On 2 July 2021, Transair Flight 810 ditches in Māmala Bay about 11 minutes into a flight from Honolulu, Hawaii, to Kahului, Maui. However, both crew members survive.
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00:00Hey, Matt, we're going down. We can't keep going down.
00:04Above the Pacific Ocean, the pilots of Transair Flight 810 can't get their cargo plane to climb.
00:10Just hitting the water is going to tear the airplane apart.
00:14We're in the water! We're in the water!
00:18Remarkably, they survive the crash and are rescued by the Coast Guard.
00:23They're covered in gasoline and hydraulic fluid, so it wasn't pretty.
00:27Investigators are eager to interview the crew.
00:30Did both engines fail at the same time?
00:33Most likely. That's my conclusion.
00:36The evidence does not support the pilot's assessment.
00:40It looks fine. No internal damage.
00:44So, it was critical for us to get more information to better understand what had happened there.
00:49It's the middle of the night at Daniel K. Inui International Airport.
01:07It's the middle of the night at Daniel K. Inui International Airport in Honolulu, Hawaii.
01:21The captain of tonight's flight is Henry Okai. He has almost 16,000 flying hours.
01:40So, this captain is highly experienced in the aircraft and doing it for a while.
01:46Engine start checklist.
01:48Engine start checklist.
01:51Tail stand.
01:52Removed.
01:53Cargo.
01:54First officer Gregory Ryan is a lawyer who recently returned to flying part-time for Transair.
02:01It's not necessarily the best pilot career straight up, but you do get to be in Hawaii.
02:06You get to fly an airplane.
02:09Engine start checklist complete.
02:11And clear right.
02:15Clear right.
02:16Transair flights use Rhodes Express as a call sign.
02:22Tower.
02:22Rhodes Express 810.
02:24Taxi Kilo.
02:26Rhodes Express 810.
02:28Honolulu Tower.
02:29Runway 8 right.
02:30Taxi via Charlie.
02:32Romeo.
02:32Tango.
02:33Romeo.
02:34Alpha.
02:34Transair is owned and operated by Rhodes Aviation, which transports cargo between the Hawaiian islands.
02:48They had the postal contract, which was quite lucrative.
02:51Their focus was on keeping their costs down to maintain their advantage over more and well-established competitors.
02:58The plane is a Boeing 737-200, built in the 1960s and 70s for passenger travel.
03:08Today, they're workhorses for transporting cargo.
03:12Twin engines, small aircraft.
03:14It was designed for short-haul operations.
03:16It wasn't very sophisticated.
03:17No automation.
03:18I love flying that airplane.
03:19The pilots prepare for takeoff.
03:25Runway 8 right confirmed before takeoff checklist complete.
03:30Road 810, cleared for takeoff.
03:34Runway 8 right, cleared for takeoff.
03:36Roads 810.
03:37Tonight's flight is a short hop to Kahului, on the neighboring island of Maui, only a hundred miles away.
03:51Okay, you have control.
03:54Okay, I have control.
03:57At 1.33 a.m., Captain Okai hands over the plane to First Officer Ryan.
04:03Engine stable.
04:1380 knots.
04:16Check.
04:18V1.
04:20Rotate.
04:22V2.
04:25Positive rate.
04:28Gear up.
04:30Within seconds of lifting off.
04:33Damn.
04:39Lost an engine.
04:41You got it?
04:42Yeah, I got it.
04:44The pilots have lost thrust in one of their engines, only 390 feet off the ground.
04:50Losing an engine after takeoff is one of the most critical events that can happen in a flight.
04:54You're close to the ground, you're slow.
04:56However, we also know from our training that the aircraft will fly perfectly well on one engine.
05:02The first officer levels the plane and continues to climb away from the airport.
05:07Flaps.
05:09Turn 220 heading.
05:12I'll give you the flaps.
05:13Okay.
05:13Okay.
05:17Rhodes, A-10.
05:18We have an emergency.
05:19Stand by.
05:20We're on 220 heading.
05:22You can inch up to 2,000.
05:24The captain wants to put more distance between the plane and the ocean, so they have space to address the problem.
05:32Anytime you have an emergency situation, maintain aircraft control.
05:35You fail to do that, nothing else you do matters.
05:38Okay, Rhodes, A-10.
05:40We've lost an engine.
05:41We're on a 220 heading, maintaining 2,000.
05:43Declaring an emergency.
05:45How do you read?
05:46Rhodes Express, A-10.
05:48You are cleared visual approach.
05:50Runway 4, right.
05:52You can turn in towards the airport.
05:55The controller clears flight A-10 to return to the airport.
05:59Okay, Rhodes, A-10.
06:01We're going to run a checklist.
06:02I'll let you know when we're ready to come to the airport.
06:04Captain Okai wants to assess the situation further before returning to the airport.
06:12Flight A-10 has been in the air less than three minutes, flying over the Pacific Ocean on a very dark night.
06:20Okay, I have control.
06:22Roger.
06:23Okay, let's see what's the problem.
06:26What's going on with the gauges?
06:28The pilots troubleshoot the situation.
06:32So it looks like they're number one.
06:34Number one's gone?
06:35Gone, yeah.
06:37We still have the number two.
06:39So we have number two.
06:40Okay.
06:42They confirm they've lost their number one, or left, engine.
06:47They now must rely on their right engine to return to the airport.
06:51Let's do the enter failure shutdown checklist.
06:54And I have the radios now.
06:55Okay.
06:55There's a number of things this checklist is going to do for you.
06:59It's going to confirm the failed engine, and you're going to want to secure that engine.
07:05Okay.
07:06Engine failure or shutdown when one of these occurs.
07:09An engine failure, an engine flame-out, another checklist directs an engine shutdown.
07:13As the pilots zero in on the problem engine, the situation intensifies.
07:20Hey, we're redline here.
07:22The right engine is now overheating, and they're losing altitude.
07:27We should pull back on the right one a little bit.
07:28Okay.
07:32We should head back to the airport.
07:34Yeah, we should.
07:35Yeah.
07:36The pilots now face the possibility of losing both engines.
07:42Problems on your second engine is going to significantly change your outlook,
07:45because you've got the dark water below you, and you know you're running out of options.
07:50Okay, Rose, A-10.
07:52We'd like to come to the airport now.
07:54We might lose the other engine.
07:56Rose Express, A-10, Roger.
07:59Confirm you still have the airport in sight?
08:02All right.
08:03Negative.
08:05The pilots have descended too low to see the airport.
08:09Only the lights on the shoreline are visible.
08:12Hey, man, we're going down.
08:14We can't keep going down.
08:16We're descending.
08:18The captain has no other option but to increase power to the overheating engine,
08:23risking a double engine failure.
08:26How's the EGT?
08:28No, that's max.
08:29It's beyond max.
08:31The temperature of the right engine is now dangerously high,
08:34and the pilots suspect it could fail at any moment.
08:38Here we go, flops.
08:39Flops one.
08:41Fearing the worst, the first officer suggests configuring the plane for a water landing.
08:46No, no, no, not, not, not yet.
08:50Okay, we're very slow, though.
08:52The captain's efforts to reduce the loss in altitude aren't working.
08:57Shoot.
08:58Okay, flaps one.
08:58Just hitting the water is going to tear the airplane apart,
09:03so you want to be at the lowest possible airspeed.
09:06The flaps will facilitate that.
09:09Rose Express A-10 low altitude alert.
09:17As Transair Flight A-10 descends below 400 feet,
09:21the controller is automatically alerted to the aircraft's dangerously low altitude.
09:26Are you able to climb at all?
09:29Negative.
09:30Can you let the Coast Guard know?
09:32We will.
09:37Watch desk, please call the Coast Guard.
09:39Flight 810-737 is probably going to be in the water.
09:44How's the EGT?
09:45If the engine temperature has improved, they might be able to climb.
09:50Hot.
09:50Way over.
09:52Marine.
09:53Marine.
09:53Pull.
09:54Up.
09:55The chances of reaching the airport six miles away deteriorate as the plane descends even further.
10:01The controller has an idea.
10:05Express 810, do you want Kalailoa?
10:08There's a closer airport.
10:10It might be the pilot's last hope.
10:12We want the closest runway available, please.
10:16Anything we can land on.
10:19If they can't make it to the closer airport,
10:22there might be no other option than to ditch the 737 into the Pacific Ocean and hope for rescue.
10:31Too low.
10:32Here.
10:32Okay, give me a heading.
10:34Terrain.
10:34Terrain.
10:35Pull.
10:35Up.
10:36The pilots of Transair Flight 810 have one last chance to reach land.
10:42Rhodes Express 810.
10:44The airport is about a 3-1-0 heading from you.
10:48But it's too late.
10:51Pull.
10:51Up.
10:52Pull.
10:52Up.
10:53Pull.
10:53Up.
10:54Pull.
10:54Up.
10:55We're in the water.
10:57Pull.
10:57Up.
10:57We're in the water.
10:5812 minutes after takeoff, Transair Flight 810 hits the ocean just two miles from the Kalailoa airport.
11:14Watch desk, 810's in the water, two miles southeast of Kalailoa.
11:18Coast Guard Air Rescue is immediately dispatched.
11:25Hearing that there's a 737 that crashed, I didn't believe it.
11:29But if there is, and there's 200 people in the water, what am I going to do?
11:34They told me two souls on board.
11:36We're like, all right, two's a lot more manageable than, like, 200.
11:3845 minutes later, there's still no sign of the plane or the pilots.
11:45Rescuers fear the worst until...
11:48There were a bunch of boxes now floating by us.
11:51I figured, all right, this might be the start of a debris field.
11:55So we started our second pass, and grabbing onto the vertical fin of the tail was one of our pilots.
12:02It's Captain Okai.
12:04I was like, all right, he is still okay, great.
12:09Still want to find the second pilot.
12:11They soon spot the first officer on a cargo pallet, bleeding from the head.
12:17Right before we started to make the moves to put me in the water to go up to him, the plane moved.
12:23The tail section the captain had been clinging to sinks beneath the waves.
12:29The captain is drowning right now.
12:34They race back and deploy the rescue swimmer.
12:39As soon as I grabbed his hand, it's like his eyes rolled back and he went limp.
12:46They're dripping wet, covered in gasoline and hydraulic fluid, so it wasn't pretty.
12:50The first officer is soon rescued by a fire department vessel as the captain is rushed to a local hospital.
12:59Both pilots survive.
13:01Good planning, good crew, good decision making, and then implementing those decisions is how we came out on top.
13:09While the pilots recover from their injuries, investigators from the National Transportation Safety Board, or NTSB, arrive on the scene.
13:19Right now we're in the fact-gathering phase.
13:22Once we finish the fact-gathering, we'll switch into the analytical side, and then that's when we'll go in to determine the probable cause and contributing factors.
13:29What can you tell me about last night?
13:36It was a normal night, slow.
13:39There was another Transair flight inbound around the same time.
13:44And when did Flight 810 alert you that there was a problem?
13:47Investigators turned to the controller to determine what might have caused Transair flight 810 to ditch into the Pacific.
13:56It was about two minutes into the flight.
13:59They reported they'd lost an engine.
14:02Okay, Rhodes 810, we've lost an engine.
14:04We're on a 220 heading, maintaining 2,000, declaring an emergency.
14:07How do you read?
14:09They wanted to work on the problem before turning back.
14:12Did they say which engine?
14:14No, but not long after they said that they might lose the other engine as well.
14:21Really?
14:22Okay, Rhodes 810.
14:24We'd like to come to the airport now.
14:26We might lose the other engine.
14:29Could Transair 810 have really lost both engines?
14:33The only information we had to go on initially was the communications between the airplane and the controller,
14:39but the airplane and its recorders were at the bottom of the ocean.
14:44Another NTSB team is tasked with recovering the airplane and its engines lying 350 feet deep on the ocean floor.
14:55At the depth that the airplane was at, it's difficult to get divers down there.
15:00So in order to actually hook all of our equipment up to the aircraft and pull it up, we needed to use ROVs.
15:09It will take time for the investigation to secure the necessary equipment from a salvage company on the mainland.
15:15Good morning.
15:16Good morning.
15:21Good morning.
15:22I'm glad to see you here.
15:23So am I.
15:24Very glad.
15:25Yeah.
15:26I'm glad to see you here.
15:27I'm glad to see you here.
15:27Investigators meet with Captain Okai to determine if Transair Flight 810 did lose both engines.
15:34The purpose of this investigation is to determine probable cause and prevent recurrence.
15:41Our role is not to assign fault.
15:43I understand.
15:44It's critical to speak to pilots as soon as we can because we want to get those fresh memories.
15:51Walk me through what happened.
15:52Everything was normal up to about 400 feet.
15:59Gear up.
16:09Damn.
16:11There was a whoosh sort of a sound.
16:13Not a pow.
16:14It was a whoosh.
16:16Then it wasn't a roll.
16:18My first officer was able to counteract that.
16:22Lost an engine.
16:24You got it?
16:25Yeah, I got it.
16:30Eventually we leveled off at 2,000 feet.
16:33And I go, Greg, what do we have?
16:36So it looks like the number one.
16:38Number one's gone?
16:39Gone, yeah.
16:41We still have the number two.
16:43So we have number two.
16:44Okay.
16:48I'm looking at number one EPR.
16:50There's no power.
16:51I'm looking at number two in EPR.
16:55It's coming down.
16:58The captain explains he first lost power in the left engine and was losing power in the right.
17:07How's the EGT?
17:10Oh, it's max.
17:10It's beyond max.
17:12Did both engines fail at the same time?
17:16Most likely.
17:17That's my conclusion.
17:22Thanks.
17:22We'll be in touch.
17:24What could have caused both engines to fail so soon after takeoff?
17:29The purpose of this investigation...
17:30A dual-engine failure seemed improbable, but both the crew seemed to agree that that is what had occurred.
17:40We couldn't confirm or deny it unless we could actually look at the wreckage and get the recorders.
17:45But those vital clues remain out of reach, deep on the bottom of the sea.
17:55Could contaminated fuel have brought down Transair Flight 810?
17:59If you're looking for an item that's common to both engines, it would cause them both to shut down at the same time.
18:06For that would be most likely the fuel.
18:08So one thing that we did do at the airport was take samples from the fuel truck that had been used to fuel the airplane before it departed.
18:23The U.S. Navy conducts the testing.
18:26If you have water in your fuel, that was most likely to be the cause of fuel contamination.
18:35When the fuel samples are analyzed, the results are conclusive.
18:41We actually found that the fuel that was in the aircraft conformed to standards as we would expect.
18:46So according to the pilots, they lose the left engine first, and then the right.
19:04All the samples from the fuel truck tested clean.
19:11What was the weather like on that night?
19:13Any volcanic activity?
19:16Hawaii is in an active volcano zone.
19:20Could volcanic ash have caused the engines to fail?
19:24Volcanic ash is very bad for jet engines.
19:27It's like throwing sand in the gears.
19:29Jet engines will shut down.
19:32In 1982, a British Airways 747 traveling from England to New Zealand flew through an ash cloud over Indonesia.
19:41All four engines failed.
19:42The plane was high enough for pilots to be able to restart the engines, find an airport, and land safely.
19:50Nothing here.
19:54Clear night.
20:02So that leaves maintenance.
20:05There were no reports of volcanic ash on that night.
20:08The only information that we have to work on is what the crew is telling us, is that they had a dual engine failure.
20:13So we're going to look at the maintenance on the engines.
20:16In the meantime, recovery crews pinpoint the exact location of the plane.
20:21It has settled on the ocean floor in two large pieces.
20:26Often with water recoveries, we have an airplane that's in multiple different pieces.
20:31They're usually smaller pieces and they're less heavy.
20:34So to bring them up intact was a bigger engineering problem.
20:39It means another delay for investigators.
20:45The plane is what, like 40-something years old?
20:50The team digs into the engine history of the accident aircraft to determine why both engines might have failed.
20:57Forty-six.
21:01Flown over 69,000 cycles.
21:05The engines have been around, too.
21:07Left engine, 32,000 flying hours.
21:10And the right, over 70,000.
21:15Engines that old are going to need upkeep.
21:19Jet engines are very solid machines with proper inspection and maintenance.
21:23They can fly on forever.
21:24Anything in the FAA database?
21:29Investigators look into service reports filed by Transair with the Federal Aviation Administration, or FAA,
21:37to see if the aircraft had any history of engine troubles.
21:40I've got three reports on this aircraft.
21:45The most recent was two and a half years ago.
21:49Left engine failure at 2,000 feet.
21:52That's something.
21:56Did an aging aircraft put the lives of two pilots in jeopardy?
22:02The team researches the repair work that's been performed on the engines over the years.
22:06Both engines were serviced two years ago and underwent a daily check the day before the accident flight.
22:16Did they report anything?
22:21No discrepancies.
22:22It's possible that maintenance could have missed something.
22:35Call your contacts at the FAA.
22:38Maybe they can shed some light on Transair.
22:40And I'll speak to maintenance personally.
22:43Because of the possibility that there had been a dual engine failure, we did a deep dive on the maintenance organization at the airline,
22:52trying to find potential theories for something that could have gone wrong.
22:57Bit of a mess over there at Transair Maintenance.
23:02What did you find out?
23:04Chief Maintenance Inspector quit six weeks ahead of the accident, citing chronic maintenance issues and being understaffed.
23:12Also found multiple reports from different pilots about engines overheating.
23:18Investigators uncover internal Transair reports, revealing issues with the engines.
23:25We noticed so many of these reported issues with temperature that we were starting to think that this might really involve a maintenance issue.
23:35There was just so much smoke, we thought there had to be some fire.
23:40Anything specific to the accident aircraft?
23:43No, they involved other airplanes, not exactly a smoking gun.
23:50Anything from the FAA?
23:52Most of the current inquiries into the company are policy and procedure related.
23:57Nothing to do with engine maintenance.
24:01Investigators don't find any maintenance issues that would have brought down Flight 810.
24:09We need those engines.
24:13So even though we were discovering these issues with pilot reports and maintenance records,
24:17there wasn't anything clearly indicating a specific problem that would have led to this reported dual-engine failure.
24:24With a salvage company in place and the weather clearing,
24:29the NTSB is finally able to attempt the recovery of Flight 810 from 350 feet of water.
24:37This was one of the largest water recovery efforts we have done in a couple decades.
24:41The wreckage is successfully razed in two large pieces.
24:45The black boxes are recovered from the rear fuselage and sent to Washington for analysis.
24:51The engines are retrieved separately and brought to a warehouse for inspection.
24:56To be able to see that wreckage come up just creates immense satisfaction because you're like,
25:01OK, now, now we can start this in earnest.
25:04Let's start with this one.
25:13Investigators begin with an examination of the right engine, the one the pilots say was overheating.
25:19It's in better shape than I expected.
25:24They were in pretty good shape.
25:26There was damage due to the water impact.
25:28Let's take a look inside.
25:33They perform a bore scope inspection of the right engine.
25:37It enables them to examine the engine interior without the need for disassembly.
25:43There.
25:44Take a look.
25:45Broken fan blades.
25:47Let's see if there's any damage downstream.
25:57Multiple puncture marks on the turbine.
26:00With that type of damage, the engine could have easily overheated.
26:06Investigators discover two fractured turbine blades, which caused shrapnel damage inside the right engine.
26:13The pilots were correct.
26:16The right engine was giving them trouble.
26:19So from the examination on the right engine, they were able to see that there were blades that had fractured in the high-pressure turbine.
26:27But it was only those two.
26:29And they knew that it would still be able to produce power.
26:33So it wasn't like a complete failure.
26:37Looks like rust and corrosion inside of the blades caused them to rupture.
26:41The routine maintenance inspection procedures contained in the maintenance manual would not necessarily have revealed the presence of cracks or one fractured blade.
26:55So this is the engine the pilot said failed first.
27:01Investigators turned their attention to the left engine.
27:09Let's see what we got.
27:11It looks fine.
27:22No internal damage.
27:25The pilot said the left engine failed, followed by the right.
27:30But investigators can't find anything wrong with the left engine.
27:33When we found out that the left engine was undamaged prior to impact, it really changed the course of our investigation in terms of focusing more on the crew actions.
27:45We pulled a flight path from the radar data.
27:48We've got the CVR data.
27:53And here's a copy of the transcript.
28:02Investigators turned to the cockpit voice recorder, or CVR, of Flight A-10 to determine why the pilots thought the left engine failed, as the evidence suggests it did not.
28:13Check.
28:14Let's hear it from takeoff.
28:15Let's hear it from takeoff.
28:1680 knots.
28:17Check.
28:18V1.
28:19Rotate.
28:20V2.
28:21Positive rate.
28:22Gear up.
28:23Damn.
28:24Stop.
28:25Did you hear that?
28:26Play it again?
28:27No.
28:28No.
28:29No.
28:30No.
28:31No.
28:32No.
28:33No.
28:34No.
28:35No.
28:36No.
28:37No.
28:38No.
28:39No.
28:40No.
28:41No.
28:42No.
28:43No.
28:44No.
28:45No.
28:46No.
28:47No.
28:48No.
28:49No.
28:50No.
28:51No.
28:52No.
28:53No.
28:54No.
28:55No.
28:56No.
28:57No.
28:58No.
28:59No.
29:00No.
29:01No.
29:02No.
29:03No.
29:04No.
29:05No.
29:06No.
29:07No.
29:08No.
29:09No.
29:10No.
29:11No.
29:12No.
29:13No.
29:14No.
29:15No.
29:16you got it yeah I got it yep looks like you lost number number two number two hold it right there
29:27they both said number two the right engine they were correct the pilot's original assessment
29:39matches what investigators have discovered the initial problem was with the right engine so
29:45why did they think that the left engine had failed we're able to hear the crew discuss they had
29:52correctly identified the right engine so at some point you know in their mindset it has flipped to
29:58the wrong engine let's hear what happens next flaps turn 220 heading I'll give you the flaps
30:08roads 810 we have an emergency stand by we're on 220 heading you can enter up to 2000
30:23captain calls in the emergency tells the first officer to climb to a safe altitude all sounds good
30:29and we're on 220 heading say again heading 240 240 heading roads 810 no roads 809 roads 809 left 240
30:45sounds like there's some overlap with another trans air flight
30:52according to these transcripts the captain spends the next minute and 40 seconds communicating with
31:01the controller that's a long time in a critical moment investigators learn that instead of monitoring
31:11the engines roads express 810 your cleared visual approach runway 4 right the captain is distracted by a
31:20conversation with the controller okay roads 810 we're gonna run a checklist I'll let you know when we're ready
31:26to come to the airport when you have an emergency situation it is important to aviate navigate and
31:33communicate your third priority is communicating your emergency what happens next okay I have control Roger okay
31:45let's see what's the problem what's going on with the gauges the captain starts flying the plane and turns
31:53his attention to the engines so it looks like the number one number one's gone gone yeah we're still
32:01the number two so we have number two okay stop the fo changes his diagnosis investigators confirm that
32:12the first officer correctly assesses that the right engine lost power on takeoff yep looks like he lost
32:19number number two but less than four minutes later he tells captain okai it's the left engine that's failed
32:27so it looks like the number one number one's gone gone yeah why it wasn't clear why they had changed their minds about it
32:40the captain then instructs the fo to do the engine shutdown checklist but he only gets through the first step
32:49hey we're red line here we should pull back on the right one a little bit okay the right engine overheats
33:00because of the internal damage leading the pilots to believe they're losing both engines once the crew
33:07had convinced themselves that they had a dual engine failure they were focused almost exclusively on altitude and
33:13airspeed and eventually they ran out of options and had to ditch it's clear that the right engine that
33:22one with the issue is overheating and not producing full thrust but what led them to think the left engine
33:30wasn't working let's see what the flight data recorder can tell us okay let's see what the engines were doing
33:40investigators examine the engine power data of flight 810 to determine what actions the pilots took that led
33:49them to believe they're perfectly working engine the left one had failed after the right engine failed both
33:58engines are brought back to flight idle once they level off at 2,000 feet that's proper percentage
34:10procedure to get the speed down but the first officer never told the captain he brought the engines
34:17back to idle they discover a key step missing in the pilots actions it was procedure for a crew member
34:29to verbalize when they moved the engine controls in this case the first officer actually did not do that
34:35and that could have affected the captain's situational awareness of where those engine throttles were why
34:43did the first officer fail to inform the captain of his action send someone to interview the first
34:50officer again about bringing the throttles back so it was critical for us to get more information to
34:59better understand what had happened there did anyone actually ever test the throttles after they leveled
35:08off the pilots could have increased power to the left engine to confirm which engine had failed no the left
35:18engine throttle stated idle for the rest of the flight if you're going into the water and you have no
35:27other option left you're going to firewall both throttles just in case it might help why didn't the
35:35captain check the first officer's misdiagnosis let's ask him when the first officer subsequently said it
35:45was the number one the captain had just accepted it he didn't effectively cross-check that erroneous
35:50assertion so we wanted to ask him why why did he accept that
35:58captain okai thanks for meeting with me again
36:04you're muted investigators speak to captain okai one more time to find out why he thought the left engine had failed
36:16sorry about that glad i can help when greg told you the left engine had failed do you recall initially thinking
36:24the right one had failed no the thing with greg is i've flown with him so many times he's never
36:32made a mistake if greg says the left is gone the left engine is gone investigators learn the captain put his
36:41faith in his first officer's diagnosis while trust is very important when it comes to crew resource
36:48management you also want to verify the captain did not verify the information that the first officer
36:55was giving him ok thank you sure thing it's really critical when you do have an engine failure to look at
37:06all the available information and cross-check and agree that you have identified the correct engine in this
37:13case that didn't occur over the power readings when the engines were at idle even if the captain trusted
37:23the first officer wouldn't there be other indicators showing which engine had failed the left engine was one
37:34point zero five right one point one two the team discovers the power was a little bit lower on the
37:44left engine even though both engines were set to idle okay let's see what's the problem what's going on with
37:52the gauges they did have slightly different power outputs and that is something you would see with two
37:59different engines that could have really affected the captain's decision-making if the captain had
38:08checked the gauges the readings would have supported his first officer's report that the left engine had
38:14failed so it looks like the number one number one's gone gone yeah so we have number two okay
38:21but this doesn't explain why the first officer never told the captain that he brought both throttles
38:30back in the first place
38:32if the first officer had said hey I pulled the thrust back on both engines then that might have
38:42caused the captain to engage in a different thought process about what might be going on
38:47first officer follow-up interview why didn't the first officer of transair flight 810 tell the captain
39:03he brought the power levers back after the right engine failed he has no recollection of bringing either
39:10thrust lever back to idle we believe that the first officer forgot because he was busy that leads to
39:22stress stress leads to tunneling of attention that can lead to fixation on a small number of parameters
39:29but even if the first officer didn't tell the captain about the thrust levers there must have been other
39:37signs which engine failed check out the rudder data immediately after the right engine failed on takeoff 5.5
39:50degrees of left rudder is applied you got it yeah I got it
39:59after the right engine lost power on takeoff the plane pulled to the right when the first officer
40:10applied the left rudder the plane straightened out the foot that isn't pressing on the rudder pedal is
40:17the side with the bad engine so it's usually a pretty clear indication of which engine has failed he held
40:24that left rudder for three minutes he had a clear indicator but it never registered the fact that the
40:33first officer was applying left rudder was an indication that the right engine had lost power it's very
40:39possible that under those stressful conditions in the middle of the night over the water you could make
40:43that mistake they made the right assessment initially but in the end the stress of the situation
40:53degraded their ability to fly the plane investigators now know the series of events that led to the
41:02ditching of Transair flight 810 when the right engine loses power after takeoff
41:10damn both pilots make the proper assessment yep looks like lost number number two number two but while the
41:27captain communicates with air traffic control okay roads 810 the first officer reduces engine power
41:37okay let's see what's the problem in a moment of stress he forgets to tell the captain what's going on with
41:47the gauges the slightly different readings on the gauges lead the pilots to believe the fully functioning
41:53left engine has failed so it looks like the number one number one scar the captain relies on the first
42:00officer's assessment without doing his own analysis of the situation gone yeah we still have the number
42:07two so we have number two okay instead of confirming which engine had actually lost power and forgetting
42:16their original assessment the pilots end up flying on a damaged engine how's the EGT has max is beyond max
42:26setting them up for an inevitable ditching we're in the water we're in the water
42:33the pilots miss identification of the damaged engine and their use of the only before the ntsb's final
42:55report is published roads aviation is shut down by the federal aviation administration for numerous safe
43:03safety and maintenance violations while it may be disappointing that the crew never actually
43:11touched their left engine that was working properly it is a testament to the human limitations that actually
43:17arise when you have stressful high workload situations and that's what we need to account for with only 50
43:25737-200s remaining in service it's deemed impractical to fit them with engine sensors that would alert pilots
43:33to a failed engine but it's now standard in most passenger airliners engine monitoring technology has improved
43:43considerably since this aircraft was manufactured newer airplanes actually give very clear indications to the
43:50pilot regarding which engine is bad and reduces the risk of the crew misidentifying it