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00:00I remember being amazed at how quickly the accident took place.
00:05They were fine, and the next thing you know, the airplane's lost.
00:11Midwest Express Flight 105 crashes.
00:14Seconds after taking off from Milwaukee, Wisconsin, all 31 people on board are killed.
00:21And what do you say to the public about the crashes that we've been having?
00:251985 becomes one of the deadliest years in civil aviation.
00:30It's up to investigators to put the public at ease.
00:33This is how the plane hit the ground.
00:36When they examine the engines, they find a component prone to failure.
00:41Well, when we heard that this part had failed 45 times before, it's a big deal.
00:47But the flight data turns the investigation on its head.
00:51The ruptured red engine didn't bring down this plane.
00:54It did not.
00:55There are 27 passengers boarding Midwest Express Airlines Flight 105,
01:23a cross-country commuter flight from Milwaukee to Atlanta.
01:28Many are employees of the manufacturer Kimberly Clark.
01:33Midwest Express Airlines used the slogan, best care in the air,
01:37and they really meant it because they had as close to an all-business aircraft as you could have.
01:45Treats for when we're airborne.
01:46And they also baked fresh cookies on board and made the place smell amazing when you walked on.
01:59Mid-X 105 requesting IFR clearance to Atlanta.
02:04Both pilots on this flight are captains with the airline.
02:08They've already flown two flights together today.
02:10Mid-X 105, clear to Atlanta.
02:17Climb and maintain 5,000.
02:20Climb and maintain 5,000.
02:22Mid-X 105.
02:23For this leg of the flight, Danny Martin will be the acting captain and Bill Weiss, the first officer.
02:30We had two captains, and they literally could switch seats because of that.
02:36And they did do that over the course of two days,
02:39flipping out who was the pilot flying and who was the pilot not flying.
02:42Our alternate will be DCA if we can't make Atlanta.
02:48There are thunderstorms in Atlanta,
02:50so the crew has taken on additional fuel in case they have to divert to another airport.
02:57Takeoff weight is 771, 22 pounds.
03:00Set stab trim to 2.2.
03:06Just past 3 in the afternoon, the pilots start the engines.
03:10The DC-9 used for today's flight is powered by two Pratt & Whitney engines,
03:23mounted on the fuselage at the rear of the plane.
03:28Because the engines were in the back, they were close together,
03:33which made for a little bit easier flying in emergency situations.
03:37Second of all, for the passengers, it's quieter.
03:41Thank you.
03:44Can I put that up here for you?
03:47Thank you.
03:49The plane is loaded and ready to depart on schedule.
03:57Airspeed bug, 1.33 set, and 1.9 on the EPR.
04:02Okay.
04:02Okay.
04:07Ladies and gentlemen, we are number one for departure,
04:13so we should be airborne within one minute.
04:16Flight attendants, please be seated.
04:23Mid-X-105, clear for takeoff.
04:27Mid-X-105.
04:32Here we go.
04:35It's pulling up.
04:35This was a very normal morning for a very normal flight.
04:44It was a gorgeous blue sky, September day.
04:48There was a little bit of gusty winds, but it was nothing for Milwaukee.
04:55Power normal?
04:58100.
04:59The pilots need to reach a speed of 127 knots for takeoff.
05:06V1.
05:08Rotate.
05:13At 3.21 in the afternoon, flight 105 begins its journey.
05:19The flight plan calls for the plane to climb to an altitude of 33,000 feet for the two-hour trip to Atlanta.
05:35Gear up.
05:37Just 450 feet above the ground.
05:40The pilots lose power in one of the engines.
05:52It's a critical situation because if you don't do something about it immediately, you won't have time to do anything about it.
06:00Altitude is your friend.
06:01Mid-X-105.
06:08Turn left heading 175.
06:13What do we got here, Bill?
06:16Here.
06:18Mid-X-105, Roger.
06:20We got an emergency here.
06:24Mid-X-105, Roger.
06:26The plane begins rolling to the right and dropping.
06:35Oh, crap.
06:38The DC-9 is stalling.
06:42Get your heads down.
06:51Heads down!
06:52Heads down!
06:56Less than a minute after take-off, flight 105 is diving towards the ground at more than 170 miles an hour.
07:15The plane hits the ground, less than 1,700 feet from the runway.
07:20A DC-9 has crashed southwest of runway 1, 9, right.
07:35All 31 people on board have been killed.
07:38The crash of Midwest Express Flight 105 is the third major accident in the United States this year, and the eighth accident worldwide.
07:53With more than 1,200 people killed, this is becoming one of the deadliest years in the history of civil aviation.
08:01Passengers are unnerved.
08:02Everyone says, my God, another one.
08:06What do you say to the public about the crashes that we've been having?
08:09Well, insofar as the National Transportation Safety Board is concerned, we are sparing no effort to determine the cause of each one of them,
08:15and we will make the necessary recommendations to keep any repeat of any one of them from happening.
08:19And what do you tell them about...
08:19Can you show me where it started to bank?
08:27Investigators from the NTSB begin by interviewing witnesses of Midwest Express Flight 105's fatal dive.
08:35They either came forward or we tracked them down.
08:38We ended up making out a questionnaire with 40 or 50 questions on it to kind of cover all the bases.
08:46Okay, got it.
08:47Okay.
08:49While the witness accounts differ in detail, they all describe more or less the same thing.
08:58I saw a couple puffs of black smoke come out, and I just figured that they had gunned the engines a little bit.
09:05Instant later, the left wing rose up, and it tipped over and went nose first into the trees here.
09:11Most of the witnesses agree that takeoff appeared normal until the airplane was about 300 feet off the ground.
09:22Almost all report smoke and fire coming from the right engine.
09:27Several remember hearing loud bangs.
09:29Most said that the plane then rolled abruptly into a steep right bank, went into a nose-low spin, and crashed.
09:36The value of having so many witness statements to look at, they gave us a picture of what happened right at the end.
09:48A loss of control, fire, and of course the impact itself.
09:54Investigators must now determine what could have caused such a catastrophic loss of control so soon after takeoff.
10:02After securing the crash site of Midwest Express Flight 105, investigators begin mapping the wreckage field.
10:23I think the whole length of the impact site was about 295 feet, not much more than two times the length of the airplane.
10:32So the airplane hit pretty steeply and didn't go very far.
10:38Right wing tip here, and the horizontal stabilizer here.
10:45This is how the plane hit the ground.
10:47It's a 90 degree right roll and a right yaw.
10:56Can you grab a picture?
10:58Got it.
11:00The wreckage path confirms eyewitness reports.
11:03Right.
11:04It very definitely indicates right up front that you've got a lost control.
11:08It doesn't suggest why you had the lost control.
11:11It kind of opens the door to a lot of different investigative avenues.
11:14Yeah, it's fire damage for sure, but it looks like all the pieces are here.
11:24Investigators study the plane's control surfaces, starting with the ailerons.
11:30The ailerons on each wing direct the plane's roll.
11:33If an aileron malfunctions and gets stuck in one position, it could cause a devastating lack of control.
11:44Control tabs are in place.
11:46They seem to be intact.
11:49We didn't find a problem with other components that are part of that system.
11:54With the ailerons ruled out, investigators turn their attention to the rudder system.
12:03Dampers are still working.
12:05Hinges are intact.
12:08The fractures look like overload, not stress.
12:13I don't think the rudder is our culprit.
12:15We didn't find anything wrong with any of the control systems based on that preliminary look-see.
12:25Could the engines provide insight into the crash of Midwest Express Flight 105?
12:31If the engines were, well, obviously banged up, they were fire damaged,
12:36and they were along the wreckage path, which is always good,
12:39and that means they didn't fall off somewhere earlier.
12:46There's a spacer missing here.
12:53Most of the blades from this stage are gone.
12:57The team finds damage inside the right engine that could not have been caused on impact.
13:03The missing engine pieces include a spacer
13:07and the compressor blades from the 9th and 10th compressor stages.
13:14They're found more than half a mile from the main wreckage site.
13:18Finding any part of the airplane short of where the airplane had crashed
13:23was a suggestion of a malfunction or failure that had occurred in flight
13:27and required further investigation.
13:30The engine and the pieces are moved to a nearby warehouse
13:35where they can be more closely examined.
13:37In the end, we ended up finding about 90% by weight of the spacer,
13:43so that was a big boon to the investigation.
13:47Investigators study the recovered spacer
13:49to determine why it failed on Midwest Express Flight 105.
13:55All on the pedestal here.
14:00It's definitely not overstress.
14:03They discover a tell-tale crack on the spacer
14:06that appears to have spread over time,
14:09what's called progressive cracking.
14:12There may be stress marks, there may be cracks,
14:16there may be things that suggest a direction of failure
14:19and a time frame where the fracture would have occurred.
14:23It doesn't occur all at one time.
14:24Can we determine how long that crack has been spreading for?
14:29I'll see what I can do.
14:32We became interested not just in detailing that,
14:36but trying to find whether this was a fracture
14:39that could have been detected previously.
14:41A closer look at the crack on the steel spacer
14:44reveals it's filled with nickel.
14:46A lightweight nickel coating is applied to certain vital engine pieces
14:52like the compressor spacers and blades to prevent corrosion.
14:58The compressor was brought in to be refurbished in 1981.
15:03Coating stripped, spacer examined, and...
15:06Oh, here we go.
15:09Re-plated.
15:11That was four years ago.
15:13The maintenance records tell investigators
15:16that work had been done on the spacer
15:18that failed on Midwest Express Flight 105.
15:22Nickel-cadmium plating
15:24is the last step of the refurbishment process
15:27that would have been done by the maintenance facility
15:31that was involved with, essentially, the overhaul of that part.
15:34Four years before the accident,
15:37the spacer was removed from the engine,
15:39stripped of its coating, and examined for cracks.
15:43The inspector reported no cracks
15:45and sent the part to be replated with nickel.
15:48Since nickel was found inside the crack,
15:51it must have been present when the nickel was applied.
15:58The DC-9 flew about 2,500 flights over the next four years
16:03with the damaged spacer
16:04until it finally ruptured on Flight 105.
16:11It should have been caught during an overhaul,
16:14but it wasn't,
16:15and so the crack kept growing and growing
16:17until it finally hit its failure point.
16:22Investigators wonder what caused the crack
16:24to form on the spacer in the first place.
16:26These spacers have been used inside the JT-8D
16:30for more than 20 years.
16:32This can't be the first one to break.
16:37There are identical spacers
16:39in more than 14,000 JT-8D engines
16:42used on airplanes around the world.
16:45Is there any history of similar failures?
16:47It turns out that Pratt and Quibby
16:50were well aware of spacer failures
16:52that occurred before,
16:54so we started to wonder,
16:56what have they done about it?
17:02Seems to happen a lot.
17:05While researching spacer issues in other aircraft,
17:09investigators uncover 45 similar failures
17:12prior to Midwest Express Flight 105's accident.
17:16Well, when we heard that this part
17:18had failed 45 times before,
17:21we kind of looked askance a bit
17:23at the manufacturer,
17:24and that's a big deal.
17:27But of all the failures uncovered by the NTSB...
17:31Not a single loss of aircraft
17:33or even a single injury.
17:36Well, that says something.
17:38In every previous incident,
17:40the plane landed safely.
17:42So why did the rupture of a spacer
17:45on Flight 105 cause the plane
17:47to become uncontrollable and crash?
17:52Well, we knew that none of the previous failures
17:54had led to an accident,
17:55so one of the questions was
17:57what made this one different?
17:59Let's see what got hit.
18:03Investigators consider the possibility
18:04that pieces of the ruptured spacer
18:07on Flight 105
18:08punctured the plane's fuselage
18:10and damaged vital control systems,
18:13such as cables or hydraulic lines.
18:17When a part like a spacer
18:19or a fan disc
18:20breaks under a lot of stress,
18:25it's almost like a small explosion going off.
18:28You have fragments of metal
18:30flying at very, very high speeds.
18:33Okay, let's see 894.
18:39They study the location and pattern
18:41of all the puncture marks
18:42found on the skin of the plane
18:44to see if any were near vital control links.
18:48No control cables, no hydraulics.
18:541012.
18:55No control cables, no hydraulics.
19:05What about the pieces of the plane
19:07that we haven't been able to find?
19:09There are many critical pieces of the plane
19:12that have not been recovered
19:13or are too badly damaged to study.
19:17Is it possible to figure out
19:19if they could have been hit
19:20by the engine pieces?
19:21We have what we need
19:24to run a trajectory analysis.
19:27All right.
19:29We were looking at
19:30could these parts
19:31that have left the engine
19:33strike a control surface
19:36or the hydraulic system
19:37or anything else
19:40where they could have done
19:41secondary damage
19:41that would have compounded
19:43the situation the pilots were facing.
19:46Knowing the plane's velocity,
19:48angle of ascent
19:49and the wind speed
19:51at the time the engine failed,
19:53the team calculates
19:54the path of debris
19:55ejected from the engine.
19:58The smallest piece we found
20:00was about half an ounce.
20:02The largest piece
20:03was just over a pound.
20:04So everything moves away
20:06from the plane,
20:07nothing hits it.
20:08The trajectory analysis
20:10tells investigators
20:11that none of the ejected
20:13engine pieces
20:14would have struck the airplane
20:15with enough force
20:16to cause substantial damage
20:18to the control systems.
20:20The analysis indicated
20:22that it was so unlikely
20:25that we considered it
20:27an impossibility,
20:28that those parts
20:29leaving the engine
20:30in the direction they went
20:31and the size
20:32that they had
20:33could have caused
20:35secondary damage
20:36that would cause lost control.
20:37If spacer fragments
20:41didn't hit vital components
20:42and cause the loss
20:43of control,
20:44perhaps the initial
20:46explosive force
20:47opened the cowling
20:48or engine cover,
20:50affecting the plane's
20:51aerodynamics.
20:52If the cowling
20:54had been blown open,
20:56it would cause
20:57a lot of drag,
20:58it might cause
20:59the airplane to roll,
21:01it might cause
21:02the airplane
21:02to become uncontrollable.
21:05There's a hole
21:05in the cowling,
21:07it looks to be
21:07about two square inches.
21:09The team finds evidence
21:11that the cowling
21:12was pierced
21:13by fragments
21:14ejected from the engine.
21:16But all four latches,
21:19one, two, three, four,
21:20they're all latched.
21:22Can't have opened
21:23in flight.
21:26They found them all
21:27either latched
21:28or fully intact
21:29with no damage at all.
21:31So that scenario
21:32kind of went out the window.
21:35So the ruptured red engine
21:37didn't bring down this plane?
21:39It did not.
21:43Well, reasonably early
21:44in the investigation,
21:46the team figured out
21:47that a spacer had failed
21:48and the engine had failed.
21:49and now we had
21:51the rest of the accident
21:52to figure out.
21:54Why would that cause
21:55a crash?
22:00Investigators examine
22:01Midwest Express Flight 105's
22:03flight data recorder
22:04in hopes of understanding
22:06how the loss
22:07of the right engine
22:08caused the death
22:09of 31 people.
22:11It doesn't give us much,
22:13but it's all
22:13we've got to work with.
22:14It was only recording
22:16four flight parameters.
22:18It had airspeed,
22:19altitude,
22:20heading,
22:21and vertical acceleration.
22:24Right here,
22:26a sudden deceleration
22:27at 450 feet.
22:28This must be
22:29where the right engine failed.
22:30Well, that's consistent
22:31with what the witnesses
22:32told us.
22:32The engine failure
22:36we know
22:37occurred
22:38above the airport,
22:39so the airplane
22:40had only been airborne
22:41for a few seconds.
22:44But
22:45the heading doesn't change
22:47when the engine fails.
22:48They must be
22:48applying left rudder
22:50to compensate.
22:52Oh,
22:52dead right engine,
22:53left rudder.
22:53That's the right move.
22:54When the right engine fails,
23:00the remaining engine
23:01should force the plane
23:02to the right.
23:03To counteract that,
23:05a pilot would apply
23:06left rudder
23:06to keep the plane
23:07flying straight.
23:15What the hell was that?
23:17The data shows
23:18that's precisely
23:19what Captain Martin did
23:20in response
23:21to Flight 105's
23:23engine failure.
23:24After a few seconds,
23:26they start this
23:26yaw to the right.
23:28So,
23:28right rudder?
23:31Four seconds
23:32after the failure
23:33of the right engine,
23:35the FDR data
23:36indicates that
23:37the pilot
23:37moved the rudder
23:39from left
23:39to right.
23:41That forced the plane
23:42into a sudden
23:43yaw to the right.
23:47He's in a side slip.
23:49He's deviating
23:50further and further
23:51to the right.
23:52and then he starts
23:55to lose altitude.
23:57Huh.
23:58148 knots.
24:01He's in a high-speed stall.
24:04How'd they let that happen?
24:05You went into a right skid
24:10and then followed by
24:12an abrupt right turn
24:13and dive.
24:13That would be consistent
24:15with a stall,
24:16but the air speeds
24:17indicated
24:18were high enough
24:20that you wouldn't
24:20normally have
24:21a stall
24:22at those speeds.
24:24Clearly lost control
24:26of the plane.
24:27Five seconds later,
24:28they hit the ground.
24:28The flight data
24:32tells investigators
24:33that it took
24:34only 10 seconds
24:35for the pilots
24:36to lose control
24:37of the plane
24:38after the failure
24:39of the right engine.
24:40I have never seen
24:44an accident sequence
24:45that brief
24:47before or since.
24:52So,
24:53he responds
24:54correctly at first
24:55with left rudder
24:56and nose down pitch.
24:58Then he inexplicably
25:00switches to right rudder?
25:01And that's what leads
25:02to the yaw,
25:03the right roll,
25:03and the eventual stall.
25:05Right rudder,
25:06it makes no sense.
25:07It was clear
25:09from all the data
25:10that the pilot
25:12didn't understand
25:13what happened.
25:13He responded
25:14inappropriately,
25:16and within seconds
25:17the airplane was lost
25:18and everybody on board
25:19was killed in the accident.
25:21Was there something
25:23about the DC-9's
25:24handling characteristics
25:25that led the pilot
25:27to input the right rudder?
25:29So,
25:30it was relatively easy
25:31to control then?
25:35Just with the control wheel?
25:37Investigators interview
25:40DC-9 pilots
25:41to determine
25:42how the plane handles
25:44with only one engine.
25:45The DC-9 pilots
25:46that we talked to,
25:47it was overwhelmingly
25:47described as a very
25:49easy, docile aircraft
25:51to handle
25:51in those situations.
25:53Oh,
25:54this has been
25:54extremely helpful.
25:55Thanks.
25:56Okay.
25:56Bye.
25:58They all say
25:59the same thing.
26:00It's no big deal
26:02with one engine.
26:02Because the DC-9's
26:07engines are mounted
26:08on the fuselage
26:09instead of the wings,
26:11when one engine fails,
26:12it does not force
26:13the plane
26:14into a severe turn.
26:15DC-9 is almost
26:17a centerline
26:17thrust aircraft,
26:19so if you lose
26:20one engine
26:21on either side,
26:23there's not that much
26:25excess yawing
26:26or controllability
26:27problems at all.
26:28How easy is it
26:32to handle
26:32a DC-9
26:33in the situation
26:34the pilots
26:35of Flight 105
26:36found themselves in?
26:38It was valuable
26:40to do a simulation
26:42or test flight
26:43to get a better idea
26:45of exactly
26:46how the airplane
26:47performed
26:48under the circumstances
26:49of the accident,
26:51but at a higher altitude.
26:55Okay.
26:56When we get to
26:5710,000 feet,
26:57I'm going to cut
26:58power to the right,
26:59leaving the left
26:59at takeoff power.
27:01Keep the flaps at 20,
27:02target speed is 170 knots.
27:06They tried to match
27:07the parameters
27:08of the airplane
27:08in terms of the flaps,
27:10gear,
27:11and airspeed,
27:13and then
27:14proceeded to
27:16cut the engine power.
27:18Okay.
27:19Cutting power.
27:20Okay.
27:28Let's go around
27:32for another.
27:32Flight demonstrations
27:35showed that
27:36the pilot
27:37didn't have to
27:38input rotor at all.
27:40If he had only
27:41used the ailerons,
27:42he could have
27:42safely fallen out of it.
27:45Okay.
27:45This time,
27:46no reaction.
27:47Let's see what
27:48the plane does.
27:50With no input
27:51from the pilot
27:52after the loss
27:53of the right engine,
27:54the plane rolls right
27:56and the nose drops.
28:01Okay.
28:02You can recover.
28:05Even with no
28:06immediate action,
28:07the pilot is easily
28:09able to recover
28:09the plane.
28:13Okay.
28:15I think we have
28:16what we need.
28:17That may have actually
28:18been the best thing
28:19to do,
28:19was to do nothing,
28:22watch the airplane's
28:23response,
28:24understand the airplane's
28:25response,
28:25and respond appropriately
28:26to the nature
28:27of the emergency.
28:31What the hell was that?
28:34If the DC-9
28:35is so easy to control,
28:38why were two
28:38experienced pilots
28:40unable to recover
28:41from the loss
28:42of their right engine?
28:48Okay.
28:49We know they were
28:49both captains
28:50with the airline,
28:51but how much experience
28:52did they actually have?
28:54Investigators look
28:55into the backgrounds
28:56of the pilots
28:57of Midwest Express
28:58Flight 105
28:59to understand
29:00why they didn't recover
29:02from a single engine failure.
29:04Neither had a lot
29:05of turbojet experience.
29:07One was upgraded
29:08to captain
29:08with 600 hours
29:10on the DC-9
29:11and the other
29:11with only 500.
29:13Doesn't seem like
29:14a whole lot.
29:16Advancement to captain
29:17happened within a year
29:18for both of these pilots
29:20at Midwest Express Airlines
29:22at that time.
29:24And the reason why
29:26was it was a small airline,
29:28it was growing quickly,
29:30they were adding airplanes.
29:31They consult large U.S. airlines
29:35to determine their qualifications
29:37for an upgrade.
29:40Okay, thanks.
29:43That's the same
29:43for both airlines.
29:45Ten years seniority
29:46and 7,500 hours
29:48as DC-9
29:48first officer
29:49to be considered
29:50for an upgrade.
29:50while the pilots
29:56may have been experienced,
29:58neither had spent
29:58much time piloting
30:00the DC-9
30:01before they were
30:01promoted to captain.
30:02The more experience
30:05someone has
30:05exercising command,
30:07the more likely
30:07they are
30:08to exercise that command
30:10in situations
30:10that call for
30:11calm thinking,
30:13for rational response
30:14and so on.
30:14So how much training
30:18did these guys get
30:19on engine failures?
30:21To understand
30:22why the pilots
30:23of Flight 105
30:24were not able
30:25to control their plane
30:26following an engine failure,
30:28investigators look
30:29at their training records.
30:31What was their experience?
30:33What kind of pilots
30:34were they?
30:34How did they respond
30:35to unusual events?
30:37Did they seem self-confident?
30:40How well did they work together?
30:43Okay.
30:44So the captains
30:47practiced 12
30:49engine failures
30:50on takeoff
30:50in the simulator.
30:52First officer,
30:5415 sessions.
30:56They discover
30:57that both pilots
30:58had been extensively trained
31:00to cope with
31:01engine failure
31:01on takeoff.
31:04Precisely the type
31:05of emergency
31:05they faced
31:06on Flight 105.
31:08But what exactly
31:09were they taught?
31:12We looked very closely
31:14at the training
31:14these pilots received
31:15and interviewed
31:17the flight instructor
31:18who oversaw
31:19their training
31:20in the DC-9
31:20from Indus Express.
31:23Tell me what you can remember
31:25about Captains Martin
31:27and Weiss.
31:30They were both
31:31excellent pilots.
31:33Trained in proficiency.
31:35Lots of simulator training
31:38on engine failure.
31:39You bet.
31:40We ran them
31:41through all sorts
31:42of scenarios.
31:45Let's focus
31:46on takeoff
31:47with simulated
31:48engine failure.
31:49What were they taught?
31:50Pay attention to your
31:57yachts,
31:57your best cube.
32:01Yowing right.
32:03Flying left
32:03rudder.
32:05Control wheel
32:06is needed.
32:07Keep the plane level.
32:09Nice and easy.
32:11It's a good job.
32:12Got it.
32:14Captain Martin
32:15was trained
32:16to pay close attention
32:17to the plane's
32:18yawing motion
32:19when identifying
32:20and correcting
32:20an engine failure.
32:23Looks like they had
32:24excellent training.
32:26Thanks for the insight.
32:29We found the instructor
32:31to be very capable
32:33and very dedicated
32:35and we found
32:35the simulators
32:36to be okay
32:37for that time.
32:41If Captain Martin
32:43was extensively trained
32:44to cope with engine failure
32:46on takeoff,
32:47why didn't he do
32:48what he was trained
32:49to do?
32:53Most of their training
32:54was for an engine failure
32:55at takeoff.
32:57Pretty easy to identify
32:58which way you're yawing.
33:00Yeah.
33:01Investigators consider
33:02the timing
33:03of the engine failure.
33:04If you're closer
33:05to the ground,
33:06there are much more
33:06visual cues available
33:08from the ground
33:09to see what the airplane
33:10is encountering.
33:12Not so easy
33:14when you're already
33:15in a steep climb.
33:16Right.
33:18As Flight 105
33:20was climbing,
33:21only blue sky
33:23would have been visible
33:23to the pilots,
33:25making it more difficult
33:26to identify
33:26the direction
33:27of the yaw.
33:28What the hell was that?
33:34With no outside
33:35visual cues,
33:37investigators believe
33:38Captain Martin's
33:39initial response
33:40was a spontaneous reaction
33:42to the plane's
33:42changing motion
33:43and not the result
33:45of an analysis
33:45of the situation.
33:46But what triggered
33:48the incorrect
33:49rudder application
33:50a few seconds later
33:51that resulted
33:52in a total loss
33:53of control?
33:56All right.
33:57Let's see what
33:57these guys are doing.
34:04X-105,
34:05clear for takeoff.
34:07Red X-105.
34:09Here we go.
34:14Investigators pin
34:15their hopes
34:15on the CVR
34:17to explain
34:17Captain Martin's
34:18actions.
34:21Spilling up.
34:23Power normal.
34:27100.
34:32V1.
34:34Rotate.
34:38Gear up.
34:39What was that?
34:44Stacey.
34:45Mid X-105.
34:47Turn left heading
34:48175.
34:49What do we got here,
34:50Bill?
34:51Here.
34:53Mid X-105,
34:54Roger.
34:55We got an emergency
34:56here.
34:59Mid X-105,
35:00Roger.
35:01Oh, crap.
35:03Head stop.
35:04Head stop!
35:05Oh!
35:05Oh!
35:09I've never heard
35:13an accident unfold
35:14so quickly.
35:16Holy smokes.
35:18And I remember
35:19just being amazed
35:20how quickly
35:21the accident took place.
35:24It was like
35:24they were flying.
35:26You hear the engine fail.
35:29And the next thing
35:30you know,
35:30the airplane's lost.
35:33Okay.
35:34So what did we hear?
35:36It sure happened fast.
35:38Yep.
35:3915 seconds
35:40from the sound
35:40of the engine
35:41exploding
35:41to the end
35:42of the recording.
35:44Astonishing.
35:50What else?
35:52What was that?
35:53What have we got?
35:54The captain
35:55seemed
35:55uncertain.
35:58Agreed.
36:03What have we got here,
36:04Bill?
36:04Well, it was clear
36:06from the cockpit
36:08force recorder
36:09that the pilot
36:10didn't recognize
36:11what had happened.
36:13He articulates that.
36:14What was that?
36:15What do we got here, Bill?
36:19What the hell was that?
36:21The sound of the engine,
36:23the sensation
36:24of the right yaw,
36:25and the instruments
36:26should have told
36:27Captain Martin
36:28that he was dealing
36:29with a failure
36:29of his right engine.
36:31anything else
36:34on that tape?
36:36Not a lot
36:37of troubleshooting
36:38or communication
36:39between them, really.
36:42Actually,
36:43none.
36:50What have we got here, Bill?
36:54Here.
36:55Mid-X 105,
36:56Roger.
36:58We got an emergency here.
37:01Investigators hear
37:02Captain Martin
37:03asking his first officer
37:04for assistance
37:05in assessing the situation,
37:07but First Officer Weiss
37:08never replies.
37:10That was troubling to me
37:12because I would have expected
37:15that in an emergency situation
37:17and especially
37:18when asked
37:19for help,
37:21that the other crew member
37:23would have helped
37:24if he could.
37:24so
37:26it prompted
37:27some further
37:28investigation.
37:31Okay,
37:31let's start with that.
37:33Why was the captain
37:34confused about
37:35what had happened?
37:36It should have been obvious.
37:414,600 flight hours,
37:43but he's never experienced
37:44an actual engine failure.
37:46NTSB investigators
37:47looking into the crash
37:48of Midwest Express
37:49Flight 105
37:50have learned
37:51that Captain Martin's
37:52only experience
37:53with a single engine failure
37:55was in a simulator.
37:57Yaw and deceleration
37:58don't feel the same,
38:00plus all the sounds
38:00are different.
38:02It's not the same
38:02as the real thing.
38:04It was a catastrophic
38:05engine failure
38:05where they had thrust
38:06and then they didn't.
38:07It was immediate.
38:09I don't think
38:10they were trained
38:11in that kind of scenario.
38:14What have we got here, Bill?
38:16The limitations
38:17of the simulator
38:18may explain
38:19Captain Martin's
38:20initial confusion,
38:22but it does not explain
38:23the First Officer's
38:24unusual silence.
38:26Let's have another listen.
38:30They return
38:32to the cockpit
38:32voice recording
38:33to better understand
38:35how First Officer Weiss
38:36reacted to the emergency.
38:38How was that?
38:43That's one.
38:44That's one of the five.
38:45Turn left heading
38:46one, seven, five.
38:48What have we got here, Bill?
38:49That's two.
38:50Here.
38:51That's three.
38:55He asked for help
38:56three times,
38:57but the F-host
38:58says absolutely nothing
38:59to him the entire time.
39:00Not even,
39:01I'm not sure,
39:02or I don't know.
39:03Not a word.
39:04In this situation,
39:07seconds were critical.
39:09Had he said right away,
39:10I don't know,
39:12then the Captain
39:13would immediately
39:13have tried to rely
39:15on his own understanding
39:16of the situation
39:16rather than expect
39:18the First Officer
39:19to come up with
39:19an explanation
39:20of what he had.
39:23What could have caused
39:25the First Officer's silence?
39:29Hang on.
39:31What altitude
39:32were they at
39:33when the engine failed?
39:34450 feet.
39:38This could be it, then.
39:40Pilots say
39:41they were taught
39:42not to make call-outs
39:43or even verbalize
39:44the nature of an emergency
39:45after 100 knots
39:47before reaching 800 feet.
39:51Let me see.
39:59Not even to identify
40:00a failed engine.
40:02No communication at all
40:03until 800 feet.
40:04Yeah.
40:06I couldn't imagine
40:07a management team
40:09at Midwest Express
40:10thinking this silent
40:12cockpit business
40:13made any sense.
40:15It just flies in the face
40:17of communication,
40:19which is kind of
40:20the fabric
40:21that holds a safe
40:22flight together.
40:23so it just blew my mind,
40:25so it just blew my mind,
40:26frankly.
40:29What the hell was that?
40:34Investigators think
40:35First Officer Weiss
40:36may have been following
40:37a Midwest Express
40:38unwritten rule
40:39of not discussing emergencies
40:41until the plane
40:42reaches 800 feet.
40:44It's important
40:45during an emergency
40:46is for people
40:47to talk to each other
40:48because they both
40:50may not be looking
40:51at the same instrument,
40:53they both may not be
40:53looking at the same thing
40:54outside.
40:55You have to talk.
40:56You have to talk.
40:58One last thing
40:59troubles investigators.
41:01In spite of his
41:02First Officer's silence,
41:04Captain Martin
41:04could have easily
41:05identified which
41:06engine had failed
41:07simply by looking
41:09at his instruments.
41:10Both pilots
41:11had visual information
41:12from the engine
41:13flight instruments,
41:14the turn indicator
41:15and so on,
41:16that would have
41:17told them
41:18what was going on
41:20in terms of
41:21the loss of thrust.
41:23I don't think
41:24either of them
41:24were scanning
41:25the instruments.
41:26Agreed.
41:27They never saw
41:28which engine had failed,
41:29the direction of the
41:30or the severity
41:31of the roll.
41:33The NTSB concludes
41:35that the pilots' failure
41:36to monitor their instruments
41:37contributed to Captain Martin's
41:40incorrect rudder application.
41:42With the lack of visual cues,
41:43the only sure way
41:45they would have had
41:45to recognize
41:47which engine failed
41:48would be to look
41:49at the instruments.
41:51The pilots' lack
41:52of awareness
41:53ultimately led
41:54to the stall
41:55that brought down
41:56Flight 105.
42:00up until here
42:04he should be fine
42:05but then there's
42:07no communication
42:07and no instrument scanning.
42:11And this,
42:11this is what dooms them.
42:13He puts in
42:14a right rudder
42:14which sends them
42:15into a side slip,
42:17an extreme right roll
42:18and a stall.
42:21If they had
42:22talked to each other,
42:23scanned their instruments,
42:25you don't get
42:26to get this accident.
42:28The reality
42:29of the situation
42:30is the mismanagement
42:32inside the cockpit
42:33caused the accident,
42:35not the engine failure.
42:38The NTSB's final report
42:40makes several key recommendations
42:42to prevent this type
42:43of accident
42:44from happening again.
42:45They recommend
42:46a directive
42:47requiring airlines
42:48to replace
42:49the existing spacers
42:50with a new type
42:51of spacer
42:52which is less likely
42:53to fail.
42:54They also recommend
42:56that airlines
42:56are advised
42:57to teach their pilots
42:58to communicate
42:59during onboard emergencies.
43:01It should never be
43:03overstated
43:04the importance
43:05of crew coordination.
43:06Every crew member
43:07has something valuable
43:08to add.
43:09Anything that
43:10is in abnormality
43:11needs to be discussed
43:14at the proper time.
43:16They also suggest
43:19that airlines
43:19review their
43:20simulator training
43:21to ensure
43:22pilots are taught
43:23to use their instruments
43:24to assess
43:25the nature
43:26of engine failures.
43:28I think
43:28this accident
43:30still has an impact
43:31today
43:31because
43:33it's such
43:35a clear
43:36illustration
43:37of what happens
43:39when you
43:39don't do
43:40what you should
43:42do in an emergency.
43:43Anytime
43:44there's an emergency
43:45should have
43:46the exact
43:47same procedures
43:48and you should
43:49run right to them.
43:52Midwest Express Airlines
43:54continued to operate
43:55until 2009.
43:57It merged
43:58with Frontier Airlines
43:59in 2010.