Mayday (2013) s05e05 Episode Script

Dead Weight

VOICEOVER: It's morning on January 8, 2003, in Charlotte, North Carolina.
A city of half a million wakes.
At Charlotte Douglas International Airport, commercial airline pilot Captain Katie Leslie is at work early.
Only 25 years old, this Texas native has been flying for Air Mid West for almost three years.
One of the youngest flight captains at her airline Hey, Tom.
Have a great flight.
she's a top-rated pilot building her career at one of the fastest-growing airports in the United States.
This airport is an important domestic hub for US Airways, with flights to most major cities in the eastern United States.
Air Mid West runs a commuter service as US Airways Express.
It operates a fleet of Beechcraft 1900D planes, a 19-passenger short-haul commuter plane and a trusted workhorse in the industry.
Today Captain Leslie is in command of a 1900D on a 30-minute hop to Greenville-Spartanburg Airport in Greer, North Carolina.
Her co-pilot is 27-year-old Jonathan Gibbs.
How did you sleep last night? Had a dream I was in Miami.
(BOTH CHUCKLE) MAN: (ON PA) Attention, Ladies and Gentlemen, this is the final boarding call for Air Mid West Flight 5481 to Greenville-Spartanburg.
All passengers wishing to board should make their way to Among the passengers flying to Greer this morning, 18-year-old Christiana Shepherd.
Christiana's parents Doug and Tereasa are Baptist missionaries working in the Portuguese Azores.
WOMAN: Christiana left 7 January from the Azores, spent the night in the airport in Boston, and then flew the next morning on the early flight from Boston to Charlotte to Greenville.
So she was on her way back to college.
Christiana was very special and she was one that would come up and give you a hug and say, you know She'd come for no reason, would give you a hug and say, "Dad, I love you.
" At 8:00 in the morning, Christiana boards her flight.
Meanwhile, as part of their standard checklist before take-off, the crew calculates the weight of all the baggage, passengers and fuel on the plane.
That's to make sure the plane isn't overweight and the weight is spread evenly.
It's a calculation that's made on all commercial aircraft.
So, we got a full house back there? You can count 19 people in the back.
- Don't know the bags yet.
- OK.
But baggage handlers raise concerns that the luggage they're loading may be too heavy.
(GRUNTS) Damn.
Captain, how many we gotta take off? We're figuring it out.
We don't think we're gonna have to take anything off.
17,120 is our weight, huh? Yeah, it's our mass.
Sowe're cool.
So, yeah.
Good morning.
Welcome aboard US Airways Express service to Greenville-Spartanburg.
It's a very short flight, maybe 30 minutes gate-to-gate, so sit back, relax, and we'll have you there in a few minutes.
Before take-off, the crew checks the flight controls, including the rudder and elevator, which help control the direction of the plane.
(INDISTINCT RADIO CHATTER) Flight controls free and correct.
WOMAN: (ON RADIO) Air Mid West 5481, runway 18 front.
Taxi into position and hold.
Captain Leslie is moments from take-off.
On the runway ahead of them is a Bombardier CRJ ready for departure.
That CRJ sure is a good-looking plane, isn't it? - Yeah.
I wish I was flying it.
- (CHUCKLES) With powerful turbulence released from the CRJ, Captain Leslie must keep a safe distance.
They're gonna blast us with his jet blasts.
Air Mid West 5481, turn right, heading 230.
Cleared for take-off.
Set take-off power, please.
Power is set.
80 knots.
At 80 knots, pilots check that key instruments are working.
With no signs of trouble, Leslie and Gibbs proceed with their take-off.
To Air Traffic Control, Flight 5481's take-off roll is perfectly normal.
Gear up.
What?! Oh! (GRUNTS) But, without warning, the plane's nose pitches dramatically upward from 7 to a staggering 54 degrees.
- Oh, help me.
Have you got it? - I'm trying.
The crew struggles to get the nose back down again.
Airflow over the top of the wings creates lift but if the nose keeps rising air won't flow smoothly over the plane's wings.
The plane will lose its lift, stall and plunge from the sky.
Push the nose down! Oh, my God.
We have an emergency on Air Mid West 5481.
Alert 3 standby.
Runway 18 right.
The controller handling Flight 5481 calls for emergency equipment.
Oh, my God.
The plane is now 350 metres from the ground.
It stalls, rolls to the left and begins falling from the sky.
Captain Leslie pulls on her control column with all her might.
If she can't get the plane to climb, she's going to hit the ground.
Captain Katie Leslie struggles desperately to get her plane to climb but it won't respond.
The plane heads towards a packed US Airways hangar.
(ALARMS BEEP) The flight was loaded with almost 1,000 kilograms of highly flammable jet fuel just before take-off.
The impact instantly ignites all that fuel.
Now the intense fire threatens to engulf the hangar.
There are several airplanes and hundreds of people working inside.
- (PHONE RINGS) - MAN: Fire station.
WOMAN: Emergency.
Plane just crashed.
There's a plane that's crashed? Yes.
At the US Airways hangar three.
It ran into the building.
There's a fire.
Code 10, aircraft crash.
The south end of runway 36 left.
I repeat, a confirmed aircraft crash.
On fire.
38-year-old Fire Chief Keith Rogers is driving to work when he gets a code 10 call.
MAN: A code 10 means that there's a confirmed plane crash.
Usually this type of call is a once-in-a-career type of incident.
Cindy Overcash is a firefighter with the Charlotte Fire Department.
You couldn't actually see the hangar from here, but you just saw a huge black plume of smoke, and we knew something really bad is here.
(SIRENS BLARE) In the adjacent building, sales director David Isola hears the explosion.
Well, I was sitting at my desk and I heard this, erthis loud boom.
And one of the guys came in from next door and said that he just saw an airplane crash and so I hopped in my truck and drove down to the site.
From 60 metres away, Isola records the opening moments of the tragedy.
There was a lot of smoke and, er, it was justjust like hell.
It looked just like hell.
The flames were coming over the fence.
Just total craziness.
Everybody was just running for their life.
(SIREN BLARES) When Chief Keith Rogers arrives at the scene, he finds himself swimming upstream against a mob in panic.
As I got onto the airport property and got onto the tarmac the people were exiting the hangar.
Those people were running out in front of the fire trucks.
The fire cars there would drive with caution.
They were getting out the building as fast as they could 'cause I think they definitely realised that this was not a drill, this was a real emergency.
CINDY: And we still weren't sure if we had a plane inside the hangar that had caught on fire or if the hangar had caught on fire.
It was quite a while before we realised a plane had hit the hangar.
Chief Rogers immediately takes command of the scene.
He knows that there are aircraft parked inside the flaming hangar.
Their fuels tanks threaten to blow.
And our concern was, one, about the people that were onboard the aircraft, two, for the people that were working in the hangar and, three, we had to worry about the airplanes that were in for repair.
Were those aircraft on fire? So we had a lot of major issues to deal with.
Within minutes, firefighters begin to get the inferno under control.
The hope now is that somewhere inside the wreck survivors are clinging to life.
The main thing probably was on anybody's mind, once we realised what we had, was survivors.
As we walk up on to see the fire and we see what we think are crash test dummies.
We thought a plane had blown up inside and blew their training dummies out.
And then it dawned on me.
"Uh-uh, that's not a training dummy.
" It took them a few minutes in determining exactly what was happening, and once they did that, it was obvious that there were no survivors.
It's a total loss.
All 19 passengers, as well as Captain Leslie and First Officer Gibbs, are dead.
At about 8:53 this morning we had an aircraft accident.
It had 19 passengers and 2 crew.
There are no survivors.
And we hope that we never have to respond to a situation with such a large loss of life, but that is our job.
This is some of the most difficult duty and tasks that a firefighter will ever do in their career.
For medics and rescue workers the ordeal is over.
But for friends and family of the victims the anguish has just begun.
TEREASA: I was walking through the living room and I stopped and said And my heart's beating right now just the way it was then.
said, "Has Christiana called yet?" She said, "No".
And I knew then what had happened.
I justI knew.
So I went and got the telephone and called the school.
He said, "Yes, Mrs Shepherd, we have some sad news.
" And he told me that the plane had crashed on take-off.
I asked if there were any survivors.
He said no.
So then I knew I had to go tell Doug, and he was in the garage.
It's something you never forget about.
I was changing a fluorescent bulb and Tereasa came to the doorway.
How do you say that? What.
? You use words every single day.
How can you use words .
to ruin someone's life? But I told him.
Said, "Doug, Christiana's plane crashed.
" At that moment, er, mymy world fell apart.
Now the Shepherds and the families of the other 20 victims want to know what caused the deaths of their loved ones.
It's been almost five hours since Flight 5481 crashed into a hangar in Charlotte, North Carolina.
With no survivors to rescue, neither bodies nor airplane parts are moved from where they fell until the arrival of investigators from the National Transportation Safety Board.
While medical examiners mark the location of human remains in red, NTSB investigators mark scraps of metal in yellow, looking for clues to help them figure out what happened aboard Flight 5481.
Among those assigned to this case, Lead Investigator Lorinda Ward.
This is her first assignment as the lead investigator of a crash.
But today she's not feeling her best.
WOMAN: That day I was a little bit under the weather.
I was fighting off a cold.
You have the adrenaline that shoots through your body at the time, and so that actually makes up for when you're not feeling well.
And I knew that the other people on my team were experienced, so I felt comfortable going to Charlotte.
At Charlotte Douglas Airport, Ward takes the first steps towards solving this accident.
I checked in with the Fire Department to make sure that the fires had been put out and then called a meeting with all the first responders to see what they had noticed when they came to the crash site.
Ward acts fast.
Because there are bodies entangled with the wreckage, she declares the crash site a potential biohazard.
Investigators who might come in contact with the wreckage must wear protective suits while they examine the wreck and identify the victims' remains.
When we arrived on scene, the accident site did not look like an airplane was there.
Due to the fire, the post-crash fire, when you initially walked up to it, it was hard to identify that you had an airplane that could hold 21 people.
While work continues at the crash site Alright, let's go! .
Lorinda Ward and her team look for clues nearby.
We had the folks go shoulder to shoulder on the runway that the accident crew took off on to pick up anything that they saw on the runway to see if it had any relevance to the accident investigation.
Runways must be clear of all debris.
The smallest object can become a deadly projectile if it strikes a plane on take-off.
Three years earlier, a Concorde jet ran over a 40-centimetre strip of scrap metal on a Paris runway.
The plane's fuel tank was pierced and caught fire.
The aircraft rose to 200 metres before it crashed into a nearby hotel.
109 people on board and 4 people on the ground were killed.
At Charlotte Douglas International, investigators scour the area.
They find a fuel cap lying dangerously close to the runway.
What have we got? The discovery raises an interesting possibility.
As Flight 5481 raced down the runway at take-off, the fuel cap bounced up off the tarmac, struck the engine rotors Oh! .
and brought Captain Leslie's aircraft crashing to earth.
A closer examination leads Ward and her team to conclude that the fuel cap could not have interfered with the propellers.
Investigators discover no other relevant debris on the runway.
The runway debris theory is ruled out.
Now NTSB air traffic control investigator Bill English explores another scenario.
When we first heard about the accident, it looked like there might be the possibility that we'd wanna look at a wake turbulence encounter.
The wings of a fast-moving jet disturb the air around them, creating a trail of violently swirling air.
NASA tests decades earlier had illustrated the power and danger of wake turbulence to other planes.
We had to see, did another airplane depart before it? That's where wake turbulence hazard would come from.
And we wanted to look at what kind of airplane departed ahead of it.
Larger, heavier airplanes are the more risky wake turbulence-creating airplanes.
Oh! Air traffic investigator Bill English must now determine if wake turbulence from the CRJ caused Flight 5481 to crash.
Bill English studies the flight path of Captain Leslie's plane and finds it consistent with a plane flying into wake turbulence.
A pitch-up is not unheard of in a wake turbulence encounter, where the airplane will suddenly go nose-up and the crew has trouble to counter that and get the nose back where it belongs.
English needs to know how close the Air Mid West flight got to the larger jet.
The Charlotte tower has a sophisticated computer system that tracks the movement of planes while they're still on the ground.
The system gave Bill English his answer.
That system had a very rapid update, so we could see exactly where on the runway and at what time the regional jet lifted off compared to when the accident airplane started its roll.
When Bill English plots the precise position of the planes at lift-off, he makes a telling discovery.
Even though both planes used the same runway, their paths never crossed.
The RJ started lifting off much further down the runway than the accident airplane did.
And the climb-out angle of the regional jet .
and the climb-out angle of the accident airplane never intersected.
The angle of the accident airplane was very steep.
It really had no possibility of intersecting the wake turbulence from the regional jet.
So if our airplane lifted off and climbed above the angle of the previous airplane we knew then that it couldn't possibly be a factor.
The wake vortex theory is ruled out and Bill English's work is done.
Now it's up to Ward and her crew to find clues in the burnt-out wreckage of the plane.
Within two days, her investigation will reveal a string of errors and faulty assumptions that has been putting tens of thousands of passengers at risk for years.
While the lab work continues, NTSB investigator Stephen Carbone travels to Huntington, Virginia.
He interviews mechanics who worked on the plane the day before the crash.
At the time we had known that it had just come out of a detail check, which is a routine check, and knowing that we were looking into the possibility that something had been done during the check that needed to be looked at from an investigation point of view.
The cables needed servicing.
My guy wrote up the service order and I put 'em on.
Don't forget the manual.
Got it.
Every 1,200 flight hours, Air Mid West planes go in for routine maintenance work.
This includes adjusting the cables that control the plane's elevator.
In the process of doing this check, he found that the mechanic had found that the cables were out of limits.
So he had written up that he was going to check the cable tensions and then adjust them as per the manual.
Everything's ready.
The mechanics tell Carbone that the work was checked and stamped for quality assurance.
They believed that the aircraft was properly rigged, as per the manual.
At first glance that belief appears to be right.
After maintenance, this Beech aircraft took off and landed nine times without incident before Captain Leslie took the helm.
Investigators turn to the flight data recorder to learn what happened on those flights.
The flight data recorder stores data from numerous flights, both before and after the plane's cables were adjusted.
No-one on any of those flights had encountered any problems with the plane's elevator.
So at the time we didn't know how that affected the airplane because it had flown nine times successfully before the accident flight.
Ward also discovers that the crew tested their elevator controls before Flight 5481 took off.
Flight controls free and correct.
WOMAN: (ON RADIO) Air Mid West 5481 To establish the correct cable tension, mechanics tighten the turnbuckles, but too much tightening of a turnbuckle shortens the cables and cuts the range of motion of the elevator control.
The elevator should be able to tilt to a nose-down position of 14 degrees.
But their downward range has actually been cut in half to only seven degrees.
The result is deadly.
As the flight got underway, the nose pitched up as expected during take-off.
What?! Push the nose down! Oh, my God! But the reduced range of the elevator made it impossible for the pilots to bring the nose down again.
Due to the adjustment that had been done and the maintenance a few nights earlier, there was nothing that the crew could have done at that time.
Unable to bring the nose down, the pitch of the wings became too pronounced.
With no air flowing over the top of the wings, the plane lost its lift and began falling from the sky.
The pilots' struggle with the elevator helps explain why Flight 5481 crashed that day.
Somehow, the elevator cables were improperly adjusted.
The pilots simply could not control the pitch of their airplane.
Stephen Carbone wants to know how mechanics had made such a critical mistake.
Yeah, I see that here.
He goes back to the hangar to question the mechanics on duty that night and this time they tell him a different story.
Most of the guys were just learning the ropes.
The mechanics working on the airline were subcontractors to the contract company and the mechanics working on the aircraft that night had limited experience on the Beech 1900D and the person performing the rig was receiving training that night on that specific task.
Once you have the rig pin set, adjust the turnbuckle barrels for more tension in the cable.
Yeah, I see that here.
Adjusting the elevator cables is not a simple process.
It's a time-consuming procedure that involves 25 different steps.
Got it.
Er, what about the other steps? Yeah, er, don't worry about those.
Just check the cable tension when you're done, and we're good.
That's it.
The quality assurance inspector and the mechanic took it upon themselves to decide which steps to perform, because they felt that the steps they were performing were the only ones necessary to get the task done.
The mechanic skipped nine steps that night.
One of those involved manipulating the elevator through its full range of motion.
Had the mechanic tried to do that, he would have noticed that the elevator's motion was restricted by cables that had been improperly rigged.
If they had followed the steps as described in the manual, they would have found the problems that had come up.
But there was an inspector supervising the work.
Carbone discovers that the inspector was actually the person teaching the mechanics how to do the work.
The problem was that the quality assurance inspector was actually acting as an instructor.
So he was taking the mechanic through the process of the job task and teaching him how to do the rig.
Well, when you put yourself in that position you're actually doing the task, because even as a teacher YOU'RE performing the task.
And then he came in behind himself and then signed off as an inspector what he had done.
- What about the other steps? - Yeah, er, don't worry about those.
When I found out that this mechanic had skipped procedures .
I was upset.
(STUTTERS) The procedures that affected our lives, that affected the lives of 21 people 21 families werewere destroyed.
You never get over something like this.
The Shepherds sue the airline.
They also demand something unheard of in US aviation - an apology.
They wanted more than just to achieve a just settlement in monetary terms.
They had a need to press the issues that humanise and put a face on the people who are the victims of these tragedies.
The Shepherds believed that their best chance of getting an apology is by putting a face to Christiana's name.
So we decided to take this picture, to send it to those people that were involved in the accident and the investigation so thatso that Christiana would not be just a number or a seat number or a ticket number or a settlement amount, so that they could actually see that she was a person.
TEREASA: The legal journey began when we determined that we wanted the apology, that we wanted someone to say, "We really blew this.
" We assumed the airline would apologise.
We had no idea that airlines DON'T apologise.
They did something wrong.
Obviously, you should stand up and say, "We are so sorry "that we messed up in this and we're fixing this.
" LORINDA: In this case, the mechanics thought they were doing something that was perfectly reasonable.
They thought this was, er, you know, another day at the job.
And then they come to find out that now 21 people have been, you know, killed due to their inadvertent act.
For Lorinda Ward and her team, it looks like they've found the problem.
Ward has to figure out what happened in the hours and minutes before the crash.
Did you notice anything unusual before take-off? Well, it was sitting low when it taxied out.
It looked heavy.
We had a couple of witnesses that were implying that we had a very heavily loaded airplane.
The baggage people said that it was hard to shut the door 'cause they thought bags were gonna come out.
Each plane has a maximum weight it can handle before the engines can't get it off the ground.
Before take-off, it's the pilot's job to calculate the onboard weight.
- We got a full house back there? - LESLIE: Mmm.
How many we gotta take off? We're figuring it out.
The crew of Flight 5481 did perform that calculation.
We hear them on the CVR going through the numbers to make sure that they'd have their centre of gravity within the range for them to take off.
- 17,120 is our weight, huh? - Yeah, is our max.
On any plane, large or small, the weight of cargo and passengers has to be distributed evenly.
The balancing point of an airplane is called its centre of gravity.
For a plane to fly safely, it can neither be too far forward nor too far back, or aft.
So we're cool? So, yeah.
We don't think we're gonna have to take anything off.
Air Mid West pilots are instructed how to make weight and centre of gravity, or CG, calculations.
They use average weights to make that calculation - 175 pounds per passenger and 20 pounds per bag.
They knew that they had a very aft CG but due to using the average weights and average calculations the paperwork showed them being within the range that they needed to take off.
But Ward needs to know if the plane really was within the proper range of weight and balance to take off.
What we did is looked at the weights of the actual baggage itself that was onboard and then the weight of the passengers and the crew.
Technicians weigh the remains of the burnt luggage from the wreckage site Doctor, yes, could you tell me, please, what the last recorded weight of your patient is, please? .
and obtained the real weight of passengers onboard that day.
Thank you.
When all the numbers are in, Ward discovers the real weight of Flight 5481 is 17,700 pounds, some 580 pounds over its maximum take-off weight.
They would not have been able to take off if they had used actual weights.
They would have had to pull either passengers or bags off.
Because of the higher-than-expected weight of the passengers and baggage on the flight and the large number of bags stowed in the rear, the airplane was tail-heavy, its centre of gravity ever-so-slightly too far to the rear, which wasn't a problem until the landing gear was raised.
Gear up.
When the gear's weight moved backwards from the nose, it tipped the balance of weight too far back.
Oh! The pilot's efforts to regain control of the aircraft were futile, crippled by the airplane's defective elevator controls.
CARBONE: When the nose gear moved aft, they lost the ability to control the aircraft because all the weight went back and they had no elevator movement enough to bring the nose back down and at the height that they were at they had no recovery.
The passengers and crew of Flight 5481 were doomed the moment the plane left the ground.
They had no way of knowing that two unrelated problems would combine to bring down their plane.
This was just a normal, routine flight for them and they did all the pre-flight checks, they did their weight and balance, they did the correct calls, they were on the right runway.
It was just another day at the job and they didn't know that they had these two hidden latent failures that were waiting for them.
But faulty maintenance and above-average weights weren't the only issues uncovered by Lorinda Ward's investigation.
You got a sec? I have an idea.
Lorinda Ward suspects she's uncovered problems that didn't just affect this one flight but that also affected every commuter plane in the air.
14 months after the accident, lead investigator Lorinda Ward and her team file a comprehensive report to ensure the mistakes that killed those aboard Flight 5481 are never repeated.
Among Ward's recommendations, that the FAA review its average passenger and baggage weights, an average that had not been revised since 1936, and since studies suggest that Americans and other adults were getting heavier from year to year, Ward suspected that the averages were off.
We made a recommendation to the FAA to have the operators go out and survey their operations in both summer and winter time to see how accurate these average weights reflected the actual flying public that was getting onto their airplanes.
After conducting a survey of passengers, the FAA comes to a shocking conclusion.
The average weight of adult American passengers was 195 pounds, not 175.
The FAA also discovered that the average weight of carry-on luggage was being underestimated by five pounds per bag.
We had an average weight that were being used that needed to be updated.
Had these higher average weights been in effect on January 8, 2003, Flight 5481 would not have been legal for take-off.
Captain Leslie would have had to remove bags and passengers.
Air Mid West pilots now use an average weight of 200 pounds per passenger, which means that their Beechcraft planes can only carry 17 passengers, not 19.
But Ward's report goes on to say that even with updated industry averages, there's still room for error.
Her report states that flying small aircraft will be safest only when airlines stop using average weight assumptions altogether and calculate the real weight onboard before take-off.
New technologies are being developed to allow air carriers to measure actual weight and control balance, in real time, as the plane is loaded.
Knowing the actual weight of passengers and baggage is vital.
More and more people are flying on small commuter jets.
As the cost of jet fuel soars, the smaller fuel-efficient planes become more attractive to airlines.
In the United States alone, more than 10 million people a year board planes with fewer than 30 seats.
Smaller aircraft are more sensitive to the weight and balance issue than, say, a larger airplane.
In spite of Ward's recommendations and the available technology, almost 70% of small planes on scheduled flights still use average instead of actual weights.
This investigation was unique to me personally because it was my first launch as an investigator in charge.
This was, in my mind, a significant investigation in the fact that we had the 22 safety recommendations that came out from a small accident investigation.
For the Shepherds, the NTSB recommendations come too late but, after a lengthy legal battle, Air Mid West does deliver a rare and formal apology for the mistakes that cost 18-year-old Christiana Shepherd her life.
My name is Ron Goldman and my role here today is I will be introducing the public apology and then I'll have a few words.
The public apology is, in aviation cases, unprecedented.
We are here today to remember the victims of Flight 5481 and to offer our apologies, our condolences and sincere sympathy to the surviving family members of the passengers and crew who perished in the January 8, 2003, crash of Air Mid West Flight Number 5481.
GOLDMAN: The acceptance of accountability suggests that the recommendations made by the safety investigators are not to be taken as a book to throw in a drawer and forget about but it to be taken seriously because if you don't take them seriously, there's going to be public accountability as well as private accountability.
What people should never forget is that, as we're going about and doing our job day to day, we need to remember the importance of doing our job.
Doesn't matter where we're at on the corporate ladder, whether we're at the bottom rung or the top rung, we have responsibilities.
It took a complicated string of errors and miscalculations to bring down Flight 5481 but some believe there was one person who performed admirably that day, Captain Katie Leslie.
With an unbalanced plane and faulty controls, Captain Leslie could not have saved the flight, but her final actions may have saved some lives.
CINDY: She's an unsung hero to me because I don't think many people know about what she did and how she was fighting it and trying to pull the plane away from the hangar and she actually did.
She kept it from really more of a head-on hit into the hangar .
which probably saved countless other people from perishing that day.
It was firefighter Cindy Overcash who found the body of Captain Katie Leslie among the wreckage.
To this day, Overcash still feels a special connection to the young pilot.
I don't know.
I just felt a kinship.
I don't know why.
I don't know.
You know, it could be as simple as I found her and I was there when she left this world.
I don't know, but I thought about her a lot.
Lorinda Ward's investigation could have ended when she uncovered the errors that caused the crash of Flight 5481.
By digging a bit deeper, she made flying safer for millions of people.
Supertext Captions by Red Bee Media Australia