Air Emergency (2003–…): Season 15, Episode 7 - Deadly Delay - full transcript

It is Spain's worst air-disaster in 25 years

It was a tremendous tragedy

A crash that kills a 154 people

Our thoughts are
with our colleagues and the passengers

Investigators face intense pressure
to pinpoint the cause

When you get to the accident site,
you need to collect facts.

When you come up with a mechanical irregularity

it is like, ah, what is next

Could a minor maintenance issue...

...have led to this deadly catastrophe?

MAYDAY
AIR DISASTER



This is a true story.

It is based on official reports
and eyewitness accounts.

It is 2:14 PM
at Madrid Barajas Airport

DEADLY DELAY

After being delayed for more than an hour,

Spanair Flight 5022
is finally getting back on their way

There are 166 passengers on board.

many of them looking to escape
the stifling heat of Madrid in August.

Everyone was full of anticipation,
everyone wanted to be on their way.

Anna Stefanides has come to Spain from Sweden.

She is on her way to the Canary Islands
to meet some friends.

Most of Europe has holidays,
different summer holidays in August.

I was going to Gran Canarian
to meet my girl friends

We were going to have one week holiday
for at least



Today, Captain Antonio Luna is in command.

A former Spanish Airforce pilot,
he has been with Spanair for 9 years.

How is our time?

About an 1:15 hr behind schedule.

First Officer Francisco Mulet joined the company
just 1,5 year ago

Almost all of his 1300 flight hours
are with Spanair.

Maybe we can make it up in the air

Maybe

The flight began with a morning hop
from Barcelona to Madrid.

From Madrid, they will fly 2:15 hr South
to Gran Canaria,

in the Canary Islands

Spanair 5022, you are next in line

on runway 36L

OKAY, here we go

The prepare for take off is an extremely busy time
for the flight crew

They've got multiple checklists to run

- Ignition
- Set

- Spoilers
- Armed

Make sure the aircraft is properly configured,
the thrust is set right, breaks etc

Air conditioning

There are a number of facts that
are all running through their minds simultaneously

final items we have 8, 11 aligned

11 stowed

Spanair 5022, you are cleared for take off
for Runway 36L

Cleared for take off, this was Spanair 5022

OKAY, your aircraft

First Officer Mulet will fly the plane from here

My aircraft.

At 2:23 PM, the MD 82 aircraft
starts speeding down the runway.

100 knots

The Captain watches their speed.

They cannot lift off
until they reach a 157 knots,

take off speed

It didn't feel right,

I thought they were putting in
all the power and force that they had

and now we will lift off

Something was just not right.

It is taking so long

Does that seem right to you?

and then I thought:
How long is this runway?

We have to lift off now.

V1

Rotate

An alarm warns the pilots
something is going wrong

The First Officer increases power,
but he is loosing control of the plane.

When we finally lifted,
everything went suddenly to the right

and then, I just heard screams and crashes.

What the hell do you turn off that warning?

The plane is less than 40 ft from the ground.

I managed to think:
This is my last trip.

I've had a good life

I thought:
Now I die

Fly the plane

I put my arms over my head

and put my head between my legs.

I protected myself as much as I could.

Just seconds after take off

Flight 5022 slams into a river bank
beside the runway.

Airport fire crews are quickly on the scene.

The plane with the 172 people on board
is now shattered wreckage

spread over 0,5 mile.

Anna Stefanides has landed in the water,
still strapped to her seat.

When I woke up
first, there was this quiet

But then I realized:
I am not dead.

I looked around me

Where am I?

What is this?

Airport workers have raced to the crash site
to try to help

but they cannot get to Anna.

The emergency personnel were calling to me

Come, on, come on,
hurry now

she is in the middle of the stream,
tangled in debris

and sinking fast

I have no idea
how I managed to get free.

Somehow, Anna makes it to the water's edge
where rescuers help her to safety

She is in shock
and suffering from a serious leg injury

but she is alive.

It was chaos,
it was so horrible

but I got out

In spite of the massive rescue effort

only 18 people survived.

A 147 passengers are dead

so are both pilots.

It was a tremendous tragedy

All the country was affected by that.

This is Spain's worst aviation-disaster in 25 years

Our thoughts are
with our colleagues and the passengers

It was a Spanish company,

so many of our colleagues
were flying that type of plane.

It was a very difficult time

Spain quickly recruits an international team
of experts to investigate the crash

They have a massive puzzle to piece together.

How could a sophisticated jet,
manned by an experienced crew...

...crash on take off on a sunny afternoon?

OKAY, people
it looks like we have our work cut off for us

Juan Carlos Lozano is an investigator
with the Spanish Pilots Union

The accident site at the beginning
is considered like a crime scene

It is very important
to find out how the pieces are located

because that will give you a lot of information.

It is demanding work,

searching acres of rough terrain
for shattered pieces of scorched debris

all under the blazing Madrid sun.

It was difficult, the heat,
because it was a very hot summer

so, the heat was probably one of the worst things.

Understanding what happened to Flight 5022
is going to one of the most difficult tasks

these air-crash investigators have ever faced.

Investigators into the crash
of Spanair Flight 5022

immediately focus their efforts on recovering
the two black boxes, or flight recorders.

For an investigator, the Flight Data Recorder
is one of the most vital records that we can get

because everything that is working
or it is not working or it is causing an issue

will be recorded there.

Once they download the data
it could provide vital clues about what went wrong

Let's get this to the lab, as soon as possible,
OKAY?

Meanwhile, the nation mourns

The Prime Minister visits the crash site.

The King and Queen and the mayor of Madrid
gather to console the grieving families.

The pressure to announce a cause

is intense.

The press was putting a lot of pressure
on the investigators to give answers

even before they had any idea
of what could have happened.

At the crash site,
marks on the ground paint a vivid picture...

Here is our first impact

...revealing just how quickly Flight 5022
turned into disaster.

The first impact marks
are just 200 ft from the runway.

The plane then passed over a road

and slid another 1800 ft
before crashing on the far side of a river.

This airplane left a trail

coming from the runway
to the edge of the airport boundary

So, it was quite clear for the investigation
that the plane had a big problem just on lift off.

The timing immediately suggests a theory
that might explain the crash

Let's take a look at this engine

When an aircraft gets only 30 ft off the ground
and falls uncontrolled back to the ground

you have to wonder:
were the engines operating correctly?

Engine power is especially crucial
during the first few moments of flight.

If the plane doesn't have enough power,

it won't achieve the speed it needs
to overcome drag and to get airborne.

Investigators study the engines,
searching for any kind of malfunction

Both are filled with debris, mud, and grass,
ingested during the crash

If we find mud, soil or grass
throughout the engine

we can determine that the engine
was fully operational at the time of the accident.

In this case,
we found traces all around the engine.

The finding means the engines were spinning
at high speed when they hit the ground:

It wasn't engine failure, that doomed the plane.

Right, the engines were fine.

but something stopped that plane from climbing.

Investigators need a new theory
to explain why the MD 82 couldn't climb.

What was it?

I want maintenance records, weather reports...

...pilot records,

Let's get to work, people

For an accident investigator, it is very important
not to establish any presumptions

You need to collect facts.

OKAY, let's see what the numbers tell us

Investigators know that for any take off

the plane's weight and balance
must be carefully calculated.

The aircraft needs to be carefully balanced
in order to get its better performance

So, when you are taking off,

you need to be sure that the aircraft has been
properly balanced and the weight is correct.

They review the passenger manifest,
cargo and fuel load.

They need to check the total weight
as well as where the loads are carried

to see if the CENTER of gravity
shifted dangerously forward or back.

but it is soon clear this isn't the smoking gun
they are looking for.

Well, there is nothing wrong
with the take off weight.

Controllers in the tower
provide a more promising lead.

They tell investigators that the Spanair crew
called off an earlier take off

They had some kind of maintenance issue
before take off.

The plane was at the threshold of the runway

when the pilots noticed a temperature gauge
was giving them faulty readings.

Madrid, Spanair Flight 5022

We have a slight problem
we have to exit the runway

5022, taxi to apron T2

Controllers clear the MD 82
to return to the terminal

He has spent the last 45 minutes

totally focused on
getting that aircraft to the runway

and when he come up
with the mechanical irregularity, it is like:

Ah, what next?

It is a show stopper

Ladies and gentlemen,
we are experiencing a minor technical problem

We are just going to head back to the terminal
to see if we can sort this out

Normally, the passengers
are more comfortable

after a clear and direct explanation
of what is going on

We are just not going anywhere just yet

I thought: why should I worry?

I have bought my ticket

I have paid for my ticket

I want to get there

and I will

So, they will have to do their job and fix this

Could the last minute repair
be the key to explaining the crash of Flight 5022?

Investigators need to know.

Spanair Flight 5022 was sent
to a remote maintenance area

in a far corner of the terminal

It took 9 minutes just to taxi there.

We are back

Shutting down the engines.

By the time they reached the maintenance stand
the plane is already 42 minutes behind schedule

That delay...

...could be an important lead

Untime performances
taken very serious in the industry

now that they are substantially behind schedule
the pressure is immense

With the engines shut down,
the plane's air-conditioning doesn't work.

Sitting on the scorching tarmac,
temperatures in the plane begin to sore

It was incredibly hot in the plane

I have never experienced that kind of heat before

Maintenance workers give investigators
more details about the delay

They were trying to fix a problem
with one of the plane's sensors

I took a look , but it wasn't serious

The sensor , called a RAM AIR temperature probe
juts out from the nose of the plane

It measures the outside air-temperature

and feeds the information
to the engines during flight.

Could you see anything outside?

No, it is not clogged

The sensor is sending
faulty readings to the engines

No, that is not going to work either

Without it,

the automation that adjusts engine power,
won't work properly.

Look at that, it is 104° now

The attempted repair eats up more valuable time.

I got to write all this up,

not to mention the delay,
we are an hour late at least

The entire economics of the present
air-transport industry is build on efficiency

An airplane in the air makes money

an airplane, sitting on the ground doesn't

So, if you have got an aircraft
that isn't where it means to be

this is thrown a severe complication into
the efficiency in the operations of the airline.

Ladies and gentlemen, thank you for your patience

We hope to be on the move again very soon.

Maintenance workers explain
that they couldn't repair the faulty sensor.

Instead, they disabled it
by cutting the electrical power to the sensor

They simply tried to avoid the symptom.

which is the high temperature in the RAM AIR probe
by pulling the circuit breaker

The quick fix eliminated the faulty readings

So, we're done?

Yeah, I popped the breakers,

OKAY, thanks

The maintenance workers have no idea
what went wrong on take off

Investigators wonder

if the disabled temperature probe
is somehow linked to the crash

I don't see how this could cause a problem.

But they quickly confirm
the probe is not an essential piece of equipment.

The crew simply has to keep
track of the air temperature

and adjust engine power manually.

There are alternate means to determine
what the outside temperature is

In this case, it is something as simple as asking
ground control or listen to the weather report

But that was not the only maintenance issue
the crew was facing that day.

It says here the right thrust reverser
was disabled as well.

Thrust reversers are used on landing
to help the plane slow down.

When engaged, bucket doors open
to deflect the jet blast and redirect it forward.

If a reverser malfunctions and activates in flight
the plane can loose lift

and can drop out of the sky

That is what happened
to Lauda Air Flight 4 in 1991

killing all 223 people on board.

Did a faulty reverser somehow
activated on take off?

It seems unlikely
but it would explain the plane's trajectory

If this thrust reverser had
deployed inadvertently

because the opening would taken
the airplane to the right hand side

which is actually where the airplane crashed.

It is an intriguing theory

but so far,
there is not enough evidence to prove it.

Investigators study the thrust reversers,
recovered from the wreckage of Spanair Flight 5022

There is no evidence
that the right side reverser deployed,

but on the left engine...

...it is a different story.

Is this the position it was in
when you found it?

The reverser is in the deployed position

a potentially deadly configuration.

If one of the thrust reversers
deployed inadvertently on take off

even when the engines are providing full thrust

that would probably be a big threat
for the controllability of the airplane.

Finally something that points to
a serious mechanical problem with the plane

one that might explain the crash of Flight 5022.

A lot of scrape-marks

But as investigators continue
to scrutinize the reverser

they realize there is a problem with the theory.

I think it was deployed...

...after impact...

...as the engines dragged along the ground

Distinctive damage to the reverser
tells investigators

it deployed after the plane came down,

not in the air.

All the damage that had sustained was very
easy to compare with the marks on the ground.

So, that led the investigators
to eliminate the thrust reverser

Something else
stopped the plane from climbing out.

Investigators need to shift gears

Once you have eliminated the engine failure

you have to think about lift

about the possibility to become airborne.

What kind of wreckage have we recovered
from the wings?

Get me everything we have

The wings are equipped with control surfaces:

the flaps and slats that extend at take off
to help generate lift.

For modern airplanes the flaps and slats
are the most critical parts besides the engines...

...and the wings itself

as it allows the airplane to take off and land
in a shorter distance with lower speeds.

If the flaps didn't extend properly

it would result in Flight 5022
not having enough lift to climb.

The investigators study the lever mechanism
that pilots use to control the flaps.

The flap lever was a very essential part
of the investigation.

If the lever was driven against
the side of its track during impact

it might leave a mark
showing how the flaps were set at take off.

Well well, what have we here?

There is a deep scratch at ZERO
or retracted position

It is a startling finding

one that suggests the flaps on Flight 5022
were not extended for take off

My first reaction as a pilot is that the flaps
and slats are absolutely necessary for take off.

This is not going to be a survivable crash

if they have attempted to take off
and they weren't extended.

It is hard to believe
a professional pilot could forget

to set such a vital piece of equipment

Did the flap-handle shift during the accident?

or did the pilots somehow fail
to set it properly before take off?

My second question is: WHY?

What happened to prevent them
from being in the right position?

The answer to that question could explain
why a 154 people died...

...in one of Spain's worst air-disasters.

Investigators dig into the personal and
professional histories of the Spanair crew

wondering if the pilots could have made
a terrible mistake.

Both qualified!

Both experienced

You always check on their experience

if they had any issues during the training

what kind of training they had.

The pilot record turned up nothing significant.

Captain Luna and First Officer Mulet
are both up to date on all necessary training.

Hard to believe,
these guys could forget to set the flaps.

The commander had an excellent reputation.

He was a person
who was considered to be very meticulous

He enjoyed flying
and took pride in being a professional.

Investigators turn to the CVR for answers

OKAY, let's hear it

Ignition

Set

When you listen a the CVR
you try to understand the pilots

and put yourself in the pilot's situation.

They are listening for
anything that might tell them

how the flaps were set for take off.

The pilots make their final preparations...

How many final items we have?

Eight, 11 aligned, 11 stowed

including a last minute check of the flaps
that is required, right before take off

Hold it, stop right there

Final items

That include checking the flaps

He called out '11'

That is the right setting

The recording suggests
that the pilots set the flaps to 11 degrees

exactly where they should be.

Perhaps,
the flap lever did somehow shift after take off

Maybe they did

I was really shocked that the crew
definitively talk about the flap-position

and it seems that the flaps
were not in that position,

so that creates a kind of
contradictory filling of saying

Wow, these guys
were really looking at the flaps or not?

Contradictory evidence threatens
to derail the investigation

It is going to take more digging to discover
what actually happened in the cockpit

Questions about the flaps on Spanair Flight 5022
could be settled once and for all

with information from the FDR.

OKAY,
let's hope the data can give us some answers.

It records every detail
about the plane's configuration,

including flap settings.

Flaps

Set and checked.

The flaps were set at 11 degrees on the first taxi
exactly where they should be.

The data reveals that the flaps were working
and have been set correctly

when the plane taxied to the runway
the first time.

But they didn't stay there.

When the crew returned to the terminal for repairs
they retracted the flaps.

And we are back

shutting down the engines.

The flaps and slats were retracted
after coming off the runway

as part of the Standard Operating Procedure.

OKAY,
let's see what happens the next time around.

Investigators need to know

Did the pilots extend the flaps again
after leaving the maintenance area

to return to the runway?

or did they make a fatal error

and amid one of the most important steps
in getting a plane safely off the ground?

When you analyze a CVR, you look for anomalies
things that are different,

things that should not be there.

After start checklist.

The MD82's preflight checklists direct the crew
to check the flaps and slats three separate times

Flaps and slats are essential for the operation
of an aircraft

for take off and landing.

So, that is why they appear
several times in the checklist.

On the after start checklist
setting the flaps is the final item.

Hydraulic pumps and valve

Set and checked

Lights

ON

Get permission from ATC to taxi, will you?

Hold it, hold it hold it

What is he doing?
This is the worst possible time to interrupt him

The CVR reveals

that just as the First Officer is about to
check the flaps and slats for the first time

The Captain asks him to make a radio call.

He never returns
to finish that crucial item of the checklist.

This is highly irregular.

In the normal tempo of a checklist

what that tells our investigators there were some
factors that were irritating his Captain,

making him want to rush the checklist,
gets things done quicker.

Was it the time schedule,

was it the cockpit heat (it was unbearably hot
and they want to get the engines started)

That, we don't know.

Let's see
what they do for the taxi checklist, please

Spanair Flight 5022 in line.

Setting the flaps is so important

crews are required to check them
again during the taxi checklist.

- Brakes
- Checked

- Flight controls
- Checked

- Air conditioning
- Set

Wow, wow wow
Guys, what is the rush?

The impression we had when we heard the CVR

was that the crew was rushing
through the checklist.

Hang on,
stop

Where is the take off briefing?

The crew skipped the flaps and slats check
for a 2nd time.

We know from scientific studies that rushing
increases the chances of human error by 11 fold

You put a pilot in the situation
where they have to rush.

A checklist is a detailed item

it is very prone to errors.

The crew has a third and final chance
to set the flaps for take off.

That was awfully quick, no?

Flaps: 11,
Horizontal stabilizer: aligned

and flaps again 11

No way he had the time to check all those settings

Let's go back to the checklist

Investigators suspect that although
the First Officer announced the flap setting

the announcement was automatic.

He wasn't focused on his instruments,

he was merely reciting the list from memory.

If he had looked at the gauge
he would have seen the flaps were set at 0, not 11

The Captain likely isn't checking either.

He is busy steering the plane towards the runway.

Humans are fallible

When we are multitasking, it is very easy
to forget or miss a critical item.

3...

...accepted checklists...

...and they never set the flaps.

Investigators now have a terrifying theory

to explain the crash of Spanair Flight 5022.

The plane couldn't climb,

because the pilots forgot to extend
the all important flaps before take off.

To prevent another accident,

investigators need to understand
the crew's behaviour.

What was going on inside their heads
to make them feel so much pressure to hurry.

They dig in to the company's books

and discover that
Spanair has been struggling financially.

It has announced
plans to cut 1/3 of its work force.

When your job is on the line,

the last thing you want is
to fall badly behind schedule

It is difficult to manage the stress
that starts building

when a delay is getting longer.

The Captain is also well aware

that his 166 overheated passengers
are getting more and more unhappy.

At the peak of the afternoon sun,
the air temperature was 30°C, or 85°F

The tarmac radiates heat,
raising the ramp temperature to over a 100°

It must have been scorching hot on that plane.

And we've got large windows,
the sun is beating in

I assure you that cockpit is going to be a 120°

you wear a shirt, a tie,
it gets unbearably hot.

No doubt about it,
those guys were coping with a lot of pressure.

When you look at all the issues
that the flight crew is facing

time, schedule, inoperative components
an irregular procedure to do

It is just human nature for us to rush
through the normal procedures.

Psychology helps explain
why the crew made the mistake in the first place.

But there is another troubling question.

When the crisis hit,

why did the crew think there was something wrong
with their engines?

If they had realized the flaps had not been set,
they might have been able to save their plane.

Understanding why they didn't
will be the final twist in the tail

Why did the First Officer think
that it was engine failure?

Investigators wonder if the faulty sensor
(shut down by the maintenance workers)

could have played an unexpected role

So, we are taking off using manual thrust, right?

With the sensor disconnected,
engine control is no longer automated

Yeah, manual thrust

Before take off,
the First Officer mentions this 5 times.

And if we go for manual thrust,
then we will engage the AUTOPILOT after take off

Right.

The disconnection
of the RAM AIR temperature probe

created a lot of concern from
the Copilots point of view

because that also affects the auto-throttle,
which is the automatic system for engine power.

Look, just check the weather for the temperatures
it won't be a problem

The Captain reassures him
that they can set the thrust levers manually,

but the First Officer is uncertain

Already preoccupied with the engines

the First Officer mistakenly assumes they have
an engine problem when things start to go wrong

10,000 times you have done
these take off procedures

in this nice slow, methodical
well thought out way

Now you are inserting
a completely irregular event.

But there is another crucial question.

Wait a minute...

...where is the warning?

If the flaps were not set
in the take off position

there should be a very conspicuous sound
saying that the aircraft is not ready for take off

The TAKE OFF WARNING...

...didn't go off, and it should have

I want to know why.

They must now track down a silent culprit,

a missing alarm that could have saved Flight 5022.

These failures have to be connected somehow

Investigators suspect there could be a link
between the failure of the TAKE OFF WARNING

and the minor problem,
that sent the MD 82 back to the terminal,

the failure of the temperature sensor.

Investigators trace
the complex electronics of the sensor

and make a shocking discovery.

The sensor and the TAKE OFF WARNING
both pass through the same electronic relay.

When you look at the electrical scheme
of the TAKE OFF WARNING system

you'll find that the relay 2-5
controls two things:

The heater of the "RAM AIR temperature probe
and the TAKE OFF WARNING alert

That's it, that is the link

Yes!

It was very shocking to find out

that the TAKE OFF WARNING system
and the RAM AIR temperature probe heating

were controlled by the same device.

Inspectors suspect the R2-5 relay failed

disabling both the temperature sensor
and the TAKE OFF WARNING.

Technicians are not able
to recreate that failure in the lab,

but for Juan Carlos Lozano,
the theory makes sense.

In my opinion, the R2-5 was the cause
of the failure of the TAKE OFF WARNING system

By opting for the quick fix
to the temperature sensor problem,

the maintenance crew missed
a critical opportunity to find the faulty relay.

Without the cockpit alarm
the pilots didn't have their final line of defence

to warn them of their mistake.

Sadly, they were not the first crew
to suffer such a fate:

In 1987, an MD 82 flying for North West Airlines
crashed on take off from Detroit,

killing a 156 people.

Just like the Spanair crew,

the pilots in Detroit failed
to set their flaps and slats

but got no warning.

A disabled electrical circuit
silenced their plane's alarm.

After the Detroit crash,

checklists were changed
to highlight the flaps and slats more often,

and the warning system was made more robust

in an effort to prevent such a tragedy
from ever happening again.

But aviation designers and engineers
could not foresee the rare failure

of the R2-5 relay.

That failure sealed the fate of Flight 5022.

As an aviation professional,
as an accident investigator too

this is probably the most frustrating
situation in the world because,

you investigate an accident
in order to avoid to happen this again

and unfortunately this is a very similar case
20 years after the Detroit accident

In both Detroit and Madrid

it was the crew's failure
to follow their checklist that led to disaster

The Spanair investigators list the inoperative
TAKE OFF WARNING as a contributing factor

that prevented the crew
from recognizing the danger.

But Juan Carlos Lozano,
representing the Pilot's Union

sees it the other way around.

The single biggest failure in this accident is
the failure of the TAKE OFF WARNING system

This system was designed
considering that the humans can make mistakes,

this is a clear example
that the last line of defence failed.

After the crash of Spanair 5022,
Boeing again revised its checklists

to make extending flaps and slats more prominent.

and electronic checklist are now being used
in some planes.

Unlike paper checklists,

they can display clear messages to the crew
to tell them what they have and haven't checked.

We can not have this absolutely vital
safety layer failed.

We've got to have a 100% guaranteed system.

Narrator
JONATHAN ARIS

Subtitles
Rein Croonen