Latest / Aviation Survival Stories / MPH Over the Highway: How Flight 331 Skidded Past Disaster

Transcript

MPH Over the Highway: How Flight 331 Skidded Past Disaster · Aviation Survival Stories

• 0:03
  Speaker 1: At 1022, on the night of December 22, 2009, a
• 0:08
  Speaker 1: Boeing 737 crossed a public highway at 72 miles per
• 0:12
  Speaker 1: hour and came to a stop in the grass, meters
• 0:15
  Speaker 1: from Kingston Harbor. 154 people were on board. Not one
• 0:19
  Speaker 1: of them died. And that survival, that improbable, almost impossible survival,
• 0:23
  Speaker 1: is exactly what allowed the failure beneath it to keep going.
• 0:26
  Speaker 1: This is the story of American Airlines Flight 331. There
• 0:30
  Speaker 1: is something that stays with you when you study this accident.
• 0:33
  Speaker 1: Not the wreckage photographs though those are striking enough. It
• 0:36
  Speaker 1: is the arithmetic. 4,100 feet. That is where the wheels
• 0:40
  Speaker 1: touched down on a runway that was 8,910 feet long.
• 0:44
  Speaker 1: More than halfway down, a Boeing 737, fully loaded at
• 0:48
  Speaker 1: night in December, And the tires finally met concrete at
• 0:51
  Speaker 1: almost the midpoint of the strip. What happened in those
• 0:54
  Speaker 1: remaining 4,000 feet, and in the years of institutional silence
• 0:58
  Speaker 1: that made them possible, is what this episode is about.
• 1:01
  Speaker 1: Two threads run through this story, and they will cross
• 1:03
  Speaker 1: at the worst possible moment. The first is the cockpit
• 1:06
  Speaker 1: of Flight 331. Two experienced pilots, a challenging airport, a
• 1:10
  Speaker 1: wind at their backs, when it should not have been.
• 1:13
  Speaker 1: The second thread is a regulatory gap that investigators had
• 1:16
  Speaker 1: already identified, already named, and already reported years before this night,
• 1:20
  Speaker 1: and that no one had converted into a binding rule.
• 1:22
  Speaker 1: When those threads crossed over the threshold of runway 12
• 1:25
  Speaker 1: in Kingston, the result was wreckage, 85 injured, and a
• 1:28
  Speaker 1: plane declared a total loss. The result was also by
• 1:31
  Speaker 1: the thinnest of margins, no deaths. And in aviation, when
• 1:34
  Speaker 1: no one dies, the story tends to disappear. Brian Cole
• 1:37
  Speaker 1: was 49 years old in December of 2009. He had
• 1:41
  Speaker 1: joined American Airlines in 1986, more than two decades before
• 1:45
  Speaker 1: that Tuesday night in Kingston. He had built his career
• 1:48
  Speaker 1: on large jets, earning his captain's rating on the Boeing 727,
• 1:52
  Speaker 1: and serving as a Czech airman, one of the pilots
• 1:54
  Speaker 1: authorized to evaluate and train others, before transitioning to the 737.
• 1:59
  Speaker 1: By the time he walked through the jet bridge in
• 2:01
  Speaker 1: Miami for the second leg of Flight 331, he carried 11,147
• 2:04
  Speaker 1: total flight hours. He had flown into Norman Manley International before.
• 2:12
  Speaker 1: He knew the airport. He knew the runway. Daniel Billingsley
• 2:15
  Speaker 1: was 45. He had come to American Airlines in 1998,
• 2:19
  Speaker 1: 12 years after Cole, but in one specific and significant
• 2:23
  Speaker 1: way he was the more experienced man in that cockpit.
• 2:26
  Speaker 1: Cole had logged 2,727 hours in the 737. Billingsley had
• 2:28
  Speaker 1: logged 5,027, nearly twice as many. The first officer sitting
• 2:36
  Speaker 1: in the right seat knew this aircraft better, by hours,
• 2:39
  Speaker 1: than the captain beside him. That detail matters, not as accusation,
• 2:43
  Speaker 1: neither man was charged with anything, but as a portrait
• 2:46
  Speaker 1: of how aviation crews are assembled, and how gaps in
• 2:49
  Speaker 1: institutional training affect everyone equally. Billingsley would later tell investigators
• 2:53
  Speaker 1: that he felt very comfortable flying with Cole, that comfort
• 2:57
  Speaker 1: was genuine, and it was earned. These were not reckless men.
• 3:00
  Speaker 1: They were professionals operating inside a system that had left
• 3:03
  Speaker 1: a specific and documented hole in their preparation. Norman Manley
• 3:06
  Speaker 1: International sits on a narrow peninsula southeast of Kingston. The
• 3:10
  Speaker 1: geography is unforgiving. Runway 12 is the approach from the northwest,
• 3:14
  Speaker 1: which means an aircraft on final is descending toward the
• 3:17
  Speaker 1: island with Kingston Harbour behind the threshold and the Caribbean
• 3:20
  Speaker 1: directly off the far end. There is very little room
• 3:23
  Speaker 1: for error and almost no room for a long landing.
• 3:26
  Speaker 1: Pilots who fly there regularly describe the approach as demanding
• 3:29
  Speaker 1: concentration even in good conditions. On the night of December 22,
• 3:33
  Speaker 1: conditions were not particularly good, the airport's approach lighting system
• 3:37
  Speaker 1: was not functioning. Crews had been notified of this before departure,
• 3:41
  Speaker 1: that is confirmed in the record, and the runway itself
• 3:43
  Speaker 1: was lit correctly, but the approach lights that help a
• 3:46
  Speaker 1: crew judge their descent path and alignment in the final
• 3:48
  Speaker 1: seconds before touchdown were dark. The cockpit would be working
• 3:51
  Speaker 1: harder than usual to build the picture that those lights
• 3:54
  Speaker 1: normally provide. One more element was already present when the
• 3:57
  Speaker 1: crew began their descent into Kingston. the wind. A tailwind
• 4:00
  Speaker 1: of 16 miles per hour was pushing the aircraft from
• 4:03
  Speaker 1: behind as it came down toward runway 12. The published
• 4:06
  Speaker 1: limit for a tailwind landing on that aircraft was 17
• 4:09
  Speaker 1: miles per hour. They were one mile per hour inside
• 4:12
  Speaker 1: the limit. Technically within bounds, but what no one in
• 4:15
  Speaker 1: that cockpit had ever been formally trained to calculate, not Cole,
• 4:19
  Speaker 1: not Billingsley, not any American Airlines pilot at that time,
• 4:24
  Speaker 1: not people, was the precise arithmetic of how a tailwind
• 4:27
  Speaker 1: that close to the limit would shrink the runway beneath
• 4:30
  Speaker 1: them once the wheels came down. That training did not exist,
• 4:33
  Speaker 1: not because no one had thought of it. It had
• 4:36
  Speaker 1: been thought of it. It had been written down. The
• 4:38
  Speaker 1: National Transportation Safety Board had already told the Federal Aviation
• 4:42
  Speaker 1: Administration that this specific gap needed to be closed. The
• 4:45
  Speaker 1: story of how that recommendation went unanswered, and what it
• 4:48
  Speaker 1: cost on a December night in Jamaica, is where this
• 4:51
  Speaker 1: episode is going. The wheels of American Airlines Flight 331
• 4:55
  Speaker 1: touched down at 10.22 in the evening on December 22, 2009.
• 4:59
  Speaker 1: Not at the beginning of runway 12, not even close
• 5:02
  Speaker 1: to the beginning. The main gear made contact 4,100 feet
• 5:06
  Speaker 1: from the threshold. That left roughly 4,800 feet of pavement ahead.
• 5:10
  Speaker 1: On paper, enough. In practice with a tailwind, a heavy
• 5:13
  Speaker 1: fuel load, and a wet surface, it was not. Captain
• 5:16
  Speaker 1: Brian Cole had flown this route before. He knew this airport.
• 5:20
  Speaker 1: he had put a plane down on runway 12 in
• 5:22
  Speaker 1: difficult conditions and warped away from it. But knowing a
• 5:25
  Speaker 1: runway and knowing precisely how much of it you will
• 5:27
  Speaker 1: consume on a given night, under a given wind, carrying
• 5:30
  Speaker 1: a given weight, those are two different kinds of knowledge.
• 5:33
  Speaker 1: One comes from experience. The other comes from a calculation.
• 5:37
  Speaker 1: And that calculation was never required. It was never even taught.
• 5:41
  Speaker 1: Here is the image that anchors everything that follows. 4,100
• 5:44
  Speaker 1: feet of runway gone before breaking had a real chance
• 5:47
  Speaker 1: to work. The aircraft was traveling at a speed that
• 5:50
  Speaker 1: made the remaining pavement shrink fast. The crew applied maximum braking.
• 5:55
  Speaker 1: The thrust reversers deployed. The plane decelerated. But not enough.
• 6:00
  Speaker 1: Not in time. It crossed the runway end at 72
• 6:03
  Speaker 1: miles per hour. At that speed the aircraft did not
• 6:07
  Speaker 1: stop at a fence or a blast pad. It crossed
• 6:10
  Speaker 1: a public road. It tore through the airport perimeter. The
• 6:13
  Speaker 1: landing gear collapsed. The fuselage fractured in two places, forward
• 6:17
  Speaker 1: of the wing and aft of the wing, and the
• 6:19
  Speaker 1: nose section was crushed. One engine was torn away. A
• 6:23
  Speaker 1: winglet was destroyed. The Boeing 737-823, registration November 9-7, Alpha November,
• 6:30
  Speaker 1: came to rest in the grass short of the Caribbean Sea.
• 6:34
  Speaker 1: 92 people went to hospitals that night. 85 of the
• 6:37
  Speaker 1: 154 on board were injured. 14 of those injuries were
• 6:40
  Speaker 1: classified as serious. Not one person died. The plane was
• 6:44
  Speaker 1: a total loss, the sixth whole loss of a Boeing
• 6:48
  Speaker 1: 737-800 in history. The published limit was 17 miles per hour.
• 6:52
  Speaker 1: The tailwind that night was 16, one mile per hour
• 6:55
  Speaker 1: inside the boundary, technically within bounds. But here is the thing,
• 7:00
  Speaker 1: that one mile per hour margin was not a margin
• 7:02
  Speaker 1: of safety. It was a margin of paperwork. The difference
• 7:05
  Speaker 1: between 16 and 17 miles per hour does not represent
• 7:09
  Speaker 1: two separate physical realities. A tailwind at 16 will do
• 7:12
  Speaker 1: most of what a tailwind at 17 will do to
• 7:14
  Speaker 1: a heavy jet on a short runway. What the number
• 7:17
  Speaker 1: does not capture is the compounding. A high-speed touchdown, a
• 7:20
  Speaker 1: fuel load carried for a return trip to the United States,
• 7:23
  Speaker 1: a wet surface, no approach lighting to guide the descent
• 7:26
  Speaker 1: path into the picture the pilots needed. Each factor alone
• 7:29
  Speaker 1: was manageable. Together they built a problem faster than the
• 7:32
  Speaker 1: remaining runway could absorb it. The crew had been told
• 7:35
  Speaker 1: the approach lights were out before they left Miami. They knew.
• 7:38
  Speaker 1: The runway itself was lit. But the approach lighting system
• 7:42
  Speaker 1: does not just illuminate the final seconds of flight. It
• 7:45
  Speaker 1: gives crews a reference for where they are on the
• 7:47
  Speaker 1: descent path. Without it, the final approach is being assembled
• 7:50
  Speaker 1: from fewer inputs, in the dark, at night, over water.
• 7:53
  Speaker 1: The crew flew it anyway. The record does not say
• 7:56
  Speaker 1: they should not have. It says no one had given
• 7:58
  Speaker 1: them the tools to precisely calculate whether under those specific conditions,
• 8:02
  Speaker 1: runway 12 was long enough. Picture the approach at night
• 8:05
  Speaker 1: from the south. The harbor is behind the runway threshold.
• 8:09
  Speaker 1: The Caribbean is beyond the far end. The approach is
• 8:11
  Speaker 1: over water in both directions. A crew coming in from
• 8:14
  Speaker 1: the north is flying a peninsula approach, ground beneath them
• 8:18
  Speaker 1: only when the runway itself appears. The visual cues that
• 8:21
  Speaker 1: normally tell a pilot how high they are and how
• 8:23
  Speaker 1: fast the ground is rising toward them are compressed into
• 8:26
  Speaker 1: a few seconds of actual visible pavement. Now add the tailwind.
• 8:30
  Speaker 1: It is not pushing the nose up, it is pushing
• 8:32
  Speaker 1: the whole aircraft forward, adding to the ground speed that
• 8:35
  Speaker 1: the wheels will carry when they make contact. Airspeed and
• 8:38
  Speaker 1: ground speed are not the same thing. A pilot manages airspeed.
• 8:41
  Speaker 1: The runway absorbs ground speed. That gap, the difference between
• 8:45
  Speaker 1: what the instruments show and what the surface must handle,
• 8:48
  Speaker 1: is exactly what tailwind landing training is designed to make visible.
• 8:52
  Speaker 1: Without it, the gap is invisible. The investigation found no
• 8:55
  Speaker 1: mechanical failure. The aircraft systems worked. The engines worked. The
• 8:59
  Speaker 1: brakes worked. The thrust reversers deployed. The plane performed as designed.
• 9:03
  Speaker 1: The problem was not inside the airplane. The problem was
• 9:06
  Speaker 1: in the 4,000 feet of runway that vanished before the
• 9:09
  Speaker 1: wheels touched, and in the absence of any formal process
• 9:12
  Speaker 1: that would have told the crew, before they descended, whether
• 9:14
  Speaker 1: the numbers that night were going to work. That process
• 9:17
  Speaker 1: had been recommended. It had been specifically recommended in writing
• 9:21
  Speaker 1: by the National Transportation Safety Board after a different accident
• 9:25
  Speaker 1: on a different airline. In December 2005, a Southwest Airlines
• 9:29
  Speaker 1: 737 overran runway 31 Charlie at Midway Airport in Chicago.
• 9:34
  Speaker 1: A child in a car on the street beyond the
• 9:36
  Speaker 1: runway died. the NTSB investigation produced a direct recommendation, require
• 9:42
  Speaker 1: airlines to calculate landing distance before every approach, using actual conditions,
• 9:46
  Speaker 1: not published performance tables built for ideal runways, the FAA
• 9:50
  Speaker 1: received that recommendation. By December 22, 2009, four years later,
• 9:55
  Speaker 1: it had not been converted into a rule. When the
• 9:58
  Speaker 1: NTSB issued its formal communication about Flight 331 on December 7, 2011,
• 10:04
  Speaker 1: it reclassified that original Southwest recommendation. The new status was
• 10:08
  Speaker 1: four words, Open Unacceptable Response, Not Pending, Not Under Review, Unacceptable,
• 10:14
  Speaker 1: The same gap that had cost a child's life in
• 10:16
  Speaker 1: Chicago in 2005 was still open the night 154 people
• 10:21
  Speaker 1: crossed a public road at 72 mph and came to
• 10:24
  Speaker 1: rest yards from the sea. The question that does not
• 10:26
  Speaker 1: resolve quietly is this. If the recommendation existed, if the
• 10:30
  Speaker 1: need had been documented, if the FAA had received it
• 10:33
  Speaker 1: in writing four years before, what exactly was being waited for?
• 10:36
  Speaker 1: The JCK published its final report on the 2nd of May, 2014.
• 10:41
  Speaker 1: four years and four months after Flight 331 crossed a
• 10:45
  Speaker 1: public highway and stopped yards from the Caribbean Sea. The
• 10:48
  Speaker 1: report named Multiple Causes, that phrasing matters. Multiple causes means
• 10:52
  Speaker 1: no single point of failure, no single person to absorb
• 10:56
  Speaker 1: the total weight of what happened. The investigation documented the
• 10:59
  Speaker 1: crew's failure to execute a stabilized approach. The late touchdown
• 11:03
  Speaker 1: more than 4,000 feet past the runway threshold, the tailwind
• 11:06
  Speaker 1: at 16 mph, One mile per hour below the published limit.
• 11:10
  Speaker 1: It also documented what was not there. No formal training
• 11:13
  Speaker 1: requirement for crosswind and tailwind landings at American Airlines. No
• 11:17
  Speaker 1: mandatory pre-landing distance calculation using actual conditions. No regulatory rule
• 11:23
  Speaker 1: that would have required either one. Captain Brian Cole was
• 11:26
  Speaker 1: 49 years old the night the airplane stopped in the mud.
• 11:29
  Speaker 1: He had logged 11,147 total flight hours. He had flown
• 11:33
  Speaker 1: that same runway before, in difficult conditions, and walked away
• 11:36
  Speaker 1: without incident. None of that made him responsible for tools
• 11:39
  Speaker 1: that had never been built. He returned to flying for
• 11:42
  Speaker 1: American Airlines in 2013. No criminal charges were filed, no
• 11:46
  Speaker 1: permanent suspension appears in the record. The investigation placed his
• 11:50
  Speaker 1: decisions inside the chain of causes. It did not place
• 11:52
  Speaker 1: him outside his institution. Daniel Billingsley had more hours on
• 11:56
  Speaker 1: the Boeing 737 than his captain did. 5,027 hours on type,
• 12:01
  Speaker 1: against Cole's 2,727. He told investigators he was very comfortable
• 12:06
  Speaker 1: flying with Cole. He received no sanction. He had also
• 12:09
  Speaker 1: never received formal training in tailwind landings, because that training
• 12:12
  Speaker 1: did not exist at American Airlines. His experience and his
• 12:16
  Speaker 1: comfort level were real. The gap in his preparation was
• 12:18
  Speaker 1: also real. Both things were true at the same time.
• 12:21
  Speaker 1: The airplane itself was declared a total loss, the sixth
• 12:24
  Speaker 1: hull loss of a Boeing 730-7800 in history at that point.
• 12:28
  Speaker 1: The landing gear had collapsed, the fuselage had fractured forward
• 12:32
  Speaker 1: and aft of the wing. One engine was gone. The
• 12:35
  Speaker 1: nose section was crushed. The winglet had been destroyed. A
• 12:38
  Speaker 1: machine built to carry people across oceans ended its service
• 12:42
  Speaker 1: life in the dark, half sunk in coastal mud on
• 12:44
  Speaker 1: the edge of a Jamaican runway. Because 4,000 feet of
• 12:47
  Speaker 1: concrete disappeared before the wheels ever touched it, 85 of
• 12:51
  Speaker 1: the 154 people on board were injured. 14 of those
• 12:55
  Speaker 1: injuries were classified as serious. 92 people were taken to hospitals,
• 12:59
  Speaker 1: not one of them died. That last fact does not
• 13:02
  Speaker 1: close anything. It only tells you how close the margin was,
• 13:05
  Speaker 1: close enough that the margin held, this time, by the
• 13:08
  Speaker 1: breadth of a few seconds and a few meters of
• 13:10
  Speaker 1: ground that happened to be there. The FAA's silence on
• 13:13
  Speaker 1: the NTSB's tailwind training recommendation remained intact at the time
• 13:17
  Speaker 1: the investigations concluded. The NTSB had first issued related guidance
• 13:22
  Speaker 1: after the Southwest Airlines accident at Midway in 2005. It
• 13:26
  Speaker 1: had issued its formal communication about Flight 331 in December 2011.
• 13:30
  Speaker 1: The classification it assigned to the FAA's inaction was not ambiguous. Open,
• 13:36
  Speaker 1: unacceptable response. The regulatory gap that existed on December 22,
• 13:41
  Speaker 1: 2009 did not close, because a Boeing 737 ran off
• 13:45
  Speaker 1: the end of Runway 12 in Kingston. It remained open.
• 13:48
  Speaker 1: The question of when it would close, or what event
• 13:50
  Speaker 1: would finally be sufficient to close it, belonged to the agencies,
• 13:54
  Speaker 1: not to the record. American Airlines was already under FAA
• 13:58
  Speaker 1: review at the time of the accident. Three landing incidents
• 14:01
  Speaker 1: in two weeks including events where wingtips had contacted the ground.
• 14:04
  Speaker 1: Flight 331 was not an isolated signal, it was one
• 14:08
  Speaker 1: of several signals arriving in close succession. What the FAA
• 14:11
  Speaker 1: did with those signals, collectively, is a matter of institutional
• 14:15
  Speaker 1: record that extends beyond this flight. There is a specific
• 14:18
  Speaker 1: kind of failure that only becomes visible after survival. If
• 14:21
  Speaker 1: one person had died on that runway, if the airplane
• 14:24
  Speaker 1: had reached the water, if the fuselage had come apart
• 14:26
  Speaker 1: at a different angle, Flight 331 would have become a
• 14:29
  Speaker 1: case study read in every aviation safety course for the
• 14:32
  Speaker 1: next generation. The regulatory gap would have had a name
• 14:35
  Speaker 1: attached to it. The FAA's four-year silence on the NTSB's
• 14:38
  Speaker 1: recommendation would have been cited in congressional testimony. The absence
• 14:42
  Speaker 1: of tailwind landing training at a major American carrier would
• 14:45
  Speaker 1: have been treated as the structural failure it was. Instead,
• 14:48
  Speaker 1: 154 people survived. And survival in this story is the
• 14:52
  Speaker 1: reason the lesson almost disappeared. The NTSB said what needed
• 14:56
  Speaker 1: to be said. The JSK said what needed to be said.
• 14:59
  Speaker 1: The record is clear. A crew flew an approach that
• 15:02
  Speaker 1: was not stable and touched down more than halfway down
• 15:04
  Speaker 1: a runway that was already too short for the conditions.
• 15:07
  Speaker 1: They had no formal training for those conditions. No procedure
• 15:10
  Speaker 1: required them to calculate, before beginning the descent, whether the
• 15:14
  Speaker 1: numbers would actually work. A recommendation to create that procedure
• 15:18
  Speaker 1: had been sitting on a regulatory desk for four years.
• 15:20
  Speaker 1: It had been classified as unacceptable and left there anyway.
• 15:24
  Speaker 1: Brian Cole had flown for American Airlines for 23 years
• 15:27
  Speaker 1: before that night. He had learned to do his job
• 15:30
  Speaker 1: inside a system that did not give him everything he needed.
• 15:33
  Speaker 1: That is not exoneration and it is not condemnation. It
• 15:36
  Speaker 1: is the more difficult thing. A description of how catastrophic
• 15:39
  Speaker 1: failures tend to actually work. Not a single reckless actor,
• 15:42
  Speaker 1: but a trained professional operating at the edge of a
• 15:44
  Speaker 1: gap that his institution had never bothered to fill. The
• 15:47
  Speaker 1: 154 people on board Flight 331 on the night of
• 15:49
  Speaker 1: December 22, 2009 did not know any of this. They
• 15:55
  Speaker 1: were flying home for the holidays or visiting family in
• 15:58
  Speaker 1: Kingston or completing a connection. They were sitting in seats
• 16:02
  Speaker 1: on an airplane that had been certificated, maintained and dispatched
• 16:05
  Speaker 1: according to every applicable rule in force at the time.
• 16:08
  Speaker 1: The rules were not enough. The rules had been told
• 16:10
  Speaker 1: in writing that they were not enough. Nothing had changed.
• 16:13
  Speaker 1: What stayed with this story, long after the reports were
• 16:16
  Speaker 1: published and the runway was repaired and the captain returned
• 16:19
  Speaker 1: to the flight line, was a single image. 154 people alive.
• 16:23
  Speaker 1: Standing in mud and darkness at the edge of a
• 16:26
  Speaker 1: Caribbean sea, they could not see, but could almost certainly hear.
• 16:29
  Speaker 1: Behind them, a destroyed airplane. Ahead of them, water. Between
• 16:33
  Speaker 1: those two facts the wreckage and the water was the
• 16:35
  Speaker 1: distance that made the difference. It was not a large distance,
• 16:38
  Speaker 1: it was enough. This show is made by Obermedia.