by Bill Adair
Brenner was convinced. The rudder had reversed.
Phillips had a similar reaction. He was still the most cautious investigator at the safety board. Long after Haueter and others had become convinced that a reversal in the PCU had caused the crash, Phillips was reluctant to draw a conclusion. Some people at the board thought he was a little too cautious and too protective of the airlines and the manufacturers. But after trying the demonstration and seeing Boeing’s new estimates, even Phillips seemed convinced that there had been a reversal.
Once again Haueter was working late.
Since his promotion, he’d gotten a better office with a sign beside his door that said NO WHINERS, but he had not bothered to get a nameplate with his new title. He had written his name on a piece of paper and taped it over the name of his predecessor.
He still had responsibility for the USAir investigation and often worked into the night. His wife, Trisha Dedik, had grown accustomed to his calls saying he would be an hour or two late, but she could never be sure exactly when he would get home. John Purvis, the head of accident investigations for Boeing, had just called their house to look for him. Dedik told Purvis her husband was still at the office, but then Purvis had called again, still looking for him. Dedik was fed up with the Boeing guys. They called at all hours and made it sound like everything was urgent. They treated her like she was Haueter’s secretary.
Though he had called Dedik to say he was headed home, Haueter ended up working for another hour before calling again to say that this time he was really leaving. Dedik was furious. She took a book into bed and read until she heard the thunder of their garage door when he arrived home. She switched off the light and pretended to be asleep. He came into the room and kissed her on the shoulder, but she was too mad to face him.
The next morning, she told him to call Purvis in Seattle, where it was three hours earlier.
“Trisha, it is five-fifteen or five-thirty in the morning out there,” Haueter said.
“So? He doesn’t care. He is calling here at ten-thirty or eleven o’clock at night. Call him right now.”
“Trisha, I’m not going to call him.”
Some days she wished that he would leave the NTSB and find a job that was less demanding, where he didn’t have to carry a beeper and work so late. She had never understood the whole preoccupation with beepers. Her office had given her one, but she stuck it in a kitchen drawer and promptly forgot the number.
“If I had to reach you, how would I?” Haueter asked her. “I can’t beep you. You can always beep me.”
“If it’s really important,” she said, “someone will find me.”
As the fourth anniversary of the crash passed, Haueter began plotting his strategy to convince the board members to approve a final report that would say the rudder had reversed. He knew that Bob Francis would be his biggest hurdle.
Francis, a tall, balding man known for wearing identical blue oxford shirts and khaki pants every day, was a former FAA official who had become something of a national celebrity after his nightly briefings on the TWA and ValuJet crashes. He considered himself the diplomat of the safety board and said he liked to work out disagreements behind the scenes. But the investigators disliked him because he did not attend their briefings or read their reports before he spoke to the press. They believed he was weak with the FBI during the TWA probe and had become too close to Boeing.
Francis had disagreed with Haueter about several of the 737 safety recommendations over the years and had not signed off on them until Haueter agreed to soften the language. In this case, Francis was not convinced that Haueter had enough proof to blame the 737 for the crash.
“I think he’ll fight us,” Haueter said. “For some reason, Bob does not like to be controversial with industry. He just backs away. He says he is concerned with the credibility of the agency and wants to make sure that we work with people and try to get them to come along. He thinks we should do more things with gentlemen’s agreements. Unfortunately, gentlemen’s agreements don’t work.”
Stilly Francis had a history of ultimately voting with the other board members, even when he disagreed. “While on one hand he seems to favor Boeing over us,” Haueter said, “in the final analysis, he has always signed the bottom line to go with the staff.”
John Goglia, the most colorful character on the board, had decided not to vote in the Flight 427 case. A burly Bostonian, Goglia was a former USAir mechanic who had represented his union in the investigation until he was appointed to the safety board by President Clinton. He said he wanted to avoid any appearance of impropriety. “I’m controversial enough as it is,” he said.
Haueter was worried that the board might reject his report or go with a weak probable cause. If that happened, he had a secret weapon: the families.
The 1996 ValuJet crash had shown how powerful they could be with the safety board. At the final meeting on the crash, the board was minutes away from adopting a probable cause that blamed the FAA and a maintenance company when Goglia suddenly recommended blaming the airline too. The family members—many holding big photographs of the crash victims—applauded and cheered. The emotional demonstration pressured the board to adopt Goglia’s recommendation. Haueter figured he could use the USAir families the same way—if necessary.
If the board still balked, he planned to quit. He’d gotten three job offers from engineering and aviation companies recently and had turned them all down. He and Trisha didn’t want to move away from Washington, and he did not want to desert the NTSB during its toughest investigation. But the offers had shown that he was valuable, and he was willing to take a new job if the board snubbed him.
23. DELIBERATIONS
Boeing and ALPA got one last chance to take shots at each other in their final submissions to the NTSB. The submissions were like closing arguments in a criminal trial. Once they were turned in, Haueter and his bosses would largely cut off communications with the parties. The report would be written in private, and the parties would probably not see it until the final board meeting. The investigators were like cardinals meeting in the Vatican to pick a pope. No one would know the outcome until white smoke poured from the NTSB chimney.
In previous crashes, the submissions had been long, boring letters written in the language of engineers. But Flight 427 was different. The parties were targeting not the NTSB investigators, who had pretty much decided to blame the airplane, but the five board members who would vote on the case. The submissions also had a broader audience: the public and the courts. Each side wanted to reassure customers and juries of its innocence.
Haueter viewed the submissions as an important part of the contentious party system. He knew they would be filled with bias, but he felt they brought a healthy discussion and helped the NTSB sort out the facts. He was eager to see them because he had heard there were internal fights at Boeing and at ALPA.
His moles at Boeing said there were two distinct camps within the company. One wanted to lay the blame squarely on the pilots, saying there was no evidence that the plane had malfunctioned. The other camp was more cautious and wanted to admit that there was no conclusive proof either way.
He also heard of a similar fight within ALPA about whether to mention the mistake the USAir pilots had made in pulling back on the stick. One group wanted to ignore that fact to avoid conceding that the pilots made a big error. The other camp wanted to acknowledge it and then show that the pilots were doing their best, given that they had no training about rudder problems or the crossover point.
The sixty-eight-page ALPA submission had no charts or drawings, but it presented a clear, point-by-point case to show why the plane was at fault. It portrayed Emmett and Germano as helpless victims of a sudden malfunction. It said they fought to regain control but could not overcome the problems of the 737. The union’s report made a circumstantial case that the valve had jammed and reversed. It conceded that there were no marks to prove a jam but said the thermal shock test showed that some jams did n
ot leave a mark.
“The situation was perilous,” ALPA wrote. “The more the aircraft turned to the left, the stronger the first officer’s tendency to apply increased right rudder pedal pressure; the harder he pushed on the right rudder pedal, the more certain it became that the jam would not clear.”
In building its case, ALPA agreed with Brenner’s interpretation of the first officer’s grunts, saying there was a distinct correlation between the grunts and when the rudder would have reversed. But ALPA stopped short of saying the plane should be grounded. Cox and other ALPA pilots continued to say that a rudder hardover was “a low-probability event.” The union also dodged the touchy question of the pilots’ pulling back on the stick. It was mentioned only briefly in the report and was not characterized as a mistake.
The submission from USAir also blamed the plane. Relations between the airline and Boeing had been strained, especially since USAir had decided to buy a fleet of new planes from Airbus, Boeing’s archrival. In its submission, USAir complained that Boeing had not warned anyone about the risks of the crossover point: “Under any circumstances then known to the airline industry, the actions of the crew of USAir Flight 427 were reasonable and correct…. The crew had seven seconds, at most, in which to recognize, analyze and recover from a previously-unknown malfunction.”
The Boeing submission came in a glossy spiral binder and was professionally typeset with headlines and subheads. There were foldout charts of the flight data, drawings of the rudder system, and a table that compared the evidence for pilot error against the possibility of a PCU jam and reversal.
The eighty-three-page report appeared to be a compromise of the two camps within Boeing. It was not as absolute and righteous as the company had been a year earlier with the “Boeing Contribution,” the blatant lobbying attempt that had been such a flop. Whereas that document had been unwavering in its conviction that the pilots were to blame, the new report conceded that there was no proof: “In Boeing’s view, under the standards developed by the NTSB, there is insufficient evidence to reach a conclusion as to the cause of the rudder deflection.”
One section cautioned the NTSB about trying to name a probable cause when there was insufficient evidence. It said there had been a “clamor for a definite and expeditious explanation” and urged the safety board to be careful. “In order to avoid the wrong answer, it is essential that any cause identified by the Board in this accident investigation be supported by facts and evidence. Mere suspicion, inference and conjecture must not suffice.” It quoted Hall as saying that the only thing worse than not being able to solve a case would be to come up with the wrong solution.
The Boeing submission said there was no connection between 427, the Colorado Springs crash, and the harrowing incident on the Eastwind plane. According to Boeing, a new computer analysis of Colorado Springs confirmed what the company had maintained all along: A powerful wind had thrown the plane to the ground. Boeing dismissed Eastwind as a minor event caused by a rudder device that was misrigged and said there was no proof that the Eastwind valve had jammed, just as there was no proof in the USAir valve.
The Boeing report seemed to have been written largely by the engineers who wanted to blame the pilots. It said the NTSB did not have enough evidence to assign a probable cause—unless the safety board wanted to blame the pilots. In that case, there was plenty of evidence.
The report offered a strong defense of the 737 rudder system and explained why it would not have malfunctioned on Flight 427. Nearly every place that the report mentioned the possibility of a jam, it used the word “hypothetical.” (“Hypothetical scenarios exist that would provide a full rudder deflection to blowdown. However, very specific conditions are required for each hypothetical failure scenario.”) The word appeared at least nineteen times.
But when Boeing discussed pilot error, the word “hypothetical” was not used. The report said airline pilots were often startled by wake turbulence, overreacted, and stomped on the rudder. That was a fact. In Boeing’s view, pilot mistakes were not hypothetical.
To show how a pilot could keep his foot on the pedal, Boeing cited the problem of “unintended acceleration,” when a driver of an automobile mistakenly stomps on the gas pedal instead of the brake, a mistake that has destroyed front windows in many 7-Elevens.
The company offered a scenario showing how the pilots could have caused the crash: Emmett was so relaxed before the wake turbulence that he referred to the Jetstream in “a drawn-out, feigned French accent.” When the plane was jostled by the wake, Emmett pushed on the rudder pedal once or twice to level the wings. He was so startled that he did not realize that he kept pressing on the rudder. He then pulled back on the stick, which stalled the airplane and made it crash.
Boeing did not discuss the dangers of the crossover point, or the fact that the pilots had not been warned about it. But the company’s submission said that Emmett and Germano could have recovered by simply turning the wheel to the right.
The message was subtle but clear: The 132 people on the plane would be alive today if the pilots had done the right thing.
In a surprise to everyone in the investigation, the FAA chimed in with a submission a week after Boeing did. The FAA was always a party in NTSB investigations, but it rarely made a submission. Its relations with the safety board were rocky, so FAA officials were selective about when to pick fights. In most investigations, the FAA sat quietly and took its licking when criticized by the NTSB. But this time the agency adopted an unusual tactic: It told the NTSB there wasn’t enough evidence to name the probable cause.
“The FAA, upon review of the evidence, cannot conclude that a failure mode… has been identified. Any causal findings, to be legitimate, must have conclusive evidence to support findings of a hardover or reversed rudder. Such evidence has yet to be found.”
Haueter was struck by how much the FAA submission sounded like Boeing’s. In his view, the FAA was just posturing to protect itself. If the NTSB blamed the airplane and said it didn’t meet federal safety standards, everyone would want to know why the FAA hadn’t grounded the plane. He thought the FAA was trying to preempt the NTSB by saying there was insufficient evidence.
Haueter believed he had enough evidence. No, he didn’t have absolute proof that the valve had jammed. But he had an extremely strong case that it was the most likely cause. Now he had to convince the most important audience: the board members.
The report was marked “DRAFT—Confidential” when it went to board members in early February 1999. It was five hundred pages long—so big that it had to be held together with a rubber band instead of the usual binder clip. It was the longest crash report in the NTSB’s history.
The probable cause statement was succinct. It said the pilots lost control because the rudder reversed. The report was sharply critical of the 737, saying the plane was not as safe as it should be. Boeing was fixing the rudder valve to prevent a reversal, the report said, but that was “not an adequate fleet-wide remedy.” The report warned that the plane was still vulnerable to rudder malfunctions that could have “catastrophic results,” and it said there could be additional 737 rudder problems that had not been discovered.
The report said the FAA should replace the unique rudder valve with one that is “truly redundant,” which could be done by adding a second valve or splitting the 737’s single rudder panel into two.
The report was very much a group effort. Haueter and his investigators had written long sections that had been compiled and edited by an NTSB report writer. But the person with the greatest influence over it was Bernard Loeb, Haueter’s boss.
Loeb was an intense, opinionated man who had become the NTSB’s director of aviation safety midway through the investigation. He had an in-your-face style and wasn’t shy about telling people they were wrong. Peter Goelz, the safety board’s managing director, recalled that once, during an argument about Flight 427, Loeb had called him an idiot. Loeb was renowned for being a micromanager. George Black,
an NTSB board member, jokingly called Loeb and his staff “the Borg,” after the evil force on Star Trek that controls the brains of drones.
Some people at the NTSB thought that Haueter relinquished too much power to Loeb and didn’t challenge him enough. Haueter himself was frustrated that Loeb had such a heavy hand, but Haueter felt that he went as far as he could. He stood up for the ideas that mattered, but ultimately he had to respect that Loeb was his boss.
Indeed, Loeb’s aggressive style was valuable. Haueter’s “Holy Mackerels” and his friendly disposition sometimes made him seem overly tentative. Loeb became the strong advocate the investigation needed at the end, someone with status and a loud voice who could get the final report approved. Loeb’s style was in keeping with the safety board’s culture of argument. The shouting matches got all the conflicts out into the open. A weak theory—or a weak investigator—didn’t last long.
Loeb was pushing a theory that was like a three-legged stool. He thought that, individually, none of the three incidents gave the NTSB enough evidence to blame the problem on a rudder reversal but, collectively, the three provided enough proof that the rudder had jammed and reversed.
