The Mystery of Flight 427

by Bill Adair

  “Sounds adventurous,” Eidson replied. “United 585, thank you.”

  She then said to Green, “I’ll watch that airspeed gauge like it’s my mom’s last minute.”

  They were parallel to the runway, preparing to turn to their base leg and then make their final descent. “Okay, start around there now and wheels down final,” Green said.

  “Gear is down, three green,” Eidson said. “Speed brakes armed, green light, flaps are five, green light, hydraulic brake pressures are normal, final descent checklist complete.”

  As they descended toward the runway, their airspeed changed suddenly.

  “We had a ten-knot change there,” Eidson said.

  “Yeah, I know. Awful lot of power to hold that airspeed,” Green said.

  It went up ten more. “Wow,” said Eidson.

  Twenty seconds later, she said, “Oh God.”

  The plane was rolling sharply to the right.

  “Oh!”

  “Oh!!!!”

  The pilots tried to adjust the flaps, apparently trying to abort the landing and go around.

  “No!”

  “Oh my God!” Eidson screamed. “Oh my God!”

  “Oh no!”

  The plane crashed nose first into a park three miles from the airport and exploded in a fireball. All twenty-five people on board were killed. A witness said the aircraft had looked like it was on a dive-bombing mission.

  The NTSB explored dozens of theories about the engines and the plane’s rudder. Many leads went nowhere. Investigators studied sound frequencies on the cockpit tape to explore whether the engines were operating normally. But gaps in the sounds prevented them from drawing conclusions. They searched for an elderly couple who reportedly had been splattered with a bad-smelling liquid as the plane flew overhead, but the couple could not be found. As in the Hopewell crash, the flight recorder was of limited help. It had only five parameters and because the plane was in turbulence, it was difficult for NTSB engineers to determine whether the movements of the plane were caused by the weather or by its flight controls.

  Much of the evidence pointed to the rudder and the likelihood of a slow-moving swing to the right. Tests in flight simulators showed that could have caused the accident. Investigators discovered that the plane’s standby rudder actuator—a backup device that would be used only if other hydraulic systems failed—had spots where metal had scraped against metal. And in the week before the crash, pilots of the same airplane had twice experienced sudden yaws to the right, problems that were attributed to minor malfunctions in other rudder components. But tests on the power control unit were inconclusive. Many PCU parts were badly burned in the crash, which raised doubts about the validity of the tests.

  Engineers found that a jam in the soda can valve could not have created the slow turn by the rudder that would have been needed to match the flight recorder. Also, internal stops in the valve would have prevented other malfunctions from moving the rudder very far. And even if there had been a malfunction, Green and Eidson should have been able to counter the rudder easily with other controls.

  Weather experts studied satellite pictures of Colorado on the day of the crash, looking for evidence of a powerful rotor, the horizontal tornadoes that Green had mentioned before takeoff. A glider instructor said he saw a rotor hit the ground the day of the accident, blowing off tree branches and damaging car hoods. Pilots in the area had reported turbulence and downdrafts. A 737 pilot reported a “good sinker.” But another 737 pilot described it as a normal windy day in Colorado. Meteorologists said rotors usually made a loud roaring sound, but witnesses to the crash said they didn’t hear anything out of the ordinary.

  When the NTSB asked the parties to submit their ideas, Boeing and ALPA offered starkly different explanations for the crash. Boeing blamed the wind. The company said a powerful rotor struck the plane at low altitude and “did not allow sufficient height for recovery.” But the pilots union said the evidence was inconclusive, that there were strong indications of heavy winds, but the possibility of mechanical problems could not be ruled out.

  Ultimately, the safety board could not reach a conclusion. After long discussions, the board decided it did not have enough for either theory. There was strong evidence implicating the rotor, but not enough to prove that it caused the crash. There was evidence that the rudder may have malfunctioned, but that should not have been enough to flip the plane. When the NTSB published its final report on the crash, the cover carried big blue embarrassing words: UNITED AIRLINES 585—UNCONTROLLED COLLISION WITH TERRAIN FOR UNDETERMINED REASONS.

  Safety board investigators pledged to keep looking for a cause. “We’re worried,” NTSB official Ron Schleede told the Washington Post, “that we may have overlooked something.”

  The Colorado Springs crash had haunted the safety board investigators ever since. To some, it was an embarrassing admission of defeat, UNDETERMINED REASONS. Those were painful words, an acknowledgment that the NTSB wasn’t up to the job. But to others, that was the responsible approach: to lay out the evidence and admit that it wasn’t conclusive.

  Flight controls specialist Greg Phillips worked on the Colorado Springs investigation and was involved in many of the tests on the valve, but he believed there wasn’t enough evidence to blame the airplane. Still, he kept a running list of 737 rudder incidents in his file drawer. Three months before the USAir crash, he met with Boeing officials about several rudder-related incidents and questioned whether Boeing had adequately informed airlines about fixing a rudder system component. When he flew to Pittsburgh, he didn’t need to bring the charts from the Colorado Springs flight data recorder. He had them memorized.

  When the Colorado Springs and Hopewell crashes were reduced to lines on a graph, there were a few similarities. The charts for airspeed and altitude showed the same basic arches. At first glance, the flights looked like mirror images of each other, the United plane rolling right, the USAir plane rolling left. The cockpit tapes showed that both crews were caught by surprise.

  But there were major differences. The United plane was at 1,000 feet, the USAir plane at 6,000. The United plane was going much slower, using more flaps on its wings. The United plane was in windy weather, the USAir plane was in calm. Boeing discounted the similarities, saying that the company still believed the Colorado Springs crash was caused by the rotor. Jean McGrew, Boeing’s chief 737 engineer, said the only similarity between the two accidents “was that they are both 737s.”

  Al Dickinson, the lead investigator in Colorado Springs, was a friend of Haueter’s. Dickinson was smart, a good investigator. But in the years since the crash, the guys in the office had come to look at Dickinson differently. He would always have an albatross around his neck because he had investigated the big one and come up short. Haueter reassured Dickinson that his work on United 585 had formed the foundation for everything Haueter did on the USAir crash. The NTSB was much farther along because of Dickinson’s persistence, Haueter told him. But Haueter was determined that his crash would not be unsolved. He vowed that the words UNDETERMINED REASONS would not appear in his report.

  On a Saturday in January 1995, Haueter drove to his office in L’Enfant Plaza to finish some paperwork in preparation for the public hearing on the crash. The office was like a ghost town, dark and lonely on weekends. Haueter didn’t like the silence, but he could get a lot of work done with no interruptions. He worked for several hours and then put on his jacket to leave. As he walked out, he went by a conference room and noticed some posters on the walls. He stepped inside.

  The posters were tacked up on three walls of the cramped room. Each of them represented a second or half-second increment of Flight 427. The thirty-two posters showed the view that Germano would have had from the captain’s seat, coupled with Boeing’s estimates of how the wheel and rudder pedals had moved. Boeing had used footprints to show how the rudder moved, a subtle dig at ALPA that suggested the pilots moved the rudder with their feet.

  Haueter had
seen the same data hundreds of times—in charts, video animations, computer spreadsheets, and M-Cab—but this suddenly brought everything together. He walked along the wall, studying where the rudder pedals had supposedly moved. The USAir 737 had been jostled by the wake of the Delta plane and then rolled to the left. That made sense. Then one of the pilots tried to stop the roll by turning the wheel to the right. That made sense. Then the left rudder pedal went in briefly and came out. That made sense. One of the pilots probably tried to slow the plane as it was rolling back to the right. But then the left pedal went in again, almost all the way.

  That made NO sense.

  Why would a pilot keep applying left rudder when the plane already was rolling left? That would be like a driver realizing his car was veering toward a cliff and then turning the wheel to go over the cliff sooner.

  Haueter kept studying the drawings and the rudder estimates, checking when the rudder came in and when the wheel moved. It all seemed out of sync. Then a light went on in his head. What if the rudder drawings were reversed? Instead of pushing on the left pedal, maybe the pilot was pushing on the right pedal, but there was some malfunction in the power control unit that caused a reversal and made the rudder go the wrong way.

  Suddenly it all made sense. The pilot had been stomping on the right pedal, trying to stop the big plane from rolling left, but the rudder wasn’t responding. In fact, he was actually pushing the rudder the opposite way, causing the plane to roll out of control. That would match the grunts and confusion on the cockpit tape. When Germano said, “What the hell is this?” maybe he was referring to rudder pedals that were not responding the way they should.

  Haueter left the room, took the elevator downstairs, and went outside. He walked down the stairs beside the subway station and took a shortcut beneath the Department of Housing and Urban Development, a beehive-shaped building beside L’Enfant Plaza. As he crossed D Street in the brisk winter weather, he thought about what he had seen.

  He didn’t know what could have made the rudder reverse. Phillips had subjected the power control unit to every malfunction they could dream up and it had withstood every one. And there were no marks showing that the valve had jammed or reversed.

  He jaywalked across Seventh Street and walked beneath the railroad tracks, where a platoon of pigeons had found shelter from the cold January weather. He turned right on Maryland Avenue, saw the dome of the U.S. Capitol looming in front of him, and then crossed Independence Avenue to the Smithsonian Air and Space Museum. This was Haueter’s secret retreat, the place where he went to escape his worries. He occasionally sneaked over on workdays when he needed to clear his head and get inspiration from the world’s greatest collection of historical planes. He was always impressed at how much progress had occurred in such a short time, from the Wright brothers to the moon landing in one lifetime. There was still a little boy inside Haueter who marveled at the beautiful planes. Even if he couldn’t fly them, he would love to just sit in them.

  He walked in the main doors, beneath the Voyager plane that had circled the globe, and headed for the west end of the building. He walked up the stairs to the second floor beneath a silver DC-3. FLY EASTERN AIR LINES, THE GREAT SILVER FLEET, it said on the side. He browsed in the World War I gallery and then went to the Pioneers of Flight room. He stopped in front of the Lockheed Sirius, a red two-seater with big silver pontoons that Charles and Anne Morrow Lindbergh had flown to the Far East. Charles Lindbergh had always been one of Haueter’s heroes. A picture of the Spirit of St. Louis hung on his office wall.

  As Haueter admired the plane, his thoughts circled back to the investigation. He felt more confident than ever that the rudder had reversed. It made perfect sense. Now he just had to figure out why.

  12. GREMLIN

  It didn’t take long for nasty jokes about USAir to show up on the Internet. One list suggested new advertising slogans for the airline: “When you just can’t wait for the world to come to you”; “Complimentary champagne during free-fair”; and “The kids will love our inflatable slides.” Another list claimed to have the cockpit tape with the final words of Flight 427’s pilots:

  “Pittsburgh will be our final destination.”

  “Let’s see if this baby can do 300!”

  “Oh stewardess! Oh yes! Oh yes! Oh no…”

  “Assume the position.”

  USAir was an easy target for wisecracks not just because of the five crashes but also because it had never been considered a big-time airline. American and United had been major carriers since the early days of commercial aviation, serving big cities across the country. But USAir’s roots were a hodgepodge of regional airlines that served the blue-collar towns the big airlines didn’t care about.

  USAir began in 1939 as a quirky little company called All American Aviation that went dive-bombing for airmail packages in the Allegheny Mountains. Most of the towns were too small or remote to justify full air mail service, so All American’s planes dove toward a contraption that looked like a football goalpost, dropped a container of mail, and then snagged the outgoing package with a hook. A clerk inside the plane reeled in the package as they flew to the next town.

  The years when All American was grabbing packages in Punxsutawney and Oil City and Slippery Rock helped it develop an image of a gritty regional airline serving the Rust Belt. And while All American was becoming famous for the drudgery of picking up envelopes, carriers such as Pan Am and United were flying wealthy business travelers to the nation’s biggest cities, earning reputations for pampering them with luxurious service.

  By 1953, All American had changed its name to Allegheny Airlines and had begun carrying passengers. It had a fleet of thirteen DC-3s serving such cities as Washington, Baltimore, Philadelphia, New York, and Newark. Over the next twenty-five years, Allegheny grew steadily by merging with Lake Central and Mohawk to become the main regional carrier in the Northeast. But it still was not in the same league as the big guys. Passengers complained about mediocre service and dubbed it “Agony Airlines.”

  With the government tightly regulating the airline industry, Allegheny was limited to routes in the Northeast. But the company had a solid market. The government was generous in setting fares, and most airlines could make a profit with planes that were half empty. Then came the revolution, the deregulation of the airline industry in 1978. Allegheny was freed to compete for national routes. It began flying to Phoenix, Tucson, New Orleans, and Raleigh and changed its name to USAir to get rid of the small-time image. Because it did not have the critical mass that the big carriers had, USAir had to buy other airlines to grow. The company’s chairman, Edwin I. Colodny, was a visionary who understood that under deregulation an airline had to be big to survive. He bought Pacific Southwest Airlines in 1987 to get a toehold in California and then merged with North Carolina-based Piedmont Airlines in 1989.

  But those mergers gave USAir indigestion that lasted for years. Colodny misjudged the difficulty of combining three very different companies, which created a mishmash of cultures, airplane types, and offices that took years to sort out. The Piedmont employees resented the swiftness of the merger and the way their friendly Southern company had been swallowed overnight by a bunch of Yankees. In defiance, many pilots continued to wear their Piedmont wings and drew graffiti of the Piedmont logo in USAir cockpits. Likewise, USAir was unprepared for the brutal competition on the California routes, where Southwest Airlines and America West were slashing fares. USAir soon made an embarrassing retreat from California, conceding most intrastate routes to its competitors.

  Airlines have always been especially vulnerable to changes in the economy. When the economy is bad, people don’t fly. And once it improves, people are slow to resume flying. The airlines are both a leading economic indicator and a lagging follower. They feel a recession sooner, and it takes them longer to recover. But USAir felt the dips even more than its competitors did because it had such high costs and the mergers made the company so inefficient. It had an expensiv
e mix of nine different airplane types, which meant more spare parts, more training, and more maintenance hangars. Even before the mergers, USAir had higher costs because it was heavily unionized and it operated in the most expensive region in the country. The mergers added an extra layer of complications. Other airlines had two or three hubs spaced across the United States, but suddenly USAir had five clustered in the East. The company had too many reservation centers, too many crew bases, too many hangars. It was a recipe for red ink.

  USAir had lost money every year since the 1989 Piedmont merger, for a total loss of $2.5 billion. The company chairman, Seth Schofield, had taken steps to shrink the fleet and close hubs, but the airline was still so inefficient that its operating costs were far and away the highest in the industry. The back-to-back crashes in Charlotte and Hopewell dealt a painful double whammy, scaring away thousands of customers. The airline lost $10 million in bookings because of the Charlotte crash and another $30 million in just three weeks after the Hopewell crash. Its stock price had fallen by 35 percent two months after the crash, down to just $4.25 a share. Some airline analysts were predicting that the company was headed for bankruptcy court.

  USAir had tried to rebuild its image. Schofield and senior vice presidents held meetings with big corporate customers to reassure them about the airline’s financial health and commitment to safety. In a letter to more than a million of the airline’s frequent fliers, Schofield wrote: “I want to reassure you that your confidence in the operational integrity of USAir is of paramount importance to us.”

  By mid-November, it seemed the campaign was paying off. Bookings had rebounded almost to normal levels. It appeared the airline had turned the corner.

  Then came the story in the New York Times.

  TROUBLES AT USAIR: COINCIDENCE OR MORE? asked the front-page headline on Sunday, November 13, 1994. The story painted a picture of sloppiness and cost cutting at the beleaguered airline, where pilots departed without enough fuel and where a maintenance supervisor tried to save money by letting a plane fly with an inoperative stall-warning system. The Times followed the classic formula for a blockbuster investigative story—scary anecdotes, lots of statistics, quotes from worried experts, and weak-sounding denials from the airline. The newspaper said it had obtained “a previously undisclosed report” from the FAA and quoted federal officials who “spoke on the condition that their names be withheld.” A front-page chart showed that the risk of dying on USAir was 5 deaths per 10 million passengers, compared with 1.5 deaths for other major airlines. Once again the USAir name was being linked with death.