Mayday (2013) s09e08 Episode Script

Cracks in the System

NARRATOR: Miami Beach, Florida.
When a tourist points his camera towards the sky, he captures a scene of horror.
A plane is falling to the sea.
The downed plane is Chalk's Ocean Airways Flight 101.
An airline renowned for safety has made a fatal error.
But it will take investigators hundreds of hours to finally uncover it.
Bingo.
The Port of Miami, December 19, 2005.
Giant freighters and ocean-going cruise ships are a common sight.
But there's another, much smaller craft that's often seen in this port.
Chalk's Ocean Airways flies seaplanes in and out of this busy waterway.
Today, Flight 101 from Fort Lauderdale is making a brief stopover here on its way to the Bahamas.
- MAN: Feather propellers? - WOMAN: Check.
Shut down engine number one.
Shutting down engine number one.
Chalk's flies to two regular destinations, both in the Bahamas - Bimini, where Flight 101 is scheduled to land this afternoon, and Paradise Island.
Ladies and gentlemen, this is your captain speaking.
We're just making a short stopover here in Miami to pick up a couple of passengers.
We apologise for the delay.
We'll be on our way again soon.
- How many are we picking up? - Just two, but they're VIPs.
For a small community like Bimini, Chalk's seaplanes are a lifeline.
It's just so much easier in the seaplane to get to the north island, where most of the population is, than going to the airport down there.
That was the main thing - the convenience factor.
Welcome aboard.
May I see your boarding passes? MAN: Certainly.
Sergio Danguillecourt is a Bacardi Rum executive.
He's the great-great-grandson of the company's founder.
The family is well-known in the local Cuban community for their anti-Castro politics.
He and his wife are flying to the Bahamas to buy a yacht.
Let's have the start-up checklist, please.
Roger.
Michele Marks is in command of today's flight.
She was promoted to captain earlier this year.
First Officer Paul DeSanctis joined the airline eight months ago.
Starter on.
Starter on.
This is his first flight with Captain Marks.
All clear to taxi? All clear.
The Grumman Mallard is a twin turbo-prop design.
It has a V-shaped hull and under-wing pontoons.
It's designed to carry up to 17 passengers.
The plane has retractable landing gear, so it can operate on either land or sea.
The Miami Seaplane Base has no control tower.
The crew has to keep a look-out for boat traffic as they taxi through one of the busiest ports in the world.
WEBER: Taking off out of Miami in the shipping channel, it's kind of like trying to take off during rush-hour traffic.
You've got boat traffic, wave traffic, the wind, the airplane to deal with And everybody's going different speeds, and you're trying to get up and go, and navigate around everybody, so it was always a handful.
Prepare for take-off.
Roger.
Ready to take off.
Both pilots have their hand on the throttles.
It's to prevent the captain from inadvertently pulling back if the plane hits a wave.
45 knots.
50 knots.
This is the moment most passengers are paying for - the take-off.
Half speed boat, half plane, it's a unique thrill.
The airplane itself was really hard to fly as far as on the water, getting on to the step, which was what we called getting on a plane, and in rough sea conditions and rough wave conditions, it could be a real challenge.
But this take-off goes smoothly.
Flight 101 is no longer a boat - it's now a plane en route to Bimini.
It's 2:38 in the afternoon.
The plane's flight path takes it past South Beach .
.
where sunbathers and surfers are out in force.
Just less than a minute into the flight, the Grumman Mallard is climbing through 500 feet - well below the clouds.
Then - (BOOM!) - (WOMAN SCREAMS) The plane rolls violently and dives.
The pilots barely have time to register what's happening.
Their struggles are in vain.
(SCREAMING) By chance, a tourist from New York catches Flight 101's final moments on his camera.
60 seconds after take-off, the plane slams into the ocean.
Lucas Bocanegra is a lifeguard stationed on South Beach near the Chalk's Ocean Airways sea lane.
As soon as I saw this, I realised.
I'm like, "Oh, no - this is the Chalk's airplane crashing.
" MAN: (OVER RADIO) We have a code four.
Repeat, code four.
A plane down in the water.
This is Lucas - we're launching the jet ski.
The two lifeguards are the first rescuers to go looking for the plane.
We drove as fast as we could to the scene of the accident.
There was a lot of things coming through my head.
I was nervous, scared.
I was kind of full of adrenaline.
Wanted to go in and try and rescue as many people as we could, but at the same time, we've never trained for a situation like this.
As soon as we turned Government Cut, with the jetty rocks, we noticed that it was very calm, very quiet.
It wasn't like the ocean side where it was very rough.
There were no waves - it was very kind of very eerie.
At first, Lucas Bocanegra finds no sign of Flight 101, or any of the passengers.
BOCANEGRA: Little by little, we started seeing debris float up onto the surface of the water.
And we saw some chairs, some luggage here and there, and suddenly we noticed there was a body in the water.
As soon as we put the body on our jet ski, we realised that from his injuries that there was nothing we could do.
From there, it was just try to recover as many bodies .
.
you know, bring 'em back for their families.
News crews swarm the beach.
REPORTER: Chalk's Flight 101 plummeted into the channel in full view of tourists lining Miami Beach.
It was so surreal.
We couldn't believe we actually witnessed that.
Chopper 4 over the wreckage as Miami Beach Coast Guard look for any survivors.
But the effort is futile.
All 20 people onboard are dead .
.
including pilots Paul DeSanctis and Michele Marks.
The residents of Bimini are devastated by the horrific news.
In Washington, senior NTSB investigator Bill English is put on the case.
MAN: I was very familiar with Chalk's Airways.
I'm a seaplane rated pilot myself, and there is the reputation - the legend - of Chalk's Airways, the oldest continuously operating airline.
Chalk's has a long and rich history.
The airline was founded in 1917.
During the Prohibition era, passenger lists included notorious rum-runners, and later, Hollywood movie stars.
Chalk's planes even patrolled for German U-boats during World War II.
WEBER: The novelty of flying at Chalk's was just all that history, all the people that have gone - and it was really a great place to work for that.
The Grumman Mallard flying boat that crashed was built in 1947.
Chalk's Ocean Airways is the only airline that uses Mallards to transport passengers.
They're not really a mainstream type of airplane, and so there's always that nostalgia about them.
Salvage crews find the plane's black box.
Investigators send it to the NTSB in Washington.
The only recorder onboard the Mallard was a cockpit voice recorder, or CVR.
have two flight recorders.
The flight data recorder, depending on the aircraft, will record all sorts of parameters of the flight - altitude, airspeed, control positions and so on.
The Chalk's airplane was not equipped with a flight data recorder.
It did have a cockpit voice recorder.
Though the lack of flight data is a big disappointment, media coverage of the crash gives investigators a very rare piece of evidence.
MAN: Authorities revealed that the final seconds of Flight 101 were captured on amateur video.
The dramatic footage was shot by a tourist on South Beach.
Let's get a copy of that video.
OK, let's see it.
The video only captured the final seconds of the plane crash, but it confirms eyewitness reports that a wing ripped off in mid-air.
Can you enhance that for me? The video showed the wing just after separation from the aircraft, the main part of the aircraft fuselage rolling off in the other direction, and the fire and smoke starting from that.
MAN: It was quite startling that the wing would fall off in this plane.
It was a beautiful day, the water wasn't rough on the take-off, and all of a sudden this wing just dropped off.
It must have been absolutely devastating.
However, the video can't reveal why the wing came off.
Answers to that question may lie at the crash site, where salvage crews are finishing their recovery of the wreckage of Flight 101.
The right wing is found separate from the plane but largely intact.
Wings falling off aircraft in modern-day situations is a very rare, extreme event, and there's only been a few cases of them in the past 20 or 30 years.
In Washington, another type of examination is already under way.
At the NTSB lab, technicians are busy analysing the Mallard's cockpit voice recorder tape.
The cockpit voice recorder, the CVR, which does what it sounds like - records the pilots' voices talking to each other or on the microphones.
(GARBLED VOICES PLAY) But the tape is a jumble of voices and sounds.
Technicians can't retrieve any useful information.
It turned out that the erase head function - it's just like a tape recorder that most people are familiar with .
.
it didn't erase the old stuff, so every subsequent flight kept getting recorded over and over and over again, and just became muddled sound and it wasn't wasn't audible to us, or useful.
It's another setback.
let's revisit this again, because we're running out of options here.
Investigators have fewer and fewer tools to work with.
Bill English considers the possibility that Flight 101 hit turbulence so violent that it tore the plane apart.
But the weather on the day of the crash doesn't support that theory.
Clearly, something else had torn this plane apart.
There's a possibility the Mallard collided with something in the water before take-off.
Seaplanes don't take off of a conventional runway.
They're in water, where there can be things like logs or other debris, which could potentially cause structural issues with an aircraft.
But before they can reach a conclusion on that theory, investigators consider some other intriguing evidence.
It's an urgent advisory issued by the Federal Aviation Administration, or FAA.
It warns that due to a faulty part, the propellers on the Mallard could come off during flight.
You're kidding me.
Something such as a blade separation, losing part of the propeller, could cause a great structural load on the aircraft.
English now has a solid lead, but his team is still missing the evidence they need to prove their case.
MAN: (ON NEWSREEL) The entire island is devastated by the loss of life, as investigators searching for answers wait for more wreckage to be pulled from the sea.
In the aftermath of the crash, Chalk's Ocean Airways grounds its remaining fleet of four Grumman Mallards.
At the NTSB's Miami command post, they're working to identify various plane fragments and other debris from the crash.
the wing itself that separated - the spar, which is the main part of the structure of the wing - and any of the other fracture surfaces, looking for obvious initiation factors.
They carefully examine the propellers, looking for evidence that might confirm suspicions raised by the FAA advisory.
But it's another dead end.
We were able to determine all the blades were attached, and the bending that we saw was the expected pattern from proper operation when those blades hit the water.
Once again, they're back to square one.
This is what I want you to look at.
Investigators focus their attention on the fractured wing.
They've noticed sooting on parts of it.
It's evidence of a very rapid fire.
We want to find anything that could be the initiating factor for the wing separation.
Could it have been a collision with an object? Could it have been a fire? Could it have actually been a criminal act? The burn marks raise a sinister possibility - an explosion.
A bomb.
This now falls outside the NTSB's area of expertise and authority.
Let's notify the FBI.
The FBI helps us in many of our investigations and we'll utilise some of their experts to rule out terrorism or criminal acts.
If it was a bomb that brought down Flight 101, a likely target would have been one of the 18 passengers.
Thanks for coming in.
We're gonna need your help on this.
One name stands out on the passenger manifest - Sergio Danguillecourt.
Welcome aboard.
- May I see your boarding passes? - Certainly.
There are rumours on the internet that the crash was an assassination plot and Danguillecourt was the target.
His family made a fortune in pre-Castro Cuba.
They were so opposed to Fidel Castro's regime that they had allegedly supported clandestine attempts to overthrow his communist government.
This is your copy.
Alright? Now, there's something I wanted to show you.
We can't tell if it's just soot or it's explosive residue.
A bomb will leave chemical traces and distinctive patterns in the torn metal.
FBI technicians are specially trained to detect them.
The samples from the wreckage will be tested at FBI labs in Quantico, Virginia.
Four days after the accident, salvage crews are still bringing in wing fragments found at the crash site.
So, we need everything that looks like it could come from the right wing.
Could we get some light over here? Overstress.
Most of the damage they see is from overstress fractures - areas where the metal was literally ripped apart when the wing tore off.
Come here.
That's the same.
When metal is suddenly stressed to the point of breaking, the fracture leaves a very distinctive rough edge.
It's easy to distinguish it from fractures that have developed slowly over time.
Cut this from here to here and get it to Clint in Washington.
to examine the right wing, spar and other components unseen at the coastguard station or the seaplane base This was a visual examination there.
We didn't have the sophisticated lab tools that we have at headquarters.
They identify parts to be shipped to the lab in Washington, where they hope closer inspection will reveal exactly what went wrong with the wing.
Hey, Clint.
Clint, we're sending you as much of the wing as we have your way.
Yeah.
OK.
Yeah.
No, I'm still waiting for that report.
The results from the FBI explosives test come in.
- Is that it? Yeah? - Yeah.
A midair bombing assassination could explain everything.
(SCREAMING) But there is no explosive residue on the wreckage.
OK, so that rules that out.
Structural failure is now the chief suspect in the downing of Chalk's Flight 101.
Well, that's all that's left.
That's tomorrow.
It was obvious the airplane had a catastrophic structural failure, so we needed to find out the cause, the initiating factor in that structural failure.
He needs to know more about the long history of this particular Grumman Mallard.
It's very typical in any accident investigation we want to look at the maintenance history of an aircraft.
For an aircraft that's 60 years old, that's even more so important.
It takes days to comb through the 28 boxes of old records.
We want to make sure that we can develop an entire history of this aircraft, what sort of chronic problems may have shown up in the maintenance of the aircraft and what types of work had been done on any of the factors that looked likely to have been involved.
Clint Crookshanks is a structures investigator for the NTSB.
When we go into an investigation, we try to go in with a very open mind and look at the wreckage and let it tell the story for what happened.
We wanted to look at every piece that broke on the right wing to determine if this was an age-related failure or if it was something that was caused by a structural overload.
As with most aircraft, the Mallard's wings are built from aluminium alloy.
The spars run the length of each wing.
In between the spars are stringers that give added support.
Together, these parts make up the wing box, which also doubles as a fuel tank.
And then the skin is over top of all of that structure to kind of give a smooth, aerodynamic look to the wing.
All of these together work to carry the flight loads that the wing is designed to carry.
Once you compromise one piece of that structure, the ability to carry the normal flight loads has been compromised.
Thanks.
Over the years, the wing box had been repaired many times.
Chalk's' mechanics had patched up areas damaged by corrosion, which is not unusual for an ageing aircraft, especially a seaplane.
The fact that they land on water means that their take-off and landing loads are different than you would have on a land-based airplane.
Also, they're always in water, and the corrosive effects of water are going to happen more readily on those airplanes.
But when investigators examine the rest of the Chalk's fleet, they find that the Mallards are in far worse shape than they imagined.
"Corrosion repairs.
" "Corrosion.
" "Corrosion.
" "Corrosion.
" "Corrosion.
" "Corrosion repairs.
" Lots of 'em.
The accident airplane and the other airplanes in Chalk's fleet were rife with maintenance issues.
Corrosion was rampant on all the airplanes.
There was evidence of shoddy maintenance practices on all of their other airplanes.
CROTTY: Many, many of the repairs exhibited extremely poor workmanship in quality - double, triple drilling of holes, excessive grinding, of corrosion, scars on the material, and this involved the structural repairs that were made to the aircraft over the past few years.
Crookshanks' attention is drawn to a section of the lower right wing.
There is a metal patch, called a 'doubler', on the surface of the wing's skin.
A doubler is simply a sheet of metal that goes over top of the skin, and it acts as a load transfer.
It acts as a second piece of skin to patch the crack.
It's kind of like the patch on a pair of jeans.
This is a big repair job.
You sure we don't have anything on this? It's an intriguing discovery.
The patch is located exactly where the wing broke off from the rest of the plane.
When he takes a closer look at this section of the wing, Crookshanks notices the edges are smooth and shiny - totally unlike the rough edges he's been seeing on other debris.
We gotta see what's under this.
This crack is not from overstress.
Instead, Crookshanks suspects it developed over many years as the result of metal fatigue.
Metal fatigue is a process by which any piece of metal - wing spar or anything - is repetitively loaded and unloaded.
You can think of it as bending a paperclip back and forth - and everyone's done this - and after a while it eventually breaks.
Metal fatigue in the wings is caused by the stress of flight over the lifetime of the aircraft.
In the case of this aircraft, every time it took off, the wing is loaded.
That's lift that gets the airplane up into the air.
Every time it lands, the wing is now unloaded and there's no more stress on the wing structure anymore.
That's just like bending that paperclip back and forth.
Crookshanks is eager to find out what's underneath the metal patch.
OK.
Let's see what this doubler's hiding.
They find even more metal fatigue.
Deep cracks cut across the wing.
The extent of the damage is staggering.
A crack 40cm long.
Man, oh, man.
Investigating further, Crookshanks makes another disturbing find.
Three machine holes in the skin forward of the leading edge.
All three appear to be stop drill holes.
The holes indicate that Chalk's mechanics had been trying to stop the crack from spreading further.
Years earlier, a mechanic had spotted the crack on the lower surface of the wing.
He repaired it by drilling a hole in the path of the crack.
It's called a 'stop drill hole'.
The end of a crack - you can see even with the naked eye - is sharp.
It comes to a point.
That tends to want to develop a crack more.
By drilling a hole at the end of the crack, that will spread out the stress and the idea is to stop the growth of the crack there.
But the stop drill holes didn't work.
CROOKSHANKS: An attempt was made to repair that skin on three different occasions by stop-drilling.
Even as mechanics put in more holes, the crack kept growing.
After the third stop drill, an attempt was made to further repair the wing by attaching doublers on the interior and exterior surface of the skin.
But the doublers didn't work either.
The crack on the plane's skin continued to grow.
Investigators now know the right wing was damaged long before the day of the accident.
What they don't understand is why the crack could not be stopped.
"Approved"? But a glimmer of an answer comes when they learn the plane was sending out warning signs of a deeper, more serious problem.
involved in the accident was showing evidence of chronic fuel leaks for a long period of time - for many years.
According to the log, fuel leaks from the right wing were repaired again and again, but they kept happening.
WEBER: The crew started to notice repeated fuel leaks during standard operations and we tried to bring it to the attention of management just for our concerns.
Just two days before the crash, it happened again.
While doing routine maintenance on the Mallard, a mechanic came across fuel dripping from the right wing.
They'd always address the problem with trying to reseal the fuel tanks or trying to fix whatever problem they thought they had.
It always seemed to be a reoccurring issue.
The procedure for plugging a leak was to apply a chemical sealant to the inside of the empty fuel tank.
The sealant would take a day to dry.
Then the plane could be refuelled and returned to service.
The leaks should have been a clue that the crack in the wing skin was just the tip of the iceberg - that there was a much more dangerous problem with the wing's interior structure.
Fuel leaks in this particular aircraft are indicative of a problem with the wing structure.
In fact, Grumman put out a service bulletin back in 1963 that warned mechanics chronic fuel leaks are an indicator of a structural issue with the aircraft.
Crookshanks examines the pieces that make up the right fuel tank.
Some kind of sealant.
He wonders why the fuel leaks persisted in spite of the constant efforts to repair them.
OK.
Hand me that scraper, please.
Thank you.
Beneath the layers of sealant, he finds his answer.
Bingo.
Cracks in a critical support beam called a 'Z-stringer'.
It's the piece that the plane's skin was directly attached to.
Crookshanks finds evidence that Chalk's mechanics had tried to repair the stringer.
It appears that they did some grinding on the Z-stringer to remove a fatigue crack.
However, they never went back in and re-inspected that area.
Instead, they only applied chemical sealant to the area to make it leakproof, and in the process concealed the damage.
Chalk's made repeated attempts to repair the airplane by stop-drilling the wing skin cracks, adding doublers over top of the cracks, but they never addressed the root of the problem, which was the cracked Z-stringer.
The reason they couldn't address the Z-stringer is it was covered in fuel-tank sealant.
The broken Z-stringer weakened the entire wing.
Now with every take-off and landing, the plane's skin was absorbing the forces.
Over time, the skin began to crack as well.
The final outcome was inevitable.
The fatigue cracking reached critical length and the wing separated from the airplane.
(SCREAMING) Investigators conclude that a hidden crack in a key component of the right wing led to the devastating crash of Flight 101.
Chalk's failure to identify such a serious problem now forces investigators to re-examine the airline's long history.
Chalk's Ocean Airways had an image as one of the safest airlines in the world.
Despite the age of their fleet, the airline had an outstanding record of safety, dating back almost 90 years.
Chalk's' safety record was great.
They had never lost a passenger in all their years of operation.
Chalk was an old, established company, but it seems to me that somewhere along the line, the management and the quality of the work done had slipped quite a bit from in the past years.
What have you got on the financial state of this company? Investigators are beginning to suspect that the company's reputation for safety may have been undermined in recent years by money problems.
Financial issues in an airline, especially a small carrier like this, can manifest themselves in many ways.
Personnel are sometimes one of the first things to go.
A search of Chalk's financial history uncovers some trouble.
In the 1980s, Chalk's went through a string of owners before going bankrupt in 1999.
The airline was revived by a Miami businessman, but it kept losing money.
Just a few months before the crash, the last attempt to sell the business fell through.
Not doing so well.
It wasn't a secret that we were having financial difficulty.
The pilots were taking pay cuts, the captains were taking concessions and, you know, we downsized a lot as far as personnel.
It wasn't just personnel that felt the pinch.
It was difficult for Chalk's to find spare parts and to do some of their repairs.
Chalk's had a number of other unflyable aircraft that they owned that they would cannibalise for spare parts.
There were maybe only 50 or 55 aircraft ever built.
In that case, the original manufacturer, Grumman, was no longer in production of that aircraft.
They no longer supplied parts.
The airline's deteriorating health and the shortage of spare parts had a direct impact on safety.
There's so much regulation and there's so muchjust necessity to make the airplane fly, it's hard to skimp on maintenance and not impact reliability.
And if you don't have reliability, then you're just spiralling downhill.
But no matter how tight the finances were, as a commercial airline, Chalk's should have been closely monitored by the Federal Aviation Administration.
In fact, the FAA did assign an inspector to work closely with Chalk's.
The FAA inspector, which is called a 'principal maintenance inspector', was responsible for the oversight of the maintenance program as carried out by Chalk.
The inspector was aware the plane was suffering from chronic fuel leaks .
.
and yet, inexplicably, he gave Chalk's a clean bill of health just two months before the crash.
What was this guy doing? Investigators are at a loss to explain why the FAA inspector didn't pick up on warning signs the Chalk's seaplane was giving off.
The fact that Chalk was an old, established carrier - maybe they just accepted, "Well, there's only two or three planes.
"It's a small operation.
"They only fly during the nice weathers.
"They're good old boys over there.
"They know what they're doing.
" In effect, the FAA didn't step back and take a look at the forest for the trees and find out just what's going on in the maintenance program with these Chalk's aircraft.
The FAA may not have found fault with Chalk's, but it turns out that several people very close to the airline did.
We did talk to this group of pilots who had left Chalk's prior to the accident, and every single one of them did have some story about maintenance aspects on their aircraft.
Whether it had to do with fuel leaks or other maintenance aspects, they all had some level of concern about the way Chalk's was taking care of these very old airplanes.
In fact, the pilots were so concerned that in the year leading up to the crash, many of them met to discuss the problem of declining maintenance.
WEBER: The captains of the company decided that it would be best for us to get together as a group, discuss the issues that we had, to try to get our concerns addressed.
One major issue that had happened, we had an elevator cable that had snapped in flight, and the crew, luckily, was able to get the airplane down using power and different settings and shifting people, but most scenarios, that would have been an accident in itself.
In aviation, there's air chains that they talk about, and you have to just If you keep compiling one link after another, it's only a matter of time before an accident will occur.
And from my point of view, I thought that if they kept going down the same road that they were going down, something could happen.
Eventually, Captain Weber decided he'd seen enough close calls.
My turning point in why I decided to leave Chalk's was I just had seen too many things in the recent months, too many mechanical issues that were major issues, in my mind, and I had 300 failures myself that year, and I had a wife at home that was pregnant.
I had lost, I guess, my confidence in the company's ability, or the airplane, and I just had had enough.
The NTSB's report on the crash of Flight 101 harshly criticised the FAA for not detecting growing maintenance and financial problems at Chalk's.
Had the maintenance program or the FAA stepped back and said, "These aircraft need more than just a one-time fix - "they need something much deeper than this," the accident probably would not have happened.
It also uncovers a loophole in the FAA's ageing aircraft regulations, which require extra inspections for older planes.
But those rules didn't apply to Mallards.
CROOKSHANKS: The Grumman Mallard was manufactured in 1947.
It only carried 17 passengers and it was not a transport-category airplane, therefore it was exempt from these supplemental inspections.
What we have here is the FAA has made an ageing airplane safety rule and they've exempted the oldest airplanes in the fleet.
The NTSB recommends that the FAA expand its oversight of ageing planes.
When we determine the probable cause of an air crash, the point is to do this so that similar accidents won't happen again in the future.
I think we've used this accident to point towards the industry and the FAA to make sure that they take a look at the overall picture of what's going on at an air carrier.
Flight 101 spelled the end of Chalk's Ocean Airways.
A few months after the report was released, the airline shut down.
WEBER: There was a lot of history and a lot of family, community involved - passengers as well as the people on the airline.
So to see the whole airline and everything else kind of go down with the airplane is additionally, you know, emotional for everybody that ever worked there or ever loved the airplanes.