Cutting Corners | Ocean Crashes | FULL EPISODE | Mayday: Air Disaster

this is a true story the reconstructions are based on original cockpit voice recordings and eyewitness accounts no family wants to lose a loved one daughter son none of us think it's going to happen to our family we read about these horrible crashes and we think thank god you know and chances are it won't happen to us the odds are in our favor [Music] you got it what are you doing in january 2000 an air alaska jet with 88 passengers and crew suffered a catastrophic failure that tore it from the sky a shocking chain of negligence and error had led to disaster when a whistleblower mechanic from the airline tried to sound the alarm about faulty maintenance procedures he was suspended from his job investigation exposes deeply worrying shortcomings in maintenance and regulation that afflict the airline industry it shows how a series of devastating errors combine to produce a tragic accident one that could happen again [Music] release it [Music] [Music] me puerto vallarta is a popular holiday resort on the mexican pacific coast one of several mexican destinations served by alaska airlines colleen wally went there to celebrate a family birthday the 34 year old was a keen traveler who spoke spanish well and have visited mexico many times [Music] colleen and the other holiday makers returning from puerto vallarta settle in for the four-hour flight to san francisco in the warm afterglow of their holidays they are looking to the future [Music] colleen and her fiance monty were planning to start a family later that year [Music] the pilots on flight 261 are very experienced both captain ted thompson and first officer bill tansky have thousands of hours flying md-80s they know the plane well the md-83 is one of a successful group of rear-engined low-wing planes originally launched in 1980 over 1100 were delivered worldwide but on the 31st of january 2000 as they prepared flight 261 thompson and tansky had no idea that deep in the plane's tail lay a critical weakness [Music] colleen warley and her fiance monty were planning their forthcoming wedding [Music] they had announced their engagement at christmas time and so it was a time for everybody to sort of congratulate them and so we decided we'd have a party for the family [Music] abby miller bush had visited mexico with her husband ryan and their friends to celebrate her new job at microsoft it's hard to describe [Music] how joyful a girl she was she was well known for that care that she had in her a trait that you can't put a value on [Music] dena and i had been there a lot together and it was the first time that he went without me dean taught me how to play he was always up he told jokes a lot people described him kind of as a puppy dog [Music] alaska airlines was a successful carrier with routes up and down the west coast of america and into mexico flight 261 left puerto vallarta as a routine flight with no hint of the danger to come [Music] the devastating failure that would bring catastrophe to flight 261 did not come out of the blue in fact it was the culmination of a chain of mistakes that began years earlier maintenance procedures at the company had come under scrutiny two years earlier when a whistleblower set off an investigation by the federal aviation administration [Music] but the day flight 261 le puerto vallarta the investigation was still underway and the whistleblower suspended from his work shortly after takeoff captain thompson and first office atansky get the first sign of trouble the horizontal stabilizer on the tail plane won't move the pilots carry out a standard checklist to try and free it stabilizer trim switch normal circuit breakers reset if tripped d90 10 d11 okay the stabilizer on the md-83 is the 40-foot wide horizontal surface at the front of the tail it's like another wing together with the elevators at the rear of the tail the stabilizer is used to adjust the angle of the plane in flight [Music] the stabilizer was jammed thompson and tansky assumed there was a fault in the electric motors that move it up and down they believed they could fix the problem they had no idea they were in great danger what they dealt with was something that that really snuck up on it it was not supposed to be a big deal if it had been they would have turned around and gone back in to the mexican airfield they came out of uh but they were led down this road of accepting this problem as a small problem so it's perfectly all right to troubleshoot him the pilots repeatedly try the two switches that operate the stabilizer the primary motor activated by the switch on the control stick known as the pickle switch and the sliding suitcase handles on the central console either system operative no both systems in operative consider stab jam do not use autopilot check the jammed stabilizer is pushing the aircraft down towards the ground at twenty eight and a half thousand feet the pilots switch off the autopilot and fly the plane manually they have to pull back hard on the control column to lift the nose of the plane up this requires considerable effort the plane climbs for the next seven minutes to its cruising altitude of thirty two thousand feet as they fly up the coast the pilots contact alaska maintenance department for assistance maintenance we need to know if any faults like this got reported recently for this aircraft were there any switches that we might not be aware of that get those motors turning again roger 261 i verify no history on your aircraft in the past 30 days yeah we didn't see anything in the log book why don't you move your seat forward i'll check this pedestal back there beyond that i don't think there's anything we haven't checked i use the example of the average layman i think can understand if you try your uh to start your car and it doesn't crank you try jiggling the key in the socket and then try it again and i think that the crew was probably understandably going through a lot of these well maybe it'll work now or let's try this let's try that the pilots want to divert to los angeles but alaska airlines dispatch coordinating the movements of the company's planes is worried this will upset the busy schedule 261 dispatch uh if you want to land at la of course for safety reasons we will do that uh i'll tell you though if we land in la uh we're looking at probably an hour an hour and a half we've got a major float program going right now well well you really put me in a spot up here i don't want to hear that the flow is the reason you're calling because i'm concerned about overflying suitable airports well we want to do uh what's safe so if that's what you feel is safe uh just wanna make sure you have all the info we might ask if they have a ground school instructor available we could discuss it with him and a simulator instructor dispatch 261 we're wondering if we can get some support at the out of the instructors up there thompson and tansky now ask for a pilot instructor who might know the solution to their unusual problem as they wait for a reply their frustration begins to show just drives me nuts you know i thought i want to go on about it but it just blows me away they think we're going to land they're going to fix it now they're worried about the flow well i'm sorry just putting pressure on you well no the pilots need to think about what will happen when they descend for landing how will the plane behave will they be able to control it but several minutes after requesting help from the ground they're getting no advice as flight 261 approached los angeles off the coast the problems on board were about to get far worse [Music] the pilots on the crippled air alaska flight 261 are flying manually at 32 000 feet in a plane that has a jam stabilizer that is forcing the plane's nose down the pilots have another go at freeing up the jam stabilizer they switch on both the electric motors that control it this will take it off holy it clicked off 261 plunges down for over a minute the crew battle for control at first they pulled back on the control columns to fight the dive but then the pilots push the aircraft's nose down into the dive to regain control it's a risky maneuver pushing the plane speed to 350 miles an hour the pilot slowly bring the plane out of its dive and back under control [Music] let's get speed brakes give me high pressure pumps okay help me back help me back okay [Music] center alaska261 we're in a dive vertical here alaska 261 say again sir yeah we're out of uh 26 000 feet we are in a vertical dive i'm not a dive yet but we have lost vertical control of our airplane just help me once we get the speed slow maybe we'll be okay maintaining level flight is difficult the jam stabilizer keeps pushing the nose of the plane down we're at 23.7 request yeah we got it under control here no we don't okay okay to contract the downward force of the stabilizer the pilots use the elevators movable panels at the back of the tail linked by cable to the control column the pilots pull with all their might the fate of the plane hangs on the strength of their arms in the cabin frightened passengers try to recover from the terrifying plunge they have no idea what might happen next holiday memories are replaced by the fear of dying dean was one of these people who would talk to whoever was around him i'm absolutely certain that he was talking to the person that was sitting next to him on the plane i'm sure that they had a connection [Music] colleen was very unique from my other kids and she loved to travel he was a beautiful girl here was a 25 year old who was like she had her own private rocket ship she was really going places in the cockpit the pilots struggled to control the plane's speed so they can land they've got a handful of airplanes they get her stabilized and they're now in in a situation where they make the decision properly to go in on an emergency landing los angeles international and they they have to be able to slow the airplane up so you've got to experiment a little bit let's take the speed brakes off no no leave them there it seems to be helping damn okay it really wants to pitch down okay don't mess with that i agree with you with the plane under temporary control the crew make the fateful decision to do more troubleshooting they need a block of clear space around the aircraft in case they lose control again they contact air traffic control alaska 261 see your conditions 24 000 feet kind of stabilized slowing down here we're and we're going to do a little trouble shooting can you give me a block altitude between 20 and 25 alaska 261 maintain block altitude flight level 200 through flight level 250. the pilots know they now have clear airspace above and below the plane they try to figure out their next move you got the airplane let me just try it okay how hard is it i don't know my adrenaline's going it was really rough back there for a while yeah it is whatever we did is no good let's not do that again yeah it went to down the full nose down it's worse than it was before yeah we're in much worse shape now the crew know this is no mere electrical problem from what they've experienced they assume the stabilizer is now jammed i think it's at the stop full stop and i'm thinking can it get any worse but i probably can but let's slow it let's get down to 200 knots and see what happens the crisis is getting worse uncertain how the plane will react if they try to slow it down the pilots must still pull on the elevators to maintain level flight captain thompson once again tries to get help from maintenance maintenance 261 are you on yeah 261 this is maintenance okay we did both the pickle switch and the suitcase handles and it went ran away it ran away full nose trimmed down oh it ran away trimmed down hulk and now we're in a damp pinch and we're holding we're worse than we were before [Music] you're getting full nose trimmed down but you don't get no nose trim up is that correct that's a firm we went to full nose down and i'm afraid to try it again to see if it would go in the other direction okay well your discretion if you want to try it that's okay with me if not that's fine [Music] as important as it is to have that ground contact with with people with maintenance manuals and experience on the ground and the ability to call up the manufacturer it's not always going to give you a magic answer the crew had already gone through every logic tree they possibly could think of maintenance clearly do not appreciate the gravity of the situation this is the last the crew will hear from them no one can help the pilots now as they struggle with the plane's faulty stabilizer ever professional however they try to put the passengers at ease folks that we have had a flight control problem up front here we're working it uh that's los angeles off to the right there and that's where we're intended to go we're pretty busy up here working this situation i don't anticipate any big problems once we get a couple of sub systems on the line but we will be going into lax and i anticipate that's parking there in about 20 to 30 minutes in fact they will never make it to los angeles a full-blown disaster is about to unfold [Music] after the terrifying 8 000 feet plans downwards alaska 261 has now leveled out la alaska 261 we're with you we're 22-5 we have a jam stabilizer and we're maintaining altitude with difficulty but uh we can maintain altitude we think and our intention is to land in los angeles the pilots request to be rooted out over the pacific ocean center at alaska 261 i i need to get down about 10 change my configurations to make sure i can control the jet and i'd like to do that over the bay here if i may if the worst happens they don't want to kill people on the ground as well as in the plane there are a lot of lives saved that people maybe don't realize by the fact that this aircrew said let's stay out over the water until we've got this thing completely under control as they maneuver over the ocean the crew again ask air traffic control for clear space around the plane alaska 261 fly a heading of two eight zero and descend and maintain one seven thousand two eight zero and one seven 17 000 alaska 261 and we're generally needing a block altitude 61 roger [Music] i need everything picked up and everybody strapped down because i'm gonna unload the aircraft and see if we can regain control that way the pilots concentrate on trying to fix the plane i'm test flying now how's it feel it's wanting to pitch over more really yep try flaps 15 11. now let's go to 11. [Music] okay get some power on i'm at 250 knots real hard well actually it's pretty stable right here see but we got to get it down to 180. the crew tried to slow the aircraft down to landing speed without losing control but every move they make could have fatal consequences [Music] okay bring the the flaps and the slats back up for me slats two yeah treading a knife edge of control the pilots are still trying to free up the stabilizer what i want to do is get the nose up and then let the nose fall through and see if we can stab it when it's unloaded the only hope for the passengers is that the pilot's skill and experience can get the plane to los angeles airport it's on the stop now it's on the stop not according to this it's not as one effort after another fails the crew wonder if the stabilizer is damaged the trim might be and then it might be if something's popped back there yeah it might be mechanical damage too i think it was controllable we ought to just try and land it think so okay let's head for l.a but just as they prepare the plane to land in los angeles something in the tail suddenly breaks did you feel that yep okay give me slacks this is a [ __ ] is it yeah the plane dives straight down from 18 000 feet to avoid collisions los angeles control has warned the pilots of nearby planes that alaska 261 is in difficulty these pilots now report back to the tower [Music] definitely out of control the pilots can barely reach the controls the plane is now upside down but they believe they might be able to roll it out of the diverse [Music] they tried to fly the airplane even upside down they never for a moment believed that they could not find a way to control this airplane [Music] plane was being knocked from side to side it turned upside down it was spinning persons were being thrown against the walls of the plane falling out of their seats a cockpit voice recorder screaming um unbelievable uh horrible last few minutes of their lives we flying we're flying we're flying tell them what we're doing [Music] and it was so violently upside down that the pilots were hanging from their shoulder straps passengers don't have shoulder straps [Music] [Music] here we go and he just hit the water oh yes sir he uh after a terrifying 60-second dive flight 261 hit the pacific ocean at over 250 miles an hour [Music] rescue helicopters were soon at the crash site but there were no survivors the plane had broken up on impact 88 passengers and crew including three young children died instantly fred miller lost his daughter abby and her husband ryan these people suffered on the way down this was not a pretty way to die one witness who i met a jogger on the beach down at port wine amy he said you look like you lost somebody and i said i did my daughter he said you know i saw the plane go down he said the plane was inverted and twisting and flipping and then he said it's fun at times almost like a top and he said to thank people somebody who has a life to live live is in there dying he said he said he says it's one of the most horrifying memories i'll ever have [Music] susan de silva lost her husband dean i know that they went through a horrible horrible experience it this was a violent and these people suffered there were no bodies that were intact or even close to intact and they were conscious for a long time before it all came apart colleen warley died along with her fiance monty as a mother keep waiting for your for your child to come home and colleen had traveled so much in her in her life that it was it was unusual not to have her just walk in the door all this time you you're thinking something caused this something made this happen and i want to find out who's responsible for this the investigation into flight 261 immediately got underway but the wreckage lay 700 feet down so national transportation board officials called on navy submersibles to retrieve the debris from the sea bed we set up the base of operations and we had a remote operating vehicle with the side scanning sonar which they used to map the debris field and get an idea of how widely spread the wreckage was at the national transportation safety board headquarters in washington the investigator's immediate concern was to find out what had brought the plane down the first clues came from the cockpit voice recordings la alaska 261 we're with you we're 22-5 we have a jam stabilizer and we're maintaining altitude with difficulty we immediately suspected some problem in the tail of the airplane which is where the controls are there something was wrong back there and that was the key piece of wreckage to look for the md-83 that crashed was a revised version of the douglas corporation's popular dc-9 over 2000 of which were delivered to airlines worldwide the engines were at the rear and the distinctive t-shaped tail was an essential element of the design in a big turbojet aircraft one of the rather brilliant elements of the design is that since you're going to be loading passengers and cargo you want to be able to have that aircraft loaded a little nose heavy or a little tail heavy well in order to do that you had actually had to have that entire stabilizer moving but the ones that are the most difficult to engineer are the t-tailed airplanes where you have the vertical stabilizer and the horizontal sitting on top and we call that stabilizer trim and that is an essential element of what makes these aircraft so usable in the md-83 a motorized jack screw in the tail moves the horizontal stabilizer up and down as the stabilizer moves up the nose of the plane moves down as the stabilizer moves down the nose moves up but what role had the two-foot jack screw played in the loss of flight 261 the investigators were anxious to inspect it as soon as it was recovered from the sea bed the jack screw wasn't mated with the nut that it screws into it was just by itself and the nut was found in another piece of structure a few feet away from where the jack screw was to have a screw separate itself from a from a nut with very thick threads surprised us secondly we noticed that there was a curled piece of brass around the jack screw and all of the threads that you can see here these ridges were gone they had been stripped out and the remnants of those were found coiled on the jack screw once the thread had been stripped off the nut the jack screw could no longer turn the pilots could not have known the real nature of the problem the crew was confronted with a situation that had never occurred before there is no failed jack screw procedure in the quick reference handbooks that they have available there is no training for it when the jack screw jammed the crew were unable to adjust the stabilizer we felt that it was due to the fact that these nut threads had worn away and it was just too hard for that jack screw under the power of the electric motor to turn that gave the flight crew an indication that there was a problem the crew knew they had a problem in the tail plane but they had no idea what two motors controlled the jack screw they tried each in turn but the pilot's attempts to free the jam stabilizer inadvertently made their situation worse we're at 23 7 request yeah we got it under control here no we don't where they went wrong was that they wanted to try both the alternate and the primary trim motors at the same time when the pilot switched both the electric motors on the jack screw moved but the threads had given way and the jack screw was now held only by a single retaining nut from here on the plane was doomed that end nut was never designed to hold the loads generated aerodynamically by the airplane let's get speed brakes give me high pressure pumps okay now we know in the glaring light of hindsight now when we turn the situation around in time and look back we can see that this air crew and no air crew should have ever been fooling with the trim and trying to run it back and forth the retaining nut grew weaker and weaker then finally through the loads beating down on that nut the nut finally failed feel that yup okay give me slacks the jack screw slid completely out of the acme nuts allowing the horizontal stabilizer to move well beyond its aerodynamic limits the stabilizer forced the plane down and now completely out of control it rolled over into its final dive okay let's keep running [Music] i can't reach it this crew was working to recover the aircraft right down to the water i mean they did not give up the whole way down through the descent [Music] here we go it was clear to the investigators that the failure of the jack screw was the only explanation for the plane's erratic flight path and final dive but why had this happened why had the jack screw failed the investigators began looking deeper and deeper into the condition of the faulty jack screw on flight 261 what had caused it to fail there was no lubrication or visible grease on the working area of the screw that was surprising and strange [Music] the discovery of no grease on the jacks crew alarmed the investigators they alerted the federal aviation administration who ordered an immediate check on all mdatas in the usa this led to a shocking discovery at alaska airlines in six of its fleet of 34 planes the jack screw assembly needed to be replaced after failing new inspections no grease is the culprit no grease or inadequate grease is the only thing that can give you that wear rate a simple lack of grease led to the failure of the jacks crew and the loss of 88 lives but why did this happen at alaska airlines the investigators attention now switched to the company's maintenance program what emerged was deeply worrying we interviewed all the mechanics who had worked on these airplanes we knew that they had been falsifying records or not doing the work they had indicated the mechanics at alaska complained that they were pressured to keep the planes in the air or that their recommendations were overruled by supervisors some allege that records were altered to show work done that was not done alaska has long been one of america's most successful airlines but in the early 1990s the economic downturn hit the company hard its response was to slash costs to revive its fortunes pilots maintenance workers management and others had to make sacrifices jobs were lost pay was cut and every hour aircraft spent on the ground was seen as waste two years of aggressive axe wielding saw costs come down by 80 million dollars profits left it was a corporate triumph in alaska's case in the early 90s this airline had to do an incredible job of reforming itself from a fairly high cost carrier to a lower cost carrier that can compete head-on with southwest airlines and with others and they did it they did it brilliantly nobody really believed that it could happen alaska airlines began flying the planes more intensively it doubled the average daily use of its fleet but keeping the planes in the air earning money put maintenance schedules under pressure john leoteam was a former lead mechanic at alaska airlines oakland maintenance facility where he worked for over eight years leoteen felt that the new pressures on maintenance put passengers lives at risk he was to pay dearly for expressing those concerns we have used an actor to portray his experiences based on his sworn evidence to the ntsb leoteen claimed that planes were pushed back into service too quickly sometimes rather than wait for a replacement part or repair supervisors pass planes fit for service free to carry passengers up into the air [Music] in october 1998 over 15 months before the crash john leoteam became so worried that he did something that would change his life forever he reported alaska airlines to the u.s department of transportation alleging violations in maintenance procedures [Music] there were very few voices at alaska who had concerns about the maintenance there should have been more and there should have been people listening john leotain is the hero in my book in december 1999 over a year before the crash the faa and department of transportation officials moved on alaska airlines the case was referred to federal prosecutors and the fbi raided alaska's maintenance facilities and seized thousands of records the raid was the opening shot in a federal grand jury investigation that would last three years no criminal charges were brought against the airline alaska officials denied that any unsafe planes were put into service or that passengers lives were ever at risk but the investigation revealed hundreds of violations of federal regulations alaska airlines was fined the faa insisted on changes to the company's maintenance and safety procedures the faa also suspended two supervisors for falsifying records [Music] like other whistleblowers john lear team would pay heavily for his efforts to save lives alaska put him on paid leave from his job losing him thousands of dollars in regular overtime earnings [Music] then in january 2000 john leotine saw his worst nightmare come true the kind of accident he had tried to prevent now took place just off the california coast [Music] after the loss of flight 261 leer team went back to his private work records incredibly he found he had a direct link to the crashed airliner two years before at the plane's last overhaul he had ordered that the jack screw on this very aircraft be replaced he then went off shift when investigators examined the record they found that leotine's recommendation had been overruled by the next shift and the plane put back into service it would be two years before the next overhaul but time ran out four months before the overhaul was due flight 261 crashed [Music] alaska airlines labelled leotin a disruptive influence he sued the company for libel alaska settled but leotine could no longer work in the industry he loved i get calls almost every week somebody's saying should i blow the whistle and i always tell them you need to know you need to be prepared to find another line of work because you will not work in the industry and you will not work in the government in most cases it's almost impossible to be a whistleblower and survive your career [Music] as the investigators continued their work into flight 261 they made another disturbing discovery about the drive to cut costs at alaska airlines to keep planes flying more intensively alaska had dramatically extended the intervals between service [Music] this was significant because when a plane is designed every part has a schedule listing when it is serviced and when it must be replaced you're supposed to go in and inspect every so many hours and that's different on parts all over the plains some things you have to look at after every flight other things have to be inspected every two or three days in 1996 alaska airlines extended the intervals between md-80 jack screw inspections by 400 before 1996 jack screws were inspected every 600 flight hours now there was over two and a half thousand hours between each service if you had 600 hours between inspection points and greasing points we have no chance of ever having a metal to metal contact situation but if you put that out to 2000 hours or 2 500 hours now what you do is eat into some of these protective stages these barriers that we have towards catastrophic failure investigations division in its final report into the crash of flight 261 the ntsb concluded that the extended service intervals for the jack screws on its md-80s was a significant contributor to the crash supervisors of the change in the engineering [Music] with carriers doing anything to save a dime maintenance safety took a back seat and then one of the shocking things about alaska is that they were allowed to increase inspection intervals it was very shocking because that is the only way we have safety the extended maintenance intervals meant that the lack of grease on the jack screw went undiscovered but now investigators also wondered if the failure of the jack screw assembly revealed a basic flaw in the plane's design they found that the md-80 broke one of the fundamental rules of aircraft design it was not fail-safe the design philosophy that has made aviation so safe is that we should never ever have a situation in which one catastrophic failure of some component of the airplane causes us to lose the airplane these backups to the backup backing up the backups is why we can get on an airplane with almost 100 assurance that we're going to get where we want to go safely there was no backup to the jack screw in its nut engineers never envisaged a situation on the md80 where the jack screw might fail with inspections every 600 flight hours and replacement every 2000 hours the designers did not add an additional redundant backup system it was elderly laughable that they said it was a redundant system there's one screw and there's one nut that's all there is it's not redundant the md-80 continues to fly worldwide despite the revelation of this dangerous design flaw the jack screw assembly has not been redesigned inspection intervals have been shortened but airlines still rely on proper maintenance to prevent the same accident happening again in its final report the national transportation safety board concluded that the crash of flight 261 was due to the lack of adequate greasing and the stretched service intervals when coupled with the design of the jacks group these failures led to a completely avoidable accident and the loss of 88 lives [Music] three years after the crash of flight 261 the relatives and friends of the dead dedicated a permanent memorial at port juanimi close to the crash site [Music] i think the the best thing and the only thing in our infinite inadequacy of making up for the loss from this life is to say something that we've been able to see on a lot of other accidents to other grieving families and that is those devs will not be in vain we will not let them be in vain every one of those lies will be made to count in terms of making sure that three four five or ten other people do not die [Music] it was carol carlson [Music] colleen was different she was adventurous and there's nobody like that in our family and i don't know what we can do except to remember colleen and to live our lives now a little bit better for her [Music] you know when i was growing up we didn't wear seat belts there weren't even seat belts in cars and now we know that we need to wear our seat belts we didn't know that much about smoking cigarettes and now we know that we can't smoke cigarettes well there's a lot to learn about airline safety too ryan bushy none of us are the same anymore it's like walking into a giant storm wave after wave forming up coming in because it never stops grief over the loss of a child is not something i wish on anybody this plane went down because of neglect it seems like such an unholy type of laws what a hard way to die so an airline can make more money [Music] you

Channel: Mayday: Air Disaster

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Id: x5nPbZpF7wE

Length: 51min 31sec (3091 seconds)

Published: Fri Oct 01 2021