The Mystery of Flight 427

by Bill Adair

  The story ricocheted around the country. Newspapers that subscribed to the New York Times News Service published shorter versions of it the same day. It was picked up by the Associated Press and became the lead item on TV newscasts in many cities. Sunday is the slowest news day of the week, so producers were happy to get a story with some pizzazz. “Shocking discoveries raise questions about safety procedures at USAir,” said a Detroit news anchor. “USAir is under attack for its safety record,” said one in Philadelphia. The New York Post said, “USAir’s future is in doubt after revelations that it skimped on safety precautions to cut costs, airline industry experts said yesterday.”

  USAir officials had tried last-minute damage control, but to no avail. General counsel James T. Lloyd sent a letter to the Times two days before the story was published that read in part: “It is possible to look through the tens of thousands of reports that accumulate over time and build a picture that distorts the fundamental truths.” His argument got a brief mention in the story, but it was overshadowed by a mountain of evidence that said the airline had a safety problem. When USAir officials saw the story, they felt they were victims of a hatchet job.

  Rick Weintraub, a former Washington Post reporter who had just been hired to be the airline’s chief spokesman, quickly put together a fact sheet that criticized the Times for making sweeping allegations that were incorrect or misleading. It said the anecdotes about nine planes leaving without sufficient fuel were correct but that most of them returned before taking off. It disputed the Times’s claim that pilot mistakes were a common thread in three of the five crashes and another claim that said the airline was in such dire straits that it was losing $2 million per day. The fact sheet pointed out that the Times buried more-favorable comments about USAir toward the end of the story.

  The Times story was correct in reporting that USAir pilots were having difficulty adhering to company procedures. That was the whole point of Operation Restore Confidence, which had begun before the Hopewell crash. The NTSB found notes from August 1994 meetings that showed pilots often did not follow company procedures. When FAA inspectors observed one hundred USAir pilots, only forty-six followed the company’s Pilot Handbook. Nine days before the Times story, USAir 737 flight manager Jim Gibbs held a meeting on the problem of pilots not flying by the book. “We must have failed to either train or enforce the standardization,” he said, according to notes of the meeting. “Now we must find a way to correct the problem.”

  But the Times story exaggerated USAir’s troubles by giving the story so much space, putting the most damaging evidence on the front page, burying the more balanced comments inside and relying on easy dial-a-quote comments from people who didn’t know the intricacies of aviation. (Ralph Nader: “The problem was that these mergers came with a price. They diverted management attention and took a lot of revenue that could have been spent on safety.”) USAir was correct in saying that it was easy for reporters to pluck incidents from the FAA’s databases to distort an airline’s safety record. Indeed, it is difficult to measure the vague concept of safety. The FAA databases are designed so the regulators can spot problems before they cause a crash—not to see which airline is most likely to kill you. Accidents are so rare that it’s usually unfair to use them to draw conclusions about a single airline. The Times made that point deep in its story, but it also used a chart on the front page that showed the likelihood of dying was more than three times higher on USAir than on the other carriers. And while the lengthy Times story was somewhat balanced, the abbreviated versions used by other newspapers around the country were more one-sided. The long, detailed Times story got boiled down to a simple message: USAir was unsafe.

  The impact was swift and powerful. The airline’s bookings plummeted again. Airline analysts said they were increasingly worried about the possibility of a bankruptcy filing. Employee morale sank to new depths, as ticket agents suffered through wisecracks from customers. Three days after the story was published, Schofield sent a bulletin-board message that tried to give everyone a boost. “I salute you for your patience and professionalism in handling these pointed conversations calmly and with confidence,” he wrote. He quoted aviation expert John Nance from a TV appearance saying, “You can take any airline in the country and find examples of things that sound this bad when taken out of context, in isolation, raise them into scrutiny, and scare everybody to death. But when you really look at this airline’s heart and soul of operations, they’re no less safe than any other major carrier.”

  Schofield urged employees not to be bitter. “I know that it is painful to see and hear negative and distorted media coverage. Our best response, however, is to prove critics wrong by action, not words. We know we’re a safe and reliable airline. We must continue to demonstrate that to our customers in every action we take and every contact we have with them.”

  Five days later, USAir launched a major public relations campaign to try to rescue its reputation. It appointed retired U.S. Air Force general Robert C. Oaks as vice president for corporate safety and regulatory compliance. USAir also said it was hiring PRC Aviation of Tucson, Arizona, “a respected and experienced aviation consulting company,” to conduct a thirty-day audit of the airline’s safety policies and procedures. Schofield said the auditors “can go anywhere, ask anyone anything, can look at any records, manuals, bulletins, letters or messages they think are germane to safety at USAir. There are no limits.”

  The airline then bought full-page ads in major newspapers to publish messages from the company’s employees and unions. The ALPA chairman’s letter said safety was the pilots’ first priority. The head of the flight attendants union said USAir was totally dedicated to “operational integrity.” Two mechanics said they would not hesitate to ground any plane if it was unsafe. A customer service supervisor said passengers’ well-being was foremost in the minds of USAir employees. Schofield concluded the series with a message that said safety “is the foundation for all we do.”

  John Cox sat down at the conference table in the NTSB listening room and put on a set of headphones. He and USAir pilot Ed Bular had come to hear the cockpit tape from Flight 427 to see if they could identify the mysterious thumps that had baffled the investigators for months. Cox had heard tapes from other crashes before, and he could never erase them from his memory—the routine of the cockpit quickly deteriorating into shouts, screams, and death. But listening to the tapes was a necessary part of an accident investigation and, as a pilot with eight thousand hours in 737s, he might recognize something that others did not.

  He and Bular sat across from each other at the small table. Al Reitan, an NTSB sound technician, sat at the head of the table so he could control the tape player. They began by listening to all the cockpit sounds for the final ten to fifteen minutes of the flight. That was a necessary step for Cox, to listen to the entire tape so he could get over the drama of the event, the fact that he was listening to two fellow pilots scream and die. He was amazed by the sound of the plane being buffeted, a violent shaking caused by insufficient air crossing the wings to keep the plane flying.

  “The buffeting sounds like a goddamn freight train,” Cox said.

  Reitan then isolated each of the four channels on the tape—Germano’s microphone, Emmett’s, the jump seat microphone, and the mike in the ceiling above the pilots’ heads. Both pilots sounded cool and confident, Cox thought. There was good rapport between them, and they were flying by the book. Emmett said very little in the final thirty seconds. His most expressive comment was a worried “Ohhh shiiiiit.” But Cox thought that was understandable because he was the flying pilot and was trying to figure out what was happening to his airplane. Germano was more expressive, but he never said what he believed was happening. His most telling comment was when the plane stalled, when he asked, “What the hell is this?”

  Reitan used filters to block out the extraneous noise so the pilots could focus better on the voices. He used a computer to trap snippets of sounds and play them repea
tedly. He trapped the thump and played it back again and again. Sheez Zuh Thump Clickety-click. Sheez Zuh Thump Clickety-click. Sheez Zuh Thump Clickety-click. Over and over the pilots listened to it, like an old record album with a scratch on it. But after hearing it dozens of times, they could not identify the sound. “Beats the hell out of me,” Cox told Bular. He thought it sounded like a briefcase falling over on a carpeted floor. But cockpits were not carpeted, and there was not much space for a briefcase to fall over.

  Several hours later when Cox walked out of the room, he was convinced that the pilots had been caught by surprise by something they hadn’t encountered before. He believed the tape proved the pilots had not done anything wrong. It offered no evidence that one of them stomped on the left rudder pedal and held it down. To the contrary, it showed the airplane was doing something the pilots did not expect.

  Cox said later, “There is a gremlin in that airplane.”

  McGrew, Boeing’s chief engineer for the 737, listened to the same tape and came to the opposite conclusion. He had to fight for months to get the NTSB to allow him to listen to it, because he was not officially part of the investigation. When he finally heard it, he used the same cool approach that he used for everything else. He concentrated on gathering data, hearing every sound he could, and didn’t think much about the screaming.

  McGrew came away convinced that the pilots were startled by something and then overreacted. He heard it in the tone of their voices when they said “Sheez!” and “Zuh!” They had no idea what hit them. McGrew heard nothing to indicate that the pilots believed the plane was malfunctioning. There was no mention of the rudder pedal or anything else not working properly. He noticed they never communicated about the fact that they were twisting out of the sky. When Germano shouted, “Pull! Pull!” McGrew knew it was the wrong thing to do. They should have pushed the stick forward to gain speed.

  The tape made it all clear to him: the pilots got startled, stomped on the pedal by mistake, and then pulled back on the stick, stalling the airplane. The crash was clearly caused by pilot error. He wanted others to listen to the tape because he was convinced they would have the same reaction he did.

  Months after hearing the tape, McGrew awoke in the middle of the night, haunted by the sounds he had heard. He wondered what the passengers felt as the plane was spinning toward the earth. What do you think about when you know you’re about to die?

  The different interpretations of the tape showed how the rivalry between ALPA and Boeing was increasing. As the investigation wound into its fifth month with no conclusive evidence as to why the rudder had moved, the two groups were beginning to disagree more often. In the absence of solid facts, both sides retreated to positions that protected their turf. It was as if Boeing and the pilots union had a default setting, like computer software. Until they got proof to the contrary, they didn’t budge.

  The two sides remained cordial, but the rivalry was apparent. Cox enjoyed taking friendly jabs at the Boeing team. He tapped McGrew on the shoulder at their first meeting and said, “I know what did it.” Cox held up a copy of the Weekly World News, a supermarket tabloid that had this headline: USAIR FLIGHT 427 COLLIDED WITH A UFO! The article reported: “Federal investigators are looking into the possibility that the crash of USAir Flight 427 was caused by a collision with a UFO—a possibility supported by the discovery of a passenger’s hastily scribbled note that says, ‘Massive, glowing, as big as a house. Oh my God! It’s going to hit!’”

  McGrew got a chuckle out of it, but he and the other Boeing investigators were wary about Cox and the rest of the ALPA guys. They felt that ALPA was overprotective of the pilot brotherhood and would go to great lengths to protect a fallen pilot, even when he was to blame.

  Brett decided to go back to Pittsburgh for the January 1995 public hearings on the crash, where the safety board would lay out the evidence it had amassed. He chose to fly because it simply wasn’t practical to drive from San Diego, where he had spent several weeks staying with his brother. But he had been very careful about choosing how to get there. He picked American Airlines because it was the only major carrier that flew to Pittsburgh and did not have any 737s.

  As the plane prepared for takeoff, the man sitting beside him noticed Brett was clenching his seat.

  “Nervous flier, huh?” the man asked.

  “Yeah,” Brett said.

  “They say your odds of dying in a plane crash are higher than winning the lottery.”

  Brett couldn’t let that go. He reached into his wallet and pulled out the card about the scholarship fund he had started in honor of Joan.

  “That plane that crashed in Pittsburgh,” Brett said, “my wife was on it.”

  “Oh my God,” the man said.

  Then the man told Brett about his own personal tragedy, that his daughter had been molested by his ex-wife’s new husband. Brett had heard lots of those sad stories since Joan died. When people found out about his tragedy, they wanted to share their own horrible tales, reassuring him that he wasn’t alone in suffering. A Newsweek photographer told Brett that his brother took a drug overdose. A cab driver said his parents died when he was twelve. A woman who handled Joan’s pension said her brother and his wife were in an accident with a drunk driver, which had killed their child and put them both in comas. Tragedies everywhere. Until this happened, Brett had no idea that life could be so miserable for so many.

  The man beside him said he was a born-again Christian and that he had decided to forgive the guy who had molested his daughter. “I’ve realized that if I want to be forgiven by God, I’ve got to forgive the people who harm me.” That really struck a chord with Brett. He had never really bought all the hype about being born again, but the guy was right. Brett realized that he couldn’t stay angry forever.

  The next day he took a cab from his downtown hotel out to Hopewell to visit the crash site again. He brought a video camera so he could record the scene for Joan’s family. He had talked with them often in the five months since the crash. He hired an artist to do an oil painting of Joan from a photograph and gave it to her parents for Christmas.

  He trudged through the snow, narrating while he described the site. He took a wide shot of the spot where the nose of the plane struck the road. “You can see it’s not very big at all,” he said. “It’s not much bigger than a family room, really.”

  He walked to the plastic wreath, which sat on a big easel with American flags on one side. “This is that wreath I was telling you guys about, where Joan’s rose blew off just as the guy from the Salvation Army was walking up to it. There are still a lot of them on there. They are glued on there pretty good. It’s still kind of an amazing thing to me.”

  He then visited the Sewickley Cemetery, where USAir had built a memorial that listed all 132 victims. He zoomed in on Joan’s name and then read the inscription on the headstone very quickly, as if he was in a hurry to leave: “Strengthen our course with every prayer, let Heaven’s breezes speed us there, and grant us mercy evermore as we sail to Heaven’s shore.”

  13. PILOT ERROR

  Pittsburgh was brutally cold the week of the public hearing. Several inches of snow covered the lawn outside the Pittsburgh Hilton and Towers, and the roads were filled with an ugly gray slush. The hearing was conducted in the hotel’s ballroom, a cavernous space with nineteen-foot ceilings that was set up like a giant courtroom. Haueter and his investigators sat at raised tables on one side, as if they were the prosecutors in the case. The parties—Boeing, the pilots union, the FAA—were positioned just below Haueter, huddled at tables as though they were the defendants. The meeting was run by NTSB chairman Jim Hall, who presided like a judge. In the audience were several hundred spectators, including about one hundred relatives of the victims. Some of them clutched photographs of Flight 427’s passengers. Others had photos pinned to their jackets and sweaters.

  The NTSB called it a public hearing, but that was a misnomer. Many families had the impression that they would be able
to stand up at a microphone and ask questions, just as they would at a city council meeting. But at an NTSB hearing, the public was to be seen and not heard. This meeting was the agency’s chance to show its work and explain the evidence. There would be no time for questions from the crowd.

  There would be no breakthroughs, either. Haueter and his investigators had spent the past five months talking with the people who would testify, so it was unlikely that the NTSB would learn anything new. If a break in the investigation ever occurred, it would be in a lab somewhere, not in a big ballroom in Pittsburgh.

  On the first day of the hearing, the board released the docket, a foot-high stack of reports, memos, letters, charts, and graphs. Much of it was technical gibberish—details about dual-concentric servo valves, rudder blowdown, and chip-shear strength. There were pages and pages of data from the flight recorder and photocopies of federal aviation regulations. Nowhere in the big package was there any guidance to understanding what it all meant—no underlined words, no comments in the margins, no Post-it notes. It looked like Haueter had emptied his file cabinet and ordered somebody to make copies. But it was consistent with the cryptic way the NTSB operated. It released hundreds of thousands of facts and allowed the public to decide which ones were important.