The Mystery of Flight 427

by Bill Adair

  The Mystery of Flight 427

  Bill Adair

  The immediate human toll of the 1994 Flight 427 disaster was staggering: all 132 people aboard died on a Pennsylvania hillside. The subsequent investigation was a maze of politics, bizarre theories, and shrouded answers. Bill Adair, an award-winning journalist, was granted special access to the five-year inquiry by the National Transportation Safety Board (NTSB) while its investigators tried to determine if the world’s most widely used commercial jet, the Boeing 737, was really safe. Their findings have had wide-ranging effects on the airline industry, pilots, and even passengers. Adair takes readers behind the scenes to show who makes decisions about airline safety—and why.

  Bill Adair

  THE MYSTERY OF FLIGHT 427

  Inside a Crash Investigation

  For Katherine

  The important thing to understand about the rudder pedals is that they are unnecessary; like your wisdom teeth, they serve no very good purpose but can cause much trouble.

  Wolfgang Langewiesche, 1944

  ACKNOWLEDGMENTS

  Tom Haueter, John Cox, and Brett Van Bortel made this book possible because of their candor. For six years, they shared their private thoughts about the investigation and how the crash had changed their lives. They endured my frequent visits, telephone calls, and repetitive questions. I thank them for their patience and their willingness to open their lives to thousands of readers. I also appreciate the help I received from Trisha Dedik and Jean Cox, who discussed how the investigation affected their husbands.

  I am grateful for the cooperation of the chairman of the NTSB, Jim Hall, and the managing director, Peter Goelz. The agency’s public affairs office initially rejected my proposal for a behind-the-scenes look at the investigation, but Hall and Goelz agreed because they believed they had a positive story to tell. They granted me special access to the investigators on the condition that I not publish anything until the report was complete. I also want to thank the NTSB public affairs staff, past and present, including Mike Benson, Pat Cariseo, Ted Lopatkiewicz, and Alan Pollock.

  I appreciate the openness of people at Boeing. The company had never cooperated with a project like mine, but several key officials realized it was in Boeing’s interest—and the interest of passengers who fly its planes—to tell its side. I appreciate the support of Bill Curry, Liz Verdier, Russ Young, Sue Bradley, John Dern, and Steve Thieme. Boeing’s historian, Tom Lubbesmeyer, shared the company’s memos and marketing materials from the 1960s, which provided tremendous insight into the decision-making process when the 737 was designed. The Boeing engineers and pilots involved in the investigation—Jean McGrew, John Purvis, Rick Howes, Mike Hewett, Mike Carriker, and Jim Draxler—were honest about their feelings and frustrations about the NTSB. Because of their candor, I was able to write a more balanced book that reveals the tensions and disagreements of the investigation.

  I am thankful for the assistance from people at USAir and the Federal Aviation Administration. At USAir: Rick Weintraub, Deborah Thompson, Dave Supplee, George Snyder, and Ralph Miller. At the FAA: Vikki Anderson, Dave Thomas, Drucella Andersen, Bud Donner, Ed Kittel, Eliot Brenner, Diane Spitaliere, Paul Turk, Bob Hawk, and Ned Preston.

  Thanks also to Joe Formoso, Mike Demetrio, Tom Ellis, Michael Pangia, Russ Chiodo, John Kretz, Steve Okun, John Masor, Bob Flocke, and Keith Hagy.

  I am deeply grateful to my colleagues at the St. Petersburg Times who helped with my series 28 Seconds, on which this book is based, and to the Times for waiving copyright on the material first published in the series. I am indebted to Richard Bockman and Neil Brown, who helped me shape the early drafts and provided crucial advice on how to tell such a complex story. Thanks also to Paul Tash, Sara Fritz, Chris Lavin, Susan Taylor Martin, Kelly Boring Smith, Bill Serne, Tom Rawlins, David Dahl, Sherry Robinson, Kitty Bennett, and Times attorneys George Rahdert and Allison Steele. I also thank my friend Don Phillips of the Washington Post, who provided help and encouragement along the way.

  I am indebted to people who read drafts of the manuscript at various stages, including Pat Trenner, Eric Adams, Peter Wallsten, Scott Moyers, and John Donnelly. My agents, David Black and Gary Morris of the David Black Literary Agency, provided tremendous support during the ups and downs of the past six years. I am especially grateful to Mark Gatlin at the Smithsonian Institution Press for his enthusiasm and persistence about the project.

  I thank my in-laws, Frank and Otey Swoboda, for providing me a place to write. My wife, Katherine, provided many valuable suggestions about the manuscript, and she and our children, Molly, Annie, and Miles, tolerated my frequent trips and my six-day workweeks as I finished the book. We’ll have time to play with the Sega Dreamcast now, guys.

  PROLOGUE

  A BAD DREAM

  Summer 1995

  Great Falls, Virginia

  The clock on the nightstand read 2 A.M., and Tom Haueter was wide awake. He was usually a leaden sleeper, dead to the world once his head hit the pillow. But tonight 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 Boeing 737 corkscrewed out of the blue sky over Pittsburgh and dived into a hill at 300 miles per hour, but Haueter still didn’t know why it had happened.

  He had run many investigations for the National Transportation Safety Board (NTSB), and this one had started like all the rest—the peculiar smell of death mixed with jet fuel and the adrenaline rush during the first few days of examining the wreckage. But the rush he received had long since passed. Investigators usually figure out the cause a week or two after a crash, but not this time. They had eliminated one theory after another—the promising ones, the far-fetched ones, and a few that were truly bizarre—and now it seemed they were back where they had started.

  At the NTSB, solving a case was paramount. It was right there in federal law: “The board shall report the facts, conditions and circumstances relating to each accident and the probable cause thereof.” If an investigator couldn’t come up with the cause, he had failed. In the entire twenty-five-year history of the NTSB, only four cases had gone unsolved—and one of those involved a 737.

  Indeed, Haueter was accustomed to solving every case, even seemingly impossible ones like the crash in Brunswick, Georgia, that killed U.S. senator John Tower. That case was especially difficult because the evidence was so sketchy. The Embraer 120 plane did not have a flight data recorder or a cockpit voice recorder. Haueter had to rely on radar data and the pilots’ last words with air traffic controllers. But ultimately the NTSB had found a piece of wreckage, no bigger than a coin, that revealed a flaw in the propeller system.

  Many of Haueter’s colleagues at the board believed that he would never find the answer to the USAir crash. Some thought he should give up. “You’ve got nothing,” one investigator said. “It’s time to walk.”

  Maybe it was. He fantasized about quitting. He was fed up with the office politics and the childish sniping between Boeing and the pilots union. He certainly could live without his beeper, without the calls in the middle of the night, and without his job stealing his weekends. It would be good for his marriage.

  But his fantasies about quitting didn’t last long. He realized there was no way he could leave in the middle of the biggest mystery in NTSB history. His personal and professional pride was on the line. And there were lives at stake.

  Haueter’s bosses were putting immense pressure on him. One of them said that if the USAir case went unsolved, Congress would abolish the NTSB. If the bozos at the board couldn’t solve this one, Congress w
ould say, they might as well find a new line of work. That was just the kind of pressure Haueter didn’t need. He not only had to figure out whether the world’s most widely used jetliner had a fatal flaw, he also had to save his agency from extinction.

  When he complained to a friend about the pressure, NTSB chairman Jim Hall got wind of it and intercepted Haueter one day as he was walking out of the office.

  “Can you follow me down for a minute?” Hall asked.

  They walked through the lobby, past the NTSB’s Most Wanted List of safety recommendations, and entered an elevator.

  “You know, you don’t have to solve it,” Hall said.

  “Jim, I appreciate that, but yeah, we do,” Haueter replied. “Greg and I need to know what happened. We don’t want this thing hanging over us. We’ve got four unsolved accidents. The safety board can’t afford a fifth.”

  Haueter felt that he could solve it. He just needed time. But he worried about what might happen in the meantime.

  In his nightmare, another 737 had crashed, which prompted Congress to launch a massive inquiry to find out why the NTSB had bungled the case.

  Suddenly he was in a giant hearing room, facing a panel of angry congressmen. The TV cameras were zooming in on him. It seemed there were thousands of people in the room, and all of them had decided he was guilty. He was at the witness table, all alone.

  “What happened?” a congressman demanded. “Why didn’t you do something sooner? Why didn’t you ground the fleet?”

  1. A GOOD AIRPLANE

  September 8, 1994

  Lisle, Illinois

  Brett and Joan Van Bortel pulled into the parking lot shortly after sunrise, with a few minutes to spare before Joan’s 6:20 train. She was a marketing manager for Akzo Nobel, a big chemical company, and liked to get to work early, even when it meant a twelve- or fourteen-hour day. This would be one of those days. She was flying to Pittsburgh for a dinner meeting.

  Joan took a trip nearly every week and had become a seasoned business traveler. She carried the same suitcase-on-wheels that pilots and flight attendants used, and she traveled light, taking only the bare essentials for each trip. Unfortunately, the prime spots for the chemical business were not the nation’s most glamorous cities. She spent a lot of time in Akron, Ohio, the rubber capital of the world.

  Joan was an ambitious person. Her goal was to become Akzo Nobel’s highest-ranking woman. She was one of the first people to arrive in the office each morning and usually ate lunch at her desk so she could keep working. She told her employees that every call should be picked up by the third ring. She was not a chemist, but she took time to learn about the company’s products. She held training sessions to teach employees how to pronounce the chemical names and made them take written quizzes with questions like “How is rubber cured?” and “Name one of our products that has zinc in it.” When Joan stopped at a gas station, she got into long conversations with auto mechanics about the chemistry of tires.

  As she and Brett kissed good-bye, Joan looked very professional in a stylish green-and-white suit, with her briefcase in hand. She wore her engagement ring, which had a distinctive marquise diamond surrounded by other diamonds. Brett had given her lots of jewelry, but this ring was her favorite.

  She was five feet two—almost a foot shorter than Brett—with shoulder-length honey-brown hair, sparkling brown eyes, and a flawless smile. With her hair up, she resembled the actress Jessica Lange. Brett loved the way Joan was comfortable with a grunge look—big glasses, a baseball cap, and messy hair—and the way she could transform herself into a knockout. She exercised every day and was in great shape, which allowed her to indulge in an occasional bag of Skittles from the office snack machine.

  While Joan was in Pittsburgh that night, Brett planned to stay home and install a tile floor in their kitchen. He had promised her the floor would be finished before she came home the following day.

  Captain Peter Germano and First Officer Charles B. Emmett III first saw Ship 513 in Jacksonville, Florida. They had spent the previous two days flying to Indianapolis, Philadelphia, Toronto, Cleveland, Charlotte, and then down to Jacksonville, a trip that involved three different 737s. Switching planes during a trip was standard procedure for most airline pilots. Because of union work rules and government time limits, USAir pilots flew no more than eight hours per day, followed by a mandatory nine hours and fifteen minutes of rest. A typical USAir 737 was in the air for ten hours every day, however. That timing mismatch led to a complex and confusing schedule, as the airline tried to maximize productivity by switching crews on and off different aircraft throughout the day.

  Ship 513 had spent the night in Windsor Locks, Connecticut, where mechanics performed a “transit check” on the plane, inspecting the hydraulic system for leaks, examining the wheels and tires, and checking the engine oil. There were no significant maintenance problems or pilot “squawks” that needed to be fixed. On the morning of September 8, a different set of pilots had flown the plane from Windsor Locks to Syracuse, Rochester, Charlotte, and then Jacksonville. Emmett and Germano were scheduled to take the aircraft to Charlotte, Chicago, and Pittsburgh.

  Ship 513 was identical to the 220 other 737s that USAir flew. It had a shiny silver fuselage (painted planes were heavier, which meant higher fuel costs) and a pair of stripes, red and blue, running the length of the plane just below the windows. The tail was navy blue with red pinstripes and the airline’s simple logo in white letters. The company colors were also featured on the inside—the seats were navy blue with red and white decorations. The bulkhead that separated coach from first class was covered in a carpet that looked like a sunset. It was supposed to absorb sound so that people talking in coach wouldn’t bother the first-class passengers.

  The first-class section had 8 leather seats, and coach had 118 fabric-covered ones, each designed to be as thin and lightweight as possible and still comply with federal safety standards to withstand a forward force of nine times the force of gravity, or 9 Gs. It was a sharp-looking plane, a big improvement over USAir’s previous colors, frumpy 1970s earth tones that one USAir official had described as “red on brown on red on brown.”

  Ship 513 was seven years old, which made it a relatively new plane in the USAir fleet. Purchased in October 1987 for about $24 million, the plane had logged 23,800 hours—the equivalent of flying continuously for nearly three years. It had made almost 14,500 flights or “cycles”—the most critical measurement of a plane’s age. Each time an aircraft is pressurized for a flight, the airframe is subjected to stress.

  The plane was part of the 300 series, which meant it was the third generation of 737s. The first generation, the 100 series, was introduced in 1967. Boeing designed the 737–300 to be in service for at least 75,000 cycles, but many planes continued to fly long after that. The life span was economic, ending when it became too costly to maintain the planes. Airlines typically kept jets for twenty to thirty years before trading them in for new models.

  Emmett, Germano, and the flight attendants had arrived in Jacksonville about 11 P.M. on September 7 and checked in to the Omni Jacksonville Hotel, a downtown high-rise overlooking the St. John’s River. Germano ordered a turkey croissant sandwich from room service shortly before midnight and called his wife, Christine, back in Moorestown, New Jersey. He and his crew would be able to sleep late the next morning; they didn’t have to be back at the Jacksonville airport for their next trip until noon.

  Their flight to Charlotte was uneventful.

  On the next leg, to Chicago, a USAir pilot named Bill Jackson rode in the cockpit jump seat, a fold-down seat behind the pilots. It was common practice in the airline industry to allow pilots to ride for free so they could commute from their home city to their crew base. Many pilots preferred riding in the jump seat so they did not have to listen to annoying chatter from passengers.

  About thirty minutes into the flight to Chicago, Andrew McKenna Sr., a passenger in first class, heard a strange gurgling sound. He was a
seasoned traveler, the head of a major paper and packaging company, so he was accustomed to the noises inside big jets. But this was unusual, like water being forced out of a sink. It seemed to be coming from just above his head.

  McKenna summoned the flight attendant and described the noise. He flew a lot, he told her, and he had never heard anything like it. She listened for a moment and then said she thought the sound was coming from the PA speaker. McKenna wasn’t sure that she was right, but he went back to his reading. He didn’t give the sound another thought.

  The flight attendant picked up the intercom phone, called Germano in the cockpit, and reported that a passenger was hearing an unusual noise that seemed to be coming from the PA system. Germano turned to Jackson behind him in the jump seat and noticed that his knee was pressing on a microphone button. Jackson moved his knee, and the flight continued to Chicago without further complaints.

  But after the plane landed at O’Hare and parked at Gate F6, passengers were still talking about the noise. The gate was packed with people waiting to board the plane for its next trip, Flight 427 to Pittsburgh. As the arriving passengers walked off, a woman whose husband was booked on Flight 427 overheard someone discussing the noise. She decided to call USAir to make sure her husband’s plane was safe.

  The phone rang in the mechanics lounge beneath the F gates just as USAir maintenance foreman Gerald Fox walked in the door. He listened as the woman explained what she had overheard. She said she was concerned because her husband was on the Pittsburgh flight.

  “I have two good mechanics on duty,” Fox told her. “If there is a problem with the airplane, it will be taken care of before leaving.” He hung up and walked outside to look for his mechanics. After searching for a few minutes, he walked up the metal stairs to Ship 513, which was being loaded for the trip to Pittsburgh. He found Germano in the covered Jetway just outside the plane and explained the woman’s complaint about the strange noise. Germano did not mention the microphone incident from the previous flight, but he did not seem concerned.