Mayday Air Crash Investigations - S10 E04 - Dead Tired
Category
📚
LearningTranscript
00:00February the 12th, 2009. Just outside Buffalo, New York.
00:15Gear down.
00:17Oak's alive.
00:19Gear's down.
00:24Jesus Christ!
00:26The airplane entered an aerodynamic stall.
00:33It did not recover.
00:42It was one of the grisliest, nastiest scenes that I think I've seen.
00:47The crash of Continental Connection Flight 3407 would be one of the NTSB's most important in decades
00:54and would see a grieving father fight for changes to the laws governing small airlines.
00:59I'm focused and determined to change what exists
01:01and not have another dad sitting here.
01:06Made it, made it, made it.
01:08That was my fault.
01:09Here we go.
01:10This is Captain Jay.
01:11Heard you, heard you.
01:14I'm a young man.
01:15As you know, I'm killed.
01:19I'm killed.
01:20I'm killed!
01:21I'm killed!
01:22I'm killed!
01:24I've killed!
01:26I've killed it!
01:28All right, I'm killed!
01:29Continental Connection Flight 3407, operated by Colgan Air, is en route from Newark, New
01:41Jersey to Buffalo, New York.
01:47It's been a busy flight for Captain Marvin Renslow.
01:50He's providing guidance to a new first officer, Rebecca Shaw, a former flight instructor from
01:55Seattle.
01:59Shaw's only been with the airline for just over a year.
02:04She must decide if she now wants to become a captain.
02:06I don't know what I want to do with the upgrade.
02:09It depends where I'm based.
02:12Well, think of it this way.
02:14If you stayed on the queue, obviously you're not making the captain right.
02:17Right.
02:18But you may have a better quality of life with regards to buying a house, having a schedule.
02:22Shaw trained to be a first officer on the plane they're flying now.
02:26A Canadian-made Bombardier Q400.
02:31It's a twin-engine turbocrop popular with regional airlines.
02:38The 45 passengers have had a long night.
02:41Their plane was held up for two hours at Newark, a delay considerably longer than their journey.
02:51Flight 3407 is heading northwest over upstate New York.
02:57The trip is only 53 minutes.
03:03And there's a forecast of snow and moderate winds in Buffalo.
03:13Just some water, please.
03:15Elise Kausner is a student at Florida Coastal School of Law in Jacksonville.
03:23She's on her way to visit her family in Buffalo.
03:25She had five nieces and nephews at the time, and they had a love luncheon at the kids' school.
03:31A couple of the nephews.
03:33And they both wanted Aunt Ellie to be their guest.
03:36Any excuse to come home, she came home.
03:39She talked to all of us from Newark.
03:40Hey.
03:41She called us from the lounge.
03:42Yeah, it's been over two hours.
03:45She was PO'd because of the delay.
03:51She's from the flight deck, your first officer speaking.
03:54It looks like at this time we're about 10, maybe 15 minutes outside of Buffalo.
04:00Weather in Buffalo is pretty foggy.
04:03Snowing a little bit there.
04:05I'd like to make sure everyone remains in their seats so the flight attendants can prepare
04:08the cabin for arrival.
04:12Colgan, 3407, descend and maintain.
04:152,300.
04:17Okay, down to 2,300.
04:19Colgan, 3407.
04:21Let's do a descent checklist, please.
04:26We can do the approach checklist along with it.
04:29Sure.
04:30Bug set.
04:31Set.
04:32GPWS landing flaps selected 15 degrees.
04:37The pilots go through a list of settings for the plane to continue its landing approach.
04:41Transfer off.
04:42Yup.
04:43Passengers can already glimpse the lights of Buffalo's suburbs.
04:48Claren's center is on the approach path for aircraft landing at Buffalo's airport.
04:55Gear down.
04:56Looks alive.
04:57Gear down.
04:58Flaps 15.
04:59Flaps 15.
05:00Extending the flaps provides more lift, allowing the plane to slow to its final approach speed.
05:07Ah.
05:08Ah.
05:09Ah.
05:10Ah.
05:11Ah.
05:12Jesus Christ.
05:13Suddenly, the control column starts to shake.
05:18The Q400 is slipping out of control.
05:19Ah.
05:20Ah.
05:21Ah.
05:22Ah.
05:23Ah.
05:24Ah.
05:25Ah.
05:26Ah.
05:27Ah.
05:28Ah.
05:29Ah.
05:30Ah.
05:31Ah.
05:32Ah.
05:33Ah.
05:34Ah.
05:35Ah.
05:36Ah.
05:37Ah.
05:38Ah.
05:39Ah.
05:40Ah.
05:41Ah.
05:42Ah.
05:43Ah.
05:44Ah.
05:45Ah.
05:46Ah.
05:47Ah.
05:48Ah.
05:49Ah.
05:50Ah.
05:51Ah.
05:52Ah.
05:53Ah.
05:54Ah.
05:55Ah.
05:56Ah, they're bitter!
06:14Just gear me up!
06:16Gear me up!
06:18Damn!
06:26Outward down!
06:36The plane crashes into a house at 6038 Longstreet.
06:47At air traffic control in Buffalo, flight 3407 disappears from radar.
06:55Check Colgan there, see if he's on you.
06:57What's his call sign?
06:58Colgan, 3407.
07:00Nope, I don't have him.
07:02You see anything out there?
07:04Nothing.
07:08Alright, call the fire department.
07:11I'll never forget the dispatcher's words, plane crash, house on fire.
07:15I immediately got my shoes on and my coat on, got in my truck and started heading down the driveway.
07:25Firefighters don't have far to go.
07:276038 Longstreet, home of the Walensky family, is less than a block from the Clarence Center Station.
07:34As I turned towards the village, the whole village was aglow.
07:39You could see the smoke, you could see the flame.
07:42Karen Walensky and her daughter make it out of their house alive, but her husband Douglas is killed.
07:51My initial reaction was there was no way that somebody made it out.
07:57But the EMS division reported that they had two people and they were taking them to the hospital.
08:03And I said, well, which firefighters are they?
08:05And they said, they're not firefighters chief, they're survivors from the house.
08:08I actually physically had to go to the ambulance and look inside for myself to believe.
08:14Firefighters have never seen a blaze like this.
08:18If you've ever gone to a bonfire and stood five feet from it and you couldn't take it anymore, that's what it felt like from 100 feet away.
08:30The height of it was just unbelievable, obviously because of the fuel that was probably added to it.
08:35And the debris area was very large. It was a very, very horrific sight.
08:43We live in the town where the plane went down right down the road.
08:47My son was driving home from a soccer game and went right by the plane crash and called me up and said,
08:53there's a plane down in Clarence. Never really entered our brain that it was Ellie's plane.
08:58Flight 3407 has crashed eight kilometers short of Buffalo Airport.
09:04All 49 passengers and crew are dead, including Captain Marvin Renslow and First Officer Rebecca Shaw.
09:12But many more people could easily have been killed.
09:17You picture a house and to see a plane on top of this house, no more house left, no more plane, only the tail section.
09:26You're asking yourself, how in God's creation did this happen? And not wipe the whole block out.
09:35The next call was again from my son and said, in fact, it was Ellie's plane.
09:39And then he said, Dad, there's no survivors.
09:41At which point my wife shrieked and just hit the ground.
09:47Chris said he'd never heard his mother make a sound like that and hope he never does again.
09:52So that's when we knew that she was gone and that was probably within 45 minutes of the accident.
09:58The scene in the morning is one of utter devastation.
10:17Clint Cruickshanks from the ATSB. Can I start poking around?
10:20Clint Cruickshanks is one of the first investigators on the case.
10:24When we arrived on scene, there was a fire still burning.
10:27Turns out it was from a gas line that had been broken in the house.
10:31The firemen would put the fire out and it would reignite every couple of minutes.
10:35It was one of the grisliest, nastiest scenes that I think I've seen.
10:41Flight 3407 may have been a small plane, but it's the worst crash in the U.S. in more than seven years.
10:52It will become one of the NTSB's most important investigations.
10:56The fire at the crash site of Flight 3407 continues to burn, preventing investigators from examining the wreckage.
11:12The airplane had crashed into a house and then it had burned all night long.
11:26So all the debris was basically in the house.
11:29Our concern is that we're losing evidence.
11:31It's perishable and if we can't get in there and get the fire out,
11:35then we're not able to maybe get a hold of evidence that might help us during the investigation.
11:41Clint Cruickshanks urgently needs to recover the black box flight recorders,
11:45which could contain valuable clues about the accident.
11:48We knew that the recorders were in the tail part of the airplane.
11:52Ordinarily, investigators don't go near a crash site that's still burning.
11:57But if the black boxes can't be rescued, they may never find out what brought down Flight 3407.
12:04We started looking around and poking around into the wreckage and actually found out where they were.
12:10Okay, whoa, whoa, it's probably in here, okay?
12:15The access panel's on the other side, so we're gonna have to cut a hole right there, okay?
12:20The fire department produced a chop saw.
12:23We were able to cut a hole in the side of the fuselage and go in and grab the recorders and pull them out.
12:29To the immense relief of all, the recorders are undamaged.
12:41Once we took the recorders out of the airplane, we put them on the jet and they were flown back to Washington DC to our headquarters.
12:47Now investigators are faced with a new hurdle.
12:53What little is left of the aircraft is hopelessly jumbled together with human remains and debris from the house.
13:01It all burned and settled into the basement, so we had probably ten feet of debris that we had to dig through in order to recover all of the airplane.
13:10Authorities wonder how they can salvage any useful evidence from this chaos.
13:16They get invaluable assistance from an unusual source.
13:23A group of students learning to process crime scenes is enlisted to separate human remains from the rest of the debris.
13:31They were graduate students from a local college, forensic anthropology students, and this was good experience for them to come think through wreckage like this and look for human remains.
13:42It's landing gear over there, please.
13:44It's dirty, painstaking work, but it frees up investigators to concentrate on the aircraft ruins.
13:51So we were on our hands and knees with brooms, with little shovels, scooping out debris, identifying it as to house debris or airplane debris, and then putting it in different piles.
14:05The first question for me as a structures engineer is to figure out if the whole airplane made it to the scene of the crash.
14:12The wreckage is carefully studied to determine if the plane's four corners, nose, tail, and both wingtips are present.
14:25If we find all four corners of the airplane, then we know that there was no in-flight breakup.
14:30There was nothing that departed the airplane during the flight that may have caused the accident.
14:35One wing has been consumed by fire. The other is shattered into pieces.
14:40Hey, have a look at this.
14:42But investigators are gradually finding what they've been searching for.
14:45Oh, yeah. It's the last piece. It's the left one.
14:48It wasn't until several days into the investigation, as we were scraping away some of the debris,
14:53that we actually found evidence of the left wing and the nose.
14:57Investigators now have all the pieces they need to conclude that the entire plane is at the crash site.
15:04Whatever caused the disaster was not the result of a breakup in flight.
15:09The tragedy of Flight 3407 is under intense scrutiny at the NTSB offices in Washington.
15:23Officials there try to determine if some kind of malfunction caused the crash.
15:28On this particular accident, we knew it was a landing accident, so we wanted to check the aircraft's performance,
15:34and then also we checked for flight control continuity.
15:37Much of this responsibility falls to Scott Warren.
15:41My role in the investigation was to be the systems group chairman for the safety board,
15:46so I was in charge of looking at all of the aircraft systems.
15:51Warren analyzes the aircraft's cockpit voice recorder, or CVR, to determine if there were any indications of a problem in the cockpit.
15:58Lieutenant, prepare the cabin for arrival. Thank you. Is that ice on the windshield?
16:06He discovers that six minutes before the crash, the crew of Flight 3407 had noticed a buildup of ice on the aircraft.
16:14Got it on my side. Do you don't have yours?
16:18Oh, yeah. Oh, it's lots of ice.
16:22Ice can be a deadly threat to any airplane.
16:25If an aircraft has ice on it, it'll have more drag on it, so it'll require more power to maintain a given airspeed.
16:33Oh, yeah. That's the most I've seen on the leading edges in a long time.
16:40Until a year ago, Rebecca Shaw had no experience with ice on an aircraft.
16:45I'd never seen ice in conditions. Never de-iced. Never experienced any of that.
16:52When ice accretes on a wing, it adds weight to the airplane, but most importantly, it changes the shape of the wing.
16:59And, of course, it's the shape, the curved shape of the wing that actually creates the lift.
17:04So by changing the lift characteristics of the airplane, it makes it less able to fly.
17:10You know, I'd have freaked out. Like, I'd have seen this much ice.
17:14I thought, oh, my gosh, we're going to crash.
17:20Observing that there was ice on the airplane was an important thing to do.
17:24But then it would be important to turn around and verify that your anti-ice and de-ice equipment was on,
17:30and there was no indication on the voice recorder that they actually rechecked.
17:34The CVR reveals that only minutes after the crew detected ice, a device called the stick shaker went off.
17:42It was a warning that the plane was about to stall, literally to fall out of the sky.
17:49Shortly afterwards, the aircraft did precisely that.
17:55We know there were icing conditions. The only question was, were they bad enough to induce this airplane to have a failure?
18:07Ice is now the chief suspect in the crash of Flight 3407.
18:12If it's ice, let's prove it.
18:15We were all convinced that we had an icing accident.
18:19We said, yeah, it's going to be an icing accident.
18:21We just got to make sure we look for these few key aspects of icing, verify that, and we're good.
18:27But some of the victim's family members are less convinced.
18:31Our initial thought was that it was an ice-related incident, that it was an icy night that brought the plane down.
18:37And as we began to talk to people who knew airline travel, who were pilots themselves,
18:42they would look kind of askance and say, I don't think so. That doesn't make sense.
18:47Some investigators share that suspicion.
18:50Scott Warren knows a plane like the Q400 has a sophisticated de-icing system.
18:56It's designed to keep ice from building up on the wings and other critical parts of the aircraft.
19:05To prevent ice accumulating, the plane has rubber bladders along the front of the wings, called de-icing boots.
19:12A series of valves uses air from the engines to inflate the boots and crack the ice off the wing.
19:19Those boots are designed to inflate periodically, and that inflation breaks off the ice that's accumulated on those leading edges.
19:29Warren now wonders if the crew of Flight 3407 actually turned on their de-icing equipment.
19:36He studies data from the plane's other black box, its Flight Data Recorder, or FDR.
19:43It tracks the workings of crucial aircraft systems, including the de-icing mechanism.
19:50We know from the FDR data that the de-icing system had been selected on by the crew,
19:55and it was on during the majority of the flight, and certainly at the end of the flight it was recorded in the on position.
20:03But now Warren needs to figure out if the device was actually working.
20:07Just because the data records that the system is on, that's a start, but you can't necessarily believe that one piece of information.
20:15The only way to know is to find what remains of the plane's de-icing system,
20:20and determine if it was active when the aircraft went down.
20:25Clint Cruickshank's team hunts for a crucial component of the system, the valves.
20:30Excuse me. Okay, everyone, I just want to...
20:34For the de-ice valves, we, you know, we said, here's what it looks like, look for something like this.
20:38If we can find those valves, then we can test them and see if they're operating correctly.
20:43The valves were very important to us because they are the key component that moves air from the engines,
20:50where the bleed air originates for the de-icing system.
20:53Okay, good. Five more to go.
21:09Five of the plane's six de-icing valves are eventually recovered.
21:24Some were badly burned, some were in fairly good shape.
21:27And we took those valves and we conducted as much testing on those valves as we thought was appropriate for the level of damage.
21:33We looked at the level of electrical conductivity and we looked at the pressure testing.
21:39We looked at a wide variety of things depending on the condition of the valve itself.
21:45And as far as we could tell, all those valves were working properly.
21:49Is that ice on the windshield?
21:51Got it on my side.
21:52Now investigators have to consider the possibility...
21:56Oh, yeah. Oh, it's lots of ice.
21:58...that there was so much ice on the wings that the de-icing system couldn't get rid of it fast enough.
22:03Oh, yeah. That's the most I've seen on the leading edges in a long time.
22:09It has happened before.
22:11In Roselawn, Indiana, a French-built commuter plane crashed in 1994 after suffering a catastrophic buildup of ice on the wing.
22:21By analyzing how much power was needed for the plane to maintain its airspeed, investigators reach a surprising conclusion.
22:36Basically, the aircraft was flying as if it had a relatively small amount of ice on it, but a very manageable amount of ice.
22:43Looks normal.
22:44It was not overloaded. It was not excessive.
22:48If ice didn't bring down the plane, something else must have caused it to stall.
22:55Warren studies the Q400's operating manual to learn the plane's stall speed, the velocity at which it can no longer generate enough lift to stay in the air.
23:05He discovers that in the conditions flight 3407 was flying through, it's roughly 111 knots.
23:12He now compares the plane's stall speed with its actual airspeed just before the stall warning went off.
23:19131 knots, well above the danger zone.
23:26Flaps 15.
23:28When the stick shaker went off...
23:33Uh...
23:34Jesus Christ!
23:35They were not necessarily at the edge of the stall.
23:46They were still 20 knots or so away from the stall.
23:50This new revelation deepens the mystery of flight 3407.
23:55If it wasn't stalling, why did it fall out of the sky?
24:03Investigators turned their attention to the critical seconds before flight 3407 went out of control.
24:09They looked for clues that could explain why the stall warning went off when the aircraft was flying well within its safety margins.
24:19They discovered that this plane has a unique feature known as a reference speed switch.
24:24It governs the sensitivity of the plane's stall warning.
24:28Very few airplanes in my experience have such a switch.
24:32This airplane is the only one I know of that has an actual switch on the overhead panel.
24:37It was designed by the manufacturer to be an extra safety feature.
24:41So we've got a variable ref speed?
24:43Pilots are supposed to turn on the reference speed switch when they're going to be flying through icing conditions.
24:49And we'll probably be picking up some ice.
24:51When in the increased position, it reminds pilots to fly faster to counteract any drag effect ice will have on the aircraft.
24:59When you are in icing conditions and ice does accrue on the wing, it can cause the stall speed to go up.
25:08And so this ref speed switch correspondingly causes the warning to come on sooner or at a higher speed.
25:15What that switch does is it basically changes the trigger settings for the stick shaker.
25:20So we had to ask the manufacturer, how does this switch work?
25:24And what we found was it was part of the system's description that the crews got when they went through training.
25:30But they didn't get a lot of training on how to handle that switch.
25:33It seemed like it was too simple to worry about.
25:36Investigators need to know if the crew of flight 3407 had turned on the reference speed switch, triggering the stick shaker at a faster than normal speed.
25:51The flight data recorder doesn't show whether the switch was on.
25:54Investigators must find another way of determining its position at the time of the accident.
25:59Clint here.
26:09Clint Cruickshanks is given a new priority.
26:11Alright, I'll see if we have it.
26:13Recover the ice protection panel from the Q400's cockpit, where the reference speed switch is housed.
26:19Since the panel was in the cockpit, finding it is a challenge.
26:24Most of the front end of the airplane was consumed by fire, and so we didn't find anything except for little balls of molten aluminum, little wire bundles, and a lot of ash.
26:35But after an extensive search, Cruickshanks discovers that the ice protection panel is one of the few pieces of the cockpit that survived.
26:43Bingo.
26:45However, the knobs and switches are barely recognizable.
26:49Cruickshanks examines the charred panel to check the position of the reference speed switch.
26:55It was set to activate stall warnings at higher than normal speeds.
27:01We did find the ref speed switch in the wreckage, and it was in the increased position.
27:07This discovery only raises more questions.
27:12We'll probably be picking up some ice.
27:16The cockpit voice recorder indicates that as Renslow was beginning his descent into Buffalo, he commanded his plane to fly at the normal approach speed.
27:24But what's strange is that with his reference speed switch on, he actually should have been flying faster.
27:33As this is what the switch would remind him to do.
27:39So why wasn't he?
27:41The plane's computer warned the crew to fly faster, according to the settings they had configured, by displaying a set of red bars on the airspeed indicator.
27:50You may have a better quality of life.
27:52These bars are meant to warn the pilots that a stick shaker activation is imminent.
27:57If you're looking at the airspeed indicator, you should be aware that you're getting slow, and the stall warning may come on.
28:06Jesus Christ!
28:07It seems Renslow and Shaw were caught off guard.
28:10Still, they could have easily corrected the situation.
28:14Once the stick shaker activated, they could have turned the switch off, or they could have put the nose down and increased their airspeed.
28:23It's clear to investigators that Flight 3407 wasn't in danger of stalling when the stick shaker went off.
28:30So now they need to know exactly what happened after the stall warning was activated.
28:36An animated simulation of the crash is constructed, based on information from the flight recorders.
28:43Watch what happens just after the stick shaker goes off.
28:48It illustrates that just after the stick shaker was triggered, the plane suddenly pulled up.
28:54This action dramatically slowed the aircraft, and at this point it did stall.
29:00Essentially the airplane entered an aerodynamic stall from which it did not recover.
29:04It pitched over and hit the ground.
29:06Investigators are dumbfounded.
29:08Flight 3407 wasn't stalling when the stick shaker went off.
29:13But a few seconds later it was.
29:16The crew's every action during that brief time now demands careful scrutiny.
29:22What did they do?
29:25It's a puzzle.
29:27How could a trained flight crew take a plane that wasn't stalling, and in the space of a few moments make it fall from the sky?
29:34Any time you have an apparent stall for no apparent reason, that's a mystery.
29:39You would expect that no flight crew would stall an airliner.
29:44So the question is why?
29:46The focus of the investigation now switches from the plane to the crew.
29:52Specifically on the moves they made during the critical seconds after the stall warning sounded.
29:57We wanted to see if the way they flew the airplane was the way they were trained, according to the standard operating procedures that are portrayed in their flight manuals.
30:08The flight data recorder retains information from more than 1,000 different aspects of the Q400's flight operations.
30:16From the airspeed and altitude to the position of the rudder pedals and throttles.
30:23It also records the movements of the most critical flight control, the control column.
30:30Pilots use the control column to change the position of the elevators and ailerons, which manage the direction of the plane.
30:39The flight data recorder stores information not just about the control column's position, but how much force is applied to it as well.
30:48The FDR records what the control positions were.
30:52It has sensors built into the control column, it has sensors built into the control wheel.
30:57What Scott Warren finds when analyzing the control column's position is stunning.
31:02In response to the stick shaker, Captain Renslow should have pushed the column forward to bring the nose down and gain speed.
31:09But for some reason, he did the exact opposite.
31:13We found that the crew, instead of pushing forward, which is the normal response to a stick shaker triggering,
31:19the crew was actually pulling back on the control.
31:23This had the effect of pulling the nose up, causing the airspeed to drop, and tipping the aircraft into an actual stall.
31:30Captain Renslow had apparently mishandled one of the most elemental piloting maneuvers, how to recover from a stall.
31:42Above everything, it requires gaining airspeed to get out of the red.
31:48The recovery procedure is fairly simple and straightforward.
31:52It requires pushing forward on the controls and adding full power.
31:57At any point in time, had the captain pushed forward on those flight controls, he had a reasonably good chance of recovering quickly.
32:07From everything we've gained, that stall was recoverable on a repeated number of levels, on a repeated basis.
32:13There was no reason for that plane to go down.
32:15Investigators also learned that First Officer Shaw, in trying to help Renslow deal with the crisis, inadvertently made things worse.
32:22I put the flaps up!
32:25She retracted the flaps, reducing the amount of lift as the plane struggled to stay in the air.
32:31Had the First Officer simply called out, you're stalled, advanced the power, pushed the nose over, the airplane would have been able to recover.
32:40From a human point of view, it's sad to recognize that those sorts of things happened and the tragedy that came from that.
32:46It's concluded that Captain Renslow's failure to properly respond to the stall warning was the primary cause of the crash of Flight 3407.
32:57As the issue is now pilot error rather than mechanical failure, human performance investigator Evan Byrne is brought on board.
33:06His first question, why hadn't either Renslow or Shaw noticed that their airspeed was too low for the icy conditions?
33:14In this case, we can look back towards the fact that there were clear and conspicuous cues of the deteriorating airspeed that were not heated by the captain.
33:26Byrne listens to the cockpit voice recording to try to understand what might have led to that oversight.
33:32Where you could be home with your husband to take care of and all that stuff.
33:36He learns that the crew had been talking throughout the flight.
33:40The conversation continued during the landing approach.
33:43It's a violation of a rule known as the sterile cockpit,
33:47which bans non-essential conversation during critical phases of the flight.
33:52You're going to be upgraded in six months.
33:54Blah, blah, blah.
33:57Quite simply, it prohibits conversations that aren't related to the operation of the flight.
34:02Let's do a descent checklist, please.
34:04We can do the approach checklist.
34:06Walk with it.
34:07Yeah, sure.
34:08Uh, bug set?
34:09Byrne also discovers that because of the cockpit banter,
34:12the crew performed critical checklists and briefings late.
34:16We're off hydraulic pressure and quantity.
34:20Distracted, the crew probably didn't see the red bar indicating they were flying too slowly
34:25for the conditions the plane had been configured for.
34:28On.
34:29Approach checklist complete.
34:31Rock and roll.
34:32When crews deviate from standard operating procedures
34:35and perform checklists late or don't make the required call-outs,
34:38they become more vulnerable to subtle mistakes that they may make inadvertently
34:44that could lead to startle and surprise or unanticipated events that they have to respond to.
34:50The evidence is unequivocal.
34:52The crew of flight 3407 was badly distracted throughout the approach.
34:57He came in when we interviewed and he said,
34:59Yeah, you're gonna be upgraded in six months.
35:01They had forgotten a key setting they had made that required them to fly faster than normal.
35:07They had missed indications that they were flying too slow for icing conditions.
35:12Then Captain Renslow had reacted incorrectly to a stall warning, sealing the fate of the plane.
35:19Evan Byrne wonders what could have caused a trained airline flight crew to have made such missteps.
35:31He finds a clue on the cockpit voice recording.
35:34Excuse me.
35:39The crew was showing signs of fatigue.
35:45Could Renslow and Shaw have been too tired to function effectively on the flight deck?
35:50It's a tough question.
35:52Answering it will require tracking their movements during the 72 hours leading up to the crash.
35:57It's basic gumshoe detective work in the investigation where we're trying to collect as many facts as we can.
36:04Byrne interviews the families of the pilots.
36:06Can I speak to Mrs. Renslow, please?
36:08He studies the pilots' mobile phone bills and records of text messages.
36:14He searches the airline's computer system to determine if and when the crew used it to check their schedules.
36:24He needs to track their every move.
36:27And what time did Rebecca leave the house?
36:29We're talking to colleagues or other pilots, check airmen, instructors,
36:34and we ask all those people about the pilots, about their recent activities.
36:39He learns that neither pilot actually lived anywhere near Newark,
36:44but could not afford to stay in hotels on their salaries.
36:48Captain Renslow was earning $60,000 annually at Colgan Air.
36:53First Officer Shaw was being paid less than $16,000 a year, substantially less than an average bus driver.
37:00As a result, both pilots had made long cross-country commutes to Newark.
37:05Captain Renslow from his home in Florida and Rebecca Shaw from Seattle, Washington.
37:11In fact, Shaw had commuted all night from Seattle on a cargo flight that connected through Memphis.
37:19Captain Renslow had spent the night in the airline's crew lounge at Newark Airport.
37:27After having already worked two days.
37:34He was seen sleeping on a couch in the lounge.
37:38It was against company rules, but pilots who couldn't afford housing near the airport did it anyway.
37:45Records show that at 3.10 a.m. on the morning of the crash, Renslow was awake.
37:50He checked his work schedule on the airline's computer network.
38:02Next stop, Buffalo.
38:05At 7.29 a.m., Rebecca Shaw sent a text message to her husband, telling him she'd arrived safely in Newark.
38:13Hi, honey, it's me.
38:17Phone records indicate that later in the morning, Captain Renslow was on the phone several times.
38:24Rebecca Shaw was noticed having a nap, catching up on the rest she'd lost flying in the night before.
38:30It's not a lot of sleep.
38:38We ultimately concluded that it was likely that both crew members were experiencing some effects of fatigue at the time of the accident.
38:45Her job is to watch the airspeed.
38:47Her job was to watch the instrument panel.
38:50And my view is she was fatigued to the point where it's like right here in your soul doll.
38:55I think that's where she was.
38:56And he just was not capable.
38:58He was just, um, he should have been flying an airplane.
39:01The revelation leads John Kausner to become a fierce advocate for changes to the industry.
39:09He raises awareness among both lawmakers and the public about the need to improve regulations governing pilots at regional airlines.
39:18This is just saying we support 3407 families that are fighting for aviation safety.
39:22And these representatives at Congressman Centers have done that for us, and we're very appreciative.
39:26He takes his fight all the way to Washington, D.C.
39:31We needed to do something, and so we began to advocate in Washington weekly, every other week.
39:37I mean, we've made innumerable trips down there.
39:39And immediately the families just gelled.
39:41We all attended the hearings and, uh, and began to say, this is what we can do.
39:47The crash of Flight 3407 focused the world's attention on a growing safety problem.
39:53The relatives of those who were killed will help eliminate that threat.
40:03The crash of Flight 3407 exposed wide-ranging shortcomings in the regulations that govern regional airlines.
40:11These smaller airlines now make up half of all daily passenger flights in the U.S.
40:16The pilots are generally younger, less experienced, earn less, and work long hours.
40:23Their levels of safety are way different from the majors.
40:27They have a much lower threshold in training, in ability, um, so, in pay, obviously, so they can't attract a higher qualified pilot.
40:36There are pretty low wages, uh, pretty difficult working conditions, and we don't seem to attract the same level of applicant that we used to.
40:47Some regional airlines get into a bind, and, uh, they have to hire the first people that meet the minimums.
40:54In the U.S., of the seven fatal accidents involving passenger jets over the past ten years, five have involved regional airlines.
41:03Those include the crash of Delta Connection Flight 5191 in August 2006, which killed 49 people when the crew took off from the wrong runway.
41:16John Kausner's campaign to change laws governing pilots has paid off.
41:28We relied on your support.
41:29We needed your support.
41:30You nurtured us.
41:31We want to thank all of you from all of us.
41:34A year and a half after the crash, under pressure from Kausner and other victims' family members,
41:40the U.S. Senate passed a bill which toughens training requirements and forces the FAA to draw up new rules on pilot fatigue.
41:52Studies into the problem of overtired pilots are already underway.
41:59At the University of Iowa, researchers are developing a system that could help pilots resist fatigue,
42:06stay engaged with the critical task of flying, and prevent future tragedies like that of Flight 3407.
42:16Thomas Schnell is a human factors engineer.
42:21We use a number of neurocognitive and physiological sensors that we apply on subjects, pilots, that we invite for our studies.
42:31He's studying how pilots stay alert on the flight deck as a test subject conducts a cross-country journey in a simulator.
42:43Using sensors, he can determine how alert and engaged a pilot really is.
42:48The research could lead to the development of fatigue detectors on airplanes.
42:52We are trying to predict pilot state so that we can adjust something on the flight deck to prevent the problem from getting worse or starting in the first place.
43:04We monitor brain activity, eye movement activity, heart, the EKG and respiration and other parameters in an effort to figure out what the pilot's or the crew's state is.
43:18Are they fatigued, overworked, are they disengaged or distracted?
43:23This section is where they were really drowsy and you can see that the gaze has become kind of bored.
43:37Schnell instructs the flight simulator to trigger a major systems failure in the cockpit.
43:41It's no good. Everything's dead. Hydraulic systems have failed.
43:52Crank up that heat map so we can see what his brain activity was.
43:57Brace for impact.
44:00When a crew is fatigued, what you might see is their reaction to events may slow down.
44:05So you'll see mistakes being made on the flight deck.
44:10It's precisely these kinds of mistakes on the part of Renslow and Shaw
44:17that ultimately crashed flight 3407
44:23and killed 50 people.
44:25It's a tragedy that should not have happened.
44:31That was foreseeable, was preventable and it's repeatable if we don't do something about it.
44:36I'm focused and determined to change what exists and not have another dad sitting here.
44:40On to the mayor of 12.
44:41We know it's been broken even
44:42a Godzilla 16.
44:43We know it's been a man that turned around to a world and released
44:44to see how Bootltry Stast Manson scenario.
44:45I love God sitting in here.
44:46I love God sitting here.
44:50I love God sitting here.
44:55I love God sitting here.
45:08I love God sitting here.