28 Seconds: The Mystery of USAir Flight 427
Part One: Zulu

STORY BY BILL ADAIR OF THE TIMES STAFF
(published April 4, 1999)

Summer 1995
Great Falls, Virginia

The clock on the nightstand read 2 a.m., but Tom Haueter was wide awake. He usually was a leaden sleeper, dead to the world once his head hit the pillow. But now a nightmare had jolted him awake.

By day, Haueter ran the investigation into the crash of USAir Flight 427. He was the consummate man in charge, all confidence and certainty. At night, though, his doubts sometimes overcame him.

It had been nine months since the USAir plane had corkscrewed out of the blue sky over Pittsburgh and dived into a hill at 300 mph, but Haueter still didn't know why.

He had run many investigations for the National Transportation Safety Board, and this one had started like all the rest. The peculiar smell of death mixed with jet fuel, the adrenaline rush from the first few days examining wreckage. But the rush had long since passed.

Investigators typically figure out the cause a week or two after a crash, but not this time. They had chased countless leads and run test after test after test and come up empty. Now Haueter lay in the dark, tormented at the prospect that he would never solve it.

The nightmare tapped into his deepest fears.

Now another 737 had crashed, and Congress clamored for answers. He sat at the witness table, alone, facing a panel of angry congressmen.

Everyone in the packed hearing room stared at him, convinced he had bungled the investigation. The TV cameras zoomed in to record his every twitch.

"What happened?" a congressman demanded. "Why didn't you do something sooner? Why didn't you ground the fleet?"

* * *

Sept. 8, 1994
Lisle, Illinois

Brett and Joan Van Bortel pulled into the parking lot at the Lisle train station before sunrise, with a few minutes to spare until Joan had to catch the 6:20 a.m. train. A sign beside the track said "TO CHICAGO," with a big arrow pointing east.

Joan, who grew up on the family farm in Iowa, was now a big-city business executive. She was 29, a marketing manager for Akzo Nobel, a chemical company that sold the raw materials for rubber. She wasn't a chemist, but she took the extra time to learn the science of her products. She even made her employees take written quizzes ("How is rubber cured?" "Name one of our products that has zinc in it.")

She was 5 feet 2, a foot shorter than Brett, with honey-brown hair and brown eyes. She did aerobics, which meant she could indulge in her afternoon ritual: Skittles or licorice from the snack machine.

Joan planned to spend the day in the office, then catch a quick flight to Pittsburgh for a meeting. Brett would be home installing tile on the kitchen floor. He had promised to be finished before she came home the next night.

They kissed goodbye. Joan looked all business in her green and white suit, briefcase in hand. She wore a simple wedding band paired with an elegant engagement ring, which had a big marquise diamond surrounded by four other diamonds.

At the office, the day got crazy with meetings and phone calls. Joan was running late when she grabbed her bags at 3:45 p.m. and caught the El train to O'Hare. She dashed to Gate F6, where the USAir plane already was boarding. She was in 14E, a middle seat just behind the wing.

To her right in 14F was Robert Connolly, a financial consultant headed home to Pittsburgh. In the row ahead of them was 7-year-old Scott Weaver, coming home after a cousin's funeral. Scott's 11-year-old sister, Lindsay, was directly behind Joan. Scattered around the plane were Department of Energy employees returning from a coal conference. The man in 17F was a drug dealer.

USAir workers filled the belly of the plane with 1,700 pounds of luggage and a ton of BusinessWeek magazines bound for subscribers in the Carolinas. The flight was running 15 minutes late, so USAir mechanic Tim Molloy had extra time for a final safety check. He circled the big silver plane twice, checking the tires, the wings, the rudder, the tubes that measure airspeed and the fluid levels for the hydraulic systems. Everything was in order.

A mechanic pushed the plane back with a tractor and told the pilots it was safe to start the engines. He stood back and snapped them a salute.

Flight 427 was on its way.

* * *

The flight from Chicago to Pittsburgh takes 55 minutes, barely enough time to serve passengers a round of drinks.

Capt. Peter Germano and First Officer Charles B. Emmett III turned on the auto-pilot and let the plane fly itself. USAir preferred that crews use the autopilot because it's smoother and more fuel-efficient than human pilots.

The pilots asked the flight attendants for soft drinks. Emmett cursed at a stubborn computer. Near Pittsburgh, they switched on the seat belt sign, but Emmett realized he hadn't told the passengers to prepare for landing.

"Ooops, I didn't kiss 'em bye. What was the temperature, 'member?"

"Seventy-five," said Germano.

"Folks, from the flight deck, we should be on the ground in 'bout 10 more minutes," Emmett said over the PA system. "Uh, sunny skies, little hazy. Temperature's, temperature's 75 degrees. Wind's out of the west around 10 miles per hour. Certainly appreciate you choosing USAir for your travel needs this evening, hope you've enjoyed the flight. Hope you come back and travel with us again. This time we'd like to ask our flight attendants, please prepare the cabin for arrival. Ask you to check the security of your seat belts. Thank you."

The pilots, nearing the end of three days of traveling together, were relaxed and happy.

"That sun is gonna be just like it was takin' off in Cleveland yesterday, too. I'm just gonna close my eyes," Emmett said, laughing. "You holler when it looks like we're close."

An air traffic controller told them a Jetstream commuter plane had just taken off from Pittsburgh and was climbing in front of them. The pilots dialed in a new heading to put the USAir plane into a gentle left turn.

"Oh yeah," Emmett said, mocking a slight French accent. "I see zuh Jetstream."

Then something happened.

"Sheeez," said Germano.

"Zuh," said Emmett.

Thump.

The plane's wings rolled suddenly to the left.

Thump.

To the passengers, it felt like routine turbulence, but it quickly became clear the plane was in trouble.

"Whoa," said Germano. The wings started to level off, but then the left wing dipped down again.

"Hang on, hang on," Germano said. They clicked off the autopilot. That triggered the whoop-whoop-whoop of the autopilot warning horn.

The plane kept rolling left and the nose plunged toward the ground.

"Oh shiiit," Emmett said with his slight Texas twang.

To passengers, it would have felt as if they had reached the top of a roller coaster and were starting the first, huge drop.

"What the hell is this?" Germano said.

The pilots pulled back on the control wheel, trying to get the plane's nose up. But it kept diving, picking up speed.

The pilots' control columns began rattling like jackhammers, warning that the plane was stalling. The autopilot alert continued blaring whoop-whoop-whoop. The plane's traffic computer spotted the commuter plane a few miles away and its electronic voice shouted "TRAFFIC! TRAFFIC!"

"Oh God! Oh God!" cried Germano.

The USAir plane was diving toward the Green Garden Plaza shopping center at 250 mph – and gaining speed. As the plane corkscrewed down, the passengers would have been driven back in their seats by centrifugal force so strong it would have been hard to lift their hands off their laps. The plane shook violently.

In the cockpit, the dials and gauges spun like clocks rushing forward in time. Germano pressed a button to talk to controllers. "Four-twenty-seven emergency!"

"Shit!"

"Pull!"

In a darkened room at the Pittsburgh airport, air traffic controller Richard Fuga heard their shouts and saw the plane's altitude reading change to "XXX" on his radar screen. The plane was falling so fast that his computer could not keep up.

The plane was diving at 280 mph now, gaining speed.

"Oh shit!" shouted Emmett.

"Pulllllllll!" screamed Germano.

"God!" said Emmett.

It had been only 28 seconds since the first inkling of trouble.

Just before impact, Emmett sounded resigned, almost pleading, as he said, "Noooo."

* * *

It was 7:03 on a warm Thursday evening in Hopewell Township, Pa., when the 737 fell from the sky. Hundreds of people at the Green Garden Plaza shopping center and a nearby soccer field saw the plane spiral toward a hill.

Trees blocked their view of the crash, but they couldn't miss the fireball. A plume rose from the hill and drifted across Route 60, over the Beaver Lakes Country Club.

At fire stations throughout Pittsburgh, firefighters heard a series of tones and then the words "Zulu at Pittsburgh International Airport." A Zulu call meant a disaster with at least 20 people killed. More than 40 fire trucks, ambulances and police cars raced to the crash site 10 miles northwest of the airport.

When Engine 921 of the Hopewell Volunteer Fire Department reached the woods at the top of the hill, Capt. James Rock hopped out and grabbed an ax and a pry bar. A professional firefighter at a nearby Air Force base, he was a veteran of drills rescuing people from plane crashes. He dashed through the woods, ready to pry passengers out of the wreckage and save some lives.

He saw mangled luggage and airplane seats. Then he saw a man's hand on the ground. He looked around feverishly; there was no one to save.

Firefighters pulled hoses into the woods and sprayed water on the wreckage and the trees to douse the flames. Others ran through the woods, shouting for survivors.

"Anybody here?" they yelled. "Anybody need any help?"

There was no reply.

At the Federal Aviation Administration in Washington, operations officer Sharon Battle quickly and calmly placed calls to the White House, the FBI, the CIA.

"We'd like to give you a briefing," she told each of them. "USAir Flight 427, a Boeing 737, O'Hare to Pittsburgh at 6,000 feet. Radio and radar contact lost. Unknown fatalities or survivors at this time. Unknown if any ground injuries."

Then she called the accident investigators from the FAA and the NTSB. She found Tom Haueter at his house in Great Falls, Va., just as he sat down with a bowl of popcorn to watch the sci-fi movie, The

Forbidden Planet.

He wasn't supposed to be on call to head the NTSB's Go Team, but he had switched with another investigator who

wanted the week off. It would be Haueter's job to figure out what happened to Flight 427.

Within minutes he had two phone lines going, discussing arrangements with the FAA and his colleagues at the NTSB.

"We've got a bad one," he told his boss Ron Schleede. "USAir just lost a 737. It went off the radar near Pittsburgh."

Haueter's first priority wasn't to solve the mystery, it was to mobilize his team to leave for Pittsburgh. He had to arrange for an FAA plane and find a hotel to be the NTSB's command center.

After he picked a Holiday Inn near Hopewell, he had to worry about trivial details like coffee. In the penny-pinching world of government work, NTSB rules were crystal clear on coffee: The agency would not pay for it. Hotels often provided big buffet tables of regular and decaf without getting approval, then included the coffee on the bill.

Haueter told a Holiday Inn employee, "We don't want to see the big coffee bar set up."

* * *

An hour after the crash, a USAir manager named Ralph Miller arrived at the company's headquarters beside Washington National Airport and made his way to the conference room that was about to be converted into the "Next of Kin Room."

Miller watched as technicians hooked up 25 telephones and the computer he would use for the laborious process of figuring out who was killed on Flight 427.

Everything in the conference room was battleship gray -- the walls, the table, the chairs. The color fit the mood. The 25 USAir managers assembled here would take calls from frantic relatives and then, once the list was complete, call back and deliver the horrible news.

Calls were pouring into USAir's reservation centers from friends and relatives desperate to find out if their loved ones were on the plane. They were screaming, crying and shouting for information. The USAir agents could say if other flights had landed safely, but they were not allowed to say a word about Flight 427. If a caller asked about a passenger on that flight, the agents could only promise to call back.

This was USAir's fifth crash since 1989, but the company still was woefully ill-prepared for handling grieving relatives. Someone had drafted a crash plan a few weeks earlier, but it was sitting on an executive's desk, waiting to be approved.

Many of the 25 managers in the room had worked on the airline's Charlotte crash two months earlier. They took frequent breaks, walking through the empty hallways of the eighth floor, shaking their heads in bewilderment.

Two crashes in two months. Why us? What have we done to deserve this?

Determining who is on a plane is surprisingly difficult. People make reservations but don't show up. Names get misspelled. First and last names are transposed. Long names are cut off by the limits of reservation computers. Babies don't need a ticket and may not show up on any list.

Miller hooked up a conference call with USAir employees in Pittsburgh and Chicago and went through the names one by one, comparing reservations with the tickets that had been collected at Gate F6 in Chicago. It was slow going.

Of the 126 passengers on the list, there was confusion about five or six. A 2-year-old girl sitting with her mother did not have a ticket. Several Department of Energy employees had been booked on later flights but used their tickets to take Flight 427. The reservation and ticket totals didn't match.

After two hours, the list still wasn't complete. As they discussed the last few names, Miller worried: Would he miss somebody? Would he put someone on the list who had not boarded the plane? He could not afford a single mistake.

* * *

Brett Van Bortel was on his knees laying the final piece of floor tile when the phone rang.

He and Joan were not do-it-yourselfers when they bought the three-bedroom

fixer-upper in the Chicago suburb of Lisle, but they had gotten better with each room they renovated.

Married for a year and a half, they had suburban dreams. Both had ambitious career plans and wanted to start a family soon. They lay in bed and talked about what the kids might look like.

The phone call was from Joan's secretary.

"There's been a plane crash," she said in a worried tone. "I think Joan was on it."

Brett flipped on CNN. The first words out of the television were "...no survivors."

"Well, we had initial reports of 123 people aboard, possibly 130 if that's counting a crew of seven," said CNN anchor Linden Soles.

Brett called the number that CNN listed for USAir, but he kept getting busy signals. When he finally got through, the airline employees were clueless. He told them his wife might have been on the plane. USAir promised to call back.

He tried anyone else who might know Joan's travel plans. He left a message for the co-worker she was supposed to meet in Pittsburgh. He called her credit card company, but they were no help. He called Joan's hotel, but the operator kept saying she had not checked in.

He kept trying to convince himself that Joan wasn't on the plane. There were dozens of flights to Pittsburgh. What were the odds that she was on the one that crashed? But as the night wore on with no word from her, reality set in. He began to cry.

When the guy Joan was supposed to meet finally called, Brett's friend Craig Wheatley answered the phone. The man said Joan's flight was listed 15 minutes late, then it was deleted from the airport TV monitors. When the man went to the front desk, someone told him the plane had crashed.

Craig hung up and, crying, came into the hallway to tell Brett.

All he needed to say was, "I'm sorry, man."

Brett felt like he was melting, like his shoulders were falling off his body. He stood there, stunned, tears streaming down his face.

He kept frantically calling USAir, but the airline's employees were no help.

"Goddammit! My wife is dead! And you can't tell me anything!"

"Hold on please," the USAir employee said.

He came back a few seconds later and said, "We don't have anything at this time. We'll try and let you know as soon as possible."

* * *

Ralph Miller had confirmed the names of many of the passengers less than two hours after the crash, but their relatives still weren't told: USAir President Seth Schofield had ordered that no families be notified until the list was complete.

About 10:30 p.m., 31/2 hours after the crash, Miller finally had every name. But Schofield personally wanted to approve the list before the calls began, and he was on a charter flight to Pittsburgh and unreachable.

None of the sullen-faced executives in the conference room wanted to override their boss. So they continued to field angry calls, under orders not to say what they knew.

The apprehension in the room had given way to gloom. The managers watched updates on CNN and gazed up at posters on the walls that listed the passengers' names. In previous crashes, there was a line beneath each name for their status -- where they were hospitalized, whether they were critical or stable. But the status lines were blank for the Flight 427 passengers. All of them were dead.

Finally Schofield landed in Pittsburgh and said the calls could begin. It was midnight now, five hours after the crash.

"We're handing out a confirmed list," Miller told the group. "Throw anything else away. If you get calls, you can find out the next of kin and notify them."

In the airline industry, the count of passengers and crew on a plane is known as "souls on board." The USAir managers now had to deliver the news about the souls on Flight 427.

* * *

When Brett awoke on a couch at his parents' house the next morning, there was a moment when all seemed okay. Then everything came rushing back.

A short time later, USAir finally tracked him down.

"Mr. Van Bortel," the man from USAir said, "this is absolutely confirmed, sir. Your wife was on the plane last night." Brett thought the USAir guy sounded weird, almost excited about it.

Brett, who was 28, had gone years without crying, but now he wept uncontrollably. Friends came by the house to comfort him, bringing trays of cold cuts and baked goods. Bright flower arrangements filled every room in his parents' big house.

A woman from the airline called and said she would be Brett's "family coordinator." She wanted to know what Joan looked like, what she was wearing, her shoes, her jewelry. Brett told her Joan's one-of-a-kind engagement ring might provide the best clue.

Brett felt the walls closing in, so he went for a run in the nature preserve across the road where he and Joan often hiked and played touch football with friends. He ran a 5-mile loop, cut through the woods, then sprinted up a hill. Up and back, up and back he ran, trying to make sense of it all.

That night, he asked his uncle, an airline pilot, whether the government would be able to find the cause. "The NTSB is the best in the world at what they do," his uncle said. "If it's possible to find out what happened, they'll find out."

* * *

As Tom Haueter was driven up the hill from Green Garden Road in a Jeep Cherokee, he scanned the woods for wreckage. He couldn't see any sign of the plane.

It was 7:30 a.m., 12 hours after the crash. The sunny weather from the previous day had given way to a thick gray fog. An eerie mist rose from the asphalt road.

Haueter got out and trudged through the woods with several investigators from the NTSB and the FAA.

Finally he saw his first hint of the crash -- insulation from the plane hanging high in the trees. Then he came to clothes and seat cushions scattered about.

As he stepped into the woods he saw a leg bone on the ground. The air was thick with the familiar odors of a plane crash -- the light scent of jet fuel, the acrid stench of burned plastic and the oddly sweet smell of burned flesh.

Haueter stepped around a wing panel and glanced up. A dismembered arm hung from a branch, a wedding ring on one of the fingers.

"Take a look," he told the group, "but don't move anything."

Nobody spoke as they absorbed the horror.

There were sections from the tail, cockpit and wings, but much of the plane had smashed into pieces no larger than graham crackers.

An odd assortment of items survived with no damage. There were thousands of BusinessWeeks with "THE GLOBAL INVESTOR" on the cover, and suitcases that looked as if the passengers of Flight 427 had set them down in the forest and walked away.

Surely this couldn't be everything from a 50-ton jetliner.

"Where's the airplane?" somebody asked.

"It's here," said NTSB engine expert Jerome Frechette. "It's all around us."

* * *

Haueter's next stop was a USAir conference room about 15 miles away, for the first meeting of his investigators. He preferred a more neutral setting like the Holiday Inn, but the rooms wouldn't be ready until later that afternoon.

Many investigators in the conference room wore jeans and work boots, but Haueter had come in slacks, a dress shirt and a tie to establish that he was in charge. He was 42 and had worked for the NTSB for 10 years, but with his young looks and friendly Midwestern demeanor ("Holy mackerel!" he liked to say), many people didn't realize he was a chief investigator. That was a sore point with Haueter, who felt he always had to prove himself.

Couldn't you be a nice guy and be a leader?

Haueter's first task was to get his team organized. Packed into the conference room near the Pittsburgh airport were more than 100 people who would be part of his investigation -- the crash experts from the NTSB, plus specialists from Boeing, USAir, the Air Line Pilots Association, the machinists union and the FAA.

They called it the "party system." The NTSB was such a small agency that it could not afford to have staff experts in every aspect of aviation. So it enlisted help from the "parties" that were affected by the accident. USAir mechanics would help identify wreckage. Boeing engineers would test the broken parts. Pilots would listen to the cockpit voice recorder.

But the party system was no party. Each group had a huge stake in the outcome of the investigation, and they fought to protect their interests. If Boeing's plane were blamed for the crash, the company stood to lose millions in sales. USAir – already reeling from the previous crashes – could be doomed if the public thought its pilots were at fault. The pilots union didn't have a financial stake, but it always fought hard to protect the reputations of its own.

It was a strange system. The detectives would include the people who flew the plane, owned it, built it and maintained it.

Critics said the approach gave parties too much influence. It was like a homicide investigation where the killer is invited to work side by side with police, given access to all the evidence, even encouraged to suggest who the real killer might be.

Haueter liked it.

Yes, it was loud and messy, but he believed it helped the NTSB uncover the truth. After hearing the arguments from all parties, the fiercely independent NTSB could issue an objective ruling on why the plane crashed.

Haueter introduced himself and explained the rules. The party representatives would be full-fledged investigators with access to the same information as the safety board. But they could not talk to the press and they had to be careful what they said in public.

"I don't want to hear from Mary, the waitress at Bob's Bar, what the NTSB thinks the cause is," Haueter told them.

At a meeting later that day, Haueter relished the opportunity to show the parties who was in charge.

As he went around the room asking everyone their role in the investigation, USAir Vice President Bruce Aubin said he was "observing."

"Please leave," Haueter told him.

"I'm not going," Aubin said.

"Yes, you are," Haueter said.

"Our company rules require that a senior . . ."

"No," Haueter interrupted. "Your company rules are in conflict with my rules. Please leave right now."

* * *

The jet that crashed outside Pittsburgh was a Boeing 737-300, a model nicknamed the "Quichewagon."

It's called that because it has computers that let the plane practically fly itself. Pilots who rely on the high-tech devices are less macho. They are "quiche-eaters."

The stubby two-engine plane has all the sex appeal of a four-door sedan. Other jets have mean-sounding nicknames like Mad Dog, Mega-Dog and Yard Dart, but the 737 names are wimpy: Fat Albert, Guppy, Fat Little Ugly Fellow, or FLUF.

It is dull but efficient, the world's most widely used airliner. As you read this, more than 700 are in the air. The plane accounts for 40 percent of the flights from Tampa International Airport, far more than any other plane.

The question facing Haueter was whether the Fat Little Ugly Fellow had a hidden flaw, a gremlin that had gone undetected since the first 737s began flying 30 years earlier. If there was a flaw, it would be like Russian roulette: Countless 737s could fly without a problem, but some day, another one would go down.

A lot was riding on the investigation: the safety of passengers boarding 737s every day; the fate of the airplane itself; the fortunes of USAir and Boeing; and the reputation of the NTSB.

Most crashes are solved within a few weeks, but this one would defy explanation. It would become one of the greatest mysteries in the history of aviation.

Haueter's detective work would require a combination of amazing science and luck. His team would explore everything from whether a hydraulic gadget failed to whether a terrorist blew up the plane to whether it crashed because a fat passenger stepped through the floor.

Finding the truth would be especially difficult because of the raw politics that intruded on the investigation. Boeing, in particular, would play hardball to keep the government from blaming its airplane.

It took 28 seconds for the plane to flip out of the sky and crash into the hill in Hopewell. It would take more than four years for the NTSB to decide if it could explain why.

* * *

The plane's black boxes – the voice and flight recorders that really are bright orange – were found a few hours after the crash and flown to Washington.

Technicians in the NTSB lab pried open the battered flight data recorder, transferred the data into a computer and zapped it back to the Holiday Inn in Pittsburgh within a few hours. The first person to see it was John Clark, a silver-haired NTSB engineer. He sat on the floor, studying the numbers on his laptop computer.

The newest recorders take more than 100 measurements of a flight, but the box in the USAir plane took only 11 basic measurements, giving only a rough picture of what happened to Flight 427. Still, the box gave Clark an important clue. The numbers for compass heading showed that at 6,000 feet above Hopewell, the nose of the 737 had abruptly moved left, like a car starting to skid sideways on wet pavement.

Many things can make a plane do that, but one was most likely: a sudden move by the rudder.

"There is something going on here with the yaw," Clark told Haueter. "It looks like this airplane had some type of rudder event."

It was an encouraging lead. But NTSB investigators have an old saying: Never believe anything you hear in the first 48 hours. The first few theories about a crash – the causes du jour – typically don't pan out.

Back in Washington, the voice recorder team was meeting in one of the safety board's listening rooms, replaying the final words of pilots Emmett and Germano. The rooms have thick walls and insulated ceilings so screams and dying words won't be overheard by people passing in the hallway.

The tape from the USAir plane made one thing clear: The pilots never understood what was going wrong.

The engineers played the recording over and over. And over and over came Germano's dying words: "What the hell is this?"

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 the problems of the 737.

Part Two: The soda can


Additional Information

National Transportation Safety Board USAir Flight 427 Accident Investigation Docket Web site

The following documents are in the Adobe Portable Document Format (PDF) and require the free Acrobat Reader 3.0 or later from Adobe for viewing.


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