The Devastating Result Of Miscommunication | Mega Marathon | Mayday: Air Disaster

los angeles international airport lax is one of the busiest in the world it's used by 40 million passengers each year more than fifteen planes take off and land every day it's august the 31st 1986 labor day weekend [Music] today a junior air traffic controller walter white will be handling some of that traffic white isn't yet a fully fledged controller he has to put in more time before he gets his final certification hey carol how's it going hey slow slow slow it was a long weekend and it was a beautiful day in los angeles it's absolutely clear outside which we call chamber of commerce type day you wanna take a break have a cigarette i could sit in for you that was my normal assigned shift and walter came in and asked me if i wanted a break wanted to go smoke a cigarette and i said sure traffic was light it wasn't very busy uh sunday morning well certainly any controller is looking to get seasoning if you will three months four months that's a pretty new controller angel's approach good morning i mean it wasn't my turn for a break walter wanted to work the sector as i remember correctly he wanted to work it for some proficiency time he hadn't worked it in a while at 60 can you see the runway two five left the roger alley approach thank you reduce speed to two zero zero then descend and maintain six thousand two zero zero descend and maintain six thousand thank you have a nice day several hundred kilometers to the south passengers are boarding an aero mexico dc-9 [Music] dr donald wong and his sons are returning from a highly successful fishing trip jason i think we should put it up in the kitchen they caught an enormous sailfish your mom will love it which they plan to display at home labor day weekend was the last weekend before school was to start um donald decided that it would be fun to take the boys fishing down in mexico to go deep sea fishing which he'd only done one other time in his life this would be a like father-son bonding weekend and it was also the first time that they had traveled without me [Music] just east of l.a the suburban city of cerritos wakes up slowly in the 1970s this bustling community had been one of the fastest growing in los angeles county my husband had been working out of town all week and he was coming home for the weekend and that sunday morning i decided let's just stay home i'll not go to church i'm gonna go out and get your favorite things for a good breakfast javier go and take a shower and i left to go to the grocery store in the home was alex he was 14 his twin sister angelica she was asleep he was asleep still and javier that was my 16 year old and my husband as estrada leaves on her errand aero mexico flight 498 is just 20 minutes from la [Music] captain antonio valdez prom is acting as co-pilot as they approach the city [Music] first officer jose valencia is piloting this leg of their [Music] about 22 kilometers south of lax sits the torrance airport operating in the mammoth shadow of lax torrance serves private planes and amateur pilots it's one of several small airports that operate near la a region that has over 6 000 weekend flyers if you're set at the end of a busy summer william cramer his daughter caroline and wife kathleen are finally taking to the skies piper 4891 all clear for takeoff good morning piper 4891 this is torence tower you're clear for takeoff for runway five they're heading to big bear lake rolling tower about 200 kilometers northeast a meticulous man william cramer is an executive for an engineering company [Music] six years ago at the age of 47 kramer bought his first airplane a stylish and swift piper cherokee [Music] wings west 5225 los angeles approach depart sealed beach heading 3-2-0 expect a visual approach runway 2-5 left report airport in sight thanks walter white's job as a rivals controller is to make sure incoming planes keep well clear of each other he's directing them to land on one of two runways we'll approach runway two five left thank you southeast of lax the crew of aeromexico flight 498 is still a few minutes from their first contact with walter white but in the skies above los angeles a deadly series of events is about to unfold dozens of people who have never met will be bound together forever in a tragedy that will affect everyone who flies [Music] august the 31st 1986 labor day weekend all clear for takeoff just south of los angeles william cramer and his family are finally on their way for a long awaited holiday okay just an hour to go we're in big bear lake uh the reporting visibility of 14 miles today pretty good [Music] as the torrance airport recedes behind him kramer begins climbing to 3 000 metres on his way north east to big bear [Music] lake several kilometers away a half-full dc-9 from mexico is approaching los angeles international airport [Music] less than 2 000 meters below them teresa estrada is driving home with the groceries for a holiday breakfast her husband and three children are waiting just a few blocks away [Music] that's it holiday's over psa 1765 it's not a busy morning and one by one arrivals controller walter white guides his planes in safely at 11 47 am he gets his first call from aeromexico flight 498. los angeles approach good morning this is aeromexico 498. aeromexico 498 los angeles approach two five left final approach course do you aeromexico flight 498 is now officially inside what's known as the terminal control area or tca sometimes referred to as the bird cage the tca is a complex piece of three-dimensional airspace around the airport it's restricted airspace that's normally found around heavily congested airports or hub airports where the traffic density is extremely high and you need to control the access into and out of that airspace aeromexico 498 traffic ten o'clock one mile northbound altitude unknown roger 498. aeromexico 498 reduce speed to one nine or zero then descend and maintain six thousand as the aero mexico plane descends william cramer and his family continue climbing i hope it's like this when we get to big bear we should be able to see the ocean by now [Music] take a look at the map and and look around the 405 and see if you can see any any kind of landmarks that we can use oh what am i looking for walter white is keeping his eye on the aero mexico jet when his attention is abruptly drawn to another plane that's just appeared on his radar it's not one he's expecting uh one approach 6-6 romeo was on a flight from fullerton cruising altitude is 4500 we'd like following the pilot of a small grumman tiger asks white to help guide him through the crowded terminal control area pilots are supposed to contact lax approach before they enter the controlled airspace this pilot could be in the path of incoming traffic but before white can deal with the private plane he gets a call from the aeromexico dc-9 uh what speed do you want we're reducing to uh two nine or zero no no two one nine or zero oh okay you can hold what you have sir white decides to give the aero mexico jet the runway closest to their gate changing plans sir stand by roger 498 with the dc-9 on hold white turns to the intruder grumman 6-6 romeo squawk 4-5-2-4 remain clear of the tca white tells the pilot of the grumman to use a unique radio channel but he seems confused four five what were the other two numbers four five two four roman six six romeo are you at 4 500 now negative we're at 3 climbing okay you are right in the middle of the tca sir roman six six romeo i suggest in future you look at your tca chart you just had an aircraft pass right off your left above you 5 000 and we run a lot of jets right through there at 3 500 well what do you suggest they do now as the crew of aero mexico flight 498 continue to close in on the mission landing lights their dc-9 is rocked by a violent shudder bugs what was that aeromexico 498 los angeles approach first officer valencia tries desperately to control their dive 498 los angeles approach [Music] [Music] [Music] i saw a huge explosion just the red vibrant colors of a fire just huge explosion like the way a bomb might hit the ground white is getting no response from the aero mexico jet aeromexico 498 los angeles approach and now he can't find it on his radar screen i'm sitting there talking with the two departure controllers and not really thinking i hear walter say something like i think i lost one hero mexico 498 los angeles approach that immediately got everybody's attention so he looked at the radars and could hear him calling air mexico 498 called him several times on the radio where was aeromexico at this point we weren't absolutely sure what had happened white calls to an incoming jet for help american 333 heavy i want you to take a look around at 11 o'clock i just lost contact with a dc-9 let me know if you see anything down there please uh eleven o'clock uh five miles what altitude uh he was last assigned six he's no longer on my radar scope american 333 heavy okay uh i see a um very large smokescreen off on the left side of the aircraft about 11 o'clock [Music] i went down the street to go to my house and i saw a woman's head that her body had been cut in a diagonal and she was just laying there there was nothing but debris and fires sporadically all over the place and i could see fire in the whole neighborhood [Music] nearby an engine from a local fire station had been on a training exercise led by fire captain larry hamilton all of a sudden one of the firemen tapped me on the shoulder and said there's a big column of smoke you know off to our left so i picked up the mic and made a guess at the address responding to a large fire north of 91 northern terminator they came back and uh said well we've got a report of an airliner down so i upgraded the response to basically triple what i initially asked for [Music] as we approached i realized that in addition to the aircraft parts in the street there were people body parts which changed the complexion of the whole thing set up a perimeter let's go hello hello can anybody hear me at los angeles approach walter white deeply shaken by the crash is relieved of duty [Applause] i remember watching walter get up and walk out of the room by himself and you know something inside of me was just you know saying this is not right this is not right somebody's got to go with him tony he can't go out alone i could have been sitting there just as easy as him and i don't know if i'd have done anything different than he did helicopter news crews are quickly on the scene there was a lot of fire in front of me and my house is just totally on fire frank angelica angelico and i saw my neighbor where are they i said to her rose where is my family what happened and she goes oh honey your family's in here they're over here we're looking for you and within myself all i could do is thank god that they were safe and sound [Music] she took me into her home and i saw alex [Music] what happened where's angelica where's angelica where's heavier where's mama i don't know mom i'm sorry and he started crying right away and said mom i'm sorry i'm the only one that came out alive and all i could do was hug him [Music] [Music] pieces of fuselage have torn through nearby homes setting them on fire the tail section of the jet has been catapulted more than a block from the crash site hello is there anybody in here as i surveyed the houses and the crash site around me it was a very surreal experience just to stand right there for probably four or five minutes before anybody else showed up and not see another living soul i have got wreckage all over the place there are no survivors just fatalities you know i dealt with death i wanna one or two or three people in a residential fire but never a whole airliner full of people let's go to work guys [Applause] [Applause] i don't think i ever saw a whole human being gave them the job of finding body parts and wrapping them or covering them with yellow rescue blankets no matter where it was ever so small or whatever you know a hand or a torso or leg or whatever that became life to us it was treated with respect my memory of the incident is in a muted shade of brown it's not black and white it's not vivid color you know the grass isn't green the houses don't have paint it's all some muted brown shade and i'm told that that's my brain's way of taking something violent and horrible and softening it a little bit so i can live with it and deal with corner of this it has just been torn apart yellow sheets marks the bodies i count one two three four five six seven eight nine ten eleven bodies right now oh gosh this neighborhood has just been devastating 16 houses have been damaged many of them completely destroyed at los angeles international airport mary wong is waiting for her husband and two young sons i went to the airport to pick them up around noon and waited in that area outside of customs and waited and waited and probably you know you're thinking customs might take a little while but about maybe 12 20 or 12 30 i started seeing a man walk around with a pack on his back with a green cross [Music] we were taken up to a lounge upstairs and on the elevator up i looked at the men and i said they're dead i just know they're gone in cerritos emergency workers are shocked by another grisly discovery in the playground of a local school they find the wreckage of a piper cherokee archer remarkably intact the plane's canopy is sliced off its three occupants are found still belted into their seats william cramer and his family are dead [Music] all the passengers and crew on aeromexico flight 498 are also dead [Music] in addition 15 people on the ground have been killed it's a horrifying situation two planes have crashed into a california neighborhood something's gone terribly wrong in the skies above one of the busiest airports in the world now investigators have to find out exactly what happened on the last day of august in 1986 a lazy labor day weekend is shattered by an enormous explosion two planes crash in la county destroying several houses it's a grisly scene bodies are scattered throughout a devastated neighborhood [Music] 82 people are dead 15 people on the ground have been killed another 67 have died in the tangled wreckage of the two planes involved [Music] investigators from the national transportation safety board arrived that night they include experts in human performance flight systems and air traffic control [Music] from the beginning investigators are focused on the fact that there are two planes on the ground it suggests a disturbing conclusion that this was a mid-air collision the idea that this had been a mid-air collision was already conveyed to us before we even launched out of hanger six back when we got to work they saw two wreckages coming down um and that's the way it got conveyed to us with that idea in mind john white and his team must painstakingly examine the wreckage it's more of now documenting where the major pieces were and then looking at the pieces to see if you can determine how the aircraft what angle the aircraft may have come together at propeller marks on the tail of the dc-9 and paint from the piper cherokee reveal how the planes crashed [Music] it looks like the piper collided at the tail section of the dc-9 and the horizontal stabilizer came off and once that happened you could no longer control the pitch of the dc-9 the descending dc-9 and the climbing cherokee met at a 90-degree angle their combined speed was 450 kilometers an hour the impact tore off the airliner's tail section discovering how the planes collided is the first step the more important question to be answered is why to piece together the tragedy investigators examine the dc-9s flight data recorder it helps them pinpoint the exact location and altitude of aero mexico flight 498. the dc-9 was inside the terminal control area the controlled airspace of the los angeles airport it was right where it was supposed to be but the kramer's cherokee was also inside the tca with all of the jets taking off and landing at lax private planes must first get permission to enter this area piper 4891 all clear for takeoff tarts william cramer was a newcomer to los angeles but investigators learned that he was well aware of the limits imposed by the tca he knew that it was restricted airspace and in the cockpit of kramer's cherokee the confirmation investigators find a map of the los angeles terminal control area investigators make another puzzling discovery they learned that the kramer's proposed flight plan took them from torrance to long beach then up to ontario and finally to big bear lake at a cruising altitude of 3000 meters that plan keeps him well out of the tca the fact of the matter is the cherokee flew into the tca and hit the dc-9 in restricted airspace without a clearance so how had kramer flown into danger and why hadn't he let anyone know on the ground in cerritos one possible answer emerges disease runs in kramer's family and the initial autopsy results show a major blockage [Music] are you all right bill yeah yeah i'm fine kramer may have suffered a heart attack on the flight leaving the plane without a pilot [Music] samples of william kramer's heart tissue are sent to the armed forces institute of pathology for testing if he suffered a heart attack it might explain why he didn't call in to la approach it's totally possible that he could have had the heart attack fell back pulled the airplane up and that's why he didn't try and avoid the dc9 [Music] but no matter why kramer was flying and restricted airspace air traffic controller walter white should have been able to see him kramer's plane should have appeared on white's radar [Music] before being questioned by investigators white reviews the radio calls from that morning he needs to be sure of what he said and what he saw [Music] richard wentworth was one of the investigators who talked to white at any time did you see the papa cherokee on your scope no no sir the piper's target was not displayed it is my belief that it was not on my radar scope he uh was positive that the aircraft was not there for him to see ntsb investigators aren't satisfied with white's memory while the radar data is being analyzed news arrives from the armed forces institute of pathology about william kramer's heart are you all right bill results from a detailed study of his body show that while he had advanced heart disease william kramer was not fighting a heart attack before the collision [Music] investigators must find another explanation for why the kramer's flight went into the los angeles terminal control area [Music] while he had submitted a flight plan small planes like kramer's cherokee don't have sophisticated instruments like most private pilots kramer was navigating by landmarks like freeways that meant keeping an eye both on the landscape below and the airspace around him that's definitely the 405. where is it again [Music] john andrews is an aviation expert who testified about the circumstances of the cerritos disaster the pilot of the piper was navigating by visual landmarks possibly attempting to follow a parallel to a freeway and that he had become confused about which freeway he should have been following new to california perhaps bewildered by the tangle of freeways below him kramer may have flown into the terminal control area without knowing it there are no lines on the ground that says the tca starts here and at this altitude you have to look at a chart you have to interpret that investigators are now confident they can explain why kramer was inside the controlled airspace of the tca but when he finally gets a look at the air traffic control radar record richard wentworth is convinced that walter white should have been able to see the piper [Music] we were able to determine that the aircraft that collided with aeromexico was there to be seen so why hadn't white reacted to the kramer's plane if it was on his radar when walter white came to work that day the arrival station was being controlled by carl grundman hey carol how's it going hey slow grundman believes that long-standing radar problems were the reason white didn't see the kramer's plane i could sit in for you controllers have been complaining about the radars for a long time cheers buddy all right thanks a lot we had reported problems with the radar uh not picking up targets several times when radar signals strike a target they bounce back to the receiver but if buildings or mountains interrupt the radar the return signal can disappear [Music] you may lose one target you may lose two targets it may not be presented for one sweep did you see the pepper cherokee on your scope no sir but that doesn't mean that the target isn't there a blind spot is only an instantaneous thing it's not a continuous thing i think i lost one there were also holes that were just because the radar was old it was just not as accurate as it might have been it was not state of the art equipment that's for darn sure there's an effect called flicker when a computer becomes overloaded the scope will flicker every now and then targets will drop out or can drop out we reviewed that data we had no evidence that there were any malfunctions of any systems in los angeles there is another possible explanation if the cherokee had appeared on the radar white still could have missed it investigators focus on the other plane in the sky that day the grumman [Music] tiger private planes are required to contact air traffic control if they are entering the terminal control area but the tiger was already deep into the tca before it radioed walter white uh one approach six six romeo was on a flight from fullerton cruising altitude is four thousand five hundred we'd like following kremlin 66 romeo are you at 4 500 now negative we're at 3 400 and climbing okay you were right in the middle of the tca sir there was an aircraft that was east of the airport which he became involved in that was what they called a violator romeo i suggest in future you look at your tca chart you just had an aircraft the problem with the conversation between the controller and the pilot of the groom is that it went on too long why were you so mesmerized by the grown i thought he posed a risk this occurred during a critical time at which the two aircraft to the south west of his display which was the euro mexico and the cherokee were merging but even if the cherokee signal did appear on white's radar and even if he had seen it investigators discover that white still would not have had all the information he needed radar signals only show controllers that a plane is in range transponders on planes can broadcast other information including height and speed but at the site of the cherokee wreckage investigators discover the plane's transponder is a basic model it only sends out information on the plane's direction it provides no information about the plane's altitude so these controllers were pretty much used to seeing a little triangle which represented a vfr aircraft with no altitude readout traversing all over the place and unless they learned firsthand from the pilot they had a expectation that the aircraft would not intrude into that airspace investigators believe that white's divided attention perhaps made worse by an older radar system explains why air traffic control never warned the dc-9 of the danger posed by kramer's cherokee landmarks that we might be able to use as a visual but there's another mystery that hasn't been solved studying the radar records from the day ntsb investigators are startled by what they find neither the crew of the dc-9 nor the pilot of the smaller cherokee took any evasive action before the crash both pilots appear completely unaware of each other definitely the 404 why hadn't the pilots of either airplane reacted visibility was over 20 kilometers how could two planes collide in the clear blue sky [Music] to try to get a better sense of what was happening inside the aero mexico cockpit investigators listened to the airplane's cockpit voice recorder los angeles approach this is aeronautics the flight crew had put walter white on their overhead speakers the microphone for the cockpit voice recorder was right beside the speakers much of what the pilot said was drowned out by white's voice then descend and maintain six thousand bugs the radar information paints a puzzling picture [Music] it indicates that for more than a minute the kramer's cherokee was there to be seen by the aeromexico crew and if the kramers had looked out of their right side window they would also have seen the aero mexico jet [Applause] but neither plane altered its course neither plane took any action to avoid the deadly collision investigators believe that if william cramer was indeed lost and using the freeways as a guide he might never have seen the approaching dc-9 the window he would have been looking out of was the pilot's window but the dc-9 was coming from the other direction visual landmark today this would have been a very unfortunate situation because the dc-9 was approaching from the far right side and in fact could not be could only be seen out the passenger's window which was on the right side of the aircraft for the crew of the dc-9 the very size of the much smaller cherokee could have prevented them from seeing the plane before it was too late in some cases when a small aircraft is closing very rapidly by the time the aircraft becomes large enough for you to easily see it it's almost too late to avoid the collision uh the faa generally uh is taken a sort of as a rule of thumb that you need about 12 seconds in order to see an aircraft decide that it's a threat and then execute an avoidance maneuver in the case of the collision at cerritos by the time the aircraft became large enough to see you were down very close to that 12-second limit in case after case of mid-air collisions we found out that the aircraft gave no indication that they saw each other until the time they actually collided the design of the cockpit windshield may also have contributed to the disaster maria it's possible that during part of the approach at least for one of the pilots the aircraft was actually behind the center post and unless the pilot moved his head back and forth to clear that airspace unless he had a reason to do that it's possible the aircraft was obscured during part of the time in which he might have had a chance of seeing the other aircraft ignition [Music] the disaster over cerritos revealed several tragic weaknesses in the air traffic control system one of the most glaring was that pilots could not be relied on to see and avoid each other they'd need new technology to keep a mid-air collision from happening again a small california neighborhood is rocked by a terrifying plane crash [Music] 82 people are killed when a private plane slams into a large passenger jet [Music] the devastation is enormous [Music] more than a dozen houses are damaged several leveled completely [Music] the ntsb report makes it clear that there are glaring problems across the air traffic system and these concerns must be addressed before inevitably there is another mid-air disaster the faa which regulates the airline industry in the united states acted swiftly to improve safety a new kind of transponder was required for smaller planes the kind that might have helped air traffic controllers recognize that the private aircraft posed a danger if you had an aircraft that flew under a controlled airspace you would have a transponder and you would be required to have altitude encoding or reporting that way it would be no mistake as to whether you had an intruder or not a new system called mode c intruder was also developed to warn air traffic controllers c intruder is an automated program that is now incorporated in all our major radar facilities that if an aircraft should inadvertently intrude the controller will now be given a visual and an oral alert thus giving him time to provide a timely warning to the pilot seat belts even for the most diligent pilot the old strategy of sea and avoid had serious limitations those limitations would be addressed with the most important innovation of all the major technological innovation that came out of cerritos mid-air was the congressional mandate that all air carrier aircraft operating within the united states would be outfitted with tcas traffic collision and avoidance system john andrews worked on the team that developed tcas the tcas collision avoidance system which was under development quite possibly could have prevented this accident tcas gives the pilot a traffic advisory at 45 seconds before the potential collision hey maria everything okay back now and then at approximately 25 seconds or so before the potential collision a resolution advisory is given to actually tell the pilots to climb or descend to avoid the altitude of the other aircraft see [Music] today commercial airlines around the world use tcas the pilot of the grumman tiger the so-called third pilot whose actions may have played a part in the crash was eventually charged for flying into controlled airspace in a careless and reckless manner [Music] for walter white the effect of the disaster over cerritos could not be overcome [Music] walter came back to the tracon and i think it was probably a month or so later and i can't give you exactly how long he stayed there but it wasn't very long and he just got up and said no no thank you uh and as far as i know he didn't talk to airplanes again within a year of the incident the old radars at lax were replaced in cerritos a memorial garden now marks the day of the disaster mary wong has since remarried but the pain of returning home that day will never go away there's nobody here the house is empty derek was already living in an apartment in san diego and here i was i was no longer a mother except to derek and i was no longer a wife and so it shattered my whole world days after the disaster mary wong met one of the few people who could fully understand her loss i went to the memorial service and it was very important to me to try to meet somebody else who had gone through this and i knew from reading stories that theresa had lost her husband and two children and so i saw someone there who i thought was teresa she says are you teresa estrada and i said yes i am she says well my marriage my name is mary wong and she says i said i lost my husband and children also i i just wanted to grab her and hug her because she was feeling what i was feeling so we had an immediate connection and we've maintained our friendship over these 20 years [Music] everyone who flies today has been affected by the mid-air collision over cerritos the disaster led to historic improvements in aviation safety since the full adoption of the tcas system there has not been another mid-air collision in the united states [Music] [Music] september 29 2006 in sao jose dos campos brazil it's a big day at embraer headquarters the brazilian aviation firm has just sold a brand new private jet to excel air a u.s charter company the price tag 25 million dollars it's a beautiful airplane and there was a beautiful little ceremony that embraer uh had in the hangar just before we we got on the plane and the guys uh from xl air were particularly proud the legacy is a modified regional jet the cabin redesigned for comfort it can seat up to 13 people and in its first four years of service embraer has delivered almost 100 of these sleek business jets xlr will use the jet to fly customers around the world but first the company has to get the plane up to the united states joseph lapore and jan palladino will be at the controls for the jets maiden voyage they've been down in brazil for a couple of weeks getting familiar with the new plane joe sharkey is a reporter for the new york times he's been offered a free ride home we were delivering an airplane basically and my role was hitchhiker and they kindly invited me along [Music] the legacy jet is heading to manhouse in northern brazil a stopover on its way to new york half an hour after takeoff the legacy is flying over the heart of brazil the countryside stretches out below the view out of the window is spectacular i glanced out and i was amazed just to the horizon nothing but tree tops and i just remember how pretty it seemed at ten minutes to four in the afternoon the legacy jet makes contact with controllers of the brasilia area control center still nearly 100 kilometers away brasilia november 600 x-ray lima flight level 370. good afternoon coming in 75 of the country's air traffic is handled by the controllers in this room the traffic volume is larger than in any other control center in the country one of the many planes they'll be dealing with today is the legacy jet every flight that's handled by brasilia acc appears on computer screens as a small circle moving in the direction of the plane the computer also displays the plane's actual and planned altitudes november 6.00 sends out a signal controllers use it to confirm that the data on their screen is coming from the plane they think it is an hour later the flight has settled into a familiar routine mood sort of settled down everybody was working and it was just a very very calm and peaceful time i was transcribing notes from one of the interviews from the embraer tour the brazilian november 6-0 x-ray but in the cockpit palladino is having trouble getting back in touch with air traffic controllers in brasilia brazilian november six zero zero x-ray lima he can't raise controllers on the frequency he used almost an hour ago he tries other channels brasilia november 600 x-ray lima brasilia november 6 0-0 x-ray lima november 6 0-0 x-ray lima after 12 attempts paladino finally gets in touch with brasilia acc this time with a different controller who provides radio frequencies for future contacts contact one two three decimal three two two six small i'm sorry i didn't get the last two sorry save frequency one more time for november six zero zero x-ray lima the legacy loses radio contact again brasilia november six zero zero x-ray lima as the pilots try to restore communication with brasilia the plane continues to power through the sky it's just minutes before five o'clock suddenly there was the loudest bang i've ever heard in my life the concussion itself seemed to affect every atom in my body what the hell is that let's just display the airplane dude back there no one's sure what's happened to the jet but when joe sharky looks out of the window he's stunned by what he sees the end of the wave was chopped off and it was serrated it looked like it had been chewed off it became clear that we were in very very big trouble xlr vice president ralph mchaley rushes to the window for a look at the damage i said to ralph how bad is it and he looked at me and he said it's bad with more experience flying this type of plane co-pilot paladino takes over control of the limping jet just let me fly the thing dude all right we're descending i want to get down okay it's yours the crew still can't make contact with controllers november 600 x-ray limit declaring an emergency do we have a wing tip no dammit the entire tip of the legacy's wing is breaking up that affects airflow and is making the plane hard to control yeah okay as the plane begins to descend passengers in the back are worried that the damaged wing is getting worse our main concern was that wing uh but had taken such a hit that the structural integrity of the wing was obviously in question the leading edge was separating with so much damage to the wing the pilots can't turn sharply too much stress could rip the wing right off we're in a position where we realized we were gonna die i thought of my wife and i thought well okay one thing i can do is i can write a note to my wife which i did i took out my reporter's notebook and i wrote you know a short note saying that i loved her and well you know just saying what i could the amazon is a bad place to have to land a plane it's a dense jungle for as far as the eye can see there's nothing down there but trees and i thought where are they going to put this airplane down just hours into its maiden voyage the badly damaged jet is going down palladino and laporz flying will soon be analyzed and debated throughout brazil the verdict against them will be harsh please answer november 600 x-ray lima the crew of the legacy jet searches desperately for a place to land their crippled plane captain joseph lapore finds a small military base on his chart november 6 00 x-ray lima we have an emergency state your emergency remember six zero zero x-ray lima declared an emergency we need to land at sierra bravo charlie charlie is that your airport affirmative do you know how long your runway is two six zero zero meters standby two six zero zero that's good right eight thousand feet okay we're coming in we're declaring an emergency this is november 600 x-ray lima did you see something something 2600 meters is more than long enough to land a legacy but the crew doesn't know how the plane will respond when it touches down the canopy of green there was a slash of brown two miles away i heard joe say there's an airport sir bravo we see you we're coming in finding an airport was a stroke of luck but the crew's troubles are far from over now they have to get the damage jet safely on the ground palladino and lapor can't configure their plane for a routine landing hold up let's dump the flaps at the top of the flare right so give me nine on the flare extending flaps increases the size of the wing since a bigger wing can generate more lift pilots can slow down to land with all the damage they've sustained the crew doesn't want to put too much pressure on their wing they won't be able to extend their flaps until the last moment they'll have to land faster than usual when you land under those sort of circumstances you're landing faster than you normally would and you get a real appreciation of just how fast an airplane is actually moving because you're you know you're coming down like gangbusters i see these trees now you know at ground level just sort of it looked almost like a movie with one of those moving backgrounds and i'm thinking i hope this runway doesn't run out paladino hits the brakes hard good good you got it hold it then finally the plane begins to slow good job oh man and then finally we just did come to a halt there's that that beautiful silence that occurs when the engines are shut down and everything was just quiet again for more than 25 minutes the business jet had flown with part of its wing torn off there's also damage to the plane's tail somehow high over the rainforest something tore into the plane the bizarre day takes another strange twist because they've landed at a military base soldiers confiscate the passports of everyone on board and that's the point at which i realized that we were in custody i don't think the others on the airplane had had the immediate sense that this was a custodial situation along with the two pilots the jets passengers are taken to the nearby air base the emergency on board the legacy jet has thrown brasilia acc into turmoil but it's not the only problem controllers there are facing another plane they're expecting to see hasn't shown up goal flight 1907 should be on radar in brasilia the missing flight is a boeing 737 with 154 people on board it's been in the air for two hours and should be nearing brasilia but controllers there can't find any trace of that plane manaus there isn't any gold there isn't any go with us here it's on its way they check its status with controllers who were last in contact with the plane anxiety was high and controllers were confused about what to say they didn't know what was happening deep in the amazon those who were on the xl air jet are also struggling to figure out what happened we hit something man that's all i know maybe it was a condor it was 37 000 feet well maybe it was a military jet no i think the plane must have exploded we flew at the debris field it would have been more effective as they're trying to piece together the day's strange events the group gets some shocking news [Music] a goal flight has crashed it's the plane that's been missing i just heard 737 went down the amazon right where we were it was like a thunderclap that the world changed immediately and joe and jan were just stricken i don't think i've ever seen two more anguished men in my life [Music] the gold flight crashed right where the legacy lost a piece of its wing it can't be a coincidence [Music] approximately 100 kilometers from the military base the wreckage of goal flight 1907 has been found greatest difficulty involved the fact that the plane fell straight down when it hit the ground the trees covered it up making it hard to get to the shattered remains of the plane litter the jungle floor [Music] the news hits controllers in brasilia extremely hard they had just realized that the worst thing that could happen in air control happened people were crying a lot of people had to be dragged out of the room things were not under control in the room over the next several days troops pour over the scene of the gold crash the dense jungle slows their progress to walk about one kilometer in the forest took us about an hour [Music] a makeshift helicopter landing pad is carved out of the jungle it's becoming increasingly clear that no one has survived 154 people are killed at the time it's the worst crash in the history of brazilian aviation what had happened in the skies above the amazon investigators face a mammoth job [Music] colonel ruffino ferreira is in charge of the investigation into the gold crash an investigator always has to keep an open mind you can't start with any preconceived ideas when we arrived at the location of the accident the only thing we knew for sure was that we had found the plane that was missing the wreckage of the gold jet is spread over more than two kilometers the widespread debris tells investigators that the plane ripped apart before crashing to the ground the aircraft disintegrated during the fall it hit the ground in pieces there was practically no damage caused by the impact with the ground the plane had already fallen apart just three days after the crash the plane's flight data recorder is found most of the cockpit voice recorder is also recovered except for one critical part because in this accident the impact was so strong that the module separated from the record modern voice recorders don't use tape conversations are recorded digitally onto a memory module but that part of the gold cvr has broken free without it the rest of the cockpit voice recorder is useless while the search for the module continues ferreira looks at the information from the 737s flight data recorder [Music] he learns that the plane was flying at 37 000 feet it was on course and flying level at its assigned altitude then without warning the plane pitched over and plummeted toward the ground whatever happened it was sudden and catastrophic [Music] the data recorder tells pereira that the plane spun 11 times before it hit the ground [Music] what else i can't see gold there isn't any gold with us here it's on its way so what's already in my area we're over half an hour police investigators want to know what air traffic controllers can tell them about gold flight 1907's final minutes there was no mayday in fact we never had contact with the gold jet controllers say there was no warning that the jet was in trouble it simply vanished colonel ferreira studies air traffic control data from the day of the accident there is no sign of the goal flight but the readings from the smaller legacy jet capture his attention it seems to be flying erratically instead of keeping to a single altitude the radar shows it flying up and down dangerously [Music] perhaps the private jet pilots were testing out their new plane by climbing and descending quickly they may have collided with the gold jet as a result of their reckless flying [Music] when that information leaks out to the country's newspapers it makes front page news the population thought it was unjust that a smaller aircraft was able to make an emergency emergency landing while the larger aircraft with 154 people just fell into the amazon and everyone died neither the lapor nor palladino are officially charged but they are confined to a hotel room in brazil while the investigation continues [Music] ferreira interviews the two pilots about what they did and what they saw look we are proceeding northwest on course to minnows at 37 000 feet okay we're attempting to contact brazilian control or you're changing altitude no i was on the plane had the plane been flying erratically or doing loop-de-loops or whatever it was i think i would have had a pretty good story for the new york times did you say you were flying at 37 000 feet yes that's right flight level 370 we never moved from that when he reviews the information from the legacy's flight data recorder ferreira confirms the pilot's story although the ground radar shows the legacy flying wildly the data from the plane shows that it didn't change altitude at all but there is something shocking about the legacy's path the business jet was flying north to manos the goal flight south from manhouse [Music] ferreira can see that both planes were flying at the same altitude 37 000 feet he makes a horrifying discovery for some reason the two planes were on a collision course air traffic is typically routed along specific corridors through the sky essentially highways in the air but planes traveling in opposite directions are supposed to be separated by at least one thousand feet the airway system for instance between brasilia and manos is very simple it makes airplanes fly northbound maintaining even levels and airplanes flying southbound maintaining odd levels but somehow the legacy jet and the goal 737 were traveling down the same aerial highway in opposite directions for long minutes they were heading straight for each other it seems more and more likely that the two planes collided at the crash site workers find support for this incredible theory the left wing of the goal flight is recovered investigators discover that about halfway along the wing it's sliced clean through none of the other wreckage is sliced this way the precise nature of the cut tells ferreira that this is not damage that was caused by impact with the ground the badly damaged wing would have sent the 737 into a spiral dive the pilots would have had no way of controlling it the sudden spiral motion would have pulled the plane apart it's the reason the wreckage is spread over such a wide area ferreira finds the most conclusive evidence of a collision on the legacy's damaged wing on the legacy we found very small traces of paint that came from the gold wing together the planes had a combined speed of 1600 kilometers an hour at that speed the wing tip of the small jet easily sliced through the 737 colonel ferreira now understands what caused the gold jet to crash but he doesn't know why how had the two jets ended up in the exact same airspace without anybody noticing [Music] investigators in brazil now realize that they are dealing with something very unusual a mid-air collision is a very rare event in aviation and it should not have happened with two very modern new aircrafts the situation becomes more complicated when investigators study a critical document the legacy's flight plan flight plans are filed by using a standard form which is the same all over the world the form will contain the flight number as well as requested flight level or altitude according to this document when it collided with the goal flight the executive jet wasn't expected to be at 37 000 feet the legacy's flight plan called for the jet to fly at 37 000 feet only until it reached brasilia then descend to 36 000 [Music] but the collision took place 850 kilometers northwest of brasilia well past the point where the legacy was supposed to descend so why hadn't the legacy followed its flight plan [Music] the flight plan calls for you to descend to 360 at brazilian why didn't you we weren't told to before we took off we were cleared for 370 all the way to manaus that's what we did sir i don't know where you're getting the information from yeah we followed the rules we were not told to descend and we did not decide [Music] colonel ferreira needs to check the story that the crew is telling he wants to know exactly what they were told by controllers when they took off from sao jose dos campos november 600 x-ray lima atc permission from announced flight level 370. the legacy's last instruction was to fly all the way to manhouse at 37 000 feet the pilots obeyed that instruction even though it differed from their flight plan air traffic control always can deviate from the flight plan because they have best knowledge of their actual traffic situation leaving manhouse the gold jet was also cleared to fly at 37 000 feet both planes were assigned the same altitude by controllers at opposite ends of the country once we were certain that both planes were flying at the same altitude we knew for sure there would be a lot to investigate on the side of air traffic control ferreira turns his attention to conversations between controllers in brasilia and the legacy jet the cockpit voice recorder from the legacy gives investigators a remarkably detailed look into what happened on the private jet the brand new legacy jet has a state-of-the-art recorder that captures two hours of conversation [Music] the cvr was probably the most important component in the investigation the crew is told to change radio frequencies and get in touch with the controller monitoring their flight frequency [Music] decimal one i'm sorry one two five zero five today at this point the legacy jet is approaching brasilia but the crew never receives any instructions regarding their altitude brazilian november 600 x-ray lima level seven zero good afternoon november 600 x-ray lima when the legacy overflow brasilia at flight level 370 according to the flight plan it should have been descending to 360 but air traffic controllers simply forgot to give the order to the legacy to descend to 360. the pilots would have assumed they were meant to stay at three seven zero thirty seven thousand feet no airplane should ever change altitudes without receiving instructions from air traffic control to discover why controllers didn't give that crucial instruction colonel ferreira takes a closer look at the technology used to monitor the traffic over brazil so can you call up the legacy jet stream on the radar screen we see the altitude speed and the transponder each flight has an individual code assigned to it that helps controllers track it underneath that there are two separate numbers on the left the plane's actual altitude on the right the altitude the plane is supposed to be at according to its flight plan so here the number changes to three six zero as the legacy jet passed over brasilia the number on the right the planned altitude changed the computerized system automatically updated it according to the flight plan at this point the plane was supposed to descend to 36 000 feet 3-6-0 to my knowledge only brazilian air traffic control system is using this kind of design in other parts of the world this update has to be done manually the computer changed a single number which led to a critical error without much experience with the computerized system the controller mistook the new planned altitude for the plane's actual altitude the system changed it automatically from the authorized altitude to the planned altitude which made the controller believe the legacy was flying at 360. police investigators talk with the controller who was on duty when the number changed on the screen it was shortly after that i went on break lucivando relieved me he tells police about a critical mistake on his part you have five aircraft the legacy is at three seasons before leaving he handed his flights off to another controller telling him where he thought the legacy was flying i believe it it was at 3c0 and that's what i told you when the new controller took over the one being relieved gave him the legacy's altitude information according to the flight plan but the jet was actually flying a thousand feet higher right in the path of the goal flight colonel ferreira studies transcripts of conversations onboard the legacy and finds that the crew was having their own difficulties during the flight how much longer guys that's a good question ralph the crew seems unfamiliar with some of the jets advanced systems still working out the kinks on how to work this flight management system where's the one that gives us total time my impression is that the pilots were trying to learn their aircraft systems during the flight investigators also uncover a breakdown in communications brazilian november 600 x-ray lima flight level 370. good afternoon november 6 0-0 after a brief conversation between the legacy jet and brasilia acc colonel ferreira notices something extremely unusual for almost an hour the legacy pilots don't talk to anyone on the ground they stayed 57 minutes without attempting any contact with air traffic control which seems like a lot of time after 57 minutes they tried to call 12 times without success brazilian november 6 0-0 x-ray paladino did try to get hold of ground control but he couldn't get through brazilian november 600 x-ray he then tried the backup frequencies listed on his navigation charts brazilian november six zero zero x-ray lima zero zero x-ray lima his only contact a single garbled message sorry save frequency one more time for november six zero zero x-ray lima both pilots and air traffic controller should have been more concerned of maintaining two-way contact all the time this is their duty brazilian november 6 0-0 had pilots and controllers spoken they might have discovered that the legacy was flying north in a corridor reserved for southbound traffic [Music] as the public learns about the mistakes in the air traffic control center there is growing pressure to make some changes we wanted to understand what had happened to these people inside the control room controllers should have been able to see on their radar screens that these two airplanes were flying in a collision course brazilian air traffic control is one of the last in the world to be run largely by the country's military since they're run by the military they're run by the brazilian air force we did not have complete access to information except for what was released as fingers appointed at controllers many of them come forward with stories of overwork and poor training they complained that they weren't well trained in english language was which is the international aviation language also they had complaints about their equipment in fact the controller who incorrectly reported the legacy's altitude had been on the job for only a year a valuable piece of the puzzle is still missing investigators still don't know what happened during the final minutes of the goal flight soldiers have been scouring the amazon jungle with metal detectors looking for the plane's missing memory module almost a month after the crash they find it [Music] colonel ferreira hopes to hear some reason why the gold crew wasn't able to avoid colliding with an oncoming jet [Music] thanks very much brasilia one two decimal two goal one nine or seven there are no alarms before the collision no warning that they were flying straight for another jet pilots rely on air traffic controllers to keep other planes out of their path they spend much of their time monitoring their instruments not the skies ahead at the speed they're traveling they'd only have to look away for a few seconds to miss an approaching plane there were no issues of communication and they had no idea what had just happened to their plane and fought until the end to regain control [Music] for less than a minute the pilots struggle for control but there's nothing they can do but why were there no warnings both planes were equipped with a safety feature designed to prevent exactly this type of accident ferreira now needs to know why that system failed earlier in the investigation strange radar images suggested that the legacy pilots were flying wildly over the amazon now those suspicions have vanished but ferreira revisits the fluctuating radar data to understand why neither plane knew the other was coming you see the altitude is varying significant to try to understand this last piece of the puzzle colonel ferreira returns to the radar display that air traffic controllers saw the day of the crash instead of displaying just the expected altitude and the actual altitude the letter z appears between them the set on the air traffic controller's screens indicates that the airplane he's looking at has lost its transponder modern commercial aircraft are equipped with transponders like small radio stations they broadcast information on the plane's altitude and flight number this information is received by computers on the ground and instantly displayed on the screens of air traffic controllers in brasilia if the transponder fails so-called primary radar takes over automatically signals are sent out from the ground that hit the target and return those readings are wildly inaccurate primary radar only is a passive indication of anything that is flying through the airspace the difference of the actual altitude in the primary radar system might differ several thousand feet the inaccuracy of the radar tracking the legacy jet explains why its altitude appeared to be rising and falling investigators discover that the transponder wasn't sending out signals for more than 50 minutes before the crash but controllers didn't notify the pilots that may be because they didn't notice the subtle change a form the way in which the information is displayed to the controller does not visually alert him to the change there are no flashing lights that would tell the controller that the plane has lost its transponder there's an even more critical role played by the transponder it doesn't just beam information to controllers on the ground but to other planes as well all commercial aircraft are equipped with a warning system called tcas the traffic collision avoidance system tcas gives a relative position of other airplanes within range of your own airplane tcas picks up a signal from an oncoming plane's transponder and issues a warning if it's too close if either plane's transponder is off the system won't work what the hell is that ferreira discovers that the legacy's transponder was working early in the flight and after the collision but for more than 50 critical minutes it was silent [Music] how had a state-of-the-art jet just off the factory floor developed problems with its transponder the failure of the transponder certainly contributed to this accident and we had to find out what caused it to fail is investigators examine the legacy jets transponder unit they discover that the system which controls it had a troubled history it had been installed on a different plane but removed because it wasn't working it was repaired and then placed on the jet that was sold to excel air investigators have the system tested but even with its suspicious past after the crash they can find no obvious problems with the plane's transponder now this is the layout now on the standard 1mb and the legacy jet colonel ferreira does notice something potentially dangerous about the design of the legacy's cockpit if a pilot uses the built-in foot rest during flight his toes can come in contact with the buttons on the transponder show me what it looks like in standby and when the transponder does go into standby it would be difficult for a pilot to notice there's no alarm a small yellow warning light is the only indication that the transponder isn't on it was not easy for the pals to detect that because it's not hooked up with the central warning and alert system but the pilots of the legacy jet do not remember using the plane's foot rest still working out the kinks on how to work this flight management system investigators suspect that one of the pilots may have turned the transponder off by mistake the most probable scenario is that by accident one of the pilots temporarily turned off the equipment as he tried to familiarize himself with the technology on board however the transponder went off at a critical moment the crew had no last-ditch safety system to warn them that they were flying right at a 737 even though the tcas system on the gold plane was working there was no signal from the approaching jet for it to receive closing in on each other at sixteen hundred kilometers an hour the pilots never saw each other coming [Music] brazil's air traffic control system would undergo some radical changes as a result of the collision but those changes would not come without a fight the investigation into the crash of goal flight 1907 has uncovered dangerous problems with brazil's air traffic control system brazilian november 600 x-ray lima level 370 good afternoon two planes were assigned to fly at the same altitude in the same airspace overworked and inexperienced controllers in brasilia neglected to instruct the legacy jet to descend to 36 000 feet [Music] you have five aircraft the legacy is at three then they mistook the legacy's planned altitude for its actual altitude to make matters worse the legacy pilots unfamiliar with brazilian airspace were unable to make contact with controllers on the ground and somehow the transponder which broadcasts their location in the sky went silent which controllers in brasilia fail to notice a multi-billion dollar atc system designed to keep planes apart had failed to detect two planes on a collision course one by one a series of human errors occurred and all of the defense systems that exist to avoid these errors were defeated a month after the crash of the gold passenger plane controllers begin a work to rule campaign they want to draw attention to problems with the system once they did start working to the rules and not stretching them anymore this triggered what we called the aviation crisis in brazil at a certain point maybe 40 percent of flights in all of brazil had over an hour delays following the crash and the work slow down changes start being made there has been a lot of changes in brazilian aviation after the accident specifically with regards to air traffic control the air force had to admit that they had a shortage of controllers and also there's a higher degree of accountability [Music] in the united states the federal aviation administration issues two recommendations as a result of the tragedy pilots flying legacy jets are warned of the possibility that putting their feet up in the cockpit could accidentally turn off the transponder and manufacturers are told that an alarm should sound if the tcas system shuts off [Music] the controllers who are involved in the crash are charged with varying degrees of manslaughter but those criminal charges worry people who were closely involved with the disaster an investigation like ours which focuses on prevention suffers huge setbacks when there is pressure to lay charges by blaming people we might be creating a culture where people will not come forth and be honest about failures and mistakes and when we try to hide that things get swept under the carpet and soon enough they'll come out again no controller leaves his home in the morning thinking he's going to crash a plane and so the criminalization only interferes with investigations that can prevent further accidents [Music] more than two months after the crash the crew of the legacy jet is finally allowed to return to the united states joe and jan barely got out of the country uh there was an attempt to to hold them under uh what i thought was a cobbled together initial criminal charge of quote failing to ensure the safety of brazilian skies while we are all grateful for the safe return of joe and jan and everyone aboard the legacy we are all saddened by this tragedy which took many innocent lives more than a year after the accident the legacy jet that survived a mid-air collision was still at the airfield in the amazon its maiden voyage cut short by a tragic series of technological and human errors [Music] at los angeles international airport united airlines flight 718 is preparing to depart for chicago the dc-7 is the newest and fastest passenger plane in america the pride of the united fleet [Music] i'm sorry sir there's no smoking until after takeoff in 1956 airline travel is something few people have had a chance to experience there are only 117 commercial aircraft in the entire state of california the girls were off bound for new york they were walking on air even before they got on board flying had a panage about it now part of this was because it cost a lot and there was a level of exclusivity about it but there was also a level of civility about it expertly prepared and tastefully served it was a special deal a dc-7 can carry almost 100 passengers non-stop from coast to coast it was no longer a situation where people said well you're going to go fly commercially you're putting your life on the line it was getting to be reliable it was getting to be if not ubiquitous and fairly common chicago for dinner gentlemen dinner can't come soon enough for me door closed and secure guys the dc-7 is powered by four huge engines each one has 18 cylinders the right 3350 turbo compound is a technical marvel but it demands a lot of attention good morning ladies and gentlemen and welcome aboard united airlines 718. our captain today is bob shirley you're in good hands 48 year old captain bob shirley has more than 17 000 flight hours he's been on the plum la chicago route for nearly a year bob shirley was an excellent pilot clay lacy is a former united pilot who was with another crew flying out of los angeles that morning he was uh highly regarded as a pilot and uh he had his own airplane and this guy loved aviation twa is running a little late this morning the 36 year old first officer robert harms is a world war ii veteran and a former flight instructor well we're on time guys let's keep it that way i'm three pages into the checklist the third member of the united airlines cockpit crew is flight engineer gerard fiore engine number one rpms 2100 the flight engineer was a busy fellow and he fine-tuned the power plants uh individually and even by cylinder checking magneto's left both right both rpm is good for left and right the proper heat mixture controls and cow flaps and so on and so forth to keep those power plants running uh at their best cylinder head temps are in the zone hello dr fiore we are blessed this morning she's all yours captain while the united crew waits to taxi the tower controller gives instructions to the plane ahead of them a twa flight to kansas city pwa2 cleared for takeoff on runway two five right roger copy cleared for takeoff too far right [Music] united flight 718 taxi to position and hold you are next on runway two five left united 718 copy taxi and hold runway 2-5 left the united flight is right on time this morning keeping to schedule is important in the small but growing air travel business where many flights carry at least some first-time passengers as they kept adding flights passengers kept coming it was almost an if you schedule it they will come situation united flight 718 cleared for takeoff take off clearance and gain take off thrust [Music] 80 knots check 120 knots [Music] v1 rotate at 904 in the morning flight 718 lifts off from los angeles the trip to chicago should take about six hours captain shirley must follow an assigned corridor through the airspace around los angeles after that he's free to fly wherever he wants as long as he reports passing a series of waypoints along the route to chicago if you had to divert it was no real big deal we did not have the sophistication of the radar equipment we have today back in the 50s there was a big sky out there and that was kind of the way everybody thought of it there weren't that many airplanes up there can i offer you something to drink man the engines sound good mr fiore how are the temps hey old steady skipper still running a little rich we were very interested in those days and policing the passengers oh time for some introductions knock yourself out good morning folks captain bob shirley here it is a beautiful bright day we're almost at our cruising altitude of 21 000 feet which is almost exactly four miles if only ten percent of the people have flown we were certainly trying to get more people to fly so i tried to make it a fun uh interesting experience 54 minutes into the flight the dc-7 reaches its second waypoint united 718 we're at needles 958 21 000 feet clear skies course direct to durango estimate crossing the painted desert line at 10 31 10 31 the crew will next check in when they cross a point on the map known as the painted desert line i'll try to get you some spectacular views in the next half hour so let's take glue to those windows we're just crossing into arizona on the right you can see lake havasu up where we are it's about 10 below zero so don't go rolling down those windows now cruising at 21 000 feet the crew spots thunder clouds ahead and adjusts their course back in those days if we'd see a thunderstorm head or a line of thunderstorm we'd turn and try and go between two of the cells and uh without radar we didn't tell anybody we'd just stare around folks we got a little weather so it could get a bit bumpy nothing to worry about just keep your eyes peeled and you'll get a spectacular view no matter where you're sitting how are we doing on your side bob thunderhead five miles south we're clear of it damn shocked passengers have no idea what's gone wrong oh god [Music] [Music] flight 718 is overdue to check in calls from dispatch go unanswered united united [Music] air traffic control headquarters in salt lake city ca salt lake controllers here don't normally communicate directly with flight crews they get flight information by phone from airline dispatchers who are in radio contact with their pilots at 10 51 they get a disturbing call from united airlines dispatch salt lake understand united 718 20 minutes overdue at painted desert moments later another dispatcher calls more disturbing news salt lake twa i'm getting no response from flight 2. understand twa flight 2 20 minutes overdue at painted desert we have had no contact here controllers now know that two planes flying from la have not reported crossing a scheduled waypoint the painted desert line united flight 718 and twa flight 2 to kansas city were both expected to reach that waypoint at 10 31. caa salt lake twa flight 2 do you copy in the absence of a radar beam hitting an airplane if the airplane disappears you're not going to know that anything is wrong until probably the second time that they fail to hit a reporting point they're supposed to get on the radio and report their position twa2 caa salt lake do you copy twa flight 2 is carrying 70 people there are another 58 aboard the united flight and dispatchers can only wait for some response to learn their fate i had a trip that morning in a dc six from los angeles to denver we got over bryce canyon about the same time that air inc was calling united 718 c.a salt lake do you copy maybe twice a minute they were trying to get a hold of and i remember slam who was above shirley's boss uh he says ah that bob isn't listening to the radio you know more than an hour has passed since the planes were last due to check-in controllers send out a bulletin asking local authorities to keep an eye out for the two missing planes and painted desert that's where you expected to hear from at least one of those two airplanes when neither of them were heard from that's the time that the hair is going to begin to stand up on the back of the heads of the controllers two commercial airliners are still missing somewhere over the arizona desert finding an aircraft in those days before we had various locator beacons before we had the the radar systems that we have today indeed was looking for a needle in a haystack the next morning news comes from authorities in arizona confirming everyone's worst fears they found him the remains of two different planes have been spotted in arizona's grand canyon there was a gentleman named palin hudgins who was an air tour pilot who had heard that they were missing airplanes and he was flying along looking at anything he could see down there and he sees some smoke coming up from char butte the twisted wreckage of united 718 lies on a rocky ledge 210 meters up the sheer canyon wall the air tour pilot spots the second crash site on the floor of the canyon about two kilometers away he banks around comes in for closer look and there is the most distinctive structure in commercial aviation at the time the tail of a constellation with the three prongs there's just no mistaking that we had one aircraft up on a bluff we had pieces down in crevasses engines and parts lying in various places the immediate priority is to get rescuers into one of the least accessible places in north america when you talk about an accident in the grand canyon you're talking about both hostile inaccessible remote and dangerous richard rodriguez is a former investigator with the civil aeronautics board you're a thousand feet above riverbed for instance depending upon where you are so it's a very dangerous place to work [Music] when rescuers finally reach the crash area they first find the scattered remains of twa flight 2. reaching the wreckage of the other plane will be even more difficult these are mountaineers from denver's rocky mountain rescue club near the rim of the grand canyon gorge they collect their gear these mountaineers will attempt to scale the steep walls from the floor of the canyon in order to reach an abutment on which rests the shattered wreckage of the united airlines dc-7 it's not long before rescuers come to a grim conclusion everyone aboard both planes is dead it is now up to investigators from the civil aeronautics board to piece together what happened the grand canyon is a graveyard for 128 passengers and crew of two airliners which crashed on peaks little more than a mile apart the impact reduced the wreckage to carbonized smears of paint and metal none survived [Music] the sudden loss of two of america's most modern airplanes shocks a country that has come to think of air travel as luxurious and safe we were not familiar as a people with having massive tragedies like this and a huge body count especially in this fledgling thing called commercial aviation we were used to an airplane crashing every now and then it was a fairly common occurrence but not two very safe airliners air accident investigators are shuttled to the crash site by helicopter the investigator of course is driven by a desire to know what caused the accident for the simple reason that we want to prevent it from ever happening again the team's lead investigator is well suited for the job jack parshall is an aviation legend not only an experienced pilot but a crash survivor himself this was one of the pioneers this is the guy who's flown air mail he's done it all over the years and he's also had four crashes of his own you would want somebody exactly like this on the job of trying to piece together the dynamics of a crash as well as piece together the metal all right let's figure out what's what start mapping this up the pieces on the ground will tell parshall what happened in the air folks who got little weather so it should get a bit bumpy how are we doing on your side bob thunderhead five miles south could a sudden thunderstorm have produced turbulence violent enough to knock both planes out of the sky jack parshall doesn't have any of the advanced technology or the considerable body of knowledge that modern day investigators have come to rely on it was night and day between the tools that the national transportation safety board has now and what they had then uh just it literally was a different world they had very little broken fragments of the plane and his own expertise are all he has to solve this mystery this is what's left of the cockpit there were no black boxes like there are today it really was by the seat of your pants situation and in fact this was the age in which accident investigation began to grow up hard enough to melt aluminum at the twa crash site partial finds evidence of an intense post-crash fire but that doesn't tell him what brought the plane down where's the connie's tail from here [Music] okay let's take a look investigators locate the constellation's distinctive triple tail about 500 meters from the rest of the plane well well well the distance tells parshall that the tail came off the plane before it hit the ground if he can figure out why the tail came off in mid mid-air he'll be one step closer to finding the cause of the crash check this out the wreckage of twa flight 2 shows clear evidence of a catastrophic impact the plane's skin has been shredded parshall also finds small streaks of blue paint i'm gonna need this product to the hanger on the canyon floor 700 meters from the constellation lies a piece of the other plane the dc-7's wingtip is streaked with red paint and is nowhere near the rest of the plane it also came off in mid-air it was a smoking gun when you find red on an airplane that has no red that pretty well proves the point that something happened up there that was not part of that airplane as it took off los angeles this is one of the things that cinched the deal the evidence points to an incredibly rare almost unheard of event they definitely swap some paint up there it wasn't severe weather that brought down two planes from two of america's largest airlines what's he doing there it was a mid-air collision for a dc-7 crew to look up and see a white constellation right in their face first of all there's going to be a a nano second or two of absolute complete disbelief oh god baby come on muscle memory kicks in for any experienced pilot and that's when the yolk gets grabbed and thrown in in whatever direction raising the wing trying to get out of the way but the dynamics at that point in time are too late the collision over the grand canyon is one of the most significant accidents in the history of commercial aviation it was an earth-shaking event uh that took place there that day what jackpot parshall uncovers through his investigation could affect commercial aviation across the country already certain there's been a mid-air collision he now needs to figure out exactly how the two planes collided and why we get that piece over there please thanks guys parshall has to recreate the final moments of the two flights based on bent metal and streaks of paint it was one heck of a challenge to match those two aircraft up and come to a deduced conclusion as to what happened they start to look at models in a mid-air collision to put things together and figure out could this wing have interfered with this horizontal stabilizer etc now let's see what we got in the dc7 to try and build a scenario that matches some of the minute clues that they may have like impact marks like paint transfer marks [Music] [Music] take a picture please the paint transfer evidence tells parshal that the dc7's left wing hit the constellation from behind it was obvious that the dc-7 had probably overrun the constellation from the right rear side had come apart literally knocked the tail off the constellation plummets towards the grand canyon more than 17 000 feet below united 718 has lost half of its left wing but not all of its engines what's the damage number one engine is out airspeed 260. 8 000 now anyone who survives emitter collision is luck because it depends on what the damage to their airplane you have to have enough left to control the airplane [Music] less than a minute after the collision twa flight 2 slams into the canyon floor in the dc-7 bob shirley and his crew struggle to avoid the same fate this airplane is going to be rolling rapidly to the left and it has no control [Music] parshal now understands the mechanics of how the two planes collided but he still doesn't know why their flight paths crossed they were supposed to be flying different routes at different altitudes they should not have been in the same place at the same time now needs to know how that happened today the only three bodies found from the united airlines plane were brought up by helicopter here army cab and airline officials talk over future operations as this sombra announcement is made that next monday a single reverent burial service in three faiths is planned at flagstaff arizona for the unidentified victims of the two planes this crash in the grand canyon startled everybody and galvanized the country i would just imagine that parshall was very cognizant of the fact that this was probably the most critical investigation he had ever been involved with and that the consequences for getting it wrong in any respect could have tremendous negative ramifications for this fledgling industry investigators continue climbing through the wreckage of two passenger planes and collided over the grand canyon jack parshall reviews the plane's flight plans so they both start the day at lax united flight 718 taxi to position and hold let's see 718 was cleared green airway 5 out of la direct to palm springs junction to needles then on the painted desert line here at 21 000 feet twa was cleared amber airway five green airway two direct to daggett and crossing painted desert line at 19 000 feet either one of them should have been over the canyon it's clear both planes diverted from their original flight plan but parshall knows that's not uncommon what you would find pilots doing is they would file a flight plan along the airways and once you get airborne and you're more or less out of the heavy congested area of an airport then you refile your what you really want to do which is direct here direct there direct someplace else with no cockpit voice recorder to help them investigators turn to radio dispatch recordings and transcripts the radio calls between the pilots and their company dispatchers may hold clues about the routes the two planes actually took that day united seven eight we're at palm springs junction united seven one eight we're at needles 21 000 feet clear skies that's the last one there reported of course direct to durango estimated crossing the painted desert line at 10 31. 10 31. they had 33 minutes to get there so how come they never made it to answer that question parshall needs to learn more about the movements of the other plane now lying at the bottom of the grand canyon let's see what twa did pwa2 cleared for takeoff on runway two five right roger coffee cleared for takeoff two five right twa flight two took off three minutes ahead of the united flight in a different direction it was to fly northeast towards its first checkpoint daggert dwa2 on route kansas city passing daggett at nineteen thousand roger twa two one nine thousand at daggett the twa pilot was jack gandy with 15 000 hours as captain he was nearly as experienced as united's bob shirley gandy knew these skies well he'd flown this route nearly 200 times good morning twa dispatch twa2 we've got a little bit of weather here we want to get on top of be a good man and ask salt lake to clear us to 21 000. [Music] roger twa 2 requesting clearance at twenty one thousand feet so twa asked for twenty one thousand so solid clears them no requests deny due to conflicting traffic advisory twa2 unable to approve to 1 000 due to traffic that's a no-go on 21 000. united 718 is captain gandhi wants to avoid the clouds in his path and in 1956 he has another way to accomplish that let's just get on top of this stuff he uses visual flight rules or vfr roger that if i salt lake i'm going to vfr and 1000 on top salt lake twa 2 requesting 1 000 on top maintain at least 1 000 on top advise twa 2 his traffic is united 718 direct durango the twa crew was cleared to fly a thousand feet above the clouds but warned to look out for united 718. well they used to have a procedure to operate a thousand feet on town you made you stayed a thousand feet away from clouds but you stayed in the clear and you were supposed to be vfr looking around for traffic so at daggett he asked for 1 000 on top that's all fine so where does that get him his next report is from mojave at 9 59. twa 2 passing lake mojave 1 000 on top at 21 000 estimate painted desert at 10 31 half an hour after requesting 1000 on top gandhi reports his actual altitude 21 000 feet now they're both there they could fly at any altitude they wanted as long as it was a thousand feet uh separation from those clouds so they took a thousand on top and then selected to fly at 21 000 feet investigators now understand how the twa flight ended up at the same altitude as united 718. as for why both planes diverted from their scheduled routes at the same time damn what's he doing [Music] the answer is the crash site itself an awe-inspiring natural wonder let's give them a look shall we all right captain it was common of making a few turns over the grand canyon to show people the grand canyon i mean that happened every flight because the grand canyon is such a spectacular sight wonderful sights to see way down below the grand canyon for instance one of the seven wonders of the world sightseeing in terms of what you could show to the passengers was something that really lit up the senior flight crew i can actually show you something that nobody else can show you i can dazzle you with things that you as an ordinary human being who doesn't fly would never see just keep your eyes peeled and you'll get a spectacular view no matter where you're sitting how are we doing on your side bob thunderhead about five miles south we're clear of it okey-dokey we've got some room you were free to if you wanted to dv a little bit for sightseeing uh that you could it wasn't dangerous nothing dangerous about him damn but on june the 30th 1956 it proves fatal god jack parshall needs to find out how such a common practice killed 128 people from the very beginning of aviation um we had the concept of see and avoid or see and be seen the responsibility for separation of aircraft was still the pilot's responsibility parshall knows that united hit twa on the right side coming from behind one of the pilots failed to see and avoid parshall needs to figure out which one what's he doing the answer will lead to sweeping changes in the rules governing commercial aviation all right let's see what captain shirley can see out there using a scale model of the dc7 cockpit and airspeed estimates for both planes parshall tries to calculate the distance at which the united pilots could have first spotted the constellation what were the views of the flight crew members from each one of the aircraft could they have seen each other did they try and avoid each other so they ended up like this let's go back a couple of minutes those are the kinds of things that that investigator in charge i'm sure was asking himself and getting his team together to try and deduce from the evidence we'll need you over there investigators begin to suspect that there may be serious problems with the whole idea of see and avoid keep going keep going let me tell you one of the dirty little truths of commercial aviation from the 50s all the way to now we have been under sea and a void but you can't see in most cases even to avoid and that's because the windows are very small i keep going a little bit further keep going stop come back half a step right there that's where shirley would have first seen the connie since the dc-7 was behind the constellation it was captain shirley's responsibility to avoid it oh god come on baby come on parshall wants to find out if he had enough time to do that there are basic rules and those basic rules are to uh indeed if you see an impending situation the overtaking aircraft will give way to the aircraft in front the six pilots in both planes were preoccupied with the demanding job of flying their aircraft you had a pistol plane you had the throttles you have the propeller rpm to adjust your rpm the engines sound good mr fiori how are the tennis yeah old steady skipper still running a little rich there's really a lot more to do a lot more to do flying a a piston airplane that'd be 53 miles pashal's test shows that in theory the constellation would have been visible to the dc-7 crew when it was 85 kilometers or 53 miles away the numbers suggest that captain shirley had two full minutes to avoid a collision that's more than enough time to safely change course oh god come on baby come why that didn't happen [Music] the answer becomes clear when he reviews the radio recordings dispatch twa2 we've got a little bit of weather here we want to get on top of you good man and ask salt lake to clear us to 21 000. on june the 30th the skies over arizona were not clear folks we got a bit of weather over the canyon so it could get a bit bumpy nothing to worry about how are we doing on your side bob thunderhead about five miles south we're clearly donkey donkey we've got some room they were flying i hate to say fat dumb and happy but in effect that's a phrase we use when you think everything's copacetic when he factors cloud cover into the equation partial reaches a stunning conclusion the crew of flight 718 had just seconds to recognize and avoid the plane ahead of them boom the collision was unavoidable you have seconds to respond to identify to develop a or formulate a evasive maneuver and execute it and for the aircraft to respond to any control inputs that you put in there there was no indication in the heads of any of the pilots on either of those two flight decks that they were in proximity of anybody else in a dangerous way until they came around a cloud and all of a sudden the dc7 crew has a connie right in their face and the connie crew i'm sure that they to the moment of death had no idea whatever hit him when jack parshall sits down to report his findings he faces intense pressure the reputation of an industry hinges on what he has to say we're really there to try and prevent the next accident a recurrence of similar circumstances that set up an accident but certainly with the uh high death toll 128 people died that day two major airlines of america running into each other there was a call to find out who was guilty who was to blame the obvious conclusion is that the pilots were to blame that's a no-go on 21 000 united 718 a lot of people want to lay the blame on twa's captain jack gandy roger that by salt lake i'm going to vfr and 1000 on top it was gandy's decision to switch altitudes that put his plane in the path of united 718. but a strict interpretation of the rules would put the blame on united pilot captain bob shirley damn what's he doing there in a perfectly sterile analysis of this the overtaking aircraft the one who's overtaking the other aircraft has the legal responsibility of avoiding the aircraft they're overtaking right there but partial's calculations have shown there was no way for captain shirley to avoid the collision i think it's not only fair to say that these two crews were following the rules and doing everything the way that they understood it should be done 21 000 feet now they're both there but that this was the way society in aviation viewed the broad way to do it at the time there is one last possible culprit the air traffic controller who told twa about the united flight but didn't advise the dc-7 crew about the constellation maintain at least 1 000 on top advise twa 2 his traffic is united seven one eight there was an attempt to throw blame in all directions very human very understandable by the same token when it came to blame put on the air traffic controllers it was very misplaced with no radar coverage air traffic controllers could not visually track flights it was impossible for them to advise every company dispatcher on the precise location of every plane in the sky i think if we try and pin the issue down to who was to blame we're probably looking at the at this this accident in an inappropriate way it has become clear to parshall that no one person is to blame for the mid-air collision those two aircraft were put in the proximity of each other by the rules and the regulations the real cause of the crash is something much bigger something that goes to the very heart of aviation in america jack parshall concludes that blame for the grand canyon disaster lies not with the pilots not with the controllers but with a completely inadequate air traffic control system the subtext in that report had to be very delicately placed in front of the congress and the american public but the subtext is very clear and that is you know it's not a matter of the system being broken guys we don't have a system this is a great non-system of air traffic control and until we get a handle on that we are not going to be able to rise to the level of assurance of separation in any degree that the public is obviously expecting the grand canyon crash and jack parshall's report provoked dramatic changes in american aviation as a result of the event in the grand canyon something new was born there was a a new awareness to the public's right desire and interest in air travel and that was fostered by lots of very innovative designs and traffic collision avoidance systems that are present in today's environment the main outcome of the grand canyon collision is that the united states now has a nationwide radar system controllers can now track the movements of planes in even the most remote parts of the country the only way you're going to assure that this will never happen again is if you've got somebody positively controlling whoever's up there to where they cannot get too close to each other they can't change altitudes at the right time you can't mix the traffic and that meant radar coverage across the entirety of the country despite all the advances air traffic controllers still face challenges more planes in the sky flying faster and higher than ever before and though extremely rare mid-air collisions still do occur [Music] so in response aviation officials are developing a system that could transform air traffic control in america the next generation air transportation system or next gen will use gps satellites to give pilots the precise location of the traffic around them by the year 2020 pilots will know exactly how close they are to all other aircraft without air traffic controllers having to tell them hopefully the next generation of air traffic control will look back on that event of the grand canyon and we'll try and get ahead of it before such another tragedy uh does uh recur as the era of romantic air travel fades into history the lessons learned from the grand canyon disaster remain flying can always be made safer i'm reminded constantly anytime i study an older accident of something that was said by george santiana in 1917 an american philosopher who said those wonderful words he who cannot remember the past is condemned to repeat it you

Channel: Mayday: Air Disaster

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Id: -bXJy6Ub6J8

Length: 141min 33sec (8493 seconds)

Published: Fri Mar 18 2022