a dc10 with 296 people on board cart wheels down a runway and breaks into pieces. >> i felt like it was rolling down the runway. >> may day, may day. the engines are falling out. we're going down. >> a dc8 runs out of fuel and crashes in a residential neighborhood. >> i thought we were landing at the airport. i was very delighted, and then the delight turns to fear. >> you didn't land? >> negative. >> oh, my god.

>> weather problems wreak havoc in the air. a 747 caught in a torrential downpour violently slams into a hill. >> initial contact finally stopping was about 17 seconds. i've got to say it's the longest 17 seconds of my life. >> in the air communication can make the difference between life and death. dramatic animations take you inside catastrophic crashes and what cause them. >> i asked was there anything different you did that day than you'd do today? and i said, yeah, i'd call in sick. on december 28th, 1978, a shocking moment when a united

airlines dc8 slams down in a residential neighborhood of the captain was absolutely the one decision maker in the cockpit. you were expected to talk to him only when you had something technical to say, and it was very difficult for junior crew members to confront a senior captain. there was a strong reluctance to criticize. >> crm breaks down the barriers of communication between two or three crew members in an airplane. it enables pilots to act as a team and come up with a common solution, rather than individuals coming up with an individual solution. >> having crm training or not could mean the difference of a plane crashing or not. it may seem like a given, that this kind of training would have always been around, but it didn't even exist until 1981.

since then, crm has been the gospel in the cockpit. >> it comes down to one word, team work. team work solves the problems. >> all of us are smarter than any of us. >> crm is the grease that causes the wheels to spin smoothly, but they have to spinning in the right direction. >> it percolated in the 1970s, after several plane crashes were contributed to communication problems in the cockpit. one accident in particular a is catalyst that puts this new concept on the map. on december 28th, 1978, a shocking moment when a united airlines dc8 slams down in a residential neighborhood of portland, oregon, just six miles shy of the airport. passenger amy ford conner, 17 at the time, is on her way back to

washington state where she's about to finish her senior year of high school. >> what it felt like is when you first land and kind of do a little bounce, that's what it felt like, so i thought we were going to have a fine landing at the airport. >> it's a nightmarish ending to what started as a routine flight. united 173 takes off from denver at 2:47 p.m. 189 people are on board. the first officer is at the controls. >> it was right after christmas. the plane was absolutely full. we were all going back to wherever we were going, and after spending the holidays elsewhere. it was a perfectly ordinary flight until we started making our final approach to the portland airport. the first time that we realized that something was wrong was when we heard a very loud thunk, and the plane jolted. >> the thunk heard around 5:10 p.m. is the sound of one side of the plane's landing gear falling

into position. the other side and the nose landing gear are extended normally. the force caused the plane to vibrate and yaw or pull to the right. a light in the cockpit to indicate the landing gear is down and locked does not illuminate. >> when the landing gear extends under normal system operation it's hydraulic and so it extends at a given rate. it extends very smoothly. in the case of united 173 what occurred is that it fell out, and it fell at the very rapid rate, and one of the other components of the landing gear also broke free and in so doing damaged the wiring that closes the switch that lights the light. captain mcbroom, a veteran pilot with united, doesn't want to land until he's confident that the landing gear is locked. that's because if it were to collapse on touch down, the plane could be badly damaged, and its passengers injured. the captain wants time to

troubleshoot the problem. >> the pilot got on the p.a. and said we're having a little trouble with the landing gear, going to be in the air just a little bit longer, that is pretty common problem, don't worry about it. >> captain mcbroom was a very experienced pilot. had tens of thousands of hours including over 5,000 hours as a captain on the dc8 he was flying that night so this was mr. dc8 expert, and that may have convinced him that if he just studied a little bit more in the manuals and talked to the people in the maintenance center he was going to figure out whether or not this landing gear was going to collapse. >> by 5:14 p.m., air traffic control knows united 173 has a problem. portland approach control clears the plane to enter a holding pattern which it does for the next hour. during that time the captain maintains close contact with the cabin crew. >> what he kept asking from the flight attendants what was the status?

were they ready? was the cabin prepared, fully prepared? he was very, very concerned about protecting the passengers and what he was not hearing was the fact that the two other pilots, the first officer and the flight engineer, were getting increasingly concerned about fuel. >> the crew members are concerned, but they are not clearly expressing it to the captain. they continue to focus on landing gear problem. >> one of the flight crew came back with a flashlight because it was dark outside to check landing gear to see if he could see out the window which i don't know if he saw or not, but that was our first clue that something was really wrong. >> on the dc8, there are mechanical indicators of the landing gear position. it's a pin that actually came up on the top of the wing that you could see. >> if a pin is up, the gear is locked. if not, the gear is retracted. so if you had a mechanical indication to either validate or invalidate what the light in the cockpit is telling you about the

position of the landing gear. >> the longer the jet remains in a holing pattern the more alarmed the first officer and flight engineer are becoming about the fuel situation. at 5:50 p.m. 18 miles south of the airport one of them speaks up, but still not forcefully. >> the flight engineer is staring at the fuel gauges said not enough. that's going to run us very close out here but in the precrm era you didn't challenge the authority figures. >> the first officer and engineer insimulated and made statements, but they were not direct. they didn't say, captain, we are running out of fuel. we have to go to the airport right now. >> it left denver with 40,000 pounds of fuel. only 4,000 pounds remain. the captain still thinks they can make it to the airport.

the passengers know nothing about the dire fuel situation. they're concern eed about a possible belly landing. >> the pilot said, we're going to be making our landing in five minutes. making our final approach. when we're 60 seconds away, i'm going to let you know so you can assume your brace positions and be prepared for a belly landing if that's what we have. he never made that one minute announcement. >> 6:03 p.m., air traffic control wants to know when they'll begin their approach. the captain replies, quote, i guess about another three, four, five minutes, end quote. but united 173 doesn't have that much time. coming up, out of fuel and out of options. >> as it became increasingly apparent that they were not going to make the airport, the question comes up, where are we going to put the jet? >> i thought we were landing at the airport. i was very delighted.

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united flight 173 has been flying in a holding pattern near the portland airport for nearly an hour. captain mcbroom wants time to troubleshoot a possible landing gear problem, but now something for more urgent is on the horizon. >> united 173. heavy may day, may day. the engines are flaming out. we're going down. we're not going to be able to make the airport. >> the passengers start to become aware of the increasingly dire situation. >> the only lights that were on were the reading lights and some people realized something was wrong and yelled for us to get our heads down.

>> the plane has run out of fuel and is coming in fast over a wooded residential area. captain mcbroom heads towards the only unlit spot he can see below between the housing. >> the plane barely clears an apartment building. >> i thought we were landing at the airport. i was very delighted, and then the delight turns to fear because i had no idea what was going on. it just felt like it was never going to stop. >> as the plane tears through the trees the front section violently rips away. >> it wasn't until after we had stopped moving that i really grasped the enormity of what had just happened. >> the aircraft is destroyed. ten people, all sitting in the front section that separated, die from the impact trauma. the rest of the passengers are dazed. >> it was so cold.

although when you're running on adrenaline you don't really notice those sorts of things, but we walked off the plane, and then we were in this neighborhood. nobody knew where we were. we just were milling about, like what do we do now? >> the four-engine plane went down five miles southeast of the airport. it missed a large apartment complex but smashed through two vacant houses. >> once on the scene, ntsb investigators quickly determine there's no fuel leak, no broken fuel gauges, no problem at all with the airplane, so why did the well run dry? the answer comes from the plane's cvr, the cockpit voice recorder. >> when i played the cvr for the first time, i realize that we've got some explaining to do and this is an accident that never should have happened. >> dr. al diehl, at the time the human factors specialist with the ntsb, can't help but notice

the cvr reveals a disturbing similarity to a number of other recent crashes. >> the giant tristar left a halfmile long path of debris in the swamp. >> we looked at the eastern airlines everglades crash, and there we lost over 100 people. started out as a landing gear light and the crew became distracted and flew into the swamp. ironically another united dc8, one year prior to the portland crash, the same thing. they had a landing gear on save flight, troubleshooting that problem and flew into a mountain. >> the common link, inefficient or nonexistent communication in the cockpit. this failure to communicate is literally crashing planes. diehl knows something has to be done to stem the tide. he begins building a case for airlines to adopt a new training procedure being developed by nasa. it's called crew resource management, crm.

>> crm is basically promoted that if you're going to work together as a team you're going to make decision as a team. you come to a joint solution, not an individual solution that is then worked into the equation. >> up till that point, we only taught the technical aspects of flying. they had to stick to the other skills, but we never taught decisionmaking and judgment in a formal way. i got with one of the top air safety investigators with the board, and he said, al, if you can sell this to the board, this is going to be a revolutionary recommendation. >> the deadliest accident in aviation history provides diehl with even more compelling evidence to take to the safety board. in this disaster, two 747s collide in the canary islands in 1977. the accident kills 583 people and is blamed in large part on bad communication. >> the whole cabin next to me

was just completely gone. >> less than six months after the portland crash, the ntsb issues its final report. it cites probable cause as, quote, the failure of the captain to monitor properly the aircraft's fuel state and the crew member's advisories regarding fuel state. a contributing factor, the failure of the other two flight crew members to successfully communicate their concern to the captain. >> communication in the cockpit is 95% of the success of the airport it self. >> the faa, federal aviation administration, approves dr. diehl's crm recommendation. in 1981, united airlines kicks off the industry's first crm training program. >> united was an easy sell. remember, united had just lost

three airliners in fatal accidents, so united management was quick to jump on board and was quick to spend the money. to develop the course. >> as veteran captain al haynes recalls the training was initially received with a dose of skepticism. >> those captains who needed it didn't want it, and wasn't really going to do it so we thought it was a waste of time until we began to get into the flow of things, and then we understood what it was all about. coming up -- >> captain haynes has no way of knowing that just a few years later, training to improve communication between crew members will help him get through one of the most terrifying situations a pilot could ever face, a catastrophic loss of control of a jumbo jet. so, i tried depend last weekend. it really made the difference between a morning around the house and getting a little exercise.

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a catastrophic inflight failure renders a dc10 virtually out of control.

the crash lands and catches fire, killing more than 100 people and leaving investigators to solve a troubling aviation mystery. july 19th, 1989, united airlines flight 232 takes off from denver's stapleton international airport bound for chicago. first officer william records, who has logged 20,000 hours of flying time, is at the controls. with him second officer dudley devorat with 15,000 hours and captain al haynes who has logged 27,000 hours, 7,000 in the dc10. on this picture perfect midwestern summer day with three highly experienced pilots in the cockpit it should be an easy flight. >> scattered clouds, good

visibility, smooth air, very fortunate weatherwise. >> as we're flying along and everything is as smooth as can be and service is humming and working well as a team, out of the blue here comes this explosion. i mean, it was a huge loud explosion. >> but passenger rod vetter, a seasoned traveler, isn't fazed. >> my first thought was a bomb went off. then i realized that it hadn't depressurized so it wasn't a bomb, and then i realized it was probably an engine blowing, and my first thought was, okay, we got off a little late maybe and we're going to get right on into chicago because a dc10 can certainly fly with two engines. >> the explosion happens at 3:16 p.m., an hour and seven minutes into the flight. the jumbo jet is at 33,000 feet over alta, iowa. after the explosion, the plane

begins to vibrate and shutter. pilots determine the number two engine has failed. >> i began to realize how serious it was when i saw the flight crew come back, and they were trying to look out the windows, the passenger windows, just to observe what was going on with the physical condition of the airplane. and you could tell by looking at the flight crew that something serious was up. >> and as they go through the checklist, officer bill records, who was flying the plane, realized they had a more serious problem than they thought. >> we were shutting the engine down and going through the procedure, and bill said, what he likes to call the attention-getting statement of the day, i can't control the

airport. he can the control wheel all the way left and all the way back to right. that's when i said, i've got it. >> he wrestles the plane back to a wing's level position. >> with the steering the aircraft started to roll over on its back and would have continued to roll over and dive into the ground except at that fact, al reached over and advanced the throttle on the right wind and retarded the throttle on the left wing and the asymmetric thrust picked the wing up slowly and steadied the aircraft. if he hadn't done it within a few seconds of when he did it, it would have been unrecoverable. >> but united 232 still has monumental problems. from the cockpit, pilots call the flight attendants' phone to make sure the cabin and passengers are prepared for an emergency landing. >> i picked it up, and they said

come to the cockpit. the minute the door opened the atmosphere just hit me full force. it was like oh, no, this isn't an emergency. it's a bleep, bleep crisis. >> the situation is grave. the plane has lost all of its hydraulic fluid. >> hydraulics in a modern large jet airplane is the lifeblood of the airplane. it is how you physically move the flight controls. it provides the muscle to move these very large surfaces against very fast moving air in a controlled manner. >> we were keeping an ear, i'll put it that way. control, no. we were just trying to keep it flying. it was doing what it wanted to do. >> in the midst of the chaos a flight attendant informs the crew there's a united captain who was a dc10 flight instructor sitting in first class. his name is denny finch, and he's offering to help.

>> he said go tell them i'm here, can i help. as soon as he said he was there, i said yes he can help. he's an instructor. >> in the past bad communication has led to disaster. now all hope is riding on teamwork to avoid a catastrophic outcome. coming up, the final shocking seconds of united flight 232. >> there was an announcement that this is going to be a seriously difficult landing. it's the little things in life that make me smile. spending the day with my niece. i don't use super poligrip for hold, because my dentures fit well. before those little pieces would get in between my dentures and my gum and it was uncomfortable. even well fitting dentures let in food particles. just a few dabs of super poligrip free is clinically proven to seal out more food particles so you're more comfortable and confident while you eat. so it's not about keeping my dentures in,

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hi. richard lui with the top stories. police are investigating the death of 2-year-old twins found dead in a home. they came for a report of someone sick and found the boys unconscious on a bed.

thousands march to honor a sheriff gunned down while fueling up. shannon miles is accused of killing sheriff goforth. now back to our msnbc special. on july 19th, 1989, united airlines flight 232 is in deep crisis. after an explosion, the dc10 loses its tail-mounted number two engine along with all of its hydraulic fluid which operates the landing gear, glass, slats, steering and brakes. the only control pilots have is over the throttles which determine engine speed. by adjusting thrust on one side or the other, pilots are able to steer the plane. but even under this unimaginable pressure, captain al haynes manages to crack a joke with air

traffic controller kevin bachman. >> you're clear to land on any red line. >> you want to be particular, make it a runway. >> runway united flight instructor danny finch flying in first class has offered to help and is now in the cockpit. captain haynes willingness to accept fitch's offer is crew resource management in action. >> he would not have said anything prior to crm because you don't go up to the cockpit and bother a captain when you've got a problem. >> captain finch was a perfect addition to an already effective crew, but he was an additional asset. >> i said take the throttles. i was asking him to do this and do that and he kind of fell into the pattern of what to do and we didn't have to say so much anymore. >> as united 232 approaches the airport, the pilots dump as much fuel as they can. this lightens the plane which increases their ability to control it. meantime, in the cabin senior flight attendant jan brown

following faa protocol advises parents to place lap children on the floor. those are kids under 2 years old without paid seats. she's about to announce that passengers should brace for impact when captain haynes overrides her on the p.a. >> there was an announcement that this is going to be a seriously difficult landing. >> he said, i won't kid you, it's going to be rough. do the best you can. >> the plane is traveling at 247 miles per hour. 100 miles an hour too fast for a dc10 to land. without hydraulic fluid, the controls that would normally slow the plane down don't work, and because they can't be properly configured, the ground proximity warning system doesn't realize that the pilots are trying to land. it begins to sound, adding to the chaos in the cockpit.

>> pull up. pull up. >> the left wing was coming up and we want the left wing down so we said left, left, left, left, left. >> i never thought it would be fine because we was going too fast and the original descent was too big and i knew something was going to happen. >> at exactly 4:00 p.m., 44 minutes after the problem began, a violent impact. >> as the right wing hit the ground, the tail snapped off. the entire tail of the plane broke off just as if it were a toy and went rocketing down the runway at 250 miles per hour. i heard explosions and loud noises and flashes of light, and it had to be with the plane breaking apart. >> al could have kept telling us that it would have been rough, but i could never in my wildest dreams have imagined smashing into the earth the way we did. >> as the jumbo jet careens out

of control, it breaks into pieces and fires erupt. it's hard to fathom anyone surviving the flames and the thick black smoke. the nose of the plane, which contains the cockpit, is crushed beyond recognition. the pilots are presumed dead. incredibly, all four are alive but injured. this photo captures first responders talking to the crew. >> they don't just start cutting. they got to size it up because with all the wire bundles and all of that sheet metal and very small compact environment, you could actually inflict greater harm or injury to those occupants trying to rescue them. >> of 296 passengers and crew, 112 are killed, including 11 children. one of them is a lap child without a paid seat. >> they can't be in a car by law without being in a seat. what are they doing in an

airplane going over 500 miles an hour? it's russian roulette. >> in the wake of the crash, the questions began immediately. how could this plane with its clean safety record suffer such a catastrophic failure in flight? right away there are some key clues. at the accident scene, a critical component called the fan disc is missing from the number two engine. it isn't found until three months later in a field 70 miles away in alta, iowa. that's where the plane experienced that initial violent jolt. these photos taken by a witness on the ground as united 232 was about to slam into the runway also provide investigators with critical information. >> you can see that there are holes in the horizontal stabilizer from the debris as

the fan disc had separated from the engine core and created shrapnel taking large chunks out of the horizontal stabilizer. in the second picture you can actually see the back side of the engine where the fan disc actually came out. >> by november 1990, 15 months after the crash, the ntsb pieces together what happened to united 232. over a farm in alta, iowa, the plane's fan disc imploded with calamitous results for the plane's hydraulics, the life blood of the jet. >> it sent shrapnel going in a multitude of directions, and it just happened that the shrapnel ended up cutting lines to all three systems. the statistical likelihood is extremely low, but in the case of 232, it actually happened. >> the titanium fan disc is determined to have a crack dating back to its fabrication.

every time the engine is used, the microscopic crack grows. the ntsb determines probable cause to be united inspectors failure to detect the crack. united airlines disputes the finding, but in the end, the ntsb upholds its report. >> i think that the united inspection team did what they believed to be a proper and complete job, or they wouldn't have signed the component off as air worthy. we have gotten better at nondestructive testing. that was one of the takeaways out of this, that we had to get better. >> not only does the inspection process improve as a result of this accident, so does the manufacturing process used to create titanium fan discs. beyond those lessons learned, united 232 is a testament to teamwork in the cockpit. executed with perfection that day, crew resource management implemented only eight years

earlier helped save 184 lives that might otherwise have been lost. >> left, left, left, left, left. >> i was asked is there anything you would do differently today than that day and i said, yeah, call in sick. >> this team made very good decisions out of an airplane that was virtually unflyable. one individual no matter how skilled an airman would not have been able to do that. >> coming up, unfortunately, that kind of teamwork is not in play eight years later on the tiny pacific island of guam. >> they are burned, skin hanging off their arms and their faces. unbelievable! toenail fungus? seriously? smash it with jublia! jublia is a prescription medicine proven to treat toenail fungus. use jublia as instructed by your doctor. look at the footwork! most common side effects include ingrown toenail,

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then, just three miles from its destination, korean air flight 801 slams into the side of a hill and breaks into pieces. eight minutes later, two air traffic controllers come to the sickening realization the plane has crashed. >> did korean air come back to you? >> korean, guam. >> no. >> he checked about landing. i don't know where he's at. >> you never saw him? >> negative. >> he didn't land? >> negative. >> oh, my god. >> 1 of the 254 people on board is new zealander barry small. unlike many of his fellow passengers who are tourists and honeymooners, small is on his

way to work as a helicopter pilot and mechanic on a large korean-owned fishing boat. the jet lifts off from seoul, south korea about 8:53 p.m. local time. the date, august 6th, 1997. >> the flight set off from seoul to guam was nothing out of ordinary. just a pleasant night flight. >> with a median temperature of 89 degrees, guam has an agreeable climate, but there's a grim flip side to that. august is rainy season with an average rainfall of more than 12 inches. as the 747 approaches the airport it runs right into a cell of heavy rain moving in from the northeast but small in seat 36k over the right wing doesn't worry. >> i can see the lights of guam out of the right-hand side of

the aircraft, and we were ascending without a carriage down. everything seemed normal to me. i reached down to get my shoes, and as i was about to grab them, there was a great thump, and i thought oh, we've landed earlier than expected. initial contact with the ground itself and the passengers were really not all that surprised. it was just a firm one, and we're home. >> at first, remarkably, small doesn't even realize they've crashed. as the 747 careens out of control and starts breaking apart, the horror of the situation becomes clear. >> the shaking of the aircraft got worse and worse to the point where you couldn't control your body. we were just like rag dolls being thrashed around in our seats. >> the plane has slammed into a rugged piece of terrain called nimitz hill, just three miles short of the destination runway. as it continues on its violent trajectory, the landing gear strikes an oil pipeline pushing part of it on to the road and

spilling a thousand gallons of oil in the process. >> they calculated from initial contact to finally stopping was about 17 seconds. i've got to say that's the longest 17 seconds of my life. >> fire erupts in the cabin. small is trapped. his right leg broken by the metal cross bar on the bottom of the seat in front of him, a common injury in plane crash victims. small's left leg is saved because of a bag he's placed under the seat in front of him. he manages to unbuckle his seat belt and hobble to the rear of the aircraft where he jumps out, escaping the flames. he drags himself nearly 200 feet away and just as he turns around for another look, small says a series of explosions rock the cabin with people still trapped inside. >> there were pieces falling short of us, like bombs, and the screaming got horrendous.

and the flames just increased again and the screams slowly faded away. never came back. >> small has survived the impact, but he desperately needs help. >> we got maybe a quarter mile down here, we stopped and we all ran to the crash site to get down to where we could hear the screams and you could see the fire. >> carl gutierrez, governor of guam at the time, lives three minutes away. he rushes to the rugged site with members of his staff. >> i ran down and found barry small with his leg broken and bone sticking out and gave him a cover also because the rain -- you know, he was incapacitated that way that he couldn't cover his eyes. >> by the time rescuers arrive, 52 minutes after the crash, barry small is stabilized, but

for most of the other passengers on korean air flight 801, it's too late. coming up -- what could lead a highly experienced crew to mistake a hill for a runway? >> when you have fatigue, it affects your decisionmaking. you don't really process information. >> they were suddenly finding things were stacking up, then suddenly, they're much closer to the ground than they expected. ♪ ♪ isn't it beautiful when things just come together? build a beautiful website with squarespace.

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you've got burns. you've got broken leg. >> good as gold. >> passenger barry small has survived a violent impact of a 747 slamming into nimitz hill three miles short of the runway in the u.s. territory of guam. more than 200 of his fellow passengers are killed.

within hours, the rescue effort becomes an investigation scene. the ntsb has challenges from the outset. >> we're talking about take a day and a half to get there, then once there it was very rugged, hilly terrain, getting down to the accident site was hot, humid. it was kind of difficult conditions to work from. >> as with virtually all plane crashes, there's no single cause. investigators quickly uncover a long list of problems leading up to the accident. to begin with, a key navigational aid called a slide slope is out of service for a scheduled reconstruction. >> the glide slope is a radio signal being beamed up from the ground to the airplane that provides electronic vertical guidance. >> together with a localizer, which provides lateral guidance, pilots align the plane with the

runway. with 9,000 hours in the cockpit, the captain is experienced. he knows the faa has issued an advisory that the guam glide slope is out of service, but in the last 2 1/2 minutes of the flight, the glide slope needle starts to move. >> he believed that that movement was, in fact, due to the fact that the glide slope may be working. >> because the glide slope is down, korean 801 is flying a nonprecision approach, which is more complex. that means the plane closes in on the runway in a step-down procedure, each step is a predetermined minimum altitude which planes must stay above. but according to the ntsb, the captain appeared to become preoccupied with the status of the glide slope, allowing the plane to descend prematurely into nimitz hill. >> they misinterpreted how the approach was being configured. and the captain never fully understood that, in my opinion.

>> the safety board also concludes that fatigue played a role in the accident by degrading the captain's performance. in the days prior to the crash, he's flown between three continents. he's suffering from bronchitis. and it's the middle of the night. >> when you have fatigue, it affects your decisionmaking. you're a bit impaired mentally because the fatigue takes over. you don't really process information. >> there are even more factors at play. august is the height of rainy season in guam. the captain might have been counting on a visual approach to the runway, but the jet flies into a downpour, making it difficult to see. >> so they were suddenly finding things were stacking up. they're not 100% sure where they are on the ground track. they're looking for visual cues that the heavy rain is preventing them from seeing, and

then suddenly they're much closer to the ground than they expected. >> flight 801's mounting problems are compounded by the crew's failure to communicate. >> the first officer and the flight engineer make comments that indicate their increasing level of concern, but they're soft comments. >> the cockpit voice recorder shows that up until 40 seconds before the plane crashes, the captain is still confused over the status of the glide slope, even though the first officer has finally stated it's not usable. the crew complies with the captain's commands, despite their concerns. probable cause, according to the ntsb? the captain's failure to adequately brief and execute the nonprecision approach and the first officers and the flight engineer's failure to effectively monitor and cross-check the captain's execution of the approach. >> one of the findings that we made after listening to the cvr and bringing all the other

additional information in as far as their culture and their training program, was the influence of this societal culture, the fact that you had junior officers who basically hinted and hoped to the captain, you shouldn't do that, you shouldn't follow the glide slope, but weren't assertive in actually correcting him or even taking command of the airplane away from the captain to prevent an accident. >> any one problem might not have been significant, but together for 228 of 254 people on board this jet, all of those problems are fatal. this is the first time guam's former governor carl gutierrez has set foot on nimitz hill since the time of the accident. like many of the survivors, he assisted on that tragic night, he hopes for closure on that painful chapter. >> i just wanted to get there and see there's still some spirit lingering around in that area because there was a lot of agony that morning.

i mean, really a lot of agony that i haven't been back since. and i haven't been as close as to where we were at today. >> in the 1980s and '90s, korean air has more than a dozen accidents with a death toll of 750. the airline is seen as so problematic, the u.s. department of defense prohibits employees from flying on its planes, and canada threatens to ban korea air from flying over its air space altogether. but then a major turnaround. korean air hires david greenberg, a retired pilot turned vp from delta airlines. he institutes new policies and procedures and completely revamps communication in the cockpit. >> you have national culture, you had corporate culture and you had pilot culture. you can't change national culture, but what the corporate culture does to mold and shape the pilot culture is critical. >> the incredible changes that happened in a short period of

time are impressive. >> the industry has come a long way since the days of authoritative captains and crews reluctant to assert themselves. since crew resource management, crm, has been instituted, the number of aviation accidents has decreased significantly. >> crm is one of the reasons that aviation is as safe as it is today. it's one of the quantum leaps that aviation safety was able to make was making pilots better team members. >> it has probably been one of those things that you can't quantitatively measure, but the effect that it's had on the success and safety of aviation today has been enormous.

all of a sudden, i heard a big explosion. >> a mysterious flaw brings down a boeing 737. >> there's something going on that left no marks, no calling card. >> shortly after takeoff, a powerful explosion rips apart twa flight 800, igniting controversy about what really happened. >> if anybody thinks that this chairman is involved in any kind of cover-up, they're damn wrong. >> conflicting commands put two jets on a collision course. >> descend, descend. >> and the devastation provokes a violent act.