The investigation plodded along, past the one-year mark, past two years, three years. For Tom Haueter, solving the crash was difficult enough; convincing NTSB board members and dealing with the politics would be even tougher.
Bendix offices, North Hollywood, Calif.
Boeing was developing a gargantuan new plane, the 747, and Ralph Vick was hoping his company would win the contract to build a special valve for it. The valve was similar to the soda can-sized one designed several years earlier for the rudder of the 737.
To pass muster, the 747 valve had to survive a series of tortures.
One test shook the valve like a can of house paint in a mixer. Another moved the valve back and forth 5-million times, to simulate a lifetime of use.
The most brutal test was called thermal shock. The valve was frozen to 40 degrees below zero, then injected with hot fluid. That was to ensure it would still work if a hydraulic pump overheated while the plane was in frigid air at 35,000 feet.
Technicians placed the valve in a freezer the size of a wastebasket and cooled it to 40 below. They flipped a switch and heard the steady whine of the hydraulic pumps, then flipped another switch to inject the piping-hot fluid.
The valve strained, then stuck for a few seconds. It had failed the test.
Vick knew it was a setback, not a catastrophe. His engineers went back to their drawing boards and redesigned the valve. It passed without problems.
* * *
The Greatest Minds in Hydraulics had arrived in Washington.
That was what NTSB Chairman Jim Hall called the special panel he invited to review Tom Haueter and Greg Phillips' work. It had been almost two years since USAir Flight 427 went down, and still they couldn't prove that their best suspect, the rudder valve, was responsible.
Haueter, the lead investigator, considered the panel a waste of time. Why did they need a bunch of so-called experts? Phillips, his hydraulics expert, knew more about the 737 rudder system than just about anybody on the planet.
Actually, Phillips had been one of the people behind Hall's idea. He thought it would help to have an impartial panel validate the investigators' work. Maybe fresh eyes would help.
Ralph Vick, a quiet, serious man who was now semi-retired, was on the panel because he had designed dozens of valves in his long career. He had never forgotten the day 30 years earlier when hot met cold and the 747 valve stuck. Maybe the rudder valve on the USAir plane had stuck the same way.
In his room at the L'Enfant Plaza Hotel, he sketched how the test might go. The valve would be frozen to 40 below zero the coldest air Flight 427 would have encountered then pumped with 170-degree hydraulic fluid.
No one expected a breakthrough. Every day, hundreds of 737s withstood huge temperature swings without problems. Jean McGrew, Boeing's chief engineer for the plane, said there wouldn't be a thermal jam until 737s could fly to the moon.
Still, Haueter and Phillips were willing to give the test a try. Why not? "We've tried the obvious and the remote," Haueter said. "We're now open to the bizarre."
Two months later, in August 1996, the safety board investigators and the Greatest Minds in Hydraulics gathered at Canyon Engineering, a tiny hydraulics company in Valencia, Calif., that looked more like a garage than a modern test facility. They would test two rudder valves one from the USAir crash and a new one straight from the factory.
The PCUs, the heavy steel contraptions that contained the valves, were placed in a big, white Coleman cooler and frozen with nitrogen gas. The room filled with a steady rhythm of clicks and hisses as the PCUs were put through their calisthenics. Click, hiss, click, hiss.
Both PCUs were passing every test. Things were going so smoothly that the Greatest Minds started to pack up and say goodbye. Another theory ruled out.
They had reached the most extreme condition, when the frigid PCU from the USAir plane was pumped with 170-degree fluid. Click, hiss, click, hiss.
But then: Click, hisssssssssss.
The valve had jammed.
* * *
It took six weeks before anyone believed the jam was real.
The Valencia tests had been conducted under such sloppy conditions that no one could be sure the results were valid. But then it happened again in a sophisticated Boeing lab: The valve from Flight 427 jammed; the valve straight from the factory did not. Not only had the tests proved that the valve could jam, they had shown the Flight 427 valve was more prone to jam.
Still, nobody was shouting that the mystery was solved. There was no evidence of a thermal shock on the USAir plane. Nor were there any scratches to indicate the valve had jammed before the crash.
But then a young Boeing engineer named Ed Kikta noticed something strange in the test results. Poring over charts and numbers at his desk, Kikta discovered odd dips in the hydraulic flow that shouldn't have been there.
If he was reading the data right, it would mean that when the valve jammed in the thermal shock test, the rudder would not have gone to neutral, the way it should. It would have reversed.
A pilot could push on the right pedal, but the rudder would go left.
That would mean catastrophe.
Could this be right? Kikta double-checked the data. Sure enough, there it was. A reversal.
He looked up and saw his boss, Jim Draxler, putting on his coat to leave. Kikta stopped him.
"We might have a problem here," he said.
The beauty of the valve-within-a-valve system was that it was designed to work even if one part jammed. But Kikta's discovery meant a single jam could cripple a plane and even cause a crash.
Boeing sprang into action. For six days, engineers worked feverishly to confirm Kikta's discovery. They concluded that levers were flexing slightly, which allowed hydraulic fluid to flow through the wrong set of holes in the valve.
They scrambled to get a 737 to check their theory. Boeing didn't own one that would be right for the tests, so the engineers took one right off the assembly line, before it was delivered to an airline. That usually takes two weeks to arrange, but the Boeing engineers were so worried that they got one within 24 hours.
The plane landed at Boeing Field in a cold Seattle rain on Oct. 29, 1996. Michael Hewett, the Boeing test pilot, climbed into the cockpit; Kikta stood on a platform on the tail of the plane, watching the rudder.
The first two tests went smoothly. Then came a more aggressive test. Hewett stomped on the pedal as fast as he could.
The rudder swung the wrong direction.
* * *
The Boeing engineers now faced the alarming possibility that their 737 the world's most widely used jetliner did not meet safety standards. They alerted the FAA and asked for 24 hours to figure out what to do. The FAA agreed.
The next day, Halloween, McGrew and other Boeing engineers drove to the FAA office in Renton, Wash., a big, silver cube about 2 miles from the plant where 737s are assembled. Boeing had no idea how the FAA would respond to its plan. The government might require nothing more than inspections, or God forbid it could ground the entire 737 fleet. That would devastate Boeing, and it would disrupt travel plans for hundreds of thousands of people. Southwest Airlines, which has an all-737 fleet, would temporarily be put out of business.
About 25 Boeing and FAA officials crowded into a conference room. McGrew took a seat beneath a smiling photo of FAA Administrator David Hinson. In the corner was a VCR with the clock flashing "12:00" throughout the meeting.
Kikta's boss, Jim Draxler, explained what Boeing had found, with Hewett frequently interrupting to give his perspective. The Boeing engineers proposed that for the short term, the company issue an alert bulletin requiring airlines to test rudders for jams. In the long term, Boeing would redesign the valve.
An FAA engineer got right to the point: Did this cause the crash of Flight 427?
The Boeing engineers said they didn't know. The tests showed that if one tube in the valve jammed, a reversal was possible. But in 30 years, with 70-million flights, there had been only a handful of confirmed jams. None had resulted in an accident. And there was no evidence of a jam on the USAir plane.
Another FAA official noted that Boeing had steadfastly blamed the pilots, but the new evidence seemed to contradict that.
McGrew spoke up. "We've received a lot of public criticism about hiding things and not wanting to spend a lot of money," he said. "But I frankly don't care (what it costs). If there is something wrong with the airplane, I want to fix it."
The FAA accepted Boeing's plan to run tests on the rudders until a new valve could be designed.
Despite all the hubbub in Renton and Seattle, word had not gotten back to the NTSB. Boeing had made a crucial discovery, but no one had bothered to tell Haueter.
* * *
As Boeing gave the FAA its big news, Haueter and Phillips were 2,500 miles away, oblivious.
They were at a Holiday Inn near the Pittsburgh airport, giving an update on their work to the pilots union, Boeing and USAir.
Rick Howes, Boeing's coordinator for the investigation, sat through the all-day meeting without saying a word about his company's dramatic findings.
Haueter and Phillips flew back to Washington. As they got off the plane at National Airport, Haueter's beeper went off. The message read:
"MAJOR FINDING REL TO PIT / DEFECT FOUND ON SERVO VALVE."
"This is a joke," Haueter told Phillips. "This isn't real. Some jerk has figured out our paging system." They headed home.
The message had come from Ron Schleede, one of Haueter's bosses. He had been working late when Boeing finally called to share the news. Schleede transmitted the beeper message to Haueter, then walked downstairs to the bar at L'Enfant Plaza Hotel, where NTSB Chairman Hall was having a drink.
"Jim," Schleede said. "I think we've got it."
But they didn't have it. They still had no proof that the valve on the USAir plane had jammed or reversed.
Boeing's failure to alert Haueter about its big discovery further damaged the company's credibility. McGrew said he had wanted to notify the NTSB sooner, but Boeing's top executives felt it was a safety issue and their first priority was to alert the FAA.
The snub so angered Haueter that he couldn't let it go. He was on vacation the next week, but made a point of calling Howes to chew him out.
"The ramification" for Boeing, Haueter said later, "was that they lost a lot of trust."
* * *
Malcolm Brenner made his name at the NTSB by studying a sailor's slurred words.
Brenner, a lanky NTSB psychologist who once made his living as a limo driver and a department-store Santa Claus, collaborated with audio expert Jim Cash on a ground-breaking study of radio tapes of the Exxon Valdez accident. They counted the number of seconds it took the captain to say each word, proving his speech was slurred just before the ship ran aground.
Brenner wanted to use similar techniques on Flight 427's cockpit tape. The pilots' voices, breathing and grunts might help answer the fundamental question of the investigation: What moved the rudder man or machine?
He studied the tape one word at a time, measuring the pitch of Capt. Peter Germano's voice. Brenner concluded that the pilot didn't panic until after the rudder had moved. That contradicted Boeing's contention that Germano stomped on the rudder pedal earlier because he was startled.
To figure out what First Officer Charles B. Emmett III did, Brenner enlisted the help of a sound expert from Russia named Alfred S. Belan, who devised a novel approach: He analyzed the word "shit."
Emmett had said the word during a calm moment about 20 minutes before the crash, when he had trouble programing the navigational computer: "Aw, c'mon, you piece of shit!"
He said it two more times once as the plane was starting to point nose-down and again just before impact.
Belan used the word to measure Emmett's stress, comparing his breathing each time and converting the words into color graphs that looked like a salmon filet.
The creative analysis of the cursing brought no breakthroughs, but Brenner made an important discovery when he studied Emmett's grunts.
His first grunt came early, right after the USAir plane got bounced around by the wake of another jet. Then he grunted again, louder.
Early in the investigation, Brenner believed Emmett grunted because he was trying to turn the wheel to level the plane. But the reversal gave him a new possibility. If the rudder had reversed, the first officer would have felt the left rudder pedal snap back against his foot.
The flight recorder showed precisely when the rudder moved, and the cockpit tape showed precisely when he grunted.
The times matched perfectly.
* * *
Brett Van Bortel had tried dating again, but it was awkward, like high school all over again. He worried what women would think if they came to his apartment and saw he still had lots of pictures of Joan, two years after she had been killed in the crash.
His grand scheme for the dinosaur restaurant had collapsed because he couldn't find any investors. "I think I overstepped my skills," Brett said. He was good at marketing, but he didn't know much about starting a restaurant.
On the bright side, he had gotten so immersed in the dinosaur project that he thought less about the crash.
"There hasn't been a day yet that I haven't thought about her or the crash," he said. "But it's not as overwhelming or as incapacitating as it was."
On Jan. 15, 1997, Brett sat down to lunch and flipped on CNN. The network was carrying Vice President Al Gore's speech to a conference on aviation safety and security.
"As you know," Gore said, "the investigations into the crashes of Boeing 737s in Colorado Springs and Pittsburgh have not yet been closed. But those investigations have identified improvements that could help eliminate the chance of rudders playing a role in future accidents. These changes can and should be made without delay."
Brett listened intently. It sounded like the 737 fleet was getting fixed.
"Boeing has developed modifications to the rudders of older 737s that will improve safety," Gore continued, "and they are going to begin retrofitting those planes, largely at their own expense, without waiting for a government mandate. Under a schedule to be developed by the FAA, these improvements will be made in the next two years. This is a major action: It affects some 2,800 planes worldwide, 1,100 of them here in the United States."
Boeing was redesigning the valve so there was no way the rudder could reverse. All 737s also would get new devices called limiters that would keep the rudder from moving suddenly.
Tears welled in Brett's eyes. Maybe something beneficial could come of Joan's death: It sounded like the government was really doing something to prevent another crash.
The timing of the announcement couldn't have been better for Boeing.
Dateline NBC was scheduled to air a segment on 737 rudder problems a few days later. But Gore and Boeing's announcement deflated Dateline's story. Instead of a sensational account that said the 737 was unsafe, Dateline was reduced to saying the plane was getting fixed.
Haueter listened to Gore's speech, too. He heard loads of praise for Boeing, but only a passing mention of the NTSB. Gore made it sound like Boeing, out of the kindness of its heart, had generously offered to spend $150-million to fix the problem.
Haueter was miffed. The NTSB had recommended the rudder fixes, but Boeing was getting all the praise. Couldn't the NTSB get the credit it deserved?
His boss, Bernard Loeb, shared his bitterness.
"Boeing didn't do this because their hearts told them to do it their lawyers told them to do it," Loeb said. "They didn't have a g- -d- - - choice."
* * *
In late February of 1997, Haueter had a hard time sleeping. He was worried that another 737 might crash. Lying in bed, he again imagined getting hauled before Congress and grilled about why he hadn't acted sooner.
It had been almost two months since Gore had said Boeing would fix the rudder valve, but Haueter had seen little action. Where was the urgency? Boeing and the FAA were taking a leisurely pace.
"We have some information that we are sitting on," he said. "If we don't get it out, then one crashes Holy mackerel! then we're really in trouble."
Haueter believed the 737 no longer met federal safety standards. He talked with colleagues about recommending that the 737 fleet be grounded but concluded he didn't have enough evidence for such a drastic step. Instead, he decided to light a fire under the FAA.
If he were a politician, he would just hold a news conference and speak his mind. But that was not how the NTSB operated. There were unwritten rules of engagement about how to blast the FAA. It was done discreetly, usually by letter to the FAA administrator, conveniently faxed to aviation reporters.
Haueter's 10-page letter, signed by NTSB Chairman Jim Hall, called on the FAA to speed up the rudder fixes. The letter was unusually frank. It said the 737 was not as safe as other planes.
That evening, NBC anchor Tom Brokaw told millions of viewers: "There may be an answer tonight to questions that for years have perplexed investigators of two deadly plane crashes. That answer is certain to raise new fears about the world's most widely used airliner, the Boeing 737."
Haueter watched the NBC report at home, relieved that his worries about the plane had been revealed to the world.
Boeing began damage control, sounding the 737's mantra: "Making a safe airplane even safer."
The company faxed a statement to the press that said, "Boeing is and has been working with suppliers on an already aggressive schedule" to fix the rudder system. The changes "will serve to make a safe airplane even safer."
The same words had been used by the FAA and the airlines after Gore's announcement two months earlier. Said Acting FAA Administrator Linda Daschle: "We believe these steps . . . will make a safe airplane even safer."
A Southwest Airlines spokeswoman declared, "We see the changes as a way to make a safe plane even safer."
* * *
Investigators often say no single problem causes a plane crash. It takes a chain of breakdowns or pilot mistakes. Break any link in that chain and the crash is averted.
After more than three years, Haueter had put together the chain for Flight 427. His theory went like this:
It was a smooth flight from Chicago to Pittsburgh, so there was not much movement by something called the yaw damper, which makes hundreds of tiny adjustments to the rudder. That lack of movement allowed particles to build up in the hydraulic fluid that flows through the rudder valve.
A problem with a hydraulic pump sent hot, dirty fluid rushing into the cold valve, making it suddenly expand. On another plane, the valve would have tolerated that thermal shock and the contaminated fluid without trouble. But the valve on USAir 427 was uncommonly tight. The valve jammed.
This happened just as the USAir plane ran into the wake of another jet. All jets leave wakes, powerful spinning tubes of air that are ordinarily nothing more than a nuisance for the trailing jet to cross. For USAir 427, the turbulence prompted co-pilot Charles Emmett to push on the right rudder pedal. But because the valve was jammed, the rudder didn't go right, it went all the way left.
The plane's speed was a key link in the chain. Flight 427 happened to be flying at its most vulnerable speed, called the crossover point, which put it at the mercy of the rudder.
If the plane were going faster, the pilots could have recovered easily from a twist of the rudder. But 737s had an aerodynamic quirk: A sudden rudder movement at the crossover speed would make the plane roll out of control unless the pilots knew exactly what to do.
Seeing the ground looming before them, Emmett and Germano pulled back on the control wheel, which made the plane stall. It spiraled down and into the hill near Pittsburgh.
"What the hell is this?"
Haueter finally felt he knew the answer.
He also believed his investigators had solved the Colorado Springs crash and the Eastwind incident near Richmond. New NTSB computer simulations showed a rudder reversal would explain them both.
Haueter's theory was like a three-legged stool. Individually, the cases on USAir 427, United 585 and Eastwind 517 were not conclusive. But taken together, Haueter felt he had a good case that all three rudders reversed.
Unfortunately, he had no proof. There were no marks or scratches from a jam and no evidence of a thermal shock. It was a circumstantial case. Would it be enough to convince the members of the National Transportation Safety Board?
* * *
As Haueter and his boss Bernard Loeb plotted strategy to win votes, they figured board member Bob Francis would be their biggest hurdle.
Francis is a former FAA official who became something of a celebrity for his nightly briefings about the crash of TWA Flight 800. Earlier in the USAir investigation, he had balked at some of the 737 safety recommendations because he wanted to give the FAA and Boeing more time to redesign the rudder valve.
"Bob does not like to be controversial with industry," Haueter said. "He thinks we should do more things with gentlemen's agreements. Unfortunately, gentlemen's agreements don't work."
The board has five members, but one, a former USAir employee, disqualified himself from the case. Haueter and Loeb needed three of the four remaining board members to approve the report. If they lost Francis, they had to get everyone else.
The swing vote likely would be George Black, a brainy engineer from suburban Atlanta. He spent far more time studying the 737 crashes than other board members and filled a spare office with maps and reports on 737s. A hand-drawn sign by the door called it "The War Room."
With the meeting a month away, Haueter began hearing rumblings that the board members were skeptical about his case. He worried they would reject his probable cause and opt for the same embarrassing words as in Colorado Springs "FOR UNDETERMINED REASONS."
Boeing, which knew all the angles to work at the NTSB, had a head start trying to sway the board members. Boeing had taken each of them for a ride in the M-Cab simulator to show how easily Flight 427's pilots could have saved the airplane. Meanwhile, Haueter's staff was behind schedule, scrambling to finish new computer simulations on the crashes.
Haueter's team kept revising the simulations with updated information, but the numbers always added up to the same conclusion: a rudder reversal. He was afraid it might look to the board members like his investigation was in chaos.
Sure enough, Black was wary about the frequent revisions and how they matched a reversal every time.
No one was sure how Black would vote. He liked playing devil's advocate, throwing out new ideas that often contradicted each other. He also liked to tease Boeing executives about the possibly dismal future for the 737.
"Boeing has no corporate sense of humor," Black grumbled.
Black and Francis opposed several items in the early draft of the crash report. One item specified how the 737 rudder system should be redesigned, but the board members felt the specifics should be left to the FAA and Boeing. Black and Francis also were unhappy with a sentence in the report that said, in effect, the 737 was unsafe.
During the behind-the-scenes negotiations, they had tremendous leverage in getting the changes they wanted. Francis said he would vote against the entire report unless the changes were made. Black compiled a list of several "drop dead" items that he wanted in exchange for his vote.
Their demands were met: Haueter and Loeb toned down several items.
There were other quibbles over individual words.
One recommendation called on the FAA to make the rudder system redundant, so it would still work if there was a failure. Haueter and Loeb knew the FAA would say the unique valve-within-a-valve already was redundant, so they plotted how to strengthen the sentence so the FAA would not have any wiggle room.
How about truly redundant, someone suggested.
They finally settled on reliably redundant.
Some board members thought the proposed wording of the probable cause statement was too strong in linking the crash to a rudder reversal. The wording was softened to say that the crash was caused by a full twist of the rudder that most likely was caused by a reversal.
With the report toned down, all four NTSB board members, including Francis and Black, appeared ready to approve it.
* * *
The final meeting on Flight 427 was held March 23 and 24 in a Hilton hotel ballroom that looked like a movie set. Blue stage lights lit up the curtains. The board members sat behind a big wooden desk like a jury deciding if the 737 was guilty.
The theatrical appearance was fitting because most of the meeting had been scripted. The board members had reached a consensus on the report long before they set foot in the ballroom.
Relatives of the victims sat together, some with photos of their lost loved ones on chains around their necks. Brett Van Bortel took a seat in the last row of the family section. He didn't realize it, but sitting directly behind him were the people he blamed for Joan's death top officials from Boeing and USAir.
It had been 41/2 years since the crash and Brett had healed as much as anyone could. He was dating again and engrossed in his job at a mutual fund company.
"It's really a matter of getting busier and not letting it overwhelm your life," he said.
Brett listened attentively as Haueter and his team explained the rudder system and how they believed it had reversed on the USAir, United and Eastwind 737s. The NTSB staffers spoke in absolutes, as if there was no doubt about what happened.
"The pilot is surprised and pushes harder as hard as he can," Malcolm Brenner said about Flight 427. "But instead the controls reversed and moved the rudder all the way to the left."
In the audience, Boeing engineers could only listen and bite their lips. They had no opportunity for rebuttal. This was the NTSB's show.
After a few final scripted questions from board members, NTSB Chairman Jim Hall read the board's findings including one that blamed the unsolved Colorado Springs crash on a reversal.
The families broke into applause, but Hall admonished them to be quiet. Then he read the probable cause statement, 41/2 years of investigation boiled down to two sentences:
"The probable cause of the USAir Flight 427 accident was a loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder PCU servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide."
Translation: The rudder reversed. The fault was with the airplane, not the pilots.
The longest investigation in NTSB history ended with little discussion and a quick unanimous vote.
As Black left the stage, he said he had misgivings about the case. "I damn near voted against it," he said. "This is a circumstantial case."
Hall, renowned for blasting the FAA and Boeing, was oddly muted. He told reporters that he flies 737s home to Chattanooga, Tenn., every week and believes the plane is safe.
Haueter and his investigators were disappointed in the board members' comments, feeling they were backing away from the report they had just approved. "That was a downer to the guys," Haueter said. "The report was adopted unscathed, but it felt like cold water was thrown on it."
Still, he took satisfaction from solving a high-profile case. He vowed to "push the FAA hard. They can't do nothing. There's too much visibility."
When Haueter returned to the office, he bought four bottles of champagne and gathered his team in a conference room. Malcolm Brenner said that Haueter must be blessed with some kind of superhuman hormone that kept him going when others were ready to quit. Someone proposed a toast to Eastwind pilot Brian Bishop, who survived a rudder reversal, saved 55 lives and gave the NTSB key evidence about what was wrong in the 737.
"To Captain Bishop," one of the investigators said, and they all clinked their plastic cups together.
Brett Van Bortel's lawsuit against USAir and Boeing is scheduled for trial this fall. Most Flight 427 families have settled their lawsuits, receiving $2-million to $4-million each, some considerably more. But Brett doesn't want to settle. "I think if I went through a trial, it would give me closure. I want to hold their feet to the fire."
Putting a value on the life of Joan Van Bortel (published November 6, 1999)
Brett Van Bortel wanted to go to court to punish the people responsible for his wife's death. But a flip of a coin changes everything.
He plans to use any money he wins to put Joan's 10 nieces and nephews through college. He also has set up a scholarship fund so every year, a young woman from Joan's hometown can attend the University of Iowa, where Brett and Joan met: "I want her life to have a contribution to this world."
Tom Haueter was promoted during the USAir investigation to chief of major aviation investigations for the NTSB. He flies 737s on business trips, but his constant talk of rudder problems has scared his wife, Trisha Dedik. When they went to Colorado on vacation two weeks ago, she insisted they fly any jet other than a 737.
Jean McGrew, now Boeing's chief engineer for product development, says the Flight 427 investigation revealed how the NTSB has become dominated by politics. "I think they ought to take the politicians and get rid of them," he says.
John Cox, the USAir pilot and pilot union representative in the investigation, has been promoted to fly the Airbus A-320. Cox and a USAir official devised the emergency procedure for 737 rudder malfunctions that is now taught to all pilots.
Congress passed the Aviation Disaster Family Assistance Act, prompted by complaints from the families of Flight 427 and other crashes. The act requires airlines to: submit plans to the government about how they will respond to an accident; release victim names to families as soon as they are confirmed, rather than waiting until the list is complete, as USAir did; and consult with families before doing anything with bodies or personal belongings and before building any monuments.
The FAA approved a rule in 1997 that requires airlines to upgrade flight data recorders in all planes by July 2001. But the FAA refused the NTSB's plea that because of extra safety concerns about the 737, those planes should be upgraded more quickly. The FAA said it would cost too much and disrupt airline schedules.
Boeing took a conciliatory approach to the NTSB after the final hearing, no longer pushing its hard-line pilot error theory.
"We respect the board's opinion," said Charlie Higgins, Boeing's vice president for airplane safety. New rudder valves being installed on 737s "completely eliminate any possibility of a reversal."
The new valves have been installed on more than half the 737 fleet and are scheduled to be on all planes by late summer.
At a news conference, Higgins looked to the back of the room where several family members stood and acknowledged their loss.
"I'd like to sincerely offer our condolences to the families," he said. "It's small consolation to them, but I believe this accident has improved aviation."
USAir changed its name to US Airways in early 1997 after former United Airlines head Stephen Wolf took over. One of Wolf's first priorities was a new image that has helped erase the memories of the airline's five crashes. The airline now has a detailed plan for helping families after a crash and has improved training for employees who deal with them.
The airline got a scare in February when one of its MetroJet 737s bound for Hartford had a strange rudder incident at 33,000 feet. Pilots discovered the rudder had moved to the right even though neither of them had their feet on the pedals. The pilots went through Cox's emergency procedure and landed the plane safely in Baltimore.
No one at the NTSB, the airline, the FAA or Boeing has figured out why the rudder moved on its own, raising concern that there could be yet another problem in the rudder system.
"What it says," said Cox, "is that there is another gremlin in the tail of the 737."
About this story
National Transportation Safety Board investigations are usually closed to reporters until the case is completed. But the agency permitted Times reporter Bill Adair to talk with its investigators as long as those interviews were not published until the safety board approved its final report. That happened on March 24. This series is based on four years of interviews with investigators from the NTSB, the Federal Aviation Administration, Boeing, USAir and the Air Line Pilots Association. During those four years, the Times published many other stories about the investigation and problems of the 737.
About the staff
Bill Adair, 37, is a reporter in the Times Washington bureau, where he covers Congress and aviation. This year, he won the Everett McKinley Dirksen Award for Distinguished Reporting of Congress. He has been with the newspaper since 1989.
Bill Serne, 48, has been a photographer for the Times since 1981. Shooting pictures for this story, he traveled to Seattle, Chicago, Pittsburgh and Washington, D.C. Serne is a private pilot and a photojournalism graduate of Kent State University.
Editor: Richard Bockman
Photo editor: Sonya Doctorian
Art director: Don Morris
News artist: David Williams
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Researcher: Kitty Bennett
Web design: Desiree Perry
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National Transportation Safety Board USAir Flight 427 Accident Investigation Docket Web site
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