- hace 12 horas
El 2 de julio de 2021, el vuelo 810 de Transair se estrelló en la bahía de Māmala poco después de despegar. Sin embargo, ambos miembros de la tripulación sobrevivieron. La causa del accidente fue un error del piloto agravado por una desorientación espacial al no realizar el procedimiento de falla del motor, no reconocer cuál de los dos motores tenía la falla y un inestable aterrizaje de emergencia.
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TVTranscripción
00:00Hey Matt, we're going down. We can't keep going down.
00:03Above the Pacific Ocean, the pilots of Transair Flight 810 can't get their cargo plane to climb.
00:09Just hitting the water is going to tear the airplane apart.
00:14We're in the water! We're in the water!
00:18Remarkably, they survive the crash and are rescued by the Coast Guard.
00:23They're covered in gasoline and hydraulic fluid, so it wasn't pretty.
00:27Investigators are eager to interview the crew.
00:30Did both engines fail at the same time?
00:32Most likely. That's my conclusion.
00:36The evidence does not support the pilot's assessment.
00:40It looks fine. No internal damage.
00:44So, it was critical for us to get more information to better understand what had happened there.
01:15It's the middle of the night at Daniel K. Inui International Airport.
01:19It's the middle of the night at Daniel K. Inui International Airport.
01:19In Honolulu, Hawaii.
01:23Okay.
01:25Let's see.
01:27Crews have just finished loading cargo for Transair Flight 810.
01:32Okay, thank you.
01:32See ya.
01:34The captain of tonight's flight is Henry Okai.
01:37He has almost 16,000 flying hours.
01:40So, this captain is highly experienced in the aircraft and doing it for a while.
01:46Engine start checklist.
01:48Engine start checklist.
01:50Next, tail stand.
01:52Next, tail stand.
01:52Removed cargo.
01:54First officer, Gregory Ryan, is a lawyer who recently returned to flying part-time for Transair.
02:01It's not necessarily the best pilot career straight up, but you do get to be in Hawaii.
02:06You get to fly an airplane.
02:08Engine start checklist complete.
02:11And clear right.
02:14Clear right.
02:16Transair flights use Rhodes Express as a call sign.
02:21Tower, Rhodes Express 810.
02:24Taxi, kilo.
02:26Rhodes Express 810, Honolulu Tower.
02:29Runway 8, right.
02:30Taxi via Charlie, Romeo, Tango, Romeo, Alpha.
02:41Transair is owned and operated by Rhodes Aviation, which transports cargo between the Hawaiian islands.
02:48They had the postal contract, which was quite lucrative.
02:51Their focus was on keeping their costs down to maintain their advantage over more and well-established competitors.
03:00The plane is a Boeing 737-200, built in the 1960s and 70s for passenger travel.
03:08Today, they're workhorses for transporting cargo.
03:12Twin engines, small aircraft.
03:14It was designed for short-haul operations.
03:16It wasn't very sophisticated, no automation.
03:18I love flying that airplane.
03:20The pilots prepare for takeoff.
03:25Runway 8, right, confirmed, before takeoff checklist complete.
03:29Rhodes 810, cleared for takeoff.
03:33Runway 8, right, cleared for takeoff.
03:36Rhodes 810.
03:43Tonight's flight is a short hop to Kahalui, on the neighboring island of Maui, only a hundred miles away.
03:51Okay, you have control.
03:54Okay, I have control.
03:57At 1.33 a.m., Captain Okai hands over the plane to First Officer Ryan.
04:03Ryan.
04:08Engine stable.
04:1380 knots.
04:15Check.
04:17V1.
04:19Rotate.
04:22V2.
04:24Positive rate.
04:28Gear up.
04:30Within seconds of lifting off.
04:38Damn.
04:39Lost an engine.
04:40You got it?
04:42Yeah, I got it.
04:44The pilots have lost thrust in one of their engines, only 390 feet off the ground.
04:50Losing an engine after takeoff is one of the most critical events that can happen in a flight.
04:54You're close to the ground, you're slow.
04:56However, we also know from our training that the aircraft will fly perfectly well on one engine.
05:01The first officer levels the plane and continues to climb away from the airport.
05:07Flaps.
05:09Turn 220 heading.
05:11I'll give you the flaps.
05:13Okay.
05:16Roads, 810.
05:17We have an emergency.
05:19Stand by.
05:20We're on 220 heading.
05:22You can enter up to 2,000.
05:25The captain wants to put more distance between the plane and the ocean, so they have space to address the
05:31problem.
05:32Anytime you have an emergency situation, maintain aircraft control.
05:35You fail to do that, nothing else you do matters.
05:39Okay, Roads, 810.
05:40We've lost an engine.
05:41We're on a 220 heading, maintaining 2,000.
05:43Declaring an emergency.
05:44How do you read?
05:55The controller clears flight 810 to return to the airport.
05:59Okay, Roads, 810.
06:01We're going to run a checklist.
06:02I'll let you know when we're ready to come to the airport.
06:05Captain Okai wants to assess the situation further before returning to the airport.
06:12Flight 810 has been in the air less than three minutes, flying over the Pacific Ocean on a very dark
06:18night.
06:20Okay, I have control.
06:22Roger.
06:23Okay, let's see what's the problem.
06:26What's going on with the gauges?
06:28The pilots troubleshoot the situation.
06:32So it looks like the number one.
06:34Number one's gone?
06:35Gone, yeah.
06:36We still have the number two.
06:38So we have number two.
06:39Okay.
06:42They confirm they've lost their number one, or left, engine.
06:47They now must rely on their right engine to return to the airport.
06:51Let's do the engine failure shutdown checklist.
06:53And I have the radios now.
06:55Okay.
06:57There's a number of things this checklist is going to do for you.
06:59It's going to confirm the failed engine, and you're going to want to secure that engine.
07:05Okay.
07:06Engine failure or shutdown when one of these occurs.
07:08An engine failure, an engine flame out, another checklist directs an engine shutdown.
07:14As the pilots zero in on the problem engine, the situation intensifies.
07:20Hey, we're redline here.
07:22The right engine is now overheating, and they're losing altitude.
07:27We should pull back on the right one a little bit.
07:36The pilots now face the possibility of losing both engines.
07:41Problems on your second engine is going to significantly change your outlook, because you've got the dark water below you,
07:47and you know you're running out of options.
08:04The pilots have descended too low to see the airport.
08:08Only the lights on the shoreline are visible.
08:12Hey, man.
08:13We're going down.
08:14We can't keep going down.
08:16We're descending.
08:17The captain has no other option but to increase power to the overheating engine, risking a double-engine failure.
08:25How's the EGT?
08:28Oh, it's max.
08:29It's beyond max.
08:30The temperature of the right engine is now dangerously high, and the pilots suspect it could fail at any moment.
08:38Here we go, flops.
08:39Flops one.
08:40Fearing the worst, the first officer suggests configuring the plane for a water landing.
08:46No, no, not yet.
08:49Okay, we're very slow, though.
08:52The captain's efforts to reduce the loss in altitude aren't working.
08:57Shoot.
08:57Okay, flaps one.
09:01Just hitting the water is going to tear the airplane apart, so you want to be at the lowest possible
09:06airspeed.
09:06The flaps will facilitate that.
09:13Rose Express A-10 low altitude alert.
09:16As Transair Flight A-10 descends below 400 feet, the controller is automatically alerted to the aircraft's dangerously low altitude.
09:26Are you able to climb at all?
09:29Negative.
09:30Can you let the Coast Guard know?
09:32We will.
09:37Watchdesk, please call the Coast Guard.
09:39Flight 810-737 is probably going to be in the water.
09:43How's the EGT?
09:45If the engine temperature has improved, they might be able to climb.
09:50Hot.
09:50Way over.
09:52Moraine.
09:52Moraine.
09:53Pull.
09:53Up.
09:54The chances of reaching the airport six miles away deteriorate as the plane descends even further.
10:01The controller has an idea.
10:04Express 810, do you want Kalailoa?
10:08There's a closer airport.
10:10It might be the pilot's last hope.
10:12We want the closest runway available, please.
10:15Anything we can land on.
10:19If they can't make it to the closer airport, there might be no other option than to ditch the 737
10:25into the Pacific Ocean and hope for rescue.
10:31Too low.
10:32Gear.
10:32Okay, give me a heading.
10:34Terrain.
10:34Terrain.
10:35Pull.
10:35Up.
10:36The pilots of Transair Flight 810 have one last chance to reach land.
10:42Rhodes Express 810, the airport is about a 3-1-0 heading from you.
10:48But it's too late.
10:50Pull.
10:51Up.
10:52Pull.
10:53Up.
10:53Pull.
10:54Up.
10:55We're in the water.
10:57Up.
10:57We're in the water.
11:0012 minutes after takeoff, Transair Flight 810 hits the ocean just two miles from the Kalailoa airport.
11:14Watch desk, 810s in the water, two miles southeast of Kalailoa.
11:20Coast Guard Air Rescue is immediately dispatched.
11:25Hearing that there's a 737 that crashed, I didn't believe it.
11:28But if there is, and there's 200 people in the water, what am I going to do?
11:33They told me two souls on board.
11:35We're like, all right, two is a lot more manageable than like 200.
11:3945 minutes later, there's still no sign of the plane or the pilots.
11:45Rescuers fear the worst, until...
11:48There were a bunch of boxes now floating by us.
11:51I figured, all right, this might be the sort of a debris field.
11:54So we started our second pass, and grabbing onto the vertical fin of the tail was one of our pilots.
12:02It's Captain Okai.
12:05I was like, all right, he is still okay.
12:08Great.
12:09Still want to find the second pilot.
12:11They soon spot the first officer on a cargo pallet, bleeding from the head.
12:16And right before we started to make the moves to put me in the water to go up to him,
12:22the plane moved.
12:23The tail section the captain had been clinging to sinks beneath the waves.
12:28The captain is drowning right now.
12:34They race back and deploy the rescue swimmer.
12:39As soon as I grabbed his hand, it's like his eyes rolled back and he went limp.
12:45They're dripping wet, covered in gasoline and hydraulic fluid, so it wasn't pretty.
12:51The first officer is soon rescued by a fire department vessel as the captain is rushed to a local hospital.
12:58Both pilots survive.
13:00Good planning, good crew, good decision making.
13:04And then implementing those decisions is how we came out on top.
13:08While the pilots recover from their injuries, investigators from the National Transportation Safety Board, or NTSB, arrive on the scene.
13:19Right now we're in the fact-gathering phase.
13:21Once we finish the fact-gathering, we'll switch into the analytical side,
13:25and then that's when we'll go into determining the probable cause and contributing factors.
13:33What can you tell me about last night?
13:36It was a normal night, slow.
13:38There was another Transair flight inbound around the same time.
13:44And when did Flight 810 alert you that there was a problem?
13:49Investigators turned to the controller to determine what might have caused Transair Flight 810 to ditch into the Pacific.
13:56It was about two minutes into the flight.
13:59They reported they'd lost an engine.
14:02Okay, Rhodes 810, we've lost an engine.
14:03We're on a 220 heading, maintaining 2,000, declaring an emergency.
14:07How do you read?
14:08They wanted to work on the problem before turning back.
14:12Did they say which engine?
14:15No, but not long after they said that they might lose the other engine as well.
14:21Really?
14:22Okay, Rhodes 810, we'd like to come to the airport now.
14:26We might lose the other engine.
14:29Could Transair 810 have really lost both engines?
14:33The only information we had to go on initially was the communications between the airplane and the controller,
14:38but the airplane and its recorders were at the bottom of the ocean.
14:42Thank you.
14:46Another NTSB team is tasked with recovering the airplane and its engines lying 350 feet deep on the ocean floor.
14:55At the depth that the airplane was at, it's difficult to get divers down there.
15:00So in order to actually hook all of our equipment up to the aircraft and pull it up, we needed
15:07to use ROVs.
15:08It will take time for the investigation to secure the necessary equipment from a salvage company on the mainland.
15:19Good morning.
15:20Good morning.
15:21I'm glad to see you here.
15:23So am I.
15:24Very glad.
15:25Yeah.
15:27Investigators meet with Captain Okai to determine if Transair Flight 810 did lose both engines.
15:35The purpose of this investigation is to determine probable cause and prevent recurrence.
15:40Our role is not to assign fault.
15:43I understand.
15:45It's critical to speak to pilots as soon as we can because we want to get those fresh memories.
15:51Walk me through what happened.
15:53Everything was normal up to about 400 feet.
15:59Gear up.
16:09Damn.
16:10There was a whoosh sort of a sound, not a pow.
16:14It was a whoosh.
16:16Then it wasn't a roll.
16:18My first officer was able to counteract that.
16:22Lost an engine.
16:24You got it?
16:25Yeah, I got it.
16:29Eventually we leveled off at 2,000 feet.
16:32And I go, Greg, what do we have?
16:36So it looks like the number one.
16:38So it looks like the number one.
16:38Number one's gone?
16:39Gone, yeah.
16:40We still have the number two.
16:42So we have number two.
16:43Okay.
16:47I'm looking at number one EPR.
16:49There's no power.
16:51There's no power.
16:52I'm looking at number two and EPR.
16:55It's coming down.
16:58The captain explains he first lost power in the left engine and was losing power in the right.
17:23What could have caused both engines to fail so soon after takeoff?
17:28The purpose of this investigation?
17:31A dual engine failure seemed improbable, but both the crew seemed to agree that that is what had occurred.
17:39And we couldn't confirm or deny it unless we could actually look at the wreckage and get the recorders.
17:46But those vital clues remain out of reach, deep on the bottom of the sea.
17:54Could contaminated fuel have brought down Transair Flight 810?
18:00You're looking for an item that's common to both engines would cause them both to shut down at the same
18:05time.
18:06For that would be most likely the fuel.
18:13So one thing that we did do at the airport was take samples from the fuel truck that had been
18:19used to fuel the airplane before it departed.
18:23The U.S. Navy conducts the testing.
18:26If you have water in your fuel, that was most likely to be the cause of fuel contamination.
18:34When the fuel samples are analysed, the results are conclusive.
18:40We actually found that the fuel that was in the aircraft conformed to standards as we would expect.
18:48So according to the pilots, they lose the left engine first and then the right.
19:04All the samples from the fuel truck tested clean.
19:11What was the weather like on that night?
19:13Any volcanic activity?
19:16Hawaii is in an active volcano zone.
19:20Could volcanic ash have caused the engines to fail?
19:24Volcanic ash is very bad for jet engines.
19:27It's like throwing sand in the gears.
19:29Jet engines will shut down.
19:32In 1982, a British Airways 747 traveling from England to New Zealand flew through an ash cloud over Indonesia.
19:40All four engines failed.
19:42The plane was high enough for pilots to be able to restart the engines, find an airport and land safely.
19:52Nothing here.
19:54Clear night.
20:03So that leaves maintenance.
20:05There are no reports of volcanic ash on that night.
20:08The only information that we have to work on is what the crew is telling us, is that they had
20:11a dual engine failure.
20:13So we're going to look at the maintenance on the engines.
20:15In the meantime, recovery crews pinpoint the exact location of the plane.
20:20It has settled on the ocean floor in two large pieces.
20:25Often with water recoveries, we have an airplane that's in multiple different pieces.
20:31They're usually smaller pieces and they're less heavy.
20:33So to bring them up intact was a bigger engineering problem.
20:39It means another delay for investigators.
20:44The plane is what, like 40-something years old?
20:49The team digs into the engine history of the accident aircraft to determine why both engines might have failed.
20:5946.
21:01Flown over 69,000 cycles.
21:04The engines have been around, too.
21:07Left engine 32,000 flying hours.
21:10And the right, over 70,000.
21:14Engines that old are going to need upkeep.
21:18Jet engines are very solid machines with proper inspection and maintenance.
21:22They can fly on forever.
21:25Anything in the FAA database?
21:29Investigators look into service reports filed by Transair with the Federal Aviation Administration, or FAA,
21:36to see if the aircraft had any history of engine troubles.
21:40I've got three reports on this aircraft.
21:44The most recent was two and a half years ago, left engine failure at 2,000 feet.
21:56Did an aging aircraft put the lives of two pilots in jeopardy?
22:01The team researches the repair work that's been performed on the engines over the years.
22:08Both engines were serviced two years ago, and underwent a daily check the day before the accident flight.
22:15Did they report anything?
22:20No discrepancies.
22:28It's possible that maintenance could have missed something.
22:34Call your contacts at the FAA.
22:37Maybe they can shed some light on Transair.
22:41And I'll speak to maintenance personally.
22:44Because of the possibility that there had been a dual engine failure,
22:48we did a deep dive on the maintenance organization at the airline,
22:51trying to find potential theories for something that could have gone wrong.
22:58Bit of a mess over there at Transair Maintenance.
23:02What did you find out?
23:03Chief Maintenance Inspector quit six weeks ahead of the accident,
23:08citing chronic maintenance issues and being understaffed.
23:12Also found multiple reports from different pilots about engines overheating.
23:18Investigators uncover internal Transair reports, revealing issues with the engines.
23:24We noticed so many of these reported issues with temperature,
23:30that we were starting to think that this might really involve a maintenance issue.
23:34There was just so much smoke, we thought there had to be some fire.
23:40Anything specific to the accident aircraft?
23:43No, they involved other airplanes, not exactly a smoking gun.
23:50Anything from the FAA?
23:51Most of the current inquiries into the company are policy and procedure related.
23:57Nothing to do with engine maintenance.
24:01Investigators don't find any maintenance issues that would have brought down Flight 810.
24:09We need those engines.
24:12So even though we were discovering these issues with pilot reports and maintenance records,
24:17there wasn't anything clearly indicating a specific problem that would have led to this reported dual-engine failure.
24:24With a salvage company in place and the weather clearing,
24:28the NTSB is finally able to attempt the recovery of Flight 810 from 350 feet of water.
24:36This was one of the largest water recovery efforts we have done in a couple of decades.
24:41The wreckage is successfully raised in two large pieces.
24:44The black boxes are recovered from the rear fuselage and sent to Washington for analysis.
24:50The engines are retrieved separately and brought to a warehouse for inspection.
24:56To be able to see that wreckage come up just creates immense satisfaction because you're like,
25:01okay, now, now we can start this in earnest.
25:10Let's start with this one.
25:13Investigators begin with an examination of the right engine,
25:17the one the pilots say was overheating.
25:19It's in better shape than I expected.
25:24They were in pretty good shape.
25:26There was damage due to the water impact.
25:30Let's take a look inside.
25:32They perform a bore scope inspection of the right engine.
25:36It enables them to examine the engine interior without the need for disassembly.
25:42There.
25:44Take a look.
25:45Broken fan blades.
25:48See if there's any damage downstream.
25:57Multiple puncture marks on the turbine.
26:00With that type of damage, the engine could have easily overheated.
26:06Investigators discover two fractured turbine blades,
26:09which caused shrapnel damage inside the right engine.
26:13The pilots were correct.
26:15The right engine was giving them trouble.
26:18So from the examination on the right engine,
26:22they were able to see that there were blades that had fractured in the high-pressure turbine.
26:26But it was only those two.
26:28And they knew that it would still be able to produce power.
26:33So it wasn't like a complete failure.
26:36Looks like rust and corrosion inside of the blades caused them to rupture.
26:44The routine maintenance inspection procedures contained in the maintenance manual would not necessarily have revealed the presence of cracks or
26:53one fractured blade.
26:55So this is the engine the pilot said failed first.
27:01Investigators turn their attention to the left engine.
27:24The pilot said the left engine failed, followed by the right.
27:29But investigators can't find anything wrong with the left engine.
27:33When we found out that the left engine was undamaged prior to impact,
27:38it really changed the course of our investigation in terms of focusing more on the crew actions.
27:46We pulled a flight path from the radar data.
27:50We've got the CVR data.
27:55And here's a copy of the transcript.
28:01Investigators turn to the cockpit voice recorder, or CVR, of Flight 810
28:06to determine why the pilots thought the left engine failed, as the evidence suggests it did not.
28:12Let's hear it from takeoff.
28:1880 knots.
28:20Check.
28:22V1.
28:24Rotate.
28:25V2.
28:27Positive rate.
28:31Gear up.
29:01They discover that Flight 810 suffered engine trouble 17 seconds after takeoff.
29:08Most likely the blades breaking apart in the right engine.
29:12Keep playing.
29:14Lost an engine.
29:16You got it?
29:18Yeah, I got it.
29:20Yep, looks like you lost number...
29:22Number two.
29:23Number two.
29:24All right.
29:26Hold it right there?
29:27They both said number two.
29:29The right engine.
29:34They were correct.
29:36The pilot's original assessment matches what investigators have discovered.
29:41The initial problem was with the right engine.
29:44So, why did they think that the left engine had failed?
29:49We're able to hear the crew discuss.
29:52They had correctly identified the right engine.
29:54So at some point, you know, in their mindset, it had flipped to the wrong engine.
29:59Let's hear what happens next.
30:02Flaps?
30:04Turn 220 heading.
30:06I'll give you the flaps.
30:12Rhodes, 810.
30:14We have an emergency.
30:15Stand by.
30:16We're on 220 heading.
30:18You can inch up to 2,000.
30:23Captain calls in the emergency.
30:25Tells the first officer to climb to a safe altitude.
30:28All sounds good.
30:30And we're on 220 heading.
30:34Say again.
30:35Heading 240.
30:37240 heading.
30:39Rhodes, 810.
30:40No, Rhodes, 809.
30:43Rhodes, 809.
30:44Left, 240.
30:47Sounds like there's some overlap with another trans air flight.
30:54According to these transcripts, the captain spends the next minute and 40 seconds communicating with the controller.
31:02That's a long time in a critical moment.
31:08Investigators learn that instead of monitoring the engines.
31:12Rhodes, express, 810.
31:14You are cleared visual approach runway 4 right.
31:17The captain is distracted by a conversation with the controller.
31:22Okay, Rhodes, 810.
31:24We're going to run a checklist.
31:25I'll let you know when we're ready to come to the airport.
31:27When you have an emergency situation, it is important to aviate, navigate, and communicate.
31:33Your third priority is communicating your emergency.
31:38What happens next?
31:41Okay, I have control.
31:43Roger.
31:44Okay, let's see what's the problem.
31:47What's going on with the gauges?
31:49The captain starts flying the plane and turns his attention to the engines.
31:55So it looks like the number one.
31:57Number one's gone?
31:58Gone, yeah.
32:00We still have the number two.
32:01So we have number two.
32:03Okay.
32:05Stop.
32:06The FO changes his diagnosis.
32:10Investigators confirm that the first officer correctly assesses that the Wright engine lost power on takeoff.
32:18Yep, looks like you lost number...
32:20Number two.
32:20But less than four minutes later, he tells Captain Okai it's the left engine that's failed.
32:27So it looks like the number one.
32:29Number one's gone?
32:30Gone, yeah.
32:33Why?
32:36It wasn't clear why they had changed their minds about it.
32:42The captain then instructs the FO to do the engine shutdown checklist, but he only gets through the first step.
32:51Hey, we're redline here.
32:53We should pull back on the right one a little bit.
32:56Okay.
32:58The Wright engine overheats because of the internal damage, leading the pilots to believe they're losing both engines.
33:05Once the crew had convinced themselves that they had a dual engine failure, they were focused almost exclusively on altitude
33:13and airspeed, and eventually they ran out of options and had to ditch.
33:19It's clear that the right engine, the one with the issue, is overheating and not producing full thrust.
33:26But what led them to think the left engine wasn't working?
33:31Let's see what the flight data recorder can tell us.
33:38Okay, let's see what the engines were doing.
33:41Investigators examined the engine power data of Flight A-10 to determine what actions the pilots took that led them
33:49to believe their perfectly working engine, the left one, had failed.
33:55After the right engine failed, both engines are brought back to flight idle once they level off at 2,000
34:02feet.
34:09That's proper procedure, to get the speed down.
34:13But the first officer never told the captain he brought the engines back to idle.
34:20They discover a key step missing in the pilots' actions.
34:26It was procedure for a crew member to verbalize when they moved the engine controls.
34:31In this case, the first officer actually did not do that, and that could have affected the captain's situational awareness
34:39of where those engine throttles were.
34:42Why did the first officer fail to inform the captain of his action?
34:48Send someone to interview the first officer again about bringing the throttles back.
34:55So, it was critical for us to get more information to better understand what had happened there.
35:03Did anyone actually ever test the throttles?
35:07After they leveled off, the pilots could have increased power to the left engine to confirm which engine had failed.
35:16No, the left engine throttle stayed at idle for the rest of the flight.
35:24If you're going into the water and you have no other option left, you're going to firewall both throttles, just
35:31in case it might help.
35:34Why didn't the captain check the first officer's misdiagnosis?
35:39Let's ask him.
35:42When the first officer subsequently said it was the number one, the captain had just accepted it.
35:47He didn't effectively cross-check that erroneous assertion.
35:52So, we wanted to ask him why.
35:56Why did he accept that?
36:01Captain Okai, thanks for meeting with me again.
36:07You're muted.
36:10Investigators speak to Captain Okai one more time to find out why he thought the left engine had failed.
36:16Sorry about that. Glad I can help.
36:19When Greg told you the left engine had failed, do you recall initially thinking the right one had failed?
36:27No. The thing with Greg is I've flown with him so many times.
36:31He's never made a mistake.
36:33If Greg says the left is gone, the left engine is gone.
36:38Investigators learn the captain put his faith in his first officer's diagnosis.
36:44While trust is very important when it comes to crew resource management,
36:48you also want to verify.
36:51The captain did not verify the information that the first officer was giving him.
36:57Okay. Thank you.
36:59Sure thing.
37:01It's really critical when you do have an engine failure to look at all the available information
37:06and cross-check and agree that you have identified the correct engine.
37:12In this case, that didn't occur.
37:16What were the power readings when the engines were at idle?
37:20Even if the captain trusted the first officer,
37:24wouldn't there be other indicators showing which engine had failed?
37:31The left engine was 1.05.
37:36The right, 1.12.
37:40The team discovers the power was a little bit lower on the left engine,
37:45even though both engines were set to idle.
37:48Okay, let's see what's the problem.
37:51What's going on with the gauges?
37:53They did have slightly different power outputs,
37:57and that is something you would see with two different engines.
38:00That could have really affected the captain's decision-making.
38:06If the captain had checked the gauges,
38:09the readings would have supported his first officer's report
38:12that the left engine had failed.
38:15So it looks like the number one.
38:17Number one's gone?
38:18Gone, yeah.
38:19So we have number two.
38:21Okay.
38:24But this doesn't explain why the first officer never told the captain
38:28that he brought both throttles back in the first place.
38:37If the first officer had said, hey, I pulled the thrust back on both engines,
38:41then that might have caused the captain to engage in a different thought process
38:46about what might be going on.
38:58Why didn't the first officer of Transair Flight 810 tell the captain he brought the power levers back
39:05after the right engine failed?
39:07He has no recollection of bringing either thrust lever back to idle.
39:14We believe that the first officer forgot because he was busy.
39:20That leads to stress.
39:22Stress leads to tunneling of attention.
39:25That can lead to fixation on a small number of parameters.
39:31But even if the first officer didn't tell the captain about the thrust levers,
39:35there must have been other signs which engine failed.
39:41Check out the rudder data.
39:44Immediately after the right engine failed on takeoff,
39:485.5 degrees of left rudder is applied.
40:02After the right engine lost power on takeoff, the plane pulled to the right.
40:08When the first officer applied the left rudder, the plane straightened out.
40:13The foot that isn't pressing on the rudder pedal is the side with the bad engine,
40:18so it's usually a pretty clear indication of which engine has failed.
40:23He held that left rudder for three minutes.
40:27He had a clear indicator, but it never registered.
40:31The fact that the first officer was applying left rudder
40:35was an indication that the right engine had lost power.
40:38It's very possible that under those stressful conditions in the middle of the night over the water,
40:42you could make that mistake.
40:46They made the right assessment initially,
40:48but in the end, the stress of the situation degraded their ability to fly the plane.
40:58Investigators now know the series of events
41:01that led to the ditching of Transair Flight 810.
41:06When the right engine loses power after takeoff,
41:15both pilots make the proper assessment.
41:19Yep, looks like you lost number...
41:22Number two.
41:23Number two.
41:26But while the captain communicates with air traffic control...
41:30Okay, Rhodes, 810.
41:32We're going to run a checklist.
41:34The first officer reduces engine power.
41:38Okay, let's see what's the problem.
41:41In a moment of stress, he forgets to tell the captain.
41:45What's going on with the gauges?
41:48The slightly different readings on the gauges
41:50lead the pilots to believe the fully functioning left engine has failed.
41:55So it looks like the number one.
41:57Number one's gone?
41:58The captain relies on the first officer's assessment
42:01without doing his own analysis of the situation.
42:04Gone, yeah.
42:06We still have the number two.
42:08So we have number two.
42:09Okay.
42:11Instead of confirming which engine had actually lost power
42:14and forgetting their original assessment,
42:17the pilots end up flying on a damaged engine.
42:21How's the EGT?
42:24It's max. It's beyond max.
42:26Setting them up for an inevitable ditching.
42:30We're in the water!
42:31We're in the water!
42:48The pilots' misidentification of the damaged engine and their use of the only...
42:53Before the NTSB's final report is published,
42:56Rhodes Aviation is shut down by the Federal Aviation Administration for numerous safety and maintenance violations.
43:07While it may be disappointing that the crew never actually touched their left engine that was working properly,
43:13it is a testament to the human limitations that actually arise when you have stressful, high workload situations.
43:21And that's what we need to account for.
43:24With only 50 737-200s remaining in service,
43:28it's deemed impractical to fit them with engine sensors that would alert pilots to a failed engine.
43:35But it's now standard in most passenger airliners.
43:40Engine monitoring technology has improved considerably since this aircraft was manufactured.
43:46Newer airplanes actually give very clear indications to the pilot regarding which engine is bad
43:52and reduces the risk of the crew misidentifying it.
44:01Engine monitoring programme