Professional Pilots Make Deadly Rookie Errors | Mayday: Air Disaster The Accident Files

a botched takeoff in Buenos Aires stun's investigators to me that was unprecedented a shocking error lies behind the deadly freefall of American Airlines flight 587. and when Continental connection 3407 stalls the flight crew's reaction is baffling not only did they not respond correctly they responded in the exactly opposite way commercial pilots undergo hundreds of hours of training and testing still experienced pilots make rookie mistakes rookie errors don't necessarily occur to just rookie Pilots it can happen to the most experienced pilot [Music] thank you it's 8 30 p.m at Jorge Newbury Airfield in Buenos Aires Argentina three zero decimal one zero a Boeing 737 flight crew prepares for takeoff their plane is operated by the Argentinian Airline lapo Jamaica no hey Captain hey the captain of lappa flight 3142 is Gustavo Weigel he's an experienced pilot who's been flying for more than 20 years everything okay fine everything's fine we're just waiting on our fuel first officer Luis echeverry has logged more than 500 hours in the 737. total fuel required 8 500 kilograms to be transferred to the wings tonight's flight is a little over an hour its destination the city of Cordoba 400 miles west of Buenos Aires along with the pilots three flight attendants and 95 passengers are on board before start checklist before start checklist the crew is making last minute preparations for takeoff cockpit preparations completed the relationship between the crew seemed to be very close it appeared that they were friends you guys should come for dinner in Cordoba that sounds good what should we bring bring the ice cream no we're seconds away you should probably get back there and strep in hi guys it's been a pleasure see you soon [Music] here for takeoff lapa 3142 taking off flight 3142 speeds down the runway [Music] as the aircraft lifts off it's immediately apparent that something is wrong the plane begins to take off but instantly it starts shaking like it was going to fall apart we all knew something was going wrong hell hurtling forward at 160 knots the 737 slams violently back to the ground straight for a busy highway and an industrial gas plant s it was very quick I just looked at my friends and I braced my head the airplane crossed a busy highway without warning killed people who were commuting at that time in their cars flight 3142 slams into the gas plant yeah I could feel extreme heat all around me I was suffocating and I needed to get out but I couldn't release my seat belt [Music] Rescuers race to the site of the crash but survivors on board don't have much time fire threatens to consume the entire plane [Music] I felt like I was dying I saw and someone said to me get out though badly injured Marisa bairo is lucky to survive the crash has killed 60 passengers three crew members including both pilots and two motorists it's a disaster unlike anything Buenos Aires has ever seen before it was a major Calamity it involved automobiles it involved natural gas regulating plant a lot of smoke hard to see anything Horacio La Rosa is a senior investigator for Argentina's accident investigation unit they try to focus on the job and look for details that later on could be harder to find Once the rescue teams have finished their work neither pilot survived okay any hope of finding out what went wrong lies in the wreckage because the 737 is American made the U.S national Transportation safety board joins the investigation whatever you need we're here to help there was just a tremendous amount of public concern and a great deal of encouragement to try to solve this definitively and quickly one of the big questions was how did this aircraft go off the end of the runway especially on takeoff look here the wings of the downed plane reveal the first clue for investigators I was able to observe with some of my colleagues but the aircraft's flaps were apparently not extended let's get this Wing piece out of here for takeoff 737 Pilots must always extend the plane's Wing flaps the flaps increase the area of the wing and give it extra lift without them a fully loaded 737 cannot get off the ground did the flaps retract during the crash or were they never deployed in the first place when you see something that's out of place you begin to wonder what has happened has someone raised the flaps or has some electronic or hydraulic intervention made the flaps come up we need to study the entire system in the meantime the team on site retrieves the plane's black boxes the importance of flight recorders and accident investigation cannot be overemphasized about their badly damaged and immediately sent to Washington for repair there was a good deal of pressure to get back the cockpit voice recorder and the flight recorder information in a timely way watch all episodes of ice Pilots watch on mobile devices or the big screen all for free no subscription of Fire download daily now in a nearby Hangar investigators carefully examine every wire gear and screw of the wing flaps actuators seem fine they focus on a part that controls the flap's movement the Jack screw which acts much like a jack used to lift a car as it turns it moves a nut that extends or retracts the flaps that nut travels along the shaft it stops at various places to indicate various degrees of flap extension we had discovered the nuts on the screw were in the retracted position the flap lever from the cockpit confirms the finding the lever is pretty banged up but it sure looks like it's in the flaps up position [Music] it had left a mark with the flat lever in the up position so there was no chance that it had moved during the accident the astonishing Discovery reveals the flaps were never extended flight 3142's configuration for takeoff was all wrong [Music] investigators wrestle with a difficult question How Could An attempted takeoff be made with the flaps in this position investigators want to know how the experienced crew onboard flight 3142 took off without their flaps extended you find yourself wondering why did this action not take place when it is indispensable for flight can we get the FDR data on the screen The crucial Black Box data finally arrives from Washington investigators hope this will help explain what happened great let's go to the flat positions in engine performance the flight data recorder confirms suspicions with no flaps they stall they get the plane back down here 50 meters from the end of the runway there's no way they could stop in time it verifies the flaps were not extended but not why investigators turned to the cockpit voice recorder for Clues the only possibility was in the voice recorder everything okay fine everything's fine investigators Begin by listening to what was happening just before takeoff any other guys you're interested in you don't know him I haven't seen him in a while what they hear from the crew is astounding you're breaking my heart not only unexpected but entirely unprofessional they should be running checklists what's going on they're required to have a sterile cockpit once you start the engines up to ten thousand feet you talk only about operational procedures this is to prevent distraction what should we bring the ice cream before start checklist before start checklist they're talking about planning a meal together they're talking about the Romantic lives and this is interspersed with the checklist and you know I'm with you in the good times and the badmora good thing I'm nothing like you you're full of it you're only with me for the good times cockpit preparations completed the checklists were interrupted and were performed incorrectly flaps are part of the before takeoff checklist do they even do that anti-ice off start lovers that'll stop rated taxi 3142 3142 ready to taxi Charlie five to Runway one three Charlie five to one three I'll smoke all of it give me a puff at least you're gonna puff could make you look great thanks they're actually smoking in the cockpit three of them are passing us there which is prohibited by the company they're not supposed to be smoking in the cockpit at all no mention of flaps they're starting to Taxi they should probably head back there and strap in I guess the reason the crew failed to extend the flaps is now clear very airy they were simply too distracted by their own careless Behavior but what investigators hear next is even more shocking there it is it's an alarm warning the crew of their mistake the sound of the alarm was loud it could be heard perfectly in the voice recorder many times it's fine okay pause how can they ignore that How could a crew forget to perform one of the most basic takeoff procedures and then go on to ignore the loud persistent warning designed to alert them to their serious mistake I believe they didn't understand the importance of this alarm which was absolutely critical for takeoff 65 people lost their lives because the crew wasn't paying attention to what they were doing if the alarm went off and it warned that the flaps weren't configured why didn't they do something in their final report investigators stress the need for Pilots to always comply with the sterile cockpit rule it restricts crew conversation and helps minimize distractions during key parts of the flight by not maintaining sterile cockpit and following every checklist and doing exactly what you're supposed to do people died sometimes following strict operational discipline can still lead to catastrophe even when Pilots are following the procedures correctly you can still have a rookie error just nine weeks after the 9 11 attacks New York's John F Kennedy Airport is busy again American Airlines flight 587 is carrying 251 passengers on route to the Caribbean [Music] your leg you check the Rudders the crew is preparing the plane for takeoff rudder's check taxi checklist is complete okay Captain Ed States is a former military pilot who joined American Airlines 16 years ago [Music] first officer Stan Molin has racked up more than 4 000 hours of flying time and is the pilot flying today wins checked [Music] 8747 ahead flight 587's Flight Plan takes it out over New York's Jamaica Bay before heading south to the Dominican Republic you have the airplane the captain indicated the first officer would be the flying pilot on this leg uh the captain designated him to fly the flight that's routine it's a Captain's Choice American 587 Kennedy Tower caution ring turbulence Runway 3-1 left taxi into position and hold with that distance I will be all right once we get rolling it's supposed to be five miles by the time we're Airborne that's the idea so you're happy I'm on the roll thank you sir G1 rotate flight 587 lifts off at 9 14 am American 587 heavy climb and maintained residents of Queens New York hear the familiar sound of jets overhead planes you know take off and land they fly right over the peninsula every 45 seconds it was just a normal thing high above a patch of turbulence rocks flight 587 max power you all right yeah I'm fine hang on to it hang on to it let's go for power please 2300 feet above the ground disaster strikes the plane is losing altitude and falling out of the sky answer there are more than 68 000 pounds of flammable jet fuel on board [Music] flight 587 plummets towards Queens New York vibrating very heavily you know this all happened really quick at impact the fuel ignites a massive Fireball engulfing several homes plane crash pretty much like in the backyard in the street uh exploded it looks like a war zone all 260 people on board are dead as well as five people on the ground many Wonder was this an accident we are still heavily involved in the investigation of 9 11. I immediately got concerned as to was this another terrorist attack that means the FBI and the NTSB will be investigating this air crash together this accident occurred so close to the tragedy of 9 11 that we naturally jumped to conclusions then we had to force ourselves to back up and carefully study the evidence it came in Fast and steep let's hope it's not what we think their mission is to answer a vital question was this terrorism or an accident any evidence of a bomb would be in the debris anything else stays here for now experts would be physically examining all of the parts of the plane to see if there was any indentations indicating that the explosion was inside and pushed everything out about the crash site and tests for explosive residue reveal no evidence that a bomb took down the plane we learned very quickly that in fact was not a terrorist event then a discovery three-quarters of a mile from the crash provides investigators with a massive clue we found the vertical stabilizer miles or miles away the vertical stabilizer is found in Jamaica Bay between the airport and the crash site the location tells investigators it broke off while the plane was still in the air that was a good first first step for us the vertical stabilizer is part of the tail along with a horizontal stabilizer it's critical for stable flight you can't fly without a tail the airplane's going to go down there's nothing you can do about it NTSB investigators are under pressure to find out what happened to the a300 one of the world's most popular aircraft [Music] that is a vertical stabilizer just fall off I've been investigator in charge with the NTSB for at that time oh gosh 20 years or so and I had never seen anything quite like this investigators turn to the plane's cockpit voice recorder hoping to discover what went wrong with the stabilizer foreign wake turbulence Runway 3-1 left taxi into position and hold after the controller issues a warning about wake turbulence the first officer sounds concerned you happy with that distance uh we'll be okay once we get rolling he's supposed to be five miles by the time we're airborne wake turbulence is caused by the movement of air over and under the wing when the two streams of air meet at the wingtips they combine to create a powerful Vortex that Trails behind the plane max power you all right holy crap did the pilots get too close to the plane in front of them holy crap investigators listen as first officer Mullen wants more speed to help them fly through the turbulence moments later catastrophe strikes 1558 that's the tail coming off was the aircraft upset by the wake of a plane taking off ahead of it we knew of course uh from listening to the air traffic control tapes that the accident aircraft took off a minute and a half or two minutes after a Jal Japanese Airline Boeing 747. radar data shows that flight 587 was flying at a safe distance the Wake was too weak to be dangerous not even close to what it would take to rip the tail off an Airbus but another piece of data provides a vital clue frantic Rudder movements [Music] 11 degrees left 11 degrees right we saw the rudder go back and forth to its maximum deflection several times very very rapidly could he have ripped the tail off his own plane NTSB investigators wonder if extreme Rudder movements on flight 587 created an aerodynamic Force strong enough to rip the vertical stabilizer off determine whether that particular motion would be violent enough to snap the vertical stabilizer off normally Pilots only move the rudder a couple of degrees in either direction to steer the plane but first officer Stan Molin was moving his Planes Rudder much more than that you ready to learn more they create a computer simulation of an a300 and fly it the same way as first officer Molin moving the rudder 11 degrees back and forth three times with each Rudder deflection the aerodynamic loads on the tail increase there that would have done it and it was those increasing loads that caused this [Music] was doing it to himself the discovery finally explains what happened to American Airlines flight 587 but it doesn't explain why so now we've eliminated several items and we're starting to look at as the actions of the flight crew very carefully why would an experienced pilot move his Rudder so violently to fly out of the way when they talk to pilots who flew with Molin investigators make a surprising discovery you can take a seat the first officer overreacted tell me what happened he had a history of responding very aggressively to wake turbulence he did the same thing seven years ago he moved the rudder pedal quickly back and forth the captain said that he was shot by this he was overworking the Rudders he said why did you do that why did you respond like that and according to the statement the first officer said they taught us to respond like that in the training when investigators turned their attention to American Airlines training they're shocked by what they learn Pilots are taught that minor wake turbulence can induce a sudden steep role be determined that they were actually providing inadvertently providing some negative training to their pilots that led us to the conclusion uh that he overreacted first officer Mullen was trained to believe that severe wake turbulence could cause a catastrophic upset max power you all right the captain asks them are you all right and it's noteworthy that the captain does not add max power in Captain's opinion max power is not appropriate in this situation the first officer began responding with the wheel back and forth and accompanied by back and forth rudder first officer overreacted on the Rudders he didn't let the aircraft stabilize in one position or the other so it it hits a stop and equips itself back back and forth back and forth and this creates huge loads on the vertical part of the fin the first officer's actions stress the vertical stabilizer Until It Breaks under the string [Music] after the accident American Airlines changes its training procedures for Wake turbulence once it became clear that some negative training was going on American Airlines through their credit uh revamped the program to prevent this type of activity American Airlines modifies their training simulator to be more realistic Pilots are now taught not to use the rudder at high speed a new warning light is also installed in the cockpit to help prevent pilots from deflecting the rudder too far I think 587 brought an awareness to the aviation industry Pilots they pushed that Rudder in full deflection it could have disastrous effects but despite the lessons learned from the crash of American Airlines 587 a rookie mistake causes disaster seven years later gear down folks alive gears down Jesus Christ it was one of the grizzliest nastiest scenes that I think I've seen [Music] Continental connection flight 3407 operated by Colgan Air is on route from Newark New Jersey to Buffalo New York [Music] it's been a busy flight for Captain Marvin renzlow he's providing guidance to a new first officer 24 year old Rebecca Shaw has been with the airline for just over a year she must decide now if she wants to become a captain I don't know what I want to do with the upgrade if you stayed on the Queue obviously you're not making the captain rate right but you may have a better quality of life with regards to buying a house having a schedule sure trained on the plane they're flying now a canadian-made bombardier aq400 there are 45 passengers on board flight 3407 is heading Northwest over Upstate New York the trip is only 53 minutes visibility is poor and there's a forecast of snow and moderate winds in Buffalo folks from the flight deck your first officer speaking at this time we're about 15 minutes outside of Buffalo weather in Buffalo is pretty foggy snowing a little bit there I'd like to make sure everyone remains in their seats so the flight attendants can prepare the cabin for arrival as the flight makes its approach the pilots prepare the aircraft for landing gear down [Music] looks alive gears down all right flaps 15 extending the flaps provides more lift allowing the plane to slow to its Final Approach speed [Music] suddenly the q400 slips out of control Captain renslow struggles to contain his aircraft [Music] but it seems to have a mind of its own it's too late the plane is now in a stall and renzlow can't recover the plane crashes into a Suburban home in Clarence Center a town five miles short of Buffalo Airport all 49 passengers and crew are killed on impact one person on the ground also dies the devastated house and downed plane are a blazing Inferno foreign the height of it was just unbelievable obviously because of the fuel that was probably added to it and and the debris area was uh was very large it was a terrific sight firefighters worked tirelessly through the night seen in the morning is one of utter devastation clay Crookshanks from the NTSB and I started poking around Clint Crookshanks is one of the first investigators on the case when we arrived on scene there was a fire still burning it turns out it was from a gas line that had been broken in the house the the firemen would put the fire out and it would reignite every couple of minutes investigators hope the flight's black boxes will provide answers [Music] we were able to cut a hole in the side of the fuselage once we took the recorders out of the airplane we put them on the Jet and they were flown back to Washington DC to our headquarters at the NTSB labs in Washington systems investigator Scott Warren analyzes the aircraft's copied voice recorder or CVR to determine if there are any indications of a problem in the cockpit is that ice on the windshield he discovers that six minutes before the crash the crew of flight 3407 notices a buildup of ice on the aircraft you don't have yours oh yeah oh it's lots of ice can be a deadly threat to any airplane if an aircraft has ice on it it will have more drag on it so it'll require more power to to maintain a given AirSpeed when ice accrets on a wing it adds weight to the airplane but most importantly it changes the shape of the wing and of course there's the curved shape of the wing that actually creates the lip so by changing the lift characteristics of the airplane it makes it less able to fly flaps 15 before the CVR reveals that only minutes after the crew detects ice a device called the stick Shaker goes off it's a warning to Pilots that the plane is losing air speed if they don't go faster the plane will stall and fall out of the sky [Music] Scott Warren knows the q400 has a sophisticated de-icing system to prevent ice accumulating the plane has rubber bladders along the front of the wings called de-icing boots a series of valves uses air from the engines to inflate the boots and crack the ice off the wing studying the flight data recorder or FDR will reveal whether the deicing system was switched off we know from the FDR data that the de-icing system had been selected on by the crew and it was on during the majority of the flight the pilots had switched the de-icing mechanisms on but were they working properly to answer that question investigators sift through piles of charred wreckage until they find the de-icing valves we took those valves and as far as we could tell all those valves were working properly if ice didn't bring down flight 3407 what else caused the plane to stall crash and kill 50 people investigators know icing conditions were not bad enough to take down Continental connection flight 3407. something else must have caused it to suddenly lose airspeed NTSB investigator Scott Warren knows the plane was flying at 131 knots when the stick Shaker went off more than enough speed to stay airborne all right flaps 15. when the stick Shaker went off they were not necessarily at the edge of a stock they were still of 20 knots or so away from the stall this new revelation deepens the mystery of flight 3407 the stall warning was triggered when the plane was in no danger of slowing to a stall speed investigators work with the plane's manufacturer to learn more about the aircraft they discover the Bombardier aq400 has a unique safety feature known as a reference speed switch the switch changes the airspeed at which the plane's stall warning is activated it's about a variable ref speed Captain renslow should have activated the switch before flying through the icy weather when you are in icing conditions and and Ice does accrue on the wing it can cause the stall speed to go up and so this ref speed switch correspondingly causes the warning to come on sooner or at a higher speed what that switch does is it basically changes the trigger settings for the stick shaker if ice was slowing the play Captain renslow would be alerted sooner than usual to pick up speed and avoid a stall situation investigators eventually find the reference speed switch panel buried in layers of Crash debris bingo and it's in the activated position [Music] I'll probably be picking up some ice if renzlow and Shaw remembered to configure the plane properly by turning on the reference speed switch why didn't they notice their AirSpeed was too slow for the icy conditions obviously you're not making the captain right right the CVR reveals a chilling answer the flight crew had been talking throughout the flight continuing into the landing approach a violation of the sterile cockpit Rule and he said yeah you're going to be upgraded in six when the stick Shaker goes off the distracted crew is caught off guard once the stick Shaker is activated they could have turned the switch off or they could have put the nose down and increase their air speed using data from the flight recorders investigators create a computer simulation to give them a better understanding of the crash Watch What Happens after the stick Shaker goes off it illustrates that just after the stick Shaker was triggered the plane suddenly pulled up this action dramatically slowed the aircraft and at this point it did stall essentially the airplane internet aerodynamics stall from which it did not recover it pitched over and hit the ground investigators are dumbfounded both Pilots should have known how to respond to one of flight's most basic tasks the crews every action during the critical seconds after the stall warning sounded now demand careful scrutiny we wanted to see if the way they flew the airplane was the way they were trained investigators dig deeper into the FDR data to examine how the pilot maneuvered the plane after the stick Shaker was triggered they focus in on the control column what Scott Warren finds is stunning in response to the stick Shaker Captain renslow should have pushed the column forward to bring the nose down and gain speed but the distracted Captain did the exact opposite we found that the crew instead of pushing forward which is the normal response to a stick Shaker triggering the crew was actually pulling back on the control this had the effect of pulling the nose up causing the air speed to drop and tipping the aircraft into an actual stalk Captain renzlow apparently mishandled one of the most Elemental piloting Maneuvers how to recover from a storm huh had the first officer simply called out your stalled Advanced the power pushed the nose over the airplane would have been able to recover all right human point of view it's sad to recognize that those sorts of things happened and the tragedy that came from that it's concluded that Captain renslow's failure to properly respond to the stool warning is the primary cause of the crash of flight 3407. he reacted in the worst possible way and sealed the fate of the plane you get a star warning and you have to take corrective action and you know the altitude is very low you don't have a lot of options you just have to be able to react no no no at the heart of some of the worst Airline accidents lie mistakes of Staggering simplicity rookie errors don't necessarily occur to just rookie Pilots it can happen to the most experienced pilot [Music] [Applause] [Music] thank you

Channel: Wonder

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Keywords: Wonder, wonder channel, survivial videos, survival stories, i shouldn't be alive, wonder i shouldn't be alive, outdoor channel, extreme documentary, mayday air disaster, mayday parade, mayday fally ipupa, mayday air disaster the accident files, air disasters full episodes, air disasters, air disasters smithsonian channel, fear files accident episode, fear files accident, plane crashes compilations 2022, plane crashes caught on camera compilation

Id: Zi1Yy1OK9uU

Length: 43min 11sec (2591 seconds)

Published: Sun Jul 30 2023