September 1978 a Boeing 727 is headed for the ground easy baby easy M I love you San Diego becomes the site of the worst Aviation disaster in US history and my hair stood up on the back of my head when I learned that this crash had occurred oh my word the accident scene was horrendous how am I going to put this puzzle together was a real big concern of mine evidence leads investigators to a remarkable conclusion oh yeah before we turned down land I saw a horrendous accident may have been caused oh yeah before we turned down land I saw him about 1:00 by a single misheard [Music] syllable made it made it Pacific Southwest Airlines flight 182 is on an early morning run down the coast of California from Sacramento to San Diego first officer Bob Fox is at the controls approach PSA 182 coming out of 95 descending to 7,000 airport is in sight a 9-year veteran with PSA he's on track to becoming a captain Captain Jim mcferon has been with the airline for 17 years known as a born pilot he is highly regarded by his colleagues this is the second Flight of the day for both Mensa cleared visual approach Runway 27 thank you cleared visual approach [Music] 27 among the 128 passengers there are 30 Pacific Southwest employees many are heading back to the company's home base in San Diego PSA was an excellent Airline they had uh super maintenance record super um safety record they were recognized uh in the industry as wow these guys are [Music] good Pilots are cautious when arriving at San Diego Lindberg field is the busiest single Runway Airport in North America San Diego limberg airport is a challenging place to fly into because it's a of its proximity to downtown and also some of the obstructions around it there's a very drastic terrain drop Pilots do it all the time and some of them don't like to talk about it but it's a little scary it was always concern that wow someday you know there could be a major crash several other airports nearby are a buzz with commercial military and private planes the airspace around San Diego International is quite busy because of the 600 flights a day in and out so there are planes taking off and Landing constantly flight 182 will have to thread its way through all this traffic while passing over the city preparing to land on Runway 27 Martin Wayne is at the Engineers console as they approach the airport he contacts the company's head office we're out of Los Angeles San Diego at 0905 P 182 Roger a little late but thank you I just called my off report the guy started laughing make it up by reporting our next takeoff now it's very nice even though they were fun and laidback they were still highly professional the crews were just personable you felt like they wanted you to be on their airplanes it was great catch our smile was their motto it was an experience it was fun flight 182's approach to Lindberg field is being handled by an approach controller at a facility 15 km north of the airport the approach control facility is quite busy and that's stressful because you're handling so many different airplanes in the same airspace when the controller spots a Cessna flying ahead of flight 182 he makes sure that they can see it PSA 182 traffics at 12:00 3 miles out 1,700 got it traffic insight they were issued traffic they acknowledge sight of the traffic okay sir maintain visual separation contact Lindberg Tower 1 33.3 have a nice day okay visual separation means that the pilot has another aircraft in sight and acknowledges it got it once the visual approach is accepted by the pilot uh he's then responsible for maintaining separation from that traffic somewhat like two boats passing is the responsibility the overtaking boat to maintain separation visually as it approaches the airport flight 182 Banks left so that it's flying parallel to the runway ready to turn and land when given permission I would characterize this as wonderfully routine there wasn't anything out of the ordinary with this flight with the plane now less than 8 kmet from the runway a controller in the airport's Tower takes over to guide the flight in for landing lber PSA 182 downwind 182 Roger within the airport traffic area which is at 5 mile radius the airplanes coming into the airport to land and take off are controlled by that controller the tower controller is juggling several planes in addition to the PSA 727 PSA 182 traffic 12:00 one mile a Cessna because there's only one Runway at Lindberg uh it requires some Air Traffic Control spacing because of the difference in the speeds of the aircraft PSA 182 cleared to land 182 is clear to land the Jets have quite a significantly faster approach speed than the sesna so you have to give them more spacing it's now 9:00 a.m. many passengers on flight 182 are planning to put in a full day's work in San Diego [Music] gear down minutes from Landing pilot Bob Fox spots a distant plane there's one underneath I was looking at that inbound over there easy baby easy baby a professional photographer happens to spot flight 182 in Flames hey what do we got here it's bad huh we're hit man we're hit time we going down this be okay we'll call the equipment for you the approach controller's radar reveals that the 727 has collided with the [Music] Cessna Jesus Christ it's an aluminum shower to have two aircraft under your control Collide is the worst nightmare I think for any controller I don't think anything else could be that bad this is it baby break M I love you [Applause] all sudden just went right in just a burst of flames it was just incredible can't do anything about it come on and my hair stood up on the back of my head when I learned that this crash had [Music] occurred this huge mushroom cloud of smoke and fire was seen by thousands of people two planes have collided and fallen from the sky over San Diego the city is in shock but the full scope of the tragedy is only beginning to emerge hundreds of people watched in horror as the two planes collided and crashed into a quiet San Diego residential neighborhood this is the biggest disaster that's ever happened in San Diego County one witness reported seeing falling bodies hit a car two bodies were bounced out of the PSA one hit through the windshield killed the mother the other one hit on the side and killed her four-month old baby police officers covered up the bodies and that spot all they could do it's feared that everyone on board the two planes is dead that PSA plane landed at Dwight and Nile streets the Sessa landed about six blocks away in front of a house near 302 in [Music] [Applause] poke 22 homes are destroyed seven residents are killed nine more are injured the city feels overwhelmed we heard D news so we came down here to see what we could do to help we've been walking still here carrying water and it's just such a bad scene it's really horrible Greg Clark is a San Diego police officer who rushes to the scene to help search for survivors for me it looked like um a large bomb had gone off everything that was in the path of the aircraft just completely destroyed there were passenger seats stuck in the side of houses and pieces of fuselage just just everywhere I found nobody that was in one piece 2 hours after the crash NTSB investigator Wally Funk arrives from Los Angeles since I was the lead investigator for that particular day I got the call from the FAA duty officer and he informed me that there had been a midair and Collision in San Diego oh my word the accident scene was horrendous first the San Diego Police Department escorted me in and introduced me to the fire marshal cuz they have control of the entire wreckage any survivors yet that was just chilling that you suddenly you realize there's there are no survivors thank you the medical personnel were frustrated because everybody came to the realization that there was nothing that they could do 144 people are dead including the seven on the ground it's the biggest airline disaster in American history it was entirely something that I had not expected there was so many bits and parts and pieces around not only the aircraft but the homes I just started by photographing and writing notes a real big concern of mine was how am I going to put this puzzle together Funk needs to confirm that the wreckage of a small plane found six blocks away is in fact what collided with the 727 there's no doubt about it we had paint transfers we had pieces and parts from the two different aircraft yes this was an absolute midair Collision there's no doubt about it but there's a much larger question looming how could such an accident happen we had to visualize from a very mangled mess of metal where the two came together I really felt compelled to bring the CES wreckage over to the main wreckage put that down right uh there please so we could kind of understand really what had happened eventually the wreckage of the two planes is sent to a hanger for reconstruction it's just a big puzzle you have to try one piece at a time putting it together Funk records as many witness interviews as possible while memories are still fresh but I find in all my investigations that children up to 17 18 years old are my best Witnesses because a youngster will give me a really good interpretation of what they saw not what they thought they heard or what they thought they saw there were quite a few people that described what they saw at falling out of the sky can you tell me exactly what you saw when you looked up but all the interviews are disappointing so you didn't see the actual Collision we had nobody that really saw the whole thing happen we only saw it after the bang the closest thing to a sighting of the Collision is a television Crews footage of the Cessna plummeting to the ground the NTSB sends additional staff from Washington including senior investigator Philip Hogue do great work here let's get right down to it all right I know that you've done a heck of a lot of research and you've been mainly concentrating on the larger air but it was great to see the guys when they finally got there the technical support was wonderful we kind of divvy up the duties so I will tackle the assessment needing to know more about the smaller plane they're reviewing it records for the day the Cessna belonged to a flight training school a student pilot was having a lesson we had a flight instructor sitting on the right side and we had a student pilot learning to get his instrument rating investigators learned that the student pilot approached Runway 9 twice practicing Landing using only his instruments instrument Pilots need more the practice of approaching the runways as opposed to The Landings local media jumped to a conclusion there were a lot of people who thought that the crash had to be the fault of that Cessna because they had a it had a student pilot there can be a built-in bias in traveling Public's mind and the media's mind that airliners should have priority uh in and out of airports and this is not the way that it works uh it it's a first come first serve system however with a jetliner on a on an assigned Glide path coming into a major airport people wanted to know how come that little airplane was up there in the way hopefully the black boxes salvaged from the crash site will help answer this question one was up front which was the voice recorder and one was in the AF stairwell which was uh the inst recorder they were flown back to Washington DC figuring out what was said in the cockpit and what the instruments said takes a lot of time in the meantime investigators interview the first of the two controllers who were guiding the planes can you show us the two flight paths the approach controller remembers the planned routes of the two planes but he can't be sure what routes they actually flew because approach radar is not recorded so the 727 was flying East to do a turnaround and land on Runway 27 and the Cessna was flying Northeast but it was Miles Ahead of the 727 probably headed home after doing touch and goes on Runway 9 they should have missed each other by over a mile since I had been into lyberg several times as a pilot it occurred to me were they on the right head altitudes learning the exact flight paths will require complex calculations that include data from an air traffic station in Los Angeles meanwhile a transcript of the controller's conversation with both planes reveals the pilots were aware of each other's positions so the PSA crew reported seeing the Cessna when they were still three miles apart planes would have been somewhere around here and here got it trafficking site the cesna pilot was also made aware of the 727 behind them traffic at 6:00 2 mi eastbound a PSA jet inbound to Lindberg out of 3,200 has you Insight investigators want to know if the pilots of both planes knew of each other why did their aircraft collide new radar equipment installed just one month earlier was designed to prevent exactly this type of incident the Collision alert a system was instituted to prevent collisions to alert controllers the fact that there was an imminent collision between two aircraft um didn't you get any warning we did we ignored it explain well when the alert sounded I I mentioned it to my supervisor alarm again I talked to both planes PSA 182 is confirmed a visual sighting of the Sessa we're not expected to contact the pilots if they're flying by visual rules uh not to mention we get about 13 alarms a day so he went to his advisor and told him what he had but since they had had so many false ones they really just kind of disregarded it the controllers decide not to act on the alert but they still contact the cesser and repeat an earlier message traffic in your vicinity PSA jet has you in sight he's descending for Linberg you could almost call it a courtesy call by the approach controller to the Cessna but at that exact moment get over here the planes Collide I feel they should have have watched these two aircraft a little closer I think they were rather Cavalier about it investigators interview the Lindberg Tower controller trying to understand why he also failed to warn both planes about their impending Collision they discover that to monitor traffic he relied on a less sophisticated form of radar the tower controller did not have the Collision alert system at the time when the controller saw the planes within 1 and A2 km of each other he made contact warning the 727 TSA 182 traffic 12:00 one mile assess I think he's passing off to our right yeah if the pilot says he's passing off to our right this implies that he's still maintaining visual separation was his responsibility and you would not worry about it after talking to both controllers investigators still have no answer to the key question in the midair Collision who crashed into whom now let's have the next acetate please and see where that takes us when they finally calculate the two planes actual radar tracks the answer becomes clear this is where the 727 has rear endered the cess the cessate never passed off to the right he was always always in front of PSA the 91 ton aircraft flying at almost 300 kmph simply tore apart the much slower and lighter Cessna we have ploted down here this is the third position the radar track reveals another important detail just before the impact the Cessna turned right into the 727s path why the change in heading the trajectories of the two airplanes are such that had the Cessna not drifted the airplanes would not have collided close examination of the cessna's training flight log reveals one possible reason for the change in Direction he was wearing a training Hood the Cessna pilot wore a training Hood it's a device worn during instrument Flight Training a pilot undergoing training for an instrument rating must learn to fly with exclusive reference to the instruments so on good weather days there has to be some means to block the natural Horizon the outside and it was a black hood that came out about this far from his face so that he couldn't see outside Funk wonders if the hood could have caused him to go off course at the worst possible time the Cessna was told to stay on a 70° heading 711 golf San Diego departure fly heading 070 Pilots are taught to scan their instruments to maintain their heading on occasion you'll see headings that will drift because the learning pilot doesn't have the the heading in that scan fast enough but even if the hood did play a role in causing the Cessna to drift but it does not explain why the PSA crew couldn't see the Cessna got it traffic inside how did the veteran crew of a 727 lose sight of a plane flying directly in front of [Music] it investigators now realize they may never find out why the pilot of a Cessna changed its heading putting it on the same flight path as a 727 why the cester pilot did not stay on his uh signed heading I can't answer that question but it's important to know that that drift of that heading wasn't so severe that the a traffic controller called them and said what's your heading so clearly they did turn according to the radar but the significance of it is uh is a bit more questionable what's not in question is that it was the responsibility of the 727s crew to avoid the Cessna the PSA crew when they acknowledged they had the Cessna in sight at that moment became responsible for keeping the airplane separate in Washington investigators review the PSA crew's last moments on the recovered cockpit voice recording all right get it are we clear of that assessment supposed to be I guess I [Music] hope oh yeah hold on go back Philip Hogue focuses in on the conversation recorded 35 seconds before the Collision are we clear of that sessment supposed to be I guess I hope oh yeah before we turned down land I saw him about 1:00 probably behind us now the PSA crew not only doesn't see the Cessna they assume they have already passed it it was right in front of them the whole time the 727 when it's it's flying in level flight is a slightly nose up uh condition so that the pilots as they look out they're looking over the nose of the airplane was the nose of the aircraft high and they didn't see the Cessna they may not have realized the Cessna was as close as it was the NTSB conducts a study to determine how long the PSA crew could see the Cessna through their windscreen welcome aboard no use the reference points to adjust your seat they start by adjusting the Pilot's seats for optimal viewing using a device called the design eye reference point the manufacturers designed a very simple but very effective system where you line up little balls in the center post of the wind screen that put your your eye in the same position every time now if you would uh please take a measurement from my ey line to the white ball the middle okay now from the eyeball to the floor please once the Pilot's viewing positions have been determined the photographer uses a special camera to take panoramic images of each Pilot's view okay let's have a look at what the pilots can see would you put up the view he starts with the captain's view radar tracks provide the cessna's heading pitch and Bank angle they plot this data on top of the photographs in 10c intervals let's see what the code pilot can see please what they find is surprising a longer than expected time period in which the PSA crew could see the Cessna 170 seconds of clear view the pilots could have seen the Cessna in plain view how can you miss a plane that is staring you in the face yeah it's something falling doesn't say what but okay all right I'll take that Sue Pritchard investigators wonder if witness reports can shed some light on the mystery they discover that there may have been something in the air that misled the pilots we had collected 220 witness reports but 16 of those witness reports revealed that they thought they saw other aircraft tra in the area air traffic controllers don't remember a third plane flying nearby but many small planes don't carry a transponder the device needed to identify them had they not had a transponder uh the third airplane may not have been visible to the uh radar in the San Diego approach facility investigators study the cockpit recordings more closely searching for clues about a third plane oh yeah before we turned down we and I saw him about 1:00 probably behind us now 35 seconds before the crash the crew assumed the Cessna was safely out of the way but the captain's 1:00 reference seems odd the flight Paths of the two planes show that the Cessna was never in that position Cessna was at there 11:00 so what plane were they looking at the fact that it was at 1:00 instead of 11:00 indicates that there's a possibility that he saw another aircraft it may have been quite some distance away but he saw another aircraft then another clue about a possible third plane there's one underneath I was looking at that inbound over there the plane he spots is flying inbound that means it's flying in the opposite direction of the Cessna that was hit it does open and add further credibility to the possibility that they saw a different airplane but what plane exactly may never be known even after factoring in the 16 reported sightings of other aircraft the team concluded that the 16 Witnesses could not really put a aircraft in that particular area at that particular time investigators are at an impass their visibility study tells them that the Cessna was technically visible for 170 seconds nearly three full minutes so why did the crew of the 727 lose sight of it they go back to the cockpit recording north of the field North eastbound cesna 172 climbing VFR 1,400 135 seconds seconds to impact this is when the controller first mentioned S no okay roll tape agains 2 minutes before the Collision the crew hears the cessna's position being described but they haven't spotted it yet the silhouette of the Cessna would have been difficult as they were approximately the same altitude they're going in the same direction so that the one of the things that the human eye picks up is movement and for a good part of the time this is not moving in the windscreen San Diego Ops were number two because we try harder the Cessna has now been visible for nearly 80 Seconds out of their window but the crew has failed to see it 90 seconds to impact they get another warning and after we read and and saw what CVR said I feel that they were distracted in their conversation roll tape PSA 182 traffics at 12:00 3 m out 1,700 got it traffic Insight stop it 85 seconds before impact the 727s pilots spot the cesser flying ahead of them the crew is then instructed to use visual flight rules and contact the Lindberg Tower okay sir maintain visual separation contact Lindberg Tower 1 33.3 have a nice day okay they saw it one second and then they didn't see it another second well was the conversation such that they looked away and missed it the crew must now keep the Cessna in view while performing other tasks the captain contacts the tower controller and prepares for landing Lindberg PSA 182 downwind the wings uh need to be configured with the proper slats and flap settings the landing gear must be lowered systems have to be adjusted all of these things are going on so it's it's a busy place for three people in a 727 at this critical moment no one is keeping an eye on the Cessna PSA 182 traffic 12:00 1 M CES is that the one we're looking at yeah but I don't see him now the Cessna should be right here in front of them the Cessna was visible just at about the windshield level of PSA and it's really incredible somehow they lost sight of them okay can you show me how you normally adjust your seat please but when investigators learn more about how PSA Pilots adjust their seats they begin to understand how the crew may have lost sight of the Cessna that's it you don't use your reference points it's not a requirement to utilize the manufacturer's designed I reference position investigators discover that many Pilots adjust their seats to to their own personal settings Pilots come in all sizes and shapes they learn quickly to adjust the seats to the position that's comfortable some Pilots want to sit lower so they can see their instruments better from this new seat position the cessna's location on the windshield is recalculated the results show an important difference between the two seat settings with the new setting the crew would have had the s in view for only 5 to 10 seconds not a few [Music] minutes 5 Seconds that's all the position of the Cessna was down below the nose or the reference that the pilots could see if they had moved their heads up uh they the sesna was still visible but otherwise it was below the wind screen okay let's play find the Cessna but even assuming that the crew did Lean Forward investigators now realize they would face other problems in spotting the Cessna it's almost camouflaged they become harder to see and the terrain makes it even more so because you have white roofs you have dark roofs you have uh roads you have lakes you have trees so the background changes and the aircraft will move across this background is that the one we're looking at yeah I don't see him now the Cessna is now Flying Too Close to the 727 to be viewed without leaning forward and it's against a backdrop that makes it hard to recognize PSA 182 cleared to land2 clear to land a collision is now imminent and the six men involved in preventing it are oblivious the Cessna pilot can't see out of his window his trainer has failed to notice the plane is off course the 727s crew have the Cessna in a blind spot but both controllers assume the crew can see the Cessna and will avoid it there's only one thing that can stop this accident from happening and 144 lives depend on it the PSA Captain should have made the suggestion to the tower I don't see him anymore Captain mcferon will talk to the tower about the Cessna but a misunderstanding over a single word will prove deadly the two planes are 70 seconds from colliding over San Diego KSA 182 traffic 12:00 1 mile flaps five is that the one we're looking for yeah I don't see him now the fate of flight 182 now depends on the captain clearly communicating this to the tower okay we had him there a minute ago but the captain is not clear 22 Roger and the controller assumes the Cessna is still in sight when the PSA Crow lost visual contact they're responsible to tell the air traffic controller I no longer see the Cessna still uncertain about the cessna's location once again the Captain tries to explain his situation to the tower I think he's passed off to it right the comment that the captain makes indicates that they're not sure that they don't have him in in sight at that moment the controller could force the PSA Flight or the cesser to change course but he does nothing it's very difficult to determine what that exchange between the air traffic controller and PSA meant to each of the pilots the captain made the comment I think he's passed off to it right indicating that he wasn't 100% sure the air traffic controller heard it as a declarative statement and answered Y what that meant to the PSA crew I'm not sure we'll ever know he was right over here a minute ago yeah but they were satisfied with the situation enough that they continued the approach and the air traffic controller was satisfied with the situation enough that he did not make any further comments about it okay we had him there investigators want to know why the controller took no action they compare two separate recordings of the conversation between the captain and the controller okay Chris let's hear the cockpit first I think he's passed off to our right passed I thought I heard passing before double check that please I think he's passed off to our right he still saying pass let's compare it with the tower because I think I heard passing [Applause] they make a startling Discovery he's passing out to right passing I was right it does sound like passing due to radio static the controller heard the word passing not passed the difference may have sealed the fate of flight 182 passing big difference the recordings reveal that while the pilot of PSA 182 said one thing the Lindberg Tower controller heard something else I think he's passing off to right yeah now investigators understand why the controller took no action if he had heard the words he's passed off to our right he would have seen from his radar that the pilot was mistaken and that the 727 had not actually pass the Cessna the air traffic controller heard it as he's passing off to our right that indicated that they still have visual contact with him he would believe that the pilot was being able to maintain the separation was his responsibility and you would not worry about it in the spring of 1979 investigators finally conclude who is at fault the determination of the board's report is very clear that the crew obviously did not see the aircraft Cessna in time to divert it away from a catastrophic accident the PSA crew when they lost visual contact is responsible to tell the air traffic controller I no longer see the Cessna and that they did not do the Cessna pilot is also mentioned as a factor for changing course without notifying the tower both controllers are criticized for not following protocol and giving the 727s crew the specific heading of the [Music] Cessna thinking back to the day there's just a tremendous sadness that comes to mind you know that accidents happen but you think this was an accident that could have been prevented but it [Music] wasn't recommendations in the report focus on improving the air traffic control system at Lindberg field they changed procedures after this they put in a terminal control area and there was a great deal of restriction on what kind of traffic could go through and at what altitude so a great many different restrictions to make it a safer operation were put into place at Lindberg after this accident we're out of Los Angeles San Diego at 0905 PSA 182 Roger I just called my off report the guy started laughing make it up by reporting our next takeoff now there's another Legacy of PSA 182 new rules governing all conversations in the cockpit when flying below 10,000 ,000 ft today's regulation requires that you concentrate your conversation exclusively the operation of the airplane uh at the time of the PSA 182 accident the that regulation was not in effect PSA 182 also helped push the FAA in the search for new technology 3 years after the accident in 1981 a safety device called tcas or tra collision avoidance system was put into development now installed in all passenger aircraft the system warns Pilots when another plane comes too close tcast was a God bless we now can put it on our transponders and we can see or hear or what's going on or be told what's going on with aircraft around us we have come in big leaps to make Aviation safer for people to fly and feel comfortable that their airplane is going to get where they want to go [Music]