- 6/20/2025
Category
📺
TVTranscript
00:00Okay, we're marker inbound. Don't forget to give me my call-outs.
00:04Captain and first officers have to work together as a team.
00:07But cockpits containing...
00:09Tony, what did you do?
00:11Domineering captains...
00:12Eddie, two, three, zero, understand?
00:16Poor communicators...
00:18No!
00:18All you have to say was stop, you're turning the wrong way.
00:21And intimidated rookies...
00:23I did nothing.
00:24Let the personnel...
00:26Don't be so stupid.
00:27Get in the way of the professionals.
00:28There were words that you wouldn't expect to hear...
00:31in a professional crew environment.
00:33And doom many lives.
00:37Investigators must now unravel three needless tragedies...
00:40He made a habit.
00:42I'm failing his check rights.
00:43...stemming from...
00:44We're clashing!
00:46...bad pilot pairings.
00:47Oh!
00:56Oh, fuck.
00:58In Douala, Cameroon...
01:14...Kenya Airways Flight 507...
01:17...is waiting for a bad storm to pass.
01:19Ladies and gentlemen, we are going to wait...
01:24...for the weather conditions to improve before we take off.
01:29There are 108 passengers on board the new Boeing 737-800.
01:37Flight 507 began in Abidjan earlier in the day.
01:41It's stopping over at Douala and flying on to Nairobi, Kenya.
01:45But the storm has caused an hour's delay.
01:54Captain Francis Wamweya is in command.
01:58Let's see what this storm is doing.
02:00He's got more than 8,000 flying hours.
02:0523-year-old Andrew Kiru is the first officer.
02:09There might be a way around it.
02:10Tower.
02:15Kenya 507.
02:16Looks like there's a break in the weather.
02:19Requesting start-up.
02:21Okay, 507.
02:23Start-up approved.
02:25Start-up checklist.
02:26Quickly, please.
02:30Generator's on.
02:34Okay.
02:35Request taxi clearance.
02:36As the plane taxis to the runway, the first officer focuses on take-off preparations.
02:45Wait till we line up.
02:47Okay.
02:48Usually, things happen quickly, though.
02:51Right.
02:52Okay.
02:53Try to keep on.
02:54Captain Wamweya verifies the position of a thunderstorm.
03:06Let's have a look.
03:07Before confirming a route around it.
03:11Tower.
03:12Kenya 507.
03:14After departure, we would like to maintain a heading slightly left of runway due to weather ahead.
03:21Right.
03:22Ah.
03:23Sorry.
03:23Slightly right.
03:27That moved.
03:33Okay.
03:35Takeoff thrust is set.
03:37Speed building on both.
03:39Check.
03:4080 knots.
03:42Check.
03:43V1.
03:44Rotate.
03:45Just after midnight, Kenya Airways Flight 507 finally takes off.
03:56Get off.
03:57Okay.
04:051,000 feet and climbing.
04:08The 737 begins turning to avoid the storm.
04:12And one.
04:13After reaching 1,500 feet, the captain calls for...
04:17Okay, come on.
04:18...the autopilot to be engaged.
04:20So, should I remain on this heading?
04:23Yep.
04:282,400 feet and climbing.
04:34Now we're getting into it.
04:36We're getting into it.
04:47Suddenly, the 737 rolls dangerously to the right.
04:53Hold on.
04:56The captain struggles to level the plane.
05:00Bank angle, bank angle.
05:11Bank angle, bank angle.
05:13Now we are clashing.
05:15Left, left.
05:15Bank angle, bank angle.
05:17Left direction.
05:18Bank angle, bank angle.
05:21Up, up, up.
05:30Flight 507 has plunged into a swamp.
05:45Search teams spend two days looking for the wreckage.
05:49It's found in a mangrove swamp southeast of the airport.
05:52All 114 people on board the 737 are dead.
06:04An international air accident team arrives in Cameroon to investigate the case.
06:10This was the toughest accident scene I've been on in my career, Boeing.
06:16With so much of the physical evidence obliterated, investigators face a huge challenge.
06:22The team gets a break when the 737's flight data recorder is recovered.
06:32Well, looks pretty good, considering.
06:38The search for the cockpit voice recorder continues.
06:45In the meantime, investigators can search the flight data for clues.
06:49They hope it will reveal why a new Boeing aircraft crashed so soon after takeoff.
06:55Let's see what we've got.
06:58The data showed us the airplane was behaving as we would expect it to.
07:03It was a perfectly airworthy aircraft.
07:05There's no question about it.
07:06As investigators examine the data,
07:10Look at this.
07:12The pilot's control wheel inputs after takeoff attract their attention.
07:16Rotate.
07:16They make a surprising discovery.
07:23He was turning left from the moment they left the ground.
07:28That information showed us that right after takeoff,
07:31the aircraft started to roll to the right a little bit and the pilot corrected it.
07:34And then he keeps making corrections to the left.
07:40Looks like he's trying to keep the plane level.
07:44Investigators wonder what caused the aircraft's slight roll to the right.
07:49They dig deeper into the flight data.
07:52Bingo.
07:53It's the way the flaps are rigged.
07:56Give it a slight right roll.
08:00On this particular 737,
08:02the left flap provided slightly more lift than the one on the right.
08:06While climbing, pilots needed to compensate for the difference
08:09by making constant adjustments to the roll.
08:12It's similar to driving down the freeway in your car
08:16and just letting go of the wheel.
08:18Then it'll start to drift off one way or another.
08:21That's the way the airplane was slowly and naturally banking it.
08:25The discovery explains why the captain kept his control column turned to the left
08:30immediately after takeoff.
08:34Well, that's weird.
08:35But it doesn't account for some readings in the flight data.
08:40Look at this.
08:42The captain's control wheel input seemed to stop.
08:44It's like he just let go of it.
08:47Six degrees right, he does nothing.
08:50Eleven degrees.
08:51Fifteen degrees.
08:53Twenty degrees.
08:54Thirty degrees.
08:55And still nothing.
08:59Why did the crew stop leveling the plane
09:02despite banking further and further to the right?
09:05Bank angle.
09:07Bank angle.
09:08Allah!
09:08The airplane just continues to roll right up to 110 degrees of bank.
09:15The crew didn't recover it before impact.
09:18The data paints a baffling picture of the short flight.
09:24Who flies like that?
09:25With little physical evidence to go on and perplexing flight data,
09:32the team is eager to locate the plane's cockpit voice recorder.
09:36It may be all they have to solve the mystery of Flight 507's crash.
09:41It takes five weeks for searchers to recover Kenya Airways Flight 507's cockpit voice recorder
09:52from a swamp near Douala International Airport.
09:56Started.
09:58Investigators hope it will reveal why the pilots didn't take action
10:01until the aircraft reached an extreme right bank angle.
10:04Selected.
10:06Check.
10:08N1.
10:09OK, come on.
10:10That's the call to activate the autopilot.
10:16So, should I remain on this heading?
10:19Yep.
10:21Flight data confirms that the captain released the control column
10:25after calling for the autopilot to be engaged.
10:28But investigators spot a problem.
10:30The autopilot didn't come on.
10:32He thought the 737 was flying itself.
10:36Investigators are stunned.
10:38After the captain released the control column,
10:4155 seconds passed before pilots noticed the plane was out of control.
10:46There was nobody flying the control, so nothing was controlling the airplane.
10:51The chilling discovery gives the investigation a new focus.
10:54N1.
10:55OK, command.
10:57Why didn't the autopilot turn on?
10:59The captain calls for the autopilot to be engaged.
11:05But the first officer does not respond.
11:09Investigators suspect that the first officer was so focused on inputting the route around the storm
11:14that he never engaged the autopilot.
11:18Now we're getting into it.
11:19It seems the captain assumed the autopilot was controlling the aircraft and the pre-selected right turn.
11:26Bank angle, bank angle, bank angle.
11:30The pilots only noticed there was a problem when the bank angle warning sounded.
11:35Bank angle, bank angle.
11:36This means the plane exceeded a 35-degree roll and was flying into danger.
11:43We're crouching!
11:45Yet the 737's bank angle warning is designed to give pilots enough time to regain control.
11:51So why didn't the crew recover?
11:54They should have been trained for such a scenario.
11:56Investigators dig into the pilot's background for clues.
12:02Wait.
12:03Look at this.
12:05They find serious shortcomings in the captain's training records.
12:10Inadequate knowledge of systems and procedures.
12:13Insufficient flight discipline.
12:15Poor cockpit scans.
12:17Below standard.
12:18Yikes.
12:20Get up.
12:21Get up.
12:22We discovered the captain had a history of training difficulties and lack of systems knowledge for autoflight systems and so forth.
12:31So he had some red flags in his history.
12:34The first officer's report isn't any better.
12:37The first officer was young and fairly inexperienced.
12:40He had had some training feedback, like you need to be more proactive about calling out deviations and so forth.
12:48Not an A-level crew.
12:49It's a troubling discovery, but it still doesn't add up.
12:55It should have been a simple recovery.
12:57Even a less experienced captain and a novice first officer would have had basic upset recovery skills.
13:04Was there something here that we were missing in the investigation?
13:07They returned to the flight data and the voice recording for additional clues.
13:12Hold on!
13:13Bank angle.
13:14When the bank warning came on and the aircraft was on a right roll, the captain turned it further to the right and which aggravated the situation.
13:27When he realized the autopilot was disengaged, the captain activated it.
13:32But when the plane didn't level immediately, he turned the control column erratically.
13:39Those inputs overrode the autopilot.
13:4222 degrees to the right, 20 left, 45 right, then 11 to the left.
13:50The timing of the first officer's response is significant.
14:09It took him 10 seconds to speak up.
14:14The first officer read the situation correctly.
14:17We're crashing!
14:19Yeah, we are crashing!
14:20The pilots needed to turn left.
14:22Left!
14:23Left!
14:24Bank angle.
14:25Bank angle!
14:26So why did first officer Kiyoru stay silent?
14:29They go back to the first leg of the flight from Abidjan to Douala on the recording for clues.
14:38Let's hear it.
14:42Sorry, did you say an altitude of 14,000 feet?
14:45Yes.
14:46Don't be so stupid.
14:47Write it down if you can't remember.
14:50Wow.
14:50There were words like stupid, shut up, stuff like that, that you wouldn't expect to hear in a professional crew environment.
15:00What is wrong with you?
15:02Did you not hear the instruction?
15:04The first officer seemed to kind of shut down.
15:06Heading 2, 3, 0.
15:10Understand?
15:12Investigators believe the captain's intimidating manner prevented the first officer from speaking up sooner.
15:17Bank angle.
15:19Bank angle.
15:21Bank angle.
15:21The captain's behavior toward the first officer on the first flight likely caused him to adopt sort of a passive role.
15:29You need both pilots actively engaged and checking each other and catching errors.
15:35Sorry, heightened ego.
15:38Really.
15:39Captain Wamweya's treatment of his first officer leads investigators to delve deeper into his professional history.
15:46He had a lot of concerning things in his training files about being overbearing, being authoritarian, in terms of how he dealt with other crew members.
15:56So, we have a young, reserved first officer and an overbearing captain.
16:05A lethal combination.
16:06So, should I remain on this heading?
16:15Yep.
16:15In the end, investigators conclude that one major mistake lay at the heart of the tragedy, the crew's failure to ensure the autopilot was engaged.
16:24Additionally, the pairing of a domineering, verbally abusive captain with an apprehensive young pilot compounded the danger.
16:32What is it?
16:33That guy?
16:34in the wake of flight 507's crash Cameroon's Commission of Inquiry made a
16:52series of recommendations including regularly updating safety manuals
16:58relating to cockpit procedures and crew responsibility they made changes to
17:04the standard operating procedures about who's responsible for engaging your
17:09autopilot and improved pilot training with a focus on upset recovery communication
17:16in a cockpit it's kind of like the fabric that holds holds a good flight together
17:19and when these break down and then you may be in trouble
17:27and when another professional mismatch leads to panic in the cockpit
17:34a short commuter flight goes horribly wrong
17:44it's a cold and rainy night at Zurich International Airport passengers on board
17:52cross-air flight four nine eight are waiting for takeoff to Dresden Germany
17:58captain Pavel Grusin is in command and Rastislav Kolasar is first officer
18:06check this completed both pilots came from Eastern Europe to work in Switzerland set
18:12takeoff to night they're flying a Saab 340 turboprop
18:22you know before the aircraft clears the clouds the controller makes a slight change
18:33to the flight path 498 turn left to Zurich East
18:40cross-air 498
18:42the new route takes the plane south of the airport over a navigation beacon and on to Dresden
18:48as the plane begins to turn the first officer notices something wrong
18:54turning turning left to Zürich East
19:01you should left
19:05cross-air 498 confirm you are turning left please stand by the plane should be turning left but instead it's banking to the right
19:16okay continue right to Zürich East
19:23no!
19:27left left!
19:33left!
19:35left!
19:36left!
19:37left!
19:39left!
19:41left!
19:43left!
19:45left!
19:50flight 498 slams into the ground just four miles from the airport
19:56all seven passengers and three crew die on impact
20:03the next morning investigators inspect the wreckage
20:06the crash site itself provides them with their first lead
20:10if you can't see a bigger structure of an aircraft and you see a crater
20:17that leads you to the idea that this aircraft has to be come quite steep into the ground
20:23the debris field tells investigators the direction the plane was flying
20:28they discover it was turning in the opposite direction to its designated flight path
20:35they question air traffic controllers working the night of the accident
20:41why weren't they flying the standard departure?
20:43498 turn left to Zürich East
20:46air traffic controllers tell investigators cross-air 498 turned right and not left as instructed
20:55cross-air 498 confirm you are turning left
20:58please stand by
21:00the controller assumed the captain wanted to follow a different route and approve the course change
21:04okay continue right to Zürich East
21:10moments later the plane spiraled out of control
21:13a steep right turn developed which led to a collision with ground
21:19but there was no indication about the reason for that
21:24the team hopes the black boxes will help focus the investigation
21:29while experts recover the recorder's data crash site debris provides a big lead
21:36a pilot's mostly intact flight bag
21:40it belongs to captain Grusin and its contents are disturbing
21:47there were some personal items in there and with them we found this medication
21:57no label or box with it
22:00it is quite uncommon that you find some medication in a in a pilot's bag
22:07turning left to Zürich East
22:10we should left
22:12investigators consider a deeply troubling scenario
22:15was a drug impaired captain at the controls on the night of the crash
22:19it is always of great concern because we all know that we're not supposed to take any kind of drugs
22:26when we go flying
22:28the team must identify the medication and determine whether captain Grusin took any before stepping into the cockpit
22:35get this to the lab
22:41the test results identify for Nazepam a powerful sedative similar to Valium
22:51the drug is often used to treat anxiety disorders
22:54in this case there was a medication which was very strong and which can have an effect on your capability to fly an airplane
23:03investigators must wait for the results of the tissue analysis
23:08could an impaired pilot be the reason 13 people lost their lives in a tragic accident
23:16the investigation into the crash of cross air flight 498 comes to a dead end with the results from the tissue analysis
23:22though captain Grusin had traces of a sedative in his system the tests don't reveal if the amount was sufficient to affect his flying
23:32we were not able to rule out this effect in the accident but we were also not sure that this medication had an effect for sure
23:43with the data from the black boxes now available the team turns to the cockpit voice recording for answers
23:50they listen to the pilots conversation in the cockpit alongside the flight data
23:55right here the turn is starting to get very steep
24:02the captain's sudden agitated reaction provides a clue
24:09that timing can't be coincidence
24:13investigators know that the captain's flight display changes the moment a turn becomes too steep
24:19the system is designed that if you go into a abnormal bank or pitch angle
24:27he removes unnecessary information to make the recovery easier for the pilot
24:34the timing of the captain's remark convinces investigators his instruments were working
24:39but for some reason the pilot turned further to the right
24:42I think the problem was that he was not aware what was going on
24:49what so confused and experienced pilot that he was unable to distinguish left from right
24:55the team examines the pilots records at cross-air
25:02nothing yet you investigators need to dig deeper into the crews training
25:10the search for an answer takes them to Russia where captain Gruzhin learned to fly
25:17thank you for seeing us
25:19captain Gruzhin was trained on soviet-era aircraft
25:22the first officer on western planes
25:25investigators learned that both pilots completed their training successfully
25:29but then Russian experts share a troubling cluster of similar accidents
25:37pilots trained on soviet-era aircraft were becoming confused by a crucial flight instrument on western planes
25:43the attitude indicator or artificial horizon
25:48this was very surprising for us because this problem was not well known at this time
25:53in the western part of aviation
25:57pilots in the former soviet union were trained to fly using an attitude indicator that looks very different from the ones in western planes
26:05turning left to Zurich east crosshair 498
26:12in the west the aircraft symbol of the center is static while the background moves
26:16soviet or eastern attitude indicators work in the opposite way
26:20the aircraft symbol moves and the horizon remains static
26:24it's easy to see how a pilot might get confused
26:28this discovery was really crucial for a probable cause of this accident
26:33under stress and possibly affected by a sedative
26:39captain Gruzhin may have reverted to what he learned when he first became a pilot
26:44in his confusion he became convinced he was in a steep left turn
26:51so he turned right
26:53putting the aircraft into a deadly spiraling dive
27:04but a question remains unanswered
27:06what prevented the first officer from noticing his captain's mistake before it was too late
27:11climbing level 110 crosshair 498
27:14it was the first officers job to monitor the instruments
27:20investigators reconstruct the flight to see what the first officer was doing when things started to go wrong
27:26let's begin
27:28crosshair 498
27:30climb to flight level 110
27:32climbing level 110 crosshair 498
27:35investigators discover the first officer must have been looking down to adjust some settings
27:42or was focused on the overhead panel
27:44wheels are on
27:46set climb power
27:49coming
27:52these duties keep a pilot's gaze well away from the attitude indicator
27:56by the time the first officer could see what was happening
27:59the plane was already in a steep right bank
28:02turning left to Zürich East
28:05you should left
28:06crosshair 498 confirm you are turning left
28:10please stand by
28:12no
28:14the stress in the first officer's voice suggests he knew there was a problem but couldn't communicate it clearly
28:19left left
28:21left
28:22and the captain thinking his plane was already turning left
28:25didn't understand what his first officer was trying to tell him
28:28left
28:29their english was basically aviation english
28:33and it is hard to communicate fluently and to communicate concerns well enough
28:45all he had to say was stop you're turning the wrong way
28:48in the end the pairing of two pilots with very limited english language skills proved lethal
28:57after the crash of flight 498 the aviation industry improved training for pilots from former soviet bloc countries
29:04and passing an english language proficiency test became a requirement
29:09recommendations that did arise from the accident
29:11people upgrading to western machines
29:13they received much more training on the differences between western and eastern bloc aircraft
29:22but when mistrust in the cockpit reaches a fever pitch
29:25your damper autopilot all the way don't touch
29:28a straightforward landing turns into disaster
29:30Tony what did you do
29:31I did nothing
29:32United express flight 62 91 is on route from washington dulles airport to columbus ohio
29:48a winter cold front is dropping temperatures below freezing in the region
29:51cold enough for you
29:52captain derrick white is in the cockpit
29:56actually i kind of like it
29:58really
29:59Anthony Samuels is his first officer
30:01he's been with united express for three months
30:07starting to get the hang of it
30:08oh yeah
30:10they're piloting a brand new jet stream 4100
30:13a small twin engine turboprop
30:15there are only five passengers plus a flight attendant in the cabin
30:24flight 62 91 is cruising at an altitude of 14,000 feet
30:31united express 62 91 be advised to just had a report of some icing at one four thousand
30:36indianapolis center united express 62 91
30:43can we get one five thousand for a while
30:47united express 62 91 climb and maintain one five thousand
30:52one five thousand united express 62 91
31:01after flying for several minutes above the bad weather
31:04i'm in the approach chart
31:07the pilots are ready to begin descent
31:10united express 62 91 reduce speed to 170 knots
31:15the plane needs to slow down to make a safe approach
31:20reduce speed to 170 knots
31:23united express 62 91
31:27united express 62 91 columbus tower
31:31runway 28 left cleared to land
31:33wind 300 at four knots
31:36okay if you have all the speeds don't worry about it anymore
31:39the ref is 112
31:42i gotta input that
31:43i did it for you
31:49okay and remark or inbound
31:51roger
31:52don't forget to give me my call outs
31:54the captain reminds the first officer to report the altitude and air speed readings
31:59as the plane pushes through the mist and drizzle the runway comes into view
32:07flaps 15
32:09landing checks
32:11flaps 15 landing gear down
32:13three green
32:14you are dapper
32:15you are dapper
32:20tony what did you do
32:21i did nothing
32:26give me flaps up
32:28no no no hold it hold it
32:29hold it up
32:31give me flaps up
32:32hold it
32:33hold it
32:35hold it
32:36hold it
32:38hold it
32:39hold it
32:47flight 62 91 crashes into a warehouse only a mile short of the runway
32:52a family of three escapes the fiery wreckage
32:57they are the only ones to survive
33:06after sunrise lead investigator al dickinson and his team from the national transportation safety board are on the scene
33:13the fire was very intense
33:16and it made it hard just to try to identify the different pieces
33:23yes now that's what i wanted to see
33:25the flight data recorder and cockpit voice recorder are found buried deep in the wreckage
33:31using flight 62 91's airspeed and altitude the team tracks the plane's descent
33:38ok this is the ice that they flew through
33:40the data gives the investigators a lead
33:43240 knots they are screaming through this
33:46looks like a slam dunk
33:48a slam dunk is when a plane approaches high and then descends rapidly to the runway
33:55it's usually done to get through bad weather quickly but it's a risky maneuver
33:59you can fly really fast to get through ice
34:02but if you don't look well ahead of the aircraft
34:05you can easily slam it right into the earth
34:07here they're going so fast the controller has to slow them down
34:16united express 62 91 reduce speed to 170 knots
34:20in response the crew moves the thrust to idle and doesn't adjust it again
34:25investigators discover the plane drops to 100 knots
34:30well below 130 knots which is the minimum speed to prevent a stall
34:35so they go from way too fast to way too slow
34:40why would pilots reduce their speed so dangerously low
34:43sifting through united express flight 62 91's data
34:56it's here
34:58the investigators make a surprising discovery
35:00they were doing all this with the autopilot on
35:01so right up until before they crashed they were using the autopilot
35:09to help them land
35:12while an aircraft on autopilot can follow the descent path perfectly
35:18the captain still needs to monitor and control the airspeed
35:22that's why pilots almost always land manually
35:24so they move thrust to idle the plane slows down below the safe approach speed
35:35which makes it descend
35:38and the autopilot tries to climb
35:41because flight 62 91 drops below the prescribed descent path or glide slope
35:47the autopilot pitches the nose up to regain altitude
35:50but this slows the plane even more and takes it into a storm
35:55Tony what did you do?
36:01i did nothing
36:03investigators now know the sequence of events that led to the crash
36:08but they still don't know why the pilots didn't increase their airspeed to save the plane
36:13ok let's go
36:15ok let's go
36:17the team listens to the cockpit voice recording for clues
36:20united express 62 91
36:22reduce speed to 170 knots
36:25reduce speed to 170 knots
36:30just as the pilots are cleared to land investigators hear things going wrong
36:35ok if you have all the speeds don't worry about it anymore
36:38the ref is 112
36:41i gotta input that
36:42i did it for you
36:44oh there's definitely tension in the cockpit
36:46ok and we'll mark our inbound
36:48roger
36:49don't forget to give me my call outs
36:51ok flaps 9
36:53gear down
36:55flaps 9 waiting for 3 grade
36:57flaps 15
36:59landing checks
37:00flaps 15 landing gear down
37:023 grade
37:04wait
37:05did anyone hear any call outs?
37:07he should have been calling out altitudes
37:09he should have been calling out air speeds
37:10but he wasn't doing any of that
37:12the first officer's omission is revealing
37:15yacht damper
37:16autopilot all the way
37:17don't touch
37:18don't touch
37:19hold another yacht damper
37:21disconnecting the yaw damper would turn off the autopilot
37:24he doesn't want to lose the autopilot
37:26this heated exchange tells investigators the captain has little faith in his own skills to land manually
37:33and even less faith in his first officer's abilities
37:36the captain's comment yaw damper don't touch
37:39and the first officer's response
37:41don't touch
37:42told us a lot about the dynamics between the captain and first officer
37:46it illustrated the tension between the two of them and the lack of trust
37:54ok that's the stick shaker it's stalling
37:56that only happens when the air speed is approaching the stall speed
38:01they must take immediate action or the airplane will likely crash
38:05Tony what did you do?
38:07i did nothing
38:09rather than increase air speed as he should have done
38:11the captain wasted precious seconds chastising his first officer
38:14his first assumption was that the first officer had done something wrong
38:18which wasn't the case
38:20i was dumbfounded
38:21give me flaps up
38:23no no no hold it hold it
38:25give me flaps up
38:27flaps up in a stall?
38:29what were these guys thinking?
38:32there is no training that involves flaps up during any kind of a go around situation
38:39with its flaps up the plane needs more speed than usual to pull out of a stall
38:44yet the crew doesn't notice their air speed is already too slow
38:48up until that time he could have recovered
38:52but after that he was along for the ride
39:00it's pretty clear that the captain did not feel he could rely on the first officer
39:05it's also clear the first officer did not diagnose the need for the captain to increase the air speed as he should have
39:11and therefore it's pretty clear that the team of the captain and the first officer was ineffective
39:17investigators wonder how these pilots ended up together in the cockpit in the first place
39:22they study the pair's professional histories for answers
39:26i got the captain's records
39:28and the first officer's
39:30the first officer's airline records are surprisingly thin
39:33that's it?
39:35this guy's totally green
39:37hired six months before the accident
39:40and he's only got two and a half hours of line experience on the jet stream 4100
39:45the captain's records also raise serious questions
39:49look at this
39:51he made a habit
39:55and failing his check rides
39:57check rides verify a pilot's competency and skill
40:02it's very rare that a captain or first officer will fail to check ride
40:09this captain failed two check rides within about a year
40:12investigators then talk to other first officers who have flown with the captain
40:17to find out more about his habits when landing
40:21so he usually used the autopilot while he was landing?
40:24thank you
40:26when a pilot constantly uses autopilot
40:31in reality he doesn't have confidence himself to fly approaches
40:36and pilots need to have that confidence
40:39investigators conclude that United Express should not have paired a novice first officer
40:45and a captain with a history of failures on the 4100
40:52unfortunately the organization needed pilots to fly the 4100 because they had been expanding
40:59and they chose to pair this pair up and it wasn't a good pairing
41:04the NTSB recommends more training to enable pilots to recognize and recover from a stall
41:11and to manage high speed approaches
41:12today many more factors are considered before pilots are placed in the cockpit together
41:19this cockpit resource management training now has moved great bounds
41:26so that the first officer feels he can question the decision from his captain
41:31he can suggest solutions to a situation and he will be listened to
41:36we're crashing!
41:40left! left!
41:42three bad pilot pairings that ended in disaster
41:45no!
41:47each a lesson for greater scrutiny of a pilot's history
41:50and the creation of compatible partnerships in the cockpit
41:53we put 93,000 flights in the air over the earth every day
41:59and get every one of them back almost all the time without anything going seriously wrong
42:03and teamwork is what gets airplanes with people back on the ground safely
42:06and see you theoretically
42:08they'll be looking back by the left!
42:09in the ass on the ground safely
42:12our lives on the ground safely
42:13we are looking back on the ground safely
42:15tho
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