ALTAI BRENT_SCHROTENBOER CAPTAIN_CLAY CAPTAIN_SASSE CONTROLLER EVAN_BYRNE FAN FIRST_OFFICER_PALMER FIRST_OFFICER_POLEHINKE GPWS INVESTIGATOR INVESTIGATOR_TWO JOE_SEDOR JOHN_COX JOHN_NANCE KIRKSVILLE_OPS KURT_DEETZ LEAD_INVESTIGATOR MALCOLM_BRENNER MARY_SCHIAVO NARRATION PILOT_ZOBAYAN SHAWN_PRUCHNICKI SOCAL_CONTROLLER TODD_CURTIS TOM_HAUETER NARRATION Commercial pilots receive extensive training� � to help them react properly to an emergency. But when that training is ignored� � dangerous situations can become deadly. INVESTIGATORs search for answers when pilots of three aircraft skip protocols and crash. Helicopter charter pilot Ara Zobayan welcomes a familiar client for today�s flight� basketball superstar Kobe Bryant. Kobe, his daughter Gianna, and six others are flying out of Santa Ana, California, for a basketball tournament near Camarillo, 80 miles (129 kilometers) away. Zobayan is chief pilot for Island Express, which flies VIPs around Southern California. Just after nine am, the helicopter lifts off from Santa Ana. From here, Zobayan will navigate using the highways around Los Angeles as a visual reference. Thirteen minutes into the flight, Zobayan requests permission to pass through Burbank�s airspace. The controller denies his request because of low visibility. Burbank is only accepting flights where pilots navigate solely on instruments and Zobayan is only authorized to fly by Visual Flight Rules, or VFR. But Zobayan knows a way around this restriction. The controller authorizes the request, allowing Zobayan through the low-visibility airspace once it�s clear of traffic. Zobayan will need to stay out of the clouds, which are about a thousand feet (300 meters) above the ground. Kobe Bryant and the other passengers are less than ten minutes from their destination. But now, the visibility gets even worse. Zobayan radios the controller handling the last leg of the flight to Camarillo for permission to climb above the clouds. Kobe Bryant, his daughter Gianna and the seven other people in the helicopter are dead. Why did a state-of-the-art helicopter crash just 24 miles (39 kilometers) from its destination? It�s up to INVESTIGATORs from the National Transportation Safety Board to find the answer. They start by examining the engines and rotors, as well as the helicopter�s flight instruments. INVESTIGATORs can piece together a detailed flight path from an ADS-B system installed on the Sikorsky helicopter. INVESTIGATORs study visibility reports from weather stations along the route. They look into the career and background of pilot Ara Zobayan. Records show that before he welcomed Kobe Bryant�s party on board, Zobayan checked the weather and determined that even though there were clouds blanketing the area, the flight was low risk. But the low clouds surrounding Los Angeles forced Zobayan to alter his usual, more direct route. INVESTIGATORs need to know the exact conditions Zobayan flew into in the final moments of the flight. The NTSB obtains photos that captured the last moments before the crash. Surveillance data shows that the helicopter was only 450 (137 meters) feet above the ground. INVESTIGATORs determine that just over a minute before the accident, Zobayan flew into dense cloud which would have reduced his visibility to near zero. Flying into cloudbanks with low visibility is a leading cause of aviation accidents. In a helicopter, the consequences are often fatal. Pilots like Zobayan are trained to do whatever they can to avoid such conditions. INVESTIGATORs take a closer look at the speed the helicopter maintained while en route to Kobe Bryant�s basketball academy at Camarillo. Instead of turning around, Zobayan decides to climb above the clouds. The helicopter�s unusual movements lead INVESTIGATORs to wonder about the level of training the pilot received. They discover that Zobayan was well trained to escape the precise conditions he flew into. It�s one of the reasons that Kobe Bryant flew with Zobayan so often. A review of Zobayan�s training shows that he was taught to reduce speed, use the autopilot to climb above the clouds and then declare an emergency. But did Zobayan follow that procedure? The higher the helicopter climbs into the dense clouds, the worse the visibility becomes. But Zobayan never asks for help. With no regard for protocol, Zobayan continues a rapid climb with no visibility and without the help of the autopilot. On the CVR, INVESTIGATORs hear him report that he�s climbing when he�s actually descending rapidly. Kobe Bryant and eight others die as a result of an all-too-common scenario � a helicopter pilot flying into low visibility and becoming disoriented. On the recommendation of the NTSB, the Federal Aviation Administration is evaluating tools that can be used to train more pilots on how to recognize and cope with the effects of disorientation. The pilot of Kobe Bryant�s helicopter had all the training he needed to avoid the situation altogether. But that education was disregarded when it was needed most. When pilots fail to follow every aspect of their training� � even the most routine procedures can lead to disaster. The pilots of Corporate Airlines flight 5966 conduct the approach briefing for Kirksville, Missouri, Regional Airport. Captain Kim Sasse has been a pilot since the late 1980s, but only started flying professionally in the last five years. First Officer Jonathon Palmer has three years� professional flying experience with regional airlines. There are thirteen passengers on board the 50-minute flight from St. Louis to Kirksville, Missouri. The pilots are flying a Jetstream 32. It�s fuel efficient and reliable, but this particular model has no autopilot. The crew is flying a non-precision approach with no vertical landing guidance. Configuring for landing early reduces the workload as they near the airport. The lights at Kirksville are pilot activated. Two-and-a-half miles from the airport, the pilots search for the runway. At two miles (3 kilometers) from the runway, the pilots are still looking for the approach lights. Corporate Airlines flight 5966 has crashed a mile (kilometer) south of the airport at Kirksville, Missouri. Only two passengers survive. The eleven other passengers and both pilots are dead. NTSB INVESTIGATORs examine the wreckage. Pilots of other flights into Kirksville Airport report that the weather posed no problems for them. So why did flight 5966 crash on the same approach? By combining flight recorder data and radar returns, INVESTIGATORs determine the flight�s descent profile. INVESTIGATORs turn to the cockpit voice recorder for an answer. INVESTIGATORs listen for clues in earlier cockpit conversations to explain why the crew ignored established procedures during the flight�s final moments. The conversation raises a major concern for INVESTIGATORs. INVESTIGATORs now hear the captain teasing the first officer while he�s confirming their altimeter setting. Did the Captain�s conduct affect the First Officer�s actions at a critical moment? INVESTIGATORs study the pilots' training and histories to determine if Flight 5966�s crew regularly deviated from airline procedures. Fatigue could explain why the pilots don�t rely on their training when confronted with a changing situation. INVESTIGATORs check the crew�s duty hours leading up to the flight. Were the pilots made to work too many hours without sufficient rest? The NTSB recommends an overhaul of the FAA�s flight and duty-time regulations to consider the length of duty day, start time, workload and other factors that can affect pilots� alertness. Had the crew of flight 5966 been rested, they likely would have adhered to their training and this tragedy might have been avoided. Disaster doesn�t just strike when pilots breach protocols for in-flight procedures. Sometimes, critical mistakes are made before the plane even leaves the ground. It�s close to six in the morning in Lexington, Kentucky. Comair flight 5191 prepares for takeoff. There are 47 passengers and one flight attendant on the Bombardier CRJ100, a small twin-engine commuter jet. In command is Captain Jeff Clay, an experienced pilot with more than 4700 flight hours. They�re bound for Atlanta, Georgia, a 67-minute flight south of the Lexington airport. Lexington�s air traffic controller clears flight 5191 to the runway. CAPTAIN CLAY hands over control of the aircraft to First Officer Polehinke. The plane hurtles past the runway� and bursts into flames. Forty-nine people are dead after Comair Flight 5191�s disastrous takeoff attempt. Only the first officer survives. But he�s too injured to assist with the NTSB investigation into why the plane crashed less than half a mile (less than a kilometers) from Lexington's Blue Grass airport. The wreckage path tells INVESTIGATORs that the plane struggled to get airborne. INVESTIGATORs realize that Flight 5191 took off from the wrong runway. But that alone doesn't explain why the plane couldn�t lift off. The aircraft wasn�t too heavy to take off. They now understand why the plane couldn't get airborne. But a mystery remains. Before takeoff, planes stop � or hold short � of the runway until air traffic control clears them to proceed. To better understand why the pilots of Comair flight 5191 stopped at the hold short line for the wrong runway� � they retrace their taxi route. EVAN BYRNE I can clearly see the signs telling us that we�re at the hold short line for runway 26. I mean it�s hard to miss that. INVESTIGATORs discover the crew had clear cues that they were at the hold short line for runway 2-6, not 2-2. Then, they uncover another disturbing fact. The cockpit voice recorder may hold the key. INVESTIGATORs can�t understand why the taxi brief, with 8 checklist items, including a very crucial one, wasn�t followed. Had the crew performed a full taxi briefing, they would have discussed the need to cross runway 2-6 on the way to 2-2. Instead of focusing on their checklists, the crew of 5191 were having a casual conversation. Could that period of inattention be the key to this tragic accident? INVESTIGATORs hope Comair Flight 5191�s CVR will give some indication why the crew turned onto the wrong runway. INVESTIGATORs are intrigued by what they hear next. The pilots realize they�re almost out of runway� ... but they don�t have the required speed to lift off. The NTSB concludes that by ignoring their training the pilots lost track of their position on the way to the runway. Among the NTSB�s recommendations is a technological change to prevent pilots from getting lost. The NTSB also makes recommendations for flight crews. Airline pilots expect the unexpected every day they go to work. But routine emergencies turn catastrophic when pilots disregard standard operating procedures and allow a bad situation to get worse. First officer James Polehinke is also a seasoned pilot, with more than 6500 hours. CAPTAIN CLAY Runway heading, cleared for takeoff, 1-91. CAPTAIN SASSE Let's go flaps ten and we'll configure early too. PILOT ZOBAYAN Uh we�re climbing to 4,000 (1,200 meters), Two-Echo-X-Ray. CAPTAIN SASSE Oh yeah, there it is. Approach lights in sight. FIRST OFFICER PALMER I... I don't see anything. LEAD INVESTIGATOR Why is the captain even looking for the approach lights? CAPTAIN CLAY 100 knots (185 kilometers per hour). FIRST OFFICER POLEHINKE That is weird with no lights. CAPTAIN CLAY Yeah. JOE SEDOR What the heck is he talking about? MALCOLM BRENNER This pilot was one of L.A.�s top helicopter pilots. INVESTIGATOR TWO How�d he let himself get into this situation? INVESTIGATOR He ignored all his training. JOHN NANCE When pilots don't follow the training that they've been given, this is not a place that you wanna be when you're sitting in the back as a passenger. PILOT ZOBAYAN How�s everyone doing today? PILOT ZOBAYAN Well let�s get going. PILOT ZOBAYAN Hey everyone, it�s about to get loud back there. PILOT ZOBAYAN Copter seven two Echo X-ray Island Express for east one departure. BRENT SCHROTENBOER Kobe and the pilot of this helicopter had really become friends, because he had piloted him so many times around Southern California that they developed a relationship. They�re flying in a luxury Sikorsky S-76B configured to carry eight passengers. BRENT SCHROTENBOER The Sikorsky 76B is sort of like an air limousine in that it�s quite common for VIP travel. KURT DEETZ Landmarks for flying aircraft in L.A. is... is really important. PILOT ZOBAYAN Burbank, helicopter seven two Echo Xray, Sikorsky helicopter, approaching the zoo for a 101 westbound transition. TOM HAUETER The threshold for visual flight is normally three miles (five kilometers). The Burbank Airport was two and a half miles (four kilometers). PILOT ZOBAYAN Asking for Special VFR transition to the 101 westbound. PILOT ZOBAYAN Copy that. We'll maintain special VFR, copter two Echo X-ray. KURT DEETZ The way he went was the lowest route available because of the weather. TOM HAUETER The controllers would not see him on radar he was so low. PILOT ZOBAYAN We�re gonna go ahead and start our climb to go above the layers. SOCAL CONTROLLER Two Echo X-Ray, say intentions. PILOT ZOBAYAN Uh we�re climbing to 4,000 (1,220 meters) Two Echo X-ray. SOCAL CONTROLLER And what are you gonna do when you reach altitude? FAN I�m just at a loss for words right now. FAN You won�t see another player like him again. He will be missed. INVESTIGATOR We need to cover all our bases on this one. TOM HAUETER Knowing that there�s a high-profile person onboard, obviously NTSB responded with a major investigations team. TOM HAUETER All the mechanical systems, electronic systems, everything at that time appeared to be working fine. INVESTIGATOR Okay. He takes off at 9 07. He flies northwest. TOM HAUETER ADS-B data is like transponder data. Controllers can see it and it�s recorded - your airspeed, altitude and headings. INVESTIGATOR And he follows the I-5 to Van Nuys and then south to the 101, which he follows until he makes this U-turn, straight into a hillside. TOM HAUETER You see this turn to the left where he�s coming back around or doing something. What�s exactly the pilot doing here? INVESTIGATOR Let's take a look at the visibility. INVESTIGATOR They were a bit socked in near Burbank and Van Nuys, but nothing he can't get through. TOM HAUETER When he got near Burbank Airport, it was two and a half miles (four kilometers) visibility. That's still totally flyable for him. INVESTIGATOR TWO More than 8300 flying hours. Instructor on the S-76. Chief Pilot at Island Express. MALCOLM BRENNER This pilot was not a rookie who just got his license. He was one of L.A.�s top helicopter pilots, working for one of its top companies. INVESTIGATOR I get it if the visibility was down to zero, but this wasn't that bad. So what happened to this guy? TOM HAUETER Why do we have a high-time pilot in an aircraft that�s capable of flight and visibility conditions he should have been able to handle either lose control or somehow inadvertently fly his helicopter into the ground? PILOT ZOBAYAN How�s everyone doing today? BRENT SCHROTENBOER Because of the weather, he flew more inland than he normally does. INVESTIGATOR Based on the forecast, his plan was okay. So what went wrong? INVESTIGATOR We need to figure out what he could actually see. INVESTIGATOR Okay. You can just make him out here, actually heading into fairly heavy cloud. Same camera three seconds later, he�s disappeared. TOM HAUETER They could collect data in real time of what this pilot would have been encountering. INVESTIGATOR So the cloud base was no more than 450 feet (137 meters) above the ground, not the 1100 feet (335 meters) which was being reported along its route. MALCOLM BRENNER Legally, he�s not allowed to enter it. He�s only allowed to go in visual conditions only, and yet he did. MALCOLM BRENNER You can�t see where the horizon is, and you can't see the sky from the ground. INVESTIGATOR TWO How did he let himself get into this situation? INVESTIGATOR He�s bombing along here at about 140 knots (260 kilometers per hour). Visibility is getting worse and worse but he�s not slowing down, he�s not turning around. He just keeps going. Why? TOM HAUETER He could have turned around, landed at Van Nuys. He could have circled for a while near the airport, waiting for the conditions to improve. For whatever reason � we don�t know � he chose none of those options. INVESTIGATOR TWO It doesn't take long for things to start going wrong as soon as he entered that cloud. PILOT ZOBAYAN We�re gonna go ahead and start our climb to go above the layers. INVESTIGATOR TWO He starts banking further and further left, descends rapidly, hits the hill here. MALCOLM BRENNER More than that, he was the chief pilot of the company. He set the safety standards for all the pilots, and he trained them on how to deal with instrument conditions. INVESTIGATOR TWO The Director of Operations says that Kobe�s relationship with Ara was quote warm and friendly, that he trusted Ara with his girls and his family and that they always wanted Ara. INVESTIGATOR His training was good. INVESTIGATOR TWO Here he�s entering an area of low visibility. Still flying well above 100 knots (185 kilometers per hour), no evidence of slowing down. INVESTIGATOR Look at that rate of climb. Fifteen hundred feet (460 meters) a minute. It can't be the autopilot doing that. TOM HAUETER That exceeds the authority of the autopilot system. Therefore, this climb was being manually controlled. KURT DEETZ He should have been saying, Mayday, Mayday, Mayday, declaring an emergency. INVESTIGATOR TWO He didn't slow down. He didn't use his autopilot. He never declared an emergency. INVESTIGATOR He ignored all his training. MALCOLM BRENNER There are basic procedures that should be followed, and you have to have a very cautious approach to any sort of instrument conditions. This was not evident in the way the pilot flew that day. PILOT ZOBAYAN Uh we�re climbing to 4,000 (1,220 meters). Two Echo X-ray. INVESTIGATOR TWO Did you hear that? INVESTIGATOR TWO The highway now veers off to the right. But he�s lost sight of it. He�s banking further and further to the left without even realizing it. There�s no sign he ever figured out what was really happening. PILOT ZOBAYAN We�re climbing to 4,000 (1,220 meters). Two Echo X-ray. MALCOLM BRENNER The industry needs to realize how common and sinister these affects can be and develop better safety standards. TOM HAUETER The last thing the NTSB wants to do is go back and investigate this kind of accident all over again. TODD CURTIS Training is an essential part of aviation at every level. And when that training is ignored, specifically ignored in a situation where the training should be put to use in flight, it could lead to an accident. FIRST OFFICER PALMER I... I don�t see anything. CAPTAIN SASSE Oh yeah. There it is. Approach lights in sight. CAPTAIN SASSE No. GPWS Sink rate. CAPTAIN SASSE No! GPWS Pull up! FIRST OFFICER PALMER Trees! CAPTAIN SASSE No. Stop. Oh my god! CAPTAIN SASSE If we have to go missed, we'll set max power. Flaps ten, positive rate, gear up. CAPTAIN SASSE Then we'll climb three thousand feet (900 meters), then direct Kirksville VOR. CAPTAIN SASSE I'll ask you to walk me through that if we need it. FIRST OFFICER PALMER Roger that. JOHN COX The pilots viewed your time with the regionals as somewhat of the dues you pay to get to the airlines or the high-end corporate jobs. CAPTAIN SASSE Uh we�re going into the crap. Look, it's so eerie and creepy. ALTAI NEGATY-HINDI The Jetstream not having any autopilot made our days very long. You had to constantly fly the airplane. FIRST OFFICER PALMER Three thousand (900 meters) till established. Cleared for the approach. CAPTAIN SASSE Let's go flaps ten and we'll configure early too. JOHN COX In any non-precision approach, you want to minimize the number of variables. And one of the ways you do that is you get the airplane in a position to land earlier than normal. CAPTAIN SASSE Let�s make sure the lights are up please. FIRST OFFICER PALMER All right. JOHN COX Airports without a lot of traffic that goes in and out of 'em, one of the ways that they reduce the cost of running the airport is they don't have the lights on all the time. The pilots have the ability to control those lights with a series of microphone clicks on a specific radio frequency. ALTAI NEGATY-HINDI If those lights are not on, particularly when you fly with a low visibility and at night, you won't see the runway. FIRST OFFICER PALMER Kirksville Ops, CorpEx Fifty-nine sixty-six. KIRKSVILLE OPS Fifty-nine sixty-six. FIRST OFFICER PALMER Yeah. Could you tell me if the approach lights are up. KIRKSVILLE OPS Lights are on. FIRST OFFICER PALMER Cool. Thanks. FIRST OFFICER PALMER Four hundred (120 meters). ALTAI NEGATY-HINDI It's very critical to maintain that altitude because if you don't see the runway, you gotta go missed because you cannot land without seeing the runway. FIRST OFFICER PALMER Three fifty. Here we are. FIRST OFFICER PALMER I... I don't see anything. ALTAI NEGATY-HINDI You're flying 336 feet (100 meters) above the ground so there�s not a lot of room for error. CAPTAIN SASSE Oh yeah, there it is. Approach lights in sight. FIRST OFFICER PALMER Flaps 35? CAPTAIN SASSE No! GPWS Sink rate. CAPTAIN SASSE No! FIRST OFFICER PALMER Trees! GPWS Pull up. CAPTAIN SASSE No! Stop! Oh my God! Oh holy crap. ALTAI NEGATY-HINDI For the pilot community, this is something that is touching us, because that could be me. We wanna know what happened. INVESTIGATOR TWO Engines, controls, instruments all checked out. TOM HAUETER It appeared that the airplane was fully functional at the time it hit the ground. LEAD INVESTIGATOR The plane�s working fine. What kind of an approach were they flying that night? INVESTIGATOR TWO A non-precision to runway 3-6. JOHN COX Unfortunately, the accident rate for non-precision approaches is dramatically higher than on those approaches with an instrument landing system. LEAD INVESTIGATOR They�re flying blind through the clouds. It�s misty. Visibility is poor. INVESTIGATOR TWO Those are bad conditions for a non-precision approach. JOHN COX You come down to the lowest altitude, you have to level off there, and you fly along looking for the runway environment. TOM HAUETER Looking at all the pieces, this accident started to look like it was a human performance issue and not an airplane issue. LEAD INVESTIGATOR Let's see how they handled the approach. LEAD INVESTIGATOR So the plane was supposed to level off at the minimum descent altitude before continuing to descend to the runway. JOHN COX The minimum descent altitude is the lowest altitude you're permitted to fly at until you see the runway environment. INVESTIGATOR TWO Why would they blow right past the MDA like that? LEAD INVESTIGATOR Take it to when they near the MDA. If there's a big mistake, it'll likely be then. FIRST OFFICER PALMER Four hundred (120 meters). Three fifty (105 meters). Here we are. LEAD INVESTIGATOR Okay. They�re at the MDA. It�s decision time. FIRST OFFICER PALMER I... I don't see anything. CAPTAIN SASSE Oh yeah, there it is. Approach lights in sight. LEAD INVESTIGATOR They�re two miles (3 kilometers) out, 300 feet (90 meters) up. They�ve just come out of the clouds. With the mist that night, they probably couldn't see the runway lights. INVESTIGATOR TWO There�s only farmland from here to the airport. LEAD INVESTIGATOR Why is the captain even looking for the approach lights? TOM HAUETER He shouldn't be doing that. He should be totally focused inside the airplane. LEAD INVESTIGATOR The first officer is supposed to see the approach lights and call out, approach lights in sight, continue. INVESTIGATOR TWO Instead, they're both looking for the runway. And nobody is paying attention to the plane's descent speed and altitude. JOHN COX The flying pilot should have been monitoring exclusively instruments and what sadly occurred was that the normal flight path continued below the minimum descent altitude and neither one of them caught it. LEAD INVESTIGATOR The captain�s looking outside when he shouldn't. The first officer doesn't challenge him. Next thing, they're crashing. MALCOLM BRENNER It's surprising how much the captain's performance suddenly fell apart at the end. FIRST OFFICER PALMER I have a good time flying with you. CAPTAIN SASSE You gotta have fun. FIRST OFFICER PALMER That�s truth, man. You gotta have fun. CAPTAIN SASSE Too many of these jerks take themselves way too seriously in this job. I've flown with them and it sucks. All you wanna do is strangle the jerk when you get to the ground. INVESTIGATOR TWO The captain is essentially telling him how he wants the first officer to behave. MALCOLM BRENNER That�s disturbing, and it sets a disturbing atmosphere. CAPTAIN SASSE Cruise check, power check. Can you push his foot away? FIRST OFFICER PALMER Yes. MALCOLM BRENNER It�s a relatively compact airplane and the passengers in the front of the airplane can sometimes put their foot into the cockpit area. CAPTAIN SASSE Cruise power, cruise check. FIRST OFFICER PALMER All you gotta do is you open the curtain a little bit. It's like, man... CAPTAIN SASSE I dropped my book on him purposely one time. Right on top of the arch of the foot. FIRST OFFICER PALMER Oh. LEAD INVESTIGATOR Okay, stop it. The captain starts his cruise power checks, but then interrupts himself to tell a story about hurting a passenger. INVESTIGATOR TWO Mm hmm. MALCOLM BRENNER It's really inappropriate. Uh the lack of respect for passengers is, is striking in his conversation. LEAD INVESTIGATOR All right, well let's see if the first officer can get him back on track. FIRST OFFICER PALMER How'd I get two niner niner zero? CAPTAIN SASSE Because you�re an idiot. FIRST OFFICER PALMER It should be two niner niner two? CAPTAIN SASSE You never set it when they cleared us to the runway? FIRST OFFICER PALMER And I�ve been sitting here living a lie for the last twenty minutes. CAPTAIN SASSE Yeah, you lying scum bucket. INVESTIGATOR TWO The captain's jokes have totally eroded procedure. Even the first officer has given in and turned his checklist into a joke. MALCOLM BRENNER The kind of atmosphere he set up earlier in making fun of other pilots and making fun of the passengers sets up the wrong tone. It doesn�t encourage the First Officer to object. When things were falling apart, he... he could have stepped in and done something. LEAD INVESTIGATOR It looks like a complete breakdown in command structure led to this accident. The question is, why? INVESTIGATOR TWO Got their personnel files. LEAD INVESTIGATOR The captain left a well-paying job to become a pilot. Plenty of hours, passed all the checks. INVESTIGATOR TWO The first officer checks out too. LEAD INVESTIGATOR They were joking a fair bit. Almost punch drunk. Do you think they may have been overtired? JOHN COX Fatigue is insidious in that once you are at a higher level of fatigue, performance impairment can be somewhat like alcohol. CAPTAIN SASSE We�re going into the crap. Look. It's so eerie and creepy. MALCOLM BRENNER People start to become giddy and are not critical enough or, or, or enough careful of their behaviour. INVESTIGATOR TWO Now how much did these guys work before the accident flight? INVESTIGATOR TWO The night of the flight, they had worked three days straight. That'll tire you out. LEAD INVESTIGATOR Yeah, well they had seven-and-a-half hours of available rest time the night before the flight. INVESTIGATOR TWO That day, they flew six flights, an hour each, and they were on duty for fourteen hours straight starting at 5 45 am. INVESTIGATOR TWO Check this out. Pilots can't fly more than eight flight hours in a day. JOHN COX I flew in those days, and you had a maximum number of flight hours in a day, but the number of duty hours and the time of day was not even taken into consideration. LEAD INVESTIGATOR The last time these regulations were updated� 1964. MALCOLM BRENNER The regulations needed to be updated, to improve the safety for everyone. MALCOLM BRENNER It's not always obvious when someone is tired, and it's not obvious to them. JOHN NANCE When pilots don't follow the training that they've been given, basically they are putting themselves into a raw position of ignoring all the lessons of the past that led to the construct of that training. And this is not a place that you wanna be when you're sitting in the back as a passenger. CAPTAIN CLAY All yours, Jim. FIRST OFFICER POLEHINKE At your leisure. Comair 121 ready to go. CONTROLLER Comair 1-91. FIRST OFFICER POLEHINKE Damn it! CAPTAIN CLAY Ladies and gentlemen, we'd like to take this time to welcome you onboard Comair Flight 5191 direct to Atlanta. CAPTAIN CLAY Are you up for flying this leg? FIRST OFFICER POLEHINKE Yeah, I'll take us to Atlanta. SHAWN PRUCHNICKI Both the captain and the first officer were very highly regarded. They had an outstanding professional reputation. CONTROLLER Comair 1-91, taxi to runway two-two. Altimeter three-zero-zero-zero. Winds are two-zero-zero at eight. FIRST OFFICER POLEHINKE Three triple zero and taxi two-two, Comair 1-91. SHAWN PRUCHNICKI During the taxi out, the first officer is running numerous checklists and verifying that the aircraft is safe for departure. FIRST OFFICER POLEHINKE Cabin reports received. Before takeoff checks complete. Ready. CAPTAIN CLAY All set. FIRST OFFICER POLEHINKE At your leisure, Comair 1-21 ready to go. CONTROLLER Comair 1-91, Lexington Tower. Fly runway heading. Cleared for takeoff. FIRST OFFICER POLEHINKE Ugh. CAPTAIN CLAY Runway heading, cleared for takeoff, 1-91. All yours, Jim. FIRST OFFICER POLEHINKE My brakes, my controls. Set thrust, please. CAPTAIN CLAY Thrust set. FIRST OFFICER POLEHINKE That is weird with no lights. CAPTAIN CLAY Yeah. A hundred knots. FIRST OFFICER POLEHINKE Checks. CAPTAIN CLAY Whoa! FIRST OFFICER POLEHINKE Damn it! JOE SEDOR The first impact point is there. Then the plane hit those trees over there. Those impact marks aren't more than 20 feet (6 meters) up those trunks. JOE SEDOR It looks like they took off from runway 26. Hang on. 26 wasn't in use last night. JOE SEDOR Maybe they were too heavy? JOE SEDOR The plane weighed 49,087 pounds (22,265 kilograms)on that day. It's close, but it's within their limit. JOE SEDOR How much runway would be needed to take off safely? SHAWN PRUCHNICKI The weight of the aircraft affects how fast they have to be going to be able to lift off, and that is directly correlated to how much runway it takes to be able to achieve that speed. EVAN BYRNE 3,744 feet (1,141 meters). JOE SEDOR 3,744 feet (1,141 meters). And runway 2-6 is...? EVAN BYRNE 3,501 feet (1,067 meters). JOE SEDOR They ran out of runway. JOE SEDOR They�re supposed to leave from runway 2-2 here. But they end up here. The question is Why? EVAN BYRNE Maybe there�s something on the security footage. JOE SEDOR Wait. Stop it right there. It looks like they�ve stopped at the hold short line for runway 26. EVAN BYRNE Why the heck would they stop there? JOE SEDOR Ugh. We need to see the taxi route. EVAN BYRNE All right. Uh let's get started. EVAN BYRNE Things that we�re looking for during that taxi demo were markings on the taxiway, the signage, whether it was illuminated or not. EVAN BYRNE All the cues are right there in plain sight. JOE SEDOR When we turned onto runway 2-6, all of the, the lights on runway 2-6 were out. As an experienced pilot, I look at that and say Why did this flight crew take off from this runway? EVAN BYRNE We need to know what was going on in that cockpit. JOE SEDOR Okay, let�s hear what we've got. JOE SEDOR In this type of human factors accident, it�s very difficult because we have to try to determine what the pilots were thinking. JOE SEDOR Okay, here comes the taxi brief. CAPTAIN CLAY It�s two-two. FIRST OFFICER POLEHINKE Two-two. The ILS is out on 2-2. Came in the other night, the runway identifier lights were out all over the place. CAPTAIN CLAY All right. FIRST OFFICER POLEHINKE Two-two's a short taxi. Any questions? CAPTAIN CLAY No questions before starting. At your leisure. JOE SEDOR Wait. Stop it right there. Is that not a short brief to you? There�s no mention of crossing runways or stopping to call ATC if they�re unsure of where they are. EVAN BYRNE Yeah, they never briefed on the runway they had to cross to get to runway 22. EVAN BYRNE The crew�s abbreviated briefing that morning was a deviation from standard operating procedures that we identified. JOE SEDOR Okay. Let�s hear their Taxi Checklist. FIRST OFFICER POLEHINKE Yeah, I know three guys at Kennedy, or actually two guys. One went but he didn�t get through the Sims. CAPTAIN CLAY Oh, really? FIRST OFFICER POLEHINKE And then a first officer from Cincinnati, he got through the second part, and that�s as far as he got. JOE SEDOR Stop it right there. What the heck is he talking about? JOE SEDOR They skipped out on the briefing, then for almost a minute, they violate the Sterile Cockpit Rule. EVAN BYRNE The Sterile Cockpit Rule requires that pilots refrain from non-operational conversation during significant portions of flight. CAPTAIN CLAY Ah. Okay. JOE SEDOR The captain should be shutting this conversation down, not encouraging it. JOE SEDOR That non-pertinent conversation was in a critical area when the flight crew was making their taxi out to the runway where the flight crew needs to be a hundred percent flying the aircraft. JOE SEDOR Let�s see what happens when they get here. FIRST OFFICER POLEHINKE Thrust reversers are armed. Auto crossflow is manual. Ignition is off. Altimeters are three triple zero across the board. Cross-checked. I�ll check in with the cabin. JOE SEDOR That�s it? When they stop their chit chat, they don't seem to recognize, know or check where they are. FIRST OFFICER POLEHINKE At your leisure. Comair 1-21 ready to go. CONTROLLER Comair 1-91, Lexington Tower. Fly runway heading. Cleared for takeoff. EVAN BYRNE They�re completely relaxed when they ask for clearance. In fact, so relaxed or distracted that the first officer uses the wrong flight number. These guys actually thought they were lined up for runway 22. EVAN BYRNE The fact that they stopped at runway two-six and subsequently called for takeoff indicates that they lost awareness that they had not crossed runway two-six. JOE SEDOR They turn onto runway 26. Then what? Keep going. FIRST OFFICER POLEHINKE Lineup check�s completed. CAPTAIN CLAY All yours, Jim. JOE SEDOR The first officer takes the controls. So he�s looking ahead, probably for the first time. JOE SEDOR The captain transferred controls to the first officer. So before this time, the first officer was heads-down in the cockpit. FIRST OFFICER POLEHINKE My brakes. My controls. EVAN BYRNE When the first officer looked out, he saw a runway. He may not have perceived that it was a narrower runway than runway 2-2. JOE SEDOR They�re looking down runway 26. Why don't they see the sign for 22 off to the right? EVAN BYRNE Neither pilot cross-checked their location at the time that they took the runway. CAPTAIN CLAY A hundred knots. FIRST OFFICER POLEHINKE Checks. CAPTAIN CLAY V-1. Rotate! CAPTAIN CLAY Whoa! FIRST OFFICER POLEHINKE Damn it! EVAN BYRNE Both crew members lost awareness of where they were on that airport surface and made a mistake that was extremely consequential. JOE SEDOR Install moving map GPS displays in CRJ-100 cockpits. JOE SEDOR Require pilots to check that they are at their assigned runway before crossing the hold short line. EVAN BYRNE This was a catastrophic accident. It affected scores and scores of lives. But the legacy of this accident are the safety changes that have been made to prevent this type of accident from happening in the future. MARY SCHIAVO A lot of thought has gone into training modules and so if you ignore part of them or just choose not to follow part of them, you are ignoring literally a whole body of knowledge that has been put together to keep you safe and keep your passengers alive.