- 6/11/2025
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00:00keeping lie takes his family to visit his son in Ohio here let me help but just before landing
00:12things go terribly wrong and soon they're fighting for their lives I didn't see any
00:21way possible that somebody in the crash could survive
00:30the badly burned wreckage leaves little for investigators to work with you see stuff and
00:36you wonder what is it looks like we're gonna have to figure this out the hard way what they discover
00:43is unthinkable wait did I miss something I was dumbfounded
01:00United Express flight 62 91 is on route from Washington Dulles Airport to Columbus Ohio a winter cold front has descended on the eastern seaboard
01:28bringing freezing temperatures cold enough for you captain Derek white is at the helm he's a seasoned pilot with more than 3600 hours of flight time
01:40actually I kind of like it really Anthony Samuels is his first officer he just started flying for United Express three months ago
01:47starting to get the hang of it oh yeah flight time is one hour and 30 minutes they're flying a brand new Jetstream 4100
02:02a small twin-engine turboprop designed for short regional flights
02:09it's a high-performance airplane it's complex it flies fast and pilots have to anticipate what the airplane is going to do before it does it
02:21before it does it the 4100 is the latest commuter plane in the Jetstream series
02:28it comes with a brand new state-of-the-art computerized instrument panel known as a glass cockpit
02:34well one of the things that's new and exciting about this aircraft is that unlike its predecessor which had a traditional cockpit this had an electronic cockpit
02:42or much of the information that was usually displayed in dials and gauges was displayed on various kinds of computer type screens
02:49the cabin holds up to 29 passengers but tonight on its last flight of the day there are only five
03:01she hasn't had much to eat today
03:08Taiwanese parents Su Chu Ling and Ki Ping Lai are traveling with their daughter Yi Sun Lai
03:16they are on their way to see their son who goes to university in Columbus
03:22the only other passengers on board are a businessman who lives outside Columbus
03:28and a 25 year old student from Akron Ohio
03:34flight 62 91 is now cruising at an altitude of 14,000 feet
03:41it's been a smooth but busy day for this particular aircraft
03:47it has already made six different commuter flights through the US Northeast
03:51United Express 62 91 be advised just had a report of some icing at 14,000
04:04an aircraft ahead is reporting icing conditions
04:08was it late right?
04:10Rime ice is a fast forming ice that can be dangerous if it freezes to the surface of an airplane
04:15for some parts of the aircraft like the wing having ice grow on that wing
04:21interrupts the airflow interrupts the amount of lift that you have and it's bad news all around
04:26United Express 62 91 he said it was moderate rime icing up to 14,000
04:31okay thanks we'll keep that in mind
04:33we'll keep that in mind
04:38in the cabin the passengers settle in
04:47approximately 50 minutes into the late night flight
04:52the captain is getting more concerned about the weather ahead
04:55we're gonna hit the rhyme soon
04:58Indianapolis center United Express 62 91 can we get one 5,000 for a while?
05:07he wants to climb to 15,000 feet to get above the icing conditions
05:13United Express 62 91 stand by
05:17they had information from an aircraft ahead of them
05:21so they had real-time information as to what the conditions were
05:23so they weren't guessing about the right thing to do
05:27they were actually taking action based on relevant data
05:30United Express 62 91 climb and maintain 15,000
05:3615,000 United Express 62 91
05:40the crew receives permission to climb
05:45and fly above the oncoming band of bad weather
05:49pilots do a number of things to keep ice from being a problem
05:54and the number one thing to do is avoid it altogether
05:56and in this case this airline crew was doing exactly that
06:00after flying for another several minutes above the clouds
06:08I'm in the approach chart
06:13the pilots are ready to begin their descent
06:15okay we'll do the ILS for runway 28L
06:22any questions?
06:24no questions
06:27an ILS is an instrument landing system
06:30which uses radio navigation aids
06:32to provide the flight crew with a reference point
06:36as to how they are aligned with the runway
06:38in the cabin the passengers also prepare for landing
06:45do you need help with your seatbelt?
06:48yeah let me help
06:54the commuter flight has begun descending back through the clouds
07:03they'll be landing in approximately six minutes
07:11what are the surface winds down there again?
07:14uh... three three zero at four knots
07:18thanks
07:22almost there
07:23united express 6291 reduce speed to 170 knots
07:35the controller wants the plane to slow down for the approach to the airport
07:39reduce speed to 170 knots
07:45united express 6291
07:47it's important for pilots to maintain proper airspeed at all times
07:52it's especially important to maintain proper airspeed as you approach the airport when you're close to the ground
07:57united express 6391 on the localizer for 28L
08:066291
08:08what did I say?
08:106391
08:12oh
08:16united express 6291 Columbus Tower
08:20runway 28L cleared to land
08:23wind 300 at four knots
08:25clear to land
08:27united express 6291
08:29okay if you have all the speeds don't worry about it anymore
08:34ref is 112
08:38I gotta input that
08:39I did it for you
08:45here comes the glide slope
08:47the glide slope is the ideal path that the plane should follow as it descends to the runway
08:53the airport's instrument landing system uses radio signals to guide the plane in at an angle of three degrees
09:02that's a standard set of degrees that's going to be nice and stable where you can control the aircraft in all phases of flight up to landing
09:11okay
09:14okay remarker inbound
09:15roger
09:16don't forget to give me my call outs
09:18the captain reminds the first officer to call out altitude and airspeed readings
09:221,014 is decision height
09:261,000?
09:27okay
09:281,000 above
09:30the decision height is the altitude at which the pilot must be able to see the runway markings or else abandon the approach
09:37as the plane breaks out of the clouds the runway is in sight
09:46okay flaps nine
09:48you're down
09:52it's okay
09:54it's only the wheels coming down
09:56the flight is just moments away from touching down at Columbus airport
10:07right on schedule
10:11flaps nine waiting for three green
10:13flaps 15
10:15landing checks
10:17flaps 15 landing gear down
10:19three green
10:20yeah damper
10:22inside the tower the controller monitors flight 62 91 as it's about to cross the runway threshold
10:34the plane becomes impossible to control
10:37Tony what did you do?
10:39I did nothing
10:40and as if into thin air
10:51United Express 62 91 Columbus Tower do you read me?
10:5662 91 vanishes from radar
11:00United Express 62 91 Columbus Tower do you read me?
11:0562 91
11:08gimme flaps up
11:10no no no hold it hold it
11:12gimme flaps up
11:15gimme flaps up
11:22hold tight
11:24only one mile from the runway
11:25outside the remains of flight 62 91's cabin fire is starting to spread
11:39and the passengers who survived know their time to escape is limited
11:45it's okay honey
11:47it's okay honey
11:48it's okay
11:49I'll get you out
11:51I'm okay
11:52help her
11:54keeping live finally gets his seatbelt undone
11:58and turns to help his daughter
11:59keeping lie now searches for a way out
12:14the emergency exit won't open
12:19the emergency exit won't open
12:24he tries the rear of the plane
12:30the situation is critical
12:33leaking fuel from the crash could ignite an explosion at any moment
12:37finally
12:42come on
12:43come on
12:44we have to move
12:45you first
12:46come on
12:47to be right behind
12:49go
12:50go
12:51go
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13:00go
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13:10go
13:11the
13:12rescue was rushed to find the crash site
13:14among them are police officers from the Gahanna Ohio Police Department
13:17the weather that night was cold
13:20but it was very moist
13:22like almost a freezing fog
13:24mist type of night
13:26really sticks out my mind how intense the fire was at the time
13:30I didn't see any way possible that somebody actually in the crash zone itself could survive
13:35could survive keeping lie his wife and daughter are the only ones to survive
13:46all of a sudden the plan just just shaking very badly so I found that
13:54something's going to happen this is the first fatal accident involving the jet
13:59stream 4100 for the safety of all the passengers using this plane it's
14:06critical to figure out what happened
14:18by morning investigators from the National Transportation Safety Board
14:23including lead investigator Al Dickinson are on the scene
14:28okay let's make sure we got all four corners they first need to find out if
14:35the entire plane is at the crash site if any major parts are missing it could
14:42mean the aircraft was breaking apart before it hit the ground the importance
14:47of finding all four corners of the aircraft is if something comes off an
14:51aircraft before impact you probably can trace it back to the initial cause of
14:57why they had a problem so it's really important to identify both wingtips the
15:02nose and the tail
15:04but their challenge is immense what's left of United Express 6291 is barely even
15:12recognizable as an airplane and the fire was very intense and it made it hard just to try to identify
15:21the different pieces of the aircraft you see stuff and you wonder what is it
15:26we've got the nose over here get the tail over here we found all four corners of
15:38the aircraft right at the accident site and we've got the wings out over there so the
15:45aircraft was intact until it contacted the ground and therefore you can eliminate any structural thing that might have
15:54happened during flight the plane did not start coming apart in mid-air but was the pilot in control the team needs more information to determine that
16:16that so main landing gear hit there nose landing gear hits up here we had marks from the left gear the center gear and the right gear it's lined up with the runway gear down the crash is short
16:34what we could determine by the ground impacts was that the aircraft was headed toward the airport on a steady heading at the time of impact
16:41hey what do you got there as the aircraft descended its propellers cut through nearby trees the angle of the cut marks tells investigators the angle of the aircraft as it came down
17:00okay the propeller cut marks started about 60 feet up same on both sides so it came in level
17:08there was no indication from the tree impact that the aircraft actually went anything other than in a straight line into the trees and the ground
17:19the impact marks on the ground and propeller cut marks in the trees suggest to investigators that the pilot was in control of the plane until moments before the accident
17:32okay flaps nine you're down so then why did it crash
17:39bring it in here Dickinson and his team soon find a clue a key part of the wing
17:47ice
17:54ice
17:56looks to be about a quarter of an inch
17:58let's get some pictures of this
18:00it's the biggest clue yet
18:02we found a couple of instances where you could see the amount of ice buildup
18:07that's always an issue because ice does degrade the performance of an aircraft
18:12and you're always wondering did that happen in this case
18:17a buildup of ice on the wings interrupts the airflow over them and increases drag
18:23this results in a loss of lift
18:29United Express 62-91
18:31be advised just had a report of some icing at one four thousand
18:36did ice buildup on the wings leading edges cause flight 62-91 to crash
18:43yes
18:49now that's what I wanted to see
18:51yeah they're pretty banged up let's get them shipped out
18:54the flight data recorder and cockpit voice recorder are found nearly side by side deep in the wreckage
19:01whenever there's a serious post crash fire
19:04it could literally destroy the evidence that's needed to figure out what happened to the aircraft
19:08two of the most important things on an airliner of course are going to be the flight data recorder
19:12and the cockpit voice recorder
19:14if the data locked in the recorders is salvageable
19:17it could break the case
19:19while investigators wait to see if the data on the flight recorders can be recovered
19:30so we know we had a quarter to a half inch of ice on the leading edge of the wing
19:36they'll need to find out if a problem with the aircraft's de-icing system caused the crash
19:43maybe it was icing
19:52the most important system that was on the aircraft for icing
19:56or anti-icing systems for the wings
19:58and that's important because quite simply the wings provide lift
20:01and without lift it's difficult to maintain both airspeed and proper control of the aircraft
20:06the jet stream 4100 is equipped with a de-icing boot
20:13a rubber membrane installed over the wing edge that inflates to break up any accumulated ice
20:19rather than melting the ice
20:22it sort of cracks the ice and the ice falls off because it's no longer able to adhere to the wing
20:27but damage to the wings
20:33the boots are completely melted
20:35prevents the investigators from determining if the de-icing system was deployed and working properly prior to the accident
20:42looks like we're gonna have to figure this out the hard way
20:46a lot of the de-icing equipment was burnt and melted
20:51when you have severe fire damage
20:54you never know what's going to be testable and what's not
20:58we have a cold front running through here
21:03what were the weather advisories telling pilots?
21:06Dickinson hopes the experience of other pilots that night
21:10can help shed light on what happened to United Express 6291
21:14rhyme mixed icing between 2,000 and 19,000 feet
21:21did any other flights fly through it?
21:23if other pilots flew through the same icing conditions
21:27they might have experienced a similar problem
21:29yes, two just before 6291 was due in
21:34ok let's talk to them
21:37in this case there were planes flying in the general area
21:40and some of them landed at the airport in Columbus
21:43so it's important to talk to these pilots
21:46to find out what the conditions were on their descent
21:50and it was Rime Ice?
21:53the pilot of a plane that landed one minute before flight 6291 was due in
21:58remembers descending through freezing drizzle
22:02what do you think you picked up?
22:04about a half inch?
22:06and it didn't give you any trouble?
22:08ok, thanks
22:10hey
22:13same amount of ice
22:15but no trouble
22:17the pilot of the other plane reported similar conditions
22:21but neither had problems landing
22:23the fact that several airplanes landed preceding this airplane
22:28under similar weather conditions
22:29means the weather should not have precluded a safe landing at the airport
22:33thanks for coming in
22:36so you left at 7?
22:40and when investigators speak to United Express pilots
22:43who earlier in the day flew the same plane
22:46and you had to de-ice
22:48through similar weather
22:50they report no difficulties with the plane's de-icing system
22:54we looked at everything that was involved in the weather situation
22:58they should have been able to fly through this moderate icing
23:01and land successfully
23:03so we went elsewhere
23:05the air traffic controller was the last person to speak with the crew about the weather
23:11he might be able to confirm what they knew about the ice in their path
23:16ok, so take me through it
23:19they asked to climb to 15,000 feet to avoid icing
23:22so they knew about it
23:24ok, does anything else stand out?
23:26yeah, they came in way too fast on approach
23:29I had to tell them to slow down
23:31United Express 6291
23:35reduce speed to 170 knots
23:38United Express 6291
23:45it's very unusual
23:47for an air traffic controller to tell a pilot to slow down
23:50that close to the airport
23:52pilots can only land the airplane within just a few knots
23:56to land it safely
23:57so to get to that point
23:59the pilot had to slow the airplane
24:01and the faster he was going
24:03the less time he had to do that
24:05it's a startling new clue
24:10but why were the pilots flying so fast so close to the airport?
24:22not a moment too soon
24:23the flight data recordings have been pulled from the damaged black box
24:28did they retrieve everything?
24:30it is a relief if you get good data from a flight recorder
24:35the only problem is
24:37if you get really good data
24:39you've got a lot of work to do
24:41because they measure everything
24:43investigators hope the data from the flight recorders
24:46can explain why the pilots flew in so fast
24:49and why they never made it to the runway
24:53okay this is the ice that they flew through
25:02Dickinson and his team have now reviewed the flight data recordings
25:06and plotted flight 6291's air speed and altitude into a descent profile
25:12wow 240 knots
25:15they are screaming through this
25:17looks like a slam dunk
25:19when I looked at the FDR data
25:22it gave me a definite indication
25:24that these guys were just trying to get through that icing condition
25:27by doing a slam dunk type approach
25:32a slam dunk is when a plane nears the approach high
25:35and then descends rapidly to the runway
25:38often to get through bad weather quickly
25:41but it's a risky maneuver
25:47the thing about doing a slam dunk
25:49is that you can fly really fast to get through ice
25:52but if you don't look well ahead of the aircraft
25:55you can easily slam it right into the earth
25:57before you realize that you've done it
26:00here they're going so fast
26:02the controller has to slow them down
26:05and then speed and altitude drop and drop and drop
26:22did the pilots lose control of their plane while performing a slam dunk
26:26barely three minutes later
26:28barely three minutes later
26:29there are 100 knots
26:31what's the airspeed supposed to be
26:33operations manual says
26:39130 knots
26:43so they go from way too fast to way too slow
26:49how'd they manage that?
26:51investigators turned to the flight data recorder
26:54looking for something that might explain the drastic change of speed
26:58it's here
27:01it's here
27:02they pulled the thrust back to idle
27:04and they left it there
27:05that'll slow you down
27:08but slow enough to stall
27:10ATC said to slow the aircraft down
27:14and that's what the pilot did
27:16reduce speed to 170 knots
27:20United express 6291
27:25the trouble is
27:26that the aircraft never stopped slowing down
27:29there's got to be more
27:33they were doing all this with the autopilot on
27:39so right up until before they crashed
27:41they were using the autopilot
27:43to help them land?
27:50when the autopilot is on during an approach
27:53it controls the aircraft's pitch
27:55and roll
27:58this is a workload reducing sort of thing for the pilot
28:02if they don't have to worry about keeping the aircraft
28:04on a particular angle or particular direction toward the runway
28:07they can focus their attention on other parts of the landing
28:10here comes the glide slope
28:13in all the years that I flew in the cockpit as an NTSB investigator
28:19I rarely saw pilots offload the approach to an autopilot
28:24the overwhelming majority of the times
28:26the pilots flew the approach manually
28:29they wanted to do that
28:31they liked doing that because it's fun
28:34and because it keeps them sharp
28:36when the pilot selects the autopilot
28:39the autopilot will fly the approach perfectly
28:42but it's up to the captain
28:44to monitor and control the airspeed
28:51so they move thrust to idle
28:53the plane slows down
28:55below the safe approach speed
28:57which makes it descend
29:00and the autopilot tries to climb
29:08because the plane drops below the glide slope
29:12the autopilot pitches the nose up to regain altitude
29:16but this slows the plane even more
29:19it's what brings flight 6291 to a stall
29:26what did you do?
29:28I did nothing
29:30what were these guys thinking?
29:34listening to the conversations on the cockpit voice recorder
29:39may be the only way left to solve the mystery of the crash
29:44did pilot error lead to the crash of United Express 6291?
30:00ok let's go
30:02investigators turn to the cockpit voice recorder
30:05to find out if the conversations between the two pilots can offer any clues
30:10hold it up for you?
30:11actually I kind of like it
30:12really?
30:14it's the only place where we can listen to what's going on inside the cockpit
30:19so you starting to get a hang of it?
30:21oh yeah
30:23you can tell from the interaction between the captain and the first officer
30:27whether they work better or they work worse
30:30if one guy had a bad night
30:32just by their comments you can tell what they're doing
30:36the CVR confirms that the crew was aware of the icing conditions
30:42we're gonna hit the rhyme soon
30:44ok so they definitely knew what they were flying into
30:47the question is
30:49how did they deal with the icing?
30:50since we have to descend through it let's keep it dry as long as possible
30:58then we can bring it down real quick
31:03like so
31:07ok so the captain's planning on a slam duck to get through the ice
31:13ok continue
31:2010 minutes later in the flight
31:23what are the surface winds down there again?
31:253-3-0 at 4 knots
31:274 knots
31:29thanks
31:31tell you what?
31:32yeah
31:33what's the boots?
31:42ok so they use the de-icing boots
31:43investigators
31:46investigators scrutinize the pilots conversation as the plane descends past the icy conditions towards its destination
31:53united express 6291 reduce speed to 170 knots
31:58reduce speed to 170 knots
32:03united express 6291
32:05ok stop
32:09ok we're here now
32:11this is where they pull back the thrust to idle
32:14to slow the plane down
32:16they were too fast at what's called the outer marker
32:20to lower the flaps and lower the gear properly
32:22so the key thing that had to happen then is they had to slow down
32:26less than a minute later they're cleared to land
32:33united express 6291 columbus tower
32:37runway 28 left cleared to land
32:40wind 3-0-0 at 4 knots
32:42clear to land
32:45united express 6291
32:47and that's when investigators hear things start to go wrong
32:51ok if you have all the speeds don't worry about it anymore
32:54ref is 112
32:57I gotta input that
32:58I did it for you
33:00there's definitely tension in the cockpit
33:02here comes the glide slope
33:04ok and we'll mark our inbound
33:06roger
33:07don't forget to give me my call outs
33:091,014 is the decision height
33:101,000
33:11ok
33:121,000 a buck
33:14ok flaps 9
33:16gear down
33:18flaps 9
33:19waiting for 3 grid
33:21flaps 15
33:22landing checks
33:23flaps 15
33:24landing gear down
33:253 grid
33:28wait
33:30did I miss something?
33:32did anyone hear any call outs?
33:34the first officer's silence is revealing
33:38he should have been calling out altitudes
33:41he should have been calling out air speeds
33:43but he wasn't doing any of that
33:45ok continue
33:47yaw damper
33:48autopilot all the way
33:49don't touch
33:51don't touch
33:52hold another yaw damper
33:54the yaw damper controls the movement of the plane's rudder
33:57preventing sudden swings
33:59disconnecting it also turns off the autopilot
34:02he doesn't want to lose the autopilot
34:03he doesn't want to lose the autopilot
34:05the captain's comment on yaw damper
34:07don't touch
34:08and the first officer's response
34:10don't touch
34:12told us a lot about the dynamics between the captain and the first officer
34:15it illustrated the tension between the two of them
34:18and the lack of trust that the captain had for the first officer
34:22ok that's the stick shaker it's stalling
34:28that only happens when the air speed is approaching the stall speed
34:33they must take immediate action or the airplane will likely crash
34:37the sound of the stick shaker should have prompted the captain to check his air speed
34:44instead he focuses on his first officer
34:47Tony what did you do?
34:50i did nothing
34:54i was dumbfounded
34:56that's the most unusual reaction i've seen
34:59to respond to a stick shaker
35:02it told me that the pilot didn't recognize something that he should have recognized immediately
35:08and his first assumption was that the first officer had done something wrong
35:13which wasn't the case
35:14the investigators now listen to the flight's final 10 seconds
35:20they expect to hear the pilot call for full power and a go around
35:25standard operating procedure in a stall
35:28give me flaps up
35:30no no no hold it hold it
35:32give me flaps up
35:34flaps up in a stall?
35:36what were these guys thinking?
35:37there is no training that involves flaps up during any kind of a go around situation
35:47with its flaps up the plane needs more speed than it normally would to get out of a stall
35:54the most important thing is add air speed
35:57you can add air speed by pointing the nose toward the ground
36:00you can add air speed by adding power to the engines or a combination of the two
36:04but the crew never seems to notice their dangerously low air speed
36:09up until that time he could have recovered
36:12but after that
36:14he was along for the ride
36:15from the CVR it's pretty clear that the captain did not feel he could rely on the first officer
36:28it's also clear the first officer did not diagnose the need for the captain to increase the air speed as he should have
36:34and therefore it's pretty clear that the team of the captain and the first officer was ineffective
36:41investigators established that the crash of United Express 6291 was caused by a series of pilot errors
36:49leading to an aerodynamic stall
36:52but they still don't know how such an ineffective crew ended up in the cockpit in the first place
36:58investigator Dickinson and his team comb through United Express pilot records for background about the crew of flight 6291
37:11I got the captain's records
37:14and the first officers
37:16the first officers records with the airline are surprisingly thin
37:20that's it?
37:22this guy's totally green
37:24hired six months before the accident
37:27finished training one month before the accident
37:30and he's only got two and a half hours of line experience on the jet stream 4100
37:35he wasn't a bad pilot
37:38he had a fairly good reputation
37:40but he was not at all familiar with flying in the 4100
37:43and he had very little confidence to state what he wanted
37:49and that was brought out in looking at his records
37:56what about the captain?
37:58the captain's records also raise serious questions about his qualifications
38:02look at this
38:05he made a habit
38:08and failing his check rights
38:12when captain white joined the company two years before the accident
38:17he trained to become a first officer
38:19he failed his first simulator check
38:22due to difficulty managing the cockpit instruments during landing
38:26more training was required
38:28you could talk to pilots as I have and ask them
38:32have you ever failed a checkride?
38:34and it's very rare that a captain or first officer will say
38:39yeah I failed one
38:41very rare not because they're not telling you the truth
38:43because it just doesn't happen
38:45this captain failed two checkrides within about a year
38:48his second failure comes while training to captain the jet stream 4100
38:53the examiner notes he seemed unusually nervous performing an ILS approach
39:06but after two hours and twenty minutes of additional flight training
39:10he passed his follow-up checkride
39:12and became a captain on the 4100
39:15as far as the training he received after failing
39:21there was less than two and a half hours of flying time
39:24that to us is unsatisfactory
39:27it's just how much can you learn in one flight basically
39:33next investigators call first officers who have previously flown with the captain
39:38to find out about his habits when landing
39:40so he usually used the autopilot while he was landing
39:44thank you
39:46when a pilot constantly uses autopilot
39:51I hate to say it's he's lazy
39:55but in reality
39:57he doesn't have confidence himself to fly approaches
40:01and pilots need to have that confidence
40:04and in this case it really resulted in a very bad situation
40:08investigators conclude that United Express should not have paired a novice first officer
40:16and a captain with a history of failures on the 4100
40:20you started to get the hang of it?
40:23oh yeah
40:28but the airline was expanding
40:30and didn't have the resources to keep up with the demand for experienced pilots
40:34to save money
40:37they upgraded less experienced pilots to new aircraft
40:43unfortunately the organization needed pilots to fly the 4100
40:49because they had been expanding
40:51and they chose to pair this pair up and it wasn't a good pairing
40:55from all sides I could understand why they did it
41:01unfortunately that also had the unintended consequence
41:06of putting two relatively inexperienced pilots
41:10into the seats of a very sophisticated airplane
41:13in their final report
41:20the NTSB concludes that pilot error was the primary cause of the crash of United Express 6291
41:28Yard damper
41:30autopilot all the way, don't touch
41:32don't touch, holding on the yard damper
41:33an ineffective crew failed to notice their airspeed had dropped so low that a stall occurred
41:41Tony what did you do?
41:43I did nothing
41:45and instead of increasing thrust as they should have
41:48give me flaps up
41:50no no no hold it hold it
41:52give me flaps up
41:54they raised their flaps, making the crash inevitable
41:57why the captain and first officer missed the airspeed
42:05to me is at the heart of this accident
42:08the captain was under so much stress
42:10focusing on the flight path that he didn't have the ability to take in additional information
42:14the first officer was inexperienced
42:17we know that he was so intimidated by the captain
42:20therefore I don't believe he felt comfortable volunteering information to the captain
42:23that he wasn't 100% sure of
42:24I think you put all that together and one can understand
42:28although none excuse
42:30why they both missed the airspeed
42:34the NTSB recommends more training on recognizing and recovering from a stall
42:40and on managing high speed approaches
42:45but one of the more notable results of the investigation comes out of the cabin
42:50rather than the cockpit of flight 6291
42:52the survivors indicated that they had a hard time releasing the buckle and they struggled with it
43:03they had to release tension in order to get the buckle to work right
43:07we tested those belts and found when you put them under tension
43:11they couldn't release them
43:13so that's one of the good things that came out of this report
43:16is the seat belts have all been replaced or taken out of aircraft that had these type of seat belts
43:24it's a valuable finding from a tragedy that could have been avoided
43:31this accident was very likely evidence of the flight crew specifically the captain
43:38perhaps leaning on technology too much
43:40the lesson which is absolutely relevant today is that no matter how sophisticated the aircraft
43:47no matter how modern the cockpit is
43:50it comes down to a combination of one's skill as a pilot
43:54and also one's understanding of how the airplane behaves
43:58at all phases of flight
43:59for all phases of flight
44:00You
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