- 30/5/2025
This special looked at careless approaches.
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TVTranscripción
00:00you're going 120 you can't keep decreasing your speed with no runway in
00:07sight it's more like 125 which is the approach to pilots argue that doomed
00:14them hey what's going on a captain believes one signal why's that ignition
00:19light on did we just have a flame out but ignores another one captain seems out
00:25of it they were just really flying sloppy come on come on come on level off then level off an
00:32exhausted pilot picks a disastrous time he's not gonna make it to try a new approach these
00:40crashes could have been avoided they could see that the needle was in the red man that captain
00:46should not have been flying passengers under any circumstances a debate about speed a question about
00:52power a case of fatigue investigators ask how such experienced pilots could have been so careless
01:00so
01:07Oh, stop.
01:29Executive Flight 1526 is climbing to cruising altitude above the US Midwest.
01:3717,000 feet.
01:41Roger, 17,000 feet, leveling off.
01:48First officer Renato Marchese is the pilot flying the twin-engine Hawker 700.
01:54He's logged more than 4,000 flying hours on various private jets.
01:59Captain Oscar Chavez has over 6,000 hours on private jets and cargo planes.
02:07It's a 35-minute flight from Dayton, northeast, to Akron, Ohio.
02:20On board are seven executives from a Florida-based property management company.
02:27Cheers.
02:27They've chartered the luxury jet from ExecuFlight, a private carrier based in Fort Lauderdale, Florida.
02:34Zipline 1526, descend to 13,000.
02:37Zipline is the call sign for ExecuFlight.
02:40Heading 249.
02:52Akron visibility, one and a half missed.
02:55Sky condition, overcast 600, broken.
02:59The crew is advised that rain is reducing visibility at their destination.
03:04And there's another complication.
03:06Zipline 1526, we do have another aircraft that's inbound to the airport that is slower than you.
03:14A student pilot is practicing a landing on the same runway assigned to Flight 1526.
03:23Akron Control requests that they alter their course and maintain altitude at 3,000 feet.
03:30Speed is 170 and 360.
03:35Zipline 1526.
03:44Zipline 1526, the Piper is on the ground.
03:47You are cleared for localizer 2-5 approach.
03:50Cleared for localizer 2-5.
03:53Zipline 1526.
03:55The plane is now 2-5 miles from the airport.
04:01Cloud still obscures the runway.
04:11Ground.
04:15Keep going.
04:16Okay, okay, level out now.
04:27I got it.
04:29Hold up.
04:31Hold up.
04:37Hey, what's going on?
04:41Hold up.
04:44Hold up.
04:45Hold up.
04:53No, no, no, no, no, no, no, no, no, no, no, no, no!
04:53Ah!
05:11We have a plane into a house.
05:12Heavy fire.
05:13We have a lot of wires down.
05:15ExecuFlight 1526 has crashed into a two-storey residential building.
05:25Everyone on board is dead.
05:28Fortunately, no one was inside the building.
05:32It's now up to the National Transportation Safety Board to determine what caused this fatal accident.
05:41It looks like the left wing hit first.
05:45As investigators comb through the wreckage, they make a crucial discovery.
05:55Found the angle of attack indicator in the cockpit wreckage.
05:59That's important because at a certain angle of attack, the wing will stall.
06:04What angle were you at?
06:07They could see that the needle was in the red band.
06:10And the angle of attack indicates it's in the red. You're stalled.
06:13In other words, this wing was no longer flying. It's as simple as that.
06:19Get that to Washington.
06:21The cockpit voice recorder is sent to NTSB headquarters for analysis.
06:26The CVR is especially important as the Hawker 700 isn't equipped with a flight data recorder.
06:33In lieu of FDR data, the NTSB obtains valuable information from air traffic control.
06:43A turning point in our investigation came when our engineer was able to recreate our aircraft performance from the radar data.
06:51The angle of attack, the attitude, the altitude, and rate of descent.
06:56Investigators find nothing unusual about the flight until its last two minutes.
07:06Look here. The speed drops to 130 knots, and then it keeps dropping to 98 knots.
07:12No wonder they stalled.
07:13Air speed is life.
07:17This is one of the most important points in flying any airplane, but especially, especially a jet.
07:23Investigators review the plane's descent profile.
07:26They level off at 9,000, 5,000, 4,000.
07:31Look at that.
07:33They hold at 3,000 feet for an entire two minutes.
07:37That's way too long.
07:39And then they plunge steeply.
07:44Once they started diving the airplane down to 2,000 feet a minute to get to that lower altitude, that approach was unstable.
07:52They should have executed a go-around.
07:53We really wondered, what is the situation in the cockpit at that time?
07:58They turned to the cockpit voice recorder to find out.
08:02Zip line 1526, we do have an aircraft inbound at the airport that is slower than you.
08:07Okay. I'll have to drag everything.
08:14Somebody lowered the landing gear to start slowing the airplane up and creating drag to hopefully get a little bit more spacing between them and the other airplane.
08:23Did you hear that?
08:28Investigators hear the sound of the engine thrust decreasing.
08:31The airspeed drops from 170 down to 140.
08:40That is way slower than he needs to be going.
08:43Zip line 1526, the Piper is on the ground.
08:46The Piper is on the ground.
08:47You are cleared for localizer 2-5 or French?
08:49Cleared for localizer 2-5.
08:53Flight 1526 is now at 3,000 feet and flying straight towards Akron.
08:58You are going 120.
08:59You can't keep decreasing your speed.
09:01Once the co-pilot received the warning from the captain that they were too slow, the co-pilot should have increased thrust significantly.
09:11But instead, the pilots get into a debate.
09:16Oh, 120. Where do you get 120? It's more like 125, which is the approach speed.
09:22But you've still got the flops to go.
09:23When they go down...
09:24This is what I'm saying. If you continue decreasing your speed...
09:27But why?
09:28Because we're going to stall. I don't want to stall.
09:30How do we...
09:33Stop.
09:36They are so busy arguing about their speed that they forget to start their descent.
09:43You're diving. Don't dive.
09:46You with me there?
09:48That delay of almost two minutes was critical.
09:50He's already too slow and he's overflown the altitude he should be at.
09:55And now they've got to chase the approach.
09:57Now he's got to get the airplane down fast.
10:04Investigators listen to the CVR to find out how two experienced pilots could so badly misjudge their situation.
10:13Okay.
10:15What investigators hear next shocks them.
10:19Full flaps.
10:23Full flaps at that speed? What was he thinking?
10:27Bring up the altitude graph again.
10:35Okay. That's why the plane starts to drop like a rock.
10:41Investigators finally understand why Flight 1526 descended at twice the recommended rate.
10:48The airplane is too high. It's too slow. And with full flaps rather than partial flaps.
10:57And really that is their turning point when we said this airplane is not configured properly for the approach.
11:03And this puts the crew and passengers in really a lot of danger.
11:07He should have just called a missed approach. Try it again.
11:14The question is, why didn't he?
11:17Let's pick up where we left off. The start of the final descent.
11:21While descending from 3,000 feet, the pilots begin their landing checklist.
11:30Can you check if I've got everything? Ignition?
11:32Ignition?
11:33Everything is all set. Standby. Your damper. Autopilot. Main air valves.
11:44He just stops. In the middle of his landing checklist.
11:47Instead of completing the checklist, the captain's focus turns to the plane's erratic descent.
11:53You're diving. Don't dive. 2,000 feet per minute. Buddy.
11:59Yeah.
12:012,000 feet per minute. Don't go 2,000 feet per minute. You with me there?
12:04This is the very serious portion of the approach.
12:08We're going to go down into weather that's very low.
12:12Why wouldn't he take over?
12:15By having the first officer fly, this captain then was dividing his time being a captain and also being an instructor.
12:24We found he wasn't appropriately managing the cockpit as a captain.
12:29They're less than 500 feet off the ground.
12:31That's below their minimum descent altitude.
12:37It's critical that you do not descend below that altitude until you have a visual view of the airport or the runway.
12:48Ground.
12:51Keep going.
12:53The cockpit voice recording makes it clear that the captain violated a fundamental rule of airmanship.
12:59If you don't see the field, then you do a go around.
13:05As he scanned for the airport, he lost track of the plane's speed.
13:10Okay. Level up now.
13:12Got it.
13:14Pull up. Pull up.
13:17They've been too slow for the last little while and they don't recognize, even with a stick shaker banging away, that they are in an aerodynamic stall.
13:25Pull up. Pull up. Pull up.
13:28That doomed them.
13:34No, no, no, no, no, no, no, no, no.
13:36They broke so many rules, it makes you wonder who trained them.
13:53The NTSB reviews the pilots' employment and training records for the last five years.
14:01What they find shocks them.
14:04The captain's termination notice says that he was fired from his last job.
14:12Captain Chavez was dismissed because he failed to show up for training.
14:16Get this, the first officer was terminated because his performance was below standard.
14:23So why did ExecuFlight hire these guys?
14:28Investigator Sathya Silva calls the president of ExecuFlight.
14:32He had hired the captain because of his extensive experience in the Hawker aircraft, as well
14:38as flights that he had personally taken with the captain prior to his employment.
14:45The first officer was hired based on a recommendation from another pilot, as well as one flight that
14:51he had taken with him personally.
14:54He said they didn't contact their previous employers.
15:00ExecuFlight did give them CRM training.
15:04Cockpit resource management training is teaching pilots to work as a team.
15:10Not much of a training manual.
15:15What we found was their training was insufficient and their evaluation of the crew was not proper.
15:23The NTSB investigation concludes that the problems on board the private jet began on the ground.
15:30Both crew members had poor training records, which their employer ignored.
15:36We determined that ExecuFlight did not enforce and did not make sure that the pilots were following standard operating procedures.
15:48In its report, the NTSB makes several recommendations for private operators like ExecuFlight.
15:56Including better training for pilots on non-precision approaches like the one into Akron.
16:02And the installation of flight data recorders that could monitor the progress of their flights.
16:11After a deadly turboprop crash in the North Carolina woods, investigators wonder why the pilots reacted quickly to some signals, but ignored others.
16:22When something happens, order a cup of coffee if you can and think about it.
16:26You can do that much more clearly if everything you're doing is stable and you're on the same page.
16:37American Eagle Flight 3379 approaches Raleigh-Durham International Airport.
16:45Okay, can you do the descent checklist please?
16:52In the cockpit, Captain Mike Hillis and First Officer Matthew Saylor prepare for landing.
16:59Altimeter 30-31, set, cross-checked.
17:0330-31, set, cross-checked.
17:08These were young pilots just starting off in their career.
17:13The pilots are flying a Jetstream 3201, a twin turboprop airplane designed for short flights.
17:21Flight 3379 took off at 6 p.m. from Greensboro, North Carolina.
17:26It's a 35-minute flight to Raleigh-Durham Airport.
17:31There are 18 passengers on board.
17:37Ten miles from Raleigh-Durham, Flight 3379 is cleared to begin its descent.
17:43The crew reduces engine power.
17:46And gear down.
17:49Gear down.
17:52Flaps 20.
17:56Flaps 20.
18:05Why is that ignition light on?
18:06Did we just have a flame out?
18:10Seeing the ignition light come on during approach would typically raise a concern.
18:16If combustion is interrupted for any reason, it's what pilots call a flame out or an engine
18:23failure.
18:23I'm not sure what's going on with it.
18:27If there is an engine failure, the pilots need to consider making a go around.
18:34Set max power.
18:36At 1500 feet, Captain Hillis aborts the landing.
18:42When you have an engine failure, you not only lost half your power, you lose 80% of your
18:49performance.
18:51Flight 3379 isn't climbing and it's losing speed.
18:57Lower the nose.
18:58Lower the nose.
18:59Lower the nose.
19:04Now it's stalling.
19:10You got it?
19:12Yeah.
19:13They're unable to climb.
19:15They're starting to lose directional control of the aircraft.
19:19The plane is turning steadily to the left and veering further off course.
19:25Lower the nose.
19:29Things are getting bad real fast and they're running out of time.
19:44The jet stream plows through the dense woods of North Carolina.
19:50First responders are on the scene within minutes.
19:57There are only five survivors.
20:00Fifteen people, including the pilots, are dead.
20:06NTSB investigators are on site by morning.
20:15They quickly notice that the plane's landing gear is extended.
20:19Do they know how the flaps are set?
20:22I'll check with that guy in the cockpit.
20:25Stroud here.
20:26What can you tell us about the flap selector?
20:28The flap selector is fused in a 20 degree position.
20:31Copy that.
20:34The flap extension was also very interesting because it was in the landing configuration.
20:40So he's four miles from the airport.
20:43He's configured to land.
20:44What happened?
20:47According to this, he veers off course.
21:00He's off to the left.
21:01Why?
21:02Okay.
21:03Can you do the descent checklist, please?
21:07The team turns to the cockpit voice recorder, hoping to find an explanation for the unusual
21:14left turn.
21:15Altimeter 30, 31.
21:17Set.
21:18Cross-checked.
21:19Pressurization.
21:20Set and checked.
21:21Why is that ignition light on?
21:22Did we just have a flame-out?
21:23We lost the left one?
21:24Yeah.
21:25A flame-out moments from touchdown should have prompted the pilots to take action.
21:36Investigators need to find out why they didn't.
21:40The cockpit voice recording from flight 3379 suggests both pilots were unaware of the danger
21:48they were in.
21:50An ignition light has illuminated.
21:53The pilots have noticed it, but they're not taking any action.
21:57You would expect during that period that there would be some sort of confirmation.
22:04Nothing happened other than absolute quiet.
22:08We needed to try and figure out what was going on.
22:18These are the engine sound waves from when the ignition light went on.
22:21The CVR records more than voices.
22:23It also records the sound of the engines.
22:26Call it the comparison.
22:28They compare the engine sounds from flight 3379 to other engines operating at 100%.
22:35They're almost identical.
22:40Both engines were operating at full speed.
22:45The ignition light must have misled the pilots into believing the left engine flamed out.
22:52We had a flame-out.
22:54We had a flame-out.
22:55He misdiagnoses the situation.
22:57Well, surely he checks his engine's RPMs.
23:00What do you want me to do? Are you gonna continue?
23:05Okay, yeah.
23:06We're gonna continue.
23:07Just back me up.
23:08He's not even checking to see if there's an actual engine failure.
23:10If you don't know if you have an engine failure, but you're responding to a potential engine failure, that's not very good.
23:23And that could very easily cause an accident.
23:26Let's go missed approach.
23:28Investigators wonder what action the pilots took to execute their go-around.
23:33Okay, so how did they configure their plane for their missed approach?
23:38They said engine power to max.
23:42As they should have. What else?
23:45There's no mention of reducing the flaps to 10 or retracting landing gear.
23:55A go-around would be done by informing the other pilot, then apply max power, retract the gear, retract the flaps.
24:07But the pilot's failure to raise the gear or retract the flaps still can't explain the accident.
24:14Hard to believe that configuration caused the plane to veer to the left and crash.
24:18Well, there's only one way to find out.
24:20So we really wanted to figure out what the crew had introduced in the configuration that would make the aircraft deviate from this intended flight path.
24:30Okay, let's go max power.
24:32Investigators turn to test pilots for help.
24:36They'll push a Jetstream 3201 to its limits to determine why the plane turned left on the go-around.
24:44Max power.
24:46Flaps to 20.
24:47Flaps to 20.
24:48They start by duplicating the configuration the pilots used for the missed approach.
24:53Flaps 20.
24:55Gear down.
24:57Okay, it's a bit slower than a regular missed approach but it's still doable.
25:09Let's do the same configuration but put max power on the right engine but not the left.
25:15Max power right engine.
25:16Yawing to the left.
25:17I can't climb like this.
25:22It's the final piece of the puzzle.
25:23It's the final piece of the puzzle.
25:29Set max power.
25:30Believing his left engine had failed, the captain increases power to the left.
25:34the right engine only.
25:35I can't climb like this.
25:36It's the final piece of the puzzle.
25:49Set max power.
25:53Lower the nose.
25:54Lower the nose.
25:55The power imbalance reduces air speed and the lowered gear and extended flaps increase drag.
26:00The flight test told us an airplane with that configuration could not happen for a long time.
26:07The flight test told us an airplane with that configuration could not happen for a long time.
26:26It had to crash.
26:33If the captain thought one of his engines failed, they should have performed a single engine missed approach.
26:39Didn't do that either.
26:44To come across an accident where a response was botched as poorly as this one, it begs the question, how did he get there?
26:53How did he get there?
26:54The investigation digs into Captain Hillis' pilot records.
26:58Hmm.
26:59Look at this.
27:02Trainer's evaluation.
27:04Oh, this is telling.
27:06He's messing up single engine missed approaches.
27:10When investigators ask American Eagle about screening checks on Mike Hillis, they're surprised at what they learn.
27:18They did not go back and check with previous employers.
27:23The NTSB does what American Eagle never did.
27:28It requisitions Mike Hillis' file from his previous employer, Comair.
27:33Moody, unpredictable, gets distracted.
27:38Concerns about tunnel vision in an emergency situation.
27:42Did American Eagle know about this guy's performance history?
27:45It doesn't look like they asked.
27:48That captain should not have been flying passengers under any circumstances.
27:53It turns out other American Eagle pilots at Raleigh-Durham were well aware of Hillis' deficiencies.
28:00Co-pilots were whispering to their colleagues, it was something not normal.
28:06But was First Officer Saylor one of those co-pilots?
28:10Pull over the nose.
28:12Pull over the nose!
28:14Investigators learned that Saylor was new to the route.
28:18So was he based out of Raleigh?
28:21Uh, no.
28:22He worked out of Miami.
28:25I think it was critical to this accident that the First Officer was from a different base than the captain.
28:33This guy had no idea who he was flying with.
28:35If First Officer Saylor had known about his captain's shortcomings, he would likely have paid more attention to his conduct during the approach.
28:44The crash of Flight 3379 reveals deep flaws in the hiring practices of US airlines.
28:51Background information on pilots is almost never shared amongst carriers.
28:57In its final report, the NTSB recommends that US airlines conduct thorough background checks on prospective pilots.
29:05In 1996, two years after the crash, the US Congress passes the Pilot's Record Information Act to ensure airlines have access to records from pilots' previous employers.
29:20Carelessness in the cockpit is usually not something that happens on a single flight only.
29:25It's usually a habit.
29:27Those habits form over time.
29:29And if there's not proper oversight or some sort of check and balance either in the cockpit or back in their training unit, then this could become the norm.
29:39In other words, their normal flying could be high-risk flying.
29:43In an aviation milestone, investigators sift through the wreckage from another careless approach.
29:54Guantanamo Bay, an isolated US Navy base that sits on the southeast coast of the island of Cuba.
30:09American International Airways Flight 808, a civilian DC-8 cargo plane, is on final approach to the Guantanamo airfield.
30:24Here it comes.
30:26On 10.
30:28On the flight deck are First Officer Thomas Curran, Flight Engineer David Richmond, and Captain James Chapo.
30:36The DC-8 is turning towards the runway, but for some reason it's banking steeply.
30:43He's not gonna make it.
30:45No way.
30:48The wings go about 90 degrees relative to the horizon.
30:56The nose pitched down and the airplane struck the ground.
30:59Yeah, I don't remember the exact moment of hitting the ground, no.
31:04Yeah, we were fortunate.
31:05You know, the DC-8, they say, was built to separate at the cockpit and cabin bulkhead.
31:11And sure enough, that's where it busted the part.
31:13And we rolled ahead of the airplane.
31:16Can you move?
31:20Yeah.
31:21My memory of the actual accident itself is gone.
31:26Please, help us.
31:28I was told when the airplane hit the ground, a large boulder came through the cockpit by my rudder pedals and broke off the rudder pedals and severely damaged my legs.
31:39The three injured pilots are transported to a hospital in Miami.
31:48Within hours of the accident, a team of investigators from the NTSB is on its way to Guantanamo.
31:54All right, let's see what we've got.
32:01Greg Feith is the lead investigator for the team.
32:07Both black boxes coming your way right now.
32:14Nope, both slightly damaged.
32:16Coming to you right now.
32:17The black boxes are sent to the NTSB lab in Washington, DC for analysis.
32:23We've checked the entire site, correct?
32:25Yep.
32:31Feith interviews two Navy pilots who witnessed the crash.
32:37Come on, come on, come on. Level off, man. Level off.
32:43Normally you don't want to be turning more than about 10, 20 degrees on final approach.
32:49They watched this airplane as it went from 30 degrees to 40 degrees to 50 degrees, 60 degrees, and they were really surprised.
32:59Sounds like a wing stall.
33:01Yes sir, it sure looked like it.
33:03Yeah.
33:04You understand how the aircraft struck the ground. Now you have to determine why.
33:10So did you pick up anything unusual in your conversation with the pilots?
33:15When they talk to air traffic control, investigators uncover an important piece of the puzzle.
33:20Connie 808, Guantanamo, go ahead.
33:2412 minutes before the crash, the crew made an unusual request.
33:29Connie 808 requesting, we'd like to make the approach for 10 this afternoon.
33:33They asked to change from their assigned runway 28 to runway 10 or 10.
33:42Guantanamo has a single runway with aircraft landing in either direction, 28 from the east and 10 from the west.
33:52Normally airplanes land on runway 28.
33:55It's more or less a straight in approach, landing to the west.
33:58Runway 10 is closer to the Cuban border.
34:04To avoid Cuban territory, aircraft must approach from the sea and then make a sharp right turn.
34:13Why would the crew of flight 808 choose the more difficult approach?
34:19Investigators try to interview the pilots, but all three are in intensive care.
34:29Thanks very much.
34:34Personnel records show that they were all highly experienced.
34:40You know that they can operate the airplane.
34:45So now the question is, why didn't they?
34:47Why didn't they?
34:55The team reviews the plane's flight data, which shows the plane's exact approach path.
35:01OK, let's see the proper approach.
35:08So they started their turn too late and never recovered.
35:12The pilot increased the bank, trying to salvage that turn and get the airplane lined up.
35:21But the steep bank hindered the plane's ability to stay airborne.
35:25The amount of lift it's producing to hold the airplane in the air is compromised because the wings aren't at this high angle.
35:35Now all of a sudden the airplane gets into an aerodynamic stall.
35:40And because you're low to the ground, you don't have sufficient altitude for proper recovery.
35:44Why did they start that turn so late?
35:52The cockpit voice recording from flight 808 is finally available.
35:57Connie 808, you're required to remain within the airspace designated by strobe light.
36:02The strobe light marks the base's border fence with Cuba.
36:06It's a visual warning so pilots don't fly into Cuban airspace.
36:10Are they giving us 28?
36:13Yeah, if it's available.
36:15The CVR reveals why the captain chose to land on runway 1-0.
36:20How to make that 1-0 approach?
36:23Just for the heck of it and see how it is.
36:28If we miss it, we'll just come back around and land on 28.
36:32For the heck of it?
36:34That's why he's landing on runway 10?
36:35You don't just do things for the heck of it in an airplane of that size.
36:41Captain seems out of it.
36:43Where's the strobe?
36:45Right over there.
36:48Where?
36:50Now the captain struggles to locate the strobe light that marks the Cuban border.
36:55You know, we're not getting airspeed back there.
36:57The flight engineer comments that the plane is flying more than 10 knots too slow.
37:03Do you think you're going to make this?
37:05The first officer and the flight engineer, they only challenged the captain by what I call hinting and hoping, where they would throw out a suggestion.
37:15Do you think we're going to make this?
37:17Yeah, if I can catch that strobe light.
37:18But the captain isn't taking the hint.
37:21As he begins his critical final turn, he still can't see the runway.
37:28He realizes he started the turn too late.
37:32To compensate, he makes the turn even steeper.
37:36The plane needs an airspeed of 147 knots to stay airborne in the tight turn.
37:41Watch. Keep your airspeed up.
37:49140.
37:53Suddenly, the stick shaker warning activates.
37:56It shakes the control column to alert the pilot of an imminent stall.
38:00Stall warning!
38:02Stall warning!
38:07Max power!
38:08I got it! Back off!
38:11Let it go!
38:13No! No!
38:14No!
38:25He completely tuned out his crew.
38:29We knew that there was some bad decision-making going on in this particular cockpit.
38:35And the question was why.
38:36Greg Feith searches for clues in the duty rosters and pilot logbooks of the DC-8's crew.
38:46He learns that the day before the crash, the crew started flying from Dallas-Fort Worth at midnight.
38:54And flew all night.
38:55They crossed the country before arriving back at their Atlanta base just before 8 a.m.
39:08That was supposed to be the end of the crew's shift.
39:11But they were called back for one last flight.
39:14Guantanamo Bay, here we come.
39:17Nothing more I'd rather do.
39:19By this point, each crew member has been awake for about 15 hours.
39:22They were now expected to fly to Virginia, pick up cargo, then fly to Guantanamo, before returning to Atlanta.
39:32Could the lengthy duty time have impaired the pilots' performance, leading them to take greater risks?
39:37Mark Rosekind, the head of NASA's fatigue countermeasures program, is brought in to help.
39:47We knew that fatigue was a risk, so we knew bad stuff was already going on in flight.
39:52The key was, how do you demonstrate fatigue actually played a role in that crash?
39:56Rosekind discovers that the pilots' long workday wasn't the only reason they were fatigued.
40:00They were all sleep deprived.
40:06The crew experienced lack of sleep from two back-to-back night shifts before the crash.
40:13When you lose sleep, it actually builds into what's called a sleep debt.
40:16And you should think about that just like a bank account. It's like going in the red.
40:20The captain's sleep debt was profound.
40:24He had only 15 hours sleep in the previous 72.
40:30His behaviour exhibits the symptoms of fatigue.
40:34One was what we call cognitive fixation.
40:37The captain just got stuck on finding a strobe light.
40:41Where's the strobe?
40:43What investigators have uncovered raises a disturbing question.
40:47Why did a sleep deprived crew, suffering from fatigue, accept the last minute flight to Guantanamo?
40:53Investigators are finally able to interview the crew members.
41:04I was tired. We were all tired.
41:08We were all tired.
41:11You didn't have to accept the flight?
41:14Technically, no. But we didn't really have a choice.
41:18The cargo industry is notorious as being a cutthroat industry.
41:24They will push the crews routinely to the edge of duty time limits.
41:28There's this fear of intimidation and the loss of a job that if you don't do it, I'll find somebody that will.
41:37The fear of job loss almost cost them their lives.
41:43Stall warning! Stall warning!
41:49Max power! I got it! Back off!
41:54There it goes!
41:56At the very end, things happened very rapidly.
41:58We were too low and our reactions were too slow.
42:02And I should have turned it over to Tom, but I was already just sort of out of it.
42:07Help! Help! Help!
42:18It still...
42:21Still gets to me because it still boils down to the captain.
42:25You know, the captain made the mistake.
42:27And that's a hard thing to live with all the time.
42:31Investigators discover one final tragic piece of the puzzle.
42:38The strobe light Captain Chapo was searching for was not operational that day.
42:44There was no beacon to see.
42:47No one thought to tell the controller that the strobe was down.
42:51So now they're trying to find something that doesn't exist.
42:54And when they saw something flash out there, which they thought was the strobe, it was actually the tin roof on a little cabana.
43:03In his final report on the crash of Flight 808, Greg Feith emphasizes the central role played by fatigue.
43:13This accident was precedent setting.
43:16It was the first commercial aviation accident actually caused by fatigue, and the industry took notice.
43:24In the aftermath of the Flight 808 crash, the Federal Aviation Administration tightens regulations on crew sleep requirements.
43:33Airlines must now stay up to date on sleep and fatigue research.
43:38Managing rest times means pilots are less likely to make poor decisions.
43:42When you're approaching a landing, if you don't feel that you have it all lined up, don't do it.
43:51Go around, get your head together, and make sure you're ready to do it.
43:55Because it's the most dangerous time of your flight.
43:57You're on your flight.
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