Cracks In The System | Ocean Crashes | FULL EPISODE | Mayday: Air Disaster

the port of miami december the 19th 2005. giant freighters and ocean-going cruise ships are a common sight but there's another much smaller craft that's often seen in this port chalk's ocean airways flies seaplanes in and out of this busy waterway today flight 101 from fort lauderdale is making a brief stop over here on its way to the bahamas feather propellers check shut down engine number one shutting down engine number one chalks flies to two regular destinations both in the bahamas bimini where flight 101 is scheduled to land this afternoon and paradise island ladies and gentlemen this is your captain speaking we're just making a short stop over here in miami to pick up a couple passengers we apologize for the delay we'll be on our way again soon how many are we picking up just two but they're vips for a small community like bimini chalk seaplanes are a lifeline it's just so much easier in the seaplane to get to the north island where most the population is then going to the airport down there so that was the main thing was a convenience factor welcome aboard i see your boarding pass certainly sergio dangila court is a bacardi rum executive he's the great great grandson of the company's founder the family is well known in the local cuban community for their anti-castro politics he and his wife are flying to the bahamas to buy a yacht passengers settled in we're all set good afternoon folks we'd like to welcome you aboard chalk's ocean airways flight 101 to bimini our travel time will be 25 minutes hope you enjoy the flight let's have the startup checklist please roger michelle marks is in command of today's flight she was promoted to captain earlier this year first officer paul desanctis joined the airline eight months ago this is his first flight with captain marxie the grumman mallard is a twin turboprop design it has a v-shaped hull and underwing pontoons it's designed to carry up to 17 passengers the plane has retractable landing gear so it can operate on either land or sea you're coming up take off in the mallard depending on the days it could be a lot of fun or it could be a real challenge weight and balance check we're good the miami seaplane base has no control tower the crew has to keep a lookout for boat traffic as they taxi through one of the busiest ports in the world taking off in out of miami in the shipping channel it's kind of like trying to take off during rush hour traffic you've got boat traffic wave traffic the wind the airplane to deal with and everybody's going different speeds and you're trying to get up and go and navigate around everybody so it was always a handful flight 101 will take off from x-44 a seaplane base near a channel known as government cut prepare for takeoff roger ready both pilots have their hand on the throttles it's to prevent the captain from inadvertently pulling back if the plane hits a wave 45 knots 50 knots this is the moment most passengers are paying for the takeoff [Music] half speedboat half plane it's a unique thrill [Music] 75 knots 80 knots for the pilots accelerating through the waves is often the most difficult part of the flight the airplane itself was really hard to fly as far as on the water getting onto the step which is what we call getting on a plane and in rough sea conditions and in rough wave conditions it could be a real challenge [Music] but this take-off goes smoothly flight 101 is no longer a boat it's now a plane on route to bimini it's 2 38 in the afternoon the plane's flight path takes it past south beach where sunbathers and surfers are out in force [Music] just less than a minute into the flight the grumman mallard is climbing through 500 feet well below the clouds then the plane rolls violently and dives [Music] the pilots barely have time to register what's happening their struggles are in vain by chance a tourist from new york catches flight 101's final moments on his camera 60 seconds after takeoff the plane slams into the ocean [Music] lucas boccanegra is a lifeguard stationed on south beach near the chalk's ocean airways sea lane as soon as i saw this i i realized i'm like oh no this is the truck's airplane crashing we have a code 4 repeat code 4 a plane down in the water this is lucas we're launching the jet ski the two lifeguards are the first rescuers to go looking for the plane we drove as fast as we could to the scene of the accident there was a lot of things coming through my head i was nervous scared i was uh kind of full of adrenaline want to go in and try to rescue as many people as we could but at the same time we've never trained for a situation like this soon as we turned government cut those jetty rocks we noticed that it was very calm very quiet it wasn't like the oceanside where it was uh very rough there was no waves it was very uh kind of very eerie at first lucas boccenegra finds no sign of flight 101 or any of the passengers little by little we started seeing debris float up onto the surface of the water [Music] and we saw some chairs some luggage here and there and suddenly we noticed it was a body in the water as soon as we we put the body on our jet ski we realized that from his injuries that there was nothing we could do from there was just try to recover as many bodies you know bring them back for their families news crews swarmed the beach chox flight 101 plummeted into the channel and full view of tourists lining miami beach even a fraction of a second the whole plane was engulfed in flames black smoke and then an explosion pure fire in the sky it was so surreal we couldn't believe that we actually witnessed that chopper 4 over the wreckage as miami beach coast guard look for any survivors but the effort is futile we retrieved some of the bodies but we were unable to find anyone that had survived all 20 people on board are dead including pilots paul de sanctis and michelle marks the residents of bimini are devastated by the horrific news it was very sad for the crew and the friends that i had lost on the airplane you never expect an accident to actually happen and to see that on television like i did it was very very sad in washington senior ntsb investigator bill english is put on the case i was just in my office doing some routine paperwork for something else and the director stuck his head around the corner and said oh there's been an accident and i said well what is it and he mentioned a crumb and mallard so i immediately knew it it had to be chalks [Music] within hours investigators are at the crash site where 19 bodies have been recovered one is still missing i was very familiar with choc's airways i'm a seaplane rated pilot myself and and there is the reputation the legend of chox airways the oldest continuously operating airline chalks has a long and rich history the airline was founded in 1917. during the prohibition era passenger lists included notorious rum runners and later hollywood movie stars chalk's planes even patrolled for german u-boats during world war ii the novelty of flying at talks was just all that history all the people that have gone and it was really a great place to work for that the grumman mallard flying boat that crashed was built in 1947 chalk's ocean airways is the only airline that uses mallards to transport passengers they're not really a mainstream type of airplane and so there's always that nostalgia about them salvage crews find the plane's black box investigators send it to the ntsb in washington the box promises to reveal critical information about what the pilots were doing in the seconds leading up to the tragic mid-air disaster in any investigation the the flight data recorder and the cockpit voice recorder are a great desire more data the better we can always learn something but bill english knows he isn't going to get all the data he wants okay thanks the only recorder on board the mallard was a cockpit voice recorder or cvr most airline aircraft have two flight recorders the flight data recorder depending on the aircraft will record all sorts of parameters of the flight altitude air speed control positions and so on the chox airplane was not equipped with a flight data recorder it did have a cockpit voice recorder though the lack of flight data is a big disappointment media coverage of the crash gives investigators a very rare piece of revealed that the evidence seconds of flight 101 were captured on amateur video the dramatic footage was shot by a tourist on south beach let's get a copy of that video okay let's see it the video only captured the final seconds of the plane crash but it confirms eyewitness reports that a wing ripped off in midair can you enhance that for me the video showed the wing just after separation from the aircraft the main part of the aircraft fuselage rolling off in the other direction and the fire and smoke starting from that it was quite startling that the wing would fall off in this plane it was a beautiful day the water wasn't rough on the take off and all of a sudden this wing just just dropped off it must have been absolutely devastating however the video can't reveal why the wing came off answers to that question may lie at the crash site where salvage crews are finishing their recovery of the wreckage of flight 101 the right wing is found separate from the plane but largely intact wings falling off aircraft uh modern-day situations is a very rare extreme event and there's only been a few cases of them in the past 20 or 30 years in washington another type of examination is already underway at the ntsb lab technicians are busy analyzing the mallard's cockpit voice recorder tape [Music] the cockpit voice recorder cvr which does what it sounds like records the pilot's voices talking to each other or on the microphones [Music] but the tape is a jumble of voices and sounds technicians can't retrieve any useful information [Music] it turned out that the erase head function it's just like a tape recorder that most people are familiar with it didn't erase the old stuff so every subsequent flight kept getting recorded over and over and over again and just became a muddled sound and it wasn't uh wasn't audible to us or useful it's another setback okay let's revisit this again because we're running out of options here investigators have fewer and fewer tools to work with bill english considers the possibility that flight 101 hit turbulence so violent that it tore the plane apart but the weather on the day of the crash doesn't support that theory there were no storms that could have caused such severe turbulence clearly something else had torn this plane apart there's a possibility the mallard collided with something in the water before takeoff seaplanes don't take off of a conventional runway they're in water where there can be things like logs or other debris which could potentially cause structural issues with an aircraft but before they can reach a conclusion on that theory investigators consider some other intriguing evidence it's an urgent advisory issued by the federal aviation administration or faa it warns that due to a faulty part the propellers on the mallard could come off during flight you're kidding me something such as a blade separation losing part of the propeller could cause a great structural load on the aircraft english now has a solid lead but his team is still missing the evidence they need to prove their case [Music] the entire island is devastated by the loss of life as investigators searching for answers wait for more wreckage to be pulled from the sea in the aftermath of the crash chalk's ocean airways grounds its remaining fleet of four grumman mallards at the ntsb's miami command post they're working to identify various plane fragments and other debris from the crash we started out with the the wing itself that separated the spar which is the main part of the structure of the wing and in any of the other fracture surfaces looking for obvious initiation factors they carefully examine the propellers looking for evidence that might confirm suspicions raised by the faa advisory but it's another dead end we're able to determine all the blades were attached and the bending that we saw was the expected pattern from proper operation when those uh blades hit the water once again they're back to square one this is what i want you to look at investigators focus their attention on the fractured wing they've noticed sooting on parts of it it's evidence of a very rapid fire we want to find anything that could be the initiating factor for the wing separation could it have been a collision with an object could it have been a fire could it have actually been a criminal act the burn marks raise a sinister possibility an explosion a bomb this now falls outside the ntsb's area of expertise and authority let's notify the fbi the fbi uh helps us in many of our investigations and we'll utilize some of their experts to rule out terrorism or a criminal act if it was a bomb that brought down flight 101 a likely target would have been one of the 18 passengers thanks for coming in i'm going to need your help on this one name stands out on the passenger manifest sergio dangila court welcome aboard unless you're boarding passes certainly there are rumors on the internet that the crash was an assassination plot and angular court was the target his family made a fortune in pre-castro cuba they were so opposed to fidel castro's regime that they had allegedly supported clandestine attempts to overthrow his communist government this is your copy all right now there's something i want to show you we can't tell if it's just sod or it's explosive residue a bomb will lead chemical traces and distinctive patterns in the torn metal fbi technicians are specially trained to detect them [Music] the samples from the wreckage will be tested at fbi labs in quantico virginia four days after the accident salvage crews are still bringing in wing fragments found at the crash site so we need everything that looks like it come from the right wing can we get some light over here over stress most of the damage they see is from over stress fractures areas where the metal was literally ripped apart when the wing tore off quick that's the sink when metal is suddenly stressed to the point of breaking the fracture leaves a very distinctive rough edge it's easy to distinguish it from fractures that have developed slowly over time cut this from here to here and get it to clinton washington as we started to examine the right wing spar and other components on scene at the coast guard station or the seaplane base this was a visual examination there we didn't have the sophisticated lab tools that we have at headquarters they identify parts to be shipped to the lab in washington where they hope closer inspection will reveal exactly what went wrong with the wing hey clint clint we're sending you as much of the wing as we have your way yeah okay yeah no i'm still waiting for that report the results from the fbi explosives test come in a mid-air bombing assassination could explain everything but there is no explosive residue on the wreckage okay so that rules that out structural failure is now the chief suspect in the downing of chalks flight 101. well that's all that's left that's tomorrow it was obvious the airplane had a catastrophic structural failure so we needed to find out the cause the initiating factor that structural failure he needs to know more about the long history of this particular grumman mallard it's very typical in any accident investigation we want to look at the maintenance history of an aircraft for an aircraft that's 60 years old that's even more so important it takes days to comb through the 28 boxes of old records we want to make sure that we can develop an entire history of this aircraft what sort of chronic problems may have shown up in the maintenance of the aircraft and what types of work had been done on any any of the factors that looked so likely to be involved clint crookshanks is a structures investigator for the ntsb [Music] when we go into an investigation we try to go in with a very open mind and look at the wreckage and let it tell the story for what happened we wanted to look at every piece that broke on the right wing to determine if this was a age-related failure if it was something that was caused by a structural overload as with most aircraft the mallard's wings are built from aluminium alloy the spars run the length of each wing in between the spars are stringers that give added support together these parts make up the wing box which also doubles as a fuel tank and then the skin is over top of all of that structure to kind of give a smooth aerodynamic uh look to the wing all of these together work to carry the flight loads that the wing is designed to carry once you compromise one piece of that structure the ability to carry the normal flight loads has been compromised [Music] over the years the wing box had been repaired many times chalk's mechanics had patched up areas damaged by corrosion which is not unusual for an aging aircraft especially a seaplane the fact that they land on water means that their takeoff and landing loads are different than you would have on a land-based airplane also they're always in water and the corrosive effects of water are going to happen more readily on those airplanes but when investigators examine the rest of the chalk's fleet they find that the mallards are in far worse shape than they imagined corrosion repairs corrosion corrosion corrosion corrosion corrosion repairs lots of them the accident airplane and the other airplanes in choc's fleet were rife with maintenance issues corrosion was rampant on all the airplanes there was evidence of shoddy maintenance practices on all of their other airplanes many many of the repairs exhibited extremely poor workmanship in quality double triple drilling of holes excessive grinding of corrosion scars on the material and this involved the structural repairs that were made to the aircraft over the past few years crook shanks attention is drawn to a section of the lower right wing there is a metal patch called a doubler on the surface of the wing's skin a doubler is simply a sheet of metal that goes over top of the skin and it it acts as a load transfer it acts as a second piece of skin to patch the crack it's kind of like the patch on a pair of jeans this is a big repair job you sure we don't have anything on this it's an intriguing discovery the patch is located exactly where the wing broke off from the rest of the plane when he takes a closer look at this section of the wing crook shanks notices the edges are smooth and shiny totally unlike the rough edges he's been seeing on other debris we gotta see what's under this this crack is not from over stress instead crookshank suspects it developed over many years as the result of metal fatigue metal fatigue is a process by which um any piece of metal wing spa or anything is repetitively loaded and unloaded you can think of it as bending a paper clip back and forth and everyone's done this and after a while it eventually breaks metal fatigue in the wings is caused by the stress of flight over the lifetime of the aircraft in the case of this aircraft every time it took off the wing is loaded that's that's lift that gets the airplane up into the air every time it lands the wing is now unloaded and there's no more stress on the wing structure anymore that's just like bending that paper clip back and forth crookshanks is eager to find out what's underneath the metal patch [Music] okay let's see what this doubler's hiding they find even more metal fatigue deep cracks cut across the wing the extent of the damage is staggering a crack 40 centimeters long [Music] investigating further crookshanks makes another disturbing fine three machined holes in the skinned forward of the leading edge all three appear to be stopped drill holes the holes indicate that chalk's mechanics have been trying to stop the crack from spreading further years earlier a mechanic had spotted the crack on the lower surface of the wing he repaired it by drilling a hole in the path of the crack it's called a stop drill hole the end of a crack you could you can see even with the naked eye is sharp it comes to a point that tends to want to develop a crack more by drilling a hole at the end of the crack that would spread out the stress and the idea is to stop the growth of the crack there but the stop drill holes didn't work an attempt was made to repair that skin on three different occasions by stop drilling even as mechanics put in more holes the crack kept growing after the third stop drill an attempt was made to further repair the wing by attaching doublers on the interior and exterior surface of the skin but the doublers didn't work either the crack on the plane's skin continued to grow [Music] investigators now know the right wing was damaged long before the day of the accident what they don't understand is why the crack could not be stopped but a glimmer of an answer comes when they learned the plane was sending out warning signs of a deeper more serious problem the chox airplane involved in the accident were showing evidence of chronic fuel leaks for a long period of time for many years according to the log fuel leaks from the right wing were repaired again and again but they kept happening the crews started to notice repeated fuel leaks during standard operations and we try to bring it up to attention to management just for our concerns just two days before the crash it happened again while doing routine maintenance on the mallard a mechanic came across fuel dripping from the right wing they always addressed the problem with trying to reseal the fuel tanks or trying to fix whatever problem they thought they had it always seemed to be a reoccurring issue the procedure for plugging a leak was to apply a chemical sealant to the inside of the empty fuel tank the sealant would take a day to dry then the plane could be refueled and returned to service the leaks should have been a clue that the crack in the wing skin was just the tip of the iceberg that there was a much more dangerous problem with the wing's interior structure fuel leaks in this particular aircraft are indicative of a problem with the wing structure in fact grumman put out a service bulletin back in 1963 that warned mechanics chronic fuel leaks are an indicator of a structural issue with the aircraft okay let's see what we got here crookshanks examines the pieces that make up the right fuel tank some kind of sealant he wonders why the fuel leaks persisted in spite of the constant efforts to repair them hand me that scraper please thank you beneath the layers of sealant he finds his answer bingo cracks in a critical support beam called a z-stringer it's the piece that the plane's skin was directly attached to all right will you finish cleaning this off and then get some pictures okay crookshanks finds evidence that chalk's mechanics had tried to repair the stringer it appears that they did some grinding on this z-stringer to remove of t-crack [Music] however they never went back in and re-inspected that area instead they only applied chemical sealant to the area to make it leak proof and in the process concealed the damage shocks made repeated attempts to repair the airplane by stop drilling the wing skin cracks adding doublers over top of the cracks but they never addressed the root of the problem which is the cracked c-stringer the reason they couldn't address the z-stringer as it was covered in fuel tank sealant the broken z-stringer weakened the entire wing now with every take-off and landing the plane's skin was absorbing the forces over time the skin began to crack as well the final outcome was inevitable the fatigue cracking reached critical length and the wing separated from the airplane [Music] [Applause] investigators conclude that a hidden crack in a key component of the right wing led to the devastating crash of flight 101 chalk's failure to identify such a serious problem now forces investigators to re-examine the airline's long history chalk's ocean airways had an image as one of the safest airlines in the world despite the age of their fleet the airline had an outstanding record of safety dating back almost 90 years chox's safety record was great they had never lost a passenger in all the years of operation chalk was an old established company but it seems to me that somewhere along the line the management and the quality of the work done had slipped quite a bit from in the past years what have you got on the financial state of this company investigators are beginning to suspect that the company's reputation for safety may have been undermined in recent years by money problems financial issues in an airline especially a small carrier like this can manifest themselves in many ways personnel are sometimes one of the first things to go a search of chalk's financial history uncovers some trouble in the 1980s chalks went through a string of owners before going bankrupt in 1999 the airline was revived by a miami businessman but it kept losing money just a few months before the crash the last attempt to sell the business fell through [Music] not doing so well it wasn't a secret that we were having financial difficulty the pilots had taken pay cuts and the captains had taken concessions and we downsized a lot as far as personnel it wasn't just personnel that felt the pinch it was difficult for chalks to find spare parts and to do some of their repairs chalks had a number of other unflyable aircraft that they owned that they would cannibalize for spare parts there were maybe only 50 or 55 aircraft ever built in that case the original manufacturer grummand was no longer in production of that aircraft they no longer supplied parts the airline's deteriorating health and the shortage of spare parts had a direct impact on safety there's so much regulation and there's so much just necessity to make the airplane fly it's it's hard it's hard to skimp on maintenance and not impact reliability if you don't have reliability then you're just spiraling downhill but no matter how tight the finances were as a commercial airline chalks should have been closely monitored by the federal aviation administration in fact the faa did assign an inspector to work closely with chalks the faa inspector which is called the principal maintenance inspector was responsible for the oversight of the maintenance program as carried out by chalk the inspector was aware the plane was suffering from chronic fuel leaks and yet inexplicably he gave chalks a clean bill of health just two months before the crash [Music] what is this guy doing investigators are at a loss to explain why the faa inspector didn't pick up on warning signs the chalk seaplane was giving off the fact that chalk was an all-established carrier maybe they just accepted well there's only two or three planes it's a small operation they only fly during the nice weathers and they're good old boys over there they know what they're doing in effect the faa didn't step back and take a look at that forest for the trees and find out just what's going on in the maintenance program with these choc's aircraft the faa may not have found fault with chalks but it turns out that several people very close to the airline did we did talk to this group of pilots who had left chalks prior to the accident and every single one of them did have some story about maintenance aspects on their aircraft whether it had to do with fuel leaks or other maintenance aspects they all had some level of concern about the way chalks was taking care of these very old airplanes in fact the pilots were so concerned that in the year leading up to the crash many of them met to discuss the problem of declining maintenance the captains of the company decided that it would be best for us to get together as a group discuss the issues that we had to try to get our concerns addressed one major issue that had happened we had an elevator cable that had snapped in flight and the crew luckily was able to get the airplane down using power and different settings and shifting people but most scenarios that would have been an accident in itself in aviation there's air chains that they talk about and you have to just if you keep compiling one link after another it's only a matter of time before an accident will occur and i from my my point of view i thought that if they kept going down the same road that they were going down something could happen eventually captain weber decided he'd seen enough close calls my turning point and why i decided to leave chalks was i just had seen too many things in the recent months of too many mechanical issues that were major issues in my mind and i had 300 failures myself that year and i had a wife at home that was pregnant i had lost i guess my confidence in the company's ability or the airplane and i just had had enough the ntsb's report on the crash of flight 101 harshly criticizes the faa for not detecting growing maintenance and financial problems at chalks [Music] had the maintenance program or the faa stepped back and said these aircraft need more than just a one-time fix they they need something much deeper than this the accident probably would not have happened it also uncovers a loophole in the faa's aging aircraft regulations which require extra inspections for older planes but those rules didn't apply to mallards the grumman mallard was manufactured in 1947 it only carried 17 passengers and it was not a transport category airplane therefore it was exempt from these supplemental inspections what we have here is the faa has made an aging airplane safety rule and they've exempted the oldest airplanes in the fleet the ntsb recommends that the faa expand its oversight of aging planes when we determine the probable cause of an aircraft the point is to do this so that similar accidents won't happen again in the future i think we've used this accident to point towards the industry and the faa to make sure that they take a look at the overall picture of what's going on at an air carrier [Music] flight 101 spelled the end of chalk's ocean airways a few months after the report was released the airline shut down [Music] there was a lot of history and a lot of family community involved with the passengers as well as the people in the airline so to see the whole airline and everything else kind of go down with the airplane is enough additionally emotional for everybody that ever worked there or ever loved the airplanes you

Channel: Mayday: Air Disaster

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Id: -RRlXOT3Gps

Length: 45min 42sec (2742 seconds)

Published: Fri Jul 02 2021