fuel here.
41:16When the captain decides to even out
41:19the fuel in the tanks, he skips a key
41:22step in the procedure and leaves the
41:24right fuel tank shutoff valve open.
41:26If the captain had shut the right
41:28fuel tank valve, there may have been
41:30enough fuel to complete the flight.
41:33It's my chicken scratch.
41:35I had it all along.
41:37Then he forgets to close the cross-feed
41:39valves.
41:40It was my own doing.
41:42Oh, man.
41:44There are priorities when you're flying
41:46and you don't want to be distracted by
41:48something like doing paperwork that's
41:50overdue.
41:52Yoke feels funny.
41:53As fuel drained out of the left fuel tank.
41:56Say again?
41:58Feels like I need a lot of force.
42:00The plane became unbalanced.
42:04It's pushing to the right for some reason.
42:05And I don't know why.
42:11When you have a flight control problem,
42:13that's an urgent problem.
42:15You have to deal with it immediately.
42:18Runway's in sight.
42:20I'll give you the in-range.
42:23Then the pilot started the in-range
42:25checklist later than required.
42:41When the captain finally realized
42:44there was a fuel problem,
42:45it was too late.
42:55Fuel is life.
42:57In an airplane.
42:59You have no more fuel.
43:00There's only one way you're going to go
43:02and it's down.
43:04Keep it steady.
43:14I think the lesson to be learned
43:16is that regardless of the airplane
43:19that you're flying and the conditions,
43:21that you should adhere to the procedures
43:24as they're provided to you.
43:35In its report on Flight 185,
43:39the NTSB makes a recommendation
43:41to all Convair 580 operators.
43:46One of the main recommendations
43:47was to inform pilots
43:49that they should shut off
43:50the fuel shutoff valves
43:51if they are cross-feeding.
43:54Ultimately,
43:55if flight crews follow the procedures
43:57that they are given,
43:58they will get on the ground safely.
44:00and screening.
44:02There can be no way they're telling you