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Air Crash Investigation (Mayday) S25E02 Running On Empty 1080p
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00:00On approach to Cincinnati, Ohio, the pilots of Air Tahoma Flight 185 face disaster.
00:122,300 feet.
00:13Keep it steady.
00:14The airplane will fall like a rock.
00:17My God.
00:19The plane crashes into a golf course.
00:23Only the captain survives.
00:26He did not remember much of the flight.
00:29When you have a tragic event happen, the memories are not there.
00:33The wrecked engines provide investigators with their first clue.
00:37There's no evidence of burning or charring.
00:39Both engines flamed out before the crash.
00:41But according to the gauges, there was ample fuel for the flight.
00:46If there was still 5,600 pounds of fuel in the right tank, why didn't that fuel feed the engines?
00:52That was certainly something that I had not seen before.
01:19Air Tahoma Flight 185 is cruising at 15,000 feet.
01:24It's headed for Cincinnati, Northern Kentucky International Airport.
01:31Coffee's still hot if you want some.
01:34No, thanks.
01:35I'm well rested.
01:37Captain Bruno Picelli is an experienced pilot who has flown all over the world and also worked as a firefighter
01:44in British Columbia, Canada.
01:46Convair 580 pilot Bruno Saint-Jacques has flown alongside Captain Picelli.
01:53He was a very good person, 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 as a pilot and flight engineer and is now a first officer
02:12for Air Tahoma.
02:15Tonight's flight from Memphis, Tennessee to Cincinnati, Ohio is 80 minutes.
02:21This was the first leg of a round trip and was done every weeknight by Air Tahoma.
02:28They're flying a Convair 580, a twin turboprop aircraft used for short-haul flights.
02:36The Convair 580 is about 50 years old, was used in passenger service for a long time, and then transitioned
02:45to cargo service.
02:49It was always reputed to be a very stable, reliable airplane.
02:57So what was it like flying as a firefighter?
03:00Well, long hours.
03:03Same plane as this.
03:05Different cargo, of course.
03:09There are five pallets containing mail and parcels from the courier DHL Express on board the aircraft.
03:26How's the paperwork?
03:29Almost done.
03:35The captain was focused on some paperwork that he needed to complete before he landed in Cincinnati, which he did.
03:45Okay.
03:49You know what?
03:50I'm just going to balance out the fuel here.
03:54Captain Pacelli notices that one of his fuel tanks has more fuel than the other.
04:00The Convair 580 has two tanks, and you can use one tank to feed both engines until both tanks are
04:08even.
04:12One hour into the flight, the 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.
04:2210 degrees left to Cincinnati when able.
04:25185.
04:27I already had it.
04:29Right on the money.
04:30Hey.
04:30As Air Tahoma 185 begins its descent, the first officer detects a change in the controls.
04:39Yoke feels funny.
04:42Say again?
04:44It feels 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 to move the control surfaces.
05:01The pilot must use a lot of arm strength when the autopilot is not on.
05:09Four in the box.
05:1430 miles from the airport, the controller provides an update on the approach.
05:19Tahoma 185, fly heading 090, maintain 4,000.
05:24Maintain 4,000.
05:25185.
05:27They're packed tonight, so we're going to go bang, bang, bang.
05:30Got it.
05:33There was pressure on it because if you get late in the sequence of the other aircraft landing
05:40in the airport, you're slowing down all the airplane behind you.
05:46Tahoma 185.
05:47Cleared for visual approach.
05:483-6 right.
05:50Keep your speed up.
05:51Visual approach.
05:523-6 right.
05:54Keep the speed up.
05:55185, thank you.
05:56As the crew receives clearance for a visual approach, the aircraft continues pulling to the right.
06:02What in the world is going on with this plane?
06:05This sucker's acting so funny.
06:08We'll do a full control check on the ground.
06:12Point it down at 3,000 as quick as you can.
06:18Usually, an airplane flies straight and wings level.
06:23It wouldn't give you a nice feeling to fly the plane, which always want to turn on one side.
06:28185, runway 3-6 right, clear to land.
06:32Clear to land, 3-6 right, 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.
06:50Quality checks.
06:51As the crew runs the in range checklist.
06:54AC pump is on.
06:56Green light.
06:57Boost pump's on.
06:59The plane continues to handle poorly.
07:02Man, I'm telling you.
07:04What is wrong with this plane?
07:05It is really funny.
07:08Then, less than five miles from the airport.
07:13And just 2,300 feet above the ground, both engines lose power.
07:29The airplane will fall like a rock, because it needs at least one engine in good shape to bring them
07:37to the runway.
07:382,300 feet.
07:43My God.
07:45Cincinnati control.
07:47Tahoma 185.
07:49We're having engine problems.
07:50Tahoma 185.
07:52Do you require emergency support?
07:58Negative.
08:03I think the reason he said no was he was still hoping that somehow he could get to the airport.
08:12Keep it steady.
08:14But they're dropping too fast to make it to the airport.
08:18Come on.
08:19They see an opening ahead.
08:21There's no time at all to raise the gear, raise the flap, restart the engine before you touch the ground.
08:27Their only option was to go straight to the safest place, to put down the plane, and hope for the
08:36best.
08:37Tahoma 185, please respond.
08:41They were at low altitude.
08:42Hold it up.
08:43They were short of the runway.
08:45It was dark outside.
08:46Tahoma 185, do you copy?
08:48The situation was very, very dire.
08:50Trees.
08:51Pull up.
08:53Pull up.
08:55Pull up.
09:01They make it through the trees.
09:03Come on.
09:04Come on.
09:08But can't keep the plane on the ground.
09:11Come on.
09:24Come on.
09:39Emergency vehicles soon arrive at the crash site, just 1.2 miles south of Cincinnati's international airport.
09:51The body of 1st Officer Gelwix is found in the wreckage.
09:59Incredibly, Captain Picelli has survived.
10:06Investigators from the National Transportation Safety Board, or NTSB, rush to Cincinnati and begin looking into the crash of Air
10:15Tahoma Flight 185.
10:16So, what have we got so far?
10:19Both black boxes have been sent to Washington for analysis.
10:22Good.
10:23Structural failure?
10:24Take a look.
10:27When we first arrived, what we typically do is look for the four corners of the airplane to be able
10:33to rule out some sort of structural failure or a part or piece of the airplane departing prior to impact
10:40with the ground.
10:44We found all four corners of the plane, we found the tail here, we located both wingtips here and here,
10:51and the nose was essentially split in half and fractured into small pieces.
10:55If it wasn't structural failure, then what?
10:58What did the captain have to say?
11:00He's still recovering in hospital, but I did speak with the air traffic controller.
11:04And?
11:05She says the crew reported having engine problems just before crashing.
11:18When we heard that the crew had reported engine problems, it made us think as investigators whether it was one
11:24engine or two engines.
11:26And that would be a big difference.
11:29With one engine, they would still be able to make the airfield.
11:43If the engines were operating before the crash, investigators expect to find burnt debris inside the engine.
11:51There's no evidence of burning or charring.
11:55I don't think we had combustion on this engine.
11:58Ditto with engine two.
12:02So both engines flamed out before the crash.
12:06With a dual engine failure, that's not common.
12:10So we would think immediately about something with the fuel, either the loss of fuel or maybe even contamination within
12:17the fuel.
12:19Was the fuel on board flight 185 contaminated?
12:24Fuel contamination is a danger to flight safety because it can affect both engines at the same time.
12:31Do we have the results of that fuel testing?
12:33Yeah, right here.
12:38Fuel checks out.
12:40Well, maybe they ran out of fuel?
12:43Well, it's possible.
12:46In 1978, pilots of United Airlines Flight 173 ran out of fuel while troubleshooting a landing gear issue.
12:56The DC-8 crashed into a neighborhood in Portland, Oregon.
13:0410 of the 189 people on board were killed.
13:10To explore the possibility of whether the airplane ran out of fuel, we wanted to look initially at the fuel
13:16quantity indicators in the flight deck.
13:18Investigators recover flight 185's instrument panel.
13:22They focus on the left and right fuel tank indicators.
13:26Zero and 5,600 pounds.
13:33That's odd.
13:35The expectation would be that both would be approximately the same value.
13:40That one was at zero wasn't surprising, I suppose.
13:44But the other one being so much different was certainly something that I had not seen before.
13:49Okay, so they didn't exactly run out of fuel, but why are the tanks so uneven?
13:55Maybe some kind of problem in the fuel system, stop fuel from flowing to the engines.
14:00See what you can salvage in terms of fuel pumps and piping from the wreckage?
14:03We'll have a look.
14:08While looking at all the different elements of the fuel system,
14:11the hope was that you would be able to document something going wrong,
14:15either loss of fuel or fuel starvation.
14:19Investigators slowly piece together elements of the plane's fuel system.
14:23So these are the cross-feed pipe and valves?
14:27Check it out.
14:32The cross-feed valves allow the pilot to provide both engines with fuel from only one tank
14:39when there's a fuel imbalance.
14:45Both valves are open.
14:47That means they were cross-feeding fuel before the crash.
14:50When we found that the cross-feed valves were open, that was a huge discovery.
14:55We wondered if that may have some sort of connection between the left tank having no fuel
15:01and the right tank having excessive fuel.
15:05But why would the crew be cross-feeding fuel so close to landing?
15:09Did they make a mistake?
15:11Only one person knows.
15:14Let's see if the captain can talk to us yet.
15:18The good thing in this accident was that the captain did survive.
15:21He was able to talk with us in the hospital because he only had minor injuries.
15:27How are you feeling?
15:29Okay, thanks.
15:35Can you tell me what you remember of the flight?
15:39Every detail counts.
15:44What is wrong with this plane?
15:45It is really funny.
15:48I remember...
15:50Visual approach, 36 right.
15:52Keep the speed up.
15:53185.
15:54I remember talking on the radio.
15:56Time is land, 85.
15:58Clear for visual approach.
16:00Keep your speed up.
16:01I saw the approach lights.
16:03Then we weren't getting power.
16:11Then the next thing I remember is the impact.
16:13Keep it steady.
16:14Keep it steady.
16:15Throw it, throw it, throw it.
16:17Throw it, throw it.
16:17Throw it, throw it.
16:22Then...
16:25I was standing outside.
16:33One more thing.
16:35We found the cross-feed valves open.
16:40Do you remember cross-feeding fuel during the flight?
16:45I'm sorry.
16:46I don't.
16:51He did not remember much of the flight because when you have a tragic event happen, the memories are not
16:58there.
17:03Investigators searched the wreckage for clues that could explain why the two cross-feed valves were open.
17:15The weight and balance form reflects where the cargo pallets are located, whether 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 or tail-heavy or right where it should be in the
17:28middle.
17:30That's strange.
17:32It looks like the captain was revising his calculations, possibly during the flight.
17:37Well, this is a stranger.
17:39Here's a second one.
17:42This one has no corrections, and the captain signed it.
17:47Finding two weight and balance sheets for the same flight with different data on it at the accident site raised
17:53lots of questions for us.
17:55What was the captain doing during the flight?
17:58So it looks like the captain was revising his numbers on this first form, almost using it like a working
18:03copy.
18:04And this was his hard copy to hand in.
18:07Did the captain's weight and balance calculations play a role in the crash?
18:13Well, the center of gravity limits were within the envelope.
18:17All right, so a mistake in his weight and balance calculations didn't bring down the plane.
18:21Well, whatever his process, he was supposed to hand this in before departure.
18:27Check with the airline.
18:28See if the captain handed in his numbers before takeoff.
18:34Taking off without having computed the weight and balance limits is against procedures.
18:40It cuts the safety margin.
18:43You're sure?
18:44Okay, thanks.
18:46The airline just confirmed the plane departed without the captain leaving a weight and balance form behind in Memphis.
18:52So, why did our captain depart before completing his paperwork?
19:06Did you get coffee?
19:08Fine, thanks.
19:10Investigators re-interview Captain Bruno Picelli to find out why he didn't follow proper procedure before Flight 185's departure.
19:18So, I found some weight and balance forms in the wreckage.
19:23Why didn't you complete them before taking off?
19:28What can I say?
19:30I ran out of time.
19:34Normally, I fill out the form using their handheld computer.
19:37It had been acting up.
19:39Now, it was just dead.
19:42I'm not used to filling out that form manually.
19:45Frankly, I'd never been trained to.
19:49So, I thought I'd finish it en route.
19:54Captain Picelli explains how he determined that Flight 185 was safe to take off.
20:00I did my own assessment.
20:04I checked that the plane's maximum weight was acceptable.
20:08I saw that the position of the cargo pallets were evenly balanced.
20:14I also looked at the nose landing gear strut.
20:18And the plane sat properly on it.
20:23If the nose wheel strut was compressed, that would be nose heavy.
20:26And if it were extended, it would be tail heavy.
20:28But it was in a normal position.
20:30So, on that basis, he decided that the airplane was actually within its weight and balance limits.
20:36From your corrections, it looks like your numbers weren't adding up.
20:43That's true.
20:44Yeah, at first, they didn't.
20:47So, I had to keep working on them.
20:51Yeah, it took me a while to get them right.
20:59How long did it take?
21:00I don't know.
21:02Did it interfere with your workflow?
21:05It was stressful.
21:06I mean, I was buried in paperwork.
21:09Right.
21:13So, even though the weight and balance was not an issue with the operation of the engines,
21:18it did raise questions with regard to the crew activity.
21:23Hey, any news?
21:25With no explanation for the cause of Flight 185's engine failure,
21:30the investigation finally gets a break.
21:32Great.
21:33Send it to us right away.
21:36The lab just finished transcribing the CVR.
21:39We've got good data, but we don't have impact.
21:44The recording stops just before the crash.
21:47Well, if the recording stopped, that means the plane must have lost power.
21:50Looks like it.
22:01Having the CVR stop about two minutes prior to impact
22:05is another indication that we lost both engines
22:08because we likely had a rollback of both engines
22:12and, therefore, a change in electrical configuration.
22:15When you're ready.
22:18Investigators listened to the cockpit voice recording, or CVR,
22:22to determine why the engines flamed out,
22:24even though the plane still had plenty of fuel.
22:27How's the paperwork?
22:30Almost done.
22:36Okay.
22:40You know what?
22:43I'm just going to balance out the fuel here.
22:53The captain wanted to balance his fuel tanks,
22:56but he didn't remember that at his interview.
22:59That must be when he opened the cross-feed valves at...
23:0212.17 a.m.
23:06The question is...
23:09did he forget to close them?
23:11Let's find out.
23:16Okay, 10 degrees left to Cincinnati, when able.
23:20185, thank you.
23:22I already had it.
23:24Right on the money.
23:25The team pays close attention to any mention of the cross-feed valves being closed.
23:31The captain doesn't indicate that he's stopping the cross-feed or even mention it.
23:36It made me wonder if they had forgotten that the cross-feeding operation was going on.
23:43Then, just minutes before the flight's scheduled arrival...
23:47AC pump is on, green light.
23:50Boost pump's on.
23:53Man, I'm telling you...
23:54What is wrong with this plane?
23:56It is really funny.
24:09Yeah.
24:10Can you feel it?
24:11Feels like it's swinging back and forth.
24:18Yeah.
24:19We've got an imbalance on this darn cross-feed I left open.
24:24The captain finally realizes he forgot to stop cross-feeding fuel from the left tank.
24:30Is that what it is?
24:33Yeah.
24:35Oh, damn.
24:37I see.
24:42The cross-feed's been going on for almost half an hour.
24:46Looks like he never shut the cross-feed valves.
24:48He forgot to close it.
24:50That explains why the plane was so hard to handle.
24:57With the cross-feed valves open for 29 minutes, only the left fuel tank fed both engines.
25:04As the tank emptied, it created an imbalance, which made it difficult to control the aircraft.
25:10That also explains why the left tank was empty.
25:14Yeah, but if there was still 5,600 pounds of fuel in the right tank, why didn't that fuel feed
25:19the engines?
25:25Do you have the list?
25:27Thanks.
25:31All right, let's figure this out.
25:34Did the pilots of Air Tahoma Flight 185 follow the correct procedure for balancing their fuel?
25:42The question that I raise for me in the investigation is, if there's ample fuel in the right tank, why
25:48did both engines fail?
25:50All right.
25:52The cross-feed fuel from the left tank to both engines, first the crew has to open the cross-feed
25:56valves here and here.
25:59Investigators consult the wreckage inventory.
26:02And we know from the wreckage, the crew did the first step correctly.
26:05The valves are open.
26:08Second, they're supposed to close the right fuel pump here.
26:12Got it.
26:13It was turned off at the time of the crash.
26:16Step three, they were supposed to close the right fuel tank shutoff valve here.
26:24Looks like the right one was left open.
26:26They didn't shut the valve.
26:28So they did the procedure incorrectly.
26:32So the question we had was, by leaving the right fuel tank valve open, did that somehow lead to the
26:38engine failure?
26:39I know they made a mistake, but I'm still confused.
26:41First, if they didn't close the valve, why wasn't fuel flowing from the right tank all the way to both
26:48engines?
26:50And why would the engines flame out?
26:55There's only one way to find out.
27:01As the investigation progressed, we decided to run a test to determine what occurred during the accident flight.
27:11Investigators build a replica of Flight 185's fuel system to better understand how both engines could have failed.
27:19Let's simulate what the captain did.
27:22Step one, open the cross-feed valves.
27:30Cross-feed valves open.
27:32All right, step two, turn off the right fuel pump.
27:36Right fuel pump off.
27:39Step three, he didn't close the right fuel tank shutoff valve.
27:44So we've got this in the open position.
27:49Let's see what happens.
27:58Okay.
28:00Looks like the left fuel pump is sending fuel from the left tank to both engines.
28:05So that part's working out just fine.
28:11Yeah, but fuel from the left fuel tank is also flowing to the right tank.
28:19Okay.
28:22With the right shutoff valve open, the left pump supplied fuel not only to both engines,
28:29but also to the right fuel tank.
28:37Look how quickly the left tank emptied.
28:41This was new to me.
28:42I had never seen a case where fuel was transferred to the point of the one tank being emptied.
28:50So the left tank ran dry, and with that pump still running, that means that air was likely being pumped
28:58through the whole system.
29:03The right fuel tank was always the right fuel tank.
29:05So the right fuel tank was running.
29:11So the right fuel tank was pushed through the right fuel tank.
29:17So the right fuel tank was actually flowing.
29:29then caused the interruption of the ignition of the fuel, and that will cause the engines
29:35to roll back and to stop.
29:38So if the captain had just followed procedure and shut off that valve?
29:43If he had, there would have been enough fuel in the left tank to power both engines to
29:47the airport.
29:50I'm just going to balance out the fuel here.
29:54The captain's failure to close the right fuel tank shutoff valve sealed their fate.
30:01So why didn't you follow procedure?
30:09As the investigation progressed and new information came to light, it was helpful to go back to
30:15the captain to discuss his recall of what happened.
30:19In your airline's handbook, they instruct pilots to shut the right tank valve during
30:25the cross-feed procedure.
30:27You didn't shut the valve.
30:30I don't remember doing a cross-feed on the day.
30:36But typically, when I do the procedure, I leave the tank valve open.
30:44Really?
30:47This was a surprise, because that is totally contrary to the flight operating manual.
30:53I heard if you shut that valve, it might fail.
30:56Then you have no access to your fuel.
30:59So you've heard the valve is faulty?
31:01I sure have.
31:03And my old employer allowed me to do it this way.
31:10Previous employers had told him that it was the captain's discretion whether he closes the
31:15shutoff valve or not.
31:17And we confirmed that that was their position.
31:22Was there a history of fuel tank shutoff valves failing?
31:27I've gone through the FAA Service Difficulty Reports database, and I found nothing.
31:32I can't find anything either.
31:35I don't think that valve has ever failed.
31:41There was no evidence of the valve getting stuck.
31:45This was a fiction that had somehow spread among the pilot community that simply did not have
31:52an accurate basis.
31:54This is the part I don't get.
31:56So what were they doing for 29 minutes?
32:0229 minutes is a long time to miss that there's a cross-feed problem, especially when the first
32:10officer reports that there are handling difficulties as well.
32:14And so it was very important to look into what might have caused this.
32:18Keep it steady.
32:25All right.
32:27Captain started the cross-feed at 12.17 a.m.
32:30He didn't notice a mistake until 29 minutes later.
32:34What happened in between?
32:37Investigators returned to Flight 185-CVR
32:40to determine why the pilots didn't notice that there was a growing fuel imbalance.
32:47Looks like the captain finished his paperwork at 12.26 a.m.
32:51But he kept talking about it.
32:56All this time I couldn't figure out why on the landing I was out,
32:59and I was okay on the takeoff.
33:02And it was my chicken scratch.
33:04Ah.
33:04And momentum is 1.667.
33:07But I thought, by the tick and scratch, I put 1.067.
33:12Couldn't work it out.
33:13Ah.
33:14It was my own doing.
33:15Ah, damn.
33:18I had it all along.
33:20We were okay all along.
33:23Is that right?
33:24Yeah.
33:25Oh, man.
33:28Okay, first he's distracted by his paperwork,
33:30and then he keeps talking about it.
33:33Yeah.
33:33The captain's focus is on his paperwork for a while.
33:37Instead of monitoring the flight.
33:39What about after that?
33:40Any mention of the fuel gauges?
33:48What about the first officer?
33:50How come he didn't pick up on this?
33:5320 minutes after the crossfeed was open,
33:55the first officer knew something was wrong.
33:58Yoke feels funny.
34:00Say again?
34:02Feels like I need a lot of force.
34:06It's pushing to the right for some reason.
34:08I don't know why.
34:10I'm trying to...
34:12I'm not sure what's going on.
34:17All right, the first officer reports a problem
34:19with the flight controls.
34:21But he doesn't check his fuel gauges for an imbalance.
34:23Why?
34:25Well, according to his work record,
34:27he was still pretty new at flying the plane.
34:30Plus, he'd only been with the airline three months.
34:35To his credit,
34:37he was assertive that he was having difficulty
34:40in the handling characteristics.
34:42So he was completely appropriate in asking for help.
34:45And unfortunately, the captain did not respond
34:47as a pilot in command would be expected.
34:51Feels like I need a lot of force.
34:54Total 185, fly heading 090, maintain 4,000.
34:59090, 4,000, 185.
35:05090, 4,000.
35:10How many times did he alert the captain to the problem?
35:14He repeated his concerns at least...
35:18seven times.
35:21Finally, the captain replied.
35:25We'll do a full control check on the ground then.
35:35He missed the cues from his co-pilot.
35:39How long has he been a captain?
35:40Here's the thing.
35:43He's been in a cockpit for over 20 years,
35:45but only 100 hours or so as a captain.
35:50As captain, we would expect him to
35:52actually help the first officer
35:55troubleshoot why the aircraft was flying
35:59in a non-normal state.
36:01Still,
36:03wouldn't they have caught this mistake
36:05during the in-range checklist?
36:07That's a good point.
36:10The purpose of the in-range checklist
36:12is to prepare the airplane for landing,
36:15and that includes a review of the cockpit instruments,
36:18including the fuel gauges.
36:21So did they perform the in-range checklist?
36:25Yep.
36:25They started the checklist at 12.45 a.m.
36:28I'll give you the in-range.
36:31AC pump is on.
36:33Green light.
36:34Fuel panel.
36:36Boost pump's on.
36:38Man, I'm telling you.
36:40What is wrong with this plane?
36:42It is really funny.
36:49It is really funny.
36:51Yeah.
36:53We have an imbalance
36:54on this darn cross-feet I left open.
36:59Is that what it is?
37:02Yeah.
37:05Oh, damn.
37:06I see.
37:07Yeah.
37:08We're going to flame out if we don't...
37:11Aren't we?
37:12What?
37:19Ten seconds later,
37:20the engines flamed out.
37:22Wow.
37:24The plane had become one gigantic glider
37:27about to hit the ground.
37:30They were too late to save it.
37:33They found out about the cross-feet issue
37:36at the same time they lost their engines.
37:43Did they start the checklist too late?
37:47They were at about 3,000 feet when they started.
37:57According to the airline's operating manual,
37:59they should have started the checklist at 12,000 feet.
38:06They should have started at least 10 minutes earlier.
38:09If they had, they would have caught their mistake with enough time to save the plane.
38:16If you're not monitoring the fuel gauges,
38:19when you run the in-range checklist,
38:20that'll remind you,
38:21but they waited until it was so late,
38:24they didn't have time to prevent the engines from flaming out.
38:31But it still bugs me.
38:33Even with all the distractions and the inexperience,
38:37all professional pilots are trained to scan their instruments.
38:52Could the pilots actually see the fuel gauges
38:56from the seating positions that they were at?
39:03All right.
39:05So both our seats are fully forward.
39:08Investigators now visit a Convair 580 cockpit
39:11to determine if its layout somehow prevented the pilots
39:15from monitoring their fuel gauges.
39:18So both fuel gauges are visible.
39:22But is that the case for every seat position?
39:25Let's make an adjustment.
39:38Wow.
39:39In this angle, the fuel gauges are much harder to see.
39:47The throttle control console is in the way.
39:52Jesus.
39:55It depended on what position the seat was in.
39:58When the seat was aft,
39:59it was more difficult to see the fuel gauges.
40:02So the degree to which the fuel gauges are obscure changes
40:05depending on the seat position.
40:09It's hard to say if it played a role.
40:13Unfortunately, because of the destruction of the aircraft,
40:16the wreckage did not allow us to determine whether the captain's seat was forward or aft.
40:24What in the world is going on with this plane?
40:26I mean, suckers acting so funny.
40:30In this case, there was a concern about the fuel gauges and their location
40:35and whether they could be seen by the pilots.
40:41Yes, he would have to rise up just a little bit and look over at the thrust levers to be
40:45able to see the gauges.
40:46But it's your job to know what those instruments are saying at all times.
40:52I've been told some pilots put this sign up during a cross-feed as a reminder.
41:01Investigators have pieced together what led to the crash of Flight 185.
41:12You know what?
41:13I'm just going to balance out the fuel here.
41:16When the captain decides to even out the fuel in the tanks,
41:20he skips a key step in the procedure and leaves the right fuel tank shut-off valve open.
41:26If the captain had shut the right fuel tank valve,
41:29there may have been enough 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 valves.
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 something like doing paperwork that's overdue.
41:52Yoke feels funny.
41:53As fuel drained out of the left fuel tank...
41:57Say 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.
42:06I don't know why.
42:11When you have a flight control problem, that'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 checklist later than required.
42:35Yeah.
42:36We've got an imbalance on that darn cross-feed I left open.
42:42When the captain finally realized there was a fuel problem, it was too late.
42:56Fuel is life in an airplane.
42:59You have no more fuel.
43:00There's only one way you're going to go, and it's down.
43:03Hold up.
43:05Keep it steady.
43:06Up.
43:07Hold up.
43:14I think the lesson to be learned is that, regardless of the airplane that you're flying
43:20and the conditions, that you should adhere to the procedures as they're provided to you.
43:36In its report on Flight 185, the NTSB makes a recommendation to all Convair 580 operators.
43:45One of the main recommendations was to inform pilots that they should shut off the fuel shutoff valves if they
43:52are cross-feeding.
43:54Ultimately, if flight crews follow the procedures that they are given, they will get on the ground safely.
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