The Mystery of Flight 427

by Bill Adair

  So Boeing had a lot at stake in the Flight 427 investigation. There now had been two mysterious 737 crashes with similar circumstances. Boeing had to reassure its jittery customers that its plane did not have a fatal flaw.

  Some airlines were so nervous about the crash that they instantly reacted to every theory that came up. When the NTSB raised the possibility that one of the plane’s thrust reversers had suddenly deployed in flight, a few carriers immediately called and said they wanted to disconnect them. Boeing officials sent telex messages to the airlines nearly every day for the first two weeks, telling them in one message, “We would like to stress that, contrary to some media reports, at this point the NTSB has not concluded there was a partial in-flight thrust reverser deployment. Boeing has no recommended operator action at this time. If the investigation shows any specific actions are recommended or required, operators will be notified.”

  Boeing had a special team to deal with crashes—Air Safety Investigations, which was a select group of engineers run by a shrewd manager named John Purvis. The team’s mission was to help the NTSB and determine whether Boeing needed to fix any problems with the plane. For Flight 427, Purvis’s office was overseeing an unprecedented effort involving more than a hundred Boeing employees. Engineers who designed flight controls were studying the 737 rudder system for possible flaws. Aerodynamic experts were studying the numbers from the flight data recorder, trying to estimate when and how far the rudder had moved. The company’s structures experts were helping the NTSB make sense of the wreckage.

  The crash was so important to Boeing that the chief engineer for the 737, Jean McGrew, had been appointed to work with Purvis and oversee the company’s response. McGrew said his mission for Flight 427 was simple: to help the safety board find the cause of the crash, and—if the 737 was to blame—fix it. It bothered him that some people thought Boeing might be trying to cover up flaws in the plane to save money. McGrew said he was open to any theory, even if it meant Boeing might be at fault.

  From his boyhood in Missoula, Montana, McGrew seemed destined to be an aviation engineer. He delivered the Missoulian newspaper and used his profits to buy model airplanes. He loved the challenge of designing and building something that could actually fly. He started his career with the Douglas Aircraft Company as a young expert on flutter, the potentially catastrophic condition that can make an aircraft shake so violently it breaks apart. He liked flutter because it was complicated. Some engineers preferred a single, more simple discipline, but McGrew chose flutter because it involved virtually every aspect of aerospace engineering—structural mechanics, stress analysis, design, and aerodynamics. The more complicated, the better.

  He was an early computer expert who introduced Douglas engineers to the power of the PC. He rented an Apple II and holed up in a Manhattan hotel room, crunching numbers to prove that their new MD-80 jet could safely land on LaGuardia Airport’s runway pier. He also was one of the first guys at the company to have a computerized Rolodex.

  In 1989 he retired from McDonnell Douglas and jumped to Boeing, which was the aerospace equivalent of switching from Pepsi to Coke. He became the chief engineer for the 737, which meant he was the plane’s godfather, responsible for any design changes.

  He was so smart that his mind seemed to leap ahead during meetings, solving problems that weren’t even on the agenda. His mind was like a mainframe. He studied a problem, processed the data, and reached a conclusion. One of his kids once gave him a gold Slinky on a plaque that said, RELAX, a reminder that he often got wrapped up in his job, but he rarely had time to play with it.

  McGrew had a wry sense of humor and a love of tennis, boating, and spicy food. He solved problems with a cool, analytical approach and calculated everything to close tolerances. He knew precisely how long it took to get to the airport and always cut it close so he wouldn’t be sitting at the gate wasting time. He fit well into the Boeing engineer-dominated culture. He looked the part—a thin fifty-six-year-old man with wire-frame glasses and a pocket protector that he kept hidden inside his shirt pocket, as if he were slightly embarrassed about it. He loved computers, but he was not the kind of guy who would surf the Web or play games. To McGrew, computers were tools, not toys.

  His decision about wearing a pocket protector was calculated with the same logic he used for everything else. He wanted pens and pencils within reach, but he didn’t want stains on his dress shirts. Never mind if the pocket protector looked nerdy. Data in, data out. A decision was made, his pockets were protected.

  Boeing and USAir kept elaborate records on everything that was done to every plane, and Ship 513 was no exception. There was paperwork virtually every time a mechanic touched it, even for the routine transit check the night before the accident. The papers said the mechanics at the Windsor Locks, Connecticut, airport had examined the engines, checked the brakes and tires, switched on the exterior lights, and checked the galleys and lavatories.

  The NTSB examined the maintenance records and found that 513 had suffered the usual ailments and hiccups of a seven-year-old plane—a blown tire, a fuel line problem, tiny cracks in a floor beam, a few spots of corrosion—but nothing extraordinary. Investigators scoured maintenance records and found a few “carryover” items, minor problems that did not need to be fixed right away. The engine thrust reversers were showing some wear. And the cabin floor was soft and spongy at Row 5 and was fixed with a temporary patch.

  A year before the crash, the plane had undergone the rigorous USAir “Q check,” a three-week exam in which mechanics inspected every beam and panel. The plane had gotten the requisite minor checkups since then, and it complied with the latest safety requirements from the FAA. Ship 513 seemed to be in great shape.

  Cox checked his records and found he had actually flown it several times, but not in the last several months. Each 737 had its own quirks. They felt different to pilots because of their age, their individual equipment, or because they occasionally got banged by a passenger walkway. Some were cranky and had a rougher ride than others. But 513 was known for a smooth and steady ride. When Cox spoke with a colleague who had flown it recently, the pilot said he was sorry 513 was gone.

  “It was a good one,” he said.

  When the systems group arrived at the Parker Hannifin plant in Irvine, Cox, the ALPA representative in the group, could feel tension in the air. To the Parker employees, this was like a visit from an IRS auditor. The NTSB group was there to see if the rudder power control unit—Parker’s bread and butter—had caused a crash that killed 132 people. Employees were jittery.

  With the help of Parker technicians, the NTSB team pulled the silver-colored unit out of the crate and methodically took it apart, piece by piece, examining each one under a bright light. They checked one of the filters and found nothing out of the ordinary. A group member acted as the scribe to document the tests. He wrote, “No large particles.”

  They checked the O-ring seals on the filters. The scribe wrote, “No deficiencies.” They opened one end of the power unit and peered inside with a borescope. “No evidence of impact marks or abnormal wear marks.” They opened another cover plate and peered inside at the fluid.

  It twinkled.

  Cox could see tiny pieces of metal in the fluid, glittering in the lights. “Is this normal?” he asked another team member. The guy shrugged.

  The question circulated through the group. Was it supposed to twinkle? Wasn’t hydraulic fluid supposed to be cleaner? Finally, someone from Parker piped up. The area was downstream of the metal parts, and it wasn’t unusual to get tiny particles there. Still, no one knew how much twinkle was too much. They looked inside with a microscope and videotaped the tiny particles. Then they drained the fluid with a syringe and sent it to be tested.

  The next day, they hooked the power control unit to a test bench that looked like a refrigerator turned on its side with dials and switches on the back. The bench acted like a hydraulic pump on an airplane, providing pressure to the unit. Some membe
rs of Phillips’s team believed the test could bring their first breakthrough. The valve-within-a-valve might be jammed, which would make its piston go hard to one side once hydraulic pressure was turned up. That would explain the crash.

  Expectations for the test were so high that Phillips had invited Carl Vogt, the chairman of the safety board, to watch. Vogt and everyone in the systems group stood around, intently watching the piston. A technician drained the last of the fluid from the unit and collected it in a clean container so they could send it to Monsanto, the manufacturer. They installed a special cover on the unit so they could watch how the valve and the levers inside reacted. They would be able to see if it went haywire.

  A technician flipped a switch and started the purple hydraulic fluid flowing at 360 pounds per square inch, about one-tenth the normal pressure. The bench vibrated with a steady hum of the pump. No one spoke. Everyone was listening for a hiss or gurgle or belch or some other strange sound that the valve might have made before it threw 132 people to a horrible death. It seemed as though everyone in the room was holding his breath, waiting for the big moment. Everyone craned to see the valve, watching for a jam or a sudden movement.

  Nothing.

  The piston just sat there. The valve didn’t budge. They might just as well be staring at a rock garden.

  A technician moved a lever to simulate the pilots’ stepping on the rudder pedals, and the slides inside the valve went back and forth smoothly. The scribe wrote, “Servo valve acted normally.” They turned up the pressure to a full 3,000 pounds per square inch, the normal pressure on a 737.

  Still nothing.

  A technician stood beside the power unit and pushed and pulled the lever harder and harder. He tried to get it to reverse, slamming it as hard as possible. “No piston reversal,” the scribe wrote. The technician tried slamming it to the left. “No piston reversal.” Then the group tested the yaw damper, an electrical device that made tiny adjustments to the rudder. “Passed. Passed. Passed. Passed. Passed. Passed. Passed. Passed. Passed.”

  The technicians removed the unique valve-within-a-valve and put it through a battery of tests. They probed it, flushed it, shined a light through it.

  “Passed. Passed. Passed. No abnormalities found. No abnormalities. No anomalies. No anomalies. Normal wear pattern. No anomalies.”

  The power control unit was fine. The scribe ended the notes with a summary:

  “The unit is capable of performing its intended functions as specified by Boeing…. Testing validated that the unit was incapable of uncommanded rudder reversal.”

  Phillips signed his name at the bottom of the page.

  10. “WANNA PIECE OF THE PLANE?”

  On a clear autumn day, Joan’s friends and family came to the Saint Michael Catholic Church in Wheaton, Illinois. They lined up to sign the guest book beneath a photograph of Joan in her wedding dress. At the altar was another Joan photo, surrounded by candles and hundreds of flowers—carnations, dark red roses, and baby’s breath. There was no casket. It was eight days after the crash and Joan’s remains had not been identified.

  Brett hugged people as they arrived. A few days earlier, he was worrying about mundane things like floor tile and getting to work on time. Now he had to deliver a eulogy for the woman he loved.

  The priest who had counseled Brett and Joan before their marriage thanked everyone for coming and said that their presence in the church was a testament to the richness of Joan’s life. “Death is not something to be explained,” he said. “It is quite beyond our understanding.”

  Friends and relatives walked up for Holy Communion, knelt at the altar, and solemnly dipped pieces of bread into the wine. When Communion was over, Brett stood up and slowly walked to the podium, brushing his short auburn hair back from his forehead.

  “When this occurred,” he said tentatively, “it left me with a terrible, empty feeling inside. Going to Pittsburgh put this in perspective. There were one hundred thirty-two victims on that plane. Imagine all of us here tonight, multiplied by one hundred thirty-two, and you begin to get some scope of this plane crash. I would just like to offer my blessings for all of them as well, and all of the other people that are suffering through the same things.”

  He got a faint smile as he described Joan.

  “Many times my friends and I would be sitting around the house watching a football game and Joan would be with us. She actually would watch the games. I’d say, ‘Oh, no! Face mask!’ and she’d say, ‘Oh, no, that’s encroachment.’ She knew more about it than anybody I know. I always enjoyed going to work functions and parties with her. There would be an occasion or two where she would get up and speak. It was just remarkable to see the transformation from the woman I know that always played to my needs, to see her take on an executive’s demeanor almost instantly, standing up and delivering a nice speech.”

  Brett said he had always been skeptical about religion and had never gone to church regularly, but he had been praying and watching for a sign from God that Joan had gone to heaven. He said he had received two since she died.

  “I know I will get through this, as we all will, with difficulty and great pain,” he said. “There’s not much more I can say other than I loved her more than anything else in this world…. She’s gone forever.”

  He paused. “I would just like to end with an Irish proverb that we both enjoyed:

  May the road rise up to meet you

  May the wind be always at your back

  May the sun shine warm upon your face

  May the rains fall softly on your fields

  And until we meet again, may God hold you in the palm of His hand.

  Three weeks after the crash, the Beaver County coroner still had not identified Joan’s remains. Don Moore, a USAir pilot working in the morgue, had talked with Brett several times and sent him photographs of engagement rings found on several hands, but Joan’s ring was not among them. Brett was in Melrose, Iowa, for another memorial service in honor of Joan when Moore called again. Brett was getting annoyed.

  “Look,” he told Moore, “it’s got two triangular-shaped diamonds, two oval-shaped ones, and a marquise in the center. It’s very unique.” Moore promised to call back.

  The phone rang again a few minutes later.

  “Did she have a very thin, simple gold band for a wedding ring?” Moore asked.

  “Yes.”

  “Mr. Van Bortel, we’ve identified your wife.”

  Joan’s belongings arrived a few days later in a zippered white pouch that said, “Joan Van Bortel, aka Lahart, Gilbert Funeral Home.” Inside were her checkbook, a phone bill, and some shattered credit cards. Her wedding and engagement rings were also included, although the engagement ring was missing a diamond. Brett hoped he could find the diamond at the crash site.

  He had grown increasingly annoyed with USAir. The airline seemed to be backing away from its promises to pay some of his expenses. His family coordinator from the airline would not tell him who was sitting beside Joan. He knew she was in Seat 14E, but he wanted to know who was beside her when she died.

  A week later, Brett drove to Hopewell Township to look for the missing diamond and to bury a gold brooch on the hill. The NTSB had finished its work there, and the Hopewell police were allowing family members to visit as long as they had an escort. Brett had arranged for Major Robert Pfeiffer of the Salvation Army to accompany him. He had met Pfeiffer when he visited Pittsburgh the weekend after Joan was killed. The night of the crash Pfeiffer had arrived on the hill very quickly, when the wreckage was still smoldering.

  On this day they met in the parking lot at Green Garden Plaza and then proceeded up a driveway that led to the crash site. As they walked through the woods, Brett asked how it had looked immediately after the crash. Pfeiffer described the scene and the odd way some things were not damaged, such as an intact briefcase that was near others that had been shredded. As they walked through the trees toward the road, a boy came up to them.

  “Hey, mis
ter!” the boy said to Brett. “Wanna piece of the plane?” The boy was carrying slivers of aluminum.

  “Goddamn NTSB,” Brett muttered under his breath. Didn’t they collect everything? How could they leave evidence behind? The wreckage was supposed to be safely inside a hangar somewhere. How could they solve the mystery if they didn’t have all the puzzle pieces?

  Brett stood there for a minute, trying to make sense of it all and then finally said sure, he’d take a piece. He looked around and found lots more. One was the size of his forearm. He walked down the road to the area where the nose had hit and knelt in the dirt. He was saying a quiet prayer when a woman tapped him on the shoulder.

  “Your wife was on the flight?” the woman asked.

  “Her name was Joan,” said Brett.

  The woman started crying. “My husband was…”

  They hugged. The woman said she was Tina Connolly and that her husband was Robert Connolly, a financial consultant who was returning from a business meeting in Chicago. Brett explained that he had been trying to find out who sat beside Joan. Tina said she had been trying to find out the same thing—who had been sitting with her husband.

  “Do you know where Joan sat?” she asked.

  “Sure. Fourteen-E.”

  Her eyes widened and her chin quivered. She called to the man with her, who was her brother-in-law, and asked, “Do you remember where Bob sat?”

  He shouted back, “Fourteen-F.”

  It took Brett a second to realize what that meant.

  They stood there, staring at each other in amazement. Brett handed her a card about the scholarship fund he had set up in Joan’s honor. The card had Joan’s photograph on it. “Do you have a photo of your husband?” he asked.