Disasters That Sparked The Most INTENSE Investigations | XMAS SPECIAL | Mayday: Air Disaster

March the 10th 1989 it's 11 39 a.m at Dryden Ontario's Airport like snowfalls as air Ontario flight 1363 stops in the remote Northern community on its way from Thunder Bay to Winnipeg the passengers stay on board while the plane is refueled foreign [Music] attendant Sonja Hartwick and the crew aboard the fokka f-28 it's been a frustrating day of delays big fluffy white snowflakes at this time were falling gently to the ground and it was very very gray and I thought hmm I guess this means we're going to be delayed again I can't see us making it to Winnipeg on time it's Friday the beginning of March break already an hour behind schedule another delay could jeopardize the vacation plans of many of the 69 passengers and crew there is a lot of families traveling on board with plans most of them were going skiing and so they were very concerned about meeting their connections in Winnipeg Kenora dried it's Ontario 363 first officer Keith Mills checks on weather conditions Captain George morward returns from making a phone call inside the airport it's the latest click that quite heavy snow looks like it's going to be a bad one it's still within our takeoff limits well that's good we've got a lot of people who want to make their connectors let's hope it holds temperatures hover around freezing visibility is decreasing if the flight doesn't leave soon it could be grounded indefinitely Dryden is a very small City it's a very remote part of Ontario with a population of about 6 500 the isolated Community lies halfway between Thunder Bay and Winnipeg harsh Canadian Winters with bitter cold reaching -35 degrees Celsius are the norm here it's not the place to be stranded in the middle of a snowstorm [Music] Royal Canadian Mounted Police Officer Don crawshaw and his partner are escorting a prisoner to Winnipeg when we did a criminal check on the prisoner before we left he came up as a violent person so two of us have to go with him he was wanted him Banff on a fraud chart and that's what he was being brought back to Alberta for okay no smoking and seat belts instruments sinks cross check Captain more wood uses the power of engine number two already running to fire engine number one more wooden Mills are both highly experienced Pilots however they've each flown fewer than 100 hours in the fokka f-28 the multi-million dollar aircraft is the first air Ontario jet to serve the remote Northern Ontario region [Music] 24 minutes after landing in Dryden flight 1363 is ready to leave and foreign we're fired up taxi for departure requesting Airways to Winnipeg an approaching aircraft's urgent request to land unbelievable gives Captain more wood little choice he delays takeoff okay 363 is holding short of the active we are going to be a few moments until a small plane lands safely I'm sorry folks this just isn't our day in the two years that I had flown with near Ontario I'd never come across anything like this before the Cessna 150 lands safely clearing the runway for flight 1363's departure tell them we're going immediately Kenora Ontario we're taxiing out at this time 363 driving finally an hour behind schedule the plane taxis to Runway 29. as we're going down the the runway to position for takeoff the blanket of snow is falling and I couldn't see the tree line anymore it was like looking through a sheer folks we're sorry for the delay flight attendants please be seated for takeoff at 1209 PM flight 1363 is ready for takeoff advise Kenora we're ready to proceed and Kenora Dryden Ontario 363 is about to roll 29 at Dryden Captain more wood performs a brief engine run-up he the engines to rid them of any accumulated snow and ice then he begins his role down the runway and we're taking off I'm usually very quiet and focused meticulously going through a checklist in my own mind what would I do in the case of an emergency one the f-28 reaches its takeoff speed rotate 18 knots our takeoff was very slow and sluggish like a slow sluggish person running up a hill clearly there's something wrong the f-28 struggles to get airborne cleared the trees a plane started shaking I thought oh my God we're in a crash that's when we all hell broke please you can equate to being in a mix master that's what the plane felt like at the time there's this dip to the left and then dipped to the right the Pilot's trying to get this plane up then all of a sudden there was a Power Burst the plane seemed to stabilize itself you could feel the fields later in the mix master again I yelled out emergency grab your ankles get your heads down and I kept yelling that and then I assumed my brace position you could hear people screaming and yelling there's loud horrible sounds we are clearly crashing the pilots are helpless 49 seconds after lifting off air Ontario flight 1363 crash lands in the bush 950 meters west of Runway 29. there is Carnage of the aircraft all over the place I didn't know where I was and at that point I thought oh my gosh I'm a lie I'm still alive that this is all happening so quickly when we trashed we came down on an angle it ripped the right side of the plane open and that's how we got out our odd sweep probably would have never gone out now the prisoner was selling handcuffs so I reached over and I took the Cuffs off of him there but he never left me and then we exited the aircraft there's fire all around there's explosions I'm thinking oh my God we're full of fuel and I started yelling come this way come this way for people to follow my voice come this way passengers Scramble for safety before the fire spreads 45 people survived the accident but 24 people do not including Captain more wood and first officer Mills foreign rushed to the crash site deep in the woods [Music] the injured are taken to hospital in Dryden I was very concerned because I kept looking at the wing all the time I thought it was a lot of snow I didn't notice anything wrong going down the run me like I said it was just when I we started hitting the trees I knew there's something wrong within 24 hours a team of investigators from the Canadian Aviation safety board arrives at the scene you're going there hopefully with the idea that you can find out what happened why it happened and how do you prevent it from happening in the future we walked the entire path of the airplane to the threshold of the runway and then we walked the flight path of the airplane right to the crash site that was the first thing that I did I wanted to document what I was seeing by photographing when you walk in on accident site like that there are two things that overwhelm you the smell of Aviation jet fuel and the smell of death the trees just past the end of Runway 29 give investigator David Rowe and his team vital clues about the f-28's failed flight what happened was the airplane went off the end of the runway in what we would call ground effect and just stayed at that height simply clipping the tops of the trees look at how these Treetops have been clipped off it didn't ever fly you've got 24 people that died you've got two pilots that died in a flight attendant that died and they died for the most part trying to do their job so you really want to do them justice but you also have to be fair and uh if there were mistakes made mistakes have to be fixed from the rear of the fuselage investigators recover the f-28's two black boxes the flight data recorder and the cockpit voice recorder [Music] the devices are designed to withstand temperatures of 1100 degrees Celsius for up to 30 minutes investigators are frustrated to learn that the Mylar tape from the recorders has suffered extreme heat damage it's estimated the black boxes were scorched by an 1100 degree Inferno for at least 90 minutes far beyond their limit the data is unrecoverable that was a big blow to us because now you have to try and gather information and try and establish that it's factual by independent roots we were just about to leave Thunder Bay and they gave us 10 new passengers investigators must now rely heavily on eyewitness reports to reconstruct the events leading up to the doomed takeoff they learned that the f-28 began its day in Winnipeg and was scheduled to fly a return route to Thunder Bay and back with a stopover in Dryden but in Thunder Bay plans changed the cancellation of another flight forced the crew to pick up 10 additional passengers when they did their calculations they realized that we were overloaded and something had to come off all right let's um offload some fuel then they ended up removing fuel in order to be within the proper way dispatch Ontario 363. so the flight was delayed an hour the extra weight of the new passengers left the crew no choice they had to unload fuel to lighten their load that meant when they arrived in Dryden they needed to pump in more than the usual amount of fuel for the final leg back to Winnipeg Roa wonders if the change in plans somehow led to a miscalculation of the weight and balance was the f-28 too heavy for takeoff he then uncovers a puzzling detail plane's Weight and Balance form for the takeoff from Dryden was never collected as required it burned in the fire Roa is forced to use air Ontario's standard averages to calculate passenger and baggage weights the data combined with the airport's fuel records allows him to estimate the plane's gross takeoff weight [Music] we knew how many people we had on board we knew how many bags we had on the airplane and we knew what our fuel load was he estimates the f-28 weighed between 62 064 000 pounds and the airplanes Max takeoff weight was 65 000 pounds and so we came to the conclusion that the airplane was not overweight the cause of the crash remains a mystery 18 days into the investigation the Canadian government appoints Justice Virgil machansky to lead a more wide-ranging inquiry into all aspects of the aviation system that might have contributed to the air Ontario tragedy the government was looking for an experienced trial judge and preferably one who had an aviation background moshanski is an experienced pilot with 13 years on the bench he will work closely with crash investigator David rower and Aviation consultant Frank Black the new team's First Step assessing the plane's Technical Systems the electrical system the hydraulic system the fuel system all of these systems are looked at both in terms of what is their history leading up to the accident and what remnants are remaining at the crash site that can be examined foreign Clues to a possible system failure arise when Sonia Hartwig recalls a troubling event aboard the same plane just days before the fatal crash I think it was Monday or Tuesday when we took off there was a smoke that filled the aircraft and there was this horrible smell I thought oh my God we have a fire in the lab but there was no fire in the lavatory or anywhere else in the cabin they told us that apparently it had something to do with oil sitting in the Apu system so every takeoff that day this would happen the auxiliary power unit is a generator that provides the power needed to start the engines did burning oil in the Apu somehow cause a fire and ultimately Doom flight 1363. Roa searches the week's Journey log for any mention of the auxiliary power unit he makes a surprising discovery the Apu wasn't working on the day of the crash it couldn't possibly have caused the fire but the inoperative power unit may still have played a role in the tragedy investigators learned that it forced the crew to make a risky decision in Dryden one of the connectors let's orbit holes normally the captain would rely on the Apu to restart his engines after shutting them both down for refueling but if he couldn't use his Apu he couldn't shut his engines down Batman flight 1363 had to be refueled with one engine still running Captain more wood is in a situation where he's got a heart refuel with passengers on board the aircraft he's got to keep an engine running to refuel the airplane hot refueling isn't against regulations but the risk of a fuel spill makes it potentially dangerous in Toronto in 1973 a maintenance person was killed when an Air Canada dc-8 jet was consumed by fire during refueling heart refueling is not a normal practice could the hot refueling have caused some kind of damage to the engines The Dryden Airport Manager a former military pilot suspects there was trouble with the plane's engines he tells rower he saw the takeoff from his office and heard a sharp explosive noise just as it disappeared from View to him it signified a flame out or engine failure [Applause] I thought this is going to be a high profile and potentially controversial investigation and the only way to ensure that the truth stands up is to have hard evidence from the aircraft accident and so we took the airplane completely and we put it in our lab in Ottawa anything with signs pointing to engine failure as the cause of the crash strip it down rower orders extensive engine testing those engines were examined in detail for damage Roa finds the f-28's two Rolls-Royce engines suffered only minor structural damage there's no evidence of an engine fire nothing at all to suggest the engines had failed with little physical evidence to explain the failed takeoff investigators are back to square one to solve the mystery they comb through Survivor and eyewitness statements Common Thread emerges they've said in their witness statements there were snow and ice on the wings when the airplane attempted to take off [Music] Roa studies weather charts for Clues we had very good meteorological information the charts show that during the half hour the f-28 was on the ground at Dryden Airport visibility shrank from four kilometers to less than one kilometer because of the snowstorm in all we may find other reasons for sure snow and ice on the wings was a factor in this act Sonia Hartwig tells investigators about an unusual sight during takeoff what is that the wings this became a solid Sheen for a gray shiny ice investigators consult the f-28's manuals to study its anti-icing systems they find that only the Wing's leading edges are protected head heated leading edges on the wings I wonder if the anti-acing system was working and the heat was provided by bleed air from the compressors on the engine they found the valves that allow the compressed air access to the leading edges and they tested the valve to see if it function then it did the anti-icing system was working but since it only heats the Leading Edge it likely didn't clear ice that formed on the surface of flight 1363's wings investigators suspect that snow and ice build up what experts call Wing contamination may have played a major role in the crash to verify that suspicion rower and his team meet with Engineers from fokka thanks for coming curious to see what you have Jack Van Hanks who was the chief engineer had the extensive aerodynamic studies and data on the effects of contamination on an f-28 airplane Engineers have run simulations of the crash they were able to get some very good data in terms of the performance of the airplane simulating the type of loads temperatures Etc that the Dryden aircraft would would have been exposed to [Music] investigators make a crucial discovery about the design of the f-28 because of the angle of the Wings a very small amount of ice makes the plane susceptible to stalling the concluded that even the most minute of contamination of the wing would disrupt the airflow and cause a loss of lift that answers a lot of questions the simulations support what Witnesses saw it just barely got Airborne dropping Wings losing lift and then hitting trees decelerating to the point where it broke up investigators are now certain that contaminated wings cause the crash but what's still unclear is why the plane was not de-iced before takeoff almost all airports in cold climates including Dryden are equipped with the technology to remove ice from a plane but Captain moorewood never requested de-icing an accumulation it's getting worse what's the latest investigators need to figure out why they want to understand what made him risk his own life let's hope it holds and the lives of the 68 other people on board flight 1363. investigators dig through Captain George morward's flight records and work history they interview crew members searching for Clues to his behavior Captain Warwood was a very very professional very old-school pilot he had his view on how things should be done properly and what his definition of proper and professional would be he also was very concerned about his passengers he enjoyed making sure that they got on their flights on time and got to their destinations on time you know air Ontario was a growing company it was their first foray into the jet operations I'm sure that there were many things that Captain Morgan would have thought in his own mind but this is not how he would do it and I'm sure at times he probably let the superiors know that morwood's history shows he's delayed and canceled flights in the past because of icing concerns Roa is stumped why didn't he request de-icing in Dryden pilot who was at Dryden airport that day provides part of the answer he heard morewood on the phone to air Ontario that is what I have been trying to tell you he was very frustrated and he was really concerned about his passengers Moore would complained to the off-duty pilot about the company guys you want to guess my weight before I left Thunder Bay 66 and change I had to offload fuel now that right so now what am I supposed to do you figure it out when he left the terminal he was observed by witnesses to appear to be very upset and very angry investigators wonder what set more wood off they try to piece together the Pilot's day on March the 10th this was the fifth day of a very long week for Captain more wood and he was the next day leaving with his family on a ski vacation before his first flight of the day he'd learned the plane's Apu still wasn't working and then once in Thunder Bay more bad news after refueling the dispatcher forces more wood to take on 10 extra passengers now he must offload Fuel and lose more time there goes the schedule let's um offload some fuel then this meant more wood would leave Thunder Bay behind schedule dispatch Ontario 363. and Captain more wood is the type of Captain who didn't want to be late now on route to Dryden and an hour behind schedule the weather forecast the crew was given of light rain and fog is no longer accurate and Captain more wood didn't get the forecast of freezing rain coming into Dryden which he should have had as flight 1363 lands in Dryden the weather was getting worse by the minute the planes sat there for half an hour while snow built up on the wings I gotta talk to somebody about this investigators may never know how concerned morewood was about the weather but there is evidence that it was on his mind when Roa questions the fueling agent he learns that morewood did ask about de-icing moments before takeoff is there de-icing available fueling agent says he pointed out the de-icing ground crew to more wood the agent then offers a compelling reason that could explain why the captain didn't de-ice air Ontario had a policy prohibiting him from de-icing with an engine running the fluid can be ingested in the engines and then find its way from there to the air conditioning on the airplane and make it extremely noxious in the cabin portion of the airplane but if more wood had shot down both engines he wouldn't have been able to restart his plane the only other way to start the airplane on the ground is with a ground-based air cart that can provide the compressed air and Dryden did not have the capability to start the airplane the equipment would have had to be flown in from Winnipeg it would have been a costly decision if he shut it down he would ground the aircraft there effectively requiring the billeting of passengers and hotels and out of the expense to the airline for which he would be answerable right so now so he was under a great deal of pressure no you figure it out I believe that the conversation on the phone would have been about that scenario and his displeasure with it but he didn't have any other chance worse what's the latest quite heavy snow looks like it's going to be a bad one still within our takeoff limits well that's good we've got a lot of people who want to make their connectors let's hope it holds though the amount of snow on the wings was still within limits it's what lay under the snow that doomed the flight the fuel in a plane's Wing can get as cold as minus 40 degrees Celsius The Frigid fuel cools the metal surface of the wing when snow hits this super cool surface it freezes instantly into a barely visible layer of ice it's a process called cold soaking and this of course is what's disrupting the airflow on the wing and destroying the lifting capabilities tell them we're going immediately kenoir Ontario we're taxiing out at this time the only reason that I can possibly think of that led to his decision to execute the takeoff was the fact that he didn't consider the cold soaking phenomena and the fact that those wings could still have ice on it advise Kenora were ready to proceed and Kenora Drive in Ontario perhaps not wanting to face the consequences of shutting down his engines Moore would opted to take off for Winnipeg without de-icing his Lane he must have concluded that the ice would blow off on takeoff that is where he made a mistake a tragic mistake but nashansky concludes that despite his mistake Captain more wood is not solely responsible for the crash it wasn't simply pilot error Myriad of factors which the words this cause of the accident one of the most important factors air Ontario's decision to let the plane fly with a broken APU they were deferring a lot of the maintenance that should have been done because of a shortage of parts and then they had to scrounge around all across Canada with various F28 operators to borrow parts from them and this this was a very bad move on the part of air Ontario management the investigation determines that by cutting corners and focusing too much on the bottom line the airline was putting all their passengers and employees at risk because the f-28s were new to air Ontario there was this urgency to get one crew off and get the next crew on flying this urgency to have them in the air producing money I came to the conclusion after a lot of thought about this accident that there were a lot of other hands on those throttles pushing those throttles forward there were a lot of people that were involved in the sequence of events that led to this tragic outcome this was a preventable accident but everything conspired against the pilots I gotta talk to somebody about this because air Ontario management did not have a safety culture and you have to have a safety culture from the top management down knowing there are dozens of foka f-28s flying around the world Justice machansky takes an unusual step he releases a report well before his inquiry concludes it warns of the plane's vulnerability to ice buildup and stresses the need for frequent de-icing in Winter conditions even a small amount of icing would be a disastrous on an f-28 [Music] months later it becomes clear that machansky's warnings have not been heard U.S Air flight 405 is preparing to fly from New York to Cleveland on March the 22nd 1992. the plane is a fokka f-28 and it's snowing it's one degree below freezing at 9pm the jet is being de-iced for a second time since its arrival from Florida in the past hour an inch of snow has fallen and shows no signs of stopping [Music] the crew prepares for takeoff flight 405 is an hour and 45 minutes behind schedule when Captain Wallace major starts taxiing to Runway 13. then unexpectedly [Music] left on the inner to hold short of echo at 907 PM flight 405 is forced to wait on the taxiway near Runway 13. another 23 minutes pass first officer John rashuber turns on a light that illuminates his wings he checks the right wing for ice he sees none looks pretty good to me as far as I can see you're there 405 Runway one three clear for takeoff even though it's now been 35 minutes since their last de-icing the crew does not request another pick up thrusts set temps okay everything proceeds as it should until the one rotate just after the f-28 begins its rotation the aircraft had enough flying speed to to lift off barely lift up the wings just could not support the airplane they knew they were in trouble 13 seconds after lifting off flight 405 crashes on the shore of flushing Bay foreign I don't think any pilot really thinks he's going to crash they were trying to save the airplane right to the end 27 of the 51 people on board are killed another fokka f-28 has crashed with tragic consequences my reaction when I heard about it was my God is Dryden all over again within days investigator in charge Robert Benson suspects that ice on the wings was the major cause it would be very very difficult for either of the pilots to really detect ice on the wings looking backwards over their shoulders through the side windows of the airplane it's pretty good to me so the captain was faced with quite a problem if you wanted to be de-iced a third time he would have had to get out on the lines taxi all the way back into the parking area and meet up with a de-icing truck again take off thrusts that would have put him very very late and it may have even caused the cancellation of the flight after all of this work after all of the efforts to see it happen again was extremely frustrating there were no regulations in place requiring the crew to seek another de-icing after their extended delay but Justice machansky had called attention to the dangers of long wait times when he issued his interim report if they had followed the recommendations in my second interim report this accident certainly could have been averted [Music] had drawn attention to the limitations of the de-icing fluid being used at the time call type 1 fluid it's a mixture of antifreeze and water those chemicals are designed as you accelerate down the runway that they'll actually Shed off your wing so that when you actually want the wing to lift and produce lift that it's not contaminated type 1 fluid is applied hot to de-ice the plane surfaces but it doesn't last long type 1 fluid had hold over time in their best conditions of about 15 minutes under poor conditions such as freezing rain it could be as low as six minutes during the air Ontario investigation machansky's team reached a stark conclusion about the effectiveness of type 1 fluid even if Captain more wood could have de-iced his plane in Dryden we're fired up taxing for departure requesting Airways to Winnipeg it may have made no difference unbelievable flight 1363 had to wait for the troubled Cessna 150 to land by the time he waited for this 150 aircraft and pilot to land and then they backtracked and got into position now they're in a serious small start and they are getting contaminated even if more wood had de-ice during his 30 minutes on the ground rotate the delay may have been enough for the fluid to stop working the plane's wings May once again have become coated in ice [Music] foreign examination of air Ontario Pilots that there was a dire need for training in terms of how the de-icing anti-icing systems worked and how long your aircraft was protected as soon as uh our accident occurred up in New York we of course understood that it was a similar aircraft in fact a nearly identical aircraft to The Dryden accident airplane the circumstances were similar in both accidents and The Dryden report was a tour de force which helped us focus our investigation quite a bit Justice machansky had released his interim report more than a year before the crash of flight 405. his recommendations could have prevented it moshansky would soon discover that a breakdown in communication had cost the lives of 27 people in New York during his inquiry Justice machansky learned that there was another type of de-icing fluid available to the airline industry it's called type 2 fluid it's thicker than type 1 which prevents it from immediately flowing off an aircraft a type 2 fluid is a much more gooey substance I've heard it referred to as almost mucus-like with holdover times of up to 45 minutes it keeps ice from accumulating then blows off the plane's surfaces at takeoff 15 months before the U.S air crash moshansky recommended greater use of the thicker type 2 fluid moshanski's investigators also studied de-icing practices at Toronto's Pearson Airport we got a hold of a film crew and we waited and watched the weather very carefully until we found a forecast of freezing rain and we've tracked one aircraft which was heading for the Caribbean the investigators discovered an alarming Gap in the time between de-icing and takeoff and from the time the aircraft was de-ice on the gate until the time the aircraft took off was somewhere in the order of 41 minutes so there was no doubt that aircraft were departing Pearson airport with a partially or largely contaminated Wing surface we then went to Chicago O'Hare this was the first airport to actually put in place Runway and the icing pads and it was very useful in terms of explaining to us how these had evolved what type of de-icing equipment they were using on them how they worked at the time of the U.S air crash LaGuardia did not offer de-icing at the runway only at the gate again 15 months before the crash Justice machansky recommended the placement of de-icing facilities at runways instead of terminal Gates moshansky also recommended that Pilots not only inspect their wings from the cockpit pretty good to me as far as I could see but also from the cabin claims that his report could have prevented the crash at LaGuardia Federal Aviation Administration claims it never received his report in 1990 and therefore couldn't pass the information along to Airlines and Pilots but just as machansky doesn't accept that my second interim report went out in December of 1990. it's about a year and a half before the LaGuardia crash occurred so I I think uh probably sat on somebody's desk [Music] the crash of Flight 1363 resulted in dozens of recommendations that could save lives the crash of Flight 405 ensured those recommendations were widely implemented well there was a lot that came out of Dryden I mean the commission came out with 192 recommendations it changed the whole nature of how we approached contamination we now have a Runway and the icing paths so they can get a final de-icing before they take off this was something directly the result of the Dryden commission inquiry today most Airlines use a new type of de-icing fluid Type 4 de-icing fluid lasts longer it will stick to a wing for up to two hours as well air traffic controllers must now be able to tell flight Crews how long they will be delayed at the runway after being de-iced Trident is really the first accident that explored not only what happens in the pointed end of an airplane but what happens within a corporate culture it puts CEOs on notice that they can't hide in the Woodwork when an accident occurs Dutch manufacturer of Hawker went bankrupt in 1996. despite this in 2009 there were still 55 fokka f-28 jets in operation worldwide mostly in warmer climates nobody should ever lose their life during a contamination accident again in commercial Aviation anywhere in a snow and ice environment we've learned all the lessons foreign South Vietnam April 1975. after more than 10 years of fighting the United States is on the verge of defeat the end of the war is fast approaching the enemy is closing in on the capital myself on April the 4th at a military base in the South Vietnamese capital of Saigon [Music] a Strange Cargo is being loaded onto an enormous c5a Galaxy this is one of the largest planes in the world the c5a is primarily a cargo plane its hold is wide enough to carry tanks and tall enough to move buses above the cargo area there's a small number of seats both the passenger area and the cargo bay are being pressed into service today dozens of Vietnamese orphans are being loaded onto the plane to be flown to safety there are thousands of Orphans to be flown out before the North Vietnamese take Saigon Barb Adams works for the American embassy she and her daughter Linda are also fleeing on April 4th my mom came home and told me that I had one hour to pack one suitcase and that we were going to be escorting the orphans on an orphan airlift back to the United States when my mother and I went upstairs to the troop compartment there's traditional Airline seats and all of the seats were filled with babies Sergeant Ray snediga is in charge of loading the plane's massive cargo bay make sure it's secure we got people down there it was hard to control the situation so many people were there so much news media so many people from the orphanages so many military people that it was actually pure chaos just the day before American President Gerald Ford announced the start of this desperate Mission of Mercy a remarkable effort called operation baby lift I have directed that c5a aircraft and other aircraft are specially equipped to care for these orphans during the flight be sent to Saigon I expect these flights to begin within the next 36 to 48 Hours Arnold Isaacs was covering the end of the war for the Baltimore Sun we had Transport Aircraft flying into Saigon every day unloading military supplies and going back empty and so it was decided that they could carry out the orphans on those returning flights there were a lot of cameras and reporters out there covering the loading and the departure of the plane [Music] Captain Bud trainer is in charge of operation babylift's first flight I got a call from the command post back in the States and they said to me how many people could you take out of Saigon if you were asked because of the last minute nature of the flight they're running behind schedule [Music] the plane is already five hours late and Captain Trainor wants to be in the air he orders the cargo bay doors to be closed tell me what the door Roadmaster closed cargo bay doors [Music] the youngest of the 145 children have been crammed into the upper passenger section of the jet my mother and I were both assigned three rows of seats with maybe four to a row so it would be 12 to 15 babies that we would be taken care of on the flight feeding them changing them whatever they needed to have done [Music] have a good flight enough there are 102 older children in the cargo area below a number of adults from the American Embassy are also down here keeping an eye on the orphans getting out of Vietnam starts by leaving the safety of the U.S base passing throttles now 15 20 time go [Music] [Music] in Europe I remembered that we had to take off at a pretty steep angle and we didn't have seats so we were to kneel on the floor between the seats during takeoff the cargo plane is heading for Clark Air Force Base in the Philippines it's a two and a half hour flight from there the orphans will be sent to adoption agencies in North America and Australia we needed to take off from Saigon and make it a very rapid accent to get out of Missile Range cargo planes are easy targets they're slow-moving and large the possibility of an attack is very real just five days before North Vietnamese troops captured the South's second largest city Da Nang South Vietnamese forces are retreating towards Saigon [Music] in the capital the situation is chaotic thousands of South Vietnamese civilians are desperate to leave every day another Province was lost especially after Danang fell the population of Saigon I think began to fall into a sort of a paralyzed petrified Terror never not for one moment that I remember did you have a feeling of anyone rallying to defend the country [Music] [Music] I was there in the troops it's all right the baby's still squalling or they quieted down with all the noise most are asleep just as well [Music] then shortly after takeoff [Applause] as the plane climbs through 23 000 feet when the rapid decompression occurred the plane filled with this mist and so until it dissipates it's you cannot see and there was this loud explosion one quick bang what was that and she said I'm not sure and you could feel the plane heading downward debris started flying around classic decompression somewhere there's a massive hole in the plane's fuselage the air inside the jet is rushing out 23 000 feet there's barely enough oxygen to breathe so I looked over at the co-pilot and he was putting on his oxygen mask and I thought I'd better do that too the oxygen masks have dropped automatically but on such an overcrowded flight there aren't enough to go round the ones that are available weren't designed to reach babies [Music] as I looked out the window I saw the ocean and I said to my mom I said we're crashing aren't we at the back of the passenger compartment Lieutenant Marshall Woods checks in with the crew from there she can usually see down to the cargo bay below her pilot what the cargo door is gone with more than 300 people on board Captain Bud trainer's jet has lost its breathable air somehow his massive aircraft has been badly damaged and he's a long way from a safe place to land [Music] the inaugural flight of operation babylift will not make it out of Vietnam the next few minutes will determine if anyone even survives oxygen levels are dangerously low unlike the passenger compartment above there are only a few portable masks for passengers in the cargo bay my first priority after a rapid decompression is to get the aircraft back down to a breathing altitude for all the passengers which is ten thousand feet taking it back to the airport thank you and so I turned 180 degrees and now I'm heading back for Saigon but before he gets back to Saigon trainer needs to know how bad the situation is uh the airplane is going down in a Left Bank at that particular point and since it we're going down I go to the cockpit sir see what's going on and Captain Trainor tells me to go to the cargo compartment to see what's happening down there when I was in my descent I went to my maximum speed which is what you're supposed to do to get to 10 000 feet I got to my maximum speed and I pulled back on the yoke and nothing happened I kept going faster and faster and faster trainer's plane is diving to the ground and he can't get it to pull up at the back of the plane Rey snediga descends into the center of the storm and noticed there was a lot of Chaos in the cargo compartment obviously people were frightened so I'm actually crawling and stepping over people that are combat loaded on the floor and I saw this huge gaping hole in the back of the airplane all daylight back there and then snedika spots what could be an even more serious problem is pumping out control cables were dangling in the breeze flocking back and forth and it just reminded me of looking at some spaghetti there's the first thought in my mind the flight engineer also notices that the plane is losing its hydraulic fluid fast pilot we've lost number one hydraulic system hydraulic fluid helps the crew move the massive control surfaces on the plane the rudder and elevator at the back and the ailerons and flaps on the wing there are four separate hydraulic systems on the plane now two of them are completely empty and as trainer Dives towards ten thousand feet his plane is going much faster than it should and he can't pull up and I kept pulling back on the Yoke thinking that I could slow down pull back more and more and more I'm not getting anything out of the year how about you we were just totally puzzled what is going wrong pulling on his yoke should bring the plane's nose up and slow it down if he can't pull the plane up soon it'll plow straight into the ground and I'm concerned at that point we're still falling we're not leveling out in the belly of the plane Ray Snedigar reports what he sees to the cockpit told him that the part of the ramp was missing pressure door was gone and hydraulic lines and control cables have been cut the problem is now much worse than we thought declare an emergency Saigon this is Mac eight zero two one eight and we're declaring emergency we require immediate recurrent debate [Music] unlike commercial airlines there was nobody that came onto the PA system and announced what was happening so I just kind of focused on the children after struggling with his crippled jet trainer's efforts finally seemed to pay off and now the airplane levels itself off and we're saying wow thank goodness that we're finally making it out of this as quickly as it leveled off the plane begins to climb again the nose of the jet begins pulling up into the sky and so I relax the yolk and what happens nothing I'm still going straight up now unless trainer can gain some speed his plane will soon stall and Tumble from the sky and it got higher and higher and pretty soon I'm going almost straight up in desperation he dips One Wing forcing the nose down I'm now in a very very steep dive and there's nothing I can do seemingly to bring the nose up and so counter-intuitive I added power and when I did that the airplane pulled itself out of the dive and I started to go back up again but this time I stopped it at 10 000 feet and rolled out and I realized that I had learned how to control the airplane trainer can't control his plane's pitch as he usually does by pushing and pulling on his control column dead by gently increasing and decreasing power to his engines he seems to be able to keep his plane level at that point I realized that my only pitch control was the throttle the plane has descended to ten thousand feet there's now enough oxygen to breathe one zero zero it's safe to remove our mask gear down before landing checklist I headed directly for Saigon and began a descent and began positioning myself for a final much like you would in a glider don't worry they're taking care of it up in the cockpit we're gonna be down soon I'm trying to provide Comfort to these passengers at the same time I know we're in serious trouble because the airplane is still going down Captain trayna has coaxed his injured jet down to just over 4 000 feet 11 kilometers from the airport he turns his jet to line up with the runway when his plane surprises him again in the final turn to the runway when I Bank the airplane the nose dropped and I couldn't continue my turn I had to level the wings so that I had enough lift that the nose didn't keep descending Captain trayna had to stop turning before he could line up with the runway he's now losing altitude fast and his prospects are becoming increasingly Grim while we were working in the cargo compartment loadmaster came to me and said we need to get upstairs because we're going to crash land when I get to the top of the ladder I've changed my mind and think I need to be in the cargo compartment when this airplane does get on the runway so I can help evacuate down there as I try to leave the places near gravity but my left elbow throws me into a seat and about the time I hit the seat I can hear the ground screaming the loud scream it's coming closer [Music] get down on the floor prepare for emergency landing mom get down when we started to go down my mother and I were focusing on what should we be doing to brace for impact we had a big open field in front of us what I got within about 200 feet of the ground I said we're going in the plane is hurtling towards the ground at almost 500 kilometers per hour I reached down grab my seat belt and when the seat belt snaps touch the ground relatively easily and we've popped back in the air the jump seat said to me but we're gonna make it but I could see looming ahead of me was this huge huge River so I added power my mom was on one side of the aisle and I was on the other [Music] over here and sit with me [Music] even with full power at that point I was still continuing to to sink foreign [Music] [Music] foreign the airplane is coming apart where I'm sitting all kinds of debris is flying through the air it went on and on and on it seemed like forever [Music] when I was going upside down I remember saying you know goodbye to my wife a couple of times because I was a god foreign [Applause] it was quiet [Music] [Music] when the plane came to a stop I looked for my mom I didn't see her anywhere at that point it was all a little bit surreal that I didn't even really know what had just happened all I knew was that we needed to get the babies out of there [Music] foreign [Music] ER and the rest of the cockpit crew have survived when I stepped out of the window what was clear after you looked around the the airplane broke up into its component parts the tail dropped off the flight deck broke away The Troop compartment the wings they separated from the cargo compartment cargo compartment itself disintegrated essentially behind the cockpit the plane's wings which hold the fuel tanks are burning the passenger section of the plane is largely intact separated from the scorching heat of the burning wings [Music] Lieutenant words and many others who had been in the passenger section survive then we started bringing babies out was not looking for my mother because I had been assured that she was okay I was to go to the hospital and just wait for her there and then that's when I took a couple of the babies and walked over and got on a day that began with the promise of hope has ended in disaster just minutes after the crash of the first baby lift Mission rescue workers are on the scene searching for survivors most everyone in the cargo area was killed instantly planes slammed down the second time the Dead the injured and the survivors are taken to hospitals in Saigon and Thailand since I was not injured I just took a seat and was waiting for my mother while they brought in a lot of the babies then somebody came over to me and told me that my mother had died I remember holding on for dear life so she said come over here and sit with me Bob Adams last decision was to be near her daughter [Music] just as I sat down on the floor we must have hit flew forward somewhere and that's the last time I saw my mother [Music] 175 people survived the crash of the Air Force jet but more than 150 have been killed more than half of them were children really such a a blow in what had already been a very tragic and sad story of the collapse of South Vietnam and then who would have thought that in the middle of all that tragedy that the American Air Force would crash a Plane full of Vietnamese babies and small children the investigation begins immediately the next day along with the investigators Captain Bud trainer returns to the smoldering wreckage of his plane on a special mission of his own I had to leave a couple of crew members out at the aircraft and so I went back the next morning the bodies of two dead crewmen are still pinned down by the wreckage so we took a lot of tie down chains and put them together and did the old heave hole with a whole lot of people to move the flap of wreckage that was pinning the two crew members and we got them out of there It's always important to finish the job and we did [Music] but then I had a very naive approach to what was going to happen next I kind of envisioned the guys in the silver helmets and put out the white rope this is going to be a secure site that was when I got the shock that hey there are no guards out here there's a Vietnamese Soldier going through my suitcase wearing my flight jacket he had an AR-15 and I didn't that's my jacket I'm Bud trainer and we established that my coat had the same name on it as mine and as my flight suit and so the coat he was wearing was mine so he begrudgingly gave me my coat and then proceeded to go through the rest of my suitcase it's not only trainer's jacket looters are picking the plane clean Dave schiding is a structural engineer with the Air Force when we got to the site we had some concern to begin with because there was a tremendous amount of Civilian people out there actually picking up parts which of course that didn't help us much as far as the investigation goes he's part of a team that goes to Saigon to try to figure out why the plane crashed this investigation was very unique from a couple of standpoints the first standpoint of course the people taking Parts away from us but second the country was in extreme chaos of essentially falling Frank Hoskin is also part of the investigative team the NBA and the VidCon are all around and we were only out there during the daytime but it was a very uncomfortable feeling very uncomfortable feeling one of the first things we wanted to rule out was sabotage in a bomb so we we brought in dog dogs from the Philippines bomb sniffing dogs [Applause] and with North Vietnamese soldiers so close a direct attack or sabotage are obvious theories initially they had all thought that it had been a bomb placed in the luggage compartment or it had been a missile that shot the plane down during the rush to board the aircraft personal luggage was loaded but not thoroughly checked this added to the speculation that a bomb may have been smuggled on board the dogs find no trace of a bomb and investigators find no evidence of explosive residue on the plane clearly wasn't attacked but something had caused the cargo door to fail we had to find the doors if at all possible to make sure that we didn't have a problem with other c5s that would cause this type of crash soon the massive c5as will be desperately needed to get America out of Vietnam finding out what happened to this one couldn't be more urgent it was beyond important at the time we had approximately 100 C5 aircraft we grounded the c5s until such time that we could figure out one what the problem was and two what were we going to do to prevent it from happening again investigators also tried to find out why the crew had such difficulty controlling the plane okay this is sheared on cables that race nedegar saw leaking hydraulic fluid were the ones that controlled the plane's elevator since the elevator controls pitch Captain trainer had no way of guiding his plane up and down emergency when there's no control of the elevator which allows for up and down pitch an airplane will set up an oscillation up and down his oscillation started as nose was going down and then it picked up speed and then it started pitching up of falling plane's aerodynamic properties will force it to follow a predictable pattern as lift increases the nose naturally tilts upwards without the elevators to counteract the motion it will continue until the plane moves so slowly that it stalls falling back to the ground it explains the strange motion of the giant c5a by adjusting the thrust to his engines trainer was able to keep the jet from rising and falling investigators believe the cables were sheared off when the cargo door exploded from the plane [Music] but they still don't know why the door failed in the first place then we made the determination we were going to have to try and find the doors but the doors are somewhere at the bottom of the South China Sea our next problem was trying to figure out the ballistics of those doors nobody had ever even thought of figuring out ballistics of two doors flying through the air from 23 000 feet relying on the airspeed and the altitude at the moment of decompression investigators learned the plane was 46 kilometers from the coast of Vietnam when the doors went out the airplane was moving across the water it had about 600 feet per second therefore we had to come down with a pretty good estimate for the Navy to even know where to look ships from the U.S 7th Fleet crisscrossed the South China Sea looking for the rear door for the first several days they can't find anything the South China Sea has swallowed the evidence at the crash site investigators are becoming increasingly frustrated a great deal of wreckage has been stolen by scavengers an important clue could be among the pieces taken away to retrieve these parts the Air Force offers to buy them back the strategy was to provide leaflets throughout the city of Saigon and the surrounding area we want every piece of material from the aircraft back and we will also pay you if you will turn this into us [Music] 11 days after the crash Flyers are delivered to local officials and distributed throughout the city [Music] investigators do eventually recover the camera that was used by a film crew on board the plane [Music] they hope it can show them exactly what happened but the film inside the camera has already been removed another piece of the wreck turned in during the buyback program is just what they're looking for we were trying to get the black boxes back because that's the thing we really wanted all c5as are fitted with a computer system that records Vital Information about the plane's operation it records engine settings AirSpeed altitude and hundreds of other parameters onto a magnetic tape the system is called Madar malfunction detection analysis and recording system it wasn't found at the crash site [Music] the Madar is eventually returned for a reward but it proves to be a disappointment it didn't identify the reason for the doors and the ramps failing but it did provide us a sequence of events in a lot of areas including altitude AirSpeed the performance of the aircraft itself during that time frame foreign as investigators continue to look for the cause of the crash the situation in Vietnam gets worse two days after they received the Madar the South Vietnamese president resigns on April the 23rd 100 000 North Vietnamese troops approached Saigon The Noose around the city is tightening quickly while we're out in the rice paddy you could see burning hamlets and Villages and in the distance they were on fire you could hear the explosions and so forth the mortars while the situation in Vietnam continues to unravel the U.S Navy finally has some success at sea on April the 26th they find the cargo ramp and part of the pressure door of trainer's plane if investigators don't find the answers here they may not find them anywhere they're running out of time and they're running out of leads when the ramp is examined investigators make a disturbing discovery on that ramp two of the stirrups were in in great condition they were perfect they had not failed so obviously it told us that at least two of the locks had just unlocked themselves the c5a has 14 locks holding the rear cargo door shut seven on each side the door recovered from the sea tells investigators that for some reason three of the locks designed to hold its shut had either unlocked in flight or had never locked at all this flight was actually like a ticking bomb when they closed the ramps all those locks would look like they were in a locked position when it took off the fuse was lit and as the aircraft climbed out the fuse kept burning as the plane climbed away from Saigon the pressure outside the jet dropped the air inside pushed with increasing Force against the cargo door then as the plane passed through 23 000 feet with three latches unlocked the pressure on the door was too much with the three locks that failed all in a row it was just too much load for the other four locks to to actually pick up and what's resulted in the catastrophic failure of the ramp itself but investigators still don't know why the locks failed before they can find the answer the situation in Vietnam deteriorates completely Saigon is under siege on April the 27th the investigators take all of the evidence they can and leave it's simply too dangerous to stay when we left Saigon we were the last two c-141s to leave Thomson interface they were essentially losing their country at that time and after that it was only helicopters that got out investigators hope they have all the clues they need to solve the mystery of the crash they know they won't be coming back to Vietnam to look for any more April the 30th 1975 the war in Vietnam ends from the rooftop of the American embassy the last remaining Americans in Vietnam are flown to safety United States investigators continue their work since the C5 is in service around the world they need to know why three locks on the cargo door failed when we got back to Texas it was to help us verify the failure sequence investigators discover something potentially alarming about the cargo plane's rear door parts from the c5a were actually removed from the plane cannibalized to service another cargo plane the locks on the rear door of the c5a are connected to each other by a series of tie rods the rods can be lengthened or shortened to ensure the locks are completely closed it's these tie rods which were removed from the baby lifts plane at the time the enormous cargo planes were in constant demand the Air Force was very short of parts and so they came up with a standard practice for maintenance that they could cannibalize Parts off of aircrafts that are not being flown it's authorized and it's a good operation if if you respect it and treat it properly the tie rods were replaced before the baby lift plane left for Saigon but for some reason they hadn't held to try to figure out what happened investigators rebuild one of the locks That was supposed to keep the rear door closed we essentially built a working model of that ramp and we had to do that because we didn't get all the parts back because the people picking them up parts out in the ocean and everything that we never got back investigators aren't convinced that the problem is in the basic design of the lock they suspect that before the plane left California the engineers who replaced the rods didn't follow the proper procedures when we're talking about the the locks the distances that we're talking about are very very small we could be talking about the 16th 32nd of an inch uh difference between being locked and unlocked the re-rigging was done before the plane left the United States after the locks were re-rigged they should have checked to make sure they were working that wasn't done without the check no one would have noticed that the re-rigging was done improperly I would say that this accident actually started back at Travis Air Force Base in California when the two tie rods that had been cannibalized earlier were replaced they were not installed properly loadmaster closed cargo bay doors when the door was opened and shot in Saigon there was a warning that not everything was perfect we had some difficulty getting at the lock so we had to open and close it three four times seemed to be routine and In the Heat of the Moment we didn't we didn't think anything about it about 12 minutes after liftoff as the plane continued to climb the three improperly closed locks were forced open by the building air pressure the remaining locks could not take the extra load go door burst open and was torn off the fuselage you just can't take shortcuts and it's pulled a couple of rods out run out and put them back in that's not going to hack it [Music] the investigators have found their answers and in their final report make specific recommendations that will make the c5as safer as a result the Air Force designs a pin that slips through each lock if the door isn't properly shut the pins can't slide into place we essentially Murphy proved it by putting steel pins in there so that when the lock is in the over Center position if you can insert these safety pins then you know that the the system is properly rigged [Music] Ray Snedigar retired from the Air Force as a chief Master Sergeant this mission to was probably the most discouraging in some ways based on part of the outcome also it was refreshing in the fact that we displayed such good internship such courage and we were able to save so many people after 28 years of service Bud Traynor retired from the Air Force as a colonel I think everyone second guesses themselves to see if there was something else that they could do I am very fortunate in that I never found something that I said I sure wish I had done X just wasn't there that pilot did a super job the fact that anybody survived this crashes is just remarkable the ones that were saved are very fortunate that that particular crew was in charge of that aircraft being a pilot myself and knowing that it only had one aileron and four engines by rights they all should have been dead investigation board does not normally recommend decorations that's not part of their job but in this case we recommended to the air force that they be considered for a high decoration surviving crew members including Captain Bud trainer and Sergeant Ray Snedigar were awarded medals by the Air Force for heroism and extraordinary achievement one of the orphans that survived was baby Eno [Music] today she's known as Kelly Jackson Brownlee April 4th 1975 it's definitely a pivotal point in my life where I left part of myself behind in Vietnam when operation baby lift resumed Kelly along with hundreds of other orphans were flown to the United States she was eventually adopted by a family near Seattle Washington there was a 25-year anniversary in April of 2000 and it brought together all of the adults that were adopted from Vietnam and I ended up meeting someone who's very special and actually ended up marrying Chris Brownlee and his wife Kelly were both airlifted out of Vietnam on April the 5th 1975. one day after the crash [Music] oh foreign 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 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 stuff here in Miami 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 and it's just so much easier in the seaplane to get to the North Island where most of the population is than going to the airport down there so that was the main thing it was a convenience factor welcome aboard your boarding passes Sergio Dan Gila 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 good afternoon folks we'd like to welcome you aboard talks ocean Airways Flight 101 to Bimini our travel time Community will be in 25 minutes hope you enjoy the flight let's have the startup checklist please Roger Michelle Marx is in command of today's flight she was promoted to Captain earlier this year first officer Paul De sanctis joined the airline eight months ago [Music] this is his first flight with Captain Marks after the taxi the Grumman Mallard is a twin turboprop design it has a v-shaped Hull and underwing pontoons designed to carry up to 17 passengers the plane has retractable landing gear so it can operate on either land or sea take off in the mallard depending on the phase 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 difference 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 to take up both Pilots have their hand on the throttles 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 takeoff half speed boat half plane it's a unique thrill 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 was what we call getting on plane and in rough sea conditions and in rough wave conditions it could be a real challenge [Music] but this takeoff 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 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] barely have time to register what's happening 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 Boca Negra is a lifeguard stationed on South Beach near the chalks ocean Airways sea Lane as soon as I saw this I I realized I'm like oh no this is the trucks airplane crashing we have a code four repeat code four plane down in the water this is Lucas we're launching the jet ski [Applause] the two lifeguards are the first Rescuers to go looking for the plane [Music] 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 you 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 as soon as we turn government cup those Jetty rocks we noticed that it was very calm very quiet it wasn't like the ocean side where it was very rough there was no waves it was very uh kind of very eerie first Lucas bocanegra 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 foreign 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 it was just try to recover as many bodies you know bring them back for their families foreign news crews swarmed the beach sharks Flight 101 plummeted into the channel in full view of tourists lining Miami Beach even a fraction of a second the whole plane was engulfing flames Coast Guard look for any survivors but the effort is futile retrieve some of the bodies but we were unable to uh find anyone that had survived all 20 people on board are dead including Pilots Paul De Sanctus and Michelle Marx the residents of Bimini are devastated by the horrific news 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 [Music] 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 Crum 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 and I was very familiar with sharks Airways I'm a sea plane rated pilot myself and and there is their reputation the legend of chalks 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 chalks planes even Patrol for German U-boats during World War II the novelty of flying attacks 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 [Music] 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 foreign 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 AirSpeed control positions and so on the chalks 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 evidence authorities reveal Ed final seconds of Flight 101 were captured on amateur video The Dramatic footage was shot by a tourists 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 mid-air 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 would fall off in this plane it was a beautiful day the water wasn't rough on the takeoff and all of a sudden the swing just just dropped off it must have been absolutely uh 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 winds falling off aircraft uh modern day situations is a very rare extreme event and that 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 the cockpit voice recorder for CVR which does what it sounds like records the Pilot's voices talking to each other or on the microphones but the tape is a jumble of voices and sounds technicians can't retrieve any useful information it turned out that the uh the race had function it's just like a tape recorder that most people are familiar with um 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 [Music] s 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 foreign there's a possibility that mallard collided with something in the water before takeoff new planes 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 [Music] English now has a solid lead but his team is still missing the evidence they need to prove their case foreign [Music] 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 plain fragments and other debris from the crash foreign we started out with the the wing itself that separated The Spar which is the main part of the structure of the wing and any of the other fracture surfaces looking for obvious initiation factors they carefully examined 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 in the bending that we saw was the expected pattern from proper operation when those blades hit the water once again they're back to square one things the damn color 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 helps us in many of our investigations and we will 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 we're gonna need your help on this one name stands out on the passenger manifest Sergio dangilicord ing pass there were rumors on the internet that the crash was an assassination plot and Dan Gila 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 all right no something I want to show you we can't tell if it's just surd or it's explosive residue a bomb will leave 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 foreign 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 clear that's the same when metal is suddenly stressed to the point of breaking the fracture leaves are 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 foreign 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 Chalk's 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 of 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 foreign Crookshanks is a structures investigator for the NTSB 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 aluminum alloy the Spas run the length of each wing in between the spars are stringers that give added support together these parts make up the winged 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 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 thanks [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 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 chokes 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 Chalk'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 crookshank's 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 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 the patch on a pair of jeans this is a big repair job you sure we don't have anything on this [Music] it's an intriguing discovery the patch is located exactly where the wing broke off from the rest of the plane [Music] when he takes a closer look at this section of the wing Crookshanks 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 processed by which um any piece of metal the 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 mental fatigue in the wings is caused by the stress of flight over the lifetime of the aircraft [Music] 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 [Music] Crookshanks is eager to find out what's underneath the metal patch [Music] okay let's see what this double is 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 find three machined holes in the skin forward of the Leading Edge all three appear to be stopped drill holes the holes indicate the Chalk's mechanics have been trying to stop the crack from spreading further foreign 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 could 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 [Music] 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 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 proved but a glimmer of an answer comes when they learned the plane was sending out warning signs of a deeper more serious problem the chalks 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 crew started to notice the repeated fuel leaks during standard operations and we tried to bring it up to attention of 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 address 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 wings interior structure mix 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 carry that scraper please eat 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 we've finished cleaning this off and then get some pictures okay thank you 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 a fatigue 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 sharks made repeated attempts to repair the airplane by stop drilling the winged 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 is it was covered in fuel tank sealant [Music] a broken z-stringer weakened the entire Wing now with every takeoff 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 in the wing separated from the airplane [Music] [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 talk to 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 surge of Chalk's Financial history uncovers some trouble in the 1980s chalks went through a string of owners before going bankrupt in 1999. [Music] Airline was revived by a Miami businessman but it kept losing money [Music] just a few months before the crash the last attempt to sell the business fell through not doing so well it wasn't a secret that we were having financial difficulty um 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 Grumman was no longer in production of that aircraft they no longer supplied parts the airlines deteriorating health and the shortage of spare parts had a direct impact on safety there's 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 [Music] 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 foreign [Music] 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 as a small operation they only fly during the nice weathers and uh they're good old boys over there they know what they're doing in effect the fa 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 chalks aircraft the FAA may not have found fault with chalks but it turns out that several people very close to the airline did but 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 taken 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 error 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 foreign 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 oh the ntsb's report on the crash of Flight 101 harshly criticizes the FAA for not detecting growing maintenance and financial problems at chalks and 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 accent 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 [Music] the NTSB recommends that the FAA expand its oversight of Aging planes [Music] 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 [Music] foreign 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 not Additionally you know emotional for everybody that ever worked there or ever loved the airplanes foreign

Channel: Mayday: Air Disaster

Views: 374,872

Keywords: Mayday Air Disaster, Mayday Air Disaster YouTube Channel, Mayday Air Disaster TV Series, Plane Crashes documentary, air crash investigation, where to watch air crash investigation, where to watch plane crashes, mayday air disaster streaming, where can i see mayday, mayday full episodes, worst plane crashes, mayday season 9 episode 6, mayday season 7 episode 5, mayday operation babylift, What happened to operations Babylift?, How many people died in Operation Babylift?

Id: Lxezr5dk0-w

Length: 139min 32sec (8372 seconds)

Published: Sun Dec 25 2022