- hace 21 horas
El 6 de septiembre de 1985, el vuelo 105 de Midwest sufrió una falla del motor y se estrelló en una montaña poco después de despegar del Aeropuerto Internacional General Mitchell, los 31 pasajeros y 2 tripulantes a bordo murieron.
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00:01I remember being amazed at how quickly the accident took place.
00:05They were fine, and the next thing you know, the airplane's lost.
00:11Midwest Express Flight 105 crashes.
00:14Seconds after taking off from Milwaukee, Wisconsin, all 31 people on board are killed.
00:20And what do you say to the public about the crashes that we've been having?
00:251985 becomes one of the deadliest years in civil aviation.
00:29It's up to investigators to put the public at ease.
00:33This is how the plane hit the ground.
00:35When they examine the engines, they find a component prone to failure.
00:41Well, when we heard that this part had failed 45 times before, it's a big deal.
00:47But the flight data turns the investigation on its head.
00:51The ruptured red engine didn't bring down this plane.
00:54It did not.
01:18There are 27 passengers boarding Midwest Express Airlines Flight 105, a cross-country commuter
01:25flight from Milwaukee to Atlanta.
01:28Many are employees of the manufacturer Kimberly Clark.
01:33Midwest Express Airlines used the slogan, best care in the air, and they really meant it
01:38because they had as close to an all-business aircraft as you could have.
01:48And they also baked fresh cookies on board and made the place smell amazing when you walked on.
01:59Mid-X 105 requesting IFR clearance to Atlanta.
02:04Both pilots on this flight are captains with the airline.
02:08They've already flown two flights together today.
02:14Mid-X 105, clear to Atlanta.
02:17Climb and maintain 5,000.
02:20Climb and maintain 5,000.
02:22Mid-X 105.
02:23For this leg of the flight, Danny Martin will be the acting captain and Bill Weiss, the first officer.
02:30We had two captains, and they literally could switch seats because of that.
02:35And they did do that over the course of two days, flipping out who was the pilot flying and who
02:41was the pilot not flying.
02:44Our alternate will be DCA if we can't make Atlanta.
02:48There are thunderstorms in Atlanta, so the crew has taken on additional fuel in case they have to divert to
02:54another airport.
02:57Takeoff weight is 771, 22 pounds, set stab trim to 2.2.
03:05Just past 3 in the afternoon, the pilots start the engines.
03:14Starting number one.
03:17The DC-9 used for today's flight is powered by two Pratt & Whitney engines mounted on the fuselage at
03:24the rear of the plane.
03:28Because the engines were in the back, they were close together, which made for a little bit easier flying in
03:35emergency situations.
03:37Second of all, for the passengers, it's quieter.
03:41Thank you.
03:43Can I put that up here for you?
03:47Thank you.
03:49The plane is loaded and ready to depart on schedule.
03:57Air speed bug, 1.33 set, and 1.9 on the EPR.
04:02Okay.
04:10Ladies and gentlemen, we are number one for departure, so we should be airborne within one minute.
04:16Flight attendants, please be seated.
04:22Mid-X 105, clear for takeoff.
04:27Mid-X 105.
04:32Here we go.
04:34It's pulling up.
04:39This was a very normal morning for a very normal flight.
04:44It was a gorgeous blue sky, September day.
04:48There was a little bit of gusty winds, but it was nothing for Milwaukee.
04:59The pilots need to reach a speed of 127 knots for takeoff.
05:12At 3.21 in the afternoon, flight 105 begins its journey.
05:21Oh, crap.
05:24The DC-9 is stalling.
05:28Get your heads down.
05:36Heads down!
05:38Heads down!
05:55Heads down!
06:01The plane hits the ground, less than 1,700 feet from the runway.
06:08A DC-9 has crashed southwest of runway 19R.
06:21All 31 people on board have been killed.
06:29The crash of Midwest Express Flight 105 is the third major accident in the United States this year,
06:36and the eighth accident worldwide.
06:39With more than 1,200 people killed,
06:42this is becoming one of the deadliest years in the history of civil aviation.
06:47Passengers are unnerved.
06:49Everyone says, my God, another one.
06:51What do you say to the public about the crashes that we've been having?
06:55Well, insofar as the National Transportation Safety Board is concerned,
06:57we are sparing no effort to determine the cause of each one of them,
07:00and we will make the necessary recommendations to keep any repeat of any one of them from happening.
07:05And what do you tell them about...
07:09Can you show me where it started to bank?
07:13Investigators from the NTSB begin by interviewing witnesses of Midwest Express Flight 105's fatal dive.
07:21They either came forward or we tracked them down.
07:23We ended up making out a questionnaire with 40 or 50 questions on it to kind of cover all the
07:28bases.
07:31Okay, got it.
07:37While the witness accounts differ in detail, they all describe more or less the same thing.
07:44I saw a couple of puffs of black smoke come out,
07:46and I just figured that they had gunned the engines a little bit.
07:50Instant later, the left wing rose up,
07:53and it tipped over and went nose first into the trees here.
08:00Most of the witnesses agree that take-off appeared normal
08:03until the airplane was about 300 feet off the ground.
08:08Almost all report smoke and fire coming from the right engine.
08:12Several remember hearing loud bangs.
08:15Most said that the plane then rolled abruptly into a steep right bank,
08:19went into a nose-low spin, and crashed.
08:26The value of having so many witness statements to look at,
08:30they gave us a picture of what happened right at the end.
08:33A loss of control, fire, and, of course, the impact itself.
08:39Investigators must now determine what could have caused
08:42such a catastrophic loss of control so soon after take-off.
08:50I'm guessing this was made by the right wing.
08:53Yep, agreed.
08:59Let's see what we can figure out.
09:02After securing the crash site of Midwest Express Flight 105,
09:06investigators begin mapping the wreckage field.
09:10I think the whole length of the impact site was about 295 feet,
09:14not much more than two times the length of the airplane.
09:18So the airplane hit pretty steeply and didn't go very far.
09:23Right wing tip here,
09:26and the horizontal stabilizer here.
09:31This is how the plane hit the ground.
09:34A 90-degree right roll and a right yaw.
09:42Can you grab the picture?
09:43Go ahead.
09:45The wreckage path confirms eyewitness reports.
09:49Right.
09:50It very definitely indicates right up front that you've got a lost control.
09:54It doesn't suggest why you had the lost control.
09:57It kind of opens the door to a lot of different investigative avenues.
10:03Yeah, it's fire damage for sure,
10:05but it looks like all the pieces are here.
10:09Investigators study the plane's control surfaces,
10:12starting with the ailerons.
10:15The ailerons on each wing direct the plane's roll.
10:20If an aileron malfunctions and gets stuck in one position,
10:24it could cause a devastating lack of control.
10:30Control tabs are in place.
10:32They seem to be intact.
10:35We didn't find a problem with other components
10:38that are part of that system.
10:41With the ailerons ruled out,
10:43investigators turn their attention to the rudder system.
10:48Dampers are still working.
10:50Hinges are intact.
10:54The crashes look like overload, not stress.
10:58I don't think the rudder is our culprit.
11:03We didn't find anything wrong with any of the control systems
11:07based on that preliminary look-see.
11:10Could the engines provide insight
11:13into the crash of Midwest Express Flight 105?
11:17If the engines were, well, obviously banged up,
11:20they were fire damaged,
11:21and they were along the wreckage path,
11:23which is always good,
11:26that means they didn't fall off somewhere earlier.
11:32There's a spacer missing here.
11:39Most of the blades from this stage are gone.
11:43The team finds damage inside the right engine
11:46that could not have been caused on impact.
11:49The missing engine pieces include a spacer
11:53and the compressor blades from the 9th and 10th compressor stages.
11:59They're found more than half a mile from the main wreckage site.
12:04Finding any part of the airplane
12:06short of where the airplane crashed
12:08was a suggestion of a malfunction or failure
12:12that had occurred in flight
12:13and required further investigation.
12:17The engine and the pieces are moved to a nearby warehouse
12:20where they can be more closely examined.
12:23In the end, we ended up finding about 90% by weight of the spacer,
12:28so that was a big boon to the investigation.
12:32Investigators study the recovered spacer
12:35to determine why it failed on Midwest Express Flight 105.
12:41All on the pedestal here.
12:45It's definitely not overstress.
12:49They discover a telltale crack on the spacer
12:52that appears to have spread over time,
12:55what's called progressive cracking.
12:57There may be stress marks, there may be cracks,
13:01there may be things that suggest a direction of failure
13:05and a time frame where the fracture would have occurred.
13:08It doesn't occur all at one time.
13:11Can we determine how long that crack has been spreading for?
13:14I'll see what I can do.
13:17We became interested, not just in detailing that,
13:22but trying to find whether this was a fracture
13:24that could have been detected previously.
13:27A closer look at the crack on the steel spacer
13:30reveals it's filled with nickel.
13:33A lightweight nickel coating is applied
13:35to certain vital engine pieces,
13:37like the compressor spacers and blades,
13:40to prevent corrosion.
13:43The compressor was brought in to be refurbished in 1981.
13:48Coating stripped, spacer examined, and...
13:51Oh, here we go.
13:54Replated.
13:56That was four years ago.
13:58The maintenance records tell investigators
14:01that work had been done on the spacer that failed on Midwest Express Flight 105.
14:07Nickel-cadmium plating is the last step of the refurbishment process
14:13that would have been done by the maintenance facility
14:16that was involved with, essentially, the overhaul of that part.
14:20Four years before the accident,
14:22the spacer was removed from the engine,
14:25stripped of its coating, and examined for cracks.
14:28The inspector reported no cracks
14:30and sent the part to be replated with nickel.
14:34Since nickel was found inside the crack,
14:37it must have been present when the nickel was applied.
14:44The DC-9 flew about 2,500 flights over the next four years
14:49with the damaged spacer
14:50until it finally ruptured on Flight 105.
14:57It should have been caught during an overhaul, but it wasn't.
15:01And so the crack kept growing and growing
15:03until it finally hit its failure point.
15:07Investigators wonder what caused the crack
15:10to form on the spacer in the first place.
15:13These spacers have been used inside the JT-8D for more than 20 years.
15:18This can't be the first one to break.
15:22There are identical spacers
15:25in more than 14,000 JT-8D engines
15:28used on airplanes around the world.
15:30Is there any history of similar failures?
15:34It turns out that Pratt and Plaby were well aware
15:37of spacer failures that occurred before.
15:40So we started to wonder,
15:41what have they done about it?
15:47It seems to happen a lot.
15:50While researching spacer issues in other aircraft,
15:54investigators uncover 45 similar failures
15:58prior to Midwest Express Flight 105's accident.
16:01Well, when we heard that this part had failed 45 times before,
16:06we kind of looked askance a bit at the manufacturer.
16:10It's a big deal.
16:12But of all the failures uncovered by the NTSB...
16:16Not a single loss of aircraft or even a single injury.
16:21Well, that says something.
16:23In every previous incident,
16:25the plane landed safely.
16:27So why did the rupture of a spacer on Flight 105
16:31cause the plane to become uncontrollable and crash?
16:37Well, we knew that none of the previous failures
16:39had led to an accident.
16:40So one of the questions was,
16:43what made this one different?
16:45Let's see what got hit.
16:48Investigators consider the possibility
16:50that pieces of the ruptured spacer on Flight 105
16:53punctured the plane's fuselage
16:56and damaged vital control systems,
16:58such as cables or hydraulic lines.
17:02When a part like a spacer or a fan disc
17:06breaks under a lot of stress,
17:10it's almost like a small explosion going off.
17:13You have fragments of metal flying
17:16at very, very high speeds.
17:19OK, let's see 894.
17:23They studied the location and pattern
17:26of all the puncture marks found on the skin of the plane
17:29to see if any were near vital control links.
17:33No control cables, no hydraulics.
17:3910-12.
17:45No control cables, no hydraulics.
17:50What about the pieces of the plane
17:52that we haven't been able to find?
17:54There are many critical pieces of the plane
17:57that have not been recovered
17:58or are too badly damaged to study.
18:02Is it possible to figure out
18:04if they could have been hit by the engine pieces?
18:08We have what we need to run a trajectory analysis.
18:12All right.
18:14We were looking at,
18:16could these parts that have left the engine
18:19strike a control surface
18:21or the hydraulic system
18:23or anything else
18:25where they could have done secondary damage
18:27that would have compounded the situation
18:29the pilots were facing?
18:31Knowing the plane's velocity,
18:33angle of ascent
18:34and the wind speed
18:36at the time the engine failed,
18:38the team calculates
18:39the path of debris
18:40ejected from the engine.
18:43The smallest piece we found
18:45was about half an ounce.
18:47The largest piece was just over a pound.
18:49So everything moves away from the plane,
18:52nothing hits it.
18:53The trajectory analysis
18:55tells investigators
18:56that none of the ejected engine pieces
18:59would have struck the airplane
19:00with enough force
19:02to cause substantial damage
19:03to the control systems.
19:05The analysis indicated
19:07that it was so unlikely
19:10that we considered it an impossibility,
19:13that those parts
19:14leaving the engine
19:15in the direction they went
19:16and the size that they had
19:18could have caused secondary damage,
19:21they would cause lost control.
19:24If spacer fragments
19:26didn't hit vital components
19:27and cause the loss of control,
19:29perhaps the initial explosive force
19:32opened the cowling
19:33or engine cover,
19:35affecting the plane's aerodynamics.
19:38If the cowling had been blown open,
19:41it would cause a lot of drag,
19:43it might cause the airplane to roll,
19:46it might cause the airplane
19:47to become uncontrollable.
19:50There's a hole in the cowling,
19:51looks to be about two square inches.
19:54The team finds evidence
19:56that the cowling was pierced
19:58by fragments ejected from the engine.
20:10They found them all either latched
20:13or fully intact
20:14with no damage at all.
20:16So that scenario
20:17kind of went out the window.
20:20So the ruptured red engine
20:22didn't bring down this plane?
20:24It did not.
20:29Well, reasonably early
20:30in the investigation,
20:31the team figured out
20:32that a spacer had failed
20:33and the engine had failed.
20:35And now we had the rest
20:37of the accident to figure out.
20:38Why would that cause a crash?
20:45Investigators examine
20:46Midwest Express Flight 105's
20:48flight data recorder
20:49in hopes of understanding
20:51how the loss of the right engine
20:53caused the death of 31 people.
20:56It doesn't give us much,
20:58but it's all we've got to work with.
21:00It was only recording
21:01four flight parameters.
21:03It had airspeed, altitude,
21:05heading,
21:06and vertical acceleration.
21:09Right here,
21:10a sudden deceleration
21:12of 450 feet.
21:13This must be where
21:14the right engine failed.
21:15Well, that's consistent
21:16with what the witnesses told us.
21:20The engine failure we know
21:22occurred above the airport,
21:24so the airplane
21:25had only been airborne
21:26for a few seconds.
21:30But the heading doesn't change
21:32when the engine fails.
21:33They must be applying
21:35left rudder to compensate.
21:37Oh, dead right engine,
21:38left rudder.
21:39That's the right move.
21:42When the right engine fails,
21:45the remaining engine
21:46should force the plane
21:47to the right.
21:48To counteract that,
21:50a pilot would apply
21:51left rudder
21:52to keep the plane
21:53flying straight.
21:56The remaining engine
21:58should force the plane
21:59to the right.
22:00To counteract that,
22:02a pilot would apply
22:03left rudder
22:04to keep the plane
22:04flying straight.
22:13The data shows
22:15that's precisely
22:16what Captain Martin did
22:17in response
22:18to Flight 105's
22:20engine failure.
22:21After a few seconds,
22:23they start this yacht
22:23to the right.
22:24So,
22:25right rudder?
22:28Four seconds
22:29after the failure
22:30of the right engine,
22:31the FDR data indicates
22:34that the pilot
22:35moved the rudder
22:36from left
22:36to right.
22:37That forced the plane
22:39into a sudden yaw
22:40to the right.
22:43He's in a side slip.
22:46And he's deviating
22:47further and further
22:48to the right.
22:51And then he starts
22:52to lose altitude.
22:54Huh,
22:55148 knots.
22:58He's in a high-speed stall.
23:01How'd they let that happen?
23:04You went into
23:06a right skid
23:07and then followed
23:08by an abrupt
23:09right turn and dive.
23:10That would be consistent
23:12with a stall,
23:13but the air speeds
23:14indicated
23:15were high enough
23:17that you wouldn't
23:17normally have
23:18a stall
23:19at those speeds.
23:21Clearly lost control
23:23of the plane.
23:24Five seconds later,
23:25they hit the ground.
23:28The flight data
23:29tells investigators
23:30that it took only
23:3110 seconds
23:32for the pilots
23:33to lose control
23:34of the plane
23:35after the failure
23:36of the right engine.
23:40I have never seen
23:41an accident sequence
23:42that brief
23:45before or since.
23:49So,
23:50he responds correctly
23:52at first
23:52with left rudder
23:53and nose-down pitch.
23:55Then he inexplicably
23:57switches to right rudder?
23:58And that's what leads
23:59to the yaw,
24:00the right roll
24:00and the eventual stall.
24:02Right rudder,
24:03it makes no sense.
24:05It was clear
24:06from all the data
24:07that the pilot
24:09didn't understand
24:10what happened.
24:10He responded
24:11inappropriately
24:12and within seconds
24:14the airplane was lost
24:15and everybody on board
24:16was killed
24:17in the accident.
24:18Was there something
24:20about the DC-9's
24:21handling characteristics
24:22that led the pilot
24:24to input
24:25the right rudder?
24:26So,
24:27it was relatively
24:28easy to control then?
24:32Just with the control wheel?
24:36Investigators
24:36interview DC-9 pilots
24:38to determine
24:39how the plane
24:40handles
24:41with only one engine.
24:42The DC-9 pilots
24:43that we talked to,
24:44it was overwhelmingly
24:44described as
24:46a very easy,
24:47docile aircraft
24:48to handle
24:49in those situations.
24:50Oh, this has been
24:51extremely helpful.
24:52Thanks.
24:53Okay.
24:53Bye.
24:55They all say
24:56the same thing.
24:57It's no big deal
24:59with one engine.
25:02Because the DC-9's
25:04engines are mounted
25:05on the fuselage
25:06instead of the wings,
25:07when one engine fails,
25:09it does not force
25:10the plane
25:11into a severe turn.
25:12DC-9 is almost
25:14a centerline
25:14thrust aircraft,
25:16so if you lose
25:17one engine
25:18on either side,
25:20there's not that much
25:22excess yawing
25:23or controllability
25:24problems at all.
25:27How easy is it
25:29to handle a DC-9
25:30in the situation
25:31the pilots
25:32of Flight 105
25:33found themselves in?
25:36It was valuable
25:37to do a simulation
25:39or test flight
25:40to get a better idea
25:42of exactly
25:43how the airplane
25:44performed
25:45under the circumstances
25:46of the accident,
25:48but at a higher altitude.
25:52Okay.
25:53When we get
25:53to 10,000 feet,
25:54I'm going to cut power
25:55to the right,
25:56leaving the left
25:57at takeoff power.
25:58Keep the flaps at 20.
25:59Target speed is 170 knots.
26:03They tried to match
26:04the parameters
26:05of the airplane
26:05in terms of the flaps,
26:07gear,
26:08and airspeed,
26:10and then proceeded
26:12to cut the engine power.
26:15Okay.
26:16Cutting power.
26:26Okay.
26:27Thank you.
26:28Let's go around
26:29for another.
26:31Flight demonstrations
26:32showed that
26:33the pilot
26:34didn't have to
26:35input rotor at all.
26:37If he had only
26:38used the ailerons,
26:39he could have
26:39safely fallen out of it.
26:42Okay.
26:42This time,
26:43no reaction.
26:44Let's see what
26:45the plane does.
26:47With no input
26:48from the pilot
26:49after the loss
26:50of the right engine,
26:51the plane rolls right
26:53and the nose drops.
26:58Okay.
26:59You can recover?
27:00Okay.
27:00You can recover?
27:01Okay.
27:01You can recover.
27:02Even with no
27:03immediate action,
27:05the pilot is easily
27:06able to recover
27:06the plane.
27:10Okay.
27:12I think we have
27:13what we need.
27:14That may have actually
27:15been the best thing
27:16to do,
27:16was to do nothing,
27:19watch the airplane's response,
27:21understand the airplane's response,
27:22and respond appropriately
27:23to the nature
27:24of the emergency.
27:30If the DC-9 is so easy
27:33to control,
27:34why were two
27:35experienced pilots
27:37unable to recover
27:38from the loss
27:39of their right engine?
27:44Okay.
27:45We know they were
27:46both captains
27:47with the airline,
27:48but how much experience
27:49did they actually have?
27:51Investigators look
27:51into the backgrounds
27:52of the pilots
27:53of Midwest Express Flight 105
27:55to understand
27:57why they didn't recover
27:58from a single engine failure.
28:00Neither had a lot
28:01of turbojet experience.
28:03One was upgraded
28:04to captain
28:05with 600 hours
28:06on the DC-9,
28:07the other
28:08with only 500.
28:09Doesn't seem like
28:10a whole lot.
28:12Advancement to captain
28:13happened within a year
28:15for both of these pilots
28:16at Midwest Express Airlines
28:19at that time.
28:21And the reason why
28:22was it was a small airline,
28:24it was growing quickly,
28:26they were adding airplanes.
28:29They consult
28:30large U.S. airlines
28:31to determine
28:32their qualifications
28:33for an upgrade.
28:36Okay, thanks.
28:39It's the same
28:40for both airlines.
28:41Ten years seniority
28:43and 7,500 hours
28:44as DC-9 first officer
28:46to be considered
28:46for an upgrade.
28:48Yeah, these guys
28:49weren't anywhere near that.
28:51While the pilots
28:53may have been experienced,
28:54neither had spent
28:55much time piloting
28:56the DC-9
28:57before they were
28:58promoted to captain.
28:59The more experience
29:01someone has
29:02exercising command,
29:03the more likely
29:04they are
29:04to exercise that command
29:06in situations
29:07that call for
29:08calm thinking,
29:09for rational response,
29:10and so on.
29:13So how much training
29:14did these guys
29:15get on engine failures?
29:17To understand
29:18why the pilots
29:20of Flight 105
29:20were not able
29:22to control their plane
29:23following an engine failure,
29:24investigators look
29:25at their training records.
29:27What was their experience?
29:29What kind of pilots
29:30were they?
29:31How did they respond
29:32to unusual events?
29:34Did they seem
29:35self-confident?
29:36How well
29:37did they work together?
29:40OK, so the captains
29:43practiced 12 engine failures
29:46on take-off
29:47in the simulator.
29:48First officer,
29:5015 sessions.
29:52They discover
29:54that both pilots
29:55had been extensively trained
29:56to cope with engine failure
29:58on take-off.
30:00Precisely the type of emergency
30:02they faced on Flight 105.
30:04But what exactly
30:06were they taught?
30:08We looked very closely
30:10at the training
30:11these pilots received
30:12and interviewed
30:14the flight instructor
30:14who oversaw
30:16their training
30:16in the DC-9
30:17from the New West Express.
30:20Tell me
30:21what you can remember
30:22about Captains
30:23Martin and Weiss.
30:27They were both
30:27excellent pilots.
30:29Trained to proficiency.
30:32Lots of simulator training
30:34on engine failure.
30:35You bet.
30:37We ran them
30:37through all sorts
30:38of scenarios.
30:41Let's focus
30:42on take-off
30:44with simulated
30:45engine failure.
30:46What were they taught?
30:52Pay attention
30:53to your yachts,
30:54your best cue.
30:57Going right.
30:59Flying left rotor.
31:02Control wheel is needed.
31:03Keep the plane level.
31:05Nice and easy.
31:07It's a good job.
31:09Got it.
31:11Captain Martin
31:12was trained
31:12to pay close attention
31:14to the plane's
31:14yawing motion
31:15when identifying
31:16and correcting
31:17an engine failure.
31:19Looks like
31:20they had excellent training.
31:22Thanks for the insight.
31:26We found the instructor
31:28to be very capable
31:29and very dedicated
31:31and we found
31:32the simulators
31:32to be okay
31:35for that time.
31:38If Captain Martin
31:39was extensively trained
31:41to cope with engine failure
31:42on take-off,
31:43why didn't he do
31:44what he was trained to do?
31:49Most of their training
31:51was for an engine failure
31:52at take-off.
31:54Pretty easy to identify
31:55which way you're yawing.
31:56Yeah.
31:57Investigators consider
31:58the timing
31:59of the engine failure.
32:01If you're closer
32:02to the ground,
32:02there are much more
32:03visual cues available
32:04from the ground
32:05to see what the airplane
32:07is encountering.
32:09Not so easy
32:10when you're already
32:11in a steep climb.
32:13Right.
32:15As flight 105
32:16was climbing,
32:18only blue sky
32:19would have been visible
32:20to the pilots,
32:21making it more difficult
32:22to identify
32:23the direction
32:24of the yaw.
32:28What was that?
32:30With no outside
32:32visual cues,
32:33investigators believe
32:34Captain Martin's
32:35initial response
32:36was a spontaneous
32:37reaction to the plane's
32:39changing motion
32:40and not the result
32:41of an analysis
32:42of the situation.
32:43But what triggered
32:45the incorrect rudder
32:46application a few
32:47seconds later
32:47that resulted
32:48in a total loss
32:49of control?
32:52All right.
32:53Let's see what
32:54these guys were doing.
33:00X.05,
33:02clear for take-off.
33:03Red X, 105.
33:06Here we go.
33:10Investigators pin
33:11their hopes
33:12on the CVR
33:13to explain
33:14Captain Martin's
33:15actions.
33:17Spilling up.
33:19Power normal.
33:23100.
33:28V1.
33:30Rotate.
33:35You're up.
33:40What was that?
33:41Stacey?
33:42Mid X 105.
33:43Turn left heading
33:44175.
33:46What do we got here,
33:46Bill?
33:47Here.
33:49Mid X 105,
33:50roger.
33:52We got an emergency
33:53here.
33:55Mid X 105, roger.
33:57Oh, crap.
34:00Head down.
34:01Head down.
34:02Woo!
34:08I've never heard
34:09an accident unfold
34:10so quickly.
34:12Holy smokes.
34:14And I remember
34:15just being amazed
34:17how quickly
34:18the accident
34:19took place.
34:20It was like
34:21they were flying.
34:22You hear the
34:23engine fail.
34:25And the next thing
34:26you know,
34:27the airplane's lost.
34:29Okay.
34:31So what did we hear?
34:33Sure happened fast.
34:35Yep.
34:3515 seconds
34:36from the sound
34:37of the engine
34:37exploding
34:38to the end
34:38of the recording.
34:40Astonishing.
34:46What else?
34:48What was that?
34:49What have we got?
34:51The captain
34:51seemed
34:53uncertain.
34:54Agreed.
34:59What have we got here,
35:00Bill?
35:02Well, it was clear
35:03from the cockpit
35:05force recorder
35:05that the pilot
35:07didn't recognize
35:08what had happened.
35:09He articulates that.
35:10What was that?
35:11What do we got here,
35:13Bill?
35:16What the hell was that?
35:17The sound of the engine,
35:19the sensation
35:20of the right yaw,
35:21and the instruments
35:22should have told
35:24Captain Martin
35:24that he was dealing
35:25with a failure
35:26of his right engine.
35:30Anything else
35:30on that tape?
35:32Not a lot
35:33of troubleshooting
35:34or communication
35:36between them,
35:37really.
35:38actually,
35:40none.
35:47What have we got here,
35:48Bill?
35:50Here.
35:52Mid-X 105,
35:53Roger.
35:54We got an emergency here.
35:57Investigators hear
35:58Captain Martin
35:59asking his first officer
36:01for assistance
36:02in assessing
36:02the situation,
36:03but First Officer Weiss
36:05never replies.
36:06That was troubling
36:08to me
36:08because I would have
36:11expected that
36:12in an emergency
36:13situation,
36:14and especially
36:14when asked
36:16for help,
36:18that the other
36:19crew member
36:19would have helped
36:20if he could.
36:22So,
36:23it prompted
36:24some further
36:24investigation.
36:27Okay,
36:28let's start
36:28with that.
36:29Why was the
36:30captain confused
36:31about what had
36:32happened?
36:32Should have
36:33been obvious.
36:374,600 flight hours,
36:39but he's never
36:40experienced
36:40an actual
36:41engine failure.
36:43NTSB investigators
36:44looking into
36:44the crash
36:45of Midwest
36:45Express
36:46flight 105
36:47have learned
36:48that Captain
36:48Martin's
36:49only experience
36:50with a single
36:50engine failure
36:51was in a simulator.
36:54Yaw and deceleration
36:55don't feel the same,
36:56plus all the sounds
36:57are different.
36:58It's not the same
36:59as the real thing.
37:00It was a kind
37:01of catastrophic
37:01engine failure
37:02where they had
37:02thrust and then
37:03they didn't.
37:03It was immediate.
37:05I don't think
37:06they were trained
37:07in that kind
37:08of scenario.
37:10What do we got
37:11here, Bill?
37:12The limitations
37:14of the simulator
37:15may explain
37:16Captain Martin's
37:17initial confusion,
37:18but it does not
37:19explain the
37:20first officer's
37:20unusual silence.
37:23Let's have
37:24another listen.
37:27They return
37:28to the cockpit
37:29voice recording
37:30to better understand
37:31how First Officer
37:32Weiss reacted
37:33to the emergency.
37:38How was that?
37:40That's one.
37:41Turn left
37:42heading 175.
37:44What do we got
37:44here, Bill?
37:45That's two.
37:46Here.
37:47That's three.
37:52He asked for help
37:53three times,
37:53but the FO says
37:54absolutely nothing
37:55to him the entire time.
37:56Not even,
37:57I'm not sure,
37:58or I don't know.
38:00Not a word.
38:01In this situation,
38:03seconds were critical.
38:06Had he said
38:06right away,
38:07I don't know,
38:08then the captain
38:09would immediately
38:10have tried to rely
38:11on his own
38:12understanding
38:12of the situation
38:13rather than expect
38:15the First Officer
38:15to come up
38:16with an explanation
38:17of what he had.
38:20What could have caused
38:21the First Officer's silence?
38:25Hang on.
38:28What altitude
38:29were they at
38:29when the engine failed?
38:31Hmm.
38:33450 feet.
38:35This could be it, then.
38:37Pilots say
38:38they were taught
38:38not to make call-outs
38:39or even verbalize
38:41the nature
38:41of an emergency
38:42after 100 knots
38:43before reaching
38:45800 feet.
38:47Let me see.
38:55Not even to identify
38:57a failed engine.
38:58No communication
38:59at all
39:00until 800 feet.
39:01Yeah.
39:02I couldn't imagine
39:04a management team
39:05at Midwest Express
39:07thinking this silent
39:08cockpit business
39:10made any sense.
39:12It just flies
39:13in the face
39:14of communication,
39:16which is kind of
39:17the fabric
39:18that holds
39:18a safe flight together.
39:20So it just
39:21blew my mind,
39:22frankly.
39:28What the hell was that?
39:31Investigators think
39:31First Officer Weiss
39:33may have been
39:33following a Midwest Express
39:35unwritten rule
39:36of not discussing
39:37emergencies
39:38until the plane
39:39reaches 800 feet.
39:41It's important
39:42during an emergency
39:43is for people
39:44to talk to each other
39:45because they both
39:46may not be looking
39:48at the same instrument.
39:49They both may not
39:50be looking at
39:50the same thing outside.
39:51You have to talk.
39:52You have to talk.
39:55One last thing
39:56troubles investigators.
39:58In spite of his
39:59First Officer's silence,
40:00Captain Martin
40:01could have easily
40:02identified which
40:03engine had failed
40:04simply by looking
40:05at his instruments.
40:07Both pilots
40:07had the visual
40:08information
40:09from the engine
40:09flight instruments,
40:11the turn indicator
40:12and so on,
40:13that would have
40:14told them
40:16what was going on
40:17in terms of
40:17the loss of thrust.
40:19I don't think
40:20either of them
40:21were scanning
40:21the instruments.
40:22Agreed.
40:23They never saw
40:24which engine
40:25had failed,
40:26the direction
40:26of the yaw
40:27or the severity
40:27of the roll.
40:29The NTSB concludes
40:31that the pilots'
40:32failure to monitor
40:33their instruments
40:34contributed to Captain
40:35Martin's incorrect
40:37rudder application.
40:38With the lack
40:39of visual cues,
40:40the only sure way
40:41they would have had
40:42to recognize
40:43which engine failed
40:44would be to look
40:45at the instruments.
40:47The pilots' lack
40:49of awareness
40:49ultimately led
40:51to the stall
40:51that brought down
40:52Flight 105.
41:00Up until here,
41:01he should be fine.
41:02But then there's
41:03no communication
41:04and no instrument scanning.
41:07And this,
41:08this is what dooms them.
41:09He puts in
41:10a right rudder
41:11which sends them
41:12into a side slip,
41:14an extreme right roll
41:15and a stall.
41:17If they had talked
41:18to each other,
41:19scanned their instruments,
41:21you don't get this accident.
41:25The reality of the situation
41:27is the mismanagement
41:28inside the cockpit
41:29caused the accident,
41:32not the engine failure.
41:34The NTSB's final report
41:37makes several key recommendations
41:38to prevent this type
41:40of accident
41:40from happening again.
41:42They recommend
41:42a directive
41:43requiring airlines
41:44to replace
41:45the existing spacers
41:46with a new type
41:48of spacer
41:48which is less likely
41:49to fail.
41:50They also recommend
41:52that airlines
41:53are advised
41:53to teach their pilots
41:54to communicate
41:55during on-board emergencies.
41:58It should never be
42:00overstated
42:01the importance
42:01of crew coordination.
42:03Every crew member
42:04has something valuable
42:05to add.
42:06Anything that
42:07is in abnormality
42:08needs to be discussed
42:11at the proper time.
42:14They also suggest
42:15that airlines
42:16review their simulator training
42:18to ensure pilots
42:19are taught
42:20to use their instruments
42:21to assess
42:22the nature
42:22of engine failures.
42:24I think
42:25this accident
42:26still has an impact
42:27today
42:28because
42:30it's such a
42:32clear illustration
42:33of what happens
42:35when you don't do
42:36what you should do
42:39in an emergency.
42:40Anytime there's
42:41an emergency
42:42you should have
42:42the exact same
42:44procedures
42:45and you should
42:46run right to them.
42:48Midwest Express Airlines
42:50continued to operate
42:52until 2009.
42:53It merged with
42:54Frontier Airlines
42:55in 2010.
42:56and then