Controlled Pod Into Terrain episode 5: Pinnacle 3701

Re-uploaded to fix technical issues.

This one has a couple of guys who managed to show off to each other so toxically that they ended up flying into the ground after toasting one engine and core locking the other. Don't be these guys.

as always, Controlled Pod Into Terrain comprises Kyra, the aviation writer who investigates plane crashes, Ariadne, the aviation business expert, and J, who is some kind of engineer.

Episode Transcript

(00:00):
Hello, and welcome to Controlled Pod into Terrain.

(00:03):
We are a multimedia podcast about air and space mishaps, aiming to put them in the broader
context of how and why things went wrong.
Now, to introduce myself and my co-hosts, my name is Ariadne.
I'm the aviation industry expert, and my pronouns are they and them.
My name is Jay.
I'm the systems and engineering expert, and also the letter between I and K. And my pronouns

(00:24):
are they and them.
And I'm Kyra Dempsey, better known as the aviation writer Admiral Cloudberg, and my
pronouns are she and her.
Next slide.
Today we're talking about Pinnacle Airlines, Flight 3701, a crash caused directly by toxic
masculinity.
This episode is going to be a cautionary tale about two guys who did some very dumb things

(00:44):
and died because of it.
That doesn't mean it wasn't a tragedy, but it does mean we will bring down the hammer
of ridicule, because this behavior needs to be seen as the sort of thing that would make
you a laughing stock so that people don't do it.
Next slide.
It's some kind of news thing.
Okay, so this morning at 7 a.m. Texas time, SpaceX did their second integrated flight

(01:07):
test.
It made it past stage separation, which was where they exploded last time.
So this was a considerably more successful launch.
The booster appears to have exploded during the relight attempt after staging, where it
would try to go back towards the launch site.
Leading theories right now are either fuel sloshing around in the tanks, creating cavitation,

(01:29):
or some kind of fluid hammer blowing the valves apart.
And as we learned in our last episode, when your turbo pumps ingest valve parts, you will
very quickly turn your rocket into chaff.
The reliability of the Raptor engine has obviously improved a lot.
They made it all the way to main engine cutoff without losing a single one.
We can tell you that the sort of complexity required to simulate these engine conditions

(01:53):
is basically infinite.
So the fact that we were able to pull this off is pretty incredible.
Somewhere before the second stage was to sort of make it to its final target, it just kind
of exploded.
We don't really know.
It could have been a loss of communication, triggered the flight termination system, some
kind of onboard fire in the tanks.
We don't know.

(02:14):
As of recording, we just don't have very much info.
But if anything comes up, we'll mention it in the no taps next episode.
Next slide.
So this is a follow up from last episode.
The NTSB released their preliminary report on the Houston hobby crash that recovered.
This was an unequivocal fuck up on the part of the Hawker crew.

(02:34):
They were only cleared to line up and wait, not to take off.
And keen listeners will note that a fuck up over line up and wait was the exact same thing
that happened in Boston earlier this year in February that also caused a runway incursion.
Very similar circumstances.
A private jet rolled into a takeoff, almost came together with a jet blue embryo.

(02:57):
This Hawker flat out ignored two different explicit commands from the tower to stop their
takeoff roll.
The command they had been given was to taxi and hold short.
It's a standard verbiage that's used throughout the industry.
After Tenerife, these were sort of made very clear that these were the exact words that
you had clearance takeoff and anything besides these exact words was not clearance.

(03:22):
They claimed to have not heard air traffic control because they were busy troubleshooting
a couple of different caution and warning error messages.
One was for a rudder bias, one for a pitch trim.
And if we take them at their word, that's kind of what they were doing.
Sort of what the fuck?
Like, he's, I mean, this is not the time to be dealing with those non-critical failures.

(03:46):
And if they are that critical, why didn't you just abort the takeoff?
Yeah, I would also add that they claimed that as they were lining up for the takeoff, when
they misheard the instructions to take off, they said that their V speeds had dropped
off of the FMS.
So the fact that all of these things were happening, their V speeds weren't showing

(04:08):
up, they were having rudder bias and pitch trim alerts.
I'm thinking they did not set up the Splite computer properly for takeoff is what I am
suspecting.
Obviously, I could be totally wrong.
I'm just speculating here.
But I think they had not finished the before takeoff checklist.
In any case, if this was happening, you would abort, right?

(04:30):
I mean, anyone sane would abort, right?
Yeah.
I mean, yeah, you should abort.
Yeah, you abort.
And it's, yeah, I don't.
And again, even if this is clear, sort of either caution and warning failure or configuration
failure, but these are, this is sort of not a problem that arose to them.
This is a problem that they caused for themselves in so many different ways, it seems.

(04:52):
So the Hawker has very, very minor damage.
Those pilots are very much about to feel the uncaring bite of the buck round and find out
alligator.
The Citation pilots on the other hand, that's this aircraft, they did nothing wrong.
This plane is very, very, very fucked.
They're phenomenally lucky.
This happened when it did, which was basically just a few feet from touchdown.

(05:15):
The impact, as you can sort of see here in the middle of the slide, listeners, basically
you have an aircraft that the entire tail has been ripped off.
The empanage is sort of unpressurized section below the rudder.
The rudder is hanging only by the top lug.
Do we know if there were a few feet in the air when this happened or were they actually
already on the ground?
Because I thought they were already on the ground.

(05:37):
I mean, either way, they're lucky that this didn't cause them to completely crash because
it could very easily have done so.
Yeah, exactly.
This rudder is now completely functionally useless.
It cannot provide any sort of aerodynamic control.
This plane, it could theoretically fly again.
Basically this entire tail section, you can kind of see it's one common bulkhead.

(05:58):
It can be removed, it can be replaced, this aircraft can be certified.
It's going to be phenomenally expensive to do so.
So it's going to be up to this particular company's insurance assessor who's currently
drinking as much Savannah moonshine as they can get their hands on.
One last thing here listeners, which is that this will not be the only time in this episode
that the three of us talk about two small jet pilots acting like real fucking assholes

(06:20):
as this theme will come up again.
George Lucas explains it here.
It's like poetry.
It rhymes.
And this is why CPIT believes that jets should be banned if you want to fly private.
You have to fly your own plane and it has to be something like single seat or two seat.
So sorry, Tay-Tay, you may no longer have your Falcon, DeSoe Falcon 9X anymore, but

(06:42):
you can have a DeSoe Rafale.
So you sort of, I guess you would fly each stop on the Eris tour in a fourth generation
low observable with super cruise capability.
I mean, why would you choose anything else?
Lawrence and the Machine shows up in an AN-2 very gradually, you know, it's their whole
sort of acoustic vibe.

(07:03):
And then Jimmy Buffett shows up in a Grumman Albatross.
Oh wait, he actually did that.
Yeah, that Albatross is, I swear to God, it's at Universal Studios in Orlando right now.
All right, next slide.
Okay, so this story happened on Thursday, so very, very recently.
This concerns a 747 freighter that was flying for Air Atlanta, which has nothing to do with

(07:25):
Atlanta but is in fact an Icelandic charter and freight carrier.
This was carrying a horse from JFK in New York to Belgium, among many other things.
They didn't charge it for just this one horse.
I thought that would be wild overkill, but maybe something like a Middle Eastern shake
would do.
So this is a thing that happens very, very somewhat regularly for these large animals.

(07:49):
It's almost always for ultra wealthy owners to move them from sort of show to show.
Major cargo hubs will have very specific animal and veterinary processing facilities.
So this is not a particularly special cargo.
There are processes and procedures for handling these horses.
About 30 minutes into the flight, it looks like the horse decided to say, hard fuck that.

(08:11):
It broke loose and started running around.
The cockpit called ATC and asked them to turn around.
Once they found out they couldn't get him calmed down and tied back down.
They did not call pan, pan, pan.
They did not declare an emergency.
They did have to dump about 20 tons of jetty over the North Atlantic, 10 miles left of

(08:34):
Martha's Vineyard and Nantucket.
So just absolutely housing some old money summer houses with kerosene.
They had a veterinary meet them on the runway.
We think that the horse probably just did not want to go to Belgium.
And I mean, like honestly, relatable.
Samuel L. Jackson could not at the time of recording be reached for comment.

(08:54):
Next slide.
Okay.
So for some note taps, we've got a few this week.
In our last episode on the slide discussing the Houston Hobby Collision, we showed three
photos of the aircraft.
The one in the top right of the slide was a different Hawker Hunter collision with a
torn wingtip.
The caption also was not quite wrong.

(09:15):
It was a different nothing LLC that owned the one that crashed at Houston Hobby.
Yeah.
And so I had seen that I had forgotten to do my homework on that slide.
And I saw the picture of the hunter with the similar damage off of the runway.
And I was like, so did they run off the runway after coming back around?
No, they didn't.

(09:35):
It was just a different accident entirely.
My bad.
Two apologies listeners, we will do better for you moving forward.
A follow up to another one of our stories.
The ground is apparently freezing in Siberia, which means it's time for airlines to make
the funny happen.
But not yet.
Hopefully soon.

(09:56):
So which is funnier, the plane fails to become airborne and trundles through a bunch of fields
trailing barbed wire, or the plane takes off and then immediately has to do an emergency
landing in a different field.
I think the second one.
I'm thinking both, like it gets barbed wire wrapped around the nose while I take off.
So it's just dragging miles and miles of barbed wire fence into the air, just like an antenna

(10:20):
on the doomsday plane, but just looking like a really stupid asshole.
They land at whichever airport and they're still dragging barbed wire and fence.
I mean, this is pretty normal Russian driver behavior according to the many, many dashcam
videos I've seen.
So you know.

(10:41):
I mean, taking off from snowpack might be very tricky if they have to abort the takeoff.
I mean, look, let's be honest, this is an A320 that has skipped the last three seat
checks, because if they took it to Lufthansa Technik, the Germans are just going to repo
it.
And it's already been landed in a field after some sort of severe hydraulic failure.
This thing is not going to want to reject a takeoff, right?

(11:03):
Like this is a yolo of it.
Do or die.
I honestly, I kind of wish like just lift the sanctions enough that RT can stream this.
Jato bottles.
Jato bottles would fix this.
Absolutely.
Always Jato bottles.
Oh yeah.
And also the NTSB, we've discussed pilot mental health last time.

(11:25):
And since then, the NTSB has learned that mental health exists and has issued some very
good positive statements.
Yeah.
As of right now, there's not really enough concrete that we want to discuss.
The FAA put out the most tone deaf video we've seen since Gal Gadot sank to her phone.

(11:46):
And the NTSB basically sort of, they released a sort of competing effort.
The NTSB came out all but sort of imploring the FAA to fully overhaul the system.
You know, we've discussed this.
This is utterly overdue.
We're going to cover mental health in the pilot community when we get to the German

(12:06):
wings incident.
Right now it seems that this incident has shocked the public enough for them to demand
action.
And hopefully what's needed right now is sort of follow through.
And one last thing, our Patreon.
We have a Patreon.
And if you want to support this show and Abra Cloud Burst work, that's where you can do
so.
We have tiers now where you can get access to special benefits.

(12:28):
Eventually, we're going to have bonus episodes, movie commentary tracks.
We're hoping to maybe kick that off after the holiday.
So patreon.com slash CPIT.
That's patreon.com slash CPIT.
Next slide.
So what is this?
What is a regional airline?

(12:49):
So these are small feeder airlines that fly routes the main carriers cannot or will not
fly.
If you are flying from Chicago to Dallas, you are probably flying on a mainline airliner.
If you're going to Presque Isle, Maine or Allentown, Pennsylvania, you're going to be
on one of these.
These are tiny airlines whose names are in a very small print on the side and on your

(13:12):
itinerary.
I should note that a lot of these airlines, it's only the airline name on the plane that's
tiny because many of them are substantially more than 100 aircraft, which is a lot.
You know, these are these are actually big airlines that carry a lot of people and have
a lot of planes, but their their social capital, shall we say, is low.
Yeah, these guys, these are not brands that most people will ever know.

(13:36):
Most passengers, honestly, will never know that they are in a regional aircraft.
Yeah, it's required to say on booking who is actually operating your aircraft, but most
people just ignore it.
Yeah, this particular aircraft flew for ExpressJet, which is one of those quite large,
original aircraft.

(13:57):
So these airlines have a complicated history, and they have a complicated arrangements with
their parrot airlines.
This will be covered substantially whenever we get around to covering Colgan Air.
But suffice to say for this episode, these are operations that run their employees very
hard with the expectation that they'll not stay very long.
Until the last decade, these airlines paid wages that ranged from poor to poverty.

(14:23):
Basically, they were just seen as a way to make it to the mainline carrier.
You were absolutely not expected to make any sort of career at these places.
You exist if you will run one of these regional airlines, you exist at the whim of your parrot
airline contracts.
The main lanes have only sort of a bare financial connection to the regional.

(14:43):
They have no control or input on maintenance, training, ramp operations.
Basically, the only thing that the major carrier is going to care about is on time performance.
It's an industry with fierce competition and razor thin margins.
Regionals have to bid each other for routes, and your entire existence is dependent on

(15:03):
these routes, and it's constantly life and death.
You don't have incinerators to make money like major carriers do, like credit cards,
loyalty programs, first class lounges.
So all you have is ticket revenue to pay your bills.
And this leads to these carriers cutting costs everywhere they can.
And not even ticket revenue.
In a lot of cases, the main lines just pay a flat rate per flight, regardless of how

(15:26):
many people are on it.
Yeah, I believe if the aircraft is full enough, you can actually lose money on it.
So they are openly hostile to their employees.
They are really hostile to unions.
And training is an area that's very easy to cut costs in because it's very hard to see
a direct financial result from it.
And training is one of these areas where some of these airlines are going to scrape FAA

(15:48):
minimums in.
And let's go ahead and post it that.
Foreshadowing.
So Pinnacle was a feeder regional airline for Northwest Airlines.
The flight we're talking about today was what's called a ferry flight.
It's a non revenue or repositioning flight.
Next slide.

(16:08):
So meet the CRJ 200.
This is a tiny jet.
It's built in Canada land, and it's closer in size to a large private jet than to a small
airliner.
It carries 50 passengers in a one class configuration, right?
So there's no first class, and it's two two.
So two seats on either side.
They tend to have some spare power, not a ton.

(16:29):
The one you see on screen November 8396 alpha is the one we're going to be covering today.
And remember, because this is a repositioning flight, there were no passengers aboard.
It was just the two pilots.
So let's meet our pilots.
Next slide.
Beavis and Butt-head.
Amazing.
Amazing.
Exactly.
And uncanny resemblance.
Unfortunately, we don't actually have any photos of these guys.

(16:53):
We tried.
It's probably for the best.
It is.
Yeah.
On the left, we have Captain Jesse Rhodes, 31 years old, 6900 hours of total flying time,
including 5055 hours as a pilot in command.
And 73 hours on the CL65 and 150 hours as a CL65 pilot in command.

(17:16):
That's the aircraft he was flying on this day.
CL65 is just a catchall for the this the particular part of the CRJ series.
We call it a CRJ 200, but CL65 is the type writing.
And on the right, we have First Officer Peter Cesarge.
And on the right, we have First Officer Peter Cesarge.

(17:40):
He has 761 hours of total flying time, including 222 hours as a second in command of this aircraft.
And he's 23 years old.
He is 23 years old.
Posted that.
So basically, he is this is an infant.
We're going to ignore that I'm not that much older than that.
He's this is a child.
Yeah, this is a very, very young pilot.

(18:00):
One thing we do want to know about Captain Jesse Rhodes is that while he was a graduate
of Embry-Riddle, he had a lot of hours, he got he was thought of well by his colleagues.
He did have remarks on some of his evaluations that he had problems with critical thinking
while in the cockpit and judgment.
So keep that in mind.
The NTSB reports state that Jesse saw a movie the night before the crash.

(18:24):
Now listeners, as part of our research for this episode, we pulled what was in theaters
at the time.
And after discussing amongst ourselves, we believe the movie he most likely saw was next
slide.
Shark tail.
Obviously, obviously shark tail.
This was the number one movie on the night before this crash happened.
So statistically speaking, this is most likely what he went to see.

(18:46):
It's a probabilistic fact.
Imagine seeing Jeffrey Katzenberg's weird Michael Eisner hatred as the last thing you
do on earth.
Next slide.
Okay, so this brings us to the next section, flying to the scene of the crash.
Next slide.
What did you take over from here?
Okay.
Yes, gladly.

(19:07):
So we pick up the story of these two guys on the night of October 14th, 2004, when they
are called in to fly an unscheduled repositioning flight without passengers from Little Rock,
Arkansas to Minneapolis.
This is flight 3701.
So this plane was supposed to leave Little Rock earlier that day, but it was rejected

(19:27):
by the crew due to the appearance of a minor engine fault indication.
That part was replaced and now the plane is in good working order, but it needed to be
in Minneapolis to resume the schedule the next day.
So that's why they had to reposition it.
Should be a relaxing time.
You've just seen shark tail, no annoying passengers to deal with.
Sounds ideal.
Yeah.
So we don't know where or why or when, but these guys, and let's be real, this is probably

(19:51):
Captain Jesse's idea, have gotten it into their heads that on a repositioning flight,
no one is watching so they can test out the limits of their airplane.
Now, listeners, this aircraft at the time of takeoff weighed 39,336 pounds.
Its engines provided 18,440 pounds of thrust.
So its thrust weight ratio was 0.468.

(20:13):
So this was not an electric lightning even when it was empty.
I mean, it was sporty, but this is not a fighter jet.
Yeah.
So anyway, it's kind of screwing around in repo flights as something that was apparently
fairly common in the regional airline industry, especially at that time.
And the NTSB report has testimony from a management pilot at another airline who said FDR data

(20:35):
from repositioning flights often revealed that pilots were doing stunts like steep climbs,
descents and bank angles.
And now I just want to be clear, just because this was happening doesn't make it okay or
normal because what we're about to describe is not normal behavior.
Just remember that.
Next slide, please.
So we don't have the cockpit voice recording from the first part of the flight, but a few

(20:58):
seconds after takeoff at 450 feet above the ground, one of the pilots abruptly pitched
to 22 degrees nose up, pulling 1.8 Gs of vertical acceleration and the stick shaker stall warning
sounded and then moments after that, the stick pusher intervened to reduce the angle of attack.
And now the stick pusher is a feature of T tail aircraft that automatically pushes the

(21:22):
control columns forward when a stall is beginning.
And this is required because T tail aircraft can sometimes get into a stalled condition
where the disrupted airflow over the wings blanks out the elevators, which is called
a deep stall.
And that's really bad with a capital R and capital B. So this automatic system tries to
prevent the plane from stalling in the first place.
And really, it's so incredibly silly that these guys were just pulling up to the point of

(21:44):
stick pusher activation for fun.
There was no operational reason to do this.
They just wanted to see how many Gs they could pull.
And this is the NTSB's actual conclusion.
You guys, we cannot stress enough that the fucking NTSB was like, mad dog, press X to
doubt.
They, they did this in the fucking report.

(22:06):
We need to increment the dipshit counter.
I think this is a possible world record.
Make a dipshit move at 450 feet.
I mean, seriously, intentionally triggering the stick pusher is one thing, but doing it
at 450 feet above the ground, that is not one fuck up high.
That's substantially less than one fuck up high.

(22:29):
And to be playing around like that with intentionally coming that close to stall, you want to be
at least three or four fuck ups high.
So Captain Jessie, what the fuck are you talking about?
Next slide, please.
Okay.
They do this once, they do it again because why the fuck not?

(22:49):
Listeners, now is a good time to tell you that this NTSB report that we alluded to is
fucking littered with these passive aggressive footnotes about how goofless and doofus behaved
at this crash.
And I don't know how I'm going to die, but I hope it's not in such a way that government
civil servants feel comfortable dumping on me, dunking on me in the report afterwards.

(23:14):
So, but first, before they do this again, they decide let's switch seats because wouldn't
it be cool for this 23 year old new first officer to fly from the captain's seat?
But wait, that's not allowed.
So I guess be gay, do crimes, I guess.
What lame crimes?
Be gay, do crimes, or so to speak, based crimes, like flipping over an LAPD cruiser, not flying

(23:39):
from the wrong seat of a plane you barely understand, like a real asshole.
Yeah, and we know they did this because the NTSB correlated who was talking on the radio
with the FDR data and which microphone is being keyed.
You just have to imagine that they were listening to the cockpit voice recorder and someone
went hang on, did they switch seats?
And then they checked it.

(24:00):
Yeah, they actually switched.
They actually switched back a few minutes before the end of the flight, which was on
the CVR.
They could hear them doing that.
And there's footnotes in the NTSB report where it's very clear that whoever it was was listening
to the CVR was like, I can't believe these guys did this.
This is just so stupid.

(24:23):
So Captain Jesse is now in the right seat and First Officer Peter is in the left seat.
And at this point, they go all, I'm gonna fucking do it again.
And they do it again.
So at 15,000 feet, they pull 17 degrees nose up, pull 2.3 Gs and achieve a climb rate of
10,000 feet per minute.
And then just for good measure, they made some large back and forth rudder inputs because

(24:46):
they were explicitly told not to do that after American Airlines flight 587 and they just
wanted to stick it to the van.
I appreciate that they really were just screaming, you're not even my real dad at physics and
material sciences.
Yeah, and so then at 24,600 feet, they pulled up sharply again 10 degrees nose up 1.87 Gs
at a climb rate of 9000 feet per minute.

(25:08):
So they fucked up three consecutive climbs and they have forgotten that they are still
not new fighter jet my dudes.
Yeah, but that was just the warm up because now we have to talk about the 410 club.
So yes, next slide.
So within Pinnacle Airlines, there was an informal club, quote unquote, of pilots who

(25:29):
had flown the CRJ-200 at its service ceiling of 41,000 feet or flight level 410.
Now there's normally no operational reason to fly this high.
So the way the pilots did it was they would climb to 410 on repositioning flights where
nobody gave a shit.
And if you had been to flight level 410, that made you cool or something.

(25:50):
I don't know.
I'm not cool.
So now first of all, we need to ask what even is a service ceiling anyway?
This is not the highest you can go in a certain aircraft type.
It's just the highest that the manual says you're allowed to go.
So this is what an aircraft's predictable and known limits are.
It's not what its absolute limit is.

(26:12):
It's when you leave what's known and you become a test pilot.
Basically, they are saying the dynamics of flight at these speeds and dynamics become
unpredictable.
Yeah, so you can physically go higher.
The margins of stable flight become too narrow to be acceptable to operators and regulators.
So what this means is that in a totally empty CRJ, the actual maximum altitude that could

(26:35):
be achieved is significantly higher than flight level 410.
And flight level 410 itself should be fairly easily attainable if you know what you're
doing.
Narrator voice.
They didn't know what they were doing.
I'm picturing Jim Halbert, but like in that short sleeve white shirt with the stripes
on his shoulder, just looking at the camera with his stupid face.

(26:57):
Yeah.
So according to the Pinnacle Airlines Flight Crew Operations Manual, the minimum climb
speed above 36,000 feet is 250 knots and the maximum climber rate is 300 feet per minute.
And to understand why that is the case, we have to talk about one of my favorite things.
Next slide.

(27:17):
The power curve.
So the power curve is this graph that you see on your screen if you're watching with
slides and the purpose of the power curve is to represent the range of airspeeds that
can be maintained by a given aircraft at a given altitude under given conditions where
the limiting factor is engine power available.
So on the X axis, we have airspeed in knots and there aren't values here because this

(27:43):
is different for every aircraft and altitude.
All you need to know is that airspeed increases from left to right like a normal graph.
And on the Y axis, we have engine thrust.
And two lines have been plotted here.
One is a parabola opening upwards, which is the amount of engine thrust Y required to

(28:04):
maintain airspeed X at the given altitude.
And the second line is the amount of engine thrust actually available, which does vary
a little depending on airspeed, but for the most part you can picture it as a straight
line slicing across the parabola.
So now let's explain what all of this information actually means in practical terms starting

(28:25):
on the right side of the graph at high airspeed.
Now it's quite intuitively obvious that if you want to fly faster, you need more thrust.
So obviously as your target airspeed increases on the X axis, the amount of thrust needed
to maintain that speed also increases.
But if you want to go a little bit slower, that's fine.
You can just reduce engine power and you will fly slower.

(28:47):
So where the thrust required line intersects the thrust available line, that's the maximum
attainable airspeed in level flight at that altitude.
So far so good.
Now the funky thing here is that this relationship only holds true up to a point.
There's a certain optimum airspeed where the required thrust to maintain it is at its lowest.

(29:08):
And then if you want to fly slower than that, you start needing more thrust again, which
is why this graph is a parabola.
And so the left side of this graph, which is shaded, is called the region of reversed
command because you need more thrust to fly slower, which is the reverse of what we would
consider normal.
And this reversal occurs because of the way the lift function works.

(29:32):
Lift is a function of a bunch of things, but at a constant altitude and aircraft configuration,
the important bits are airspeed and angle of attack, which for new folks is the angle
of the lifting surfaces relative to the oncoming air stream.
So if you want to stay at your current altitude, you need a constant amount of lift, right?
So if your airspeed decreases, you need to increase the angle of attack to compensate

(29:56):
or else the plane is going to descend.
At the same time, to maintain airspeed, thrust must be equal to drag.
However, increased angle of attack causes additional drag because more of the fuselage
is presented to the oncoming air.
So unless thrust is increased, this drag from the increased angle of attack will cause airspeed

(30:17):
to decay further, which will necessitate a further increase in angle of attack and so
on in a progressively accelerating feedback loop, or shall we say decelerating.
So to sum up, lower speed equals higher angle of attack equals higher drag equals higher
thrust required, and by the transitive property, maintaining altitude while flying at a lower

(30:41):
speed therefore requires more thrust.
So therefore, as you move toward the left side of the graph, the required thrust again
rises up to meet the available thrust, and the point where they intersect is the particular
airspeed at which the maximum available thrust becomes insufficient to overcome the drag

(31:02):
from the angle of attack that is required to maintain lift at that airspeed.
Just let you process that for a moment.
So if you try to fly slower than that, the feedback loop of decreasing speed at increasing
angle of attack will continue until the airplane stalls, and if you're in the area of reverse

(31:23):
command you can accelerate out of it by increasing thrust, but if you're beyond that intersection
point there's nothing you can do because the thrust required to stop your airspeed from
decaying is greater than the thrust available.
And if you're in that situation, the only way to recover is to pitch down to reduce the
angle of attack and thus reduce drag, but by decreasing the angle of attack you also

(31:45):
lose some of your lift so the plane is going to descend, at which point you basically trade
potential energy, height, for kinetic energy, speed, and then your Gucci again.
Now what does all this have to do with Flight 3701?
Next slide please.

(32:06):
So for some fucking reason our pilots have decided they are going to join the Flight
Level 410 club tonight.
They should have tried joining the Mile High Club instead, it would have been much safer.
Yeah, and Gair, and that is preferable.
Yeah, so as I mentioned earlier, by this point they're up to around 37,000 feet, and at
these altitudes the performance of the CRJ is pretty restricted.

(32:30):
The Flight Cooperation Manual says if you want to climb at these altitudes, again, you
need to maintain at least 250 knots and your rate of climb can't exceed 300 feet per minute.
And that's because if you try to climb faster than 300 feet per minute, or at an airspeed
slower than 250 knots, at that altitude you will fall behind the power curve.

(32:52):
This means that to do this you need to use the autopilot in flight level change mode,
or whatever the CRJ equivalent of that is, I'm not totally sure, with an airspeed greater
than 250 knots selected.
That will make the autopilot maintain that airspeed and then climb at whatever climb
rate results from that, which is perfectly safe.
So guess what, our heroes ignore this advice entirely and tell the autopilot to maintain

(33:15):
a climb rate of 500 feet per minute all the way to 41,000 feet, and to make matters worse,
they start this climb from 37,000 feet at a speed of only 203 knots.
Next slide please.
So if we plug all of those values into the fancy lift equation, what it'll tell you is
that to achieve enough lift to climb at 500 feet per minute at 37,000 feet with a starting

(33:38):
airspeed of 203 knots, you need an angle of attack that is too great for the resulting
drag to be overcome even with maximum thrust.
Now doesn't that sound familiar, right?
That's why we just went over all that stuff about the power curve.
So what that means is that with the autopilot having been commanded to maintain 500 feet
per minute, it's just going to keep increasing the angle of attack higher and higher to maintain

(34:01):
the required lift to climb, while the airspeed keeps dropping lower and lower, all while
the thrust levers sit at max power.
So you're exchanging kinetic energy, airspeed, for potential energy, altitude, and like all
satanic bargains, the devil is going to collect his due.
But the pilots are utterly clueless that this is going on, and we know because the cockpit

(34:23):
voice recording starts around this time, and they are just laughing at their low fuel burn.
And they're also just talking like two absolute dude bros.
I mean, you should read this CVR transcript, I'm serious.
Now at some point around here, the first officer, Peter says, man, we can do it.
41 it, baby.
And so Captain Jesse says not to let their airspeed drop below 170 knots, but it'll be

(34:46):
fine because they're leveling off soon.
But I mean, that was never true.
But also guess what?
By the time they level off at 41,000 feet, their airspeed is only 163 knots, which is
crazy low at that altitude.
But the pilots are just joking around like, there's 410, my man.
This is great.
410, four fucking one oh.

(35:08):
Sound of laughing.
Yes.
There's so many little annotations on the CVR transcript that are just sound of laughing.
So Captain Jesse proposes that they celebrate with a drink and first officer Peter orders
a Pepsi.
So our captain gets up and goes to the galley, leaving the FO alone in the cockpit to go
get soft drinks.
And I should note, this is not allowed.

(35:30):
And actually what Captain Jesse said was a Pepsi.
I thought you said a beer, man.
I'd like one too.
To which FO Peter says, is that seal on the liquor cabinet?
So our boys pop open their Pepsi's and Jesse is like, they're cold as fuck, dude.
Is this product placement in my cockpit voice recording?

(35:51):
So does all the Pepsi placement, would that mean that this crash was sponsored by Pepsi
or Coke?
Yeah, interesting philosophical question there.
So at this point they finally realize that something's not right because Jesse asks,
accelerating up at all?
And Peter says, no man, it ain't speeding up worth shit.
Because of course it isn't.

(36:12):
They're way off the back end of the power curve in that nasty feedback loop bit where
the speed just keeps decreasing and the angle of attack keeps increasing.
And the only way out of it is to descend or stall because they're already at maximum thrust.
So Jesse also points out how nose high they are because the autopilot is increasing the
angle of attack to observe values to maintain lift as the airspeed falls, but they're still

(36:35):
treating this like it's a joke.
They could end this so easily.
If they had just slowly pushed the nose over at any point and sort of slowly and observably
built their airspeed back up, the rest of the story never happens.
Yeah, but that would cause the plane to descend and we don't want to ruin the party by leaving
flight level 410 now, do we?

(36:56):
So at this point ATC asks if they are actually a CRJ 200 because he's quote, never seen you
guys up at 41 there.
And Captain Jesse replies, we don't have any passengers on board.
So we decided to have a little fun and come on up here.
This is actually our service ceiling.
Listeners don't admit to your crimes on ATC radio.

(37:16):
So meanwhile to first officer Peter, he points out that quote, the damn thing's losing it
and quote, we're going to be fucking coming down in a second here, dude.
They're still laughing like it's funny.
And Jesse says, this thing ain't going to fucking hold altitude, is it?
And Peter replies, it can't man.
We fucking greased it up here, but it won't stay.

(37:37):
Listeners, this is the rare unknown protagonist foreshadowing.
Yeah.
So Captain Jesse realizes they need to escape this feedback loop by descending to convert
that potential energy into kinetic energy.
So he asks air traffic control for lower.
Honestly, ATC should just say skill issue and deny lower.

(37:58):
Yeah, for real.
So ATC has to coordinate with another sector to make sure that giving them a lower altitude
won't cause a traffic conflict because they're right by a sector boundary.
So he tells them to stand by because this will take a minute.
But Flight 3701 doesn't have a minute.
It's coming down whether they want it to or not because they're at 150 knots with an angle

(38:18):
of attack of 12.5 degrees.
And that's more or less the most you can do.
So stall is now imminent, which brings us to our next section.
Next slide, please.
Okay this is whoop whoop pull up.
So our stage is set.
We're ready to talk about the actual accident sequence.
Kyra, please continue.

(38:38):
Right.
So right as the controller says, standby, the stick shaker activates warning that they're
about to stall and the autopilot disconnects automatically.
So at this point, they have to pitch down and descend right fucking now.
But instead they ignore the stick shaker completely.
Imagine Death with his scythe coming up to you, handing you everything but a written

(39:01):
warning and then going, lol, meh bro.
Yeah.
So the plane starts to stall.
The stick pusher intervenes, physically forcing the control columns forward to bring the nose
down.
But when the plane tries to dive, the pilots pull back and override the stick pusher to
try to stay at 41,000 feet.
So the stick pusher activates two more times and the pilots pull back and override it two

(39:25):
more times.
And you can override the stick pusher on the CRJ because it isn't an Airbus something-something
die by wire.
Somewhere there is a Bombardier flight dynamics engineer saying, pilots know best, over and
over again while crying into a bottle of shitty scotch.
He's probably doing it in French though.
True.
Yeah so predictably the aircraft responds to three consecutive overrides of the stick

(39:47):
pusher by stalling.
The angle of attack skyrockets until it's literally off the charts.
The highest the sensors could measure was 27 degrees.
While writing this out in our notes, we refer to this as a 3.6 ronkin moment.
Except for the fact that this is of course both not great and terrible.
Yes.
So the pitch angle reaches 29 degrees nose up while the plane is falling downward.

(40:13):
So that's a very high angle of attack.
Roll becomes unstable and the plane banks 82 degrees to the left before rolling level.
So this is a remarkable tribute to the aerodynamics of the CRJ.
This is actually a huge thing.
Swept wing stalls are an absolute fuck.
They are almost always completely unrecoverable and hugely fatal.

(40:38):
If you stall a swept wing plane, yes, it tends to lose roll stability and that's a very big
problem if you're very close to the ground.
If you're not close to the ground, it's fine.
But that's probably what Jay, you meant by almost always hugely fatal.
Yeah.
So, but these guys rolled some 20s here and they got themselves into a recoverable position.

(40:58):
So what did they do with this new found good luck?
Well.
Listen, it's bad enough that at one point in the host chat, we had to go, it happened
during stall?
Which stall?
Oh, the main one.
You should never have to clarify which stall.
Yeah.
So at this point, Captain Jesse pitches down and he executes a stall recovery maneuver.

(41:24):
Great.
This is everything's fine, right?
And actually the answer is no, because now they have a whole other problem.
Next slide.
Oh shit, it's engine failure with the steel chair.
Because when the angle of attack gets too high, air stops flowing into the engines in
sufficient quantities to sustain their functioning as the engines can flame out, which they both

(41:45):
immediately did.
And this turns the plane into a glorified glider.
This also causes electrical power to be lost.
So the instruments mostly go blank.
The pilots comment that they don't have any engines and Captain Jesse declares an emergency,
but he doesn't say what the problem is yet.
So they start the, they start, also I should add, they start the auxiliary power unit,

(42:09):
which brings back power to the captain side instruments among many other systems, but
not the first officer side, which is, we're going to come back to that later.
So now obviously priority number one is they need to restart the engines.
But before you can initiate combustion, you need to make sure the core is rotating first.
And the way you normally restart an engine is by getting the core to start rotating using

(42:31):
bleed air supplied by the other engine, then initiate combustion.
But this doesn't work if both engines have flamed out because which one is going to provide
the bleed air?
It doesn't work.
So in this case, the best method is to do a windmill restart where you get the core rotating
fast enough to start the engine purely by letting it windmill in the oncoming airflow.

(42:53):
But this only works below 21,000 feet where the air is denser.
This is specific, this values are specific to the CRJ, I should clarify.
So the double engine failure checklist for the CRJ200 instructs the pilots to descend
to 21,000 feet, then attempt a windmill restart.
And this is very important, the minimum airspeed required for a windmill restart is 300 knots.

(43:17):
And under no circumstances can you let the airspeed drop below 200-240 knots while on
the way down, because if you do, then you can core lock the engines.
Now what the hell does that mean?
OK, let's talk about core lock.
Next slide please.
No, that's a door lock.
Next slide.

(43:37):
No, that's Adam Warlock.
Next slide.
No, this is a lock core.
You're getting further away.
Next slide.
OK, this is better.
OK, so this is a GE CF-34, the engine that there were two of on this plane.
You see the two festive green arrows here?
They're pointing at the high pressure turbine interstage seals on the GE CF-34.

(44:04):
They are where you can get core lock.
Next slide please.
So have you ever had a glass stopper get stuck in a bottle or a flask?
This happens because the bottle got heated up so it expanded.
The stopper was inserted or maybe it was just sitting there under gravity and then the bottle

(44:25):
cooled down again and it contracted.
Yeah, science.
So core lock is the same, except instead of needing to run it under a hot water, it can
kill you.
Next slide please.
So it turns out that the CF-34 was particularly prone to it.

(44:45):
GE isolated the problem to the high pressure turbine interstage seal, which was a pressurized
piece of honeycomb steel fouling on the seal teeth on the outer torque coupling.
On the left here you can see an image of seals on the CF-6.
I couldn't find a picture of the CF-34 and even finding this one was very difficult.

(45:07):
The finger that you can see here is actually pointing to the interstage seal.
Listeners, we do a lot of research and GE is very good at this kind of thing, but even
they cannot find pictures of a possibly proprietary part from this exact engine.
So apologies.
You have this thing and you need to stop gas from getting from one turbine rotor to the

(45:28):
other without passing through the stator, which means you need a seal.
But the gas here has just come out of the combustor, so it's very hot, over 1000 degrees
C and possibly up to 1700 degrees C. So you can't use rubber or Teflon or Viton or whatever.
Instead use what's called a labyrinth seal.

(45:50):
Listeners this does not involve Jennifer Connolly, it does not involve Jareth the Goblin King
and Ariadne, real, unscreen or mythical, cannot help lead you out of this one.
Yeah, so the zigzaggy part on the image on the left gets very close to but does not quite
touch a part that looks like the thing on the right.

(46:13):
This means that the gas path from one side to the other is very, very long and it stops
gas from being able to easily get through.
It acts as a seal.
Effectively it increases the resistance.
The problem is that metal, like most things, expands when it gets hot and contracts when
it cools down.
And of course, a labyrinth seal by its nature has a lot of surface area.

(46:35):
In a turbofan engine, even if the core stops turning, air can still pass through the bypass
ducts which cools the housing around the core faster than the core itself can cool down.
Which means that the outer seal can shrink enough to make it interfere with the inner
seal which locks the core in place.

(46:55):
And obviously you don't really want this to happen to planes that you care about.
Bombardier knew that the CF-34 could corelock and Bombardier had a process to screen for
corelock on the GECF-34 before allowing them into service.
They would do this thing where they would climb to 31,000 feet, run the engine at idle

(47:16):
for several minutes and then shut it down and leave it for 8 minutes while descending.
If the core didn't lock, then all good.
And if it did lock, they would restart the engine using bleed air from the other engine
which overcomes the corelock, then climb back to 31,000 feet, shut it down again and then

(47:37):
descend while maintaining an airspeed of at least 240 knots.
And the high speed was so that they would have enough energy in the core rotation so
that even when the two seals came into contact with each other, they would grind against
each other and this would wear them so that they couldn't corelock against each other

(47:58):
again.
GE also modified the engine to give these high pressure turbine interstage seals more
clearance, reducing the likelihood that it would corelock, but even after this modification,
GE noted that about 1.5% of CF-34s could still corelock before grinding in, even though they

(48:19):
claimed that after grinding in it wasn't possible to corelock them.
Bombardier may or may not have been convinced that they kept using the CF-34 and kept screening
them for corelock, and all of this is completely besides the point because the screening was
completely irrelevant.
Next slide please.
And the reason this doesn't much matter in this case is that they absolutely fried the

(48:41):
shit out of both of these engines, sufficiently that they melted the turbine section in one
of them.
So the engines were far enough outside of this testing envelope that the temperature
difference was enough for them to lock up anyway.
Yeah, because the screening procedure involved running the engine at idle for several minutes
before shutting it down at 31,000 feet, the temperature differential was much smaller

(49:03):
than would be experienced during a flameout at maximum power at 41,000 feet.
So if the differential was sufficiently greater than the one encountered in screening, you
could corelock an engine that passed all of Bombardier's tests, which is what happened
here.
Both of these engines had previously been screened for corelock and found not to suffer
from it, but that didn't matter.

(49:24):
Okay, so here's one thing I want to know, how did these engines get so hot?
Because you would think that if you start them with oxygen, that should deplete the
energy of the fire, right?
Well you might think so, but remember our least favourite plane, the BAC 111, and it's
burning out of both engines during the invention of the before burner?

(49:49):
That was because there was too much fuel for the amount of air the engine had.
The 111-500 is the official kicking post of CPIT, got that plane sucked so much.
Right, so normally jet engines run very, very, very lean.
So lean that the fuel only burns at about 1700 degrees C, rather than the 2200 degrees

(50:09):
C it would burn at stoichiometry where it had exactly enough air to actually burn.
In the case of the plane in that other story, episode three?
Two.
No, two.
Two.
Episode two.
Yeah, it was caused by suddenly pouring jet A into the front of the engine, but in this
case it was actually somehow dumber.

(50:34):
Because the reason the engines can't make much thrust at flight level 410 and low air
speed is that the air is not dense enough, and there's not enough ram air pressure to
help the compressor along.
During the stall, engine two had its airflow disrupted enough that it pushed the mixture
all the way to rich, which made the combustion temperature rise to the point where the turbine

(50:59):
couldn't tolerate it anymore.
It promptly got all melty.
Engine two has left the building.
Dusty.
Seriously, they found bits of the high pressure turbine rotor splattered all over the place.
This voids the warranty.
No, seriously, a quote from the NTSB examination.

(51:19):
The core was rotated at the starter pad and required 450 inch pounds to turn.
Crunching noises could be heard from the tailpipe during core rotation.
Modern turbines are miracles of tolerance and precision machining and balance.
The word crunch should never apply to any part or process of a turbine engine.

(51:45):
As for engine one, it had been run at very high power for quite a while at very high
altitude.
And then Captain Jesse and his fearless first officer completely failed to maintain air
speed high enough to stop this engine from core locking, which also voids the warranty.
Actually it might not, because once the engine cools down, it should resume working just

(52:07):
fine.
There should really be any damage.
Well it voids the we pinky promise this engine won't core lock on you warranty.
True.
Okay, next slide.
So now we are at altitude with two dead power plants.
One has been well and truly goosefucked and the other will core lock unless they maintain
a speed of at least 240 knots.

(52:30):
So the proper thing to do is to follow the checklists and procedures exactly as they
are written so as to not die.
And spoilers listeners, they did not do this.
They did not maintain 240 knots.
Okay so we've established core lock, we've established the kinetic energy situation of

(52:50):
our pilots.
We are on descending and we have two dead engines so we're going to restart them by windmelling.
Start an engine in flight as Kyra discussed, you normally use bleed air from the other
engine.
We don't have another engine because Clown Shoe and Shower Shoe have killed both.
So we're looking at a double engine restart with a windmill method.

(53:10):
We need to get the air moving through the fan at 300 knots because this will spin it
up fast enough that it will sustain ignition.
But for some reason, Céchage doesn't push the nose down enough so they only get up to
236 knots.
That's not nearly enough.
Wait, why doesn't Rhodes call that out?
Okay so do you remember when they switched seats?

(53:33):
Well the backup power coming from the APU only provided power for the captain side instrument
displays on the left side of the aircraft.
The captain was sitting in the right seat so he could not monitor to make sure that
the first officer was achieving the needed aircraft parameters.
Nor at any point did he say, I will take the aircraft, you monitor.

(53:54):
Yeah and he could have looked at the standby instruments which are on the center pedestal
but I guess we guess he just didn't.
So by this point they have been flying too slowly for too long.
They are running out of kinetic energy.
Both engines core rotation speeds have dropped to zero and guess what?
They both core lock.

(54:15):
Now these guys are well and truly fucked and they have one card left that they can play
which is to glide to a suitable airport.
Now weird footnote, about 20 seconds into the engine failure checklist the cabin altitude
warning system fired and our two heroes know that they should put their masks on.
They do so but then they take them off and put them back on a couple of times for reasons

(54:37):
that are not speculated enough for the report and reasons that we will never know.
So what I read seemed to indicate that it was possibly because the cabin altitude kept
fluctuating up and down right above and below the put your oxygen masks on now threshold
and so they literally just did keep taking them on and off.

(55:00):
This was the one rule that they decided to follow to the letter.
Yeah, to the letter.
Do you think that maybe they just wanted to finish their Pepsi?
I mean actually plausible.
It's hard to drink Pepsi when you have an oxygen mask on.
Right exactly.
So after the windmill method failed the captain decided he wants to try and do a restart with

(55:22):
the APU.
So to get this to work he has to get down to 13,000 where the air is dense enough to
start the APU.
He's going to make four attempts over the next couple of minutes to start the engines.
Two for each engine.
All of them will fail because the engines are core locked and one of them is trashed.
Next slide.
Yeah so this is basically this is a bleed air restart but the bleed air is coming from

(55:43):
the auxiliary power unit and yeah that only works at low altitude.
Yeah by the time they got there it was completely out of the question.
Okay so now about this time ATC comes on the radio and they ask for the nature of emergency
and this is the wildest part of this entire story listeners.
Captain Jesse fucking lies.

(56:06):
He tells ATC that they have lost one engine not two engines.
Now this is a major deal because a single engine is a big problem.
A dual engine failure is fucking catastrophic.
It is the end of the world.
We want ATC to know that because they are there to help you.
We have no idea why he did this.
We will never know.

(56:27):
It is probably because he was worried he was going to get in trouble.
Like how does this lie work in his head?
Does he think the cheap pilot isn't going to figure out that he stalled CRJ200 and core
locked both engines?
I mean they were probably aware that turbofan engines are extremely expensive.
That's what this slide is.
Even little ones like the CF-34.

(56:49):
This is the cost estimate from the Airworthiness directive to replace a single cracked turbine
blade for a single CF-34 engine.
That one blade just the part costs $11,000.
There are about 150 blades in that engine.

(57:12):
Now imagine how much an entire toasty engine was going to cost.
A repair invoice like this is familiar to anyone who's owned generally a German luxury
car or any kind of Porsche really.
At this point it should be obvious that these guys are so fired.

(57:36):
A hundred times fired.
The most fired you can be.
And that their focus should be on survival only.
They cannot save their jobs at this point by lying.
All they can do is try to improve their own odds of survival and yet they're still lying.
It's just ridiculous.
Okay, so next slide.
Yeah, so here's why this is a problem.

(57:59):
Because when they had the incident, that is at the moment of the stall, there were six
airports in glide range, all of which were suitable for CRJ200.
And these are shown on the slide.
So at 30,000 feet, all six of these airports are in range.
At 20,000 feet, five of these airports were still in range.

(58:19):
But at 10,000 feet, only Lee C. Fine Municipal Airport was in range.
And these all assume that they averaged the optimal glide speed of 170 knots.
So we don't even know if they'd even made it to Lee C. Fine that they might have.
But they only admitted their mistake, that is that they had double engine failure to

(58:40):
ATC at 10,000 feet.
And now, as you can see, they're down to one landing site, the one I just mentioned, and
even then only barely.
So instead of going to one of the closest airports right from the beginning, where they
would have had ample time to set up a stabilized approach and make it to the airport, all they
have left now is this one Hail Mary move, which is to turn around and go to Lee C. Fine,

(59:07):
but they don't because the air traffic controller has not been told until now how deep the shit
that these guys are in is.
And so the controller vectors them to Jefferson City Memorial Airport instead, which is a
spot that is actually out of their best glide range now.
And that's because air traffic control doesn't know what their range is, and the pilots haven't

(59:28):
calculated what their range is.
So Jefferson City sort of looked like it was maybe theoretically doable, but it actually
wasn't.
So they keep gliding down in the dark, and eventually they make visual contact with the
airport and see the runway lights.
And at that point, it's clear they're not going to make it.
So now you may be asking why they didn't try to land on a field or in a large parking lot.

(59:52):
I mean, it's a regional check.
Come on.
Do you know where you can land a CRJ 200 with no passengers and minimal fuel?
Fucking anywhere.
Yeah, but the problem is it was at night, there was high cloud cover, and there's only
about three quarters moon.
So it was really hard to see much of anything until it was way too late.

(01:00:13):
Once they realized they were not going to make it, it was very difficult to pick a landing
site because it was just black and lights where there's buildings.
So you don't know what's in the black.
If they'd managed to stretch the glide a couple more minutes, they'd have made it to a runway
and they might even have been able to restart the one engine they hadn't melted.

(01:00:35):
Although we'll never know because these guys managed to biff it by not following any of
the procedures ever.
If they'd managed to follow the proper procedure to get to flight level 410, they would still
be alive today to harass and under-tip wheatstaff.
Hey baby, I have my own pilot's license.
They'd probably still have the pilot's license too because if they got to 41,000 feet with

(01:00:59):
adequate airspeed and so on, this probably would never have been discovered that they
did this.
And actually it wouldn't have been something they shouldn't have done because it was within
the surface ceiling of the plane.
It was designed to be able to fly that high.

(01:01:20):
It was supposed to be safe if you didn't do it like a complete asshole.
But anyway, instead they found themselves here.
And they were only a couple miles from the runway.
Jato Bottles could have saved them.
As always.
No, except these clowns probably would have used them already to try to join the flight
level 500 club.

(01:01:40):
Yeah, that's a much more exclusive club, isn't it?
At this point, all hope is lost, they didn't put the landing gear down because they saw
a road at the last second.
They're like, there's a road over there, try to land on that.
But it was clear within seconds they weren't going to make that either.

(01:02:01):
So the last words on the cockpit and voice recorder are, aw shit, we're going to hit
houses, dude.
I mean, imagine that's your legacy.
So they hit a tree which ripped off the wingtip and then they went the plane turned inverted
and crashed into the ground and plowed through six different residential backyards in suburban

(01:02:25):
Jefferson City before it finally came to a stop in somebody's yard next to a street.
And both pilots were killed instantly on impact.
But thankfully they did not hit anyone else on the way down.
Damage was only to backyards and outbuildings.
No houses were hit.
Nobody on the ground was injured.

(01:02:46):
So that actually made these pilots eligible for Darwin Awards and they actually did receive
the 2004 Darwin Awards, I should add.
We didn't have that in the script, but it's a fun fact.
All right, next slide.
Let's talk about the aftermath.
So the immediate thing that baffled investigators was why these guys fucked up so badly so many

(01:03:10):
times in a row.
Short version, beyond the obvious bad judgment, their training was fucking ass.
All the memory items related to double engine failure, including the minimum airspeed requirement
were covered in a classroom, not a simulator.
Simulators are expensive.
Airlines try and minimize the use as much as possible unless they own their own.

(01:03:33):
And these regionals for the most part do not own their own.
They have to lease them.
So they were not able to practice any of these processes in the stress of an actual cockpit.
They did undergo upset and recovery training, but it was at low altitude.
They did not fly maneuvers or stalls at high altitudes.
High altitude climbs were discussed in training.
They were never practiced.

(01:03:54):
Enged failure responses were considered memory items, but they also didn't practice high
altitude single or dual engine flame mounts.
Stick pusher activation was not systematically demonstrated in training.
Clinical Airlines gave newly minted captains two hours of leadership training.
We're painting a picture for you.

(01:04:16):
As well, César was so new.
Just call him First Officer Peter.
The first up as well.
The first officer was so new to the CRJ.
He hadn't had enough sim time to feel comfortable with the aircraft.
And you have to feel comfortable with the aircraft because the 10 degree nose down that
is required for a windmill restart is very unsettling.

(01:04:37):
It feels like you're pointing the aircraft straight at the ground.
Yeah.
And that's to be clear, that's how much you have to pitch down to get 300 knots, which
is the minimum.
Because he was poorly trained, it was probably hard to with, you know, with no entrance go,
oh, okay, well, I'm losing air, air, I'm losing airspeed and altitude.
I need to point the nose down.

(01:04:57):
That kind of thing can be overcome with good training.
But good training is expensive.
And neither of these guys got it.
And we want to know why did these pilots override the stick pusher and stall the plane?
Well, in addition to poor training on high altitude stalls and stick pusher, I would
add they had just asked air traffic control for lower, but we're told to stand by.

(01:05:18):
So we think that it's possible they were trying to keep the plane at 41,000 feet until they
heard back in an effort to avoid descending without air traffic control permission.
Yeah, no, obviously, the correct move here is to just say unable, we must descend immediately.
But I think these guys are probably nervous about doing anything that would make waves
and possibly get their behavior discovered.

(01:05:38):
And this led to certain, you know, irrational behaviors, like repeatedly overriding a stick
pusher in a desperate attempt to stay at an altitude that you physically cannot stay at
just because you don't have permission from air traffic control to descend.
It's remarkable that they thought that this sort of positive thinking was going to overpower
the very dire signals that they were being sent by the airplane, that it was going to

(01:06:00):
stall.
Yeah, and I should I should also add, you know, that this time stall training was basically
it was approach to stall training.
The way it worked was the plane would slowly decelerate until the stick shaker activates,
and then you increase thrust and pitch down just a little to maintain altitude without

(01:06:21):
stalling.
And that doesn't work when you're about to go into a full stall at 41,000 feet.
So it and that type of training also doesn't result in the stick pusher activating.
So it's not entirely clear that the pilots understood what the stick pusher was was trying
to do and that the fact that it was trying to put the plane into a dive was necessary.

(01:06:42):
And on top of that, we also have to mention that and this was sort of a footnote in the
report that the their airspeed indicators have a low speed queue on them, which shows
the speed at which the stick shaker will activate and due to a quote unquote software error.
This is not not explained in detail.
This stick shaker activation speed queue on their airspeed tape was 10 knots too low.

(01:07:06):
Now obviously they should have responded to the stick shaker properly anyway, but this
is one small thing that might have contributed to an environment where they weren't taking
the stick shaker seriously enough if they thought the margin above it was actually bigger
than it was.
You know, this kind of mentality could persist even after the stick shaker activated early,
well earlier than they thought it would, but actually right on time.
I think it's actually important to note that the plane that first caused a stick pusher

(01:07:34):
to be implemented was the BAC 111.
It was.
It was.
That's actually a great fact.
I'm glad.
Our least favorite slash favorite plane.
The official kicking post.
It's following us around.
I'm telling you.
So this accident forced sort of forced regional airlines to reckon with pilot behavior on

(01:07:57):
these repositioning flights.
Before when Zero Club was banned immediately, any ascending above 37,000 feet was banned
at Pinnacle for any reason.
Skill issue.
They started pulling FDRs and a worrying number of cases of regional pilots acting like assholes
were uncovered.

(01:08:20):
Pinnacle overhauled their training with more simulator training, including high altitude
engine failures.
Given how aware Bombardier clearly were of the CF-34's Proclued Coralock, it could be
argued that the QRH wasn't sufficiently forceful about how important following the restart
procedure to the letter was.
They did rewrite the double engine failure checklist to clarify that you will have to

(01:08:44):
pitch down a lot to achieve the windmill restart speed.
And they also put in language clarifying where you have to maintain at least 240 knots after
an engine failure at altitude, which is of course because the engine could Coralock if
you don't.
The pilots in this accident were almost certainly unaware that Coralock was even a thing, let

(01:09:05):
alone that it was the reason the checklist said to maintain 240 knots.
They never said the words Coralock during the accident sequence.
And the NTSB recommended that all regional airlines adopt these reforms.
And I mean, as we said, to what extent they adopted those practices, I mean, we'll just
write the word Colgan Air on a post and pull that one down and drop that episode.

(01:09:27):
I also talk about it in my article on Colgan Air, but a lot of the biggest reforms to the
regional airline industry came after that crash and not this one.
But this was part of the buildup to it.
But that's another episode.
Next slide, please.
Okay.

(01:09:48):
Now, what did we learn from this?
Lesson one, don't do this or you'll be made fun of by a bunch of nerds on a podcast.
And you also might die, which is a little extreme if you ask me, but we don't make the
rules.
I think that pilots should have to visit an endocrinologist to make sure that they don't
have too much testosterone so that they can get an ATP.

(01:10:10):
Yeah, the FAA has clarified that being a super aggressive Kyle that punches walls because
he has anger issues is not disqualifying for an ATP.
But if you see a therapist about it, that is disqualified.
Yeah, as it should be, I guess.
No, no, we're kidding.
That's not how it should be.
All right.

(01:10:31):
Do we have any final thoughts to close this episode out?
Yeah, I already said it, but don't be these guys.
Just don't do it.
If you are going to be these guys, please try to have a surname that's easier for Ariadne
to pronounce, please.

(01:10:51):
Please don't put that in the episode.
You know it's going in the episode then.
That's going to be in there.
I'm sorry.
Thank you everyone for joining us.
Our next episode will be on Malaysia Air 370.
As it always is.
Bye.
All right.

(01:11:12):
See you.
Bye.
See you then.