by Bill Adair
The trimotored Fokker F-10A carrying Rockne was flying from Kansas City to Wichita when witnesses saw a wing break off. The plane crashed on a farm, killing Rockne and the seven other people on board.
Because the nation was eager to hear how Rockne had died, the Commerce Department’s Aeronautics Branch scrambled to tell what had happened. That was a dramatic change for the agency, which had always been secretive about its investigations.
Investigators initially blamed the crash on pilot error. They said the pilot had pulled out of a dive too sharply, which put too much strain on the wing. But then they found an engine with a missing propeller. They reversed themselves and said that ice had come off the plane and broken a propeller blade, causing severe vibration that snapped the wing. Five days later, the investigators changed their minds yet again when they found the missing propeller in one piece. They said the ice had “rendered inoperative certain of [the plane’s] instruments” and caused the plane to go into a steep descent. The wing snapped off as the plane came out of the dive. The embarrassing flip-flops prompted the New York Times to question in an April 9, 1931, editorial whether accident investigators could truly find the cause: “Who can tell from a mass of tangled wreckage what actually occurred?”
But eventually investigators found yet another cause: structural failure in the wings. The discovery was especially tragic because the Aeronautics Branch had known of the problem with Fokker planes before the crash and was considering grounding them.
The lessons of the Rockne investigation can be seen in the methodical, cautious approach that the NTSB uses today. The board is usually open about what it finds, describing each discovery at nightly press briefings, but investigators are careful never to speculate publicly about the cause of a crash. The probable cause is not announced until the five board members vote, about one year later.
Despite the embarrassing mistakes on the Rockne crash, accident reports from the 1930s show that investigators were becoming better at using wreckage, pilot interviews, and witness reports to determine what had happened. With no radar records to track a plane’s flight path, they often relied on witnesses from different towns to create a map of a plane’s final minutes.
Investigators of the thirties used the same basic techniques with wreckage that are used today. When they saw lots of pieces spread over a large area, they knew the plane broke apart in flight. Bent propeller blades told them the engine was operating normally when the plane hit the ground. An open drain valve in an empty gasoline tank meant the plane ran out of fuel. Metallurgists learned to distinguish between parts that broke off in flight because of vibration and those that broke on impact.
As planes got more sophisticated, so did crash investigations. X-ray machines were used to find metal fatigue. Investigators began reassembling wreckage to look for patterns in the broken metal. They even used passenger autopsies to solve cases. Flight data recorders got their start in the 1950s, providing basic information about altitude, airspeed, heading, and vertical acceleration on foil strips. If the recorders managed to survive a crash—and many did not—they could give investigators a rough idea of what had happened. Investigators began enlisting help from airlines, unions, and manufacturers to provide technical expertise, an approach that became known as the party system.
Tension has always existed between accident investigators and the agencies that regulate aviation. The Civil Aeronautics Board, which investigated crashes in the 1950s and 1960s, often got into spats with the Federal Aviation Agency (which became the Federal Aviation Administration in 1967). FAA administrator Elwood R. Quesada frequently angered the investigators by showing up at crash sites and spouting theories about what caused the accident. His behavior violated the post-Rockne rules about not speculating in public. The CAB frequently criticized the FAA for lapses in safety, but FAA officials saw that as a self-serving effort by the watchdog to get more money from Congress.
The NTSB was created in 1966 to consolidate the government’s safety offices. It investigates all types of transportation accidents—aviation, railroad, highway, marine, and pipeline. The 1966 law says the board should find the “cause or probable cause of major transportation accidents and disasters.” That phrase, which dates back to the 1930s, when the Commerce Department was conducting investigations, gives the NTSB some important wiggle room. It is probable cause because Congress believed there would be times when no one would know the absolute truth about why a plane crashed.
In a city of bureaucratic elephants, the NTSB is a mouse. It has only 450 employees and has to mooch off other government agencies in virtually every investigation. It calls the navy when it needs divers, the FBI when it needs bomb experts, and the Armed Forces Institute of Pathology (AFIP) when it needs a coroner.
The NTSB is governed by five political appointees who serve five-year terms. They act as judge and jury after a crash. Investigators such as Haueter are the prosecutors who must convince the board that there is sufficient evidence for the probable cause. But the board often modifies or even rejects the staff recommendation.
The board has little official power, but it still manages to have an impact. When the board determines the cause of a crash, it sends recommendations to the FAA, the airlines, airplane manufacturers, and others. The board may ask for new pilot procedures, changes in training, modifications to an airplane, or all three. The targets of these missives often roll their eyes and sometimes refer to the NTSB as the “Not Too Smart Boys.” But the recommendations get results. More than 80 percent are enacted.
With such a tiny budget, the NTSB has to rely on the party system to get help for its investigations. The parties—airlines, airplane manufacturers, the FAA, and unions representing the pilots and mechanics—are invited to provide expertise. They work side by side with the investigators. Pilots explain sounds on the cockpit voice recorder, FAA officials explain how they tested a plane, and airline mechanics identify wreckage.
Representatives from the parties become the NTSB posse. They help at the crash site, attend the nightly meetings, and are invited to submit their ideas about the crash. The parties also benefit from being part of the team. If the NTSB discovers something wrong with an airplane, the team members from Boeing can make sure it gets fixed quickly. Likewise, if the NTSB finds that an airline has a shoddy maintenance program, the airline can correct the problem before it causes another crash.
Critics say the party system is a dangerous way to run an investigation. They say big companies such as Boeing and the airlines are more interested in protecting themselves from lawsuits and costly safety fixes than in finding the truth. The critics say the companies can overpower the NTSB and divert attention from the true cause. They liken it to a police homicide investigation. If the party system were used after a homicide, the suspected killer would be allowed to work side by side with the police. He would be given access to all the evidence and allowed to steer the detectives to other suspects. Arthur Wolk, a Philadelphia lawyer who represents families of plane crash victims, said once on Larry King Live that the NTSB protects big companies. “We all know that government is nothing more than a vehicle for special interests and Boeing is one of the biggest special interests in this country.”
Haueter liked the party system. Yes, it could be loud and ugly. Each party had its own interests at stake. The pilots union often protected its members, while Boeing defended its planes. The parties often clashed like Republicans and Democrats. But the safety board was well aware of their biases, and investigators were smart enough not to be bamboozled. Haueter felt the system provided healthy checks and balances.
Arguments were a big part of the NTSB culture. Although board members and investigators were careful not to speculate publicly about a crash, there were intense debates behind the locked glass doors at the NTSB offices in L’Enfant Plaza. Rudy Kapustin, a former investigator in charge, remembers having frequent loud arguments with colleague Bud Laynor during their daily commute home to the Maryland suburbs. They wo
uld argue nonstop during the thirty-minute drive and then exchange friendly good-byes. When they drove to work the next morning, they would pick up the argument right where they had left off. Two other safety board employees once got into such a heated argument in a conference room that they started slugging each other and had to be pulled apart. “If people watched the way we worked, they would be totally shocked,” Haueter said. “There’s yelling and screaming, but it works. All these major issues come out and they all get addressed.”
The safety board had a near-perfect record at finding the cause of a crash. After all, aviation was a black-and-white science. Engineers knew the exact speed at which a plane lifted off the runway and when it would stall and tumble to the ground. With flight data recorders and cockpit voice recorders, they could do amazing calculations to figure out why a plane crashed. In the NTSB’s thirty-year history, only four major accidents had been unsolved. But one of those—a crash in Colorado Springs in 1991—involved the same type of plane used for Flight 427.
A Boeing 737.
After surveying the horror at the scene, Haueter drove to a USAir office building about ten miles away for his first meeting with the parties and the safety board employees who were taking part in the investigation. He didn’t like the fact that the meeting was held at USAir. He wanted an impartial setting, but the hotel meeting rooms were not yet available and he needed to get started.
Representatives of the NTSB, Boeing, ALPA, USAir, the FAA, and the machinists and flight attendants unions crowded into the conference room as Haueter explained the rules and how he was organizing the investigation. The place was so packed that people sat on the floor, stood around the back of the room, and crowded in the doorway. The parties stuck together, like teams getting ready for a big game. In one clump sat ALPA, in another sat Boeing. The conference room had been stripped of any evidence that it belonged to USAir. The walls were bare.
First Haueter explained how the investigation would be organized. Groups with representatives from the parties would look into different factors that may have played a role in the crash: weather, air traffic control, and operations, which covered such areas as fueling and cargo. Other groups would study the plane—its structure, engines, maintenance records, and the systems that moved the flight controls. Additional groups would interview witnesses, listen to the cockpit voice recording, analyze the flight data recorder, and study the pilots, even reviewing the details of their lives for the few days that immediately preceded the crash to see if they showed any signs of fatigue or depression. The group would even track down what Emmett and Germano ate for dinner the night before they died.
Next Haueter went over the rules. The parties were to provide technical help. They would also be in a position to respond quickly if the investigation uncovered a safety problem that needed an immediate remedy. But they could not discuss the accident publicly or talk with the press. He warned them even to be careful what they said if they were out for dinner. “I don’t want to hear from Mary, the waitress at Bob’s Bar, what the NTSB thinks the cause is,” he said.
Haueter, who was sensitive to complaints that he looked young, was pleased that he got an opportunity to assert himself and show he was in charge at a progress meeting that night. As he went around the room asking everyone his or her role in the investigation, USAir vice president Bruce Aubin responded that 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 said. “Your company rules are in conflict with my rules. Please leave right now.”
5. THE FIRST CLUES
The morning after the crash, the two “black boxes” from Flight 427 arrived at the NTSB’s laboratories in Washington, D.C. The boxes weren’t really black, they were bright orange, but they had earned the nickname because of their mystique. They survived accidents that humans could not, allowing investigators to hear the voices of the dead.
The boxes survive partly because they are in the plane’s tail, the section of the aircraft that usually has the least damage. They also are extraordinarily strong, resembling steel toolboxes from Home Depot painted with the words FLIGHT RECORDER DO NOT OPEN. Inside are steel cocoons to protect the audiotape or computer chips. They are built to withstand an impact of 3,400 Gs and a 2,000-degree-Fahrenheit fire for thirty minutes.
The cockpit voice recorder, or CVR, runs a continuous-loop tape of the last thirty minutes before a crash. The tape from the USAir plane had four channels of sounds—one from a microphone in the cockpit ceiling, one from each of the pilots’ headsets, and one from an oxygen mask in the jump seat. The CVR tapes are tightly controlled. Transcripts are released to the public, but only investigators are allowed to hear the actual recordings. The only exceptions are the rare instances when the tapes are played in court.
The tapes are creepy, like a cross between a horror movie and the Nixon White House recordings. They allow the listeners to eavesdrop on people going through their daily routine. Pilots talk about the “cabbage patch” (the airline’s headquarters) and “putting down the girls.” (Pilots still refer to flight attendants as girls. “Putting down the girls” refers to the point during final approach when pilots ask flight attendants to be seated.) They say things in a cockpit that they would never say in front of paying customers—they talk about turbulence so rough they’re afraid passengers will start vomiting and they make wisecracks about urinating. More than three-fourths of pilots are heard whistling or singing on CVRS. (Bob Rudich, the father of cockpit tape analysis, once wrote an article titled “Beware the Whistler,” contending that the whistling was a sign of complacency.) They chat about birds, food, weather, union work rules, and football scores.
The tapes can be embarrassing to airlines, revealing amazing sloppiness in the cockpit. Pilots of a commuter plane on a training flight in Nebraska, for example, sounded like teenagers out for a joyride. “Ye bo, look at all those Softball fields. I can really groove on them,” one pilot said. “We’re just like cruisin’ along here, aren’t we? We’re just, like, toolin’.” They talked about trucks and a prank where one pilot had used a Mr. Potato Head as a hood ornament. The captain said he wanted to pull another prank, using a front-end loader to place a friend’s Jeep on top of a fuel truck. A few minutes later, they apparently tried to execute a barrel roll and crashed in a field.
The pilots on Eastern Airlines Flight 212 in 1974 made racial slurs and gabbed about politics. “Well, hell, the Democrats, I don’t know who in the hell they’re going to run,” the first officer said. “If they’re going to run Kennedy, that’s…”
“That’s suicide,” the captain said.
The political gabfest went on for thirty minutes. The pilots talked about busing, the Vietnam War, Arab investments in the United States, President Ford’s pardon of Nixon, and the implications of Chappaquiddick on the political future of Senator Edward Kennedy. They were so deep in conversation that they silenced the warning systems on the airplane, ignored standard procedures, lost track of their altitude, and crashed short of the Charlotte, North Carolina, airport.
“Hey!” said the first officer right before impact.
“Goddamn!” said the captain.
When pilots realize they are about to die, their reactions vary. Some plead with the airplane. “Up, baby,” begged the captain of an American Airlines jet as it was about to plow into a Colombian mountain. Others are resigned to their fate. “We’re dead,” said the first officer of a Southern Air Transport cargo plane just before impact. A few shout final messages to their wives and girlfriends. “Amy, I love you!” cried the pilot of an Atlantic Southeast commuter plane just before it hit the ground. Many pilots curse, although the words have changed over the years—they used to nearly always say “shit,” but now a growing number say “fuck.”
The orange CVR box from the USAir pla
ne was badly mangled, but the tape inside the steel cocoon was fine. In fact, it was one of the clearest the safety board employees had ever heard. Both Emmett and Germano had worn “hot” mikes—headsets similar to the ones astronauts wear. The mikes were so close to the pilots’ mouths that they picked up every word clearly. They even recorded the pilots’ breathing.
The room where the NTSB played tapes of pilots dying was the size of a small bedroom, with a conference table at the center and six chairs around the edge. At the end of the table were a computer and a small mixing board that allowed NTSB technicians to isolate sounds. Cockpit posters were tacked to the walls so team members could look at the switches and gauges that the pilots were using.
The job of the voice recorder team, which included representatives from the NTSB, Boeing, ALPA, the FAA, and the other parties, was to compile a transcript of the full thirty-minute tape, from the routine chatter at the beginning to the dramatic final seconds. The tape indicated that the pilots were fighting for control, but they never talked about what was happening. Germano said “Hang on” four times but never said why. Emmett cursed but said little else. The most haunting comment came just as the plane’s stall warning sounded, when Germano asked, “What the hell is this?”
Bud Laynor, the NTSB’s deputy director of aviation safety, called Haueter in Pittsburgh and told him, “This crew had no idea what happened. They never realized what was going on.”
The other orange box, the flight data recorder, takes constant measurements such as altitude, airspeed, and heading, allowing investigators to find out how the plane was behaving shortly before the crash. Primitive recorders were used on the first airplanes. The Wright brothers used one to keep track of airspeed, time, and the engine. Charles Lindbergh had one on the Spirit of St. Louis that measured altitude and time, to make sure he didn’t cheat on the world’s first nonstop flight from New York to Paris.
