Mayday (2013) s18e01 Episode Script
Nuts and Bolts
- GPWS: Terrain.
Pull up.
- Emery 17.
We have an emergency.
NARRATOR: An American cargo plane needs to make an emergency landing.
Pull up.
Bring it around.
They didn't have controllability of the aeroplane.
Roll out to the right! - Power.
- More? Yeah.
The pilots bring their DC-8 to within sight of the runway.
(YELLS) And I said, you know, "Oh, my god, we've lost an aeroplane.
" MAN: It was, like, basically a war zone.
OK.
You ready? To try to understand what went wrong, investigators call on a friend and colleague of the crew.
(YELLING) (STATIC) I can still hear it.
You know, you just don't It doesn't stop.
(ENGINE ROARS) MAN: Mayday, mayday.
You flew jump seat from Dayton, right? Yes, sir.
What was the hold-up? New windshield.
That took what - four, five hours? That'll mess up a day.
Rather they just stuck it on with crazy glue? Hey, at least my side would be fine.
Well, that's all that matters, then.
Captain Kevin Stables is preparing to pilot Emery Worldwide flight 17.
His first officer is George Land.
They're flying freight across the country aboard a 30-year-old DC-8 cargo plane.
JOHN ALBRIGHT: The DC-8 was a fantastic plane.
That thing was built like a tank.
Captain John Albright has just checked into a hotel after finishing his latest shift for Emery Worldwide.
The DC-8 was, um - it was kind of a pilot's plane.
It took a lot of work, and it took a lot of physical effort.
Getting all prettied up for the load master? Hey.
At least I try to look like a professional.
JOHN ALBRIGHT: The crew was just fantastic.
They were enjoying being with each other and enjoying the job that they were getting ready to do.
I'd flown with George several times.
He was always smiling and always friendly, always had his hair fixed just right, which we all kind of thought was funny 'cause we were flying night freight and nobody got to see us.
Captain Stables started his day as a passenger on the plane as it flew from Dayton, Ohio, to Reno, Nevada.
In Reno, he took over as captain and flew to Sacramento.
Now he and First Officer Land are taking the cargo plane back to Dayton.
Hi there.
Is that the load plan? Just before they're finished up and loading the last couple of containers, they would give us a list of all the freight containers and how much it weighed and what position on the aeroplane it was.
There you go, boss.
Then we'd take that information and we would calculate the weight and balance on the aeroplane and make sure that it was all correct.
Inspection's complete.
Cargo doors closed.
Joining the pilots is flight engineer Russell Hicks.
The flight engineer - he handled all the systems, the electrical systems, the hydraulic systems and pneumatic systems.
He was the man behind the curtain, so to speak, and kept the aeroplane running.
Alright, boys, let's hit it.
Left rudder, centre.
Checked.
As they taxi to the runway, the pilots conduct a series of flight control checks.
Right rudder, centre.
Checked.
Elevator forward.
Coming back.
Elevator position indicator checks.
It's all calm efficiency in the cockpit.
Taxi checklist.
Taxi checklist - flaps and slots.
15-15-15.
Slot lights out.
15-15-15.
Slot lights out.
JOHN ALBRIGHT: Some days you sit up in the cockpit and you look out the window and you think, "Boy, I just can't believe "anybody's paying me to do this.
Taxi checklist complete.
MAN (OVER RADIO): Helicopter one-six-seven-one-nine.
Position report to Mather.
It sounds like he's getting a massage.
(BOTH CHUCKLE) Once you got assigned a schedule you'd be with the same three guys for a month.
So, uh, you they'd be your second family.
I've never been up in one of those Airstar helicopters - you know, like the Cadillac of helicopters.
You'd go eat dinner with them, you'd go hang out with them on layovers, so you got to be very close with who you were flying with.
Emery 17, Sacramento approach.
You're released for departure.
Report when airborne.
Emery 17 heavy, we'll call you once we're in the air.
GREG FEITH: The controllers cleared the pilots to be able to take off and actually start to establish and navigate from Mather, Sacramento to Dayton, Ohio.
JOHN ALBRIGHT: On that particular day, I was laying over in Salt Lake City, and I happened to be laying on the bed and the TV was running in the background.
Hey, it's me.
Yeah, I just checked into the hotel.
Airspeed's alive.
Alive here.
80 knots.
80 knots.
Elevator checks.
NARRATOR: Just another routine take-off.
V-1.
Rotate.
But as the nose wheel leaves the ground .
.
the DC-8 pitches upward much more steeply than it should.
Watch the tail.
GREG FEITH: They recognise that they have an issue during the course of the aeroplane actually starting to rotate as it lifts off the runway.
V-2.
Positive rate.
The sudden take-off is quickly followed by an uncommanded left bank.
- I got it.
- You got it? Yeah.
This is anything but routine.
- We're going back.
- What the hell? The centre of gravity is way out of limits.
They need to return to the airport as quickly as possible.
Emery 17, emergency.
Emery 17, say again.
GREG FEITH: When a pilot declares an emergency, that really cues an air traffic controller to know that this isn't just an abnormal situation - this is a critical situation.
Emery 17.
We have an emergency.
You steer.
I'm pushing.
So now you have three pilots trying to work in harmony.
That's good from a cockpit resource management standpoint.
GPWS: Terrain.
Terrain.
Pull up.
The ground proximity warning begins to sound.
GPWS: Terrain.
Terrain.
Pull up.
RUSSELL HICKS: We're sinking.
We're going down, guys.
Alright, alright.
GPWS: Pull up.
Terrain.
RUSSELL HICKS: OK.
We're going back up.
The DC-8 starts climbing again.
Roll out.
Roll out! But the pilots are still struggling for control.
Emery 17, extreme balance problem.
Emery 17, roger.
The aeroplane started to go into these big perturbations - dive and then climb, dive and then climb.
Roll out to the right! (ALARM BLARES) Push.
Push forward.
(GRUNTS) They push their control columns all the way forward in a desperate effort to level the plane.
Power.
- More? - Yeah.
Left turn.
OK, what I'm trying to do is make the aeroplane's position match the elevator.
That's why I'm putting it in a bank.
So we're gonna have to land it in, like, a turn.
GREG FEITH: They were trying to return back to Mather.
So it was gonna be a long, sweeping traffic pattern that they were gonna have to fly because they didn't have controllability of the aeroplane.
Bring it around.
- Damn it! - GPWS: Too low.
Terrain.
You got the airport? GREG FEITH: Mather doesn't have a lot of surrounding lights.
It's considered what's called a 'black hole'.
Bring it around.
Power.
NARRATOR: Captain Stables and his crew have managed to get their crippled plane to within sight of the runway.
JOHN ALBRIGHT: It was working very well.
They made it almost all the way around to the back side of the airport.
GREG FEITH: They knew if they could get back to the airport there was gonna be crash fire rescue that would have been able then to help them.
NARRATOR: They've now got less than a mile to go.
They're still trying to look ahead to figure out what needs to be done next.
But they know that sooner or later they gotta get on the ground.
(BOTH YELL AND GRUNT) NARRATOR: Emery Worldwide captain John Albright relaxes in his hotel room on a layover in Salt Lake City.
I had CNN on and I was talking to my wife on the phone and, uh, there was a lot of sirens and noise and flashing lights on the TV, and it kind of distracted me from talking to her.
REPORTER: Investigators are collecting clues Then when I looked up, I saw something about Emery.
A DC-8 that took off from Mather Airport immediately ran into trouble.
The plane, along with its crew, went down.
I said, "Oh, my god.
We've" We've lost an aeroplane.
They now know that the DC-8 clipped a building on the salvage yard.
She said, "What do you mean?" I said "Well, turn the TV on.
"I'm watching right now and a plane's crashed.
" It's one of ours.
Billowing orange flames and black smoke marked the fiery end of flight 17, an Emery Worldwide Freight DC-8 bound for Dayton, Ohio.
(SIREN WAILS) Emery flight 17 has crashed into a car scrap yard one mile east of Sacramento's Mather Airport.
All three crew members are dead.
MAN: Our fire crews arrived.
They had a large fire, and there was no chance of rescue.
The next day, the site is a smouldering scar of twisted metal.
GREG FEITH: It was, like, basically a war zone because the aeroplane had crashed into this auto salvage yard.
The job of figuring out why this happened now falls to the National Transportation Safety Board.
Hey.
There were hundreds of cars out there, many of which had burned, and then of course the aeroplane just cut a swath through all of these cars.
There were still smoking automobiles and car parts and aeroplane parts.
This place is a mess.
Yeah.
With so much fire damage and thousands of car parts on-site, just finding the aeroplane wreckage is going to be a huge challenge.
The NTSB's John Goglia helps lead the effort.
Put this in the plane bin for me, please.
Mechanical pieces, especially after they're burned, it's very difficult to tell a piece from an automobile from a piece from an aeroplane.
So I looked at the scene and said, "Wow, we got a real tiger by the tail here.
" You can't just get everybody out there and start rummaging through parts.
You have to have a very systematic and methodical process.
Alright, guys, listen up! Let's build the grid.
Alright? Let's go! Investigators will have to sift through a debris field about 450 feet wide and a quarter of a mile long.
That looks like wiring from a car.
We actually had all of the investigators working through this very methodical grid process deciphering car parts from aeroplane parts, making that separation and then moving on systematically.
They went down less than a mile from the airport.
Whatever went wrong, it went wrong right away.
They were in a cargo plane.
Maybe it was a load problem.
Make sure we get those load sheets sent to the office.
I want to take a look at those, alright? (RADIO CHATTER) NARRATOR: The team soon makes a crucial find - the most important items of evidence in any air crash investigation.
Well done, guys.
We did find both the cockpit voice recorder and the flight data recorder, which actually sped up that part of the investigation 'cause we could send those two boxes back on the aeroplane that we had flown in on.
MAN: The description that was given to me regarding the two boxes were that they had sustained some fire damage but they were in relatively good shape.
The NTSB sends the critical recording devices to Washington, where lab technicians can begin the job of processing the data.
At the same time, investigators hunt down as much other evidence as they can.
Morning.
I just spoke with the air traffic controller.
He said that the pilots called in a centre of gravity issue immediately after take-off.
Emery 17, extreme balance problem.
It sounds like a problem with the cargo.
Well, could be.
Because the initial report was that there was a possible centre of gravity issue, we had to confirm what was on the aeroplane.
Alright, so there's supposed to be 18 positions, right? One container for each pallet.
We had to get the load manifest.
We had to understand what was in the pallets, how many pallets were loaded, how many containers were on the aircraft and what was in those containers.
You got that load sheet? They learn that flight 17 was carrying nothing unusual - mostly clothing.
But they wonder - did the positioning of the freight cause a dangerous imbalance? If you look at an aeroplane, there is a point in the middle of the aeroplane that is the centre, and everything flows around it.
So if you have too much weight in the back, alright, the centre of gravity's gonna shift to the rear and the aeroplane's gonna fly differently.
Alright.
This looks a little lighter than usual, but it's well within the centre of gravity limits.
Load distribution was not the culprit.
Something else must have caused the crash.
The team is soon chasing a new lead .
.
past complaints to the FAA from Emery pilots.
It seems some pilots were worried about how the company was securing its cargo.
They reported seeing frayed straps and netting.
(SIGHS) You know, if Emery was lax with their loading practices, the load could have shifted.
We had to talk to the folks that actually did the loading.
"What was the position of the pallets and the containers? "How did you load 'em? How did you secure them?" What if the cargo wasn't properly secured? NARRATOR: To understand just how secure the cargo was on flight 17, investigators head to California.
I decided I would take a trip out to Sacramento to see who was loading, how they were loading.
The NTSB's John Goglia tracks down the freight handlers who worked on Emery Flight 17.
I actually had a company that loaded and unloaded aeroplanes, including Emery's aeroplanes, so I was very familiar with the loading process.
Gentlemen, hi.
How are ya? I'm with the NTSB.
Mind if I ask you a few questions? At first they were standoffish, and then as the conversation went on, naturally I mentioned that I used to work for them and I did the job that they were doing, so then they opened up.
Just like I told you, it was routine - nothing we haven't done a thousand times before.
Any chance any of the cans were misloaded? No.
We did everything by the book.
Any problems with any of the equipment, like maybe a bear claw that you had trouble locking up or something? We wouldn't load anything if we felt it was unsafe.
Gotcha.
OK.
Well, listen, thank you so much.
I appreciate it.
And they were very vehemently opposed to a load shift.
They said it couldn't possibly have a load shift.
Despite the assurances from the load team, investigators need hard evidence that the cargo was secure.
The NTSB goes by facts, right? So even though we have a thought, you have to prove the thought.
They examine cargo fasteners recovered from the wreckage.
If there was a load shift, the metal clamps, known as bear claws, should display distinct damage.
GREG FEITH: When we're looking at these bear claws, we're looking for physical evidence.
That is, if the pallet was clamped in place and the energy from the impact pushed it, it would typically break it or leave a witness mark or impact mark.
They find no such evidence.
All of these restraints look just fine.
The thing is, if there wasn't a problem in the cargo hold, why were the pilots reporting a problem with their centre of gravity? Is that the CVR? Oh, finally.
Alright, let's do this.
They hope the cockpit voice recorder from Emery flight 17 will provide some answers.
- Here you go, John.
- Thank you.
The NTSB asks Emery Worldwide captain John Albright to listen in.
JOHN ALBRIGHT: You want somebody that knows the pilots.
I was the only one out there that was able to say, "This is Kevin" or "This is George".
I know the voices.
OK.
You ready? OK.
They told me that one of the things I had to be concerned about is that a very high percentage of people that go out and listen to the CVR, within two years quit flying.
When you hear the voice recorder on flights that have .
.
where the crew has perished, it can be quite painful and be emotional because you know that the person you're hearing is no longer with us.
KEVIN STABLES: Uh, 15-15-15.
Slot lights out.
GEORGE LAND: 15-15-15.
Slot lights out.
That's Kevin, uh, Captain Stables.
OK.
Then George Land, the FO.
Set right.
Taxi checklist complete.
When you listen to it, of course they're very professional.
They're doing their checklist items.
They respond appropriately, and everything appears to be normal.
MAN (OVER RADIO): Helicopter one-six-seven-one-nine.
Position report to Mather.
(CHUCKLES) Sounds like he's getting a massage.
(LAUGHS) Airspeed's alive.
Alive here.
80 knots.
80 knots.
Elevator checks.
So at 80 knots, they do their elevator check.
You push the control column full forward to verify that the elevator is in fact moving.
V-1.
They'd call V-1 .
.
and as they get close to VR the aeroplane rotated all on its own.
Rotate.
Watch the tail.
NARRATOR: The captain sounds concerned that they're pitching up too quickly.
When something like that happens, you run through it in your mind as fast as you can.
"What's going on?" - We're going back.
- What the hell? The centre of gravity is way out of limits.
So immediately he ran through the scenarios in his head and came up with, "This is probably load shift".
NARRATOR: But the investigation hasn't found any evidence of a load shift.
They keep listening for any sign of what else might have caused the sudden upward pitch.
- GEORGE LAND: Power.
- More? - Yeah.
Left turn.
- GPWS: Pull up.
OK.
What I'm trying to do is make the aeroplane's position match the elevator.
That's why I'm putting it in a bank.
Wait, wait, wait, wait.
What did he just say about the elevators? The elevators are part of the tail and control the aircraft's pitch.
When tilted upward, the force of the deflected air pitches the plane's nose up.
When the elevators move downward, they cause the nose to pitch down.
GEORGE LAND: OK, what I'm trying to do is make the aeroplane's position match the elevator.
That's why I'm putting it in a bank.
NARRATOR: Investigators now wonder if there was a problem with the elevator.
If your elevator isn't where you think it is, uh, an aeroplane can take off by itself.
You got the airport? - GPWS: Too low.
Terrain.
- Bring it around.
- Caution.
Terrain.
- Power.
Caution.
Terrain.
(GRUNTS) NARRATOR: It seems the pilots were trying to control the plane by dipping the left wing to bring the nose down.
DENNIS CRIDER: I think that the crew did a remarkable job of working together, and this technique that they were doing - trying to control their pitch with roll - that was very, very advanced.
They did a very good with the set of cards that they were dealt, but their hand was not a winnable hand.
- GPWS: Pull up.
Airspeed low.
- Come on! Come on! Come on! - Pull up.
- Come on! Pull up.
Airspeed low.
Terrain.
Terrain.
Pull up.
(STATIC) You'd start listening to that thing early in the morning a couple of seconds at a time.
So you'd listen to your buddies die for three days straight ten seconds at a time.
They did everything that they could, alright? Something doomed them right from the start.
Hey, uh, John? I still hear it.
You know, you just don't It doesn't stop.
OK? Take care of yourself.
NARRATOR: The cockpit recording has focused investigators' attention on the DC-8's elevators.
But their job is far from done.
It will take more digging and more hard evidence to understand what caused flight 17 to crash.
NARRATOR: Performance data from Emery Worldwide flight 17 is now in investigators' hands.
For the first time, they can see exactly how the plane was moving during its short, erratic flight.
OK.
Everything's up.
They hope the data will also hold clues that will explain why the flight went so horribly wrong.
Alright, let's see what the data says about the load shift.
The critical part of a flight data recorder is that it gives us performance of the aeroplane.
We can find out, "Was that characteristic of a cargo shift "when the aeroplane pitches up like that?" You know what? Let's put up the data from the flight that crashed because of the load problem.
It's Fine Air 101.
The investigators know that just three years earlier in Miami, a Fine Air DC-8 crashed on take-off when its cargo load suddenly shifted.
Five people died in the disaster.
One of the things that the performance engineers will look at is they'll compare it and contrast it to previous flights.
Alright.
Let's take a look at them side-by-side.
And the rotation rates, please.
The rotations are totally different.
Definitely not a cargo shift.
What about the elevators? Look at that.
Look at that right there.
The first officer, he pushed the column forward and the elevators did not respond.
Look at that! Boom.
NARRATOR: The data clearly shows that there was something wrong with the right elevator.
DENNIS CRIDER: The big thing, of course, is the FDR shows the elevator nose-up, and he's pushing.
- Push.
- GPWS: Pull up.
Obviously then the pilot can't fly if the elevator is not doing what he wants it to do.
That became the crux of the matter.
Push forward.
Terrain.
Why was that elevator, um, nose-up when the pilot was commanding nose-down? Let's take a look at that wreckage.
And everything - everything to do with those elevators.
We went through the storage facility where we had collected everything that we could, and we dug through there looking for any pieces whatsoever of the flight controls, the elevators in particular.
The elevator wasn't hydraulically-powered.
It had, uh, control tabs on it to move the elevator.
Everything was analogue - cables and pulleys.
They closely examine the recovered elevator assembly, looking for signs of failure.
So these are the push rods from the elevator assembly.
The push rods are a key part of the elevator mechanism.
They move a crank that in turn moves a control tab that makes the elevator swing up or down.
Investigators know there are two push rods, one to control the right elevator and one for the left.
The left control rod was broken.
Why isn't the right one damaged like the left? GREG FEITH: When we looked at the right control rod, we didn't see the same kind of damage.
We didn't see what we would have expected if it had been properly secured in the linkage.
And in fact all it was, it was relatively intact.
Have we got the crank tab fitting to this one somewhere? They hunt down the part that the push rod was supposed to be attached to.
Once again, the kind of damage they see is not what would occur in a catastrophic crash.
It looked like they were hitting each other or had an interference rub against each other.
But that was not what we would have expected to see if they had actually been linked together in their proper position.
We didn't see the typical overload type damage.
It all leads to a disturbing conclusion.
This right push rod wasn't even connected.
It was clear that one of them had been disconnected.
There was physical damage shown.
On the one side, it was still fully connected.
On the other side, it wasn't the case.
It's a major discovery.
An important flight control mechanism somehow became disconnected before the DC-8 hit the ground.
The big question now - is that what caused the crash? Can a disconnected push rod really have brought down this plane? Metal doesn't lie, right? So we've got physical marks on there.
Now we can actually do some analysis and try to determine what those bang marks were caused by.
NARRATOR: The NTSB is ready for some real-world testing.
A DC-8, just like the one flown by the Emery pilots, is the test subject.
Alright, let's do this.
Investigators want to study how the plane's elevator assembly moves Alright.
Hand me the ratchet, please.
.
.
and see what happens when a push rod is disconnected.
So this is the rod in question, and this is the bell crank right here.
And you can see this little slot inside the bell crank, and this is where this would fit into.
Alright.
Let's see what happens when we move the elevator.
Go ahead.
Move the elevator.
So as this rod moves, and this rod is connected to the control column in the cockpit, as it moves up and down it pulls on this bell crank, which is attached to the elevator and causes it to move in the proper direction that the pilot wants it to move in.
Alright, cut it.
I'm gonna disconnect it now.
It would be attached with a nut and a bolt, and the nut is what they call castellated, so it looks like a castle, and inside those castellations you would put a cotter pin that would lock it in place.
With the right side rod assembly disconnected, they call for the elevator to be moved again.
OK, now try it.
It seems that disconnecting the push rod neutralises the elevator, but it does not jam it in the nose-up position.
Alright, you can stop.
There's nothing here.
It's looking like their experiment has failed to reveal any answers.
Let me try one more thing.
Then, in a final effort, they attempt to simulate the kind of vibration experienced during an actual take-off.
80 knots.
80 knots.
The air forces on that elevator are rather severe, so it's not wiggling around like I show it here.
It's banging.
It's showing some real force.
With the extra force, they discover that the push rod can jam the elevator in the nose-up position.
This rod is jammed in.
Even though the elevator is trying to move and the crew is trying to move it Push! .
.
it's not gonna go anywhere because it's jammed in place.
GREG FEITH: No matter what you did with the flight controls, that interference fit would always be there and it would jam the flight control.
So that was more of a Eureka moment.
Without the cotter pin in the bolt, a push rod can jam.
That gave us a good indicator of why this aeroplane was commanding nose-up all the time.
It's the breakthrough investigators have been hoping for - evidence that a disconnected push rod assembly jammed the right elevator on Emery Worldwide flight 17, making the plane practically impossible to fly.
But they still don't know why the assembly came apart.
GREG FEITH: We had to determine, really, what caused that separation of that control rod.
We know it was a bolt, a nut and a cotter key.
The question is, did it fail? Was it properly installed? And who was responsible for it? Investigators scan maintenance reports, checking to see if any work had been done on the right elevator assembly recently.
So it looked like the plane was in for a major overhaul just three months before the accident.
The elevators, the control tabs, the rudder and its tab - all of that had been removed for overhaul and then reinstalled during this very inclusive and invasive check.
Have you got that work card? The work was carried out by Tennessee Technical Services, TTS, in Smyrna, Tennessee.
The question is did the maintenance folks actually follow the proper procedure and then inspect it as it was supposed to be inspected? Well, it looks like everything was done properly.
The paperwork from Tennessee is all in order.
It seems the DC-8 was perfectly fit to fly after the major overhaul.
Alright, so was there any other work done on this aircraft? One of the things that you always look at is what was the last thing touched on the aeroplane? Well, well, well.
Look at this.
TTS wasn't the only place to do maintenance on this plane.
Well, after it left the facility in Tennessee, there was one other piece of maintenance on the tail of this aeroplane - and it was done over the weekend in Dayton, which is where many of the aeroplanes spend the weekend for Emery.
12 weeks before the fatal flight, Emery mechanics swapped the aircraft's elevator dampers, parts located near the control rod.
It could be an important new lead.
I think it's about time we go pay a visit to Emery's mechanics.
Agree? GPWS: Too low.
Terrain.
So can you show me how you go about swapping the dampers on this DC-8? Reach over here In Dayton, they talk to the last mechanic to have worked on the plane's tail.
Detach it from the elevator.
GREG FEITH: One of the things that, uh, mechanics are always looking for is an easier way to perform their responsible duties.
That looks tricky.
Do you ever just disconnect the elevators to get it out of your way? Well, we're really not supposed to.
I know.
Is it hard to do? An easy way to do it is to relieve the control tab by removing the bolt, the nut and the cotter key .
.
and allowing the elevator tab to flex down.
That makes getting into this damper easier and quicker to replace.
(GRUNTS) Well, that was easy.
You ever do it that way on an actual job? Like I said, we're really not supposed to.
Right.
Uh (CLEARS THROAT) .
.
it says that you were the one who did the actual work.
Was there anyone here to help you? One of the things that came through loud and clear was how thin they were with labour, how thin they were with management of their workforce.
Ever done this procedure before? Well, I followed the manual.
And now if you take that and look at a young mechanic, relatively inexperienced, working alone on the weekend doing something he had never done before - nobody to ask for advice and nobody to provide him guidance or supervision - so he was between a rock and hard place.
One more question.
Um, it says they gave this plane a complete overhaul.
Why did you bother swapping the dampers? Well, the guy in Tennessee put them on the wrong way.
OK.
Well, thanks very much for your time.
I appreciate it.
A mishandled overhaul in Tennessee and a disturbing lack of supervision at Emery's maintenance facility lead investigators to wonder - does the airline have a systemic problem with aircraft maintenance? NARRATOR: Investigators dig deeper into Emery's maintenance practices, eager to learn if they played any role in the crash of flight 17.
JOHN ALBRIGHT: We were the best of the worst, which is what the saying was.
We weren't FedEx.
We weren't UPS.
We weren't Airborne.
Um, but there was a whole 'nother sub-tier of freight hauler.
They discover that the once respected airline's maintenance program was causing serious concern among its pilots.
I mean, look at this.
We have improper repairs.
We have mechanical irregularities.
We have pilots that are reporting the same problems on the same planes over and over and over again.
GREG FEITH: Emery had had a sordid history with regard to the maintenance of their aircraft and their maintenance practices.
It's unbelievable.
Unbelievable.
We were extremely concerned that we were gonna have an accident, to the point we wound up writing letters.
"Here are the things that are happening.
"If we don't do something, people will die.
" As I went down this pathway, and starting to see all this, it really bothered me 'cause it wasn't the Emery that I knew.
When you have hands-off management style, you're gonna have problems.
And that's exactly what we saw at Emery.
It's pretty clear what happened.
After months of detective work, NTSB investigators finally believe they understand what caused the crash of Emery Worldwide flight 17.
They know that in the weeks leading up to the accident, two different teams of mechanics worked on the plane's tail.
The NTSB can't be 100% sure where the error occurred - the routine maintenance in Tennessee or the damper swap at Emery.
I believe that when this work was done on the damper the second time, he simply put the rod up, put the nut on it .
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did some other work closing up and forgot to put the cotter pin in the nut.
Investigators believe that the DC-8 flew for some time without incident, despite the loose nut.
So now over the next few weeks the nut comes loose because there's nothing holding it on, essentially, and now the bolt starts to work loose.
Yeah.
There it is.
Boom.
A slight bump on the FDR data indicates that the bolt likely came out eight minutes before the plane's last landing in Sacramento.
The crew would have had no idea what was going on in the tail of their plane.
And because the disconnected push rod didn't jam the elevator controls, the captain was able to land safely.
The subsequent take-off is a very different story.
Airspeed's alive.
Alive here.
80 knots.
80 knots.
As the plane accelerates down the runway, airspeed increases, pushing the elevator control tab up, forcing the crank fitting against the push rod and jamming the elevator in a nose-up position.
Watch the tail.
The plane instantly pitches up even as the first officer pushes down on the yoke.
You got the airport? Bring it around.
Power.
GPWS: Pull up.
Don't sink.
The crew works valiantly to try and get back to the runway, but their fate is sealed.
Power! Argh, come on! Come on.
(ALARM BLARES) (ALL YELL) (SIREN WAILS) GREG FEITH: Nobody's out there to intentionally do something that would cause harm to anybody else.
But sometimes we get a little bit of, you know, lackadaisical attitude or complacent.
We get distracted.
And those little things end up resulting in a big tragedy.
On behalf of all the employees of Emery Worldwide Airlines, we want to express our sympathies to the families of the victims of this tragedy.
In their final report, investigators recommend that air carriers explicitly highlight all maintenance procedures to help ensure that no steps are missed.
Emery Worldwide is also singled out for responsibility.
Emery said, "Well, this is the first fatal accident we had in 50 years" basically at that time.
Well, that's great, but three pilots lost their lives because of a bolt, a nut and a cotter key.
Before the report is published, however, the air carrier goes out of business.
At the end of the day when it was all said and done, the FAA moved in and pulled the certificate and grounded the airline.
To this day, John Goglia has kept a poignant reminder of the tragedy.
I kept this because I use this to teach other mechanics.
I spend a great deal of my time sharing these experiences so that they don't have to repeat and feel the pain that I have felt observing maintenance accidents.
JOHN ALBRIGHT: The airline had a horrible attitude towards safety.
If you want to be safe, you gotta make an effort.
You have to try to be safe, and you have to work at it.
Pull up.
- Emery 17.
We have an emergency.
NARRATOR: An American cargo plane needs to make an emergency landing.
Pull up.
Bring it around.
They didn't have controllability of the aeroplane.
Roll out to the right! - Power.
- More? Yeah.
The pilots bring their DC-8 to within sight of the runway.
(YELLS) And I said, you know, "Oh, my god, we've lost an aeroplane.
" MAN: It was, like, basically a war zone.
OK.
You ready? To try to understand what went wrong, investigators call on a friend and colleague of the crew.
(YELLING) (STATIC) I can still hear it.
You know, you just don't It doesn't stop.
(ENGINE ROARS) MAN: Mayday, mayday.
You flew jump seat from Dayton, right? Yes, sir.
What was the hold-up? New windshield.
That took what - four, five hours? That'll mess up a day.
Rather they just stuck it on with crazy glue? Hey, at least my side would be fine.
Well, that's all that matters, then.
Captain Kevin Stables is preparing to pilot Emery Worldwide flight 17.
His first officer is George Land.
They're flying freight across the country aboard a 30-year-old DC-8 cargo plane.
JOHN ALBRIGHT: The DC-8 was a fantastic plane.
That thing was built like a tank.
Captain John Albright has just checked into a hotel after finishing his latest shift for Emery Worldwide.
The DC-8 was, um - it was kind of a pilot's plane.
It took a lot of work, and it took a lot of physical effort.
Getting all prettied up for the load master? Hey.
At least I try to look like a professional.
JOHN ALBRIGHT: The crew was just fantastic.
They were enjoying being with each other and enjoying the job that they were getting ready to do.
I'd flown with George several times.
He was always smiling and always friendly, always had his hair fixed just right, which we all kind of thought was funny 'cause we were flying night freight and nobody got to see us.
Captain Stables started his day as a passenger on the plane as it flew from Dayton, Ohio, to Reno, Nevada.
In Reno, he took over as captain and flew to Sacramento.
Now he and First Officer Land are taking the cargo plane back to Dayton.
Hi there.
Is that the load plan? Just before they're finished up and loading the last couple of containers, they would give us a list of all the freight containers and how much it weighed and what position on the aeroplane it was.
There you go, boss.
Then we'd take that information and we would calculate the weight and balance on the aeroplane and make sure that it was all correct.
Inspection's complete.
Cargo doors closed.
Joining the pilots is flight engineer Russell Hicks.
The flight engineer - he handled all the systems, the electrical systems, the hydraulic systems and pneumatic systems.
He was the man behind the curtain, so to speak, and kept the aeroplane running.
Alright, boys, let's hit it.
Left rudder, centre.
Checked.
As they taxi to the runway, the pilots conduct a series of flight control checks.
Right rudder, centre.
Checked.
Elevator forward.
Coming back.
Elevator position indicator checks.
It's all calm efficiency in the cockpit.
Taxi checklist.
Taxi checklist - flaps and slots.
15-15-15.
Slot lights out.
15-15-15.
Slot lights out.
JOHN ALBRIGHT: Some days you sit up in the cockpit and you look out the window and you think, "Boy, I just can't believe "anybody's paying me to do this.
Taxi checklist complete.
MAN (OVER RADIO): Helicopter one-six-seven-one-nine.
Position report to Mather.
It sounds like he's getting a massage.
(BOTH CHUCKLE) Once you got assigned a schedule you'd be with the same three guys for a month.
So, uh, you they'd be your second family.
I've never been up in one of those Airstar helicopters - you know, like the Cadillac of helicopters.
You'd go eat dinner with them, you'd go hang out with them on layovers, so you got to be very close with who you were flying with.
Emery 17, Sacramento approach.
You're released for departure.
Report when airborne.
Emery 17 heavy, we'll call you once we're in the air.
GREG FEITH: The controllers cleared the pilots to be able to take off and actually start to establish and navigate from Mather, Sacramento to Dayton, Ohio.
JOHN ALBRIGHT: On that particular day, I was laying over in Salt Lake City, and I happened to be laying on the bed and the TV was running in the background.
Hey, it's me.
Yeah, I just checked into the hotel.
Airspeed's alive.
Alive here.
80 knots.
80 knots.
Elevator checks.
NARRATOR: Just another routine take-off.
V-1.
Rotate.
But as the nose wheel leaves the ground .
.
the DC-8 pitches upward much more steeply than it should.
Watch the tail.
GREG FEITH: They recognise that they have an issue during the course of the aeroplane actually starting to rotate as it lifts off the runway.
V-2.
Positive rate.
The sudden take-off is quickly followed by an uncommanded left bank.
- I got it.
- You got it? Yeah.
This is anything but routine.
- We're going back.
- What the hell? The centre of gravity is way out of limits.
They need to return to the airport as quickly as possible.
Emery 17, emergency.
Emery 17, say again.
GREG FEITH: When a pilot declares an emergency, that really cues an air traffic controller to know that this isn't just an abnormal situation - this is a critical situation.
Emery 17.
We have an emergency.
You steer.
I'm pushing.
So now you have three pilots trying to work in harmony.
That's good from a cockpit resource management standpoint.
GPWS: Terrain.
Terrain.
Pull up.
The ground proximity warning begins to sound.
GPWS: Terrain.
Terrain.
Pull up.
RUSSELL HICKS: We're sinking.
We're going down, guys.
Alright, alright.
GPWS: Pull up.
Terrain.
RUSSELL HICKS: OK.
We're going back up.
The DC-8 starts climbing again.
Roll out.
Roll out! But the pilots are still struggling for control.
Emery 17, extreme balance problem.
Emery 17, roger.
The aeroplane started to go into these big perturbations - dive and then climb, dive and then climb.
Roll out to the right! (ALARM BLARES) Push.
Push forward.
(GRUNTS) They push their control columns all the way forward in a desperate effort to level the plane.
Power.
- More? - Yeah.
Left turn.
OK, what I'm trying to do is make the aeroplane's position match the elevator.
That's why I'm putting it in a bank.
So we're gonna have to land it in, like, a turn.
GREG FEITH: They were trying to return back to Mather.
So it was gonna be a long, sweeping traffic pattern that they were gonna have to fly because they didn't have controllability of the aeroplane.
Bring it around.
- Damn it! - GPWS: Too low.
Terrain.
You got the airport? GREG FEITH: Mather doesn't have a lot of surrounding lights.
It's considered what's called a 'black hole'.
Bring it around.
Power.
NARRATOR: Captain Stables and his crew have managed to get their crippled plane to within sight of the runway.
JOHN ALBRIGHT: It was working very well.
They made it almost all the way around to the back side of the airport.
GREG FEITH: They knew if they could get back to the airport there was gonna be crash fire rescue that would have been able then to help them.
NARRATOR: They've now got less than a mile to go.
They're still trying to look ahead to figure out what needs to be done next.
But they know that sooner or later they gotta get on the ground.
(BOTH YELL AND GRUNT) NARRATOR: Emery Worldwide captain John Albright relaxes in his hotel room on a layover in Salt Lake City.
I had CNN on and I was talking to my wife on the phone and, uh, there was a lot of sirens and noise and flashing lights on the TV, and it kind of distracted me from talking to her.
REPORTER: Investigators are collecting clues Then when I looked up, I saw something about Emery.
A DC-8 that took off from Mather Airport immediately ran into trouble.
The plane, along with its crew, went down.
I said, "Oh, my god.
We've" We've lost an aeroplane.
They now know that the DC-8 clipped a building on the salvage yard.
She said, "What do you mean?" I said "Well, turn the TV on.
"I'm watching right now and a plane's crashed.
" It's one of ours.
Billowing orange flames and black smoke marked the fiery end of flight 17, an Emery Worldwide Freight DC-8 bound for Dayton, Ohio.
(SIREN WAILS) Emery flight 17 has crashed into a car scrap yard one mile east of Sacramento's Mather Airport.
All three crew members are dead.
MAN: Our fire crews arrived.
They had a large fire, and there was no chance of rescue.
The next day, the site is a smouldering scar of twisted metal.
GREG FEITH: It was, like, basically a war zone because the aeroplane had crashed into this auto salvage yard.
The job of figuring out why this happened now falls to the National Transportation Safety Board.
Hey.
There were hundreds of cars out there, many of which had burned, and then of course the aeroplane just cut a swath through all of these cars.
There were still smoking automobiles and car parts and aeroplane parts.
This place is a mess.
Yeah.
With so much fire damage and thousands of car parts on-site, just finding the aeroplane wreckage is going to be a huge challenge.
The NTSB's John Goglia helps lead the effort.
Put this in the plane bin for me, please.
Mechanical pieces, especially after they're burned, it's very difficult to tell a piece from an automobile from a piece from an aeroplane.
So I looked at the scene and said, "Wow, we got a real tiger by the tail here.
" You can't just get everybody out there and start rummaging through parts.
You have to have a very systematic and methodical process.
Alright, guys, listen up! Let's build the grid.
Alright? Let's go! Investigators will have to sift through a debris field about 450 feet wide and a quarter of a mile long.
That looks like wiring from a car.
We actually had all of the investigators working through this very methodical grid process deciphering car parts from aeroplane parts, making that separation and then moving on systematically.
They went down less than a mile from the airport.
Whatever went wrong, it went wrong right away.
They were in a cargo plane.
Maybe it was a load problem.
Make sure we get those load sheets sent to the office.
I want to take a look at those, alright? (RADIO CHATTER) NARRATOR: The team soon makes a crucial find - the most important items of evidence in any air crash investigation.
Well done, guys.
We did find both the cockpit voice recorder and the flight data recorder, which actually sped up that part of the investigation 'cause we could send those two boxes back on the aeroplane that we had flown in on.
MAN: The description that was given to me regarding the two boxes were that they had sustained some fire damage but they were in relatively good shape.
The NTSB sends the critical recording devices to Washington, where lab technicians can begin the job of processing the data.
At the same time, investigators hunt down as much other evidence as they can.
Morning.
I just spoke with the air traffic controller.
He said that the pilots called in a centre of gravity issue immediately after take-off.
Emery 17, extreme balance problem.
It sounds like a problem with the cargo.
Well, could be.
Because the initial report was that there was a possible centre of gravity issue, we had to confirm what was on the aeroplane.
Alright, so there's supposed to be 18 positions, right? One container for each pallet.
We had to get the load manifest.
We had to understand what was in the pallets, how many pallets were loaded, how many containers were on the aircraft and what was in those containers.
You got that load sheet? They learn that flight 17 was carrying nothing unusual - mostly clothing.
But they wonder - did the positioning of the freight cause a dangerous imbalance? If you look at an aeroplane, there is a point in the middle of the aeroplane that is the centre, and everything flows around it.
So if you have too much weight in the back, alright, the centre of gravity's gonna shift to the rear and the aeroplane's gonna fly differently.
Alright.
This looks a little lighter than usual, but it's well within the centre of gravity limits.
Load distribution was not the culprit.
Something else must have caused the crash.
The team is soon chasing a new lead .
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past complaints to the FAA from Emery pilots.
It seems some pilots were worried about how the company was securing its cargo.
They reported seeing frayed straps and netting.
(SIGHS) You know, if Emery was lax with their loading practices, the load could have shifted.
We had to talk to the folks that actually did the loading.
"What was the position of the pallets and the containers? "How did you load 'em? How did you secure them?" What if the cargo wasn't properly secured? NARRATOR: To understand just how secure the cargo was on flight 17, investigators head to California.
I decided I would take a trip out to Sacramento to see who was loading, how they were loading.
The NTSB's John Goglia tracks down the freight handlers who worked on Emery Flight 17.
I actually had a company that loaded and unloaded aeroplanes, including Emery's aeroplanes, so I was very familiar with the loading process.
Gentlemen, hi.
How are ya? I'm with the NTSB.
Mind if I ask you a few questions? At first they were standoffish, and then as the conversation went on, naturally I mentioned that I used to work for them and I did the job that they were doing, so then they opened up.
Just like I told you, it was routine - nothing we haven't done a thousand times before.
Any chance any of the cans were misloaded? No.
We did everything by the book.
Any problems with any of the equipment, like maybe a bear claw that you had trouble locking up or something? We wouldn't load anything if we felt it was unsafe.
Gotcha.
OK.
Well, listen, thank you so much.
I appreciate it.
And they were very vehemently opposed to a load shift.
They said it couldn't possibly have a load shift.
Despite the assurances from the load team, investigators need hard evidence that the cargo was secure.
The NTSB goes by facts, right? So even though we have a thought, you have to prove the thought.
They examine cargo fasteners recovered from the wreckage.
If there was a load shift, the metal clamps, known as bear claws, should display distinct damage.
GREG FEITH: When we're looking at these bear claws, we're looking for physical evidence.
That is, if the pallet was clamped in place and the energy from the impact pushed it, it would typically break it or leave a witness mark or impact mark.
They find no such evidence.
All of these restraints look just fine.
The thing is, if there wasn't a problem in the cargo hold, why were the pilots reporting a problem with their centre of gravity? Is that the CVR? Oh, finally.
Alright, let's do this.
They hope the cockpit voice recorder from Emery flight 17 will provide some answers.
- Here you go, John.
- Thank you.
The NTSB asks Emery Worldwide captain John Albright to listen in.
JOHN ALBRIGHT: You want somebody that knows the pilots.
I was the only one out there that was able to say, "This is Kevin" or "This is George".
I know the voices.
OK.
You ready? OK.
They told me that one of the things I had to be concerned about is that a very high percentage of people that go out and listen to the CVR, within two years quit flying.
When you hear the voice recorder on flights that have .
.
where the crew has perished, it can be quite painful and be emotional because you know that the person you're hearing is no longer with us.
KEVIN STABLES: Uh, 15-15-15.
Slot lights out.
GEORGE LAND: 15-15-15.
Slot lights out.
That's Kevin, uh, Captain Stables.
OK.
Then George Land, the FO.
Set right.
Taxi checklist complete.
When you listen to it, of course they're very professional.
They're doing their checklist items.
They respond appropriately, and everything appears to be normal.
MAN (OVER RADIO): Helicopter one-six-seven-one-nine.
Position report to Mather.
(CHUCKLES) Sounds like he's getting a massage.
(LAUGHS) Airspeed's alive.
Alive here.
80 knots.
80 knots.
Elevator checks.
So at 80 knots, they do their elevator check.
You push the control column full forward to verify that the elevator is in fact moving.
V-1.
They'd call V-1 .
.
and as they get close to VR the aeroplane rotated all on its own.
Rotate.
Watch the tail.
NARRATOR: The captain sounds concerned that they're pitching up too quickly.
When something like that happens, you run through it in your mind as fast as you can.
"What's going on?" - We're going back.
- What the hell? The centre of gravity is way out of limits.
So immediately he ran through the scenarios in his head and came up with, "This is probably load shift".
NARRATOR: But the investigation hasn't found any evidence of a load shift.
They keep listening for any sign of what else might have caused the sudden upward pitch.
- GEORGE LAND: Power.
- More? - Yeah.
Left turn.
- GPWS: Pull up.
OK.
What I'm trying to do is make the aeroplane's position match the elevator.
That's why I'm putting it in a bank.
Wait, wait, wait, wait.
What did he just say about the elevators? The elevators are part of the tail and control the aircraft's pitch.
When tilted upward, the force of the deflected air pitches the plane's nose up.
When the elevators move downward, they cause the nose to pitch down.
GEORGE LAND: OK, what I'm trying to do is make the aeroplane's position match the elevator.
That's why I'm putting it in a bank.
NARRATOR: Investigators now wonder if there was a problem with the elevator.
If your elevator isn't where you think it is, uh, an aeroplane can take off by itself.
You got the airport? - GPWS: Too low.
Terrain.
- Bring it around.
- Caution.
Terrain.
- Power.
Caution.
Terrain.
(GRUNTS) NARRATOR: It seems the pilots were trying to control the plane by dipping the left wing to bring the nose down.
DENNIS CRIDER: I think that the crew did a remarkable job of working together, and this technique that they were doing - trying to control their pitch with roll - that was very, very advanced.
They did a very good with the set of cards that they were dealt, but their hand was not a winnable hand.
- GPWS: Pull up.
Airspeed low.
- Come on! Come on! Come on! - Pull up.
- Come on! Pull up.
Airspeed low.
Terrain.
Terrain.
Pull up.
(STATIC) You'd start listening to that thing early in the morning a couple of seconds at a time.
So you'd listen to your buddies die for three days straight ten seconds at a time.
They did everything that they could, alright? Something doomed them right from the start.
Hey, uh, John? I still hear it.
You know, you just don't It doesn't stop.
OK? Take care of yourself.
NARRATOR: The cockpit recording has focused investigators' attention on the DC-8's elevators.
But their job is far from done.
It will take more digging and more hard evidence to understand what caused flight 17 to crash.
NARRATOR: Performance data from Emery Worldwide flight 17 is now in investigators' hands.
For the first time, they can see exactly how the plane was moving during its short, erratic flight.
OK.
Everything's up.
They hope the data will also hold clues that will explain why the flight went so horribly wrong.
Alright, let's see what the data says about the load shift.
The critical part of a flight data recorder is that it gives us performance of the aeroplane.
We can find out, "Was that characteristic of a cargo shift "when the aeroplane pitches up like that?" You know what? Let's put up the data from the flight that crashed because of the load problem.
It's Fine Air 101.
The investigators know that just three years earlier in Miami, a Fine Air DC-8 crashed on take-off when its cargo load suddenly shifted.
Five people died in the disaster.
One of the things that the performance engineers will look at is they'll compare it and contrast it to previous flights.
Alright.
Let's take a look at them side-by-side.
And the rotation rates, please.
The rotations are totally different.
Definitely not a cargo shift.
What about the elevators? Look at that.
Look at that right there.
The first officer, he pushed the column forward and the elevators did not respond.
Look at that! Boom.
NARRATOR: The data clearly shows that there was something wrong with the right elevator.
DENNIS CRIDER: The big thing, of course, is the FDR shows the elevator nose-up, and he's pushing.
- Push.
- GPWS: Pull up.
Obviously then the pilot can't fly if the elevator is not doing what he wants it to do.
That became the crux of the matter.
Push forward.
Terrain.
Why was that elevator, um, nose-up when the pilot was commanding nose-down? Let's take a look at that wreckage.
And everything - everything to do with those elevators.
We went through the storage facility where we had collected everything that we could, and we dug through there looking for any pieces whatsoever of the flight controls, the elevators in particular.
The elevator wasn't hydraulically-powered.
It had, uh, control tabs on it to move the elevator.
Everything was analogue - cables and pulleys.
They closely examine the recovered elevator assembly, looking for signs of failure.
So these are the push rods from the elevator assembly.
The push rods are a key part of the elevator mechanism.
They move a crank that in turn moves a control tab that makes the elevator swing up or down.
Investigators know there are two push rods, one to control the right elevator and one for the left.
The left control rod was broken.
Why isn't the right one damaged like the left? GREG FEITH: When we looked at the right control rod, we didn't see the same kind of damage.
We didn't see what we would have expected if it had been properly secured in the linkage.
And in fact all it was, it was relatively intact.
Have we got the crank tab fitting to this one somewhere? They hunt down the part that the push rod was supposed to be attached to.
Once again, the kind of damage they see is not what would occur in a catastrophic crash.
It looked like they were hitting each other or had an interference rub against each other.
But that was not what we would have expected to see if they had actually been linked together in their proper position.
We didn't see the typical overload type damage.
It all leads to a disturbing conclusion.
This right push rod wasn't even connected.
It was clear that one of them had been disconnected.
There was physical damage shown.
On the one side, it was still fully connected.
On the other side, it wasn't the case.
It's a major discovery.
An important flight control mechanism somehow became disconnected before the DC-8 hit the ground.
The big question now - is that what caused the crash? Can a disconnected push rod really have brought down this plane? Metal doesn't lie, right? So we've got physical marks on there.
Now we can actually do some analysis and try to determine what those bang marks were caused by.
NARRATOR: The NTSB is ready for some real-world testing.
A DC-8, just like the one flown by the Emery pilots, is the test subject.
Alright, let's do this.
Investigators want to study how the plane's elevator assembly moves Alright.
Hand me the ratchet, please.
.
.
and see what happens when a push rod is disconnected.
So this is the rod in question, and this is the bell crank right here.
And you can see this little slot inside the bell crank, and this is where this would fit into.
Alright.
Let's see what happens when we move the elevator.
Go ahead.
Move the elevator.
So as this rod moves, and this rod is connected to the control column in the cockpit, as it moves up and down it pulls on this bell crank, which is attached to the elevator and causes it to move in the proper direction that the pilot wants it to move in.
Alright, cut it.
I'm gonna disconnect it now.
It would be attached with a nut and a bolt, and the nut is what they call castellated, so it looks like a castle, and inside those castellations you would put a cotter pin that would lock it in place.
With the right side rod assembly disconnected, they call for the elevator to be moved again.
OK, now try it.
It seems that disconnecting the push rod neutralises the elevator, but it does not jam it in the nose-up position.
Alright, you can stop.
There's nothing here.
It's looking like their experiment has failed to reveal any answers.
Let me try one more thing.
Then, in a final effort, they attempt to simulate the kind of vibration experienced during an actual take-off.
80 knots.
80 knots.
The air forces on that elevator are rather severe, so it's not wiggling around like I show it here.
It's banging.
It's showing some real force.
With the extra force, they discover that the push rod can jam the elevator in the nose-up position.
This rod is jammed in.
Even though the elevator is trying to move and the crew is trying to move it Push! .
.
it's not gonna go anywhere because it's jammed in place.
GREG FEITH: No matter what you did with the flight controls, that interference fit would always be there and it would jam the flight control.
So that was more of a Eureka moment.
Without the cotter pin in the bolt, a push rod can jam.
That gave us a good indicator of why this aeroplane was commanding nose-up all the time.
It's the breakthrough investigators have been hoping for - evidence that a disconnected push rod assembly jammed the right elevator on Emery Worldwide flight 17, making the plane practically impossible to fly.
But they still don't know why the assembly came apart.
GREG FEITH: We had to determine, really, what caused that separation of that control rod.
We know it was a bolt, a nut and a cotter key.
The question is, did it fail? Was it properly installed? And who was responsible for it? Investigators scan maintenance reports, checking to see if any work had been done on the right elevator assembly recently.
So it looked like the plane was in for a major overhaul just three months before the accident.
The elevators, the control tabs, the rudder and its tab - all of that had been removed for overhaul and then reinstalled during this very inclusive and invasive check.
Have you got that work card? The work was carried out by Tennessee Technical Services, TTS, in Smyrna, Tennessee.
The question is did the maintenance folks actually follow the proper procedure and then inspect it as it was supposed to be inspected? Well, it looks like everything was done properly.
The paperwork from Tennessee is all in order.
It seems the DC-8 was perfectly fit to fly after the major overhaul.
Alright, so was there any other work done on this aircraft? One of the things that you always look at is what was the last thing touched on the aeroplane? Well, well, well.
Look at this.
TTS wasn't the only place to do maintenance on this plane.
Well, after it left the facility in Tennessee, there was one other piece of maintenance on the tail of this aeroplane - and it was done over the weekend in Dayton, which is where many of the aeroplanes spend the weekend for Emery.
12 weeks before the fatal flight, Emery mechanics swapped the aircraft's elevator dampers, parts located near the control rod.
It could be an important new lead.
I think it's about time we go pay a visit to Emery's mechanics.
Agree? GPWS: Too low.
Terrain.
So can you show me how you go about swapping the dampers on this DC-8? Reach over here In Dayton, they talk to the last mechanic to have worked on the plane's tail.
Detach it from the elevator.
GREG FEITH: One of the things that, uh, mechanics are always looking for is an easier way to perform their responsible duties.
That looks tricky.
Do you ever just disconnect the elevators to get it out of your way? Well, we're really not supposed to.
I know.
Is it hard to do? An easy way to do it is to relieve the control tab by removing the bolt, the nut and the cotter key .
.
and allowing the elevator tab to flex down.
That makes getting into this damper easier and quicker to replace.
(GRUNTS) Well, that was easy.
You ever do it that way on an actual job? Like I said, we're really not supposed to.
Right.
Uh (CLEARS THROAT) .
.
it says that you were the one who did the actual work.
Was there anyone here to help you? One of the things that came through loud and clear was how thin they were with labour, how thin they were with management of their workforce.
Ever done this procedure before? Well, I followed the manual.
And now if you take that and look at a young mechanic, relatively inexperienced, working alone on the weekend doing something he had never done before - nobody to ask for advice and nobody to provide him guidance or supervision - so he was between a rock and hard place.
One more question.
Um, it says they gave this plane a complete overhaul.
Why did you bother swapping the dampers? Well, the guy in Tennessee put them on the wrong way.
OK.
Well, thanks very much for your time.
I appreciate it.
A mishandled overhaul in Tennessee and a disturbing lack of supervision at Emery's maintenance facility lead investigators to wonder - does the airline have a systemic problem with aircraft maintenance? NARRATOR: Investigators dig deeper into Emery's maintenance practices, eager to learn if they played any role in the crash of flight 17.
JOHN ALBRIGHT: We were the best of the worst, which is what the saying was.
We weren't FedEx.
We weren't UPS.
We weren't Airborne.
Um, but there was a whole 'nother sub-tier of freight hauler.
They discover that the once respected airline's maintenance program was causing serious concern among its pilots.
I mean, look at this.
We have improper repairs.
We have mechanical irregularities.
We have pilots that are reporting the same problems on the same planes over and over and over again.
GREG FEITH: Emery had had a sordid history with regard to the maintenance of their aircraft and their maintenance practices.
It's unbelievable.
Unbelievable.
We were extremely concerned that we were gonna have an accident, to the point we wound up writing letters.
"Here are the things that are happening.
"If we don't do something, people will die.
" As I went down this pathway, and starting to see all this, it really bothered me 'cause it wasn't the Emery that I knew.
When you have hands-off management style, you're gonna have problems.
And that's exactly what we saw at Emery.
It's pretty clear what happened.
After months of detective work, NTSB investigators finally believe they understand what caused the crash of Emery Worldwide flight 17.
They know that in the weeks leading up to the accident, two different teams of mechanics worked on the plane's tail.
The NTSB can't be 100% sure where the error occurred - the routine maintenance in Tennessee or the damper swap at Emery.
I believe that when this work was done on the damper the second time, he simply put the rod up, put the nut on it .
.
did some other work closing up and forgot to put the cotter pin in the nut.
Investigators believe that the DC-8 flew for some time without incident, despite the loose nut.
So now over the next few weeks the nut comes loose because there's nothing holding it on, essentially, and now the bolt starts to work loose.
Yeah.
There it is.
Boom.
A slight bump on the FDR data indicates that the bolt likely came out eight minutes before the plane's last landing in Sacramento.
The crew would have had no idea what was going on in the tail of their plane.
And because the disconnected push rod didn't jam the elevator controls, the captain was able to land safely.
The subsequent take-off is a very different story.
Airspeed's alive.
Alive here.
80 knots.
80 knots.
As the plane accelerates down the runway, airspeed increases, pushing the elevator control tab up, forcing the crank fitting against the push rod and jamming the elevator in a nose-up position.
Watch the tail.
The plane instantly pitches up even as the first officer pushes down on the yoke.
You got the airport? Bring it around.
Power.
GPWS: Pull up.
Don't sink.
The crew works valiantly to try and get back to the runway, but their fate is sealed.
Power! Argh, come on! Come on.
(ALARM BLARES) (ALL YELL) (SIREN WAILS) GREG FEITH: Nobody's out there to intentionally do something that would cause harm to anybody else.
But sometimes we get a little bit of, you know, lackadaisical attitude or complacent.
We get distracted.
And those little things end up resulting in a big tragedy.
On behalf of all the employees of Emery Worldwide Airlines, we want to express our sympathies to the families of the victims of this tragedy.
In their final report, investigators recommend that air carriers explicitly highlight all maintenance procedures to help ensure that no steps are missed.
Emery Worldwide is also singled out for responsibility.
Emery said, "Well, this is the first fatal accident we had in 50 years" basically at that time.
Well, that's great, but three pilots lost their lives because of a bolt, a nut and a cotter key.
Before the report is published, however, the air carrier goes out of business.
At the end of the day when it was all said and done, the FAA moved in and pulled the certificate and grounded the airline.
To this day, John Goglia has kept a poignant reminder of the tragedy.
I kept this because I use this to teach other mechanics.
I spend a great deal of my time sharing these experiences so that they don't have to repeat and feel the pain that I have felt observing maintenance accidents.
JOHN ALBRIGHT: The airline had a horrible attitude towards safety.
If you want to be safe, you gotta make an effort.
You have to try to be safe, and you have to work at it.