- hace 20 horas
El 6 de septiembre de 1985, el vuelo 105 de Midwest Express sufrió un fallo incontrolado del motor y se estrelló en un campo abierto en Oak Creek, Wisconsin, 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 flying, and the next thing you know, the airplane's lost.
00:11Midwest Express Flight 105 crashes seconds after taking off from Milwaukee, Wisconsin.
00:18All 31 people on board are killed.
00:21And 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.
00:30It'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 flight
01:26from 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.
02:00Mid-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.
02:15Mid-X 105, clear to Atlanta.
02:17Climb and maintain 5,000.
02:20Climb and maintain 5,000.
02:22Mid-X 105.
02:24For this leg of the flight, Danny Martin will be the acting captain and Bill Weiss, the first officer.
02:30You had two captains, and they literally could switch seats because of that.
02:36And 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.
03:00Set stab trim, 2.2.
03:06Just past three in the afternoon, the pilots start the engines.
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.
03:43Oh, can I put that up here for you?
03:47Thank you.
03:49The plane is loaded and ready to depart on schedule.
03:57Airspeed bug, 1.33 set, and 1.9 on the EPR.
04:02Okay.
04:11Ladies and gentlemen, we are number one for departure, so we should be airborne within one minute.
04:16Flight attendants, please be seated.
04:23Mid-X, 1.05, clear for takeoff.
04:27Mid-X, 1.05.
04:32Here we go.
04:35It'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.
05:00The pilots need to reach a speed of 127 knots for takeoff.
05:05V-1.
05:08V-1.
05:08Rotate.
05:13At 3.21 in the afternoon, flight 105 begins its journey.
05:21The flight plan calls for the plane to climb to an altitude of 33,000 feet for the two-hour
05:27trip to Atlanta.
05:35You're up.
05:37Just 450 feet above the ground.
05:45What the hell was that?
05:47The pilots lose power in one of the engines.
05:52It's a critical situation because if you don't do something about it immediately, you won't have time to do anything
05:58about it.
06:00Altitude is your friend.
06:06Mid-X, 1.05.
06:08Turn left heading 1.75.
06:13What do we got here, Bill?
06:16Here.
06:18Mid-X, 1.05, Roger.
06:20Uh, we got an emergency here.
06:24Mid-X, 1.05, Roger.
06:28The plane begins rolling to the right and dropping.
06:35Oh, crap.
06:38The DC-9 is stalling.
06:42Get your heads down.
06:51Heads down!
06:52Heads down!
06:56Less than a minute after take-off, flight 105 is diving towards the ground at more than 170 miles an
07:03hour.
07:15The plane hits the ground, less than 1,700 feet from the runway.
07:22A DC-9 has crashed southwest of runway 19R.
07:35All 31 people on board have been killed.
07:39All 31 people on board have been killed.
07:56This is becoming one of the deadliest years in the history of civil aviation.
08:01Passengers are unnerved.
08:04Everyone says, my God, another one.
08:06What do you say to the public about the crashes that we've been having?
08:09Well, insofar as the National Transportation Safety Board is concerned, we are sparing no effort to determine the cause of
08:14each one of them.
08:15And we will make the necessary recommendations to keep any repeat of any one of them from happening.
08:19And what do you tell them about...
08:23Can you show me where it started to bank?
08:27Investigators from the NTSB begin by interviewing witnesses of Midwest Express Flight 105's fatal dive.
08:35They either came forward or we tracked them down.
08:38We ended up making out a questionnaire with 40 or 50 questions on it to kind of cover all the
08:43bases.
08:46Okay, got it.
08:51While the witness accounts differ in detail, they all describe more or less the same thing.
08:58I saw a couple puffs of black smoke come out and I just figured that they had gunned the engines
09:04a little bit.
09:05Instant later, the left wing rose up and it tipped over and went nose first into the trees here.
09:14Most of the witnesses agree that take-off appeared normal until the airplane was about 300 feet off the ground.
09:22Almost all report smoke and fire coming from the right engine.
09:27Several remember hearing loud bangs.
09:29Most said that the plane then rolled abruptly into a steep right bank, went into a nose-low spin and
09:36crashed.
09:40The value of having so many witness statements to look at, they gave us a picture of what happened right
09:46at the end.
09:47A loss of control, fire, and of course the impact itself.
09:54Investigators must now determine what could have caused such a catastrophic loss of control so soon after take-off.
10:15After securing the crash site of Midwest Express Flight 105, investigators begin mapping the wreckage field.
10:24I think the whole length of the impact site was about 295 feet, not much more than two times the
10:31length of the airplane.
10:32So the airplane hit pretty steeply and didn't go very far.
10:38Right wing tip here and the horizontal stabilizer here.
10:45This is how the plane hit the ground.
10:48A 90 degree right roll and a right yaw.
10:56Can you grab a picture?
10:58Got it.
10:59The wreckage path confirms eyewitness reports.
11:03Right.
11:04It very definitely indicates right up front that you've got a lost control.
11:09It doesn't suggest why you had the lost control.
11:11It kind of opens the door to a lot of different investigative avenues.
11:18Yeah, it's fire damage for sure, but it looks like all the pieces are here.
11:24Investigators study the plane's control surfaces, starting with the ailerons.
11:30The ailerons on each wing direct the plane's roll.
11:34If an aileron malfunctions and gets stuck in one position, it could cause a devastating lack of control.
11:44Control tabs are in place.
11:46They seem to be intact.
11:49We didn't find a problem with other components that are part of that system.
11:55With the ailerons ruled out, investigators turn their attention to the rudder system.
12:03Dampers are still working.
12:05Hinges are intact.
12:08The crashes look like overload, not stress.
12:13I don't think the rudder is our culprit.
12:17We didn't find anything wrong with any of the control systems based on that preliminary look-see.
12:25Could the engines provide insight into the crash of Midwest Express Flight 105?
12:32If the engines were, well, obviously banged up, they were fire damaged, and they were along the wreckage path, which
12:38is always good,
12:40that means they didn't fall off somewhere earlier.
12:46There's a spacer missing here.
12:53Most of the blades from this stage are gone.
12:57The team finds damage inside the right engine that could not have been caused on impact.
13:04The missing engine pieces include a spacer and the compressor blades from the 9th and 10th compressor stages.
13:14They're found more than half a mile from the main wreckage site.
13:18Finding any part of the airplane short of where the airplane crashed was a suggestion of a malfunction or failure
13:26that had occurred in flight and required further investigation.
13:31The engine and the pieces are moved to a nearby warehouse where they can be more closely examined.
13:38In the end, we ended up finding about 90% by weight of the spacer, so that was a big
13:44boon to the investigation.
13:47Investigators study the recovered spacer to determine why it failed on Midwest Express Flight 105.
13:55All on the pedestal here, it's definitely not overstress.
14:03They discover a telltale crack on the spacer that appears to have spread over time, what's called progressive cracking.
14:12There may be stress marks, there may be cracks, there may be things that suggest a direction of failure and
14:19a time frame where the fracture would have occurred.
14:23It doesn't occur all at one time.
14:25Can we determine how long that crack has been spreading for?
14:29I'll see what I can do.
14:32We became interested not just in detailing that, but trying to find whether this was a fracture that could have
14:39been detected previously.
14:41A closer look at the crack on the steel spacer reveals it's filled with nickel.
14:47A lightweight nickel coating is applied to certain vital engine pieces, like the compressor spacers and blades, to prevent corrosion.
14:58The compressor was brought in to be refurbished in 1981.
15:03Coating stripped, spacer examined, and oh, here we go.
15:08Re-plated.
15:10That was four years ago.
15:13The maintenance records tell investigators that work had been done on the spacer that failed on Midwest Express Flight 105.
15:21Nickel-cadmium plating is the last step of the refurbishment process that would have been done by the maintenance facility
15:31that was involved with, essentially, the overhaul of that part.
15:34Four years before the accident, the spacer was removed from the engine, stripped of its coating, and examined for cracks.
15:43The inspector reported no cracks and sent the part to be re-plated with nickel.
15:49Since nickel was found inside the crack, it must have been present when the nickel was applied.
15:58The DC-9 flew about 2,500 flights over the next four years with the damaged spacer until it finally
16:06ruptured on Flight 105.
16:12It should have been caught during an overhaul, but it wasn't.
16:15And so the crack kept growing and growing until it finally hit its failure point.
16:22Investigators wonder what caused the crack to form on the spacer in the first place.
16:27These spacers have been used inside the JT-8D for more than 20 years.
16:32This can't be the first one to break.
16:37There are identical spacers in more than 14,000 JT-8D engines used on airplanes around the world.
16:45Is there any history of similar failures?
16:48And it turns out that Pratt and Quibi were well aware of spacer failures that occurred before.
16:54So we started to wonder, what have they done about it?
17:02Seems to happen a lot.
17:05While researching spacer issues in other aircraft, investigators uncover 45 similar failures prior to Midwest Express Flight 105's accident.
17:16Well, when we heard that this part had failed 45 times before, we kind of looked askance a bit at
17:23the manufacturer.
17:24And that's a big deal.
17:26But of all the failures uncovered by the NTSB...
17:31Not a single loss of aircraft or even a single injury.
17:35Well, that says something.
17:37In every previous incident, the plane landed safely.
17:42So why did the rupture of a spacer on Flight 105 cause the plane to become uncontrollable and crash?
17:51Well, we knew that none of the previous failures had led to an accident.
17:54So one of the questions was, what made this one different?
17:58Let's see what got hit.
18:02Investigators consider the possibility that pieces of the ruptured spacer on Flight 105 punctured the plane's fuselage and damaged vital
18:11control systems, such as cables or hydraulic lines.
18:16When a part like a spacer or a fan disc breaks under a lot of stress, it's almost like a
18:26small explosion going off.
18:28You have fragments of metal flying at very, very high speeds.
18:34Okay, let's see eight, nine, four.
18:38They study the location and pattern of all the puncture marks found on the skin of the plane to see
18:44if any were near vital control links.
18:47No control cables, no hydraulics.
18:5310, 12.
18:59No control cables, no hydraulics.
19:04What about the pieces of the plane that we haven't been able to find?
19:09There are many critical pieces of the plane that have not been recovered or are too badly damaged to study.
19:16Is it possible to figure out if they could have been hit by the engine pieces?
19:22We have what we need to run a trajectory analysis.
19:27All right.
19:28We were looking at could these parts that have left the engine strike a control surface or the hydraulic system
19:37or anything else where they could have done secondary damage that would have compounded the situation the pilots were facing.
19:45Knowing the plane's velocity, angle of ascent and the wind speed at the time the engine failed, the team calculates
19:53the path of debris ejected from the engine.
19:58The smallest piece we found was about half an ounce.
20:01The largest piece was just over a pound.
20:04So everything moves away from the plane, nothing hits it.
20:07The trajectory analysis tells investigators that none of the ejected engine pieces would have struck the airplane with enough force
20:16to cause substantial damage to the control systems.
20:19The analysis indicated that it was so unlikely that we considered it an impossibility that those parts leaving the engine
20:30in the direction they went and the size that they had could have caused secondary damage that would cause lost
20:36control.
20:38If spacer fragments didn't hit vital components and cause the loss of control, perhaps the initial explosive force opened the
20:47cowling or engine cover, affecting the plane's aerodynamics.
20:52If the cowling had been blown open, it would cause a lot of drag, it might cause the airplane to
20:59roll, it might cause the airplane to become uncontrollable.
21:04There's a hole in the cowling, looks to be about two square inches.
21:09The team finds evidence that the cowling was pierced by fragments ejected from the engine.
21:16But all four latches, one, two, three, four, they're all latched.
21:22Can't have opened in flight.
21:25They found them all either latched or fully intact with no damage at all.
21:30So that scenario kind of went out the window.
21:35So the ruptured red engine didn't bring down this plane?
21:38It did not.
21:43Well, reasonably early in the investigation, the team figured out that a spacer had failed and the engine had failed.
21:50And now we had the rest of the accident to figure out.
21:53Why would that cause a crash?
21:59Investigators examined Midwest Express Flight 105's flight data recorder in hopes of understanding how the loss of the right engine
22:07caused the death of 31 people.
22:11Doesn't give us much, but it's all we've got to work with.
22:14It was only recording four flight parameters.
22:17It had airspeed, altitude, heading, and vertical acceleration.
22:23Right here. A sudden deceleration at 450 feet. This must be where the right engine failed.
22:29Well, that's consistent with what the witnesses told us.
22:34The engine failure we know occurred above the airport, so the airplane had only been airborne for a few seconds.
22:44But the heading doesn't change when the engine fails.
22:47They must be applying left rudder to compensate.
22:51Oh, dead right engine, left rudder. That's the right move.
22:56When the right engine fails, the remaining engine should force the plane to the right.
23:03To counteract that, a pilot would apply left rudder to keep the plane flying straight.
23:14What was that?
23:15The data shows that's precisely what Captain Martin did in response to Flight 105's engine failure.
23:24After a few seconds, they start this yaw to the right.
23:27So, right rudder?
23:31Four seconds after the failure of the right engine,
23:34the FDR data indicates that the pilot moved the rudder from left to right.
23:40That forced the plane into a sudden yaw to the right.
23:46He's in a side slip.
23:48He's deviating further and further to the right.
23:53Then he starts to lose altitude.
23:57Huh, 148 knots.
24:00He's in a high speed stall.
24:03How'd they let that happen?
24:07You went into a right skid and then followed by an abrupt right turn and dive.
24:13That would be consistent with a stall.
24:16But the air speeds indicated were high enough that you wouldn't normally have a stall at those speeds.
24:24Clearly lost control of the plane.
24:26Five seconds later, they hit the ground.
24:30The flight data tells investigators that it took only 10 seconds for the pilots to lose control of the plane
24:37after the failure of the right engine.
24:42I have never seen an accident sequence that brief, um, before or since.
24:52So, he responds correctly at first with left rudder and nose down pitch.
24:58Then he inexplicably switches to right rudder?
25:01And that's what leads to the yaw, the right roll, and the eventual stall.
25:05Right rudder, it makes no sense.
25:08It was clear from all the data that the pilot didn't understand what happened.
25:13He responded inappropriately, and within seconds the airplane was lost and everybody on board was killed in the accident.
25:21Was there something about the DC-9's handling characteristics that led the pilot to input the right rudder?
25:29So, it was relatively easy to control then?
25:34Just with the control wheel?
25:38Investigators interview DC-9 pilots to determine how the plane handles with only one engine.
25:45The DC-9 pilots that we talked to, it was overwhelmingly described as a very easy, docile aircraft to handle
25:51in those situations.
25:52Oh, this has been extremely helpful. Thanks. Okay. Bye.
25:58They all say the same thing. It's no big deal with one engine.
26:05Because the DC-9's engines are mounted on the fuselage instead of the wings, when one engine fails, it does
26:12not force the plane into a severe turn.
26:15DC-9 is almost a centerline thrust aircraft, so if you lose one engine on either side, there's not that
26:24much excess yawing or controllability problems at all.
26:30How easy is it to handle a DC-9 in the situation the pilots of flight 105 found themselves in?
26:38It was valuable to do a simulation or test flight to get a better idea of exactly how the airplane
26:46performed under the circumstances of the accident, but at a higher altitude.
26:55Okay. When we get to 10,000 feet, I'm going to cut power to the right, leaving the left a
26:59takeoff power. Keep the flaps at 20. Target speed is 170 knots.
27:05They tried to match the parameters of the airplane in terms of the flaps, gear, and airspeed, and then proceeded
27:15to cut the engine power.
27:17Okay. Cutting power.
27:29Okay. Thank you. Let's go around for another.
27:34Flight demonstrations showed that the pilot didn't have to input rotor at all. If he had only used the ailerons,
27:41he could have safely fallen out of it.
27:44Okay. This time, no reaction. Let's see what the plane does.
27:49With no input from the pilot after the loss of the right engine, the plane rolls right and the nose
27:57drops.
28:01Okay. You can recover.
28:05Even with no immediate action, the pilot is easily able to recover the plane.
28:13Okay. I think we have what we need.
28:16That may have actually been the best thing to do, was to do nothing, watch the airplane's response, understand the
28:24airplane's response,
28:25and respond appropriately to the nature of the emergency.
28:31How was that?
28:33If the DC-9 is so easy to control, why were two experienced pilots unable to recover from the loss
28:41of their right engine?
28:47Okay. We know they were both captains with the airline, but how much experience did they actually have?
28:53Investigators look into the backgrounds of the pilots of Midwest Express Flight 105 to understand why they didn't recover from
29:01a single engine failure.
29:03Neither had a lot of turbojet experience.
29:05One was upgraded to captain with 600 hours on the DC-9, the other with only 500.
29:12Doesn't seem like a whole lot.
29:15Advancement to captain happened within a year for both of these pilots at Midwest Express Airlines at that time.
29:23And the reason why was it was a small airline, it was growing quickly, they were adding airplanes.
29:31They consult large US airlines to determine their qualifications for an upgrade.
29:38Okay, thanks.
29:42That's the same for both airlines.
29:44Ten years seniority and 7500 hours as DC-9 first officer to be considered for an upgrade.
29:51Yeah, these guys weren't anywhere near that.
29:54While the pilots may have been experienced, neither had spent much time piloting the DC-9 before they were promoted
30:01to captain.
30:02The more experience someone has exercising command, the more likely they are to exercise that command in situations that call
30:10for calm thinking, for rational response and so on.
30:15So how much training did these guys get on engine failures?
30:20To understand why the pilots of Flight 105 were not able to control their plane following an engine failure, investigators
30:28look at their training records.
30:30What was their experience?
30:32What kind of pilots were they?
30:34How did they respond to unusual events?
30:37Did they seem self-confident?
30:38How well did they work together?
30:41Okay, so the captains practiced 12 engine failures on takeoff in the simulator.
30:51First officer, 15 sessions.
30:55They discover that both pilots had been extensively trained to cope with engine failure on takeoff.
31:03Precisely the type of emergency they faced on Flight 105.
31:07But what exactly were they taught?
31:11We looked very closely at the training these pilots received and interviewed the flight instructor who oversaw their training in
31:19the DC-9 from Inter-West Express.
31:22Tell me what you can remember about Captains Martin and Weiss.
31:29They were both excellent pilots.
31:32Trained to proficiency.
31:34Lots of simulator training on engine failure.
31:38You bet.
31:39We ran them through all sorts of scenarios.
31:44Let's focus on takeoff with simulated engine failure.
31:48What were they taught?
31:55Pay attention to your yachts. Your best cube.
32:00Yawing right.
32:02Wined left rudder.
32:04Patrol wheel as needed.
32:06Keep the plane level.
32:08Nice and easy.
32:10That's a good job.
32:11Got it.
32:13Captain Martin was trained to pay close attention to the plane's yawing motion
32:18cuando identificando y correcto un error de engine.
32:21Parece que tuvieron excelente entrenamiento.
32:24Gracias por el insight.
32:28Se encontró el instructor a ser muy capaces y muy dedicado,
32:34y se encontró el simulador a ser ok por ese tiempo.
32:40Si Martín estaba extensivamente trained
32:43para lidar con el error de la enfermedad en el takeoff,
32:46¿por qué no lo hizo lo que estaba tratando?
32:52Mostra de su entrenamiento era para un error de la enfermedad en el takeoff.
32:56Es fácil identificar cuál es el camino.
33:00Investigadores consideran el timing de la enfermedad en el error.
33:03Si estás cerca del sur el sur,
33:05hay más más visual cues disponible de la enfermedad
33:08para ver lo que el aeropuente está encontrando.
33:11No tan fácil cuando ya estás en un descanso.
33:17As flight 105 was climbing,
33:20only blue sky would have been visible to the pilots,
33:23making it more difficult to identify the direction of the yaw.
33:30What the hell was that?
33:33With no outside visual cues,
33:36investigators believe Captain Martín's initial response
33:39was a spontaneous reaction to the plane's changing motion
33:42and not the result of an analysis of the situation.
33:45But what triggered the incorrect rudder application a few seconds later
33:50that resulted in a total loss of control.
33:55All right, let's see what these guys were doing.
34:13Investigators pinned their hopes on the CVR to explain Captain Martín's actions.
34:18Spooling out.
34:22Power normal.
34:25100.
34:30V1.
34:32Rotate.
34:36Gear up.
34:43Stacey.
34:44Mid-X 105.
34:45Turn left heading 175.
34:48What do we got here, Bill?
34:50Here.
34:51Mid-X 105, roger.
34:54We got an emergency here.
34:58Mid-X 105, roger.
35:11I've never heard an accident unfold so quickly.
35:15Holy smokes.
35:17And I remember just being amazed
35:20how quickly the accident took place.
35:22It was like they were flying.
35:25You hear the engine fail.
35:26Uh, and the next thing you know, the airplane's lost.
35:32Okay.
35:33So what did we hear?
35:35Sure happened fast.
35:37Yep.
35:3815 seconds from the sound of the engine exploding
35:40to the end of the recording.
35:43Astonishing.
35:48What else?
35:50What was that?
35:52What have we got?
35:53The captain seemed uncertain.
35:57Agreed.
36:02What have we got here, Bill?
36:05Well, it was clear
36:05from the cockpit force recorder
36:08that the pilot didn't recognize
36:10what had happened.
36:11He articulates that.
36:13What was that?
36:14What do we got here, Bill?
36:18What the hell was that?
36:20The sound of the engine,
36:22the sensation of the right yaw,
36:24and the instruments
36:25should have told Captain Martin
36:27that he was dealing with a failure
36:28of his right engine.
36:32Anything else on that tape?
36:35Not a lot of troubleshooting
36:37or communication between them, really.
36:42Actually, none.
36:49What have we got here, Bill?
36:52Here.
36:54Mid-X 105, Roger.
36:57We got an emergency here.
37:00Investigators hear Captain Martin
37:02asking his first officer for assistance
37:04in assessing the situation,
37:06but First Officer Weiss never replies.
37:09That was troubling to me
37:12because I would have expected
37:14that in an emergency situation,
37:16and especially when asked for help,
37:20that the other crew member
37:22would have helped if he could.
37:25So it prompted some further investigation.
37:30Okay, let's start with that.
37:32Why was the captain confused
37:34about what had happened?
37:34It should have been obvious.
37:404,600 flight hours,
37:42but he's never experienced
37:43an actual engine failure.
37:45NTSB investigators
37:46looking into the crash
37:47of Midwest Express Flight 105
37:49have learned that Captain Martin's
37:51only experience with a single engine failure
37:54was in a simulator.
37:56Yaw and deceleration don't feel the same,
37:59plus all the sounds are different.
38:01It's not the same as the real thing.
38:03It was a catastrophic engine failure
38:04where they had thrust
38:05and then they didn't.
38:06It was immediate.
38:08I don't think they were trained
38:10in that kind of scenario.
38:13What do we got here, Bill?
38:15The limitations of the simulator
38:17may explain Captain Martin's
38:19initial confusion,
38:20but it does not explain
38:22the First Officer's unusual silence.
38:26Let's have another listen.
38:29They return to the cockpit voice recording
38:32to better understand
38:33how First Officer Weiss
38:35reacted to the emergency.
38:40How was that?
38:42That's one.
38:436-105.
38:44Turn left heading 175.
38:46What do we got here, Bill?
38:48That's two.
38:49Here.
38:50That's three.
38:54He asked for help three times,
38:56but the FO says absolutely nothing
38:58to him the entire time.
38:59Not even, I'm not sure,
39:01or I don't know.
39:02Oh, my word.
39:04In this situation,
39:06seconds were critical.
39:08Had he said right away,
39:09I don't know,
39:11then the Captain would immediately
39:13have tried to rely on
39:14his own understanding
39:15of the situation
39:15rather than expect
39:17the First Officer
39:18to come up with
39:18an explanation of what he had.
39:22What could have caused
39:24the First Officer's silence?
39:28Hang on.
39:30What altitude were they at
39:32when the engine failed?
39:34Hmm.
39:35450 feet.
39:37This could be it, then.
39:39Pilots say they were taught
39:41not to make call-outs
39:42or even verbalize
39:43the nature of an emergency
39:44after 100 knots
39:46before reaching 800 feet.
39:50Let me see.
39:58Not even to identify
39:59a failed engine.
40:00No communication at all
40:02until 800 feet.
40:04Yeah.
40:05I couldn't imagine
40:06a management team
40:07at Midwest Express
40:09thinking this silent
40:11cockpit business
40:12made any sense.
40:14It just flies in the face
40:16of communication,
40:18which is kind of
40:19the fabric that holds
40:21a safe flight together.
40:22So it just
40:23blew my mind, frankly.
40:31What the hell was that?
40:33Investigators think
40:34First Officer Weiss
40:35may have been following
40:36a Midwest Express
40:37unwritten rule
40:38of not discussing emergencies
40:40until the plane
40:41reaches 800 feet.
40:43It's important
40:44during an emergency
40:45for people to talk
40:47to each other
40:47because they both
40:49may not be looking
40:50at the same instrument.
40:52They both may not
40:52be looking at
40:53the same thing outside.
40:54You have to talk.
40:55You have to talk.
40:57One last thing
40:58troubles investigators.
41:00In spite of his
41:01First Officer's silence,
41:03Captain Martin
41:03could have easily
41:04identified which engine
41:06had failed
41:06simply by looking
41:08at his instruments.
41:09Both pilots
41:10had visual information
41:11from the engine
41:12flight instruments,
41:13the back turn indicator
41:14and so on
41:15that would have
41:16told them
41:18what was going on
41:19in terms of
41:20the loss of thrust.
41:22I don't think
41:23either of them
41:23were scanning
41:24the instruments.
41:25Agreed.
41:26They never saw
41:27which engine
41:27had failed,
41:28the direction of the
41:29or the severity
41:30of the roll.
41:32The NTSB concludes
41:33that the pilots'
41:35failure to monitor
41:36their instruments
41:36contributed to
41:38Captain Martin's
41:39incorrect rudder
41:40application.
41:41With the lack
41:41to visual cues
41:42the only sure
41:43way they would
41:44have had
41:44to recognize
41:45which engine
41:46failed
41:47would be
41:47to look
41:48at the instruments.
41:50The pilots'
41:51lack of awareness
41:52ultimately led
41:53to the stall
41:54that brought
41:54down Flight 105.
42:02Up until here
42:03he should be fine
42:04but then there's
42:06no communication
42:06and no instrument
42:08scanning.
42:09and this
42:10this is what
42:11dooms them.
42:12He puts in
42:13a right rudder
42:13which sends them
42:14into a side slip
42:15an extreme right
42:17roll
42:17and a stall.
42:20If they had
42:21talked to each other
42:22scanned their instruments
42:24you don't get
42:25this accident.
42:27The reality
42:28of the situation
42:29is the mismanagement
42:31inside the cockpit
42:32caused the accident
42:34not the engine failure.
42:36The NTSB's final report
42:39makes several
42:40key recommendations
42:41to prevent this
42:42type of accident
42:43from happening again.
42:44They recommend
42:45a directive
42:46requiring airlines
42:47to replace
42:48the existing spacers
42:49with a new
42:50type of spacer
42:51which is less
42:51likely to fail.
42:53They also recommend
42:55that airlines
42:55are advised
42:56to teach their pilots
42:57to communicate
42:58during onboard emergencies.
43:00It should never
43:02be overstated
43:03the importance
43:04of crew coordination.
43:05Every crew member
43:06has something
43:07valuable to add.
43:08Anything that
43:09is an abnormality
43:10needs to be discussed
43:14at the proper time.
43:16They also suggest
43:18that airlines
43:18review their
43:19simulator training
43:20to ensure
43:21pilots are taught
43:22to use their
43:23instruments
43:23to assess
43:24the nature
43:25of engine failures.
43:26I think
43:27this accident
43:29still has
43:29an impact
43:30today
43:30because
43:33it's such
43:34a clear
43:35illustration
43:36of what happens
43:37when you
43:38don't do
43:39what you
43:41should do
43:41in an emergency.
43:42Anytime
43:43there's an emergency
43:44you should have
43:45the exact
43:46same procedures
43:47and you should
43:48run right
43:49to them.
43:51Midwest Express Airlines
43:53continued to operate
43:54until 2009
43:56it merged
43:57with Frontier Airlines
43:58in 2010.