- 30/5/2025
This special looked at accidents caused by pilots ignoring their training.
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00:00Runway heading clear for takeoff 191
00:05Commercial pilots receive extensive training
00:10Let's go flaps 10 and we're going to figure it early too
00:12To help them react properly to an emergency
00:15We're climbing to 4,000 to echo x-ray
00:18But when that training is ignored
00:20Oh yeah, there it is, approach lights in sight
00:23I don't see anything
00:24Why is the captain even looking for the approach lights?
00:28Dangerous situations can become deadly
00:31Under knots?
00:32That is weird with no lights
00:33Yeah
00:34What the heck is he talking about?
00:37This pilot was one of LA's top helicopter pilots
00:40How did he let himself get into this situation?
00:47He ignored all his training
00:49Investigators search for answers when pilots of three aircraft
00:53Skip protocols and crash
00:56When pilots don't follow the training that they've been given
01:00This is not a place that you want to be
01:02When you're sitting in the back as a passenger
01:03How's everyone doing today?
01:27Helicopter charter pilot Ara Zabayan
01:30Welcomes a familiar client for today's flight
01:33Basketball superstar Kobe Bryant
01:36Let's get going
01:40Kobe, his daughter Gianna, and six others
01:46Are flying out of Santa Ana, California
01:48For a basketball tournament near Camarillo
01:5180 miles away
01:52Hey everyone, it's about to get loud back there
01:56Zabayan is chief pilot for Island Express
02:02Which flies VIPs around Southern California
02:06Copter 72 Echo X-ray Island Express for East 1 departure
02:10Kobe and the pilot of this helicopter had really become friends
02:15Because he had piloted him so many times around Southern California
02:19That they developed a relationship
02:21They're flying in a luxury Sikorsky S-76B
02:26Configured to carry eight passengers
02:28The Sikorsky S-76B is sort of like an air limousine
02:33In that it's quite common for VIP travel
02:36Just after 9am, the helicopter lifts off from Santa Ana
02:41From here, Zabayan will navigate using the highways around Los Angeles
02:46As a visual reference
02:48Landmarks for flying aircraft in L.A. is really important
02:55Burbank Helicopter 72 Echo X-ray Sikorsky Helicopter
02:59Approaching the zoo for a 101 westbound transition
03:0213 minutes into the flight
03:04Zabayan requests permission to pass through Burbank's airspace
03:08The controller denies his request because of low visibility
03:12Burbank is only accepting flights where pilots navigate solely on instruments
03:17And Zabayan is only authorized to fly by visual flight rules, or VFR
03:23The threshold for the visual flight is normally three miles
03:29The Burbank airport was two and a half miles
03:32But Zabayan knows a way around this restriction
03:36Asking for special VFR transition to the 101 westbound
03:40The controller authorizes the request
03:43Allowing Zabayan through the low visibility airspace once it's clear of traffic
03:48Copy that, we'll maintain special VFR, copter 2 Echo X-ray
03:52Zabayan will need to stay out of the clouds
03:59Which are about a thousand feet above the ground
04:02The way he went was the lowest route available
04:07Because of the weather
04:09The controllers would not see him on radar, he was so low
04:13Kobe Bryant and the other passengers are less than 10 minutes from their destination
04:21But now, the visibility gets even worse
04:26Zabayan radios the controller handling the last leg of the flight to Camarillo
04:33For permission to climb above the clouds
04:35We're going to go ahead and start our climb to go above the layers
04:39Two Echo X-rays, say intentions
04:46Uh, we're climbing to 4,000, two Echo X-ray
04:50And what are you going to do when you reach altitude?
04:54Kobe Bryant, his daughter Gianna
05:19And the seven other people in the helicopter are dead
05:22I'm just at a loss for words right now
05:26You won't see another player like him again
05:30He will be missed
05:31Why did a state-of-the-art helicopter crash just 24 miles from its destination?
05:43It's up to investigators from the National Transportation Safety Board to find the answer
05:48We need to cover all our bases on this one
05:51Knowing that there was a high-profile person on board
05:55Obviously NTSB responded with a major investigations team
05:59They start by examining the engines and rotors
06:04As well as the helicopter's flight instruments
06:06All the mechanical systems, electronic systems
06:09Everything at that time appeared to be working fine
06:12Okay
06:13He takes off at 907, he flies northwest
06:16Investigators can piece together a detailed flight path from an ADS-B system installed on the Sikorsky helicopter
06:25ADS-B data is like transponder data
06:30Controllers can see that it's recorded
06:34Your airspeed, altitude, and headings
06:38He follows the I-5 to Van Nuys
06:40And then south to the 101, which he follows until he makes this U-turn
06:45Straight into a hillside
06:47You would see this turn to the left
06:49Where he's coming back around or doing something
06:52What's exactly the pilot doing here?
06:55Let's take a look at the visibility
06:57Investigators study visibility reports from weather stations along the route
07:03A bit socked in near Burbank and Van Nuys
07:07But nothing he can't get through
07:09When he got near Burbank Airport
07:12It was two and a half miles visibility
07:13But still totally flyable for him
07:16They look into the career and background of pilot Ara Zabayan
07:21More than 8,300 flying hours
07:23Instructor on the S-76
07:26Chief pilot at Island Express
07:28This pilot was not a rookie who just got his license
07:33He was one of LA's top helicopter pilots
07:37Working for one of its top companies
07:39I get it if the visibility was down to zero
07:43But this wasn't that bad
07:45So what happened to this guy?
07:47Why do we have a high-time pilot
07:49In an aircraft that's capable of flight
07:52And visibility conditions he should have been able to handle
07:55Either lose control
07:57Or somehow inadvertently fly his helicopter to the ground
08:01How's everyone doing today?
08:03Records show that before he welcomed Kobe Bryant's party on board
08:07Zabayan checked the weather
08:09And determined that even though there were clouds blanketing the area
08:12The flight was low risk
08:15But the low clouds surrounding Los Angeles
08:18Forced Zabayan to alter his usual, more direct route
08:22Because of the weather, he'd flew more inland than he normally does
08:28Based on the forecast, his plan was okay
08:31So what went wrong?
08:37Investigators need to know the exact conditions Zabayan flew into
08:40In the final moments of the flight
08:42We need to figure out what he could actually see
08:45The NTSB obtains photos that captured the last moments before the crash
08:51Okay, you can just make him out here
08:55Actually heading into fairly heavy clouds
08:57Same camera, three seconds later, he's disappeared
09:01They could collect data in real time
09:05Of what this pilot would have been encountering
09:07So the cloud base was no more than 450 feet above the ground
09:12Not the 1,100 feet which was being reported along its route
09:15Surveillance data shows that the helicopter was only 450 feet above the ground
09:22Investigators determined that just over a minute before the accident
09:26Zabayan flew into dense cloud which would have reduced his visibility to near zero
09:32Legally, he's not allowed to enter it
09:36He's only allowed to go in visual conditions only
09:38And yet he did
09:40Flying into cloud banks with low visibility is a leading cause of aviation accidents
09:47In a helicopter, the consequences are often fatal
09:51You can't see where the horizon is
09:53And you can't see the sky from the ground
09:56Pilots like Zabayan are trained to do whatever they can to avoid such conditions
10:01How do you let himself get into this situation?
10:10Investigators take a closer look at the speed the helicopter maintained
10:13While en route to Kobe Bryant's basketball academy at Camarillo
10:18He's bombing along here at about 140 knots
10:23Visibility is getting worse and worse
10:25But he's not slowing down
10:27He's not turning around
10:28He just keeps going
10:30Why?
10:33He could have turned around
10:34Landed at Van Nuys
10:36He could have circled for a while
10:38We're near the airport
10:40Waiting for the conditions to improve
10:42For whatever reason we don't know
10:44He chose none of those options
10:46It doesn't take long for things to start going wrong
10:49As soon as he enters that cloud
10:50Instead of turning around
10:53Zabayan decides to climb above the clouds
10:55We're going to go ahead and start our climb to go above the layers
10:58He starts banking further and further left
11:04Descends rapidly
11:05Hits the hill here
11:07The helicopter's unusual movements
11:11Lead investigators to wonder about the level of training the pilot received
11:15They discover that Zabayan was well trained to escape the precise conditions he flew into
11:22More than that, he was the chief pilot of the company
11:25He set the safety standards for all the pilots
11:28And he trained them on how to deal with instrument conditions
11:32It's one of the reasons that Kobe Bryant flew with Zabayan so often
11:37The director of operations says that Kobe's relationship with Ara was
11:42Quote, warm and friendly
11:45That he trusted Ara with his girls and his family
11:48And that they always wanted Ara
11:50A review of Zabayan's training shows that he was taught to reduce speed
11:58Use the autopilot to climb above the clouds
12:01And then declare an emergency
12:03His training was good
12:06But did Zabayan follow that procedure?
12:11Here he's entering an area of low visibility
12:13Still flying well above 100 knots
12:16No evidence of slowing down
12:18Look at that rate of climb
12:221,500 feet a minute
12:24Can't be the autopilot doing that
12:27That exceeds the authority of the autopilot system
12:30Therefore this climb was being manually controlled
12:32The higher the helicopter climbs into the dense clouds
12:36The worse the visibility becomes
12:38But Zabayan never asks for help
12:41He should have been saying
12:43Mayday, mayday, mayday
12:45There's an emergency
12:47He didn't slow down
12:49He didn't use his autopilot
12:51And never declared an emergency
12:53He ignored all his training
12:55There are basic procedures that should be followed
12:59And you have to have a very cautious approach
13:03To any sort of instrument conditions
13:04This was not evident
13:06In the way the pilot flew that day
13:08With no regard for protocol
13:14Zabayan continues a rapid climb
13:16With no visibility
13:17And without the help of the autopilot
13:20We're climbing to 4,000
13:22Two echo x-ray
13:23Did you hear that?
13:25On the CVR
13:26Investigators hear him report
13:28That he's climbing
13:29When he's actually descending rapidly
13:32The highway now veers off to the right
13:37But he's lost sight of it
13:38He's banking further and further to the left
13:40Without even realizing it
13:42There's no sign he ever figured out
13:44What was really happening
13:45We're climbing to 4,000
13:49Two echo x-ray
13:49Kobe Bryant and eight others die
14:07As a result of an all too common scenario
14:10A helicopter pilot flying into low visibility
14:13And becoming disoriented
14:15The industry needs to realize
14:17How common and sinister
14:19These effects can be
14:20And develop better safety standards
14:22On the recommendation of the NTSB
14:25The Federal Aviation Administration
14:28Is evaluating tools
14:29That can be used to train more pilots
14:31On how to recognize and cope with
14:33The effects of disorientation
14:35The last thing the NTSB wants to do
14:40Is go back and investigate
14:42This kind of accident all over again
14:44The pilot of Kobe Bryant's helicopter
14:47Had all the training he needed
14:48To avoid the situation altogether
14:50But that education was disregarded
14:54When it was needed most
14:55Training is an essential part of aviation
14:58At every level
14:58And when that training is ignored
15:00Specifically ignored in a situation
15:03Where the training should be put to use in flight
15:05It could lead to an accident
15:07When pilots fail to follow
15:12Every aspect of their training
15:14I don't see anything
15:16Oh yeah, there it is
15:17Approach, sight, sight
15:19Even the most routine procedures
15:22Can lead to disaster
15:23No
15:24No
15:25Trees
15:26No, stop
15:27Oh my God
15:28If we have to go missed
15:41We'll set max power
15:42Flaps 10 positive break
15:43Gear up
15:44The pilots of corporate airlines
15:47Flight 5966
15:48Conduct the approach briefing
15:51For Kirksville, Missouri
15:52Regional airport
15:53Then we'll climb 3,000 feet
15:55Then direct Kirksville VOR
15:56Captain Kim Sassy
15:58Has been a pilot
15:59Since the late 1980s
16:01But only started flying professionally
16:03In the last five years
16:05I'll ask you to walk me through that
16:06If we need it
16:07Roger that
16:08First officer Jonathan Palmer
16:11Has three years professional flying experience
16:14With regional airlines
16:15The pilots viewed your time
16:18With the regionals
16:19As somewhat of the dues
16:21You pay to get to the airlines
16:23Or the high-end corporate jobs
16:24There are 13 passengers
16:27On board the 50-minute flight
16:28From St. Louis
16:29To Kirksville, Missouri
16:31We're going into the crap
16:39Look, it's so eerie and creepy
16:43The pilots are flying a Jetstream 32
16:46It's fuel-efficient and reliable
16:49But this particular model
16:50Has no autopilot
16:52The Jetstream
16:53Not having any autopilot
16:55Made our days very long
16:57You had to constantly fly a jet airplane
17:003,000 until established
17:02Cleared for the approach
17:04The crew is flying
17:06A non-precision approach
17:07With no vertical landing guidance
17:09Let's go flaps 10
17:11And we're going to figure early too
17:12Configuring for landing early
17:16Reduces the workload
17:17As they near the airport
17:18In any non-precision approach
17:20You want to minimize
17:21The number of variables
17:23And one of the ways you do that
17:24Is you get the airplane
17:25In a position to land
17:27Earlier than normal
17:28Let's make sure the lights are up
17:32Please
17:33The lights at Kirksville
17:36Are pilot-activated
17:38Airports without a lot of traffic
17:41That goes in and out of them
17:42One of the ways that
17:43They reduce the cost
17:45Of running the airport
17:46Is they don't have the lights
17:47On all the time
17:48The pilots have the ability
17:50To control those lights
17:52With a series of microphone clicks
17:55On a specific radio frequency
17:57Evil slides are not on
18:00Particularly when you fly
18:02With low visibility
18:03And at night
18:04You won't see the runway
18:06Kirksville Ops
18:10Corpex 5966
18:125966
18:15Yeah, could you tell me
18:16If the approach lights are up
18:17Lights are on
18:20Cool, thanks
18:21Two and a half miles
18:25From the airport
18:26The pilots search for the runway
18:28400
18:29It's very critical
18:32To maintain that altitude
18:33Because if you don't see the runway
18:34You've got to go missed
18:35Because you cannot land
18:37Without seeing the runway
18:37350, here we are
18:47At two miles from the runway
18:50The pilots are still looking
18:51For the approach lights
18:52I don't see anything
18:54You are flying
18:56336 feet above the ground
18:59So there's not
19:01A lot of room for error
19:03Oh yeah, there it is
19:04Approach lights inside
19:06Flaps 35
19:09No
19:12No
19:12No
19:13Oh my God
19:16Holy crap
19:18Corporate Airlines
19:26Flight 5966
19:27Has crashed
19:28A mile south of the airport
19:30At Kirksville, Missouri
19:31Only two passengers survive
19:39The 11 other passengers
19:40And both pilots are dead
19:42For the pilot community
19:44This is something that
19:46Is touching us
19:47Because
19:49That could be me
19:50We want to know
19:51What happened
19:52NTSB investigators
19:56Examined the wreckage
19:57Engines, controls, instruments
20:03All checked out
20:04It appeared that the airplane
20:05Was fully functional
20:06At the time it hit the ground
20:07So the plane's working fine
20:11What kind of an approach
20:16Were they flying that night?
20:19Non-precision to runway 36
20:21Unfortunately, the accident rate
20:24For non-precision approaches
20:26Is dramatically higher
20:27Than on those approaches
20:29With an instrument landing system
20:31They're flying blind
20:36Through the clouds
20:37It's misty
20:38Visibility is poor
20:39Those are bad conditions
20:42For a non-precision approach
20:43You come down
20:47To the lowest altitude
20:48You have to level off there
20:50And you fly along
20:53Looking for
20:54The runway environment
20:56Pilots of other flights
21:01Into Kirksville airport
21:02Report that the weather
21:03Posed no problems for them
21:05So why did flight 5966
21:09Crash on the same approach?
21:13Looking at all the pieces
21:15This accident started to look like
21:17It was a human performance issue
21:19And not an airplane issue
21:21Let's see how they handled
21:25The approach
21:25By combining flight recorder data
21:30And radar returns
21:32Investigators determine
21:34The flight's descent profile
21:35So the plane was supposed
21:37To level off
21:38At the minimum descent altitude
21:39Before continuing
21:42To descend
21:43To the runway
21:44The minimum descent altitude
21:46Is the lowest altitude
21:48You're permitted to fly at
21:49Until you see
21:51The runway environment
21:52Why would they blow
21:53Right past the MDA like that?
21:55Investigators turn
21:58To the cockpit voice recorder
21:59For an answer
22:00Take it to when
22:05They near the MDA
22:06If there's a big mistake
22:08It'll likely be them
22:09400
22:14350
22:18Here we are
22:19Okay, they're at the MDA
22:21It's decision time
22:22I don't see anything
22:24Oh yeah, there it is
22:25Approach sites in sight
22:27They're two miles out
22:30300 feet up
22:32They've just come out of the clouds
22:33If they missed that night
22:35They probably couldn't see
22:36The runway lights
22:37There's only farmland
22:38From here to the airport
22:39Why is the captain
22:41Even looking for the approach lights?
22:45He shouldn't be doing that
22:47He should be totally focused
22:48Inside the airplane
22:50The first officer
22:51Is supposed to see
22:53The approach lights
22:53And call out
22:54Approach lights in sight continue
22:56Instead they're both
22:58Looking for the runway
22:59And nobody is paying attention
23:01To the plane's
23:02Descent speed and altitude
23:03The flying pilot
23:05Should have been monitoring
23:07Exclusively instruments
23:08And what sadly occurred
23:11Was that the normal flight path
23:14Continued below the minimum
23:16Descent altitude
23:17And neither one of them caught it
23:19The captain's looking outside
23:20When he shouldn't
23:21The first officer
23:22Doesn't challenge him
23:23Next thing they're crashing
23:25It's surprising
23:27How much the captain's performance
23:30Suddenly fell apart
23:32At the end
23:33Investigators listen for clues
23:37In earlier cockpit conversations
23:39To explain why the crew
23:41Ignored established procedures
23:43During the flight's final moments
23:45I have a good time flying with you
23:48You gotta have fun
23:51That's truth man
23:52You gotta have fun
23:53Too many of these jerks
23:54Take themselves way too seriously
23:56In this job
23:56I've flown with them
23:58And it sucks
23:59What do you want to do
24:00Strangle the jerk
24:00When you get to the ground
24:01The conversation raises
24:04A major concern
24:05For investigators
24:06The captain is essentially
24:09Telling him how he wants
24:10The first officer to behave
24:11That's disturbing
24:15And it sets a disturbing atmosphere
24:16Cruise check
24:18Power check
24:19You push his foot away
24:19Yes
24:20It's a relatively
24:23Compact airplane
24:25And the passengers in the front of the airplane
24:28And the passengers in the front of the airplane
24:28Can sometimes put their foot
24:30Into the cockpit area
24:32Cruise power
24:35Cruise check
24:36All you gotta do is
24:38You open the curtain a little bit
24:40It's like
24:41Man
24:42I dropped my book on him
24:44Purposely one time
24:44Right on top of the arch of the foot
24:47Oh
24:48Okay, stop it
24:50The captain
24:53Starts his cruise power checks
24:57But then interrupts himself
24:58To tell
24:59A story about hurting a passenger
25:01It's really inappropriate
25:04The lack of respect for passengers
25:08Is striking in his conversation
25:10All right
25:12Well, let's see if the first officer
25:14Can get him back on track
25:15How'd he get 299 or 0?
25:20Because you're an idiot
25:21Investigators now hear the captain
25:24Teasing the first officer
25:25While he's confirming their altimeter setting
25:28And it should be 299 or 2
25:31You never said it
25:33When they clear us of the runway?
25:35And I've been sitting here
25:36Living alive for the last 20 minutes
25:37Yeah, you lying scumbucket
25:39The captain's jokes
25:41Have totally eroded procedure
25:43Even the first officer
25:44Has given in
25:45And turned his checklist
25:46Into a joke
25:47Did the captain's conduct
25:50Affect the first officer's actions
25:52At a critical moment?
25:55The kind of atmosphere
25:57He set up earlier
25:58In making fun of other pilots
26:00And making fun of the passengers
26:01Sets up the wrong tone
26:03It doesn't encourage
26:04The first officer to object
26:06When things were falling apart
26:08He could have stepped in
26:10And done something
26:11It looks like a complete breakdown
26:14In command structure
26:16Led to this accident
26:17The question is
26:19Why?
26:24Got their personnel files?
26:28Investigators study the pilot's training
26:31And histories
26:32To determine if flight 5966's crew
26:35Regularly deviated from airline procedures
26:38Captain left a well-paying job
26:41To become a pilot
26:42Plenty of hours
26:45Pass all the checks
26:47First officer checks out too
26:51They were joking a fair bit
26:55Almost punch drunk
26:57Do you think they may have been overtired?
27:01Fatigue is insidious
27:03And that once you are at a higher level of fatigue
27:08Performance impairment
27:09It can be somewhat like alcohol
27:12We're going into the crap
27:16Look, it's so eerie and creepy
27:20Fatigue could explain
27:23Why the pilots don't rely on their training
27:26When confronted with a changing situation
27:28People start to become giddy
27:30And are not critical enough
27:32Or enough careful of their behavior
27:35Now, how much did these guys work
27:41Before the accident flight?
27:44Investigators check the crew's duty hours
27:46Leading up to the flight
27:47The night of the flight
27:49They had worked three days straight
27:50That'll tire you out
27:52Yeah, well they had seven and a half hours
27:54Of available rest time
27:55The night before the flight
27:56That day
27:58They flew six flights an hour each
28:00And they were on duty for
28:0114 hours straight
28:04Starting at 5.45am
28:05Were the pilots made to work
28:08Too many hours
28:09Without sufficient rest?
28:16Check this out
28:17Pilots can't fly
28:19More than eight flight hours in a day
28:21I flew in those days
28:23And
28:24You had a maximum number of flight hours
28:26In a day
28:27But the number of duty hours
28:29And the time of day
28:30Was not even taken into consideration
28:32Last time these regulations were updated
28:341964
28:36The regulations needed to be updated
28:41To improve the safety for everyone
28:43The NTSB recommends an overhaul
28:48Of the FAA's flight and duty time regulations
28:51To consider the length of duty day
28:54Start time
28:56Workload
28:57And other factors
28:58That can affect pilots' alertness
29:00It's not always obvious
29:03When someone is tired
29:04And it's not obvious to them
29:06Had the crew of flight 5966 been rested
29:10They likely would have adhered to their training
29:13And this tragedy
29:15Might have been avoided
29:16When pilots don't follow the training
29:19That they've been given
29:20Basically they are putting themselves
29:22Into a raw position
29:23Of ignoring all the lessons of the past
29:26That led to the construct of that training
29:28And this is not a place
29:30That you want to be
29:31When you're sitting in the back
29:32As a passenger
29:32Disaster doesn't just strike
29:36When pilots breach protocols
29:38For in-flight procedures
29:39All yours Jim
29:40At your leisure
29:42Comair 121
29:43Ready to go
29:43Comair 191
29:46Sometimes
29:47Critical mistakes are made
29:49Before the plane even leaves the ground
29:51Damn it
29:53It's close to 6 in the morning
30:03In Lexington, Kentucky
30:04Comair flight 5191 prepares for takeoff
30:08Ladies and gentlemen
30:09We'd like to take this time
30:10To welcome you on board
30:11Comair flight 5191
30:13Direct to Atlanta
30:14There are 47 passengers
30:16And one flight attendant
30:17On the Bombardier CRJ-100
30:20A small twin-engine commuter jet
30:23In command is Captain Jeff Clay
30:26An experienced pilot
30:27With more than 4,700 flight hours
30:30You up for flying this leg?
30:32Yeah, I'll take us to Atlanta
30:33First officer James Polhinke
30:35Is also a seasoned pilot
30:37With more than 6,500 hours
30:39Both the captain and the first officer
30:42Were very highly regarded
30:43Right seat flex
30:45They had an outstanding professional reputation
30:47They're bound for Atlanta, Georgia
30:52A 67-minute flight
30:54South of the Lexington airport
30:56Comair 191
30:58Taxi to runway 22
31:00Altimeter 3-0-0-0
31:03Winds are 2-0-0 at 8
31:073-0-0-0-0
31:09Taxi 2-2
31:10Altimeter 191
31:11During the taxi out
31:16The first officer
31:17Is running numerous checklists
31:20And verifying that
31:21The aircraft is safe for departure
31:22Lexington's air traffic controller
31:27Clears flight 5191
31:29To the runway
31:29Kevin reports received
31:32Before takeoff checks complete
31:34Ready
31:34All set
31:36At your leisure
31:38Comair 121
31:39Ready to go
31:40Comair 191
31:42Lexington Tower
31:44Fly runway heading
31:45Clear for takeoff
31:46Runway heading
31:49Clear for takeoff
31:50191
31:51All yours, Jim
31:56Captain Clay
31:58Hands over control
31:59Of the aircraft
32:00To First officer
32:01Polhinke
32:02My brakes
32:04My controls
32:05Set thrust please
32:18Thrust set
32:21That is weird
32:27With no lights
32:28Yeah
32:30Under knots
32:36Checks
32:36Whoa
32:42Damn it
32:48The plane
33:02Hurtles past the runway
33:03And bursts into flames
33:0949 people
33:1749 people are dead
33:19After Comair
33:19Flight 5191's
33:21Disastrous takeoff attempt
33:23Only the first officer
33:26Survives
33:27But he's too injured
33:28To assist with the
33:29NTSB investigation
33:31Into why the plane crashed
33:33Less than half a mile
33:34From Lexington's
33:35Bluegrass airport
33:36First impact point
33:41Is there
33:41And the plane
33:46Hit those trees
33:47Over there
33:47Those impact marks
33:52Aren't more than
33:5320 feet up those trunks
33:54The wreckage path
33:56Tells investigators
33:57That the plane
33:58Struggled to get airborne
34:00Looks like they took off
34:02From runway 26
34:03Hang on
34:0926 wasn't in use
34:12Last night
34:13Investigators
34:14Realised that
34:15Flight 5191
34:16Took off
34:17From the wrong runway
34:18But that alone
34:22Doesn't explain
34:23Why the plane
34:24Couldn't lift off
34:25Maybe they were
34:26Too heavy
34:26The plane weighed
34:3049,087 pounds
34:32On that day
34:33It's close
34:36But it's within
34:36Their limit
34:37The aircraft
34:39Wasn't too heavy
34:40To take off
34:41How much runway
34:42Would be needed
34:43To take off safely
34:43The weight of the aircraft
34:47Affects how fast
34:48They have to be going
34:49To be able to lift off
34:50And that is
34:51Directly correlated
34:52To how much runway
34:53It takes to be able
34:54To achieve that speed
34:553,744 feet
35:003,744 feet
35:04And runway 26 is
35:063,501 feet
35:10They ran out of runway
35:12They now understand
35:15Why the plane
35:16Couldn't get airborne
35:17But a mystery remains
35:21They're supposed to leave
35:25From runway 22 here
35:27But they end up
35:30Here
35:31The question is
35:34Why?
35:36Maybe there's something
35:37On the security footage
35:38Wait, stop it right there
35:43It looks like
35:45They've stopped
35:46At the whole short line
35:47For runway 26
35:49Before take off
35:52Planes stop
35:53Or hold short
35:54Of the runway
35:55Until air traffic control
35:57Clears them to proceed
35:58Why the heck
35:59Would they stop there?
36:04We need to see
36:05The taxi route
36:06To better understand
36:09Why the pilots
36:09Of Comair Flight 5191
36:11Stopped at the whole short line
36:13For the wrong runway
36:14All right
36:15All right
36:15Let's get started
36:16They retrace
36:18Their taxi route
36:19Things that we were
36:20Looking for
36:21During that taxi demo
36:22Were markings
36:24On the taxiway
36:25The signage
36:26Whether it was
36:27Illuminated or not
36:28I can clearly see
36:32The sign is telling us
36:33That we're at the whole
36:34Short line
36:34For runway 26
36:35I mean
36:36It's hard to miss that
36:38Investigators discover
36:40The crew
36:40Had clear cues
36:41That they were at the whole short line
36:43For runway 26
36:44Not 22
36:46All the queues
36:47Are right there
36:48In plain sight
36:49Then they uncover
36:51Another disturbing fact
36:53When we turned on
36:54To runway 26
36:55All of the
36:56Lights on runway 26
36:57Were out
36:58As an experienced pilot
37:00I look at that
37:01And say
37:02Why did this flight crew
37:03Take off
37:04From this runway?
37:05We need to know
37:05What was going on
37:06In that cockpit
37:07The cockpit voice recorder
37:11May hold the key
37:13Okay let's hear
37:15What we've got
37:15In this type
37:19Of human factors accident
37:21It's very difficult
37:22Because we have to try
37:23To determine
37:24What the pilots
37:25Were thinking
37:26Okay here comes
37:31The taxi brief
37:32That's 22
37:3522
37:36The ILS
37:37Is out on 22
37:38Came in the other night
37:39The runway
37:40Identifier lights
37:41Were out all over the place
37:42Alright
37:4322 is your short taxi
37:45Any questions?
37:46No questions
37:47Before starting
37:48At your leisure
37:48Wait stop it right there
37:51Is that not
37:53A short brief to you?
37:56There's no mention
37:57Of crossing runways
37:58Or stopping to call
38:00ATC
38:00If they're unsure
38:01Where they are
38:02Investigators can't
38:04Understand why
38:05The taxi brief
38:06With eight checklist items
38:08Including a very crucial one
38:09Wasn't followed
38:10Yeah they never briefed
38:12On the runway
38:12They had to cross
38:13To get to runway 22
38:15The crew's abbreviated
38:17Briefing that morning
38:18Was a deviation
38:19From standard operating
38:20Procedures that we identified
38:21Had the crew
38:24Performed a full taxi briefing
38:26They would have discussed
38:27The need to cross
38:28Runway 26
38:29On the way to 22
38:31Okay let's hear
38:34Their taxi checklist
38:35Yeah I know
38:37Three guys at Kennedy
38:38Actually two guys
38:39One went
38:40But he did get
38:41Through the Sims
38:41Oh really?
38:43Then a first officer
38:43From Cincinnati
38:44He got through the second part
38:45And that's as far as he got
38:47Stop it right there
38:48What the heck
38:49What the heck
38:49Is he talking about
38:50Instead of focusing
38:57On their checklists
38:59The crew of 5191
39:01Were having a casual conversation
39:03They skipped out of their briefing
39:05Then for almost a minute
39:07They violate the sterile cockpit rule
39:10The sterile cockpit rule
39:12Requires that pilots refrain
39:14From non-operational conversation
39:17During significant portions of flight
39:20Oh okay
39:20The captain should be shutting
39:22This conversation down
39:23Not encouraging
39:24That non-pertinent conversation
39:26Was in a critical area
39:28When the flight crew
39:29Is making their taxi
39:31Out to the runway
39:32Where the flight crew
39:34Needs to be
39:35100%
39:36Flying the aircraft
39:37Could that period
39:42Of inattention
39:43Be the key
39:44To this tragic accident
39:45Let's see what happens
39:51When they get here
39:52Investigators hope
39:54Comair flight 5191
39:55CVR
39:56Will give some indication
39:58Why the crew
39:59Turned onto the wrong runway
40:00Thrust reversers are armed
40:05Autocross flow
40:06Is manual
40:08Ignition is off
40:11Altimeters are
40:133 triple zero
40:14Across the board
40:15Cross checked
40:16I'll check in with the cabin
40:18That's it
40:21When they stop their chit chat
40:23They don't seem to recognize
40:25Know or check where they are
40:27Investigators are intrigued
40:30By what they hear next
40:31At your leisure
40:33Comair 121
40:34Ready to go
40:34Comair 190
40:36Lexington Tower
40:38Fly runway heading
40:41Clear for takeoff
40:42They're completely relaxed
40:44When they ask for clearance
40:45In fact so relaxed
40:47Or distracted
40:48That the first officer
40:49Uses the wrong flight number
40:50These guys actually thought
40:52They were lined up
40:53For runway 22
40:55The fact that they stopped at runway 26
40:58And subsequently called for takeoff
41:01Indicates that they lost awareness
41:05That they had not crossed runway 26
41:08They turn on to runway 26
41:10Then what?
41:12Keep going
41:13Lineup checks completed
41:15All yours Jim
41:16First officer takes the controls
41:18So he's looking ahead
41:21Probably for the first time
41:24The captain transferred controls
41:26To the first officer
41:27So before this time
41:29The first officer
41:30Was heads down in the cockpit
41:32My brakes
41:34My controls
41:35When the first officer looked out
41:38He saw a runway
41:39He may not have perceived
41:41That it was a narrower runway
41:43Than runway 22
41:45They're looking down runway 26
41:47Why don't they see the sign
41:51For 22 off to the right?
41:54Neither pilot cross-checked
41:55Their location
41:56At the time that they took the runway
41:58100 knots
42:01Checked
42:02The pilots realize
42:05They're almost out of runway
42:06V1
42:07Rotate
42:08But they don't have
42:10The required speed
42:11To lift off
42:12Whoa
42:13Damn it
42:16The NTSB concludes
42:27That by ignoring their training
42:29The pilots lost track
42:31Of their position
42:31On the way to the runway
42:33Both crew members
42:34Lost awareness
42:36Of where they were
42:37On that airport surface
42:38And made a mistake
42:40That was extremely consequential
42:42Among the NTSB's recommendations
42:47Is a technological change
42:50To prevent pilots
42:51From getting lost
42:52Install moving map
42:55GPS displays
42:56In CRJ-100 cockpits
42:59The NTSB also makes
43:01Recommendations for flight crews
43:03Require pilots to check
43:05That they are at their assigned runway
43:07Before crossing the hold short line
43:11Before crossing the hold short line
43:11This was a catastrophic accident
43:14It affected scores and scores
43:18Of lives
43:20But the legacy of this accident
43:22Are the safety changes
43:24That have been made
43:25To prevent this type of accident
43:27From happening in the future
43:28Airline pilots expect the unexpected
43:32Every day they go to work
43:33But routine emergencies
43:35Turn catastrophic
43:37When pilots disregard
43:38Standard operating procedures
43:40And allow a bad situation
43:42To get worse
43:43A lot of thought
43:44Has gone into training modules
43:46And so if you ignore part of them
43:48Or just choose not to follow
43:50Part of them
43:50You are ignoring literally
43:52A whole body of knowledge
43:54That has been put together
43:55To keep you safe
43:56And keep your passengers alive
43:58And if you feel sick
43:59And you are calling
43:59It helps you degli traumy
44:00Back in the future
44:01Once you 아impится
44:02To keep you safe
44:02And the customer
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