AIR_TRAFFIC_CONTROLLER AUTOMATED_WEATHER_REPORT BARRY_STRAUCH BOB_MACINTOSH CAPTAIN_CHAPO CAPTAIN_CHAVEZ CAPTAIN_HILLIS CAPTAIN_SASSE COCKPIT_INVESTIGATOR CONTROLLER DAVID_LAWRENCE DOUG_TAUBER EMERGENCY_CALL FIRST_OFFICER_CURRAN FIRST_OFFICER_MARCHESE FIRST_OFFICER_SAILOR FLIGHT_ENGINEER_RICHMOND GPWS GREG_FEITH INVESTIGATOR JAMES_CHAPO JIM_CHAPO JIM_SILLIMAN JOHN_COX JOHN_NANCE MARK_ROSEKIND MARY_SCHIAVO NARRATION NAVY_PILOT NTSB_INVESTIGATOR NTSB_INVESTIGATOR_TWO PASSENGER PILOTS SATHYA_SILVA TEST_PILOT THOMAS_CURRAN TODD_CURTIS NARRATION With no runway in sight� � two PILOTS argue. A captain believes one signal� ... but ignores another one An exhausted pilot picks a disastrous time� � to try a new approach. These crashes could have been avoided. A debate about speed, a question about power, a case of fatigue. INVESTIGATORs ask how such experienced PILOTS could have been so careless. ExecuFlight 1526 is climbing to cruising altitude above the US Midwest. First Officer Renato Marchese is the pilot flying the twin engine Hawker 700. He�s logged more than 4,000 flying hours on various private jets. Captain Oscar Chavez has over 6,000 hours on private jets and cargo planes. It�s a 35-minute flight from Dayton northeast to Akron, Ohio. On board are seven executives from a Florida-based property management company. They�ve chartered the luxury jet from ExecuFlight, a private carrier based in Fort Lauderdale, Florida. The crew is advised that rain is reducing visibility at their destination. And there�s another complication. A student pilot is practicing a landing on the same runway assigned to Flight 1526. Akron control requests that they alter their course, and maintain altitude at 3,000 feet . The plane is now two and a half miles from the airport. Cloud still obscures the runway. ExecuFlight 1526 has crashed into a two-story residential building. Everyone onboard is dead. Fortunately, no one was inside the building. It�s now up to the National Transportation Safety Board to determine what caused this fatal accident. As INVESTIGATORs comb through the wreckage, they make a crucial discovery. The cockpit voice recorder is sent to NTSB headquarters for analysis. The CVR is especially important as the Hawker 700 isn't equipped with a Flight Data Recorder. In lieu of FDR data, the NTSB obtains valuable information from air traffic control. INVESTIGATORs find nothing unusual about the flight, until its last two minutes. INVESTIGATORs review the plane�s descent profile. They turn to the cockpit voice recorder to find out. INVESTIGATORs hear the sound of the engine thrust decreasing. Flight 1526 is now at 3,000 feet and flying straight towards Akron. But instead, the PILOTS get into a debate. INVESTIGATORs listen to the CVR to find out how two experienced PILOTS could so badly misjudge their situation. What INVESTIGATORs hear next shocks them. INVESTIGATORs finally understand why Flight 1526 descended at twice the recommended rate. The question is Why didn't he? While descending from 3,000 feet , the PILOTS begin their landing checklist. Instead of completing the checklist, the captain�s focus turns to the plane�s erratic descent. The cockpit voice recording makes it clear that the captain violated a fundamental rule of airmanship. As he scanned for the airport, he lost track of the plane�s speed. The NTSB reviews the PILOTS� employment and training records for the last five years. What they find shocks them. CAPTAIN CHAVEZ was dismissed because he failed to show up for training. INVESTIGATOR SATHYA SILVA calls the president of ExecuFlight. The NTSB investigation concludes that the problems on board the private jet began on the ground. Both crew members had poor training records, which their employer ignored. In its report, the NTSB makes several recommendations for private operators like ExecuFlight, including better training for PILOTS on non-precision approaches like the one into Akron, and the installation of flight data recorders that could monitor the progress of their flights. After a deadly turbo-prop crash in the North Carolina woods, INVESTIGATORs wonder why the PILOTS reacted quickly to some signals but ignored others. American Eagle Flight 3379 approaches Raleigh-Durham International Airport. In the cockpit, Captain Mike Hillis and First Officer Matthew Sailor prepare for landing. Ten miles from Raleigh-Durham, Flight 3379 is cleared to begin its descent. The crew reduces engine power. At 1500 feet , CAPTAIN HILLIS aborts the landing. Flight 3379 isn�t climbing, and it�s losing speed. Now it�s stalling. The plane is turning steadily to the left and veering further off course. The Jetstream plows through the dense woods of North Carolina. First responders are on the scene within minutes. There are only five survivors. Fifteen people, including the PILOTS, are dead. NTSB INVESTIGATORs are on site by morning. They quickly notice that the plane�s landing gear is extended. The team turns to the cockpit voice recorder, hoping to find an explanation for the unusual left turn. A flameout moments from touchdown should have prompted the PILOTS to take action. INVESTIGATORs need to find out why they didn�t. The cockpit voice recording from Flight 3379 suggests both PILOTS were unaware of the danger they were in. An ignition light has illuminated. The PILOTS have noticed it, but they are not taking any action. The CVR records more than voices. It also records the sound of the engines. They compare the engine sounds from Flight 3379 to other engines operating at a hundred percent. Both engines were operating at full speed. INVESTIGATORs wonder what action the PILOTS took to execute their go-around. But the PILOTS� failure to raise the gear or retract the flaps still can�t explain the accident. INVESTIGATORs turn to TEST PILOTS for help. They'll push a Jetstream 3201 to its limits to determine why the plane turned left on the go-around. They start by duplicating the configuration the PILOTS used for the missed approach. It�s the final piece of the puzzle. Believing his left engine had failed, the captain increases power to the right engine only. The power imbalance reduces airspeed and the lowered gear and extended flaps increase drag. The investigation digs into CAPTAIN HILLIS' pilot records. When INVESTIGATORs ask American Eagle about screening checks on Mike Hillis, they�re surprised at what they learn. The NTSB does what American Eagle never did. It requisitions Mike Hillis� file from his previous employer, Comair. It turns out other American Eagle PILOTS at Raleigh-Durham were well aware of Hillis' deficiencies. But was FIRST OFFICER SAILOR one of those co-PILOTS? INVESTIGATORs learn that Sailor was new to the route. If FIRST OFFICER SAILOR had known about his captain�s shortcomings, he would likely have paid more attention to his conduct during the approach. The crash of Flight 3379 reveals deep flaws in the hiring practices of US airlines. Background information on PILOTS is almost never shared amongst carriers. In its final report, the NTSB recommends that US airlines conduct thorough background checks on prospective PILOTS. In 1996, two years after the crash, the US Congress passes the �PILOTS Record Information Act� to ensure airlines have access to records from PILOTS� previous employers. In an aviation milestone, INVESTIGATORs sift through the wreckage from another careless approach. Guantanamo Bay � an isolated US Navy base that sits on the southeast coast of the island of Cuba. American International Airways Flight 808, a civilian DC-8 cargo plane, is on final approach to the Guantanamo airfield. On the flight deck are First Officer THOMAS CURRAN, Flight Engineer David Richmond, and Captain JAMES CHAPO. The DC-8 is turning towards the runway, but for some reason, it's banking steeply. The three injured PILOTS are transported to a hospital in Miami. Within hours of the accident, a team of INVESTIGATORs from the NTSB is on its way to Guantanamo. GREG FEITH is the lead INVESTIGATOR for the team. The black boxes are sent to the NTSB lab in Washington, D.C., for analysis. Feith interviews two NAVY PILOTS who witnessed the crash. When they talk to Air Traffic Control, INVESTIGATORs uncover an important piece of the puzzle. Twelve minutes before the crash, the crew made an unusual request. They asked to change from their assigned runway two-eight to runway ten or one-zero. Guantanamo has a single runway, with aircraft landing in either direction, two-eight from the east and one-zero from the west. Runway one-zero is closer to the Cuban border. To avoid Cuban territory, aircraft must approach from the sea and then make a sharp right turn. Why would the crew of Flight 808 choose the more difficult approach? INVESTIGATORs try to interview the PILOTS, but all three are in intensive care. Personnel records show that they were all highly experienced. The team reviews the plane�s flight data, which shows the plane�s exact approach path. But the steep bank hindered the plane�s ability to stay airborne. The cockpit voice recording from Flight 808 is finally available. The strobe light marks the base�s border fence with Cuba. It�s a visual warning so PILOTS don�t fly into Cuban air space. The CVR reveals why the captain chose to land on runway one-zero. Now the captain struggles to locate the strobe light that marks the Cuban border. The flight engineer comments that the plane is flying more than 10 knots too slow. But the captain isn't taking the hint. As he begins his critical final turn, he still can�t see the runway. He realizes he started the turn too late. To compensate, he makes the turn even steeper. The plane needs an airspeed of 147 knots to stay airborne in the tight turn. Suddenly, the stick shaker warning activates. It shakes the control column to alert the pilot of an imminent stall. He learns that the day before the crash, the crew started flying from Dallas-Fort Worth at midnight and flew all night. They crossed the country, before arriving back at their Atlanta base just before 8 am. That was supposed to be the end of the crew�s shift, but they were called back for one last flight. They were now expected to fly to Virginia, pick up cargo, then fly to Guantanamo, before returning to Atlanta. Could the lengthy duty time have impaired the PILOTS' performance, leading them to take greater risks? Mark Rosekind, the head of NASA�s Fatigue Countermeasures Program, is brought in to help. Rosekind discovers that the PILOTS' long workday wasn't the only reason they were fatigued. The crew experienced lack of sleep from two back-to-back nightshifts before the crash. The captain�s sleep debt was profound. He had only 15 hours� sleep in the previous 72. His behavior exhibits the symptoms of fatigue. What INVESTIGATORs have uncovered raises a disturbing question Why did a sleep- deprived crew, suffering from fatigue, accept the last-minute flight to Guantanamo? INVESTIGATORs are finally able to interview the crew members. The fear of job loss almost cost them their lives. INVESTIGATORs discover one final, tragic piece of the puzzle. The strobe light CAPTAIN CHAPO was searching for was not operational that day. There was no beacon to see. No one thought to tell the CONTROLLER that the strobe was down. In his final report on the crash of Flight 808, GREG FEITH emphasizes the central role played by fatigue. In the aftermath of the Flight 808 crash, the Federal Aviation Administration tightens regulations on crew sleep requirements. Airlines must now stay up to date on sleep and fatigue research. Managing rest times means PILOTS are less likely to make poor decisions. CAPTAIN CHAVEZ You�re going 120 . You can't keep decreasing your speed. FIRST OFFICER MARCHESE It�s more like 125 , which is the approach speed. JOHN NANCE That doomed them. PASSENGER Hey, what�s going on? CAPTAIN SASSE Why is that ignition light on? Did we just have a flameout? INVESTIGATOR The captain seems out of it MARY SCHIAVO They were just really flying sloppy NAVY PILOT Come on, come on, come on. Level off, man. Level off. NAVY PILOT He�s not gonna make it. DAVID LAWRENCE They could see that the needle was in the red band. BARRY STRAUCH That captain should not have been flying PASSENGERs under any circumstances. FIRST OFFICER MARCHESE Seventeen thousand feet . CAPTAIN CHAVEZ Roger. Seventeen thousand feet . Levelling off. PASSENGER Cheers! CONTROLLER Zipline 15-26, descend to 13,000 . Zipline is the call sign for ExecuFlight. FIRST OFFICER MARCHESE Heading? CAPTAIN CHAVEZ Two-forty-nine. AUTOMATED WEATHER REPORT Akron visibility, one and a half mist. Sky condition, overcast, six hundred broken. CONTROLLER Zipline 15-26, we do have another aircraft that�s inbound to the airport that is slower than you. CAPTAIN CHAVEZ Speed is one seven zero and 360. Zipline 15-26. CONTROLLER Zipline 15-26, the Piper is on the ground. You are cleared for localizer two-five approach. CAPTAIN CHAVEZ Cleared for localizer two-five. Thank you. Zipline 15-26. CAPTAIN CHAVEZ Ground! Keep going. Okay, okay! Level out now! FIRST OFFICER MARCHESE I got it. GPWS Pull up. Pull up. PASSENGER Hey, what's going on? GPWS Pull up. Pull up. CAPTAIN CHAVEZ No, no, no, no, no, no, no! Ah! EMERGENCY CALL We have a plane into a house. Heavy fire. We have a lot of wires down. NTSB INVESTIGATOR Yeah. It looks like the left wing hit first. DAVID LAWRENCE We found the angle of attack indicator in the cockpit wreckage. That's important because at a certain angle of attack the wing will stall. NTSB INVESTIGATOR What angle were you at? DAVID LAWRENCE They could see that the needle was in the red band. JOHN NANCE When the angle of attack indicates it's in the red, you're stalled. In other words, this wing was no longer flying. It�s as simple as that. NTSB INVESTIGATOR Get that to Washington. JIM SILLIMAN A turning point in our investigation came when our engineer was able to recreate our aircraft performance from the radar data � the angle of attack, the attitude, the altitude and rate of descent. NTSB INVESTIGATOR Look here. The speed drops to 130 knots and then it keeps dropping to 98 knots . No wonder they stalled. JOHN NANCE Airspeed is life. This is one of the most important points in flying any airplane but especially, especially a jet. NTSB INVESTIGATOR They level off at 9,000 , 5,000 , 4,000 . Look at that. They hold at 3,000 feet for an entire two minutes. That's way too long. And then they plunge steeply. DAVID LAWRENCE Once they started diving the airplane down to two thousand feet a minute to get to that lower altitude, that approach was unstable. They should have executed a go-around. JIM SILLIMAN We really wondered What is the situation in the cockpit at that time? CONTROLLER Zipline 15-26, we do have an aircraft inbound to the airport that is slower than you. FIRST OFFICER MARCHESE Okay. I'll have to drag everything. DAVID LAWRENCE Somebody lowered the landing gear to start slowing the airplane up and creating drag to hopefully get a little bit more spacing between them and the other airplane. NTSB INVESTIGATOR Did you hear that? NTSB INVESTIGATOR The airspeed drops from 170 down to 140 . That is way slower than he needs to be going. CONTROLLER Zipline 15-26, the Piper is on the ground. You are cleared for localizer two-five approach. CAPTAIN CHAVEZ Cleared for localizer two-five. Thank you. CAPTAIN CHAVEZ You�re going 120 . You can't keep decreasing your speed. DAVID LAWRENCE Once the co-pilot received the warning from the captain that they were too slow, the co-pilot should have increased thrust significantly. FIRST OFFICER MARCHESE No. 120 ? Where did you get 120 ? It�s more like 125 , which is the approach speed. CAPTAIN CHAVEZ But you've still got the flaps to go. FIRST OFFICER MARCHESE And when they go down... CAPTAIN CHAVEZ This is what I'm saying. If you continue decreasing your speed... FIRST OFFICER MARCHESE But why? CAPTAIN CHAVEZ Because we're gonna stall! I don't wanna stall! FIRST OFFICER MARCHESE How do we...? NTSB INVESTIGATOR Stop. They are so busy arguing about their speed that they forget to start their descent. CAPTAIN CHAVEZ You�re diving! Don't dive. You with me there? JOHN NANCE That delay of almost two minutes was critical. He's already too slow, and he's overflown the altitude he should be at, uh, and now they've got to chase the approach. Now he�s got to get the airplane down fast. NTSB INVESTIGATOR Okay. FIRST OFFICER MARCHESE Full flaps. NTSB INVESTIGATOR Full flaps at that speed? What was he thinking? Bring up the altitude graph again. NTSB INVESTIGATOR TWO Well hey, that's why the plane starts to drop like a rock. JIM SILLIMAN The airplane is too high, it's too slow, and with full flaps rather than partial flaps. And really that is our turning point when we said this airplane is not configured properly for the approach, and this puts the crew and PASSENGERs in really a lot of danger. NTSB INVESTIGATOR He should have just called a missed approach, tried again. NTSB INVESTIGATOR Let�s pick up where we left off, the start of the final descent. FIRST OFFICER MARCHESE Can you check if I've got everything? Ignition? CAPTAIN CHAVEZ Everything is all set. Standby. Yaw damper. Autopilot. Main air valves. NTSB INVESTIGATOR He just stops in the middle of his landing checklist. CAPTAIN CHAVEZ You�re diving. Don't dive. Two thousand feet per minute. Buddy. FIRST OFFICER MARCHESE Yeah. CAPTAIN CHAVEZ Two thousand feet per minute! Don't go two thousand feet per minute! You with me there? DAVID LAWRENCE This is the very serious portion of the approach. You're gonna go down into weather that's very low. NTSB INVESTIGATOR Why wouldn't he take over? DAVID LAWRENCE By having the first officer fly, this captain then was dividing his time being a captain and also being an instructor. We found he wasn't appropriately managing the cockpit as a captain. NTSB INVESTIGATOR They�re less than 500 feet off the ground. That's below their minimum descent altitude. DAVID LAWRENCE It�s critical that you do not descend below that altitude until you have a visual view of the airport or the runway. CAPTAIN CHAVEZ Ground! Keep going. JOHN NANCE If you don't see the field then you do a go-around. CAPTAIN CHAVEZ Okay. Level off now! FIRST OFFICER MARCHESE Got it! GPWS Pull up. Pull up. JOHN NANCE They�d been too slow for the last little while and they don�t recognize even with a stick shaker banging away that they are in an aerodynamic stall. GPWS Pull up. Pull up. JOHN NANCE That doomed them. CAPTAIN CHAVEZ No, no, no, no, no, no! Ah! SATHYA SILVA They broke so many rules it makes you wonder who trained them. SATHYA SILVA The captain�s termination notice says that he was fired from his last job. NTSB INVESTIGATOR Get this. The First Officer was terminated because his performance was below standard. So why did ExecuFlight hire these guys? SATHYA SILVA He had hired the captain because of his extensive experience in the Hawker aircraft, as well as flights that he had personally taken with the captain prior to his employment. The First Officer was hired based on a recommendation from another pilot, as well as one flight that he had taken with him personally. SATHYA SILVA He said they didn't contact their previous employers. ExecuFlight did give them CRM training. DAVID LAWRENCE Cockpit Resource Management training is teaching PILOTS to work as a team. SATHYA SILVA Not much of a training manual. DAVID LAWRENCE What we found was their training was insufficient, and their evaluation of the crew was not proper. JIM SILLIMAN We determined that ExecuFlight did not enforce and did not make sure that the PILOTS were following standard operating procedures. JOHN NANCE When something happens, order a cup of coffee if you can and think about it. You can do that much more clearly if everything you're doing is stable and you're on the same page. CAPTAIN HILLIS Okay. Can you do the descent checklist, please? FIRST OFFICER SAILOR Altimeter thirty, thirty-one, set, cross-checked. CAPTAIN HILLIS Thirty, thirty-one, set, cross-checked. DOUG TAUBER These were young PILOTS just starting off in their career. The PILOTS are flying a Jetstream 3201, a twin turbo-prop airplane designed for short flights. Flight 3379 took off at 6 pm from Greensboro, North Carolina. It�s a 35-minute flight to Raleigh-Durham airport. There are 18 PASSENGERs onboard. CAPTAIN HILLIS And gear down. FIRST OFFICER SAILOR Gear down. CAPTAIN HILLIS Flaps 20. FIRST OFFICER SAILOR Flaps 20. CAPTAIN HILLIS Why�s that ignition light on? Did we just have a flame-out? DOUG TAUBER Seeing the ignition light come on during approach would typically raise a concern. If combustion is interrupted for any reason, it's what PILOTS call a flame-out, or an engine failure. FIRST OFFICER SAILOR I'm not sure what's going on with it. If there is an engine failure, the PILOTS need to consider making a go around. CAPTAIN HILLIS Set max power. DOUG TAUBER When you have an engine failure, you not only lost half your power, you lose eighty percent of your performance. FIRST OFFICER SAILOR Lower the nose. Lower the nose! FIRST OFFICER SAILOR You got it? CAPTAIN HILLIS Yeah. DOUG TAUBER They�re unable to climb. They�re starting to lose directional control of the aircraft. FIRST OFFICER SAILOR Lower the nose! DOUG TAUBER Things are getting bad real fast and they�re running out of time. PILOTS Noooo! Ahh! Whoa! BOB MACINTOSH Do we know how the flaps were set? BARRY STRAUCH I'll check with our guy in the cockpit. Strauch here. What can you tell us about the flap selector? COCKPIT INVESTIGATOR The flap selector is fused in a 20-degree position. BARRY STRAUCH Copy that. BOB MACINTOSH The flap extension was also very interesting because it was in the landing configuration. BOB MACINTOSH So he�s four miles from the airport. He�s configured to land. What happened? BARRY STRAUCH According to this, he veers off course. BOB MACINTOSH He�s off to the left. Why? CAPTAIN HILLIS Okay. Can you do the descent checklist please? FIRST OFFICER SAILOR Altimeter thirty, thirty-one set, cross-checked. Pressurization set and checked. CAPTAIN HILLIS Why is that ignition light on? Did we just have a flameout? FIRST OFFICER SAILOR We lost the left one? CAPTAIN HILLIS Yeah. BOB MACINTOSH You would expect during that period that there would be some sort of confirmation. Nothing happened other than absolute quiet. We needed to try and figure out what was going on. BARRY STRAUCH These are the engine sound waves from when the ignition light went on. BOB MACINTOSH Call up the comparison. BOB MACINTOSH They�re almost identical. BOB MACINTOSH The ignition light must have misled the PILOTS into believing the left engine flamed out. CAPTAIN HILLIS We had a flame-out. BARRY STRAUCH He misdiagnoses the situation. BOB MACINTOSH Well surely he checks his engines� RPMs. FIRST OFFICER SAILOR What do you want me to do? Are you gonna continue? CAPTAIN HILLIS Okay. Yeah, I'm gonna continue. Just back me up. BARRY STRAUCH He�s not even checking to see if there�s an actual engine failure. BARRY STRAUCH If you don't know if you have an engine failure, but you�re responding to a potential engine failure, that�s not very good. And that could very easily cause an accident. CAPTAIN HILLIS Let's go missed approach. BOB MACINTOSH Okay. So how did they configure their plane for their missed approach? BARRY STRAUCH They set engine power to max. BOB MACINTOSH As they should have. What else? BARRY STRAUCH Uh there�s no mention of reducing the flaps to 10 or retracting landing gear. DOUG TAUBER A go around would be done by informing the other pilot, then apply max power, retract the gear, retract the flaps. BARRY STRAUCH Hard to believe that configuration caused the plane to veer to the left and crash. BOB MACINTOSH Well, there�s only one way to find out. BOB MACINTOSH We really wanted to figure out what the crew had introduced in the configuration that would make the aircraft deviate from this intended flight path. BOB MACINTOSH Okay. Let�s go max power. TEST PILOT Max power. BOB MACINTOSH Flaps to 20. TEST PILOT Flaps 20. BOB MACINTOSH Gear down. TEST PILOT Okay. Gear down. BOB MACINTOSH Okay. It�s a bit slower than a regular missed approach but it's still doable. Let�s do the same configuration but put max power on the right engine but not the left. TEST PILOT Max power right engine. Yawing to the left. I can't climb like this. CAPTAIN HILLIS Set max power. FIRST OFFICER SAILOR Lower the nose. Lower the nose! PILOTS Nooo! Whoa! BARRY STRAUCH The flight test told us an airplane with that configuration could not have been flown safely. It had to crash. BOB MACINTOSH If the captain thought one of his engines failed, they should have performed a single engine missed approach. He didn't do that either. BARRY STRAUCH To come across an accident where a response was botched as poorly as this one, it begs the question, how did he get there? BARRY STRAUCH Hmm. Look at this. A trainer�s evaluation. BOB MACINTOSH Oh well this is telling. He�s messing up single engine missed approaches. BOB MACINTOSH They did not go back and check with previous employers. BARRY STRAUCH Moody. Unpredictable. Gets distracted. Concerns about tunnel vision in an emergency situation. Did American Eagle know about this guy�s performance history? BOB MACINTOSH It doesn't look like they asked. BARRY STRAUCH That captain should not have been flying PASSENGERs. Under any circumstances. BOB MACINTOSH Co-PILOTS were whispering to their colleagues. It was something not normal. FIRST OFFICER SAILOR Lower the nose. Lower the nose! BOB MACINTOSH So was he based out of Raleigh? BARRY STRAUCH Uh no. He worked out of Miami. BARRY STRAUCH I think it was critical to this accident that the first officer was from a different base than the captain. BOB MACINTOSH This guy had no idea who he was flying with. TODD CURTIS Carelessness in the cockpit is usually not something that happens on a single flight only. It's usually a habit. Those habits form over time and if there's not proper oversight or some sort of check and balance, either in the cockpit or back in their training unit, then this could become the norm. In other words, their normal flying could be high risk flying. NAVY PILOT Here he comes. On ten. NAVY PILOT He�s not gonna make it. No way. GREG FEITH The wings go about 90 degrees relative to the horizon. The nose pitched down and the airplane struck the ground. JAMES CHAPO Yeah I, I don't remember the exact moment of hitting the ground, no. Yeah, we were fortunate. You know, the DC-8 they say was built to separate at the cockpit and cabin bulkhead, and sure enough that�s where it busted apart and we rolled, uh, ahead of the airplane. FIRST OFFICER CURRAN Can you move? CAPTAIN CHAPO Kind� yeah. THOMAS CURRAN My memory of the actual accident itself is gone. THOMAS CURRAN Please help us. THOMAS CURRAN I was told when the airplane hit the ground, a large boulder came through the cockpit by my rudder pedals and broke off the rudder pedals and, and severely damaged my legs. GREG FEITH All right, let's see what we've got. GREG FEITH Both black boxes coming your way right now. Nope. Both slightly damaged. Coming to you right now. GREG FEITH Well we�ve checked the entire site, correct, yeah. NAVY PILOT Come on, come on, come on. Level off, man. Level off. GREG FEITH Normally you don't wanna be turning more than about ten, twenty degrees on final approach. They watched this airplane as it went from 30 degrees to 40 degrees to 50 degrees, 60 degrees and they were really surprised. GREG FEITH It sounds like a wing stall. NAVY PILOT Yes, sir. It sure looked like it. GREG FEITH Yeah. GREG FEITH You understand how the aircraft struck the ground. Now you have to determine why. GREG FEITH So did you pick up anything unusual in your conversation with the PILOTS? AIR TRAFFIC CONTROLLER Connie eight-zero-eight, Guantanamo. Go ahead. THOMAS CURRAN Connie eight-zero-eight, requesting, uh, we�d like to make the approach for ten this afternoon. GREG FEITH Normally, airplanes land on runway two-eight. It�s more or less a straight-in approach, landing to the west. GREG FEITH Thanks very much. GREG FEITH You know that they can operate the airplane. So now the question is Why didn't they? GREG FEITH Okay, let's see the proper approach. So they started their turn too late and never recovered. GREG FEITH The pilot increased the bank trying to salvage that turn and get the airplane lined up. JOHN COX The amount of lift it's producing to hold the airplane in the air is compromised because the wings are at this high angle. GREG FEITH Now, all of a sudden, the airplane gets into an aerodynamic stall and because you're low to the ground, you don't have sufficient altitude for proper recovery. GREG FEITH Why did they start that turn so late? CONTROLLER Connie eight-zero-eight, you are required to remain within the airspace designated by a strobe light. FLIGHT ENGINEER RICHMOND Are they giving us two-eight? FIRST OFFICER CURRAN Yeah, if it's available. CAPTAIN CHAPO Ought to make that one-zero approach, just for the heck of it and see how it is. If we miss it, we'll just come back around and land on two-eight. GREG FEITH For the heck of it? That's why he�s landing on runway 10? GREG FEITH You don't just do things for the heck of it in an airplane of that size. INVESTIGATOR The captain seems out of it. CAPTAIN CHAPO Where�s the strobe? FLIGHT ENGINEER RICHMOND Right over there. CAPTAIN CHAPO Where? FLIGHT ENGINEER RICHMOND You know, we�re not getting our airspeed back there. FIRST OFFICER CURRAN Do you think you�re gonna make this? GREG FEITH The first officer and the flight engineer, they only challenged the captain, um, by what I call hinting and hoping, where they would throw out a suggestion. Do you think we're gonna make this?" CAPTAIN CHAPO Yeah, if I can catch that strobe light. FLIGHT ENGINEER RICHMOND Watch. Keep your airspeed up. FIRST OFFICER CURRAN 140 ! FIRST OFFICER CURRAN Stall warning! FLIGHT ENGINEER RICHMOND Stall warning! GPWS Pull up! FIRST OFFICER CURRAN Max power! CAPTAIN CHAPO I got it! Back off! FIRST OFFICER CURRAN There it goes! CAPTAIN CHAPO No! No! No! No. INVESTIGATOR He completely tuned out his crew. GREG FEITH We knew that there was some bad decision-making going on in this particular cockpit and the question was why? GREG FEITH searches for clues in the duty rosters and pilot logbooks of the DC-8�s crew. CAPTAIN CHAPO Thank you. FLIGHT ENGINEER RICHMOND Mm hmm. CAPTAIN CHAPO Guantanamo Bay, here we come. FIRST OFFICER CURRAN Nothing more I'd rather do. By this point, each crew member has been awake for about 15 hours. MARK ROSEKIND We knew that fatigue was a risk, so we knew bad stuff was already going on in-flight. The key was how do you demonstrate fatigue actually played a role in that crash? MARK ROSEKIND They were all sleep deprived. MARK ROSEKIND When you lose sleep, it actually builds into what's called a sleep debt. And you should think about that just like a bank account. It's like going in the red. MARK ROSEKIND One was what we call cognitive fixation. The captain just got stuck on finding a strobe light. CAPTAIN CHAPO Where�s this strobe? GREG FEITH What have we got over here? CAPTAIN CHAPO I was tired. We were all tired. GREG FEITH You didn't have to accept the flight. CAPTAIN CHAPO Technically no, but we didn't really have a choice. JOHN COX The cargo industry is notorious as being a cut-throat industry. They will push the crews routinely to the edge of duty time limits. GREG FEITH There is this fear of intimidation and the loss of a job, that if you don't do it, I'll find somebody that will. FIRST OFFICER CURRAN Stall warning! FLIGHT ENGINEER RICHMOND Stall warning! FIRST OFFICER CURRAN Max power! CAPTAIN CHAPO I got it! Back off! FIRST OFFICER CURRAN There it goes! THOMAS CURRAN At the very end, things happened very rapidly. We were too low, and our reactions were too slow. JIM CHAPO And I should've turned it over to Tom, but I was already, uh, just sort of out, out of it. FIRST OFFICER CURRAN No! CAPTAIN CHAPO No! No! JAMES CHAPO It still� still gets to me �cause it still boils down to the captain. You know, the captain made a mistake and that's a hard thing to live with all the time. GREG FEITH So now they're trying to find something that doesn't exist and when they saw something flash out there, which they thought was the strobe, it was actually the tin roof on a little cabana. GREG FEITH This accident was precedent-setting. It was the first commercial aviation accident actually caused by fatigue, and the industry took notice. MARY SCHIAVO When you're approaching a landing if you don't feel that you have it all lined up, don't do it. Go around. Get your head together and make sure you're ready to do it. Because it's the most dangerous time of your flight.